Every finding on record at Havenwood Care Center

Based on observations, interviews and document review, the facility failed to provide sufficient staffing to provide exercise services for the restorative nursing program for 6 of 6 residents (R14, R20, R32, R40, R53, R66) reviewed for restorative exercise program. This had the potential to affect all 38 residents who had exercise programs. Findings include:See also F688: Based on observation, interview, and document review, the facility failed to provide exercise programs as ordered for 6 of 6 residents (R14, R20, R32, R40, R53, R66) reviewed for restorative exercise program. This had the potential to affect all 38 residents who had exercise programs. R20:R20's Restorative Care Program identified the following:9/19/25, identified R20 was discharged from occupational therapy (OT) and was to have a restorative program to maintain her upper extremity strength and range of motion of participation in self-care and functional tasks of choice. The restorative aide was directed to completed ten repetitions of shoulder flex, chest press and side to side with a two-pound weight, ten repetitions of elbow flexion and extension with a red TheraBand and ten repetitions of pro/supination with a yellow TheraBand. 10/1/25, identified R20 was discharged from physical therapy (PT) and was to have a restorative program to maintain lower extremity strength and range of motion for continued level of ambulation and transfers to decrease burden of care. The restorative aide was directed to complete 15 repetitions of marching, lower ankle and hip abduction, and leg curl with a two-pound ankle weight and ball squeezes and ball press. R20 was also to stand with her four wheeled walker for two, one-minute sets or as long as R20 tolerated. The Restorative Program logs dated 1/19/26 through 4/29/26, identified R20 in the list of residents who were to receive exercise one to two times per week. Next to each resident name was columns for each day of the week. The logs documented R20 had received restorative exercises one time and refused three times during the 15-week time period. R53:R53's Restorative Care Program identified the following:9/4/25, identified R53 was discharged from OT, and an FMP program was setup with goals to maintain both upper extremity ROM in order to complete self-cares. The restorative aide was directed to perform active and passive ROM to all upper extremity wrist, shoulder, elbow planes as well as digit extension. 12/9/25, identified R53 was discharged from PT, and an FMP program was setup with goals to maintain lower extremity ROM, to prevent further contractures. The restorative aide was directed to complete passive ROM to R53's hips, knees and ankles in all planes. The restorative aide was also to assist R53 with two thirty second sets of hamstring and heel cord stretch. The Restorative Program logs dated 1/19/26 through 4/29/26, identified R53 in the list of residents who were to receive exercise one to two times per week. Next to each resident name was columns for each day of the week. The logs documented R53 had received restorative exercises five times and refused one time during the 15-week time period. R40 R40's Restorative Care Program identified the following:12/3/25, identified R40 was discharged from OT, and an FMP program was setup with goals to maintain upper extremity strength and ROM in order to participate self-cares. The restorative aide was directed to perform upper extremity exercises for three minutes, use a two pound therapy bar for 15 repetitions for shoulder flexion, chest press, shoulder circumduction forward and backward, The restorative aide was to assist with elbow extensions using the green TheraBand for 15 repetitions two times as well as using the red flex bar for 10 repetitions of pronation, supination and wrist flexion and extensions. 12/9/25, identified R40 discharged from PT and an FMP program was setup with goals to maintain lower extremity strength and ROM to assist staff during her ADL's. The restorative aide was directed to assist R40 with seated exercises with ball presses, knee flexes, ankle pumps, hip abductions and adductions with small therapy ball and hip flexions. R40 was to stand with a four wheeled walker and march twenty times with two-pound ankle weights. The Restorative Program logs dated 1/19/26 through 4/29/26, identified R40 in the list of residents who were to receive exercise one to two times per week. Next to each resident name was columns for each day of the week. The logs documented R40 had not received restorative exercises at all and refused three times during the 15-week period.R14 R14's Restorative Care Program dated 12/15/23, directed to maintain lower extremity range of motion/strength to assist staff during activities of daily living. Approaches/recommendations included: NuStep level 5, seat 9, arms at 8 for 5 minutes Seated exercises with 3-pound ankle weights for 15 repetitions. Left knee flex with geriatric Thera-band, Hip abduction with geriatric Thera-band, Hip adduction with small yellow t-ball, Ball presses and standing with front wheeled walker. Marching 20 times with contact guard assist R14's Restorative Program log dated 1/19/26 through 4/29/26, identified R14 had 105 opportunities to receive restorative exercises. R14 received the exercises 3 times and refused 3 times during the period reviewed.R66 R66's Restorative Care Program dated 4/15/26, identified R66 was to maintain range of motion to decrease incidence of contractures and bedsores. Approach/recommendations included: Supine in bed: 2 sets of 15 repetitions of passive range of motion, SLR, hip abduction, hip flexion/extension, knee flexion/extension, ankle passive range of motion in all planes, hamstring stretch 2 x 15 repetitions, heel-cord strength 2 x 15 repetitions, and Encourage R66 to assist with movements if she is awake/alert.R66's Restorative Program log dated 4/15/26 through 4/29/26, identified there were 15 opportunities for R66 to receive the exercise. R66 received restorative exercises twice during the period reviewed.R32:R32's Restorative Care Program dated 11/7/25, identified R32 was placed on the program to maintain lower extremity (legs) strength and range of motion to decrease burden of care with transfers and ambulation (walking). The program identified which exercises to complete to help maintain R32's level of function. The exercises include doing them 15 times in a row once: Seated chair march, Long Arc Quad (big muscle on the front of the leg) stretch (sitting in a chair and lifting your foot straight out), Hip adduction with a ball. (squeezing your knees together with a ball between them), Hamstring (main muscle on back of leg) curls (the restorative aide would hold R32 up with a green TheraBand and would have to pull against it), Hip abduction with a green TheraBand (placing the band around both knees and spreading your knees apart), Hamstring and heel cord stretch (with leg straight out you would pull your toes back towards your body) and With a physical therapist, assist R32 to stand, and they may ambulate up to 100 feet or up to R32 tolerance using the front wheel walker and a gait belt (a belt to place around a resident to assist with standing and balance). R32's Restorative Program documentation identified from 1/29/26 through 4/26/26, R32 only received FMP exercises twice and did not include any ambulation services during period of time reviewed.The restorative program documentation was reviewed and identified the following:1/19/26-1/25/16, 6 of 39 residents received services.1/26/26-2/1/26, 0 of 38 residents received services.2/2/26-2/8/26, 25 of 39 residents received services.2/9/26-2/15/26, 9 of 40 residents received services. 2/16/26-2/22/26, 28 of 38 residents received services.2/23/26-3/1/26, 6 of 39 residents received services.3/2/26-3/8/26, 2 of 38 residents received services.3/9/36-3/15/26, 0 of 38 residents received services.3/16/26-3/22/26, 0 of 37 residents received services.3/23/26-3/29/26, 1 of 37 residents received services.3/30/26-4/5/26, 3 of 40 residents received services.4/6/26-4/12/26, 0 of 40 residents received services.4/13/26-4/19/26, 27 of 40 residents received services.4/20/26-4/26/26, 26 of 41 residents received services.4/27/26-5/3/26, 30 of 38 residents received services.During an interview on 4/28/26 at 12:26 p.m., nursing assistant (NA)-H, who was a restorative aide, stated initially she was going to be just doing functional maintenance programs for the residents today (4/28/26) but was only able to work until about noon. She was then instructed to stop working on the FMP's and was pulled to the floor to work as a NA. NA-H stated being pulled to the floor happened a lot. There was another NA who would help with FMPs, but they also called to work as an NA on the floor. When NA-H is working as the restorative aide she reviewed the lists of residents and decide which ones could be done on that day. NA-H can't get through the list and there are residents who do not get the FMP services. Most of the residents on an FMP had not received services on a regular basis or not even at all. Most of the residents were not receiving their ordered FMP due to having to be pulled to the floor all the time and only working a couple of days a week. During a follow up interview on 4/29/26, at 2:30 p.m. NA-H stated she had only been back working in the facility for the last two weeks and had been off for six months prior to that. NA-H stated she mainly worked restorative nursing but was pulled to the floor a lot to help with resident care due to short staffing and/or call ins. NA-H tried to document on the restorative logs when she was pulled off restorative to help on the floor. NA-H did not know if the nursing assistant who covered while she was gone was pulled off the restorative program as the aide had not documented, but few exercises had been documented in the logbook, prior to her return. NA-H stated even if she was not pulled off to work on the floor, it would be very difficult to see every resident on the FMP program. During an interview on 4/29/26 at 4:04 p.m. the director of nursing (DON) stated there are two aides who worked the restorative nursing program and they are both part time. For about 6 months the facility only had one part-time restorative aide. The restorative aides would start with the FMPs right away when they get to the facility, but they are frequently called out to floor to work as a NA. This is because of call-ins or short staffing on the floor. She stated it was not acceptable to be pulling the restorative aides to the floor all the time, because they have close to fifty residents to assist and are unable to get to all of them in a week and the residents go without their FMP.A staffing policy was not obtained.

Based on observation, interview and document review the facility failed to ensure staff served meals while securing their hair with a hair covering on1 of 2 units Walnut Unit) . This had the potential to affect all 23 residents who ate meals on the Walnut Unit.Findings include:According to section 2-402.11 of the Food and Drug Administration (FDA) Food code dated 2017: A hair restraint keeps dislodged hair from ending up in the food and may deter employees from touching their hair. This is crucial to prevent cross-contamination. Staphylococcus aureus is an example of a common pathogen that is found on skin and hair. If enough of the bacteria is ingested, it could cause illness. Common symptoms of this illness include vomiting, nausea, and stomach cramps. During an observation on 4/28/26 at 12:06 p.m., dietary aide (DA)-A was serving meals from the Walnut Grove kitchenette. DA-A leaned over the steam table food containers while setting up the individual resident plates for the noon meal. DA-A was not wearing a hairnet. At 12:15 p.m., DA-A left the kitchenette to deliver food to a resident and then began to clean off tables where residents had finished.During an interview on 4/28/26 at 12:20 p.m., DA-A stated hairnets were required whenever in the kitchen and/or while serving food. DA-A touched her head and stated I don't have one on? Oh no, I thought I had one on. DA-A left the Walnut Grove kitchenette and went into the main kitchen. When DA-A returned a moment later, DA-A was wearing a hair net. During an interview on 4/29/26 at 3:17 p.m., the dietary manager (DM)-A stated staff should always wear a hairnet, especially while serving food to ensure hair does not get into the food to prevent illness and for palatability. The facility policy Employee Sanitary Practices dated 2019, identified all food and nutrition services employees will practice good personal hygiene and safe food handling procedures. All employees will: wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food

Based on observation, interview, and document review, the facility failed to provide exercise programs as ordered for 6 of 6 residents (R14, R20, R32, R40, R53, R66) reviewed for restorative exercise program. This had the potential to affect all 38 residents who had exercise programs.Findings include: R20 R20's annual Minimum Data Set (MDS) dated [DATE], identified R20 had severe cognitive impairment and required moderate assistance with activities of daily living (ADLs), R20 was unable to ambulate. Diagnoses included osteoporosis, Alzheimer's disease, weakness and history of hand and hip fractures. R20's care plan reviewed 3/16/26, identified R20 had decreased physical mobility with a potential for falls due to a left hip fracture. Staff were directed to assist R20 to turn and reposition and transfer to her wheelchair. R20's care plan lacked documentation of a functional maintenance program (FMP). R20's undated Physician Orders identified an order for physical therapy FMP with a start date 10/1/25, and the end date was open ended. An order for physical and occupational therapy FMP was also listed with start date 9/26/25 with an open-ended end date. R20's Restorative Care Program identified the following: 9/19/25, identified R20 was discharged from occupational therapy (OT) and was to have a restorative program to maintain her upper extremity strength and range of motion of participation in self-care and functional tasks of choice. The restorative aide was directed to completed ten repetitions of shoulder flex, chest press and side to side with a two-pound weight, ten repetitions of elbow flexion and extension with a red TheraBand and ten repetitions of pro/supination with a yellow TheraBand. 10/1/25, identified R20 was discharged from physical therapy (PT) and was to have a restorative program to maintain lower extremity strength and range of motion for continued level of ambulation and transfers to decrease burden of care. The restorative aide was directed to complete 15 repetitions of marching, lower ankle and hip abduction, and leg curl with a two-pound ankle weight and ball squeezes and ball press. R20 was also to stand with her four wheeled walker for two, one-minute sets or as long as R20 tolerated. The Restorative Program logs dated 1/19/26 through 4/29/26, identified R20 in the list of residents who were to receive exercise one to two times per week. Next to each resident name was columns for each day of the week. The logs documented R20 had received restorative exercises one time and refused three times during the 15-week time period. On 4/29/26, at 3:23 p.m. physical therapist (PT)-A and therapy director (TD) assisted R20 to complete the full OT and PT FMP program exercises in the therapy room. R20 became visibly weak, shaky toward the end of the exercises. PT-A and TD both stated R20 had no decline since P20 was last seen by therapy. R53 R53's quarterly MDS dated [DATE], identified R53 had intact cognition and was dependent on staff for most ADLs, mobility and transfers. R53 had impaired range of motion (ROM) to both lower extremities and was unable to ambulate. Diagnoses included paraplegia (paralysis lower half of body), spondylosis (degenerative spinal condition) and chronic pain. R53's care plan revised 3/16/26, identified R53 had decreased physical mobility with potentials for falls due to low back pain with bilateral sciatica, spinal stenosis, weakness and limited functional ROM. Staff were directed to assist R53 with mobility, transfers and repositioning. R53 was to participate in FMP per her plan of care. R53's undated Physician Orders report identified an order for FMP dated 9/4/25, with an open-ended end date. R53's Restorative Care Program identified the following: 9/4/25, identified R53 was discharged from OT, and an FMP program was setup with goals to maintain both upper extremity ROM in order to complete self-cares. The restorative aide was directed to perform active and passive ROM to all upper extremity wrist, shoulder, elbow planes as well as digit extension. 12/9/25, identified R53 was discharged from PT, and an FMP program was setup with goals to maintain lower extremity ROM, to prevent further contractures. The restorative aide was directed to complete passive ROM to R53's hips, knees and ankles in all planes. The restorative aide was also to assist R53 with two thirty second sets of hamstring and heel cord stretch. The Restorative Program logs dated 1/19/26 through 4/29/26, identified R53 in the list of residents who were to receive exercise one to two times per week. Next to each resident name was columns for each day of the week. The logs documented R53 had received restorative exercises five times and refused one time during the 15-week time period. On 4/29/26, at 4:02 p.m. R53 was seated in her room watching television. TD entered the room and received permission to assist R53 with her exercises. TD completed all exercises from the PT and OT FMP program. R53 was smiling and cooperative throughout the exercises. After completion of the exercises, TD stated she did not find a decline in R53's function since she was last seen by therapy. R53 stated she was unsure how often staff assisted her with her exercises or when they were last done. R53 stated she wished it were more often. R40 R40's quarterly MDS dated [DATE], identified R40 had moderately impaired cognition and was independent with ADLs. R40 had full ROM of extremities and was able to ambulate independently. Diagnoses included dementia, traumatic subdural hemorrhage, repeated falls, dizziness and giddiness, disorder of the autonomic nervous system, and osteoarthritis of the knees. R40's undated Physician Orders report identified an order for PT and OT FMP one time per day with start date 12/5/25 and open-ended end date. R40's care plan revised 3/16/26, identified decreased physical mobility with potential for falls due to dementia, poor coordination and balance, history of falls, and poor sequencings skills. Staff were directed to provide limited assistance with transfer and ambulation and OT and PT FMP per plan of care. R40's Restorative Care Program identified the following: 12/3/25, identified R40 was discharged from OT, and an FMP program was setup with goals to maintain upper extremity strength and ROM in order to participate self-cares. The restorative aide was directed to perform upper extremity exercises for three minutes, use a two pound therapy bar for 15 repetitions for shoulder flexion, chest press, shoulder circumduction forward and backward, The restorative aide was to assist with elbow extensions using the green TheraBand for 15 repetitions two times as well as using the red flex bar for 10 repetitions of pronation, supination and wrist flexion and extensions. 12/9/25, identified R40 discharged from PT and an FMP program was setup with goals to maintain lower extremity strength and ROM to assist staff during her ADL's. The restorative aide was directed to assist R40 with seated exercises with ball presses, knee flexes, ankle pumps, hip abductions and adductions with small therapy ball and hip flexions. R40 was to stand with a four wheeled walker and march twenty times with two-pound ankle weights. The Restorative Program logs dated 1/19/26 through 4/29/26, identified R40 in the list of residents who were to receive exercise one to two times per week. Next to each resident name was columns for each day of the week. The logs documented R40 had not received restorative exercises at all and refused three times during the 15-week period. R14 R14's quarterly Minimum Data Set (MDS) dated [DATE], identified R14 had severe cognitive impairment and was non-ambulatory. A diagnosis of dementia was included. R14's Restorative Care Program dated 12/15/23, directed to maintain lower extremity range of motion/strength to assist staff during activities of daily living. Approaches/recommendations included: NuStep level 5, seat 9, arms at 8 for 5 minutes Seated exercises with 3-pound ankle weights for 15 repetitions. Left knee flex with geriatric Thera-band, Hip abduction with geriatric Thera-band, Hip adduction with small yellow t-ball, Ball presses and standing with front wheeled walker. Marching 20 times with contact guard assist R14's care plan revised 3/16/26, identified falls and alteration in skin related to poor coordination/balance, pain, dementia with cognitive losses and poor sequencing skills manifested by inability to transfer, always wheel self, always turn and reposition self, sit up, lie down or get feet and legs into bed independently. Unable to ambulate. Occupational therapy (OT) and physical therapy (PT) functional maintenance program as ordered. R14's Restorative Program log dated 1/19/26 through 4/29/26, identified R14 had 105 opportunities to receive restorative exercises. R14 received the exercises 3 times and refused 3 times during the period reviewed. During an interview on 4/28/26 at 1:26 p.m., nursing assistant (NA)-H, who is also the restorative aide, stated R14 frequently refused to do restorative exercises, however, the documentation did not reflect R14 had refused or had been offered. R66 R66's MDS dated [DATE], identified R66 was cognitively intact and required substantial/maximal assistance with upper body dressing and personal hygiene, partial/moderate assistance with eating, and was dependent on staff for all other care areas. Diagnoses included dementia, anxiety and diabetes. R66's care plan revised 3/16/26, identified decreased physical mobility with potential for falls and alterations in skin r/t Diabetes, Dementia, Alzheimer's disease, Heart failure, poor balance at times and poor sequencing skills manifested by need for staff assist with mobility needs at times. R66 was to participate in a functional maintenance program as ordered by therapy. R66's Restorative Care Program dated 4/15/26, identified R66 was to maintain range of motion to decrease incidence of contractures and bedsores. Approach/recommendations included: Supine in bed: 2 sets of 15 repetitions of passive range of motion, SLR, hip abduction, hip flexion/extension, knee flexion/extension, ankle passive range of motion in all planes, hamstring stretch 2 x 15 repetitions, heel-cord strength 2 x 15 repetitions, and Encourage R66 to assist with movements if she is awake/alert. R66's Restorative Program log dated 4/15/26 through 4/29/26, identified there were 15 opportunities for R66 to receive the exercise. R66 received restorative exercises twice during the period reviewed During an interview on 4/28/26 at 1:26 p.m., nursing assistant (NA)-H, who is also the restorative aide, stated R66 frequently refused to do restorative exercises, however, the documentation did not reflect R66 had refused or had been offered. R32: R32's quarterly MDS dated [DATE], identified R32 was cognitively intact. R32 was substantial to maximal assist with bed mobility and transfers and did not walk. R32's had a diagnosis of joint replacement of left knee. R32's medical record contained the following information on the restorative program: R32's provider orders dated 11/19/25, identified Functional Maintenance Plan (FMP) was ordered with special instruction for walking program as part of FMP. R32's progress noted dated 11/19/25, identified R32 was discharged from PT services on 11/7/25. PT FMP in place with walking program apart of her FMP. Restorative Care Program dated 11/7/25, identified R32 was placed on the program to maintain lower extremity (legs) strength and range of motion to decrease burden of care with transfers and ambulation (walking). The program identified which exercises to complete to help maintain R32's level of function. The exercises include doing them 15 times in a row once: Seated chair march, Long Arc Quad (big muscle on the front of the leg) stretch (sitting in a chair and lifting your foot straight out), Hip adduction with a ball. (squeezing your knees together with a ball between them), Hamstring (main muscle on back of leg) curls (the restorative aide would hold R32 up with a green TheraBand and would have to pull against it), Hip abduction with a green TheraBand (placing the band around both knees and spreading your knees apart), Hamstring and heel cord stretch (with leg straight out you would pull your toes back towards your body) and With a physical therapist, assist R32 to stand, and they may ambulate up to 100 feet or up to R32 tolerance using the front wheel walker and a gait belt (a belt to place around a resident to assist with standing and balance). R32's Restorative Program documentation identified from 1/29/26 through 4/26/26, R32 only received FMP exercises twice and did not include any ambulation services during period of time reviewed. During an interview on 4/28/26 at 12:26 p.m., nursing assistant (NA)-H stated they were only able to provide FMP services to R32 twice and that did not include ambulation services. The nursing assistants on the floor would be responsible for ambulation. During an interview on 4/29/26 at 9:49 a.m., TD stated the restorative aide would provide the exercise services and nursing and NAs provided ambulation services on the floor. R32's program for the exercises #1-6 (above) would be completed by the restorative aide and #7 would be completed by NAs on the floor. During an interview on 4/29/26 at 10:39 a.m., a trained medication aide (TMA)-C stated there was a list of residents who required ambulation and would be updated regularly by the nurse manager. If there were concerns on ability of the resident to continue walking, then we would let the nurse manager know and she would have ordered a screening from therapy to see if changes needed to be made with the program. I think there was a screening done for R32 that stated she was not to ambulate. During a follow up interview on 4/29/26 at 10:47 a.m., the TD stated when a request came in it would be charted and documented in their system. R36 had never received a request to rescreen her regarding ambulation. This was also verified by the physical therapist (PT)-A. During interview on 4/29/26, at 2:30 p.m. NA-H stated she had only been back working in the facility for the last two weeks and had been off for six months prior to that. NA-H stated she mainly worked restorative nursing but was pulled to the floor a lot to help with resident care due to short staffing and/or call ins. NA-H tried to document on the restorative logs when she was pulled off restorative to help on the floor. NA-H did not know if the nursing assistant who covered while she was gone was pulled off the restorative program as the aide had not documented, but few exercises had been documented in the logbook, prior to her return. NA-H stated even if she was not pulled off to work on the floor, it would be very difficult to see every resident on the FMP program. During an interview on 4/29/26 at 4:07 p.m., the director of nursing (DON) stated when residents were started on an FMP the restorative aide would work on the range of motion aspect of the plan and the NA's on the unit would do the ambulation portion of the plan. R36 should have received the ordered FMP to maintain their level of function related to activities of daily living. During interview on 4/29/26, at 4:30 p.m. TD stated therapy completed the functional maintenance program form to initiate restorative nursing exercises when they discharged a resident from therapy. Therapy did not oversee the program. If a resident was not being seen or refusing restorative services, they would report to the charge nurse, and the charge nurse would notify therapy, if they needed to be re-evaluated. TD thought nursing oversaw the restorative program. When interviewed on 4/29/26, at 5:36 p.m. the interim DON stated she did not know if the previous restorative aide had documented her work correctly, but the facility did pull the restorative aide from time to time to work on the floor assisting with resident care. The facility had two restorative aides who each worked two days per week, and one worked every other weekend and the other, one weekend a month, for resident restorative program. The facility policy Quality of Care reviewed 10/2023, identified the facility would ensure a resident with limited range of motion or mobility would receive appropriate treatment and services to increase range of motion and mobility and/or prevent further decrease in range of motion or mobility. The facility policy Restorative Care dated 7/19/21, identified it was the intent of the restorative program to promote the resident's ability to adapt and adjust to living as independently and safely as possible. The resident would be assessed by physical therapy and recommendations for restorative care therapy were submitted on the restorative therapy form. A nursing assistant trained to perform restorative care therapy would complete 15 minutes daily with the resident. Time would be documented by the therapy aide. The restorative care lead nurse would maintain documentation of residents who received restorative care and would make progress notes on therapy, minutes of therapy provided and plan review.

Based on interview and document review, the facility failed to revise the care plan to include ordered functional maintenance program (FMP) with goals and interventions for 2 of 6 residents (R20, R32) who received exercises, in addition, the facility include enhanced barrier precautions (EBP) including measurable goals and interventions for 1 of 6 residents (R66) whose care plans were reviewed for EBP. Findings include: R20: R20's annual Minimum Data Set (MDS) dated [DATE], identified R20 had severe cognitive impairment and required moderate assistance with activities of daily living (ADLs), R20 was unable to ambulate. Diagnoses included osteoporosis, Alzheimer's disease, anxiety, weakness and history of hand and hip fractures. R20's undated Physician Orders report identified an order for physical therapy FMP with a start date 10/1/25, and the end date was open ended. An order for physical and occupational therapy FMP was also listed with start date 9/26/25 with an open-ended end date. R20's Restorative Care Program identified the following: 9/19/25, identified R20 was discharged from occupational therapy (OT) and was to have a restorative program to maintain her upper extremity strength and range of motion of participation in self-care and functional tasks of choice. The restorative aide was directed to completed ten repetitions of shoulder flex, chest press and side to side with a two-pound weight, ten repetitions of elbow flexion and extension with a red TheraBand and ten repetitions of pro/supination with a yellow TheraBand. 10/1/25, identified R20 was discharged from physical therapy (PT) and was to have a restorative program to maintain lower extremity strength and range of motion for continued level of ambulation and transfers to decrease burden of care. The restorative aide was directed to complete 15 repetitions of marching, lower ankle and hip abduction, and leg curl with a two-pound ankle weight and ball squeezes and ball press. R20 was also to stand with her four wheeled walker for two, one-minute sets or as long as R20 tolerated. R20's care plan dated 3/16/26, identified R20 had decreased physical mobility with a potential for falls due to a left hip fracture. Staff were directed to assist R20 to turn and reposition and transfer to her wheelchair. R20's care plan lacked documentation of a functional maintenance program (FMP), with goals and staff interventions. During interview on 4/29/26, at 5:36 p.m. the director of nursing (DON) stated if a resident was being seen by the restorative aide for the FMP, that should be addressed in their plan of care. R32: R32's quarterly MDS dated [DATE], identified R32 was cognitively intact. R32 was substantial to maximal assistance with bed mobility and transfers and did not walk. R32's had a diagnosis of joint replacement of left knee. R32's undated Physicians Orders report identified an order for a FMP with walking as part of the FMP with a start dated of 11/19/25, with no end date identified. R32's Restorative Care Program dated 11/7/25, identified R32 was discharged from PT and was to start a FMP to maintain lower extremity strength and range of motion to decrease the burden of care with transfers and ambulation. The FMP identified the resident was to do each exercise 15 times. The exercises included: Seated chair march Long Arc Quad (big muscle on the front of the leg) stretch (sitting in a chair and lifting your foot straight out) Hip adduction with a ball. (squeezing your knees together with a ball between them) Hamstring (main muscle on back of leg) curls (the restorative aide would hold R32 up with a green TheraBand and would have to pull against it) Hip abduction with a green TheraBand (placing the band around both knees and spreading your knees apart) Hamstring and heel cord stretch (with leg straight out you would pull your toes back towards your body) With a physical therapist, assist R32 to stand, and they may ambulate up to 100 feet or up to R32 tolerance using the front wheel walker and a gait belt (a belt to place around a resident to assist with standing and balance). R32's care plan with the last review date of 3/13/26, identified R32 had decreased physical mobility with potential for falls due to recent left knee replacement. Staff were directed to assist R32 to turn and reposition, pivot transfer and to assist with sit up and lay down in bed and get leg and feet in and out of bed. R32's care plan lacked any documentation related to a FMP with goals and interventions. During an interview on 4/29/26, registered nurse (RN)-B stated when a resident was started on an FMP the care plan for the resident should be updated. R32's care plan lacked any documentation of an FMP. During an interview on 4/29/26 at 4:07 p.m., the DON stated the FMP for a resident was ordered by PT and should be placed on the resident's care plan. R32's FMP lacked any documentation related to an FMP or ambulation. R66: R66's quarterly MDS dated [DATE], identified R66 required extensive assistance from staff for all activities of daily living (ADL's) and diagnoses included colostomy, diabetes, and Alzheimer's disease. R66's care plan dated 8/27/21, identified R66 was at risk for alteration in nutrition due to gastrostomy tube (g-Tube), tube feedings and not taking nutrition by mouth. The care plan did not address what PPE staff should wear with cares. On 4/29/26 at 10:00 a.m., registered nurse (RN)-C stated R66 was at risk for infection because of her g-tube and staff wore PPE including a gown and gloves during direct patient cares. During interview on 4/29/26 at 5:26 p.m., DON stated staff were instructed to wear a gown and gloves when providing direct cares for a resident with indwelling tubes including catheters and tube feedings. Direct care included anytime staff touched the residents and included emptying a catheter and repositioning residents in bed. The facility policy Quality of Care dated 10/2023, identified the facility would strive to ensure residents received treatment and care in accordance with professional standards of practice, their comprehensive care plan and their personal preferences. A policy for resident care plan was not received.

Based on observation, interview and document review, the facility failed to provide timely cares to dependent residents for 2 of 7 residents (R14, R18) who's activities of daily living cares were observed. Findings include: R14: R14's quarterly Minimum Data Set (MDS) dated [DATE], identified R14 had severe cognitive impairment and was dependent on staff for toileting. R14 diagnoses included dementia, edema, restlessness and agitation. R14's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 8/21/25, identified the CAA was triggered due to R14's needing extensive assistance with toileting and frequent incontinence of urine. Staff offer to assist R14 to the restroom or to use his urinal every 2-3 hours and as needed. R14 was at risk for alterations in skin, offensive body odor, falls and bladder infections. Complicated by history of falls, dementia, R14's care plan revised 4/29/26, identified R14 had an alteration in elimination related to dementia with cognitive losses, receiving diuretic, poor sequencing skills, history of retention of urine and constipation manifested by need for staff assistance with toileting, R14 was incontinent of bladder and bowel. Staff will check brief for incontinence q 2-3 hours and as needed, change brief as needed with incontinence. Provide total assistance of 1 staff to change brief. May require 2 staff to change brief at times. Provide total assistance of 1-2 staff to pull up/down pants and provide peri rectal care after elimination. A continuous observation of R14 was completed on 4/29/26 starting at 8:04 a.m., through 11:10 a.m. At 8:04 a.m. R14 was seated in his wheelchair and was pedaling himself with his feet up and down the hallway in front of the nurses' station. R14 was dressed and groomed for the day. R14 stated he didn't know if he had eaten breakfast yet and pointed at the other residents in the dining room through the dining room doors. [It was unknown what time R14 was placed in the wheelchair] At 8:40 a.m., nursing assistant (NA)-E stepped out of the dining room and told NA-F R14 still needed to eat breakfast. NA-F approached R14 and asked R14 if he was ready to eat breakfast, R14 nodded yes and NA-F wheeled R14 to his table in the dining room where NA-E assisted R14 to eat. At 8:51 a.m., R14 finished with his meal and was wheeled to the hallway in front of the nurses' station. R14 was not offered toileting. At 8:56 a.m., R14 began pulling himself down the hall using the handrail and his left hand while pedaling with his feet. staff including the director of nursing walked past R14 but did not greet or approach R14. At 9:01 a.m., R14 pulled himself along the handrail until R14 was blocked by the medication cart. Registered nurse (RN)-C assisted R14 to his room where RN-C applied a topical pain medication to R14's knees. RN-C asked R14 if he wanted to lie down and rest before the noon meal. R14 replied yes and smiled. RN-C provided R14 with his call light, tv remote, his overbed table then turned on R14's call light. RN-C then requested staff to assist R14 to lie down over the walkie. RN-C told R14 I'll go let someone know you're ready to lie down for a rest, ok? and exited the room. At 9:15 a.m., housekeeping was vacuuming the hallway carpet outside R14's room. R14 backed his wheelchair to the doorway and sat with this back to the hallway. At 9:32 a.m., RN-C walked past R14 sitting in his doorway and, again, asked for staff to lie R14 down over the walkie. A response was heard of the walkie that it would be a few minutes. At 9:38 a.m., R14 wheeled himself to sit in front of his tv. R14's call light was still on. At 9:41 a.m., activity aide (AA)-A entered R14's room and offered the sing-along activity for R14. AA-A wheeled R14 to the activity room. R14 was not offered toileting. AA-A did not turn off R14's call light. At 10:54 a.m., the sing-along activity was done and trained medication aide (TMA)-A obtained R14's blood pressure while he was seated in his wheelchair in the activity office. R13 approached TMA-A and asked if R14 was going to stay for exercises and that staff usually toileted R14 before the noon meal. TMA-A stated she would talk to the nursing assistants and find out. At 11:02 a.m., TMA-A returned with R14's medications with RN-C. R14 was given his medications and RN-C wheeled R14 to his room. At 11:06 a.m., RN-A entered R14's room with the full body mechanical lift. RN-A and RN-C transferred R14 into his bed and told R14 he could rest for a while. R14 was not offered nor placed on the commode to attempt to void. At 11:10 a.m., trained medication aide (TMA)-B entered R14's room and RN-A exited. RN-C and TMA-B changed R14's incontinence brief which was saturated with urine and provided perineal care. During an interview on 4/29/26 at 11:20 a.m., RN-C stated she did bring R14 to his room at 10:00 a.m. and asked for him to be toileted but R14 went to activities instead. RN-C nor TMA-B knew what time R14 had been previously toileted that morning and would have to ask the nursing assistants. RN-C stated R14 was due to a bowel movement that morning and had received a laxative. When the laxative kicked in, staff would place R14 on the commode. However, when R14 was already incontinent staff laid him down and provided incontinence care. R14 was not placed on the commode every time he was toileted because staff did not want to cause R14 agitation. At 11:33 a.m., TMA-B stated she asked the nursing assistants when R14 was last toileted. TMA-B stated she was told R14 had been assisted with morning cares by the night shift staff and had toileted before day shift started at 6:00 a.m. The night shift staff had not reported the time of R14's toileting so staff really had no idea. R14 should have been toileted at 9:00 a.m. at the latest because R14 was care planned to be toileted every 2-3 hours. We try our best. TMA-B stated every staff person kept track of toileting times differently. TMA-B used her care sheet and wrote down the times and whether the resident was incontinent or had voided. Then, at the end of her shift she entered those times into the electronic system. However, TMA-B could not say what other staff did. During an interview on 4/29/26 at 2:48 p.m., NA-G stated the previous shift reported the residents' last toileting time and staff just kept a mental note when they resident was due again. Yea, some staff did write it down on the care sheet but to each his own I guess. NA-G was able to keep it in his mind and kept track that way. During an interview on 4/29/26 at 2:51 p.m., licensed practical nurse (LPN)-A stated toileting times were given during shift report. For R14, staff should offer toileting every hour. During an interview on 4/29/26 at 2:54 p.m., RN-C stated she did speak with the nursing assistants to determine when R14 had been toileted that morning. R14 had been incontinent around midnight the night before and R14's morning cares were completed between 4:00 a.m. and 6:00 a.m. RN-C stated she did ask staff to toilet R14 at 10:00 a.m. and when RN-C saw it had not been done, she did it as observed. RN-C stated, if she had known R14 got up that morning between 4:00 a.m. and 6:00 a.m., RN-C would have expected R14 to be toileted between 6:00 a.m. and 7:00 a.m. to prevent skin breakdown. During an interview on 4/29/26 at 2:58 p.m., RN-A stated she did hear RN-C ask for R14 to be assisted with toileting over the walkie that morning. R14 should be toileted every 2-3 hours as care planned to prevent skin breakdown. RN-C stated there was no expectation on how staff tracked toileting times. Some staff wrote times on their care sheet, but others did not. Not keeping track could lead to prolonged toileting times which could lead to prolonged exposure to moisture and skin breakdown. If R14 was assisted with morning care between 4:00 a.m. and 6:00 a.m., R14 should have been toileted before 9:00 a.m. or earlier. During an interview on 4/29/26 at 3:31 p.m., the director of nursing (DON) stated R14 should have been toileted immediately after breakfast or within his care planned timeframe to prevent incontinence/skin breakdown and to lessen R14's behaviors/agitation. Additionally, staff should always offer R14 to sit on the commode even when R14 was incontinent as care planned. During an interview on 4/29/26 at 4:18 p.m., the assistant administrator stated staff were expected to follow the care plan as written and to document times and reapproach for refusals or resistance. R18: R18's five-day MDS dated [DATE], identified R18 had severe cognitive impairment and required maximum to total assistance with activities of daily living (ADLs). Diagnoses included dementia, kidney disease, cerebral infarction (stroke), anxiety and diabetes. R18's care plan dated 3/31/26, identified R18 had a self-care deficit with a goal to remain clean and free of odor daily. Staff were directed to comb R18's hair, brush his teeth and shave him. R18's Resident Care Sheet dated 4/22/26, directed staff in bold and capitalized text to shave daily, family request. During observation on 4/27/26, at 11:17 a.m. R18 was seated in his wheelchair in the Walnut Grove wing's television room. R18 had 1/4-inch grey whiskers scattered over his chin, cheeks, neck and below his nose. R18 was unable to recall if he had shaven that day. During observation on 4/28/26, at 10:38 a.m. R18 was seated in his wheelchair in the Walnut Grove wing's television room. R18 continued to have grey whiskers scattered over his face and neck and remained unshaven. During observation on 4/29/26, at 8:59 a.m. R18 was seated in his wheelchair in the hallway. R18's was clean shaven. When interviewed on 4/29/26, at 9:00 a.m. LPN-B stated she was not sure why the aides would not have shaved R18 on 4/27/26, or 4/28/26, but he was shaved today. There were different nursing assistants on then there were the other two days. R18 was supposed to be shaved every day. When interviewed on 4/29/26, at 9:53 a.m. RN-B stated R18 should be shaven daily. RN-B was not sure why R18 was not shaved the other two days. RN-B was aware R18's shaver battery was very low when he was shaved that morning, so perhaps that was the reason, but the goal was to shave him every day. R18 could have refused, however the point of care documentation did not indicate R18 refused care. During interview on 4/29/26, at 9:54 a.m. NA-B stated she was not sure why R18 was not shaved the previous two days, but he was shaven now. R18 was supposed to be shaven every day. Some of the younger NA's just did not notice or didn't know better. R18 never refused assistance with cares and always allowed them to assist hiem to shave daily without any problems. During interview on 4/29/26, at 4:36 p.m. the DON stated she would have expected staff to shave R18 as care planned or document why it could not be completed. The facility Quality of Care Policy reviewed 10/2023, identified based on the comprehensive assessment of a resident the facility strove to ensure residents received treatment and care in accordance with professional standards of practice, their comprehensive care plan and their personal preferences. The facility provides the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with State and Federal Regulations.

Based on observation, interview and document review, the facility failed to ensure residents received timely repositioning for 1 of 3 residents (R14) reviewed for pressure ulcers.Findings include:R14's quarterly Minimum Data Set (MDS) dated [DATE], identified R14 had severe cognitive impairment was dependent on staff for repositioning. Diagnoses included dementia, edema, restlessness and agitation. R14's Braden Scale (prediction for pressure ulcer scale) dated 2/13/26, identified R14 was a moderate risk for pressure injury/ulcer.R14's care plan revised 4/29/26, included an intervention to provide assist of one staff to turn and reposition every 2-3 hours.A continuous observation was conducted on 4/29/26 at starting at 8:04 a.m., R14 was seated in his wheelchair and was pedaling himself with his feet up and down the hallway in front of the nurses' station. R14 was dressed and groomed for the day. R14 stated he didn't know if he had eaten breakfast yet and pointed at the other residents in the dining room through the dining room doors. It was unknown when R14 was seated in his wheelchair.At 8:40 a.m., nursing assistant (NA)-E stepped out of the dining room and told NA-F R14 still needed to eat breakfast. NA-F approached R14 and asked R14 if he was ready to eat breakfast, R14 nodded yes and NA-F wheeled R14 to his table in the dining room where NA-E assisted R14 to eat.At 8:51 a.m., R14 finished with his meal and was wheeled to the hallway in front of the nurses' station. R14 was not offered repositioning.At 8:56 a.m., R14 began pulling himself down the hall using the handrail and his left hand while pedaling with his feet. Staff including the director of nursing walked past R14 but did not greet or approach R14. At 9:01 a.m., R14 pulled himself along the handrail until R14 was blocked by the medication cart. Registered nurse (RN)-C assisted R14 to his room where RN-C applied a topical pain medication to R14's knees. RN-C asked R14 if he wanted to lie down and rest before the noon meal. R14 replied yes and smiled. RN-C provided R14 with his call light, tv remote, his overbed table then turned on R14's call light. RN-C then requested staff to assist R14 to lie down over the walkie. RN-C told R14 I'll go let someone know you're ready to lie down for a rest, ok? and exited the room. RN-C did not offer to reposition R14.At 9:15 a.m., housekeeping was vacuuming the hallway carpet outside R14's room. R14 backed his wheelchair to the doorway and sat with this back to the hallway. At 9:32 a.m., RN-C walked past R14 sitting in his doorway and, again, asked for staff to lie R14 down over the walkie. A response was heard of the walkie that it would be a few minutes. At 9:38 a.m., R14 wheeled himself to sit in front of his tv. R14's call light was still on.At 9:41 a.m., activity aide (AA)-A entered R14's room and offered the sing-along activity for R14. AA-A wheeled R14 to the activity room. R14 was not offered toileting. AA-A did not turn off R14's call light.At 10:54 a.m., the sing-along activity was done and trained medication aide (TMA)-A obtained R14's blood pressure while he was seated in his wheelchair in the activity office. R13 approached TMA-A and asked if R14 was going to stay for exercises and that staff usually repositioned R14 before the noon meal. TMA-A stated she would talk to the nursing assistants and find out.At 11:02 a.m., TMA-A returned with R14's medications with RN-C. R14 was given his medications and RN-C wheeled R14 to his room.At 11:06 a.m., RN-A entered R14's room with the full body mechanical lift. RN-A and RN-C transferred R14 into his bed and told R14 he could rest for a while.At 11:10 a.m., trained medication aide (TMA)-B entered R14's room and RN-A exited. RN-C and TMA-B changed R14's incontinence brief which was saturated with urine and provided perineal care. R14's skin was pink, dry and intact.During an interview on 4/29/26 at 11:20 a.m., RN-C stated she did bring R14 to his room at 10:00 a.m. and asked for him to be toileted but R14 went to activities instead. RN-C nor TMA-B knew what time R14 had been previously repositioned that morning and would have to ask the nursing assistants.During an interview on 4/29/26 at 11:33 a.m., TMA-B stated she asked the nursing assistants when R14 was last repositioned. TMA-B was told R14 was assisted with morning cares by the night shift staff and had toileted before day shift started at 6:00 a.m. The night shift staff had not reported the time of R14's repositioning so staff really had no idea. R14 should have been repositioned at 9:00 a.m. at the latest because R14 was care planned to be repositioned every 2-3 hours. We try our best. TMA-B stated every staff person kept track of repositioning times differently. TMA-B used her care sheet and wrote down the times. Then, at the end of her shift she entered those times into the electronic system. However, TMA-B could not say what other staff did. During an interview on 4/29/26 at 2:48 p.m., NA-G stated the previous shift reported the residents' last repositioning time and staff just kept a mental note when they resident was due again. Some staff wrote it down, but not everyone. NA-G was able to keep it in his mind and kept track that way. During an interview on 4/29/26 at 2:51 p.m., licensed practical nurse (LPN)-A stated repositioning times were given during shift report. For R14, staff should offer repositioning every hour. During an interview on 4/29/26 at 2:54 p.m., RN-C stated she did speak with the nursing assistants to determine when R14 had been repositioned that morning. R14's morning cares were completed between 4:00 a.m. and 6:00 a.m. RN-C stated she did ask staff to toilet R14 at 10:00 a.m. and when RN-C saw it had not been done. RN-C stated, if she had known R14 got up that morning between 4:00 a.m. and 6:00 a.m., RN-C would have expected R14 to be repositioned between 6:00 a.m. and 7:00 a.m. to prevent skin breakdown.During an interview on 4/29/26 at 2:58 p.m., RN-A stated she did hear RN-C ask for R14 to be assisted with toileting over the walkie that morning. R14 should be repositioned every 2-3 hours as care planned to prevent skin breakdown. RN-C stated there was no expectation of how staff tracked times. Some staff wrote times on their care sheet, but others did not. Not keeping track could lead to prolonged repositioning times which could lead to skin breakdown. If R14 was assisted with morning care between 4:00 a.m. and 6:00 a.m., R14 should have been repositioned before 9:00 a.m. or earlier. That is a large time span and, because it wasn't kept track of, staff don't know.During an interview on 4/29/26 at 3:31 p.m., the director of nursing (DON) stated R14 should have been repositioned immediately after breakfast or within his care planned timeframe to prevent skin breakdown and to lessen R14's behaviors/agitation.During an interview on 4/29/26 at 4:18 p.m., the assistant administrator stated staff were expected to follow the care plan as written and to document times and reapproach for refusals or resistance. The facility policy Skin Care reviewed 6/2023, identified staff would ensure proper identification of residents at risk for skin breakdown, prevention of development of pressure ulcers, and determining appropriate treatment of pressure ulcers and/or impaired skin for residents. Care plans will be individualized to address resident specific needs.

Based on interview and document review, the facility failed to ensure a stop date for medication was confirmed by the primary care provider for temporary medications that required an end date for 1 of 6 residents (R12) reviewed for medication management.Findings include:R12's five-day Minimum Data Set (MDS) dated [DATE], identified R12 had intact cognition. R12 received injectable medication for all seven days of the observation period and received anticoagulant medication. A complete drug regimen review was completed, and no potentially clinically significant medication issues were noted. Diagnoses included diabetes, fracture of the right femur, altered mental status, calculus of the kidney, hydronephrosis and metabolic encephalopathy.R12's Interagency Transfer Orders dated 4/15/26, identified an order for enoxaparin (a blood thinner) 40 milligram (mg) syringe, inject 0.4 millimeters (ml) under the skin every night to prevent deep vein thrombosis for diagnosis of total right hip arthroplasty. The quantity listed 13.6 ml with no refills. R12's Medication Administration Record (MAR) for April 2026, identified enoxaparin syringe 40 mg/0.4 ml: subcutaneous (SQ) at bedtime for fracture of right femur. Start/End date 4/15/26 to 5/18/26. Special Instructions were listed as RX for 13.6 ml/ 0.4 ml per dose=34 doses total. The medication was recorded as administered as ordered starting 4/15/26. When interviewed on 4/28/26, at 4:13 p.m. licensed practical nurse (LPN)-C stated the pharmacy had filled the enoxaparin in 40 mg / 0.4 ml prefilled single use syringes. Nursing staff administered the one prefilled syringe every evening. LPN-A was unsure what the special instructions on P12's MAR meant. During interview on 4/28/26, at 4:36 p.m. registered nurse (RN)-B stated the special instructions were to demonstrate how the end date of the medication was determined. The medication was filled for 13.6 ml quantity with no refills, so she did the math, versus contacting the medical provider, to determine 34 doses were ordered and figured out the end date from there. RN-B stated she had not contacted R12's primary care provider to verify the stop date of the medication and no verbal order had been obtained to stop the medication. During telephone interview on 4/29/26, at 9:06 a.m. the consulting pharmacist (CP)-D stated if a medication required an end date, either the pharmacist would call the provider to obtain it or nursing would do it. The quantity of medication with no refills could mean that the med should be stopped when ran out of medication, but not always. CP-D thought she would probably just check with the provider to make sure. It was better to double check with the provider rather than just assume. When interviewed on 4/29/26, at 4:27 p.m. the director of nursing (DON) stated usually medication orders such as enoxaparin had a stop date, especially when discharging from the hospital. She would expect staff to reach out to the provider to notify of the need for an end date to the enoxaparin and verification the dose was completed when the medication was gone. No refills on a medication did not always mean to discontinue the medication and needed to be verified by the primary care provider. The facility policy Pharmacy Services dated 10/2022, identified prescription medications were dispensed only upon receipt of clear, complete, and signed orders of a person lawfully authorized to prescribe. Any dose or order that appeared inappropriate, considering the resident's age, allergies, diagnosis or current medication regimen would be verified with the prescriber.

Based on observation, interview and document review, the facility failed to ensure food was prepared and served to meet resident needs for 1 of 2 residents (R12) reviewed for nutrition. Findings include:R12's Speech Therapy Daily Note dated 3/16/25, recommended general precautions to include resident seated at 90 degrees for all oral intake, one to one assist to follow safe swallow strategies of small bites/sips, slow rate, alternate bites/sips and only feed resident when she is alert. R12's five-day Minimum Data Set (MDS) dated [DATE], identified R12 had intact cognition and required set up assistance with eating. R12's care plan dated 4/27/26, identified a potential for alteration in nutrition with a goal to maintain independence with eating after set up. Staff were directed to assist to setup meals as needed. R12 should be sitting upright as close to 90 degrees as possible when eating in bed. Staff were to encourage R12 to sit up in wheelchair with eating. R12's Physician Orders with print date 4/29/26, identified a dietary order 4/15/26, for a heart healthy/cardiac diet. Special instructions included to cut food into small bite size pieces, resident to sit at 90 degrees for all intake, slow rate of intake, small bites/sips, alternate bites/sips, assist of one and to only feed when alert. R12's Dietary Menu card,Tuesday dinner dated 4/28/26, identified a heart healthy diet and to cut P12's food into bite sized pieces. During observation on 4/28/26, at 12:19 p.m. R12 was in bed in her room, watching television and eating her lunch. R12's lunch tray was on her bedside table over her bed and R12 was in a semi upright position in bed, with the head of the bed raised to an approximately 75-degree angle. R12's lunch consisted of a half of a submarine sandwich on a white hoagie roll with lunch meat and cheese. Three large pieces of lettuce and a large slice of tomato was also on the plate. R12 had the half-consumed sandwich in her hand and was taking bites from it. No one was in the room with R12 as she ate. During interview on 4/28/26, at 12:28 p.m. trained medical assistant (TMA)-A entered R12's room and stated R12 was not positioned at a 90-degree angle as ordered and TMA-A stated she was not aware R12 had orders for her food to be cut into bite size pieces. TMA-A knew R12 had eaten a full sweet roll the day prior that had not been cut up for her. R12 should be seated at a 90-degree angle and food cut up in bite size pieces if that was what was ordered, as it would have been ordered to assist R12 to eat safely and prevent choking. TMA-A thought the order stemmed from when R12 had been more acutely ill and less alert. When interviewed on 4/28/26, at 12:33 a.m. nursing assistant (NA)-A stated the nurse aide care plan did identify R12's food was to be cut into bite size pieces but did not direct staff to ensure R12 was at a 90-degree angle to eat. NA-A stated R12's head of bed was elevated but was not fully at a 90-degree angle. NA-A stated usually the dietary staff was responsible to make sure resident food was cut up as ordered but if it wasn't, then the NA's should be doing it, kind of like a second check. During interview on 4/28/26, at 12:44 p.m. dietary aide (DA)-A stated dietary staff were supposed to cut up resident food when it was ordered, but if it wasn't, then the NA's should do it. DA-A felt sure she had cut up R12's sandwich into bite size pieces and thought maybe the NAs had given her the wrong tray instead, but she could not be entirely sure of that. DA-A stated R12's dietary slip identified her food needed to be cut up in small bite size pieces. During interview on 4/28/26, at 12:52 p.m. registered nurse (RN)-B stated it was not an official order to keep R12's diet as small bite size pieces and to be seated at a 90-degree angle when eating. RN-A left those special instructions on her chart as an additional note and R12's family had requested that as well. RN-A felt it was important to keep the special instructions listed when R12 had returned from the hospital on 4/15/26, but now R12's diet may need to be re-evaluated as she has improved since her return. The facility policy Diet Orders dated 2/2025, identified all meals provided to residents would have a written physician order. No further information was received.

Based on observation, interview and document review the facility failed to ensure staff wore the appropriate personal protective equipment (PPE) according to CDC guidelines during direct cares for 2 of 4 residents (R25, R66) reviewed who were on enhanced barrier precautions.Findings include:R25R25's annual Minimum Data Set (MDS) dated [DATE], identified R25 had an indwelling Foley catheter and was dependent on staff for activities of daily living (ADL's) including catheter care. R25's had a diagnosis of renal insufficiency.R25's care plan dated 3/6/25, identified R25 was at risk for infection due to his indwelling catheter and staff were to wear PPE, including gown and gloves, when caring for R25.On 4/27/26 at 1:45 p.m., nursing assistant (NA)-C exited R25's bathroom wearing gloves and was holding a urine collection graduate. NA-C bent down next to R25 and drained urine from the catheter drainage bag into the graduate. NA-C stood, walked into the bathroom and emptied the urine into the toilet. NA-C failed to wear a gown during catheter cares. During interview, NA-C stated when he emptied a resident's catheter, he always wore gloves and if there was a risk of infection then he would also wear a gown. NA-C stated he had worn gloves but not a gown when he emptied R25's catheter. NA-C stated there was a risk of splashing urine onto his clothes and potentially spreading bacteria to another resident. NA-C stated he should have worn a gown with R25's catheter cares.R66R66's quarterly Minimum Data Set (MDS) dated [DATE], identified R66 required extensive assistance from staff for all activities of daily living (ADL's) and diagnoses included colostomy, diabetes, and Alzheimer's disease.R66's care plan dated 8/27/21, identified R66 was at risk for alteration in nutrition due to gastric tube, tube feedings and not taking nutrition by mouth. The care plan did not address what PPE staff should where with cares. On 4/29/26 at 10:00 a.m., registered nurse (RN)-C was at R66's bedside and administering medication through the resident's gastrostomy tube (G-tube). Nursing assistant (NA)-D entered the room, put on a pair of gloves and walked to the resident's bedside. RN-C and NA-D were on either side of the bed. RN-C was wearing a gown and gloves. NA-D was wearing gloves, however, was not wearing a gown. R66's bed was thigh-height, and the resident was lying in bed with a lift sheet behind her hips and back, and her legs were resting on pillows behind her calves. RN-C and NA-D leaned over the bed and used the lift sheet to scoot the resident up towards the top of the bed. RN-C and NA-D walked to the foot of the bed and lifted and repositioned the pillows behind R66's lower legs. NA-D walked into the bathroom, removed her gloves, washed her hands and then exited the room. RN-C stated R66 was at risk for infection because of her g-tube and NA-D should have worn a gown and gloves while assisting with direct care.During interview on 4/29/26 at 10:35 a.m., NA-D stated she usually wears a gown when caring for residents with any type of tubes including g-tubes, although forgot to put on a gown when she repositioned R66. NA-D stated wearing a gown was important to prevent bringing in and spreading bacteria to R66, as well as to help prevent spreading bacteria to/from other residents.During interview on 4/29/26 at 5:26 p.m., director of nursing (DON) stated staff should wear a gown and gloves when providing direct cares for a resident with indwelling tubes including catheters and tube feedings. Direct care included anytime staff touched the residents and included emptying a catheter and repositioning residents in bed.The facility Enhanced Barrier Precautions policy dated 3/26, identified EBP expanded the use of PPE and referred to the use of gown and gloves during high-contact resident care activities that provided opportunities for transfer of multidrug-resistant organism (MDRO)'s to staff hands and clothing. MDRO's may indirectly be transferred from resident to resident during high contact care activities. Resident with wounds and indwelling medical devices are at an especially high risk of both acquisition of and colonization with MDRO's. The policy further identified EBP would be implemented for residents with wounds and/or indwelling medical devices during high-contact resident care activities regardless of MDRO infection or colonization. High risk care activities included device care or use.

Based on observation, interview and document review, the facility failed to ensure a report of missing personal property was followed up on for 1 of 3 residents (R14) reviewed for resident rights.Findings include:R14's quarterly Minimum Data Set (MDS) dated [DATE], identified R14 had severe cognitive impairment. Diagnoses included dementia, edema, restlessness and agitation. R14 required set up/clean up assistance with eating, maximal/substantial assistance with dressing, bathing and personal hygiene and was dependent on staff with toileting and putting on and taking off footwear. During an interview on 4/28/26 at 6:09 p.m., family member (FM)-A stated R14's wedding ring went missing a few months ago. FM-A reported the missing wedding ring to the nursing assistants, the cart nurses, registered nurse (RN)-A who was the unit manager and the previous director of nursing (DON) who was no longer at the facility. FM-A stated she was simply told no staff had seen the ring. After the wedding ring was missing for a week, FM-A reported the missing ring to the police. FM-A had received no further information about the missing ring. FM-A stated she was concerned a staff member had taken the ring and the facility was not investigating the concern. During an interview on 4/29/26 at 3:22 p.m., trained medication aide (TMA)-B stated she had heard something about R14 was missing a wedding ring a few months prior but really didn't recall anything else about it. During an interview on 4/29/26 at 3:22 p.m., RN-A stated she didn't recall anyone reporting R14 had a missing wedding ring.During an interview on 4/29/26 at 3:25 p.m., RN-C stated she was unaware of R14's missing wedding ring. Any missing item should be documented in a progress note, and it should be documented on the report sheet in the binder at the desk. The report sheet was kept in the binder for two weeks and then the report sheets were filed away by the director of nursing (DON). Then, an investigation would be done to try to find the missing item: laundry, housekeeping and nursing staff would be told to look for the item and be aware that it was missing.R14's medical record failed to identify R14 was missing a wedding ring.R14's Missing Item form was requested but not received. During an interview on 4/29/26 at 3:27 p.m., the social services (SS)-A stated she was unaware R14 was missing a wedding ring and there was no missing item report completed.During an interview on 4/29/26 at 3:28 p.m., licensed practical nurse (LPN)-A stated she didn't know anything about R14 missing a wedding ring. When a resident was admitted , staff really encouraged family to swap out any expensive or meaningful jewelry like a wedding for another ring, so the resident was still able to wear a ring but the likelihood of getting lost was not there. Staff report to social services and then an investigation was done to look in the room etc. During an interview on 4/29/26 at 3:31 p.m., the DON stated she was unaware R14 was missing a wedding ring. Staff were expected to complete a missing item report and, if possible, the resident was interviewed to determine when the item was last seen. Laundry, housekeeping, activities and nursing staff were informed to look for the item, and, on certain items, a police report may be filed. The DON stated she honestly did not know if a report had been filed for R14's missing ring because she was unaware it was missing. At 5:25 p.m., the DON stated R14's wedding ring had been found. It was found in laundry back in December 2025 and kept in the safe until 4/29/26 when the SA began asking about it. Staff did not complete a missing item report. The DON stated she expected staff to follow the procedure for a missing item and to report the concern to ensure all were aware of the missing item. If staff had been aware of R14's missing wedding ring, they would have known who the found wedding ring belonged to and R14 would have gotten it back sooner. The facility.The facility Missing Items Report revised 11/18/18, included information for staff to collect and identified the following: the resident's name, date, description of item(s) missing, date/time last seen, date/time noticed missing, thinks misplaced details, thinks taken and, if so, by whom, who it was reported to and who reported the missing item(s). Staff were instructed to complete the form immediately and give the report to the unit manager. The unit manager would search probably places immediately and list the employee(s) assigned to search. If the item was not found, family would be contacted. If the family was unaware of the item(s) location, the item was to be treated as a misappropriated item and reported to law enforcement and the state agency (SA).

Based on observation, interview and document review the facility failed to ensure 1 of 3 residents reviewed for safety from hot liquids was free from burns. This resulted in actual harm to R1 who spilled hot coffee on his lap and sustained a second-degree burn. In addition, the facility failed to implement a system to assess residents for safety with hot liquids.Findings include:R1's Resident Face Sheet indicated he admitted to the facility 7/21/23. R1's diagnosis included dementia, aspiration pneumonia, dysphagia (difficulty swallowing) and insomnia. R1's quarterly Minimum Data Set, dated [DATE], identified severe cognitive impairment and indicated he required set up or clean up assistance to eat.R1's care plan dated 1/11/26, identified a selfcare deficit related to dementia, poor coordination and weakness. The care plan identified a potential for alteration in nutrition and directed staff to assist with set up for meals. The care plan indicated R1 was independent with eating but required supervision and cueing at times.R1's nursing assistant care guide dated 12/26/25, indicated covered mug with cooled coffee only, no styrofoam cups. R1's Event Report dated 12/28/25, indicated a burn with moderate pain. Activity during occurrence indicated he had been drinking coffee.R1's Progress Notes indicated the following:11/7/25 at10:26 a.m., R1 had a burn on his left foot after spilling coffee on himself. 11/7/25 at 12:14 p.m., Assessed R1's left foot after spilling coffee on himself in the morning. Minimal to no redness at this time.12/17/25, New speech recommendation. Regular diet. R1 to be supervised, cue and possibly assist at meals as he was having a more difficult time with self-feeding.12/28/25, 5:36 a.m., Staff was called to R1's room and notified he had been drinking a cup of coffee and spilled on himself. R1's shirt removed and he had a large area to left side of his body, including his forearm that was bright red. Three inch x three inch area of skin was peeling. R1 would not let writer touch areas. 12/28/25 at 8:03 a.m., Staff reported R1 had spilled coffee on his left forearm and abdomen. Pain medication had been administered and cold pack applied to areas. Upon assessment there was redness to forearm and abdomen with an area of peeling skin to his abdomen. Treatment completed with minor discomfort. Monitoring of burn implemented. 12/29/25, Nurse Practitioner (NP) assessed burn. Orders to start Bacitracin and monitor for secondary infection.R1's Physician Progress Note dated 12/31/25, indicated R1 was seen due to a burn that occurred on 12/28/25, due to hot coffee. The left abdomen and forearm were burned. R1 seemed to have some discomfort of the left forearm. Second degree burn on left abdomen with open blistering area. First to second degree burn on left forearm, skin intact. During observation on 1/16/26 at 8:01 a.m., R1 was seated in his room in a wheelchair. When spoken to, R1 answered non-sensically. During observation and interview on 1/16/26 at 8:03 a.m., the dietary manager (DM) said early morning coffee was probably made by staff in the activity kitchen because the main kitchen was closed and locked. The DM made a pot of coffee using the pot in the activity kitchen and temped the coffee. The coffee temperature in the cup was 170 degrees Fahrenheit. On the counter in the kitchen were several coffee cups with lids and a small package of syrofoam cups. During interview on 1/16/26 at 8:32 a.m., nursing assistant (NA)-A stated several residents liked to have coffee early in the morning. When asked how staff knew who required a lid, NA-A said she would ask the charge nurse or other staff. NA-A said, there should have been a list in the kitchen.During interview on 1/16/26 at 9:02 a.m., the director of nursing (DON) confirmed the overnight staff used the activity kitchen to make coffee for the residents. During interview on 1/16/26 at 10:34 a.m., the administrator stated the facility did not have a policy related to safe serving temperatures for hot liquids.On 1/16/26 at 10:42 a.m., NA-B and NA-C were interviewed. NA-B said she gave everyone a lid when serving hot beverages. NA-C said if someone required a lid, it should have been in the care plan. NA-C said R1 was a little shaky at times and said he could pick stuff up but did not have good dexterity. During interview on 1/16/26 at 10:48 a.m., The DON stated they had gotten rid of the styrofoam cups for all the residents. The DON said they now used a handled cup with a lid instead of trying to determine who could use styrofoam and who could not. The DON said the facility did not have an assessment tool to determine who was safe to have hot liquids. In regard to R1's burn, the DON said the skin peeled immediately then blistered.During interview on 1/16/26 at 12:13 p.m., the chemical and beverage technician form the company that leased the coffee pot said the coffee needed to be brewed at a certain temperature for sterilization and palatability. The technician said the temperature had to be at least 180 degrees Fahrenheit to kill germs and said they recommended 195 - 200 degrees for brewing. He said they recommended bringing the temperature down to 150 degrees for service.During interview on 1/16/26 at 12:40 p.m., NA-D stated she had served R1 his coffee the morning he had been burned. NA-D said she had not been aware R1 required a specific cup and said no handled cups had been available. NA-D stated R1's care sheet had reflected no styrofoam cups, but she had not seen it. NA-D said she would not have known how to check the temperature of the coffee but at times she had cooled coffee by putting some cold water in it.During interview on 1/16/26 at 12:35 a.m., NA-E said there was only one resident she was aware of aside from R1 who used a cup with a lid. NA-E said if she had to cool coffee, she would add a little bit of cold water or ice. NA-E said there were several residents with dementia that drank coffee but none had been identified as needing the coffee cooled before serving.

Based on interview and document review, the facility failed to ensure the correct administration of insulin per physician orders for 1 of 3 residents (R1) who received 20 units of Novolog (rapid acting used to lower blood sugar levels onset in 15 minutes) instead of the physician ordered Lantus (long-acting onset 3 to 4 hours and duration of 24 hours). Findings included: R1's annual Minimum Data Set (MDS) dated [DATE], identified intact cognition with no behaviors. Her diagnoses include diabetes mellitus (DM) and received insulin injections 7 out of 7 days a week. R1's care plan dated 9/18/25, identified a potential for alteration in nutrition related to obesity, diabetes, and chronic pain. Staff were directed to offer snacks two times a day. Medicate as ordered. Follow diabetic protocols. Monitor continuous glucose monitoring (CGM) as ordered. Monitor for signs and symptoms of hypoglycemia/hyperglycemia (low blood/high blood sugars). R1's physician orders identified: -Start date 3/21/25, bedside glucose monitoring to be performed four times a day; call primary care provider or family provider if blood sugars (BS) are greater than 300 or less than 60 at 7:00 a.m., 12:00 p.m., 5:00 p.m. and 8:00 p.m. -Start date 3/21/25, Novolog (lowers blood glucose levels quickly after meals, typically starting to work within 5 to 10 minutes after injection, with a maximum effect after 1 to 3 hours, and a duration of action of 3 to 5 hours) U-100 insulin solution; 100 units/milliliter (ml) amount per sliding scale, if BS less than 70 call medical doctor. Blood sugar 200 to 250, give 2 units, if BS 251 to 300; give 4 units. If BS 301 to 350; 6 units. If BS 351 to 400; give 10 units. If BS greater than 400 all MD. Three times a day; 8:00 a.m., 12:00 p.m., 5:00 p.m. -Start date 4/1/25, Novolog U-100 insulin solution 100 unit/ml; amount 4 units subcutaneously (SQ) with meals; 8:00 a.m., 12:00 p.m. and 5:00 p.m. Special instructions: hold insulin if eats less than 25% of meal. -Start date 9/24/25, Lantus (long-acting insulin works over a 24-hour period to provide a steady, continuous release of insulin, helping to keep BS levels consistent between meals and overnight) U-100 insulin solution 100 unit/ml; amount 20 units; subcutaneously (SQ) at bedtime 8:00 p.m. R1's Electronic Medication Administration Record (EMAR) on October 16th, 2025, identified: -Lantus Units (U)-100 insulin solution; 100 units/milliliters (ml) administer 20 units subcutaneous (SQ) at bedtime. At 8:00 p.m. Documented as not administered by RN-A --Novolog U-100 insulin Rapid acting insulin; 100 U/ml administer 4 units SQ with meals and hold if eats less than 25 % of meal. BS 129 milligrams per deciliter (mg/dl) prior to meal and she ate 75% of supper. RN-A Charted late at 6:43 p.m. administered 4 U. -Novolog U-100 insulin per sliding scale; at 4:50 p.m. not administered BS 129 mg/dl. R1's progress notes from 10/16/25 through 10/17/25, identified: -on 10/16/25 at 9:26 p.m., R1 was given her short acting insulin at 8:37 p.m. when noted by writer immediately called DON and the on call for family practice. While she waited for the on-call writer called the ambulance for transport . sent to emergency room (ER) for evaluation and treatment. -on 10/16/25 at 12:38 a.m., writer called ER department and was notified she was given carbohydrates along with fluids. Last two blood sugars obtained were stable. While in ER, chest x-ray was completed for her wet, productive cough and diagnosed with pneumonia and placed on antibiotics. -on 10/17/25 at 4:32 a.m., ambulance transported R1 back to facility. R1's BS record on 10/16/25, identified: -documented at 4:49 p.m. 129 mg/dL -documented at 9:42 p.m. 182 mg/dL R1's Emergency Department (ED) visit dated 10/16/25 at 9:20 p.m. through 10/17/25 4:20 a.m., identified clinical impressions hypoglycemic (low blood sugar) reaction to insulin type 2 diabetes mellitus (DM), insulin overdose, accidental or unintentional, initial encounter, conjunctivitis of left eye, bronchitis, and bronchial pneumonia.- on 10/16/25 at 9:31 p.m., BS 127 mg/dl -on 10/16/25 at 10:13 p.m., glucose dropped despite having eaten. Will give some dextrose and continue to monitor closely. Neurological status remains intact. -on 10/16/25 at 10:15 p.m., dextrose 10% intravenous (IV) solution 250 milliliters (ml), glucagon injection 1mg vial, and glucose chewable tablet 16 grams (g) administered. -on 10/16/25 at 10:20 p.m., BS 89 mg/dl -on 10/16/25 at 11:14 p.m., BS 134 mg/dl -on 10/17/25 at 12:22 a.m., BS 141 mg/dl -on 10/17/25 at 12:23 a.m., Should have passed the peak effects of insulin she was given. Will check one more to ensure stability. -on 10/17/25 at 1:16 a.m., BS 173 mg/dl -on 10/17/25 at 1:18 am., Glucose has stabilized. Passed the peak effects of the insulin. At this time will discharge back to care center with new treatment for pneumonia and conjunctivitis as well. -on 10/17/25 at 4:15 a.m., BS 136 mg/dl. discharged from ED at 4:20 p.m. back to care center. Medication Error Report dated 10/16/25 at 9:00 p.m., R1 was given short acting insulin 20 units instead of Lantus 20 units by RN-A. R1 was sent to ER, no negative outcome. Plan to correct the problem: double check insulin prior to administration by another staff. During an interview on 10/21/25 at 11:15 a.m., RN-A stated on 10/16/25 just after 8:30 p.m., R1's blood sugar was 182 ml/dl. Other residents and a staff asked questions while RN-A attempted to draw up R1's insulin at the medication cart. RN-A became distracted. She entered the insulin expiration date and site where it would be administered into the EMAR and administered the insulin. RN-A returned to the medication cart, realized she had picked up the wrong insulin vial and administered 20 units of the wrong type of insulin (fast acting versus long acting). RN-A was aware R1's BS would drop quickly and could have gone into a coma. RN-A immediately called DON, checked for an order of glucagon (an injectable medication used in an emergency to raise blood sugars) but order stated should only be given for blood sugars below 70. RN-A called the on-call provider, waited 15 minutes, then called the on-call back and was informed it would be another 30 minutes before they called her back. RN-A called an ambulance to get emergency medical technician (EMT) on site. The EMTs arrived the same time the provider called back. R1's BS was not checked again prior to the EMT arrival, RN-A prepared transfer paperwork to send R1 to the hospital for evaluation. RN-A stated she had made a horrible medication mistake, knew it could happen, became distracted, and was an accident. During an interview on 10/21/25 at 1:55 p.m., RN-B stated the nurse was expected to follow the rights of medication administration when preparing insulin. The staff nurse would be expected to contact provider, charge nurse, DON, and administrator if a significant medication error occurred. The nurse would be expected to have completed a full assessment, check blood sugars and if low follow facility protocol for use of glucagon from the E-Kit, call 911, and possibly have them transferred to ER. During an interview on 10/21/25 at 2:09 p.m., R1 stated she had diabetes and received insulin injections for quite a while now. Last week the staff nurse gave her a large dose of the wrong insulin (fast acting) and should have been the long acting, was taken to emergency room (ER), stayed overnight to be monitored closer. R1 stated received intravenous fluids, sweet foods/drink such as apple juice, four graham crackers, cookies, and rice krispie bar after her blood sugar started to drop down. She returned to the facility around 5:30 a.m. the following day. During an interview on 10/21/25 at 3:10 p.m., DON stated RN-A worked as the treatment nurse on 10/16/25. DON was contacted by RN-A between 8:30 p.m. and 9:00 p.m. regarding a significant medication error. R1 had received 20 units of the wrong type of insulin, Novolog instead of Lantus as ordered. RN-A was instructed to call the on-call provider, monitor blood sugars, watch for symptoms of hypoglycemia (low blood sugars), and stay with R1 until EMTs arrived. RN-A stated to DON, she was scared so called EMT for assistance, and stayed with R1. DON was unsure if RN-A rechecked the BS as instructed. The root cause analysis identified the cause of the medication error was lack of communication between the two nurses working that evening, distraction, lack of the rights of medication administration and EMAR/orders were not followed. The following morning, DON discussed the medication error with RN-A on the telephone and how to proceed going forward. The rights of medication administration would be expected to be followed, vital signs and blood sugars should have been monitored, improved communication among nurses, and to limit distractions. RN-A was allowed to work the weekend, and a plan was created to have a second nurse check all RN-A's insulin doses prior to administration. RN-A was also instructed, when distracted during medication preparation move the cart and relocate to a different location to help prevent medication errors, required further re-education now, ongoing, and disciplinary action. During an interview on 10/22/25 at 12:37 p.m., assistant administrator stated she was contacted on 10/16/25 at 8:53 p.m., by RN-A regarding a medication error. RN-A informed her she was about to prepare R1's insulin, was interrupted, grabbed the wrong insulin (short acting versus long acting), had not realized it until after it was administered. DON and provider were contacted with a significant amount of time without a call back. RN-A called 911. Assistant administrator stated our investigation identified the root cause of the medication error was distraction. R1 was not harmed and could have possible been treated here at the facility. Facility Standards of Care and Protocols for Diabetes Management dated 3/2013, identified report hypoglycemia incident to physician. Call if less than 80. Facility policy Administering Medications dated 12/2023, identified all RN's, LPNs, and TMAs employed at the facility will be trained to do the medication passes according to industry standards. Conversations or other distractions should be avoided while preparing medications. The labels of all medicine bottles and cards will be neat and legible. The nurse may never re-label a medication. It must be sent to pharmacy or a new label brought in by the pharmacist and applied by them. Injectable medications will be administered according to facility policy for safe injection practices and by only a licensed nursing staff. TMAs cannot administer injectable medications. High risk medications: a list of high-risk medications will be available at each nurse's station and on each medication cart. The identity of medication will be verified three times with the MAR, when taking the container from the cart, as preparing it, and before replacing it in the cart. Facility policy Insulin Administration - Pen identified verification of the insulin medication/prescription (RX) label matches the medication administration record (MAR): right resident, medication, dose, dosage form, frequency and route.

Based on observation, interview and document review, the facility failed to ensure medications were secured at all times in 1 of 3 medication carts used. This had the potential to affect 20 residents whose medications were stored in medication cart. Additionally, the facility failed to ensure medication was labeled with clear and unaltered administration instructions to prevent potential error for 1 of 3 residents (R4) observed to receive medication.Findings include:R4's admission Minimum Data Set (MDS) dated [DATE], diagnosis: multiple sclerosis (MS) (a chronic autoimmune disease affects the central nervous system damaging the protective covering of nerve fibers with symptoms of muscle weakness, spasms or stiffness, and problems with balance and coordination). R4's provider order dated 9/6/25, identified: -Baclofen (muscle relaxant) tablet 20 milligrams (mg); amount 1 1/2 tabs (30mg); oral twice a day 7:00 a.m. and 9:00 p.m. -Baclofen tablet 20 mg 1 tablet oral twice a day 12:00 p.m. and 5:00 p.m. Special instructions: please wake resident to give this medication if she is sleeping. She needs it. During an observation/interview on 10/21/25 at 8:20 am., medication cart was in the hallway of Walnut Grove, no staff were seen in the hallway. The computer screen was left open with R4's identifying information readable, medication cart unlocked, a small plastic cup 1/2 full of clear liquid with tongue blade in it, and 3 white pills in a medication cup were located on top of the cart. At 8:25 am., an unidentified resident pushed herself down the hallway in a wheelchair past the medication cart. At 8:30 a.m., trained medication assistant (TMA)-A opened R4's room door located rooms away from the medication cart and walked out into the hallway to the medication cart. TMA-A stated staff had requested assistance with a total lift for R4. She moved the medication cart closer to R4's room, left the computer screen open, cart unlocked with R4's medications left on top of the cart, unattended and was in R4's room for approximately five minutes. She verified the clear liquid in the cup was MiraLAX (laxative) prepared with water and the three white pills were Baclofen (muscle relaxant) 10mg each. TMA-A stated she was running late with the medications and was in a hurry. TMA-A stated this was not good practice and would have been expected to have locked the medication cart and computer screen, with all medications placed inside the cart prior to walking away. During an interview on 10/21/25 at 1:55 p.m., RN-B stated nursing staff were expected to protect all resident personal health information by locking the computer screen prior to leaving the area. A violation of Health Insurance Portability and Accountability Act (HIPPA) would mean that anyone walking by an open computer would have access to personal information. Medication cart should be locked and no mediations left on top when unattended. Anyone could have grabbed them, and it would be a safety hazard (syringes, oral/injectable medications). During a follow up interview on 10/22/25 at 10:45 a.m., TMA-A searched the medication cart and unable to locate R4's Baclofen 30 mg pills (labeled bottle on top 2) she had administered yesterday. She located one bottle of Baclofen label information included: R4's name, Baclofen 10 mg tablets, bottled filled on 6/9/25 by local pharmacy, instructions take 2 tablets by mouth (po) 8:00 a.m., 2 tablets at 12:00 p.m., 2 tablets at 4:00 p.m., and 3 tablets at 8:00 p.m. Handwritten on the bottle with a black marker, direction change refer to electronic medication administration record (EMAR) BAC 1 of 2. She verified the label was wrong. Yesterday she placed three pills into a pill cup, and a staff nurse split two of them in 1/2. The three half pills went back into the container so that they could be given later. She was unaware she had administered R4 the wrong doses of Baclofen yesterday and today until now and considered medication errors. Staff were expected to have placed an orange sticker on the medication bottle direction change refer to EMAR. She verified there was not an orange sticker on the bottle. She had been off work for 6 weeks and just returned yesterday. TMA-A verified located in the Baclofen pill bottle label 2 on top (10 mg tablets) were 73 whole pills and 5 half pills. She stated there had to be other staff that had made medication errors on this same medication, yesterday she had placed 3 half pills back into the medication bottle and now there were five. The pills were 10 mg each and there would be no reason to cut them in half. At 11:07 a.m. TMA-A placed an orange-colored label direction sticker printed, DIRECTIONS CHANGED REFER TO CHART, over the written directions on the pill bottle and back into the located medication cart. She notified the staff nurse and requested the half pills be destroyed, reported to the DON, a mediation error filed, to avoid further errors. During an interview on 10/22/25 at 11:46 a.m. director of nursing (DON) verified R4's Baclofen dose was increased on 8/28/25 to 30 mg twice a day 7:00 a.m. and 9:00 p.m. and the other dose remained the same 20 mg twice a day at 12:00 p.m. and 5:00 p.m. On 9/6/25, the pharmacy sent over enough pills for two weeks in a bubble pack each one had 1 1/2 tabs. They ran out of that dose on 9/20/25, and staff started to use the 10 mg tablet bottle (her own she brought in from home), there were times when staff used home medications brought in. The order should have been reactivated to take 30 mg at 7:00 a.m. and 9:00 p.m. and was not done. The order was correct, but label and order did not match; label 20 mg 1 1/2 tablets twice a day and the label on the Baclofen bottle indicated 10 mg tablets. The staff had not completed the rights of medication administration and unfortunately R4 received the wrong dose (1/2 of what was ordered) from 9/21/25, through today 10/22/25. R4 was prescribed the Baclofen for spasms and had not seen any increased pain that she was aware of. TMA-A reported medication errors this morning and explained as to what happened. Facility policy General Policies in Administrating Medications dated 12/2023, identified the labels of all medicine bottles and cards will be neat and legible. The nurse may never re-label a medication. It must be sent to pharmacy if re-labeling is necessary or a new label brought in by the pharmacist and applied by them. Labels shall include prescription number, name of drug, strength, quantity of drug, expirations date, directions for use, name of resident, physician's name, date of refill and if a generic the name of medication being given for. Errors of omission, dosage or type of medication must be reported at once to the registered nurse (RN) supervisor and an incident report filled out. Requested facility policy medication cart safety and was not received.

Based on interview and document review, the facility failed to ensure a system to provide the correct physician ordered diet texture for 1 of 3 residents (R1) who was at risk for choking and had a history of dysphagia. This resulted in an Immediate Jeopardy (IJ) for R1 when she was provided lunch which was not cut up into bite sized pieces as ordered. As a result, R1 was observed to choke, requiring the Heimlich to clear obstruction, suctioning, and oxygen after she lost consciousness. R1 was transferred to the hospital, was intubated and placed on a ventilator.The IJ began on 7/30/25 at 12:10 p.m., when nursing assistant (NA)-A provided R1 with a lunch tray which included potato chowder with kielbasa pieces and a chicken salad sandwich that were not cut up per physician orders. This resulted in R1 choking and requiring the Heimlich Maneuver, was hospitalized and placed on a ventilator. The Administrator and director of nursing (DON) were notified of the IJ on 8/7/25 at 2:25 p.m. The IJ was removed on 8/7/25 at 6:23 p.m., but noncompliance remained at the lower scope and severity level D, with isolated actual harm that is not immediate. Findings include:R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 with moderately impaired cognition, did not reject cares, impaired mobility of both lower extremities, required setup or clean up assistance with eating and substantial assistance with oral care. In addition, R1's active diagnoses include spastic paraplegia (progressive stiffness and contraction in the lower limbs), Parkinsonism and dysphagia (difficulty swallowing). Diet was identified as Mechanically altered diet (require change in texture of food or liquids).A Facility Reported Incident (FRI) report was submitted to the State Agency (SA) on 7/30/25 at 3:25 p.m. The report identified, on 7/30/25, at 12:10 p.m., R1 experienced a choking incident requiring the Heimlich Maneuver and was sent to the hospital for treatment/evaluation.R1's hospital noted dated 7/30/25, identified R1 was intubated for airway protection following out of hospital cardiac arrest and respiratory failure and [R1 with history] of COPD presented to the ER (emergency room) following a choking event. Per EMS (Emergency Medical Services) report, patient choked on a sausage while at the assisted living facility, stopped breathing, attempt was made at Heimlich maneuver and R1 was unresponsive.R1's care plan dated 11/21/21, identified Approach: Regular Diet/Dysphagia level 4 (regular texture) with honey thick liquids; Cut food into small pieces. Encourage small bites and to chew well before swallowing.R1's physician orders dated 4/16/24, identified Honey Thick for Thickened Liquid, and Special Instructions: Cut all foods into bite size pieces. Encourage small bites and to chew well.R1's speech language pathology (SLP) evaluation and plan of treatment dated 4/2/24, recommended moderately thick liquids and Regular diet cut into bite sized pieces.R1's lunch meal ticket for 7/30/25, identified menu of Kielbasa and Potato Chowder, Chicken Salad Sandwich, Pickled Beets and Fruit Salad. The ticket identified food to be cut into bite sized pieces. During interview with family member (FM)-A on 8/5/25 at 1:06 p.m., FM-A stated she was present in the dining room at the time of R1's choking episode. FM-A stated R1 was eating food off her meal tray and then raised her left hand up in a ‘wave'. Then, FM-A stated, I think [R1] is choking aloud to staff. Then a staff member approached R1. FM-A stated R1's skin color turned from normal to a gray color. FM-A stated staff immediately took R1 out of the dining room.During interview with nursing assistant (NA)-B on 8/5/25 at 1:17 p.m., NA-B stated, she presented R1's lunch tray to her in the dining room on 7/30/25. NA-B confirmed she did not double check the meal ticket to ensure it was accurate. NA-B stated the process for following meal ticket was for dietary staff to lay out meal tickets on the dining room tables prior to each meal, then the aides or nurses would bring the meal ticket to the kitchenette [located in each dining room] and the dietary aide would dispense the food per meal ticket. The aide would then bring the meal and meal ticket back to the resident. NA-B stated, I should have checked the ticket and I could have cut her sandwich with a butter knife but I did not. Her meal was not bite-size pieces.During interview with licensed practical nurse (LPN)-A on 8/5/25 at 2:08 p.m., LPN-A stated when R1 was suctioned there was little pieces of food noted. LPN-A obtained R1's meal tray and observed the kielbasa was large sausages about a 50-cent piece is size. LPN-A stated there was not formal education provided to staff following the choking incident.During interview with NA-C on 8/6/25 at 5:16 p.m., NA-C stated R1 choked pretty easily and if she swallowed wrong there was a lot of clearing her throat.During interview with trained medication aide (TMA)-C on 8/6/25 at 6:11pm, TMA-C stated they did not know who ensured the food was cut up. TMA-C indicated sometimes the dietary aide completed the task and sometimes it was the nursing staff. TMA-C stated it was unclear who was responsible. During interview with NA-E on 8/6/25 at 6:37 p.m., NA-E stated they though it was a mix of both dietary aides and nursing staff who were responsible to cut the food up. NA-E indicated there was no one specifically identified who had the responsibility to ensure the food was cut up when served to the resident.During interview with NA-F on 8/6/25 at 6:40 p.m., NA-F stated they would not have thought about to cut the sausage pieces for R1. NA-F indicated that was the hard part of not knowing who is and is not responsible for cutting up food when the resident gets the food in front of them.During interview with director of nursing (DON) on 8/6/25 at 6:52 p.m., DON stated she was in the area of the dining room when R1's choking incident occurred on 7/30/25. DON stated she was notified of the choking incident and ran to R1 knowing R1 was full code. Suction machine was obtained. DON indicated when the Heimlich was first initiated, a small piece of food came out. DON stated staff removed R1's dentures and put the suction lower in her throat. Staff applied Oxygen and the fire department arrived. DON stated a piece of chicken come up. DON went and asked to see the plate of food R1 was eating from and noted the sausage pieces in the soup were the size of quarter- too big to swallow. DON stated, I would not feed that to a two-year-old for fear of choking. DON stated the responsibility of making sure the food was cut up per orders before serving should be dietary staff. DON explained the food should come out cut up from the kitchenette and the next staff to touch the plate should have caught it. DON stated it was a learning situation. During a follow-up interview with DON on 8/7/25 at 9:23 a.m., DON confirmed facility staff had not received formal education regarding R1's choking incident and the process to address it.During interview with dietary aide (DA)-B on 8/6/25 at 5:32 p.m., DA-B stated meal ticket process involved the aides retrieving the meal tickets from the tables and give it to the dietary staff serving the meal. DA-B dietary staff would review the ticket and dish up the meal. DA-B was unable to state who was responsible for ensuring meals with orders for cut up food was done.During interview with DA-C on 8/6/25 on 5:36 p.m., DA-C stated the meal ticket would inform the staff of the consistency of meal. DA-C stated they were unsure who was ultimately responsible for cutting up food into bite sized pieces per orders.During interview with dietary manager (DM) on 8/7/25 at 8:10 a.m., DM stated soup had been served on 7/30/25, and a chunk of meat in the soup became lodged in R1's throat. DM stated he reviewed R1's meal ticket and orders and it clearly says bite sized pieces. DM stated they thought everyone was responsible [for ensuring diet orders were followed and usually it was the dietary aide that cut up the food when plating it. DM stated there was no education provided to any dietary staff following R1's choking incident. DM indicated this was a life and death situation for R1. DM stated it was important to follow orders for a safety reason and to ensure that something like this did not happen again. During interview with SLP on 8/7/25 at 7:55 a.m., SLP stated she was very familiar with R1. SLP stated the food items in R1's lunch were not appropriate in size for R1. Staff said it was cut into small circles or discs which was way too big. SLP stated they really felt like it was the duty of the kitchen and dietary staff to ensure consistency of ordered food is appropriate. SLP stated they felt like this could have been avoided.During interview with registered dietician (RD) on 8/7/25 at 9:37 a.m., RD stated the dietary aides were supposed to cut it up and then the tray brought to the resident. RD stated R1's choking incident never should have happened. RD stated importance for following dietary orders was if not followed, problems like choking could occur.During interview with nurse practitioner (NP) on 8/7/25 at 9:40 a.m., NP stated she was made aware of R1's choking incident and indicated it looked like it was non-compliance with food recommendations. R1]followed her diet really well. NP stated there was negligence on what the food looked like and what was served and should have been avoided on multiple levels. NP stated it was a very serious thing that happened and no one deserved that. NP stated dietary orders were in place to help protect these individuals and if they were not followed serious side effects can occur.During interview with medical director (MD) on 8/7/25 at 12:47 p.m., MD stated the goal was to be clear with following orders, and ensuring the diet order was followed. MD stated the R1 choking incident was unfortunate and the facility learn from this and move forward.The IJ was removed and deficient practice corrected on 8/7/25 at 6:23 p.m., after the facility implemented a systemic plan that included the following actions:-Resident Diet Communication and Implementation Procedure was reviewed and identified dietary aide is responsible for serving meals according to orders and preferences.-Residents were identified as at risk for receiving improper meals due to diet orders with special instructions. All dietary orders were reviewed by SLP to assure they were current and accurate and matched the meal ticket, care sheets and care plan.-Education started 8/7/25 for all nursing and dietary staff prior to each shift. Training includes the definition of bite sized pieces, that all food must be cut into bite sized pieces, and that all staff understand and can demonstrate what to do if a resident is choking.

Based on interview and document review the facility failed to report an allegation of neglect of care to the state agency (SA) for 1 of 3 residents (R1) reviewed who alleged neglect of care.R1's Resident Face Sheet indicated she admitted to the facility on [DATE]. R1's diagnosis included atrial fibrillation, adult failure to thrive and hypertension. R1's Individual Resident Care Plan dated 6/19/25, indicated she required assistance with repositioning, toileting and wheelchair mobility and displayed no behaviors. R1's Progress Note dated 6/22/25, indicated R1's family spoke with nurse regarding R1's condition. R1's family insisted R1 be sent to the emergency department because they felt facility's care of R1 was poor. R1 had not been eating or drinking much and refusing to take her medications. Family asked for boxes to pack up R1's belongings and said they would not be bringing R1 back to the facility. R1's Progress Note dated 6/23/25, indicated social services designee (SSD) called and spoke with R1's family member (FM)-A to discuss the weekend happenings. FM-A said the lack of care was neglect and everyone could see R1 had not been doing well. FM-A said, this was uncalled for, poor care/neglect. Later in the afternoon, SSD spoke with hospital staff who reported R1 was dehydrated and throwing up on arrival to the hospital. A facility Grievance Form dated 6/23/25, indicated R1's family expressed concerns about her care and condition. R1 was sent to the hospital for evaluation and facility informed facility she would not be returning.During interview on 7/16/25 at 1:46 p.m., the SSD stated she thought the allegation of neglect from the family was because R1 was not getting enough to drink or food. The SSD said R1's FM-A had reported neglect to her and said she did not believe it had been reported to the SA.During interview on 7/16/25 at 1:57 p.m., licensed social worker (LSW)-A stated the allegation of neglect was not reported to the SA because the facility did not feel neglect had occurred. LSW-A said the facility felt the family was unhappy that staff had not sent R1 to the hospital.During interview on 7/16/25 at 3:11 p.m., licensed practical nurse (LPN)-A stated he had worked with R1 over the weekend. LPN-A said R1 seemed okay on Friday when she admitted to the facility. LPN-A said on Sunday the family was really upset and talked about the care at the facility being poor and that R1 would not be coming back. During interview on 7/16/25 at 3:38 p.m., the administrator stated the allegation of neglect had not been reported to the SA. The administrator said she had not been aware of any concerns until Sunday night after some of the owners had spoken with the family. The administrator stated her understanding had been that family was upset about care and the facility wanted to talk to them and ask what the issues had been. Facility policy Abuse Prevention/Prohibition Program dated 4/23/24, defined neglect as the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotions distress. The policy indicated allegations of neglect would be reported within two hours if neglect resulted in serious bodily injury and within 24 hours if the neglect did not result in serious bodily injury.

Based on observation, interview and document review the facility failed to utilize assistance devices (transfer belt) and provide a hazard free environment as care planned for 3 of 4 residents (R1, R3, R4) reviewed for falls. Findings include: R1's Resident Face Sheet indicated she admitted to the facility 8/21/24, with diagnosis that included fracture of left scapula, weakness, moderate dementia and back pain. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and indicated she had upper extremity impairments to one side. The MDS indicated R1 required substantial to maximal assistance to transfer and stand and indicated ambulation was not attempted due to medical condition or safety concerns. R1's MDS indicated she had sustained two or more falls since the prior assessment with no injury and two or more falls with minor injury. R1's care plan dated 6/5/25, identified a risk for falls and decreased physical mobility related to left shoulder injury, muscle weakness and inability to ambulate. Care plan interventions included extensive assitance from one to two staff to transfer from recliner and assistance from one staff with gait belt on/off the toilet. 5/22/25, Event Report indicated at 4:00 a.m., R1 was being assisted to sit down in the chair, suddenly felt a bit dizzy and hit the floor. R1 was face down on the floor and had hit her head. Progress Note dated 5/22/25, indicated nurse was called into R1's room. R1 was seen face down on the ground with no transfer belt around her waist. nursing assistant (NA) stated she was trying to assist R1 into the recliner chair when she fell forward on her face. During observation and interview on 6/10/25 at 10:38 a.m., R1 was seated in a wheelchair in her room. R1 had a bump on her forehead that was purple in color along with dark purple bruising under both eyes, on both sides of her mouth and under her chin, covering the upper part of her neck. R1 said NA-A had assisted her to the bathroom and said on the way back, NA-A was walking behind her and she fell. R1 stated NA-A had not used the transfer belt and said, she remembered her head hitting the floor. R1 said, I heard it just pop. R3's Resident Face Sheet indicated she admitted to the facility 2/25/25, with diagnosis that included dementia, history of fracture, osteoporosis and anxiety. R3's quarterly MDS dated [DATE], identified severe cognitive impairment The MDS indicated she required substantial to maximal assistance for transfers and ambulation and had no falls since the prior assessment. R3's care plan dated 6/5/25, identified a self care deficit related to right hip and wrist fractures, cognitive deficits and decreased physical mobility with potential for falls. Resident Care Sheet dated 6/6/25, indicated R3 was a fall risk. Interventions included, do not leave bed remote with R3. The care sheet further directed staff to transfer R3 using assistance from two staff and a transfer belt. Event Report and correlating Progress Notes indicated on 6/2/25 at 12:00 a.m., nurse was called to R3's room where she was sitting on the floor next to her bed. The bed was in the highest position. R3 reported she had hit her head. Staff had been in the room [ROOM NUMBER] minutes prior and the bed had been in the lowest position. Staff believed R3 was on the remote control which caused the bed to raise resulting in the fall. During observation on 6/11/25 at 7:44 a.m., R3 was laying in bed. The control for the bed was in reach of R3 next to her head. During observation and interview on 6/11/25, at 7:51 a.m., NA-B reviewed the care sheet and said staff were not to leave the remote in reach of R3. NA-B verified placement of the remote and said the overnight shift had been the last ones in the room. R4's Resident Face Sheet indicated she admitted to the facility 5/23/25, with diagnosis that included hemiplegia and hemiparesis, cerebral infarction (stroke), weakness of upper and lower extremities and disorder of bone density. R4's admission MDS dated [DATE], identified intact cognition and indicated she had upper extremity impairment on one side. The MDS indicated R4 required partial to moderate assistance for transfer and ambulation and had not fallen since admission. R4's Individual Resident Care Plan dated 5/23/25, indicated she transferred with assistance from one staff using a transfer belt and was receiving therapy. Resident Care Sheet dated 6/6/25, indicated R4 required assistance from two staff using a transfer belt for transfers and ambulation. During observation on 6/11/25 at 7:36 a.m., NA-C was walking with R4 down the hall past the nurses station. NA-C was not using a transfer belt. At 7:41 a.m., NA-C was interviewed about the transfer belt. NA-C said R4 was supposed to have a transfer belt and said, it bothers her and I couldn't find it. During interview on 6/11/25 at 8:58 a.m., registered nurse (RN)-A stated based on the care plan and the care sheet, a transfer belt should have been used when transferring R4. R4's therapy Ambulation Recommendations to Caregivers dated 6/4/25, directed staff to ambulate R2 twice daily with four wheeled walker and assistance from two staff. During interview on 6/11/25 at 9:07 a.m., the director of nursing (DON) stated staff were expected to follow the care sheets. The DON said staff should be able to pick up the care sheet and take care of any of the residents. The DON further stated R4's bed remote could be locked but not all the staff were aware so she directed them not to place the remote within R4's reach. During interview on 9/11/25 at 9:15 a.m., physical therapy assistant (PTA)-A stated the transfer belt enabled staff to control a residents movement while walking with them at their center of gravity. PTA-A said if a resident started to fall, the transfer belt allowed staff to correct the movement and/or assist with lowering the resident to the floor. PTA-A stated therapy recommended a transfer belt as it was the easiest and safest way to control a resident. During interview on 6/11/25 at 9:43 a.m., NA-B stated she was not aware the bed remotes could be locked. NA-B said she used the remote to adjust the bed when completing cares. During interview on 6/11/25 at 9:45 a.m., family member (FM)-A stated R3 had sustained two falls since she admitted to the facility. FM-A said the second fall happened when she fell out of bed. FM-A said she was told the bed could not be controlled by the remote. FM-A said when staff transferred R4, sometimes staff used a transfer belt and sometimes they did not. FM-A said the order was for two staff and a transfer belt and said sometimes it's two and no belt, sometimes one and no belt and sometimes a belt. FM-A stated it would help if the staff looked at their sheets (care sheets). Facility policy Transferring of Residents dated 5/2025, indicated residents who are unable to transfer themselves independently or with minimum assistance shall be transferred following the principles of this policy to allow for maximum safety during transfer. -Transferring resident with single assist, assure transfer belt is in position on resident. - Transferring resident with double assist, assure transfer belt is in place on resident.

Based on observation, and interview, the facility failed to have a system in place to ensure water temperatures were maintained a comfortable temperature for 2 of 13 residents (R22 ,R45) who resided on Maple Lane unit reviewed for complaints of cold-water temperatures. This had the potential to affect all 13 residents residing who resided on Maple Lane unit. Findings include: R22's annual Minimum Data Set (MDS) dated [DATE], identified R22 had severe cognitive impairment and was dependent on staff for bathing, dressing and grooming. R45's quarterly MDS dated [DATE], identified R45 had moderate cognitive impairment and was independent with dressing and grooming and required supervision with bathing. During interview on 2/10/25, at 1:45 p.m. family member (FM)-H stated R22 did not have hot water in his room. Staff had to take R22 to another wing in the facility for his showers as there wasn't any hot water on the wing R22 resided. FM-H felt it was terrible the residents had to wash up in cold water and were carted down two halls half naked for their showers. During interview on 2/10/25, at 6:23 p.m. R45 stated the water never got hot in their sink. It was always lukewarm at best. They washed up the best they could and had to take their showers on the other wing. On 2/11/25, at 8:14 a.m. licensed practical nurse (LPN)-B was observed running water at the end of the resident hallway in the facility's sunshine conference room. LPN-B stated running the water in the sink helped to get hot water going to the resident rooms in the wing. At 9:15 a.m. the continuously running water in the sink remained a cool tepid temperature to the touch. During interview on 2/11/25, at 3:48 p.m. maintenance director (M)-A stated the facility installed a new hot water heater in November 2024 alongside the exiting water heaters, and he thought that had corrected the problem until now. M-A had only just learned of the lack of hot water on the Maple Lane unit the day prior and had called a local heating and plumbing to come out, however, they would not be able to come until the following week. M-A had done a few water temperatures that day and had ranged 93 to 98 degrees, so the temperatures were a little under what they should be. M-A stated hot water temperatures should be at maximum temperature of 115 degrees. M-A did not have a consistent process for monitoring the water temperatures. On 2/11/25, at 5:09 p.m. LPN-B stated she reported the cold-water issues to maintenance a few times over the past couple of months. Staff filled out their requests to maintenance in the maintenance logbook on each wing. The maintenance staff would pick up the forms and she did not know what happened to them after that. There were no copies made of the requests. The current maintenance book for the wing was reviewed and had several blank maintenance requests forms, however, no current requests were documented. The maintenance book failed to identify staff requests for hot water on Maple Lane. On 2/12/25, at 8:32 a.m. M-A was observed testing the water temperature at the end of resident's hall Maple Lane. The hot water had been running five minutes prior to test. The temperature of the running hot water at the sink registered 89.7 degrees. M-A stated he only did hot water tests when he had complaints about the hot water, and he had only gotten complaints two days prior. M-A stated he thought the aides had been bringing residents from Maple Lane to another resident wing to take their showers as the showers on Maple Lane did not work. Hot water issues had been coming up from time to time. MD-A thought the old plumbing was causing the issues and so the facility kept getting sporadic cold water that showed up for a day or so. During interview on 2/12/25, at 12:00 p.m. the director of nursing (DON) stated the facility had ongoing hot water issues on the south wing and were doing their best to correct the problem. DON thought it was something to do with the piping and would possibly requiring tearing into some walls to fix the plumbing. A joint interview was conducted with administrator, owner and registered nurse (RN)-A on 2/12/25 at 1:56 p.m., the administrator stated there were ongoing concerns with the water temperature that were discussed during the quality assurance and performance improvement (QAPI) meeting. A new water heater had been installed but that had not resolved the issue. They called in the previous facility director who had also given them some direction on what to try to resolve the issue. Also, the administrator had started a new process for maintenance requests because it had become apparent staff were making verbal requests that could not be verified. A binder was placed on each unit for maintenance requests. That way, the administrator was able to audit those requests and ensure they were followed up on. A policy on water temperature management was not received.

Based on observation, interview and document review, the facility failed to ensure flooring was maintained in a safe manner for 1 of 1 resident (R49) reviewed for environment. Findings include: R49's quarterly Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment and had non-Alzheimer's dementia. During observation on 2/11/25 at 8:42 a.m., the floor in R49's room had a black substance built up on the seams between the flooring tiles in the room which covered approximately 50 percent of the floor. When walking on the black substance between the seams would stick to your shoes. During an interview on 2/12/25 at 11:44 a.m., housekeepers (HSK)-A and HSK-B stated R49's room was cleaned about three days a week and included sweeping and mopping the floor. They stated the stuff coming up between the tiles was sticky and not sure if it was cleanable. HSK-A and HSK-B stated sometimes they can get a little bit of it to come off, but within a couple of days more sticky stuff would come up through the seams. During an interview on 2/12/25 at 11:58 a.m., the maintenance director (M)-A stated he was aware of the substance coming between the seams in R49's room and sated it was probably the glue from the tiles. M-A stated the resident resident's floor was replaced in the past year, and after the resident moved into the room is when the glue started to come out. About mid-summer R49 was moved out of his room and the floor was scraped and rewaxed. Within a week more of the glue was coming out from between the seams. M-A stated the floor needed to be replaced in the room, but the resident would need to be moved out of the room before they could do it; however, there was not a current plan in place to replace the flooring. During an interview on 2/12/25 at 12:40 p.m., licensed practical nurse (LPN)-A, the infection preventionist, stated she was aware of the substance on R49's floor and stated it was sticky and tacky to touch and the floor could not be cleaned thoroughly because of the substance being sticky. Further, the floor in R49's room would need to be replaced. During an interview on 2/12/25 at 1:20 p.m., the administrator stated it was unacceptable for R49 to be in the room with a floor in that condition and it needed to be replaced. A policy for maintenance of flooring was requested, but not received.

Based on observation, interview and document review, the facility failed to develop a baseline care plan to ensure immediate resident needs were identified and addressed for 1 of 4 residents (R211) whom were newly admitted . Findings include: R211's Discharge Summary dated 1/24/25, identified R211 was hospitalized for acute blood loss anemia and acute knee pain due to gout. R211's bleeding resolved and was restarted on anticoagulant medications as well as gout medications to treat his left knee pain. R211's progress note dated 1/24/25, identified R21 arrived at the facility to be admitted . R21 had a foley catheter in place, which would remain until his urology appointment in March. R21 had experienced a lot of falls at home prior to admission and would need assist of one and walker with ambulation. On 2/11/25, at 8:14 a.m. R211 was observed sitting in a recliner watching television in his room. The door to the room was open and R211's foley catheter bag was visible attached to the side of his recliner. R211's medical record lacked evidence a baseline care plan had been developed to ensure staff were knowledgeable in R211's care needs despite R211 having an indwelling foley catheter, need for enhanced barrier precautions, and need for assistance with activities of daily living (ADLs) and mobility. When interviewed on 2/12/25, at 12:43 p.m. the director of nursing (DON) stated they were unable to locate a baseline care plan for R211. It was the facility's practice to have a baseline care plan completed for all residents within 48 hours of their admission. A baseline care plan was important as it identified a resident's care needs and how to care for each resident. The facility's undated Baseline Care Plan policy, identified the facility would develop a baseline care plan within 48 hours of admission. The care plan would include at minimum initial goals, physician orders, dietary orders, therapy services, social services, PASARR recommendations, instructions to provide effective and person centered care, address resident health and safety concerns to prevent decline or injury and identify needs for supervision, behavioral interventions and assistance with ADL's.

Based on interview and document review, the facility failed to accurately code a significant weight loss on the Minimum Data Set (MDS) for 1 of 3 residents (R30) reviewed for nutrition Findings include: R30's quarterly MDS dated [DATE], identified R30 had a severe cognitive impairment and diagnoses t included diabetes, hemiplegia (paralysis on one side of the body), hemiparesis (weakness on one side of the body), chronic kidney disease, dysphasia (difficulty swallowing food or liquids) and aphasia (a comprehension and communication (reading, speaking, or writing) disorder resulting from damage or injury to the specific area in the brain). R30's weight was 153 pounds (lbs.) and R30 had no loss of 5% or more in the last month or loss of 10% or more in last 6 months. R30's medical records identified the following weights: - 7/14/24 172.5 lbs. - 1/3/25 153.3 lbs. Which is a 11.13 percent decrease in weight in 180 days. R30's Mini Nutrition assessment dated [DATE], identified the registered dietician would continue R30's current plan of care and monitor weights monthly. Intake would be assessed regularly to ensure that nutrient needs were being met. Laboratory values would be reviewed for trends, and interventions would be adjusted as necessary. R30 would not trigger for any significant weight changes as evidenced by a 5% change in 30 days or 10% change in 180 days. The RD would continue to monitor weights monthly and reassess quarterly or as needed if significant changes in weight, intake, or health status occurred. During an interview with the RD-A and dietary manager (DM)-A on 2/11/25 at 1:10 p.m., the RD stated she just did the quarterly assessment on R30 and R30 was not a significant weight loss. Upon review of R30's weights, the RD stated her initial report did not identify R30's 180-day weight for some reason it did not pull that. R30 should have been triggered on the MDS as a significant weight loss. During an interview on 2/12/25 at 9:33 a.m., registered nurse (RN)-D stated her role was the facility's MDS coordinator. The RD completed the nutrition assessment, and that information was pulled into section K of the MDS. RN-D stated R30's quarterly MDS dated [DATE] was coded incorrectly. Coding of the MDS was important because it affected reimbursement, quality reports, and R30 could have had further weight loss because the appropriate interventions were not put into place. During an interview on 2/12/25 at 12:21 p.m., the director of nursing (DON) stated R30 should have been recognized as a significant weight loss in 6 months. During an interview on 2/12/25 at 1:05 p.m., the administrator stated assessments were expected to be completed accurately to ensure accurate care planning and interventions were implemented to either stabilize weight and/or to prevent further weight loss. The facility policy Resident Assessment Minimum Data Set (MDS revised 1/2025, identified assessments will be completed by staff qualified and knowledgeable to assess a specific care area. Assessments would be coded accurately to correctly assess medical, functional, and psychosocial problems and strengths to develop person-centered care plans and interventions to maintain and improve status.

Based on interview and document review the facility failed to develop and implement a process to ensure high risk medications were administered and failed to implement a process to report missed doses and/or lack of availability of medications to the provider for 1 of 3 residents (R1) reviewed for medication errors. This resulted in an Immediate Jeopardy (IJ) for R1 when the facility's failure to obtain and administer anti-epileptic medication (used to treat seizures) resulted in increased seizure activity and hospitalization . The IJ began on 11/16/23, when The facility failed to administer three consecutive doses of a high-risk medication to prevent or reduce the risk of seizures resulting in repetitive seizures and hospitalization for R1. The facility failed to implement a plan to secure the medication at the facility or develop alternative interventions via provider notification. The administrator in training, licensed social worker (LSW) and corporate nurse (CN) were notified of the IJ on 12/1/23, at 3:50 p.m. The IJ was removed on 12/4/23, at 2:50 p.m. but noncompliance remained at the lower scope and severity level D, with no actual harm with potential for more than minimal harm that was not immediate jeopardy. Findings include: R1's undated, facility Continuity of Care Document identified a diagnosis of localization-related (focal) (partial) symptomatic epilepsy (neurological disorder that causes seizures) and epileptic syndromes (identification of specific seizure type) with simple partial seizures, not intractable (hard to control), without status epilepticus (seizure involves abnormal electrical activity in the brain affecting both the mind and the body). R1's significant change Minimum Data Set, dated dated dated [DATE], identified R1 had intact cognition. R1's care plan updated 11/20/23, identified a potential for alteration in electrical impulse related to seizure disorder and had a self-care deficit related to hemiplegia (paralysis of one side of the body), dementia and failure to thrive. R1's physician orders dated 11/15/23, included the following orders: - Levetiracetam (anti-epileptic drug used to treat partial, myoclonic, and tonic-clonic seizures) 1500 milligrams (mg) twice daily in the a.m. and p.m. - Levetiracetam 500 mg daily between 11:30 a.m. and 1:00 p.m. R1's Medication Administration History dated 11/1/23 through 11/17/23, identified R1's 11/16/23 a.m. dose of levetiracetam was not administered, listed as drug/item unavailable. R1's 11/16/23, midday dose of levetiracetam was not administered, listed as drug/item unavailable. The facility investigation related to the error indicated R1's p.m. dose of levetiracetam was documented as administered on 11/15/23, however, it was determined to be documented in error as the medication had not been delivered to the facility. An undated, Medication Error Report identified a medication error on 11/15/23. R1's levetiracetam 1500 mg was marked as given but medication was not at facility per pharmacy. The plan to correct the problem was identified as VA [vulnerable adult] investigation, follow-up POC. R1's progress notes identified the following: - 11/16/23, Staff went to R1's room to provide cares at approximately 6:35 a.m. and asked writer to check on R1 because she thought something was wrong with her. Upon entering the room R1 was tense with hands and arms constricted and her head was stiff to the right side. Upon neurological checks R1 did not follow commands such as squeezing hands and her eyes were fixed and not reactive to light. The right side of R1's face was drooping and she was verbally unresponsive. After assessment an ambulance was called for transport to the emergency department (ED). Ambulance crew arrived approximately 7:05 p.m. at which time R1 stared coming around but was very confused and kept stating her head and right-side hurts resident also kept stating please help me. - 11/17/23, Contacted [NAME] ED regarding an update on R1. ED staff stated R1 had been admitted to the intensive care unit (ICU) with seizures. R1's Hospital Admission History and Physical (H and P) dated 11/16/23, identified R1 presented to the ED with encephalopathy and concern for seizures at nursing home with several seizures in the hospital in the context of under dosing her anti-epileptic medications. The H and P indicated the physician suspected R1's presentation was related to seizures and indicated clear seizure like activity in the ED related to under-dosing of R1's levetiracetam at facility because they were not able to fill the medication. Admit to ICU given she had two witnessed seizures in the hospital. R1's undated hospital Continuity of Care Document identified a Keppra (levetiracetam) level of 2.5. (The therapeutic index of Keppra is approximately 12.0 - 46 mg/Liter.) During interview on 12/1/23, at 9:00 a.m. CN stated during the medication exchange with the pharmacy staff on 11/15/23, it was identified R1's levetiracetam had not been delivered. Staff contacted the pharmacy between 2:30 p.m. and 3:30 p.m. and the pharmacy stated it would be sent with the evening medication delivery. The levetiracetam did not show up; however, that was not identified by the evening staff. CN added, the evening staff member reported she thought she had given the medication but could not have since it was not delivered. Staff contacted the pharmacy again on 11/16/23, and the medication still was not delivered so R1 missed both her a.m. and midday doses of levetiracetam. CN confirmed the physician was not notified of the missed doses because the pharmacy kept telling staff the medication would be delivered. The unit manager was aware the medication was not delivered but there was no evidence the DON was updated. The facility had been performing medication administration audits and general education on medication administration but there was no evidence of education related to how to respond or who to notify when a medication was not available other than providing staff with a 24 hour phone number for the pharmacy. During interview on 12/1/23, at 9:29 a.m. licensed practical nurse (LPN)-A stated when the pharmacy dropped off medications staff compared the medication cards against the orders. If something was missing LPN-A made a list and normally they called the pharmacy. The day R1's medication was not delivered the unit manager (LPN-C) was there and called the pharmacy. LPN-A thought the facility was going to consider doing the medication checks differently but had not received any training or direction related to who to notify if a medication was missing. LPN-A was not aware of a list of medications that were deemed higher importance. During interview on 12/1/23, at 9:24 a.m. LPN-B stated usually two staff did the medication exchange from the pharmacy. If a medication was missing staff would call the pharmacy right away and if a medication was needed right away they could have someone pick it up from the pharmacy. LPN-B was not aware of the incident with R1's missing medications and had not received any education. Further, LPN-B indicated the charge nurse and the physician should have been notified on a missing anti-seizure medication. During interview on 12/1/23 at 10:06 a.m., the DON stated there was currently no evidence staff were educated on a process that directed what to do if a medication was not available. During interview on 12/1/23 at 10:09 a.m., registered nurse (RN)-A stated she was providing education related to medication administration and if a medication was not available staff were to notify the charge nurse and the charge nurse would get a hold of the pharmacy. The pharmacy had an after-hours phone number if the need was urgent. The medication audits were reviewed and lacked evidence staff were trained on what to do when a medication was not available. During interview on 12/1/23, at 10:26 a.m. LPN-C (unit manager) stated when the pharmacy sent out the medications on 11/15/23, they let the pharmacy know R1's levetiracetam had not been delivered. The next day LPN-C worked until 6:00 p.m. and the medication had not arrived. LPN-C did not follow up with pharmacy but had let the oncoming nurse know. After the incident the facility posted a number for the after-hours pharmacy. On 12/1/23, at 12:39 p.m. the CN and DON were interviewed. The CN stated the facility did not have a policy or procedure for identification of high risk medications or a procedure for staff to follow if medications were not available. The CN did not think a lot of the TMA's knew what was considered a high risk medication. The CN stated after R1 was sent to the hospital her physician was notified and said the physician felt the missed medication resulted in R1's seizures. The DON stated she was not aware R1's medications had not been administered as ordered and there was a lack of follow through. The DON said the staff on duty had reported to the unit manager and the process was started but not completed. During interview on 12/1/23, at 1:01 p.m. R1's physician stated, I do think the missed medications contributed to the seizures, and ultimately the hospitalization , adding R1 had not had seizures for several months and had been very stable. If the facility was unable to obtain a medication for any reason a call should have been made to the provider or an on-call to determine next steps. The facility General Policies in Administering Medications policy dated 7/20/22, identified errors of mission, dosage, or type of medication must be reported at once to the RN supervisor and an incident report filled out. The IJ that began on 11/16/23, was removed on 12/4/23, at 2:50 p.m. when it was verified through interview and document review the facility developed a process to educate staff on identification of high risk medications and developed and educated staff on a process for notification to the provider when medications were omitted for any reason. Education included a posting of some of the common high risk medications on the medications carts a long with a clear procedure for staff to follow for communication to management staff when medications were not available.

Based on interview and document review, the facility failed to provide adequate supervision when staff did not appropriately respond to a sounding exit door alarm for 1 of 3 residents (R1) identified at risk for elopement, who was able to exit the building, despite wander alert alarming, resulting in R1 being outside the facility without staff knowledge. This resulted in an immediate jeopardy (IJ) for R1. The immediate jeopardy began on 9/23/23, at approximately 6:39 p.m. when R1 was found outside the facility by a visitor walking through the parking lot. The IJ was identified on 10/6/23, and the administrator was notified of the IJ on 10/6/23, at 4:15 p.m. The immediate jeopardy was removed on 9/28/23, and the deficient practice was corrected prior to the start of the survey and was therefore issued at past noncompliance. Findings include: R1's quarterly Minimum Data Set, dated dated dated [DATE], identified severe cognitive impairment, wandering behaviors and indicated she required limited assistance from staff for ambulation. R1's care plan revised 9/22/23, identified an alteration in thought process related to anxiety and Alzheimer's disease. The care plan indicated R1 wandered and required the use of a wander alert. The care plan identified decreased physical mobility and indicated R1 ambulated with limited assist of one staff using a walker. R1's facility Progress Note dated 9/23/23, indicated she was found outside by a visitor. The visitor reported seeing R1 halfway between the care center and the assisted living. The visitor reported R1 was asking can you help me, I am not sure where I should go. The visitor assisted R1 to the assisted living as she believed R1 was a resident there. Assisted living staff called the care center and assisted R1 back to the care center. R1's wander alert sounded when she re-entered the facility. Nursing assistant (NA)-A reported hearing the wander alert system alarm and said she looked out the door and did not see anyone so she reset the alarm after asking licensed practical nurse (LPN)-A how to do it. Review of video footage, dated 9/27/23, identified the following: 9/23/23, at 6:39 p.m., R1 left the garden door and walked along the sidewalk. She had her walker. At 6:41 p.m. R1 reached the edge of the sidewalk and stepped down into the parking lot in front of the care center. R1 walked across the parking lot toward the street. R1 reached the curb on the east side of the lot, turned left and walked toward the parking lot exit which took about a minute. At 6:43 p.m. R1 was trying to cross the parking lot when a car was trying to turn into the lot. The car pulled up next to R1 and directed her through the window to turn around and walk back to the side walk. The visitor parked her car and walked over to R1 who was on the sidewalk. At 6:47 p.m. the visitor led R1 to the front door of the care center but was unable to get in as the doors were locked. The visitor then brought R1 to the assisted living. During observation of the unit and facility on 10/6/23, at 12:32 p.m. R1's room was noted to be on the north end of the facility. At the end of the hall was an exit door that led to a sidewalk leading to the parking lot. The facility parking lot was adjacent to a moderately busy road in a residential neighborhood to the east. The South end of the campus, approximately 1/2 block from the facility parking lot connected to a highly trafficked road. Behind the facility the road was closed due to construction. During interview on 10/6/23, at 1:34 p.m. Licensed Social worker (LSW)-A and the corporate registered nurse (RN) were intervieweed. LSW-A stated staff were trained on the wander alert system during orientation and when training on the floor. RN stated after the elopement occurred, she had spoken to NA-A who said she heard the alarm sound and had gone to the door and looked but had not seen anyone. RN stated NA-A said she thought the alarm was sounding due to another resident with a wander alert being close to the door and she was unable to turn off the alarm because she did not know the code. The corporate RN said NA-A asked LPN-A what the code was and turned off the alarm. RN said after the elopment occurred all staff were re-trained on the procedure and ongoing elopment drills were being conducted. During interview on 10/6/23, at 3:05 p.m. LPN-A stated when NA-A asked her for the code for the alarm her first thought was that one of the other residents with a wander alert had been sitting by the door and set off the alarm. LPN-A stated she had been trained on how to respond if a wander alert alarm sounded but it had been a crazy day and she had not even thought about it, she just gave NA-A the code to clear the alarm. Facility policy/procedure dated 4/2015, indicated if any unauthorized departure occurred an audio alarm would sound at the door and at the nurses station. Any staff hearing the alarm will immediately investigate and respond accordingly. The policy/procedure lacked direction in regard to how to respond if no resident was seen when responding to an alarm. The past noncompliance immediate jeopardy began on 9/23/23. The immediate jeopardy was removed, and the deficient practice corrected by 9/28/23 , after the facility implemented a systemic plan that included the following actions: - Care planned interventions were implemented to keep R1 occupied after meals. - Elopement training on 9/23/23 - 9/28/23, to include review of the policy and procedure for responding to a wander alert for all nursing care staff. - Elopement drills performed each shift then daily beginning 10/3/23, and ongoing.

Based on observation, interview and document review, the facility failed to implement the Centers for Disease Controls (CDC) guidelines for isolation and transmission-based precautions (TBP) with appropriated personal protective equipment (PPE) to prevent the spread of COVID-19; failed to track signs and symptoms of infection for 1 of 1 residents (R1) reviewed who displayed symptoms of COVID-19 and was not placed in isolation with appropriate TBP when symptomatic. This practice resulted in an immediate jeopardy (IJ) situation which had the high likelihood to cause serious illness and/or death to all residents residing in the facility. In addition, the facility failed to ensure all healthcare personnel (HCP) were fit-tested for N95 respirators; and failed to track, trend all actual and potential infections in real time and then analyze the infections for any patterns or trends. These deficient practices had the potential to affect all 61 residents residing in the facility; along with staff and visitors. The IJ began on 10/28/21, when it was determined the facility failed to implement isolation precautions with transmission based precaution that included staff wearing N95 respirators, gowns and gloves while providing cares for R1, when R1 began displaying COVID-19 symptoms. Further, R1's symptoms were not documented and were not communicated to the facility infection preventionist (IP) to ensure appropriate infection control precautions were implemented to reduce the spread of COVID-19 within the facility. R1 subsequently tested positive for COVID-19 on 11/3/21, after being transferred to the hospital for further evaluation. The acting administrator, administrator/owner, assistant director of nursing (ADON) and corporate nurse were notified of the IJ at 1:07 p.m. on 11/3/21. The IJ was removed at 4:35 p.m. on 11/5/21, but noncompliance remained at the lower scope and severity level of F, widespread, which indicated no actual harm with potential for more than minimal harm that is not IJ. Findings include: The CDC guidance People with Certain Medical Conditions dated 10/14/21, identified older adults were more likely to get seriously ill from COVID-19. More than 81% of COVID-19 deaths have occurred in people over the age of 65, and the number of COVID-19 deaths among people over 65 is 80 times higher than the number of deaths among people aged 18-29. Further, the risk of severe COVID-19 increases as the number of underlying medical conditions increases in a person. Severe illness means a person with COVID-19: may require hospitalization , need intensive care, require a ventilator to help them breathe, or die. The CDC guidance Interim Infection Prevention and Control Recommendation to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes dated 9/10/21, directed residents symptomatic residents, regardless of vaccination status, should be restricted to their rooms and cared for by healthcare personnel (HCP) using a N95 or equivalent or higher-level respirator, eye protection (goggles or a face shield that covers the front and sides of the face) gloves, and a gown pending evaluation for [CONDITION(S)]-CoV-2 infection. The CDC guidance Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes updated 9/10/21, identified healthcare personnel (HCP) caring for residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection should use full personal protective equipment (PPE) (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator). During entrance conference on 11/1/21, at 3:15 p.m. the acting administrator stated the facility had two staff test positive for COVID-19 earlier that day during routine testing of unvaccinated staff which was occurring twice weekly due to the county transmission rate. The facility would begin outbreak testing on 11/2/21, of all residents and staff regardless of vaccination status. The acting administrator was unaware of any residents who exhibited signs/symptoms of COVID-19 and no residents were in isolation and on transmission-based precautions (TBP). The CDC's COVID Data Tracker identified the [NAME] County transmission rate for the week of 11/1/21, was high (greater than 10%). ISOLATION and PPE: R1's significant change Minimum Data Set (MDS) dated [DATE], identified R1 was [AGE] years old and was was cognitively intact. R1 was independent with eating after meal setup; however, required assistance with bathing, dressing, and grooming. R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's undated immunization record identified R1 was fully vaccinated for COVID-19. R1's care plan dated 8/9/21, identified R1 was at risk for infection related to decreased mobility and cognitive losses. The care plan directed staff to monitor for respiratory changes such as cough, wheezing or rapid respirations ; and be aware temperature elevation was not always present in the elderly. R1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's nursing progress note(s) identified the following: - 10/30/21, R1's family member (FM)-A notified the facility she received a positive COVID test. FM-A visited R1 on 10/28/21, and FM-A was notified R1 would be placed into transmission-based precautions due to exposure and would not be allowed visitors. - 11/1/21, The facility's IP notified the charge nurse on 10/30/21, R1 had no signs or symptoms of COVID-19 and did not require quarantine or TBP per CDC guidelines. R1's facility COVID [MEDICATION(S)] Test Requisition forms identified the following: -10/28/21, R1 was tested for COVID-19 on 10/28/21, due to muscle aches (a potential COVID-19 symptom) The result was negative. The form did not identify if a confirmatory COVID-19 PCR test was collected or if R1 was placed in isolation with TBP. - 11/1/21, R1 was tested for COVID-19 on 11/1/21 due to a muscle ache. The result was negative. The form did not identify if a confirmatory COVID-19 PCR test was collected or if R1 was placed in isolation with TBP. - 11/2/21, R1 was tested for COVID-19 on 11/2/21, due to a cough and muscle aches. The result was negative. The form did not identify if a confirmatory COVID-19 PCR test was collected or if R1 was placed in isolation with TBP. During observation on 11/1/21, at 3:27 p.m. R1 was lying in bed with the head of his bed elevated approximately 30 degrees. R1 was using O2 per nc at 2L/minute. R1 had a non-productive cough. There was no isolation cart containing PPE or signage indicated R1 was in isolation with TBP. During observation on 11/2/21, at 7:28 a.m. R1 was lying in bed on his right side. R1 continued to use O2 per nc at 2L/minute. R1 had a deep, productive cough. There was no isolation cart containing PPE or signage indicated R1 was in isolation with TBP. During interview on 11/2/21, at 7:43 a.m. licensed practical nurse (LPN)-C stated R1 was recently in the hospital for pneumonia but was unaware if R1 had a cough or when it started because she had not worked the previous week. LPN-C reviewed R1's electronic medical record and stated the record did not identify if R1 had a cough. R1 was fully vaccinated and, due to his recent hospitalization , the nurses conducted daily assessments/documentation. The documentation was a template, and the nurse had to choose a symptom, such as a cough, to document on that symptom. R1 was recently hospitalized and tested for COVID-19 prior to discharge from the hospital and again at the facility. All tests should have been negative and R1 did have pneumonia, so a cough was expected ; however, there was no documentation R1 had a cough since his return to the facility following hospitalization on [DATE]. LPN-C was not aware if R1 had a negative confirmatory COVID-19 PCR result. Further, R1 was not in isolation with TBP initiated. During a phone interview on 11/2/21, at 12:33 p.m. FM-A stated they were at the facility on 10/28/21, to see R1. FM-A visited in R1's room for approximately one and a half hours. FM-A pulled a chair next to R1's bed with only the overbed table between which left them approximately 3 feet (ft) between them. FM-A wore a surgical mask the entire visit but R1 did wear any source control mask. On 10/29/21, FM-A became symptomatic for COVID-19 with a runny nose, chest and [MEDICATION(S)] heaviness, and a slight cough and since worsened. On 10/29/21, FM-A had a COVID-19 test collected and she received COVID-19 positive results on 10/30/21. FM-A immediately called the facility to report her positive test results on 10/30/21. FM-A stated R1 did not have a cough on 10/28/21, when she visited. If he's coughing now, that's new. During interview on 11/2/21, at 1:17 p.m. trained medication aide (TMA)-A stated she was assigned to care for the residents on the unit that day. R1 was more confused or out of it today. TMA-A had asked R1 if he was tired, and he said no. TMA-A stated she checked R1's oxygen saturation (O2 sats - the amount of oxygen traveling through the body with red blood cells. Normal oxygen saturation is usually between 95% and 100% for most healthy adults) which were 93% on O2 per nc at 2L/minute, which was normal for R1. TMA-A did not check R1's temperature to determine if he had a fever. TMA-A was informed of R1's recent COVID-19 exposure and was instructed to monitor for fever, body aches, that kind of thing but did not correlate his confusion or cough with symptoms of COVID-19. On 11/2/21, at 1:24 p.m. TMA-A was observed to enter R1's room. TMA-A wore a surgical mask (not an N95 respirator) and eye goggles, but did not put on a gown or gloves prior to entering R1's room. TMA-A obtained R1's temperature via a temporal thermometer and stated R1's temperature was 99.3 degrees Fahrenheit (F). TMA-A stated this was a low-grade fever and would notify the nurse. - At 1:32 p.m. TMA-A stated she was instructed by the charge nurse to administer Tylenol per standing order and to place a cool washcloth on R1's forehead. TMA-A entered R1's room without putting on a gown, N95 respirator or gloves. TMA-A administered Tylenol to R1 and placed a cool washcloth on R1's forehead. A COVID-19 test was not collected at this time. During continuous observation on 11/2/21, at 1:49 p.m. R1 continued to lie in bed with a washcloth on his forehead. - At 2:27 p.m. TMA-B stated she was the TMA for the unit for the evening and was informed of R1's elevated temperature and was going to recheck it. TMA-B entered R1's room without a gown or gloves or N95 respirator and obtained R1's temperature of 97.6 degrees F via a temporal thermometer. TMA-B was unaware if R1 had ever been tested for COVID-19. - At 2:32 p.m. R1 continued to cough while lying in bed. - At 2:35 p.m. TMA-B stated she was informed R1 had a COVID-19 PCR test collected earlier that day by the nurse who did the COVID stuff, but the results would not be available for approximately two days. TMA-B was instructed by the acting administrator to obtain a rapid [MEDICATION(S)] COVID-19 test for R1. - At 2:37 p.m. R1 continued to cough while lying on his back in bed while watching tv. - At 2:43 p.m. R1 continued to have a deep, productive cough. - At 2:45 p.m. TMA-B approached R1's room. There was now an isolation cart containing PPE (gown, gloves, surgical masks and face shields). N95 respirators were not on the the isolation cart. TMA-B put on a gown, gloves, face shield and surgical mask before she entered R1's room. TMA-B collected a swab from both sides of R1's nose. At that time, TMA-B stated the rapid test would result in 15 minutes. TMA-B removed all PPE and performed hand hygiene before exiting R1's room. If R1 had a positive test, he would be put in the COVID-19 unit with TBP. TMA-B further stated she was not fit-tested for N95. - At 3:00 p.m. TMA-B stated R1's rapid [MEDICATION(S)] test was negative, and TMA-B stated R1 would remain in his room because he did not have COVID-19. During interview on 11/2/21, at 3:29 p.m. the assistant director of nursing (ADON) stated she was the IP at the facility and the facility did everything for COVID-19. For example, resident testing for the five residents (R8, R9, R10, R11, and R12) in the facility who were unvaccinated residents was conducted twice a week because the [NAME] County transmission rates were high. The facility entered outbreak on 11/1/21, due to two staff testing positive for COVID-19. All residents and staff, vaccinated and unvaccinated, would be tested twice a week for the next 14 days unless they had additional positives for facility outbreak testing. - A rapid [MEDICATION(S)] test was collected if residents experience any symptoms. If positive, the facility would collect a confirmatory COVID-19 PCR test. If the rapid [MEDICATION(S)] test was negative, a nurse would conduct an assessment to determine if an alternative issue could be identified: did the resident have chronic obstructive pulmonary disease ([CONDITION(S)]), did the resident have [CONDITION(S)], was the resident exposed to COVID-19, etc. -The ADON was not aware if a confirmatory COVID-19 PCR test was required after a negative [MEDICATION(S)] test. The ADON stated she was called at home, on 10/30/21, by the charge nurse to inform her of R1's exposure to FM-A. The nurse in the building reported R1 did not show any signs or symptoms of COVID-19 and was fully vaccinated. ADON could not answer for the staff who took care of him and if the nurses did not report symptoms the ADON would remain unaware. ADON was not aware R1 was previously rapid [MEDICATION(S)] tested on [DATE], and 11/1/21, due to COVID-19 signs and symptoms of muscle ache and was unaware of R1's current elevated temperature or cough until the rapid [MEDICATION(S)] test was collected earlier that day, after surveyor inquiry. At that time, the ADON stated R1 should have had a confirmatory COVID-19 PCR test collected after each rapid [MEDICATION(S)] test if he was symptomatic, but again could not speak for the staff. R1 should have been placed into isolation until the confirmatory COVID-19 PCR test result was received. During observation on 11/2/21, at 3:42 p.m. an isolation cart was in the hallway outside of R1's room. There was no signage posted to direct staff that R1 was isolated and on TBP. During the observation the ADON stated staff were in the process of printing the stop sign and it would be placed as soon as possible. During interview on 11/2/21, at 3:45 p.m. registered nurse (RN)-C stated she just found out about R1's symptoms a little bit ago but was in to see him a couple of times that day and didn't think he was in any distress. RN-C instructed the TMA-B to administer Tylenol to R1 and place a cool washcloth on his forehead; and to recheck his temperature because the thermometers could be off. RN-C stated the symptoms for COVID-19 were fever and cough, but she wasn't thinking that when she assessed R1. During observation at 11/2/21, at 4:56 p.m. a stop sign was placed on R1's door with an isolation cart in the hallway by his door. There were PPE donning (putting on) and doffing (taking off) instructions for staff with an additional sign that directed visitors need to speak with the charge nurse before entering room. On 11/2/21, at 5:09 p.m. the acting administrator was observed telling LPN-E R1 was in TBP due to his cough. During interview on 11/2/2021, at 5:11 p.m. RN-A stated R1 had a temperature of about 99 F. R1 was in and out of the hospital due to pneumonia and had lots of congestion since his return. He's struggling with that today and his rapid [MEDICATION(S)] test was negative. R1's PCR results were not back and so R1 was placed in isolation with TBP (after surveyor identified R1 was symptomatic and had not had a confirmatory PCR test to rule out COVID-19). During interview on 11/3/21, at 8:54 a.m. LPN-A stated she worked full time at the facility and cared for all the residents on the unit. If a resident had COVID-19, the resident would be moved to the COVID-19 unit. However, there were no residents at the facility with COVID-19. LPN-A reported all residents with COVID-19 symptoms to the charge nurse. The charge nurse would assess the resident and determine if a rapid [MEDICATION(S)] test was warranted. The charge nurse would document all symptoms. LPN-A stated she was not allowed to document any resident's symptoms because she was not able to assess a resident, but she could enter an elevated temperature. During observation on 11/3/21, 9:15 a.m. occupational therapist (OT) exited R1's room. The OT wore a surgical mask and eye goggles. OT stated she did not wear any additional PPE such as a gown, gloves or N95 because she was told R1 was not in TBP and the isolation cart outside of his room door just hadn't been removed yet. OT provided R1 direct assistance with morning cares while in R1's room. The OT stated she was fit tested for N95 through her employer because she was a contracted employee but was never provided an N95 mask while at the facility. I've only seen surgical masks here. On 11/5/21, at 1:33 p.m. the acting administrator and ADON were interviewed. The acting administrator verified all symptomatic residents should have a confirmatory COVID-19 test after a negative rapid COVID-19 [MEDICATION(S)] test and should be placed into isolation until the confirmatory COVID-19 PCR test result of negative was received. Further, the acting administrator stated they were aware the facility COVID-19 testing process was broken and the facility would be correcting it to meet CDC guidance. During interview on 11/3/21, at 2:51 p.m. RN-B stated R1 was hospitalized for pneumonia and returned to the facility on [DATE]. R1 was then re-hospitalized due to low blood sugars and returned to the facility again on 10/26/21. RN-B stated she transferred R1 to the emergency department (ED) earlier that afternoon on 11/3/21, because he wasn't doing well. His vitals were all stable, but he's not fine. I called the doctor and got the order to send him over for evaluation. R1's nursing progress note dated 11/3/21, at 3:54 p.m. indicated R1 was diagnosed with COVID-19 while in the emergency department. During interview with the ADON and the acting administrator on 11/3/21, at 4:05 p.m. the acting administrator stated the facility was in the process of fit testing all staff for N95 masks. The staff were required to complete a questionnaire that was provided in approximately July of 2021. The questionnaire was provided to all staff and again upon hire for new staff. Once the facility provider approved the fit testing the staff member was fit tested . The staff were not very good at returning the questionnaire and the facility knew this was an issue that needed to be resolved. However, the facility failed to follow up on ensuring N95 fit testing was completed. There were four boxes of N95 masks available for staff in the ADON's office and the charge nurse had a key during off hours. In addition there were three cases of N95 respirators that were available for staff in the basement storage area. SURVEILLANCE: The facility untitled form dated September 2021, tracked actual infections and antibiotic use. The information collected included unit name, resident name, room number, admitted , existing infection from previous month, infection type, body system of the infection, surveillance definition, symptoms, onset date, device type, date of insertion, date of removal, device days, infection risk factors, diagnostic performed, test date, type of test, specimen source, results (organism colony counts for urine), antibiotic resistant organism, antibiotic name, drug class, dose, route, frequency, provider, antimicrobial prescription origin, antibiotic start date, antibiotic end date, total days of therapy, criteria met, antibiotic reassessment performed, other antimicrobial's prescribed, drug class, transmission-based precautions, and date symptoms resolved. The form provided a graph that included monthly infection rates for the facility. - The September 2021 tracking form identified the following infections: three urinary tract infections ([CONDITION(S)]), one other wound infection, and four prophylactic antibiotics. The symptoms listed were open wound drainage; blood in urine, dark color, foul smell, increased behaviors; urinary retention with dysuria; recurrent [CONDITION(S)], [CONDITION(S)] bladder; rosacea (a common skin condition that causes blushing or flushing and visible blood vessels in your face) outbreaks; [MEDICATION(S)] for [CONDITION(S)] pain; and dark concentrated urine, blood tinged, foul odor, daughter demanding urinary analysis and culture. Further, the facility tracking sheet did not identify potential or actual infections that were not treated with antibiotics. The facility did not provide an analysis of the infections to include patterns or what interventions were implemented to reduce incidences of further infection for September 2021. - The October 2021, tracking form with analysis was requested and not provided. - The November 2021, current and ongoing tracking form was requested and not provided. During interview on 11/3/21, at 10:16 a.m. the ADON stated she had not started a tracking and trending log for the month of October 2021 nor November 2021, as she always completed this task at the end of the month, usually on a weekend at home. She reviewed resident information daily for infections and handwrote them down on notes for review. She accomplished this by reviewing progress notes, physician orders, physician notes, and/or relied on the nursing staff to report signs/symptoms of infections. ADON was at the facility every day but had other duties other than infection prevention. ADON reviewed [CONDITION(S)] infections as well and had another log for these; however, when the log was requested, it was not provided because it was blank. ADON's handwritten notes were also requested for review but were not provided. There was no evidence R1's symptoms of COVID-19 were tracked during the month of October or November. On 11/3/21, at 10:30 a.m. the acting administrator and the ADON were interviewed. The acting administrator stated the ADON worked full time at the facility as a cart nurse as well as the facility infection preventionist and tracking/ trending facility infections were completed when time was available. The ADON stated she relied on nursing staff to report all signs/symptoms of infections for tracking purposes. ADON unaware of R1's symptoms; I can't speak for the staff, but if they don't report to me, I don't know. The ADON stated previous months of 2021 were like September 2021. At that time, the acting administrator stated infection tracking and trending was a fall out and would be part of the correction plan. The undated facility Policy for Suspected or Confirmed Coronavirus, directed staff to use the following PPE : gown, respiratory protection (NIOSH-certified disposable N95 filtering facepiece respirator prior to entry and removal after exiting) or facemask if N95 respirator unavailable, eye protection that covers both the front and sides of the face, and gloves. The undated facility policy Guidelines for Isolation Precautions , identified any resident suspected or diagnosed as having a communicable disease shall be placed in the appropriate type of isolation as delineated in these policies and procedures. These policies and procedures were based on the Centers for Disease Control and Prevention (CDC) recommendations. The guidelines were prepared by the Hospital Infection Control Practices Advisory committee and the National Center for Infectious Diseases. If the infection, according to those guidelines, required isolation or precautions, the resident will be isolated only to the degree necessary to isolate the infectious organism. The undated facility policy Outcome Surveillance for Healthcare Acquired Infections, identified the Infection Control Coordinator would perform surveillance of healthcare acquired and cluster infections occurring within the facility to provide guidelines and forms. The Infection Control Coordinator was directed to collect data and to report the information collected at the quarterly Quality Assurance meeting. The policy did not direct the Infection Control Coordinator on the timeliness of data collection or the purpose of trending of infections to prevent the spread of disease. The IJ which began on 10/28/21, was removed on 11/5/21, at 4:45 p.m. when it could be verified through observation, interview and document review the facility: conducted a general risk assessment for those potentially exposed to R1 and outbreak testing was conducted. Residents were assessed to ensure no one else was symptomatic. The facilty decloped a tracking log for resident symptoms and a process to communicated to the IP. A quick reference tool was developed to instruct staff on which symptoms should be monitored for and appropriate response when symptoms were identified. Additionally, the facility revised their policies and procedures to include the necessity of transmission-based precautions for suspected COVID-19 residents and the use of N95 during COVID-19 testing and during the care of suspected or confirmed COVID-19 residents; and with increased monitoring for resident who were exposed to COVID-19 and when to isolate residents. Staff were educated to implement and follow those revised policies and procedures.

Based on observation, interview and document review, the facility failed to ensure resident safety resulting in an increased risk for falls and the potential for serious harm, injury, or impairment to 1 of 1 resident (R8) who was identified as at risk for falls, had visual and cognitive impairment, and resided on the Maple Lane secured memory care unit when the staff mopped the floor surrounding the couch she was seated on, put up a wet floor caution sign and left the resident unattended. In addition, the facility failed to utilize a gait and ambulate side by side with 1 of 1 resident (R11) as directed and observed to be ambulated without the use of a gait belt and with staff walking backwards in front of the resident. The immediate jeopardy began on 10/17/18, at 9:06 a.m. when the staff completed mopping the Maple Lane memory care unit's TV/sitting room floor and left the room leaving R8, who was at risk for falls, seated on the couch, surrounded by a wet floor. The administrator and the director of nursing (DON) were notified of the IJ on 10/18/18, at 1:55 p.m. The IJ was removed on 10/19/18, but noncompliance remained at the lower scope and severity level of D-isolated, which indicated no actual harm with potential, for more than minimal harm that is not immediate jeopardy. Findings include: R8's undated Face Sheet and Havenwood Care Center [DIAGNOSES REDACTED]. R8's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R8 had severely impaired cognition, unclear speech, was rarely understood and rarely understood others, had moderately impaired vision, inattention, and wandered daily. The MDS also indicated R8 required extensive staff assistance for bed mobility, dressing, eating, and toileting. Total assist with personal hygiene and limited assistance of one staff for transfers, ambulation and locomotion. The Balance During Transitions and Walking section indicated R8 was not steady but was able to steady herself without staff assistance. The Functional Limitation in Range of Motion section indicated R8 had impairment on both upper and lower extremities. In addition, the MDS indicated R8 had two or more falls without injury and received daily antianxiety, antidepressant and hypnotic medications. R8's Falls Care Area Assessment (CAA) dated 4/15/18, indicated R8 had two falls since last MDS completed on 7/26/18. One fall had occurred while R8 was standing still and lost her balance, and the other due to orthostatic [MEDICAL CONDITION]. The CAA further indicated R8 had impaired balance during transitions and received antipsychotic medication daily. The analysis indicated the Falls CAA was triggered due to R8 wandering, being unsteady with transitions, and a previous fall. The CAA also indicated R8 was at risk for fractures, soft tissue injury, head injury, and discomfort. Her fall risks were complicated by Dow[DIAGNOSES REDACTED], mood and impulse disorder. R8's Visual Function CAA dated 4/15/18, indicated R8 had decreased visual acuity with inability to determine if able to see any size print due to cognitive losses. R8 had difficulty seeing television, reading material of interest, or participating in activities of interest because of vision problem, however, R8 was able to see objects in the environment. R8's Quarterly MDS Nurses Notes dated 10/3/18-10/9/18, indicated R8 had inattentive behaviors which did not fluctuate, wandered daily on the unit, and would yell out. R8's Care Plan revised 10/10/18, indicated R8 resided on the Maple Lane memory care unit, had decreased physical mobility with the potential for falls manifested by inability to always ambulate, transfer, and sit up. Interventions directed staff to provide limited assistance of one staff to transfer when needing to reach a specific destination at a specific time otherwise R8 transferred independently. Limited assist of one staff to ambulate when needing to reach a specific destination at a specific time on the unit and to all destinations off the unit otherwise R8 was independent. The care plan also indicated R8 preferred to wear gripper socks over her shoes when ambulating. In addition, the care plan indicated R8 was rarely able to make self-understood and rarely understood others and her speech was slurred with mumbled words. The care plan also indicated R8 had an alteration in thought process with the potential for anxiety related to Down's syndrome and [MEDICAL CONDITION]. R8 was able to hear normal tones and follow objects with her eyes. True visual ability unable to be determined due to cognitive loss, however, was able to navigate the environment without difficulty. Behaviors included wandering, and attempts to elope. The undated nursing assistant (NA) care sheet indicated R8 required total assist of one staff for cares, was resistive to cares, and independent with transfers and ambulation. Staff were directed to provide gripper socks, encourage R8 to sit down when drinking beverages, contour mattress on bed, and hip protectors. R8's Event forms were reviewed and revealed R8 had 12 falls since 3/30/18, two of which were related to [MEDICAL CONDITION] activity, two were related to R8 walking hand in hand with another resident when their feet became entangled resulting in both residents falling, one which was related to R8 walking into the back of a staff member which caused R8 to lose her balance and fall and a follow up occupational screen recommended a pediatric sized wheelchair for R8 in order to reduce falls, however R8 refused to sit in it. Another fall which occurred when R8 was attempting to sit in a chair when R8 missed the chair seat and squatted self on the floor and also when R8 was found on the floor in front of her wheelchair, however it was unclear if R8 had slid out of the chair or if she was attempting to stand up. The additional falls revealed the following: -8/9/18, at 3:55 p.m. staff found R8 sitting on the floor in the dining room. R8 had been ambulating per usual prior to this fall. Staff reported R8 was slightly unsteady on her feet and was leaning back slightly while standing. No injuries. -7/20/18, 3:00 p.m. staff reported R8 lost her balance and fell in the dining room. R8 got herself up and proceeded to ambulate around the unit. Staff reported another earlier fall when R8 was receiving her medications, lost her balance and fell . R8 had returned from an inpatient stay at a psychiatric hospital where she had medication changes made in order to assist with managing mood/behaviors. While there, R8's antipsychotic medications had been discontinued and she returned to the facility with an [MEDICATION NAME] medication order and three new medication orders [REDACTED]. -4/14/18, 9:40 a.m. staff witnessed R8 ambulating out of her room and into the hallway. Staff reported R8 had an unsteady gait, however, before staff could intervene, R8 had fallen into the doorway and lowered herself to the floor. -3/30/18, 11:15 a.m. staff witnessed R8 lose her balance in the dining room and fall to the floor, landing on her left side. R8 had been standing next to the railing when the fall had occurred. Ambulates independently without an assistive device. Root cause of the fall was loss of balance. On 10/17/18, at 7:35 a.m. R8 and R30 were observed seated on the couch in the TV room (an enclosed room with opened entry way on both sides), holding a doll and a piece of paper. Tennis shoes on. A moderate amount (approximately ½ to ¾ cup) of moist, brown, feces like matter was noted on the floor between the couch and the wing backed chair which appeared to have been stepped in. An odor was noted. Shortly thereafter, R8 stood up and with short, heavy steps, walked independently into the dining area. The medication nurse greeted R8, however, R8 did not respond. -At 7:41 a.m. R8 was standing by the medication cart. Balance ok. -At 7:49 a.m. R8 was assisted to sit in a dining room chair and provided a glass of thickened juice and milk. R8 did not sit erect in the chair, rather curled up/scrunched down. -At 7:58 a.m. a nursing assistant assisted another resident into the bathroom next to the TV room. The staff member did not enter the TV room. The brown matter remained on the TV room floor. -At 8:08 a.m. R8 was served the breakfast meal. A staff member sat with R8 until 8:18 a.m. while totally assisting R8 to eat her meal. Throughout the meal time, R8 intermittently made crying sounds and facial expressions. -At 8:31 a.m. a staff member pulled R8's chair away from the table and walked away. Shortly thereafter, R8 independently stood up from the chair and walked around the dining room holding the doll and a piece of paper while making intermittent crying facial expressions. -At 8:34 a.m. a staff member guided R8 to just outside of the dining area. With small, intermittent shuffled steps, R8 walked in and just out of the TV room. -At 8:38 a.m. R8 was walking around in the TV room, stepped on the edge of the brown matter on the floor and sat herself in the wing backed chair. -At 8:44 a.m. an activity staff member entered the TV room inviting another resident to join in the activity game which was to take place in the dining area. The activity staff member stood and sat next to the resident seated on the couch which was next to the feces like matter. The staff member stood up, retrieved a walker, positioned it in front of a resident while stepping on the edge of the brown matter and proceeded to walk with the resident out of the TV room and into the dining room for the activity game. The staff member proceeded to walk around the dining room talking to other residents without alerting staff of the dirty floor or cleaning her shoes. -At 8:49 a.m. when asked how often housekeeping (HSKP) cleaned on the unit, licensed practical nurse (LPN)-A stated HSKP came to the unit once a day, sometimes in the morning and sometimes in the evening to clean. She also stated the janitors would mop the floor either in the early morning or around 9-9:15 a.m. LPN-A stated it would be hard for the floors to be mopped at that time due to the activity which was taking place so they would have to come back later. At this time, the surveyor went with LPN-A and showed her the matter on the floor in the TV room. R8 was seated in the chair. LPN-A confirmed it appeared to be feces but stated it could have also been natural food prep which was used to mix the resident medications in. At this time, the same brown matter was noted on the arms and left upper side of the wing backed chair which R8 was seated in. The matter was smeared with small chunks/specks of medication like particles in it. LPN-A stated this area (TV room) was cleaned and mopped on a less than weekly basis. LPN-A also stated on some days, prior to starting her morning shift, she would mop the unit's floor because it had not been done. At this time, the activity director entered the TV room, obtained a rag, got down on her knees, wiped the area and stated the matter did not have a fecal odor. LPN-A obtained a mop/water bucket and both proceeded to clean the floor. R8 remained seated in the TV room, now on the couch, while to floor was swept and mopped in front of her. -At 9:06 a.m. staff completed mopping the floor including the area around the couch where R8 was seated with her feet up. The mopped, wet floor extended from the couch/chair out to the hutch and extended to both sides of the room. A wet floor sign was placed near the area in which the matter was. The floor was visibly wet. The staff left the room. -At 9:12 a.m. the floor remained visibly wet. R8 remained seated on the couch. No staff in the room. LPN-A was passing medications in/around the dining room. When at the medication cart, her back was towards the TV room. Other staff were assisting residents and/or the activity game. -At 9:13 a.m. R8 stood up on the wet floor and proceeded to start to walk. While attempting to reach the resident, the surveyor alerted the staff that R8 was standing up and walking on a wet floor. A staff member came and assisted R8 to ambulate out of the TV room. Shortly thereafter, LPN-A was asked if R8 should have been left alone surrounded by a wet floor and LPN-A confirmed the resident should not have been left alone. -At 9:20 a.m. R8 was walking around the dining area with small, heavy steps with intermittent shuffling. -At 9:22 a.m. R8 was making crying like sounds and continued to ambulate with small, shuffled steps. -At 10:56 a.m. R8 was standing near the dining area ambulating around a dining room chair. Her steps remained slow, heavy and shuffled. -At 10:59 a.m. R8 was pushing a dining chair around, picked up a coloring paper, looked at it and handed it to the surveyor. R8 continued to walk around the area with the same slow, heavy steps. On 10/17/18, at approximately 11:00 a.m. NA-H stated R8 aimlessly wandered around the unit continuously off and on, daily. R8 was independent with ambulation and required assistance with redirection. NA-H confirmed R8 had a history of [REDACTED]. -At approximately 11:05 a.m. NA-G stated medication changes had been wanted for R8 in order to calm her down so she would be able to sit in a wheelchair because she was so unsteady on her feet. NA-G stated R8 had two falls in last two months, however, would grab onto other residents therefore when she fell , she would take another resident down with her. NA-G stated R8 tolerated ambulating around and about 2-3 weeks ago she got new shoes with the thought that those would help her with ambulating, however, no change had been noted. She also stated when staff would walk with R8, she would immediately try to sit on the floor. NA-G stated R8's behaviors included sitting on other people and putting herself on the floor, however, due to recent medication changes, R8's behaviors such as crying out and sitting when walking had been worse. NA-G stated the staff tried to keep an eye on R8 and probably should have had her on every 30 minute visual checks but we don't right now. NA-G stated the staff on the unit had to mop the floor as needed, but when they did this, the staff would place a wet floor caution sign down, mop the floor, and immediately dried the floor because on the dementia unit the sign did not do any good due the residents' inability to read and understand the warning, therefore she used a dry towel to dry the floor. NA-G stated R8 was a very busy resident and the staff never knew when she was going to get up or down so staff should have never left her in the TV room surrounded by a wet floor as it was very possible for R8 to have slipped and fallen on the wet floor. -At 1:01 p.m. custodian (Cust)-A stated he came to the unit twice a day to sweep and mop the floors which was done seven days a week. When cleaning the floors on the unit, Cust-A stated he made sure a fan was on and would also make sure the floor was dry before leaving the area or section of the floor before moving to another area, he mopped section by section. Cust-A stated it was not safe to mop around a resident and leave the area. Cust-A stated when he cleaned the floors, there were three residents who also resided on the unit that needed to be watched a little more than the others. He stated R8 would stand and watch him, and if she attempted to walk or get close to the wet floor she could be redirected. When the wet floor signs were up, one of the residents would always aim for the signs, like they were targets and she would intentionally bump into it so the staff needed to be cautious on where the wet floor signs were placed. Cust-A stated it was unsafe to leave a resident near a wet floor and unsupervised because the residents in the unit wandered and a wet floor is risky for anyone, not just a resident. When asked if a wet floor would increase the risk for falls, Cust-A replied, Oh of course! Cust-A stated if he mopped near a resident, the fan would be on and he would make sure all was dry before leaving. When asked if the facility had a policy related to mopping/wet floor care, he stated each unit had policies, however, on the unit, a person did not know what each day was going to be like therefore the safety rules changed daily. Cust-A confirmed there was no specific policy related to the wet floors on the unit, however, it was known that if the floor was wet, it was to be dried immediately or as quickly as possible. The staff on the unit did not have the luxury of waiting for the cleaning staff to take care of it. -At 1:24 p.m. LPN-A stated R8 wandered daily and was pretty unsteady on her feet. She stated a tilt in space wheelchair had been attempted to see if R8 would stay seated in it but she did not like to sit still. LPN-A stated, I worry about her (R8) so much. LPN-A confirmed R8 shuffled her feet when walking and had recently got new shoes, however, she wondered if R8 liked them or not. LPN-A thought they should get R8 a lighter pair of shoes. When asked if R8 should have been left alone surrounded by a wet floor, LPN-A stated, absolutely not, she should not have been left alone in the room when the floor was wet. LPN-A stated it was hard with all the wandering residents that resided on the unit. She confirmed the custodian brought a fan with him when mopping the floors, and she herself had went to look for a fan when cleaning the TV room floor earlier but she could not find one. LPN-A stated the floor cleaning protocol was to wipe up any spills, mop the area, place a wet floor sign out and depending on where the area was, a staff person was to sit there until the floor was dry or place a fan in order to dry it. When asked if a wet floor increased R8's risk of falling, LPN-A stated, Oh ya! On 10/24/18, at 1:10 p.m. registered nurse (RN)-D again confirmed R8 had a history of [REDACTED]. RN-D verified the staff should not have mopped the TV room floor while R8 was seated on the couch, rather they should have removed her from the area and ensured the floor was dry. The IJ that began on 10/17/18, was removed on 10/19/18, at 1:34 p.m. when the facility developed and implemented a floor mopping policy and procedure which directed the staff to supervise a wet floor until dry, and to intervene and redirect a resident if found ambulating on a wet floor. The facility also educated all staff on the new policy and procedure. R11's quarterly MDS dated [DATE], indicated R11 was severely cognitively impaired, had [DIAGNOSES REDACTED]. R11 was not steady moving from seated to standing position and while ambulating. R11 had impairment to both upper and lower extremities on both sides of the body. R11 did not require an assistive device to ambulate. R11's Review of Rehabilitation Screen dated 2/9/18, recommended assistance for all ambulation. Gait belt and nursing assistant on the side. Do not walk in front of patient pulling her down the hallway. R11's Care Plan provided on 10/17/18, indicated R11 had decreased physical mobility with potential for falls and directed staff to provide limited and sometimes extensive assist of one staff to transfer and limited assist of one staff to ambulate. R11's nursing assistant care sheet provided 10/17/18, directed the use of gait belt when ambulating and one staff to assist to all designations, do not pull from wheelchair, and hand hold assist. On 10/18/18, at 9:00 a.m. NA-G was observed to approach R11 from behind and encourage her to stand up from the chair. Once up, NA-G stood in front of R11 and held onto R11's hands while NA-G walked backwards, guiding R11 from the dining room to R11's room located near the unit's entrance. After assisting R11 to the toilet, NA-G assisted R11 to stand and ambulate to the bed by holding onto her hands, walking backwards, and pulling R11 towards her. - At 9:14 a.m. NA-G confirmed a gait belt was to be used and she should have used a gait belt when transferring and ambulating R11. On 10/18/18, at 9:47 a.m. LPN-A stated a gait belt was to be used whenever staff ambulate R11. On 10/24/18, at 1:34 p.m. RN-D stated staff should be using a gait belt and walk to the side of R11. RN-D recalled informing the staff to not hand hold and walk backwards when assisting R11 with ambulation. - At 2:21 p.m. the DON stated the staff should have used the appropriate assistive devices which included gait belts when ambulating with the residents. The Transfer and Lifting policy reviewed on 4/2015, indicated all certified nursing assistants (CNA's) would be issued a transfer belt, which must be worn while on duty. The Rehab RN and Charge Nurse, along with CNA's would determine the proper lifting procedures for each resident which would be documented on the Care Plan and Care Sheet.

Based on observation, interview, and document review, the facility failed to ensure proper working order of resident care equipment used to transfer residents to ensure safety and prevent accidents. Staff were observed to transfer a resident with a faulty mechanical lift utilizing an unsafe practice resulting in the lift almost tipping. The facility failed to operationalize a process for reporting unsafe use of the full body lifts while ensuring faulty lifts remained off the unit/out of use resulting in the risk of potential serious harm or injury to 1 of 2 residents (R66) who was observed to be transferred using the faulty full body lift. The facility's lack of assessment, reporting, and maintenance procedures, resulted in an Immediate Jeopardy (IJ), with the potential for serious harm, injury, or death, for 11 of 11 residents (R66, R28, R21, R10, R24, R59, R33, R43, R37, R19, R61) who resided on the Walnut Grove unit and required the use of the full body mechanical lift for transfers. The immediate jeopardy began on 10/26/17, when the full body lift was fist noted to be faulty by maintenance staff and was again identified to be malfunctioning on 11/30/17, when the full body lift was observed to malfunction during a resident transfer and staff failed to report the malfunction to administration. The administrator and director of nursing (DON) were notified of the immediate jeopardy on 12/1/17, at 1:30 p.m. The immediate jeopardy was removed on 12/3/17, at 5:31 p.m., but non-compliance remained at the lower scope and severity of (E) pattern scope and severity with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: R66's current face sheet and [DIAGNOSES REDACTED]. R66's admission Care Area Assessment (CAA) dated 2/16/17, indicated he had a communication impairment related to the inability to make self understood verbally/non verbally due to an [MEDICAL CONDITIONS] at birth, noting his speech was slurred and difficult to understand. The CAA further indicated R66 received assistance with all activities of daily living (ADLs) and mobility needs. The CAA noted R66 was unsteady with transfers and needing staff assist to steady him at times. R66's most recent quarterly Minimum Data Set ((MDS) dated [DATE], identified no cognitive impairment, had functional limitations in all extremities, and continued to be totally dependent on staff for transfers. R66's current care plan, last reviewed 11/22/17, identified decreased physical mobility with the inability to transfer, turn, reposition, sit up, or lie down with out staff assistance. The care plan noted R66 could operate and control the electric wheelchair with set up. The care plan directed: Provide total assist of 2 staff and hoyer (full body lift) to transfer. The care plan did not provide direction or instruct staff that is was safe to transfer R66 from the side or in a perpendicular way. During observation on 11/30/17, at 8:20 a.m. R66 was lying in bed and nursing assistant (NA)-D was completing R66's morning cares. NA-A knocked on R66's door, asked if NA-D needed assistance, left the room and returned with a full body sling for a mechanical lift. After completing cares and assisting R66 to dress, NA-D assisted R66 to roll from side to side in order to position the full body sling under him. After positioning the sling under R66, NA-A pushed a Joerns Hoyer Presence Lift (a type of full body mechanical lift) into R66's room, numbered 3 on it. R66's electric wheelchair was positioned in the middle of the room at the foot of the bed, approximately four feet from the bed. The electric wheelchair was facing the bed, which was against the right wall of the room. NA-D and NA-A positioned the lift over R66, double looping all four points of the sling, using the orange loops on the two top hooks and the two black loops on the bottom, to the lift. The lift had two long legs, one on either side of the lift, which were in the narrow position to fit under the bed. Using the lift's electronic controller, NA-D lifted R66 up off the bed in the sling, then maneuvered him to the left so he was suspended in the air while in the lift and positioned in the middle of the room. Neither NA-D nor NA-A tested the functioning of the lift's lower legs before use per manufacturer's instructions. At that time, NA-D attempted to push the lower left button of the remote, which would operate the legs of the lift, spreading them apart wider in order to fit around R66's electric wheelchair. NA-D noted the legs would not open when she pressed the control button, and she suggested to NA-A to lie R66 back down on the bed. NA-A directed NA-D to push the lift perpendicular to the electric wheelchair so R66 could be transferred from the side. With the legs of the lift in a narrow position, NA-D pushed the lift forward, threading the left leg of the lift through the electric wheelchair's front two wheels, making a T shape with the chair and lift. NA-D and NA-A positioned R66 so his back was facing the electric wheelchair seat, and NA-D began to lower R66 into the wheelchair, while NA-A held onto the sling from the back to guide it down to the wheelchair. As NA-D was lowering R66 into the wheelchair, the lift's right leg began to rise off the floor (a couple of inches at that time). NA-A told NA-D to watch the lift it's coming up, as NA-A went from the back of the wheelchair and positioned herself at R66's left side. Neither NA-D nor NA-A stopped the transfer to get a different lift. Instead, NA-D proceeded to lower R66 into the wheelchair using the controls and positioning herself in front of R66, with her left leg on the outside of R66's wheelchair and her right leg in between the legs of lift. The right leg of the lift continued to lift off the ground as R66 was lowered into his wheelchair, until the leg was approximately one and half feet off the ground and the boom of the lift (overhead metal beam that holds the sling) was resting in the back of NA-D's head. Once R66 was seated in the electric wheelchair, NA-D used the controls to lift the boom, while NA-D and NA-A unattached the sling from the hooks. The right leg of the lift was observed to hit the ground as the weight of R66 was removed from the lift. After transferring R66, NA-A was observed to push the lift outside R66's room, place it in the hallway just outside R66's door, and walked away. NA-D was observed to fix R66's bed and take out his garbage before proceeding into another resident's room. Neither NA-D nor NA-A notified other staff, administration, or maintenance of the faulty lift or of the incident. The lift was continuously observed in the hallway outside of R66's room, available on the unit for potential use. The lift was observed in the hallway outside of R66's room on 11/30/17, until 10:16 a.m. when registered nurse (RN)-B and NA-P were observed bringing the same lift, containing the number 3, into R66's room to transfer him from his electric wheelchair into bed. At that time, the surveyor intervened, informing RN-B the lift's legs had not worked during the previous transfer that morning, and requested verification the lift worked before transferring R66. RN-B verified the lift was working by turning on the lift, releasing the red emergency stop button, and pressing the lower left button to expand the lower legs. R66 was not in the sling or attached to the lift at the time RN-B tested the lift, and at that time, the legs were observed to expand wide and work properly. RN-B proceeded to transfer R66 using the lift, this time positioning the lift parallel to the wheelchair, so the lift faced straight forward toward R66, with the legs spread wide in order to fit around R66's wheelchair. R66 was lifted in the sling, and after pulling the lift away from the wheelchair, RN-B used the control to narrow the legs in order to fit them under R66's bed. R66 was then lowered onto his bed, and RN-B pushed the lift out of R66's room, across the hallway, to be used to transfer R28. During interview on 11/30/17, at 10:26 a.m. NA-D stated she rarely worked with R66 and had never transferred him from the side like that before. NA-D stated the lift was not working as the legs were not expanding or opening. NA-D stated the legs of the lift needed to expand or open when transferring R66 because otherwise the lift itself would not fit around his wheelchair. NA-D stated she would normally have sat R66 back down if the lift was not working, and had wanted to lay R66 back down on the bed that morning, but had proceeded with the transfer because NA-A told her to transfer him sideways. NA-D stated she was following NA-A's instruction. NA-D stated she should probably have used a different lift to transfer R66, noting that during the transfer she had moved herself in between the lift and R66, in order to keep the lift from tipping. When asked if the lift would have tipped if she had not been there, NA-D stated, I don't know, probably, acknowledging the boom of the lift was resting on the back of her head. NA-D stated they probably would not have continued to transfer R66 if she had not been there to stop the lift from falling. NA-D further stated they would not normally continue to transfer a resident if the lift was coming up off the floor, however, she again stated she had continued with the transfer because NA-A was directing her to and R66 was already in the wheelchair. NA-D stated she had been taught to go straight forward with the lift when transferring a resident. NA-D further stated there was a specific trainer who taught her how to use the sit to stand mechanical lifts; however, during orientation the trainer had been unable to find a full body lift to train us with, so NA-D was trained on how to use the full body lift by another nursing assistant. NA-D stated, I don't think we should have put (R66) up there (in the sling) when the lift wasn't working. NA-D stated she had reported the faulty lift to the charge nurse, licensed practical nurse (LPN)-A. R28's quarterly MDS dated [DATE], indicated R28 had [DIAGNOSES REDACTED]. R28's care plan dated 10/4/17, directed the staff to assist R28 with transfers via two staff and a full body mechanical lift. On 11/30/17, at 10:27 a.m. RN-B and NA-P were observed in R28's room with a full body mechanical lift. R28 was seated in her wheelchair as RN-B opened the legs of the mechanical lift, positioned the lift so the lift legs were on either side of the wheelchair as RN-B attached the lift to R28's body lift sling. RN-B utilized the lift controls to raise R28 out of the wheelchair. Once in the air, RN-B moved the lift backwards away from the wheelchair and attempted to close the legs of the lift. RN-B stated the lift was not functioning as the legs did not move upon command of the lift controller. RN-B stated she did not know what was wrong with the lift as it had just worked while transferring R66. RN-B pushed the lift control panel again to close the legs and the lift did not respond. With R28 still in the lift and suspended in the air, RN-B proceeded to physically push the lift approximately three feet from the wheelchair area to R28's bed. Once the lift was placed with the feet under the bed and the sling with R28 over the bed, RN-B again pushed the controller to direct the legs of the lift to close. The lift legs closed and R28 was lowered into the bed. -At 10:32 a.m. RN-B directed NA-P to obtain a second mechanical lift and stated the current lift would need to be reported to the maintenance department to determine why it was not functioning properly. NA-P removed the lift from R28's room. -At 10:32 a.m. NA-P returned to R28's room with a second full body mechanical lift. -At 10:35 a.m. RN-B and NA-P transferred R28 from bed to a wheelchair without difficulties. -At 12:21 p.m. RN-B stated the malfunctioning mechanical lift had been removed from the nursing unit and taken to the maintenance directors office. RN-B stated the lift could not be in use on the unit until it was functioning properly. RN-B stated she was unsure why the lift had worked correctly while transferring R66 however, it did not function properly while transferring R28 moments later. During interview on 11/30/17, at 1:52 p.m. LPN-A stated she was not aware of any issues with the full body lifts that day, nor had any incidents been reported to her. LPN-A was surprised to hear the full body lift was back on the unit, stating it had malfunctioned a couple weeks ago and, the girls came up and said the legs won't open. LPN-A verified the issue with the full body lift had also occurred approximately two weeks ago in that the legs would not open, therefore maintenance had taken it off the floor/removed from use, and wasn't aware the lift was back out on the floor to be used again. During interview on 11/30/17, at 1:59 p.m. NA-A confirmed the legs on the full body lift had not worked that morning, and verified staff had the same issues with that lift before. NA-A stated the lift's legs would open and work when there wasn't a resident or any weight in the lift, but when there was weight, the legs would not work and would not open. NA-A stated the lift had been malfunctioning for the last couple of weeks and thought maintenance had fixed it, for awhile. NA-A wondered if it had something to do with weight being in the lift. During the interview, LPN-A walked by and confirmed she also was aware the lift would not work if there was weight in it, and wondered if maintenance had tested the lift with someone/weight in it. NA-A stated staff rarely transferred anyone sideways like they did that morning, and if they did, it would have been to a shower chair not a wheelchair. NA-A stated the transfer that morning was, kind of scary, because (the lift) was tipping. When asked why the malfunctioning lift was used, NA-A replied, You got a good point, we probably should have gone and gotten a different lift. NA-A stated she had been trained on the lifts by the manufacturer when they originally purchased the lifts. NA-A stated the process would be to let the charge nurse or maintenance know when equipment malfunctioned. During interview on 12/1/17, at 7:17 a.m. NA-F verified she was aware of the lift not working the previous day, noting it was now torn apart and maintenance was waiting for a part to come in. NA-F stated the other day the lift was put back on the floor for use, and had heard it should not have been out on the floor to be used. NA-F further stated the unit had one bad lift which had been faulty for awhile and it had seemed that it malfunctioned depending on how much weight was in the lift. NA-F stated the facility had the full body lifts for a few years and they were used so much they don't stay good. NA-F stated if the lift malfunctioned, she would have put the resident back down on the bed and got a different lift that worked. NA-F further stated the new nursing assistants were trained to use the lifts properly by the older nursing assistants, and had never received a refresher course on the lifts. During interview on 12/1/17, at 7:40 a.m. RN-A stated that over the holiday weekend of 11/23 - 11/26/17, she was aware the facility had one malfunctioning mechanical lift from the Walnut Grove unit but was not sure if the lift had been repaired or if it was still in the maintenance department. During interview on 12/1/17, at 8:07 a.m. NA-G stated in a situation where the lift's legs would not open, staff would take the lift and get it as close as possible to the wheelchair, attempting to get the legs underneath the wheelchair if possible, and would go straight on with the lift at first, but might need to turn the lift at an angle or thread the lift's legs through the wheelchair. NA-G stated she would then pull the resident down to the wheelchair making the transfer as safe as possible so the resident would not fall. NA-G stated there should never be a reason why any resident would fall from a lift, however, she would still want to make the transfer as time efficient as possible because the resident would not want to remain suspended up in the lift for long. NA-G stated, if the lift was starting to tip, and if she was in the front of the lift controlling it, she would put her foot down on the lift leg to stabilize it, and if she was on the other side of the transfer, she would hold onto the resident while the other staff person stabilized the lift. NA-G stated she was trained on how to use the mechanical lifts by another nursing assistant. During interview on 12/1/17, at 8:27 a.m. the nurse scheduler stated nursing assistants watched a video on the use of mechanical lifts provided by Health Care Academy during orientation and once a year. The nurse scheduler further stated nursing assistants trained each other on the lifts during orientation, and the nursing assistant who was orienting new staff checked off the lifts on the orientation checklist indicating the staff person had been trained. Staff received further education if the facility purchased new lifts and if rehab had anything new to teach. During interview on 12/1/17, at 8:50 a.m. RN-B stated she was not aware of, and confirmed no staff had informed her of, the mechanical lift's malfunctioning until the surveyor had brought it to her attention the day before. RN-B said had she been aware, she would have taken the lift off the floor and out of service. RN-B also stated she was not aware of any previous malfunctions of the lift. RN-B stated she was unaware of the lift almost tipping with a resident suspended in it, and no staff had reported the incident to her. RN-B stated she had seen that maneuver, of transferring a resident perpendicularly from the side work appropriately adding, this maneuver doesn't scare me but in the instance of R66's transfer, it wasn't good, the lift was lifting up off the ground. RN-B stated clearly with R66's body type, the side maneuver transfer does not work and would have expected staff to tell someone about the incident. RN-B would have further expected staff to tell maintenance and find a functioning lift to use or tell her the lift was malfunctioning so she could alert maintenance and inform other staff not to use the lift. RN-B stated she would also expect staff to keep R66 as safe as possible during transfers, and could not state if the wheelchair or bed would have been the safest place for R66 at the point the lift was starting to tip. RN-B stated the older nursing assistants used to transfer residents from the side with the old lifts they had to use and wasn't aware if they had reverted back to that or not. RN-B stated for residents who utilized tilted wheelchairs, transferring that way could be safer, however, was not aware if R66 would be safe or not and stated, our newer staff would not know that though. RN-B stated she was not sure that maneuver was used very often or only with residents who had tilted chairs, and verified it was obviously an unsafe transfer maneuver for R66. RN-B acknowledged nursing assistants trained new nursing assistants with the lifts during orientation and stated she herself did not go around individually telling the nursing assistants who was safe to transfer from the side or question if the every resident was assessed for safety with transferring techniques. RN-B stated she felt the nursing assistants would assess or problem solve enough to know if it was not safe to use that maneuver with every resident. RN-B stated having been an NA herself, she had used the side transfer maneuver appropriately in the past, therefore she would try it again. RN-B stated maintenance had taken the wheels off the lift, cleaned them for dust, and lubed the gears, however, was not aware of any other maintenance work and could not approximate how long ago it had taken place. During interview on 12/1/17, at 9:21 a.m. NA-H stated she was aware of issues with the full body lift and confirmed the lift would stall when used. NA-H stated sometimes the lift would stall when lifting residents up and down and also when staff would attempt to close and open the lift's legs. NA-H stated she had worked with the lift twice and the legs had malfunctioned both times. NA-H further stated she had heard the lift was malfunctioning prior to her working there in October. NA-H stated when the lift malfunctioned, she would push the red emergency stop button in order to turn the lift off and start it back up again to get the legs to work. NA-H stated she had always transferred R66 from the front, going straight and head on was safer and due to the position R66 sat in the sling, it would be more difficult to transfer from the side, however, with some residents who sat tilted back in wheelchairs, it had worked better to transfer them from the side. NA-H stated she was trained by other NAs on how to use the mechanical lifts and she had only known how and who to transfer from the side because the nursing assistant who had trained her told her it would work better that way. During interview on 12/1/17, at 9:38 a.m. the DON stated she was aware the lift had malfunctioned the previous day due to the legs not opening appropriately with weight on it and confirmed she knew the full body mechanical lift had been having issues already months previous. However, the DON stated the maintenance staff had looked at it and could not reproduce the issues when attempted. The DON stated she had been told the maintenance staff had previously looked at the functioning of the lift's legs because the legs would not open, but did not know the approximate timeframe as to when they looked at it. The DON stated she was not aware of the lift almost tipping with R66 in it and stated staff should have placed R66 back on the bed and obtained another lift. The DON also stated she would have expected staff to notify her of this incident and to also inform other staff as well as maintenance that the lift had malfunctioned. The DON stated side transfers had worked better for some residents for positioning purposes however, thought the nursing assistants would have received direction from the RN if the side transfers were safe to utilize or not. The DON stated if she had known about the incident, she would have started an investigation. During interview on 12/1/17, at 1:31 p.m. the administrator stated he was not aware of the lift malfunctioning or that it had started tipping while a resident was suspended in it. The Joerns Hoyer Presence Instruction Manual indicated the lift had legs with adjustable width which could be opened to, enable access around armchairs or wheelchairs, noting the legs should be closed when negotiating narrow passages. The manual further instructed to always check, The legs of the lift open and close satisfactorily, with the hand control before operating the lift. It further directed to, Always plan your lifting operations before commencing. The Facility's Lift Operation Procedure Policy, reviewed 4/15, directed step by step instructions for transferring residents with the lift from the bed to chair and from chair to lift. The procedure instructed to position the wheelchair under the resident in the lift. However, the procedure lacked direction on when to open the lift legs while transferring nor did it provide instructions on transferring from the side. In addition, the policy lacked direction for staff on procedures when the lift malfunctioned. A copy of the Health Care Academy orientation video/education was requested but not provided. MAINTENANCE OF EQUIPMENT Review of the preventative maintenance logs for the facility's seven Joerns Hoyer Presence lifts, from 2/17 to 11/17, identified the following: - The logs included monthly preventative maintenance, which included checking the leg adjustment to, Check the legs operate in both full extensions Inward/outward. No preventative maintenance to any of the lifts was completed or checked in November. - The log for lift number 3, identified a notation on 10/26/17, which noted the leg adjustments did not work, reading, Doesn't work with Resident suspended. The log noted the leg adjustments were not operational. - A Purchase Order, dated 11/1/17, identified a Hoyer controller box had been ordered. - A Purchase Order, dated 11/17/17, identified a [MEDICATION NAME] (motor) for the Joerns Hoyer lift had been ordered. During interview on 12/1/17, at 7:26 a.m. maintenance staff (M)-A stated the lift had malfunctioned two weeks prior, and was brought down to the shop. M-A stated at that time there was a retaining pin which kept the motor for the legs in place had malfunctioned causing the motor to rotate back and forth and was slipping. M-A further stated at that time the motor had been replaced and the lift had been put back on the floor for use. However, M-A stated the lift had malfunctioned again yesterday so they had torn the lift apart and he had assisted in taking the same motor out. M-A stated this time they tested the legs by putting weight on the end of the lift which when demonstrated, the legs would not open. M-A thought staff was notified yesterday of the lift malfunctioning with weight and was not aware if the lift was tested with weight again before it was put back into use the first time as M-B had repaired the lift the first time if malfunctioned. During interview on 12/1/17, at 7:30 p.m. M-B confirmed a short time ago the lift was malfunctioning which at that time he had ordered and replaced the lift's motor. M-B stated after replacing the motor, the lift was not tested with weight in it before it was put back out on the floor for use. M-B stated the lift had malfunctioned yesterday because there was a busted part causing the motor to slip. M-B stated the part had snapped when weight was put in the lift. M-B stated the lift worked just fine without weight; however, when there was weight in the lift, the motor would slip back and forth causing the legs to malfunction. During interview on 12/1/17, at 7:40 a.m. the director of maintenance (DOM) stated the facility had performed monthly preventative maintenance (PM) checks on the lifts; however, the staff person that had previously completed the PM checks had quit and M-A would be doing the preventative maintenance. M-A stated he had started in that position that same day therefore, had not yet completed the preventative maintenance checks for the lifts. The DOM could not identify when the lift initially began to malfunction however, confirmed when the malfunctioning was originally identified, they had ordered a new control box for the lift. The DOM stated they had never installed the new controller box because they had identified the actual problem was with the [MEDICATION NAME] (a type of motor) in which a bracket had broken off which controlled the lift's legs opening and closing. The DOM stated [MEDICATION NAME] default was identified around November 13th, and around that time, he had tested the lift by putting weight on the end of it which resulted in the lift malfunctioning. The DOM stated the lift's motor was replaced but was not aware if the lift had been checked with weight in it prior to sending it back onto the floor for use, nor was he aware when the lift was pulled from the floor the second time it had been pulled from the floor or had malfunctioned. The DOM stated he did not keep maintenance records for when equipment was pulled from the floor or for the maintenance and tests done to faulty equipment. The DOM stated when they had torn the lift open, they could see it was a broken motor, had replaced it, and assumed it was fixed. The DOM stated yesterday the other motor (each motor operates one side of the legs) had busted and did not have a good explanation for why it was not working. The DOM stated he had tested the lift twenty five times with weight in it and was able to make it malfunction twice. The DOM verified he had not contacted the manufacturer, but was in contract with Pro Medical, the supplier who the facility bought the lifts from, in order to get replacement parts. The DOM acknowledged the order for the control box was placed on 11/1/17, and the order for the [MEDICATION NAME] was placed on 11/17/17, and stated the lift had been malfunctioning on and off, sporadically. The DOM stated the lift was not officially pulled off the floor until the motor was identified as the problem and verified it had been in use in between that time. During interview on 12/5/17, at 3:39 p.m. the Joerns Hoyer Representative (JHR) stated the malfunction could have been from a faulty [MEDICATION NAME] and if the company had been notified, they would have requested a short video or picture from the facility showing the malfunction so they could attempt to diagnose the problem and attempt to reverse engineer the malfunction. The JHR stated the purpose of the lift's legs spreading was purely common sense, further stating their lifts were meant to get around wider objects like recliners. The JHR stated the lifts could be used from the side but it depended upon the approach, further stating the training was to approach the wheelchair from the front, if you could. The JHR stated their lifts were designed not to tip even with the legs in the narrow position and in the event that the lift did tip, he would expect it to be taken very seriously and an investigation be conducted in order to see if there was operator error. No further maintenance or equipment policies were provided. The immediate jeopardy that began on 10/26/17, was removed on 12/3/17, at 5:31 p.m., when the facility took the following actions: -removed the lift out of service. -checked all mechanical lifts to ensure proper working order. -assessed residents who utilize mechanical lifts for safe transfers with the lifts. -updated policies and procedures for malfunctioning lifts. -educated nursing staff on safe use of the lifts and updated policies, which included inspecting their current lifts to ensure proper functioning. -implement preventive maintenance plan for all lifts. The IJ was removed but the noncompliance remained at the lower scope and severity level of E - pattern scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy.

Based on observation, interview, and document review, the facility failed to comprehensively assess pressure ulcer risk, reassess the efficacy of interventions, update the medical practitioner, and/or consistently implement interventions to promote healing and prevent the development of new pressure ulcers for 3 of 3 residents (R58, R54, R50) who were reviewed for pressure ulcers. This failure resulted in actual harm to R58 and R54 due to the worsening of facility acquired pressure ulcers. In addition, R45 was identified at risk for pressure ulcers and the facility failed to provide turning and repositioning assistance as directed by the care plan. Findings include: R58's Care Center [DIAGNOSES REDACTED]. R58's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R58 had moderate cognitive impairment, required extensive physical assist from one staff for bed mobility and transfers, was at risk for pressure ulcers and had an unstageable (extent of tissue damage could not be confirmed due to obscurity by slough or dead tissue) pressure ulcer which measured 1.5 centimeters (cm) by 1.3 cm with a depth of 0.2 cm and was covered by slough (Slough is non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed). R58's Pressure Ulcer Care Area Assessment (CAA) dated 3/2/17, indicated R58 had two stage two (Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) pressure ulcers on her bottom without signs/symptoms of infection, required extensive assistance with bed mobility, and was at risk for worsening pressure ulcers, development of new ulcers, infection,[MEDICAL CONDITION], weight loss, and discomfort. R58's Physician order [REDACTED]. R58's Physician order [REDACTED]. -apply barrier cream to coccyx with cares and toileting every shift. -Egg crate mattress to bed. -Inspect skin on bath days for reddened or opened areas. -Right buttock open area: cleanse and pat completely dry. Apply foam dressing. Change every three days and as needed until healed. R58's quarterly Tissue Tolerance Assessment (assessment used to determine the skin's ability to tolerate pressure over bony prominences over time) dated 11/15/17, indicated next to no change in skin condition section still open. R58 was weaker and the assessment determined no change in care plan was required and to encourage R58 to turn every one hour. R58's quarterly Tissue Tolerance Assessment (TTA) dated 8/15/17, indicated R58's skin condition was improving and to encourage every one hour repositioning. The quarterly TTA dated 8/1/17, indicated reopened coccyx and to continue to encourage every one hour repositioning, often refuses. R58's Braden Scale assessment (tool to identify pressure ulcer risk) located on the Observation Detail List Report completed on 11/29/17, with an observation date of 11/29/17, indicated R58 was chairfast, had slight limited ability to make frequent, through slight changes in body or extremity position independently, had adequate nutritional intake, had a potential friction and shearing problem and was at risk for the development of pressure related ulcers. The assessment did not identify any current open areas. R58's physician order [REDACTED]. This order was obtained during the survey, as R58's pressure ulcer services were being reviewed. R58's care plan last reviewed 11/8/17, indicated R58 had decreased mobility, and was nonambulatory and had a potential for alteration in skin integrity related to history of pressure ulcers, [MEDICAL CONDITION] and valvular [MEDICAL CONDITION]. R58 also had a potential for fluid overload and alteration in circulation related to kidney disease and [MEDICAL TREATMENT] treatments. The plan directed staff to provide the following: -Assist of one to transfer, sit up and lie down, get legs in/out of bed, was independent with turning and repositioning -Encourage to turn and reposition every one hour when in bed and wheelchair. -R58 frequently refused to reposition and staff to provide education on the importance of repositioning. -[MEDICAL TREATMENT] notified to have R58 sit on a cushion while there and to encourage every one hour repositioning. -Monitor for persistent red areas and report to RN. -Maintain adequate nutrition and hydration by providing dietary decub program -Pressure relief cushion in wheelchair, however, at times R58 would put personal pillow over wheelchair cushion and has been educated that this would decrease efficiency of the cushion. -egg crate mattress on bed -R58 refused the alternating airflow mattress overlay -R58 refuses APP mattress overlay -[MEDICAL TREATMENT] as ordered. The care plan did not identify or address R58's current stage two pressure ulcer. R58's Treatments Administration History (TAR) dated 8/1/17-8/31/17, directed staff to check R58's skin on bath days for reddened or open areas and to report to the RN. On 8/4, 8/11, 8/18, documentation indicated R58 had both reddened and open areas. Location not identified. On 8/25/17, documentation revealed R58 had an open area with no redness. Skin check directive was initiated on 4/27/17, with a discontinuation date of 12/1/17. The report further directed staff to cleanse, pat dry, and apply a foam dressing to the right buttock open area every three days and as needed, until healed. The treatment was initiated on 5/23/17, with a discontinuation dated of 12/1/17. R58's physician office visit form dated 8/8/17, section ROS Review of Systems read: Skin: Negative. R58's TAR dated 9/1/17,- 9/30/17, directed staff to check R58's skin on bath days for reddened or open areas and to report to the RN. Weekly skin documentation revealed red and opened areas. Location not identified. The report further directed staff to cleanse, pat dry, and apply a foam dressing to the right buttock open area every three days and as needed, until healed. The treatment was initiated on 5/23/17, with a discontinuation dated of 12/1/17. R58's TAR dated 10/1/17-10/31/17, weekly skin check documentation revealed red and open areas. On 10/6/17, shins was noted as red. The report further directed staff to cleanse, pat dry, and apply a foam dressing to the right buttock open area every three days and as needed, until healed. The treatment was initiated on 5/23/17, with a discontinuation dated of 12/1/17. R58's physician office visit form dated 10/9/17, section titled ROS Review of Systems read: Skin: Negative. R58's TAR dated 11/1/17-11/30/17, weekly skin check documentation revealed red and open areas, however on 11/8/17, no redness was present. location not noted. The report further directed staff to cleanse, pat dry, and apply a foam dressing to the right buttock open area every three days and as needed, until healed. The treatment was initiated on 5/23/17, with a discontinuation dated of 12/1/17. On 11/29/17, during continuous observations from 1:47 p.m. until 7:15 p.m. the following was observed: -At 1:47 p.m. R58 was seated in her recliner, on a flat firm pillow with her legs in the dependent position. -At 2:38 p.m. an unidentified staff member delivered clean linen to R58's room and exited. The staff member did not offer or encourage R58 to reposition. -At 2:41 p.m. R58 remained in the same position, sleeping. Nursing assistant (NA)-K entered the room and immediately exited. -At 2:55 p.m. NA-K peeked her head into R58's room without verbalizing anything and exited. -At 3:15 p.m. R58 remained in the same position and had not repositioned self. Trained medication assistant (TMA)-B entered the room and asked R58 if she wanted her eye drops. Following the administration of the eye drops, TMA-B exited the room without offering or encouraging R58 to reposition. R58 remained seated in her recliner, in the same position without repositioning until 4:49 p.m. -At 4:49 p.m. NA-L entered the room, informed R58 it was dinnertime, applied a transfer belt around R58's waist and within seconds had transferred R58 into her wheelchair. R58 did not bear any weight during the transfer, and was not provided or encouraged to stand long enough to ensure adequate pressure relief or tissue re-perfusion occurred. R58 remained seated in her wheelchair until 5:39 p.m. -At 5:39 p.m. NA-K and TMA-B applied the transfer belt and within less than five seconds, had R58 transferred and seated back into her reclining chair. Neither NA-K or TMA-B offered or encouraged R58 to stand or lay down in order to ensure adequate tissue re-perfusion/pressure relief was achieved. -At 6:05 p.m. TMA-B entered the room and slightly elevated the recliner's footrest. -At 7:08 p.m., RN-C stated in order for R58 to sustain tissue perfusion in the coccyx area, R58 would have to be off of the coccyx for greater than one minute. RN-C confirmed R58 was not allowed enough time for tissue perfusion during the quick transfers. -At 7:15 p.m. RN-C and RN-G transferred R58 to bed. R58's coccyx was covered with a foam dressing. RN-C removed the dressing which had a moderate amount of reddish/brown drainage and exposed a pressure ulcer on R58's coccyx. The wound had a very strong, foul odor and varying levels of depth, slight undermining (the tissue under the wound edges becomes eroded, resulting in a a pocket beneath the skin at the wound's edge) and a small area of white slough at the top of the wound. RN-C stated the wound was way worse than when she had previously observed it, and according to the 11/28/17, assessment documentation, the wound had worsened. R58 was not provided adequate pressure relief for five hours and 30 minutes. On 11/30/17, at 7:09 a.m. R58 was observed seated in her recliner. R58 stated staff did not usually offered to reposition her, however, when they did, she would refuse if she was too tired. R58 confirmed she was not able to independently reposition and required staff assistance to do so. R58 also stated she did not request staff to assist her. R58's Skin Condition Report (SCR) dated 9/12/17, indicated R58's coccyx wound was about the same with a brown scab and a pinpoint pen area. Continue foam dressing. Will try Nepro (protein, carb steady supplement for [MEDICAL TREATMENT] patients). Additional SCR revealed the following information: -10/3/17, indicated scab no longer present, shallow crater. Reeducate R58 to turn and reposition, [MEDICAL TREATMENT] nurse reeducated, Nepro supplement and encourage daily vitamin. -10/10/17, wound measured larger in circumference, but less depth. Encourage turning and repositioning due to resistiveness, reeducate [MEDICAL TREATMENT] to encourage and will see if resident will take more Nepro. -10/18/17, indicated R58's wound had questionably worsened, the wound was smaller in size but was deeper with whitish slough. The plan was to increase [MEDICAL TREATMENT] medication, daily vitamin, encourage hourly turning and repositioning, and to try to get R58 to use her special wheelchair cushion, and often uses her small blue pillow at [MEDICAL TREATMENT] per their staff. -10/24/17, indicated R58's coccyx wound appeared smaller with no change and to continue foam dressing. -10/31/17, indicated wound was worse, physician was aware, continue foam dressing. R58's blue personal pillow she chooses to sit on is not as good as her pressure redistribution cushion but R58 insists on using her pillow. -11/23/17, wound much improved, no longer a crater, just surface, forming light tab scab again. Continue all measures including foam dressing. -11/28/17, indicated wound worse and to continue foam dressing. No further information was noted. R58's E-Z Graph Wound Assessment Worksheets revealed the following information: -9/12/17, the coccyx wound measured 0.1 centimeters (cm) by 0.1 cm with no depth indicated. The wound had scant amount of serous (serum like fluid) drainage and redness around the wound. No odor, eschar/slough, undermining or tunneling noted. May be open due to dot of drainage on dressing. Brown scab formation. Stage of wound not indicated. No further documentation of the wound until 10/3/17. -10/3/17, stage two coccyx wound which measured 0.9 cm by 0.8 cm with a depth of 0.2 cm. Wound base yellow, scant serosanguinous (blood and serum) drainage with redness around the wound. No odor, eschar, undermining or tunneling noted. Foam dressing utilized. -10/10/17, coccyx wound measured 1.4 cm by 0.9 cm by 0.1 cm depth. Scant serosanguinous drainage with redness around the wound. No odor, eschar/slough, undermining or tunneling noted. Stage of the wound not identified. -10/17/17, stage two coccyx wound measured 0.6 cm by 1.0 cm by 0.1 cm depth. wound base yellow/white with small amount serosanguinous drainage. Redness around the wound. Slough noted with no odor, undermining or tunneling. Foam dressing utilized. -10/24/17, stage two coccyx wound measured 0.7 cm by 0.8 cm by 0.1 cm depth. Wound base pink with scant serosanguinous drainage with redness around the wound. No odor, eschar/slough, undermining or tunneling noted. -10/31/17, stage two wound measured 1.5 cm by 1.3 cm by 0.2 cm depth. Yellow wound base with small amount serosanguinous drainage and redness around the wound. Slough was present with no odor, undermining, or tunneling noted. No further wound graphic documentation noted until 11/23/17. Foam dressing utilized. -11/23/17, stage two coccyx wound measured 1.7 cm by 1.3 cm by 0.1 cm depth. Wound base pink with scant amount bloody drainage with redness around wound. No odor, eschar/slough, undermining, or tunneling noted. Starting to have tan scab over part of wound. -11/28/17, stage two coccyx wound measured 3.5 cm by 1.5 cm with depth not recorded. Wound base yellow and white with odor and undescribed drainage. Odor and eschar/slough noted. No undermining or tunneling noted. Foam dressing utilized. R58's medical record lacked evidence R58's physician was notified or additional interventions implemented following the identification the pressure ulcer had worsened. R58's Resident Progress Notes dated 10/31/17, indicated coccyx wound examined. Open area is larger and wound is covered with yellow slough. Moderate amount serosanguinous draining with slight foul odor. Encourage R58 to use her pressure relief cushion rather than her small blue pillow. Res stated she could sit on what she wanted. R58 educated and allowed to make this choice. Concern that resident has also refused her vitamin and Nepro. Will continue to monitor. No further progress note documentation related to R58's pressure ulcer noted until 11/23/17. R58's Resident Progress Notes dated 11/23/17, indicated the wound had shown improvement since last full assessment. The writer had only been doing spot checks with PRN (as needed) dressing changes, for instance, when resident was being toileted and needed a clean one since last full assessment on 10/31/17, but there were no additional concerns in the interim; the area is not surface in nature, and no longer presents as a shallow crater; will continue all measures including the foam dressing; see wound notebook for measurements. No further progress note documentation related to R58's wound noted until 11/28/17. R58's Resident Progress Note dated 11/28/17, indicated wound had a a significant odor with some slough with a yellow/dark drainage on previous dressing. Although R58's progress notes revealed intermittent refusals for [MEDICAL TREATMENT] with a subsequent order for comfort cares, the documentation failed to identify if the development of the wound and it's deterioration was avoidable or unavoidable. On 11/30/17, 12:10 p.m. RN-C verified R58's wound had gotten larger and deeper and stated R58's physician had not yet been notified of this change, but planned to do so today. RN-C confirmed R58's skin assessment from 11/28/17, was incomplete and verified weekly skin assessments were missing, and should have been performed. RN-C stated the type of wound care was left up to the nursing staff to determine which dressing would be most appropriate and felt the foam dressing was the most appropriate and had not attempted nor tried any other type of dressing or treatment. RN-C confirmed R58 often refused assistance with repositioning but stated staff had not consistently documented the refusals. On 12/1/17, at 7:36 a.m. NA-M confirmed R58 required every one hour repositioning and stated when a resident was repositioned, they needed to stay off of the area for at least five minutes to ensure adequate pressure relief. On 12/1/17, at 7:45 a.m. RN-A stated offloading (pressure relief) needed to occur for one to two minutes in order to ensure good blood flow back to the areas prone to pressure and skin breakdown. At 8:15 a.m. RN-C also confirmed offloading needed to occur for two to three minutes in order to adequate ensure tissue perfusion. On 12/4/17, at 8:39 a.m. the DON stated R58 required every one hour repositioning which meant she would be free from pressure for at least 2 minutes. The DON stated even though R58 often refused repositioning, the staff should have still offered and attempted to reposition her as directed by the care plan and not assume she would always refuse. DON stated staff were to document R58's refusals and then provide her education. The DON also stated resident wounds were to be monitored with each dressing change and comprehensively assessed weekly, and as needed. The wound assessment documentation should include: root cause, stage, measurements, if improved or worsened, evaluation of the effectiveness of interventions and treatments. The DON stated if the wound had worsened, the physician was to be notified as soon as possible for potential changes in treatment. In addition, the DON confirmed R58's care plan should have identified the presence of the actual pressure ulcer, with realistic goals, and interventions. R54's admission MDS dated [DATE], indicated R54 had [DIAGNOSES REDACTED]. The MDS indicated R54 had severe cognitive impairment, required extensive assistance with bed mobility, transferring, ambulation, toileting and bathing. The MDS also indicated R54 had a two stage 2 pressure ulcers, one which was present on admission, and utilized a pressure reducing device in the bed (not chair), turning and positioning program, and received pressure ulcer care. R54's Pressure Ulcer CAA dated 10/24/17, indicated R54 spent most time in the bed or wheelchair, required staff assist for bed mobility, was frequently incontinent of bowel and bladder and had two stage 2 pressure ulcers present upon admission. R54 was at risk for the worsening of the pressure sores, the development of additional pressure ulcers, discomfort and gangrene/sepsis and was complicated by R54's weakness/fatigue, dementia, diabetes, and incontinence. Staff directed to turn and reposition R54 hourly and to complete weekly rounds until ulcers were healed. R54's care plan dated 10/25/17, indicated R54 had a potential for alteration in skin integrity related to history of a stroke, and inability to ambulate, transfer, turn and reposition, sit up or lie down and place legs into bed independently. Staff were directed to turn and reposition R54 every hour, utilize an alternating pressure mattress, and to monitor skin for red areas. The care plan did not address the presence of the two stage 2 pressure ulcers. R54's temporary care plan identified a problem dated 10/11/17, which indicated R54 had open areas on right buttocks, coccyx/sacrum, and directed staff to provide a pressure relief mattress, Laniseptic (added 10/24), [MEDICATION NAME] dressing every 3rd day and as needed (PRN) (no date when added), Roho pressure redistribution cushion to wheelchair (added 11/22/17), and nutritional supplements to promote healing such as Vit C, Diabetshield, Thera-M, Glucerna and Promod. R54's Braden Scale dated 10/14/17, indicated R54 was at risk for the development of pressure ulcers. On 11/28/17, at 9:54 a.m. family member (FM)-E was visiting and stated R54 had sores on her bottom. At this time, R54 was observed in bed positioned partially on her right side, with a wedge pillow behind her. -At 10:29 a.m. R54 was observed to remain in the same position. On 11/28/17, at 2:21 p.m. R54 was observed in bed, asleep. A wedge pillow was positioned partially behind her on the left side. Both heels laid directly on mattress, unsupported. On 11/29/17, at 12:50 p.m. R54 was observed in bed, asleep with the head of bed (HOB) elevated approximately 30 degrees. The wedge pillow was positioned behind her back, slightly on the right side. R54 rolled towards her back creating no pressure relief to the right buttocks and coccyx noted. Both heels rested directly on the mattress. -At 1:10 p.m. R54 remained in the same position. -At 2:16 p.m. R54 remain in bed, on her back. Cushions to the right of her but not under her. Heels directly on mattress. - 2:45 p.m. same position. - 3:00 p.m. Family here visiting. Position same. - 3:30 p.m. Family has left. R54 asleep. Still on back and heels on mattress. - 3:45 p.m. Observed NA-K and NA-L turn and reposition R54 onto her right side. Placed 2 wedge pillows behind her back. R54 came back so not positioned all way over to right side. R54 wanted HOB elevated some. Heels directly on mattress. Has indwelling urinary catheter. NAs stated R54 may not want to get up for supper as not unusual for her to stay in bed. - 4:15 p.m. R54 is positioned mostly on her back now. - 5:00 p.m. Position same. - 5:15 p.m. NA-L brought supper tray to her room. Positioned R54 onto back and elevated the HOB to approximately 45 degrees. Served cheese pizza, salad and peaches. Also small juice and milk. Feeding self. - 6:15 p.m. R54 ate 100%. HOB has been elevated since 5:15 pm. - 7:00 p.m. R54 was positioned on her right side with a wedge pillow behind her back, only slightly on the right side. Direct pressure to the right buttocks and coccyx. R54 was not positioned to relieve pressure to the right buttocks/coccyx pressure ulcers during observations. On 11/30/17, at 7:12 a.m. R54 was observed in bed positioned on her back and FM-E was visiting. - 7:20 a.m. R54 is awake. Position same. - 7:40 a.m. The DON and NA-J just coming out of R54's room. Stated they just got done repositioning R54 on her back for breakfast. HOB elevated. - 8:00 a.m. Position same. - 8:15 a.m. Position same. - 8:20 a.m. R54 was served breakfast. Feeding self. - 8:56 a.m. NA-J was observed to provide cares for R54. NA-J assisted with washing R54's back and axillae. R54 complained of pain with turning onto side, but once on her right side appeared less uncomfortable as no longer moaning. NA-J performed catheter cares then turned R54 onto her right side again. Incontinent of soft bowel movement. Observed large dressing to the buttocks/coccyx area was almost off. NA-J summoned LPN-C to change dressing. LPN-C washed hands and removed the dressing and cleansed wound. Large pressure ulcer covering coccyx and right buttocks. The coccyx has approximately 3 x 2 inch area of black/brown eschar, and to the right of the coccyx the buttocks area is red and open with an area of slough between the coccyx and buttocks. LPN-C stated the pressure ulcer looks deeper. She applied a new [MEDICATION NAME] dressing that covered the entire area, and washed her hands. NA-J finished assisting with oral cares. NA-J stated that R54 prefers to lay on her back and tends to roll back once she is positioned on her side. - 9:30 am R54 was observed on her left side and has wedge pillows behind her. However, she was not off coccyx area a was almost on back completely. - 12:15 p.m. R54 was observed up in the w/c next to bed. Does have Roho cushion in chair. Denies pain to the bottom when up. Served nutritional supplement. - 12:45 p.m. Still eating dinner. - 1:15 p.m. Still up in wheelchair. On 12/04/17, at 9:32 a.m. observed RN-C and NA-P provide cares. NA-P stated R54 does not stay over when positioned with the wedge pillow as likes to be on her back. RN-C and NA-P turned R54 far over on her left side to perform wound care. Sacral [MEDICATION NAME] dressing has large amount of exudate (light green, yellow). RN-C removed dressing and there was a sweet/foul odor to the drainage. RN-C stated the odor was new and thinks may be infected. RN-C washed hands then cleansed the wound with wound cleanser. R54 complained of some pain. RN-C touched the outside of the wound cleanser bottle with contaminated gloves and placed in window sill. RN-C stated the coccyx was deeper and pressure ulcer was worse. She measured the pressure ulcer. The black/brown eschar area to coccyx appeared larger and deeper since last observed by surveyor, in addition the area of yellow slough to the right of the black area is larger. RN-C applied skin prep and then the [MEDICATION NAME] dressing. R54 did not complain of pain while on left side during cares. RN-C stated the black/brown scabbed area measured 3 x 2 cm at coccyx and is 0.4 cm deep. RN-C washed her hands and had the contaminated wound cleanser bottle in her hand to return to the medication cart. Surveyor told RN-C the cleanser was contaminated and she left the bottle in the R54's room - 10:00 a.m. R54 was positioned on her left side, far over with pillows. No pressure to the coccyx area at this time. Review of Skin Condition Reports from 10/13 - 12-4/17, indicated pressure ulcers present at admission that healed and then reopened on 11/10/17: 10/13/17: 1st documentation of pressure ulcer Skin Condition Report - arrived from hospital with pressure ulcers to both buttocks. Continue Laniseptic barrier - foam dressing failed. EZ Graph -1.2 cm x 0.8 and 1.5 cm x 1 cm bottom. 10/17/17: Skin Condition Report - areas much smaller - can see where the outline used to be - continue with Laniseptic and turn/repositioning. EZ Graph - 0.4 x 0.2 x 0.1 deep (left buttock) 0.3 x 0.8 x 0/1 (right buttock) 10/24/17: Skin Condition Report - left buttock healed - right almost healed - will continue Laniseptic. EZ Graph - left buttock healed - right scabbed. 10/31/17: Skin Report - no longer open at all - still discolored reddish. 11/13/17: Reopened Skin Condition Report -reopened possibly from lying on back at ER (emergency room ) on 11/10. APP (alternating pressure mattress) applied - continue with diabetic shake - Glucerna - Promod - [MEDICATION NAME] instead of Laniseptic, MVI (multi-vitamin) and vitamin C. EZ Graph - right coccyx and right buttocks - started Sacral [MEDICATION NAME] instead of Laniseptic - coded as DTI (deep tissue injury). Area measures 7.5 cm x 5.5 cm with 2.5 cm purple pink color and 0.2 cm depth. There was no physician (MD) notification of the newly developed pressure ulcer. 11/22/17: Skin Condition Report - reinforced hourly turn and positioning - took off APP - got new Embrace mattress - Roho for w/c - has Foley now (urine retention) - MD faxed. EZ Graph - 7.5 x 5.5 area - PU 3.1 x 2 x 0.2 eschar to right buttock. 11/28/17: Skin Condition Report - the outer perimeter of the right buttocks is smaller - eschar unchanged - called MD due to no response from fax - continue with [MEDICATION NAME] dressing. EZ Graph - 2.5 x 2.5 eschar right buttocks - 7 cm area discolored. 12/4/17: Skin Condition Report - not yet documented at time of survey. EZ Graph - 3 x 2 cm scab - additional slough since last exam - undermining along edge of scabbed area. 0.4 cm depth. 6.5 c 7.5 area. Wound Round Documentation: 12/04/17: Wound note: Assessed wound after resident finished her breakfast in conjunction with her turning schedule. The [MEDICATION NAME] had been changed yesterday according to the label of the dressing, and yet there was already a foul odor upon removal of resident's dressing, and the dressing was saturated throughout the bottom 1/2 with heavy purulent tan drainage. Cleansed the wound with dermaclenz and patted dry. The area covered with eschar is beginning to undermine on the proximal wound edge, with a depth of 0.4 cm. There is more adherent yellowish white slough below the area of eschar, which now measures 3 cm x 2 cm. The irregular area that is open and more surface in nature distal to the eschar on the right buttock is smaller in total area and still showing signs of improvement. Tried to call MD office for advice, but had to leave message. Tried to get resident in today to the wound clinic due to the decline, but there spaces were all full, and the MD that was there could not add a visit, he had another clinic to get to at lunch. Due to concern of the speed of decline in the wound along with the odor, felt that the wound should be seen by a provider today, so called back and was able to schedule an office visit for resident to be seen by Dr. (name) PA, (PA name), this afternoon at 1:40 PM. Medivan will pick her up between 1:10 and 1:20. Family is in agreement and son will accompany. Son called resident's husband (his dad)on his own cell to update while this writer was present and he is OK with the transfer. Instructed the CNA about the appt., but to make sure she did not get her up too soon due to length of time she will be on the Roho cushion. Asked on the clinic form whether resident should have a wound culture or antibiotics and asked for advice on what dressing to use. Also notified them that she is still resistive to turning despite regular turning, she starts to roll herself toward her back. Asked if the indwelling cath should remain in place or not. Will send resident to the appt. and watch for new orders as a result of today's appt. Also mentioned that she continues to have intermittent abdominal discomfort. This morning she c/o (complained of) abdominal discomfort, but denied discomfort in the buttocks. Went back later to assess abdomen, and bowel sounds were active, and abdomen at that time was soft and non-tender; it feels much better and resident smiled. She had, however, already started to roll toward her back and assisted to reposition again. 11/28/17, Dietary note: (skin issue update report) is noted res admitted with open are on bottom, left buttock healed, but now has an open area on sacrum. Res on Thera M, Vit C, Diabetishield 8oz BID (twice daily) , Glucerna 4oz (four times daily) QID, Promod 30 cc's BID. Note most recent Prealb completed on 10/23/17 at 15.0 this is low. Res offered decub as well. Will continue to review skin issue update report and labs as available prn. Continue nutr. intervention at this time. 11/28/17: Wound Rounds: Assessed resident's sacral area and right buttock early yesterday morning with dressing change. The eschar found last week remains firmly fixed next to the right buttock crease. Actually, the perimeter of the rest of the open area that has no eschar has actually improved since last week with the switch to the Embrace mattress and Roho chair cushion. Will continue with the sacral [MEDICATION NAME] because of this, but will reattempt to get wound clinic involved due to the presence of this eschar. Discussed this with resident's husband this morning due to his previous reluctance for her to attend appts, but he is willing to have her go to the wound clinic if we get the order. The fax that was sent Monday was returned to us with no response from the MD, so called to get this rectified. See wound notebook for measurements of area. Resident has been willing to eat better in the past few days. She seems to do better when her family visits. 11/2

Based on observation, interview, and document review, the facility failed to ensure a physician was notified of a change in condition for 1 of 1 resident (R28) who had developed, fever, vomiting and decreased lung sounds. The facility's failure to contact the physician resulted in actual harm for R28 who required hospitalization for pneumonia,[MEDICAL CONDITION] and dehydration. In addition, the facility failed to notify the physician of the development and/or worsening of a pressure ulcer for 2 of 3 residents (R58, R54) reviewed for pressure ulcers, and failed to notify the physician of the increase in lower extremity [MEDICAL CONDITION] with the development of a ruptured blister and weeping skin for 1 of 2 residents (R58) reviewed for non-pressure related skin conditions. Findings include: R28's physician was not notified of a change of condition. R28's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R28 had [DIAGNOSES REDACTED]. R28 was not able to communicate or make decisions on her own. The assessment indicated R28 was totally dependent upon staff for all activities of daily living. On [DATE], at 12:50 p.m. family member (FM)-A and FM-B requested to speak to the State agency surveyor regarding a concern. FM-B stated FM-A and FM-B had been out of town in [DATE], and upon returning home, had stopped at the facility to see R28. When they arrived at the facility, they found R28 with a high fever, she was lethargic and unable to drink. They approached registered nurse (RN)-D, the charge nurse, and requested to have R28 seen in the emergency department, however, RN-D refused to assist the family with transportation to the hospital. FM-B stated RN-D told them that R28's primary physician had ordered an antibiotic earlier that day and R28 was not to go the hospital for an evaluation. When requested again by the family, RN-D refused to contact the physician again or to assist in transferring R28 to the hospital. FM-A became tearful as FM-B stated an unidentified staff member obtained the phone number for the transportation company so that R28 could be transported to the hospital. FM-B contacted the transportation company and had R28 transferred to the emergency room without assistance from the facility. While at the hospital, R28 was diagnosed with [REDACTED]. FM-B stated the emergency room physician informed the family that if R28 had not been started on IV therapy that day, she would have died by morning. FM-B stated she had reported the concern to the facility administrator, however, the administrator supported the actions of RN-D. Review of R28's Progress Notes revealed the following information: -On [DATE], at 3:35 p.m. indicated R28 had experienced an emesis prior to lunch, R28's temperature was noted to be 101.0 degrees Fahrenheit (F). R28 had another emesis at lunch and R28's temperature was around 102 degrees F. After lunch, R28 was noted to have wheezes ([MEDICATION NAME] or rattling sound in the chest, as a result of obstruction in the air passages). R28's primary physician was called and an antibiotic was ordered for twice a day for ten days for possible aspiration (entry of material from the oropharynx or gastrointestinal tract into the larynx (voice box) and lower respiratory tract). -At 4:59 p.m. indicated R28's temperature at 2:20 p.m. was 100.9 degrees F. R28 was lethargic, skin was hot and moist to the touch, cheeks were red and R28 was only taking sips of fluids. Will continue to monitor. -At 5:01 p.m. indicated R28's temperature was 101.6 at 3:00 p.m. and was given Tylenol. R28 was seated in wheelchair, and received the first does of the antibiotic. FM-A and FM-B had requested R28 be evaluated in the emergency room . The charge nurse was informed of the request. -At 5:07 p.m. RN was called down R28's unit. Husband looks angry when RN walking towards him. FM-A and FM-B both requested to have R28 sent immediately to the hospital. FM-B had stated to the RN just look at her. RN explained to FM-A and FM-B that R28's physician had ordered resident to stay at facility and had also ordered an antibiotic to be started for possible aspiration. FM-A stated he did not care what the physician had ordered or said. RN informed FM-A and FM-B that if they wanted R28 sent to the hospital that it was their choice and they had every right to do so but she would not be arranging rides or taking part of the situation due to having no doctor's order. The note further indicated the RN attempted to explain to FM-A and FM-B the reasoning for keeping R28 at the facility was due to the hospital or emergency room (ER) not doing anything more that what the facility was currently doing for R28 here and now. FM-B had questioned R28's breathing and oxygen in which the RN indicated R28's oxygen level was 91% and that she would receive oxygen if her levels went below 90%. FM-A became angry, red in the face, pointing finger, and hollering at the RN. RN called the ER charge nurse to give a little heads up on the situation. The note lacked evidence an assessment of R28's condition was completed at the time of the family request and also lacked evidence of any attempts to contact R28's primary physician or an on call physician regarding the family's wishes. -6:01 p.m. R28 left facility via MediVan. RN notified the ED that the resident was on her way with family. -9:41 p.m. RN received call from the ER which informed the facility R28 was really sick, was started on an intravenous antibiotic, had a nasogastric tube inserted, and R28 was septic therefore was admitted to the hospital. Review of R28's physician's orders [REDACTED]. R28's Uniform Code Level Direction for Cardiopulmonary Resuscitation form dated [DATE], indicated the family had determined that no interventions were to be made in the event of a cardiac or respiratory arrest. Other conditions were to be treated as medically appropriate. The family had not restricted any other medical treatments in the event of an emergency. They had not refused further hospitalization s. The Hospital Triage Chief Complaint documentation dated [DATE], indicated R28 arrived at the emergency room with family complaints of fatigue. Family reported when they arrived at the facility, R28 was observed hanging over the side of her chair with her tongue hanging out. R28 was not responding to family and her tongue was white and dry appearing. R28 had recently been treated for [REDACTED]. The emergency room note dated [DATE], indicated R28's white blood count was elevated to 29.400 (normal number of WBCs in the blood is 4,500 to 11,000 a high number indicates the body's reaction to fight infection). R28 was admitted to the hospital with [REDACTED]. The hospital Progress Note dated [DATE], indicated R28 had [DIAGNOSES REDACTED]. R28's Hospital Discharge Summary dated [DATE], indicated R28 required hospitalization for the provisional [DIAGNOSES REDACTED]. R28 received IV fluids and antibiotics, her temperature had returned to normal, she was alert and was able to swallow food comfortably. R28 was to continue on oral antibiotics for a total of 10 additional days. On [DATE], at 7:10 a.m. LPN-D stated if a family member requested a resident to go to the hospital, she would check on the resident, notify the charge nurse, and make arrangements to assist to transfer the resident to the hospital. On [DATE], at 7:30 a.m. RN-A stated if a family member requested to send a resident to the hospital, the resident was to be assessed, a physician (either the resident's primary physician or the on call physician) was to be contacted and the facility staff were to assist with the transfer. RN-A stated she was aware of the concern on [DATE], with R28's family request to be transferred to the hospital. RN-A stated ultimately R28 was seen in the hospital and admitted and verified it was the family's right to have the resident seen in the emergency room if they wished. On [DATE], at 8:22 a.m. RN-B stated if a family member wished to have a resident seen in the emergency room , the staff were to complete an assessment, contact the primary physician or on call physician and obtain an order to transfer the resident to the hospital for further evaluation per the family request. RN-B stated R28 had a history of [REDACTED]. RN-B stated R28 had not been physically evaluated by the primary physician on [DATE], rather due to the physician knowing R28's history or aspiration pneumonia and previous treatments, and R28 having been recently treated with an antibiotic for aspiration pneumonia, R28's physician had instructed the facility to treat R28 at the facility, had ordered an antibiotic and requested to not send R28 to the emergency room . RN-B confirmed the instructions to refrain from hospital transfer/evaluation had not been written as a physician's orders [REDACTED]. R28's primary physician and the family had discussed hospitalization s in the past and there was a verbal agreement to treat R28 at the facility versus in the acute hospital. RN-B stated she had attempted to contact R28's family on [DATE], to notify them of her deterioration however, she was unable to reach the family and did not document her attempts to contact the family in R28's record. Upon review of the [DATE] documentation, RN-B stated it would have been beneficial for RN-D to have completed an assessment of R28's condition, contact a physician and assist to transfer R28 to the emergency room per the family request. -At 8:52 a.m. the director of nurses (DON) stated if a family member wished to have their loved one evaluated by the emergency room physician, the staff were to assess the resident, contact a physician and assist to make the arrangements to transfer the resident to the hospital. The DON stated she would not expect the staff to refuse to transfer a resident when the family requested. -At 8:56 a.m. RN-C stated if a family member requested to have their loved one transferred to the hospital, she would complete a resident assessment, contact the primary physician or the on call physician, and make the arrangements to transfer to the hospital. -At 9:03 a.m. the DON stated R28's primary physician was notified of R28's vomiting, fever and wheezes on [DATE], and had ordered R28 a new antibiotic. R28's primary physician prefers the residents of the facility to be treated in the facility and staff were to inform him of any changes. The DON confirmed R28's medical record did not contain a physician's orders [REDACTED]. The DON confirmed RN-D's documentation lacked an assessment of R28's condition on [DATE], and verified RN-D did not attempt to notify a physician of any potential changes in R28's condition. Upon review of the progress note dated [DATE], at 6:01 p.m. the DON stated she was unaware the documentation clearly indicated RN-D refused to assist FM-A and FM-B to transfer R28 to the emergency room for an evaluation and stated that was not the facility's normal practice. The DON stated she had talked to RN-D about the actions on [DATE], and directed RN-D and the rest of the staff to assist with transfers to the hospital per the family choice. However, the DON stated she had not documented the directive nor had she provided any type of formal training to the staff rather during shift to shift report, she had directed the staff to remind each other to follow family requests. The DON stated she had not considered R28's response to requested care on [DATE], to be neglectful. -At 9:21 a.m. the DON and state agency attempted to contact RN-D without success. -At 9:49 a.m. the facility administrator reviewed RN-D's documentation from [DATE], at 5:07 p.m. and stated he was unaware RN-D had not assessed R28 at the time of the family request, had refused to contact a physician, or assist the family in transferring R28 to the hospital. The administrator confirmed R28's physician should have been notified of R28's change of condition, however, had not considered the lack of response to R28's family request or lack of further assessment related to R28's decline in condition to be neglectful. On [DATE], at 4:00 p.m. RN-D stated it was her understanding R28 had been started on a new antibiotic and she was not to be sent to the emergency room as they could not do anything differently than what was being done at the facility. RN-D confirmed R28's medical record did not contain a physician's orders [REDACTED]. RN-D stated on [DATE], when FM-A had requested R28 be sent to the emergency, FM-A was angry and threatening towards her so she had to walk away from the situation. RN-D stated she did not feel she had the time to assess R28 or to help with the transfer as the family had already made the arrangements and left with R28. RN-D stated she had called the emergency room regarding R28's family request, however, she had not attempted to contact a physician. RN-D stated she did not consider her response to R28's condition or family request to be neglectful The Resident Incidents/change in Resident Health Status date ,[DATE], directed staff to provide continued care for a resident when they become acutely ill. The policy directed the charge nurse to assess the illness, notify family and physician of any changes, assist with transfers to the hospital as needed and update the resident's care plan as needed. R58 was identified to have a deteriorating pressure ulcer, increased lower extremity [MEDICAL CONDITION] and the presence of a new non pressure related wound and the physician was not notified of these changes. R58's Care Center [DIAGNOSES REDACTED]. R58's nursing progress note dated [DATE], indicated both lower extremities were swollen, weeping, and had a fluid filled blister which had recently ruptured. A dressing was applied to the ruptured blister area and a wound dressing change schedule was set up to include dressing changes for both legs. However, R58's medical record lacked evidence of physician notification of the right leg wound, the increase in leg [MEDICAL CONDITION] (swelling), blister formation, and weeping of fluid in the legs. R58's E-Z Graph Wound assessment dated [DATE], indicated R58 had a stage two pressure ulcer (partial loss of the first layer of skin) on the coccyx which measured 1.7 centimeters (cm) by 1.3 cm with a depth of 0.1 cm with no odor present and no slough (yellow or white tissue that can be stringy or thick and adheres to the tissue bed), and had tan scab like formation over part of the wound. R58's E-Z Graph Wound Assessment System [DATE], indicated R58's stage two coccyx pressure ulcer measured 3.5 cm by 1.5 cm with no depth recorded. The assessment also indicated the pressure ulcer worsened and had eschar/slough present along with odor. However, R58's medical record lacked evidence the physician was notified that the wound had worsened and had the presence of an odor. On [DATE], at 12:00 p.m. R58 was observed seated in the recliner with both legs in the dependent position, [MEDICAL CONDITION] was noted from ankle to mid-calf area, bilaterally. The left leg had large scales of dry skin on the foot and ankle. On [DATE], at 6:09 p.m. R58's lower extremities were observed to be [MEDICAL CONDITION]. The right leg wound was observed with registered nurse (RN)-G. The wound measured approximately 2.0 inch by 0.5 inch with a depth of approximately 0.1 cm. A thin layer of yellowish/green slough was observed in the lower area of the wound. On [DATE], at 7:15 p.m. R58's coccyx wound was visualized with RN-C. The pressure ulcer had varying levels of depth, had a very strong foul odor, slight undermining (when the tissue under the wound edges becomes eroded, resulting in a a pocket beneath the skin at the wound's edge) and a small area of white slough at the top of the wound and dark reddish/brown drainage on the dressing. RN-C stated the wound was way worse than when she had previously observed it on [DATE], and had furthered worsened since the [DATE], documented assessment. R58's E-Z Graph Wound assessment dated [DATE], indicated the right shin wound measured 5.0 cm by 1.0 cm, depth could not be determined because it was covered with slough. On [DATE], at 12:10 p.m. RN-C confirmed R58's physician had not been notified of the change in the pressure ulcer and stated the physician should have been notified when the wound was fist noted to have worsened. In addition, RN-C stated she was not aware of R58's increase in [MEDICAL CONDITION], blister formation, or the right leg wound and verified R58's physician should have also been informed about the increase in [MEDICAL CONDITION] and the presence of a new wound. On [DATE], at 8:39 a.m. the DON stated R58's primary physician should have been notified of the worsening pressure ulcer and the skin integrity changes, as soon as possible. R54's admission MDS dated [DATE], indicated R54 had [DIAGNOSES REDACTED]. The MDS indicated R54 had severe cognitive impairment, required extensive assistance with bed mobility, transferring, ambulation, toileting and bathing. The MDS also indicated R54 had a two stage 2 pressure ulcers, one which was present on admission, and utilized a pressure reducing device in the bed (not chair), turning and positioning program, and received pressure ulcer care. R54's Pressure Ulcer CAA dated [DATE], indicated R54 spent most time in the bed or wheelchair, required staff assist for bed mobility, was frequently incontinent of bowel and bladder and had two stage 2 pressure ulcers present upon admission. R54 was at risk for the worsening of the pressure sores, the development of additional pressure ulcers, discomfort and gangrene/sepsis and was complicated by R54's weakness/fatigue, dementia, diabetes, and incontinence. Staff directed to turn and reposition R54 hourly and to complete weekly rounds until ulcers were healed. R54's care plan dated [DATE], indicated R54 had a potential for alteration in skin integrity related to history of a stroke, and inability to ambulate, transfer, turn and reposition, sit up or lie down and place legs into bed independently. Staff were directed to turn and reposition R54 every hour, utilize an alternating pressure mattress, and to monitor skin for red areas. The care plan did not address the presence of the two stage 2 pressure ulcers. R54's temporary care plan identified a problem dated [DATE], which indicated R54 had open areas on right buttocks, coccyx/sacrum, and directed staff to provide a pressure relief mattress, Laniseptic (added ,[DATE]), [MEDICATION NAME] dressing every 3rd day and as needed (PRN) (no date when added), Roho pressure redistribution cushion to wheelchair (added [DATE]), and nutritional supplements to promote healing such as Vit C, Diabetshield, Thera-M, Glucerna and Promod. R54's Braden Scale dated [DATE], indicated R54 was at risk for the development of pressure ulcers. Review of Skin Condition Reports from ,[DATE] to - 12-,[DATE], indicated pressure ulcers reopened on [DATE], and the MD was not notified until [DATE]. [DATE]: Reopened Skin Condition Report -reopened possibly from lying on back at ER (emergency room ) on ,[DATE]. APP (alternating pressure mattress) applied - continue with diabetic shake - Glucerna - Promod - [MEDICATION NAME] instead of Laniseptic, MVI (multi-vitamin) and vitamin C. EZ Graph - right coccyx and right buttocks - started Sacral [MEDICATION NAME] instead of Laniseptic - coded as DTI (deep tissue injury). Area measures 7.5 cm x 5.5 cm with 2.5 cm purple pink color and 0.2 cm depth. There was no physician (MD) notification of the newly developed pressure ulcer. [DATE]: Skin Condition Report - reinforced hourly turn and positioning - took off APP - got new Embrace mattress - Roho for w/c - has Foley now (urine retention) - MD faxed. EZ Graph - 7.5 x 5.5 area - PU 3.1 x 2 x 0.2 eschar to right buttock. [DATE]: Skin Condition Report - the outer perimeter of the right buttocks is smaller - eschar unchanged - called MD due to no response from fax - continue with [MEDICATION NAME] dressing. EZ Graph - 2.5 x 2.5 eschar right buttocks - 7 cm area discolored. [DATE]: Skin Condition Report - not yet documented at time of survey. EZ Graph - 3 x 2 cm scab - additional slough since last exam - undermining along edge of scabbed area. 0.4 cm depth. 6.5 c 7.5 area. Wound Round Documentation: [DATE]: Wound note: Assessed wound after resident finished her breakfast in conjunction with her turning schedule. The [MEDICATION NAME] had been changed yesterday according to the label of the dressing, and yet there was already a foul odor upon removal of resident's dressing, and the dressing was saturated throughout the bottom ,[DATE] with heavy purulent tan drainage. Cleansed the wound with dermaclenz and patted dry. The area covered with eschar is beginning to undermine on the proximal wound edge, with a depth of 0.4 cm. There is more adherent yellowish white slough below the area of eschar, which now measures 3 cm x 2 cm. The irregular area that is open and more surface in nature distal to the eschar on the right buttock is smaller in total area and still showing signs of improvement. Tried to call MD office for advice, but had to leave message. Tried to get resident in today to the wound clinic due to the decline, but there spaces were all full, and the MD that was there could not add a visit, he had another clinic to get to at lunch. Due to concern of the speed of decline in the wound along with the odor, felt that the wound should be seen by a provider today, so called back and was able to schedule an office visit for resident to be seen by Dr. (name) PA, (PA name), this afternoon at 1:40 PM. Medivan will pick her up between 1:10 and 1:20. Family is in agreement and son will accompany. Son called resident's husband (his dad)on his own cell to update while this writer was present and he is OK with the transfer. Instructed the CNA about the appt., but to make sure she did not get her up too soon due to length of time she will be on the Roho cushion. Asked on the clinic form whether resident should have a wound culture or antibiotics and asked for advice on what dressing to use. Also notified them that she is still resistive to turning despite regular turning, she starts to roll herself toward her back. Asked if the indwelling cath should remain in place or not. Will send resident to the appt. and watch for new orders as a result of today's appt. Also mentioned that she continues to have intermittent abdominal discomfort. This morning she c/o (complained of) abdominal discomfort, but denied discomfort in the buttocks. Went back later to assess abdomen, and bowel sounds were active, and abdomen at that time was soft and non-tender; it feels much better and resident smiled. She had, however, already started to roll toward her back and assisted to reposition again. [DATE]: Wound Rounds: Assessed resident's sacral area and right buttock early yesterday morning with dressing change. The eschar found last week remains firmly fixed next to the right buttock crease. Actually, the perimeter of the rest of the open area that has no eschar has actually improved since last week with the switch to the Embrace mattress and Roho chair cushion. Will continue with the sacral [MEDICATION NAME] because of this, but will reattempt to get wound clinic involved due to the presence of this eschar. Discussed this with resident's husband this morning due to his previous reluctance for her to attend appts, but he is willing to have her go to the wound clinic if we get the order. The fax that was sent Monday was returned to us with no response from the MD, so called to get this rectified. See wound notebook for measurements of area. Resident has been willing to eat better in the past few days. She seems to do better when her family visits. [DATE]: RN note: Writer did fax MD regarding resident's wound to sacral area. Writer informed MD what staff is currently doing to facilitate wound healing, and asked if he had any suggestions. Writer has asked MD if resident should see Wound care, and have a [MEDICATION NAME] lab completed. [DATE]: Wound Rounds: Assessed the area on resident's sacrum and right buttock again this week during [MEDICATION NAME] change with (name), DON. The sacral area is now larger instead of smaller, and brown eschar is beginning to cover the area, which increased somewhat to 3.1 x 2 cm. The area that had been purplish, the surface skin separated and now some areas throughout are reddish pink surface, but mostly open. See wound notebook for all measurements. Additional measures needed to be taken. Was able to get a Roho cushion for this resident, which was placed in w/c and adjusted by (name), OT. The APP mattress will be removed, since the area had worsened. Had found that the first Embrace mattress was not the brand name Embrace, but a substitute called pressure relief; maintenance now has received brand new in the package Embrace mattress which was placed on resident's bed. Hourly turns were reinforced to staff, although resident often rolls herself from side where staff has her positioned onto her back despite being propped with pillows when staff leaves the room. Resident has been insisting to eat in bed, but there are some shearing forces in play there with resident sliding down, so reeducated resident and staff that sitting on the roho cushion in w/c for meals is preferable, then returning to side in bed within the proper turning time frame is imperative. She is on diabetishield 1 box twice daily; promod; Glucerna 4x daily, thera-M and Vitamin C. Her most recent [MEDICATION NAME] in October was 15, which was below normal range, so these measures were instituted at that time. Will continue with the sacral [MEDICATION NAME] at that time and if still no improvement with all additional measures next week, will contact MD for suggestions. [DATE]: Wound Rounds: Due to reports of resident's skin breakdown, assessed resident's buttocks for the wound round book early this AM. Her left buttock remains intact. Her right buttock has worsened and has reopened since last Friday, ,[DATE], per (name), LPN, who visualized the area on Friday when assisting staff to toilet resident. The proximal margin is the top of the right buttock crease. There is a dark red area that had no drainage that appeared as a shallow ulcer with no drainage measuring 2.5 cm x1.5 cm x 0.2 cm. Extending from this is an additional area that is purplish in color but 5.5 x 6.5 in additional measurement of mostly intact skin. There was an abraded area within this purple area that measured 0.5 x 0.2 that had scant bloody drainage. Decision was made to remove resident's brief that had been in place; washed and dried the area and left the brief off, since resident has had a foley catheter in place since her visit to theER on Friday night,to attempt to keep the area from becoming moist again from perspiration. A soaker was carefully placed under the resident. After about an hour, at the next repositioning, (name), LPN placed a sacral comfort foam border dressing over the entire area to prevent shearing forces. Will change this every 3 days and PRN. Will continue with the hourly turns. Resident is tolerating the APP mattress, and turning, in fact turned her to her left side and went back to check her and she was sound asleep and looked comfortable within 15 minutes. Resident denied stomach discomfort this AM and ate at least ,[DATE] of her breakfast; was able to feed herself. Concern for this worsening over the weekend; resident had spent Friday evening in the ER, not sure of her turning and repositioning at that time. (However, the MD was not notified of the development of pressure ulcer on [DATE], nor when the pressure ulcer worsened on [DATE].) [DATE]: LPN note: temp 100.1, writer gave PRN Tylenol at 7am, writer noted resident is tired but did say a few words to writer, noted residents wound to buttocks is worse and is open and bruising around it, Staff is repositioning resident from side to side every hr and applying barrier cream as needed. On [DATE], at 1:32 p.m. RN-C was interviewed and verified the pressure ulcers have worsened and believes that it re-developed when she was sent to theER on ,[DATE] and was on gurney for long period of time. On [DATE], at 9:02 a.m. RN-C verified the odor to the pressure ulcers and stated she contacted the MD to send to the clinic as the pressure ulcers may be infected and have worsened. She also verified that there was not a fax to the MD when the pressure ulcers opened on ,[DATE] or when she assessed on [DATE], and changed treatment. RN-C added she probably did this but did not document it, and she changed the order to [MEDICATION NAME] dressing without contacting the MD. The Skin Care Protocol policy and procedure revised ,[DATE], section titled with onset of all ulcers directed staff to initiate wound flow sheet/EZ graph and to document on the following every week: -location -size (length, width, depth, undermining or tunneling -color -odor -exudate -skin condition around wound -wound edges -wound bed appearance -only stage pressure related ulcers. Other ulcers are considered partial or full thickness. -assess for causative factor and implement intervention to prevent an injury from occurring again -initate Braden's scale and do weekly unit healed. Once healed do Braden every week for four weeks. -wound rounds weekly -pain assessment -review chart and discuss with physician to determine type and etiology of ulcer. Venous ulcer described as shallow weeping [MEDICAL CONDITION] with irregular wound edges. Leg hyperpigmentation, [MEDICAL CONDITION] and palpable pulses. -notify family and physician about change in skin condition and current treatment plan -obtain and review labs -assure resident receives multivitamin with zinc and vitamin C at least daily -notify registered dietician -document in nurses notes daily by LPN and weekly by the RN -if no improvement in two weeks, update physician and change plan of care. -start pressure relieving devices (wheelchair, recliner and bed) The undated Pressure Ulcers in Long Term Care policy section titled Other Skin Concerns identified a Stasis Ulcer as a destruction of tissue resulting from the stoppage or slowing of the normal blood flow to an area. This causes a back up in fluid causing congestion. The section titled Assessment Of Other Skin Concerns directed the documented identification of the type of wound, the site, the size (width, length, depth, and condition of surrounding tissue) in centimeters, and if exudate. The policy Appendix described [MEDICAL CONDITION] as a local or generalized condition in which the body tissues contain and excessive amount of tissue fluid. Exudate was described as fluid that leaks from injured tissue which may be oozing pus or serum. The policy went on to direct staff on how to measure for the extent of [MEDICAL CONDITION].

Based on observation, interview and document review, the facility failed to ensure 1 of 1 resident (R28) received necessary medical attention following the onset of an acute illness and the facility staff refused to transfer R28 to the hospital for treatment. R28 sustained actual harm as required hospitalization for treatment of [REDACTED]. In addition, the facility failed to comprehensively assess, monitor, and implement interventions for 1 of 1 resident (R58 ) who had non pressure related open areas to the lower legs and also had increase of [MEDICAL CONDITION] (swelling) to legs. R58 sustained actual harm as the skin conditions worsened. Findings include: R28's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R28 had [DIAGNOSES REDACTED]. R28 was not able to communicate or make decisions on her own. The assessment indicated R28 was totally dependent upon staff for all activities of daily living. On [DATE], at 12:50 p.m. family member (FM)-A and FM-B requested to speak to the State agency surveyor regarding a concern. FM-B stated FM-A and FM-B had been out of town in [DATE], and upon returning home, had stopped at the facility to see R28. When they arrived at the facility, they found R28 with a high fever, she was lethargic (a state of tiredness, weariness, fatigue, or lack of energy), and was unable to drink. They approached registered nurse (RN)-D, the charge nurse, and requested to have R28 seen in the emergency department, however, RN-D refused to assist the family with transportation to the hospital. FM-B stated RN-D told them that R28's primary physician had ordered an antibiotic earlier that day and R28 was not to go to the hospital. When requested again by the family, RN-D refused to contact the physician again or to assist in transferring R28 to the hospital. FM-A became tearful as FM-B stated an unidentified staff member obtained the phone number for the transportation company so that R28 could be transported to the hospital. FM-B contacted the transportation company and had R28 transferred to the emergency room without assistance from the facility. While at the hospital, R28 was diagnosed with [REDACTED]. FM-B stated the emergency room physician informed the family that if R28 had not been started on IV therapy that day, she would have died by morning. FM-B stated she had reported the concern to the facility administrator, however, the administrator supported the actions of RN-D. Review of R28's Progress Notes revealed the following information: -On [DATE], at 3:35 p.m. indicated R28 had experienced an emesis prior to lunch, R28's temperature was noted to be 101.0 degrees Fahrenheit (F). R28 had another emesis at lunch and R28's temperature was around 102 degrees F. After lunch, R28 was noted to have wheezes ([MEDICATION NAME] or rattling sound in the chest, as a result of obstruction in the air passages). R28's primary physician was called and an antibiotic was ordered for twice a day for ten days for possible aspiration (entry of material from the oropharynx or gastrointestinal tract into the larynx (voice box) and lower respiratory tract). -At 4:59 p.m. indicated R28's temperature at 2:20 p.m. was 100.9 degrees F. R28 was lethargic, skin was hot and moist to the touch, cheeks were red and R28 was only taking sips of fluids. Will continue to monitor. -At 5:01 p.m. indicated R28's temperature was 101.6 at 3:00 p.m. and was given Tylenol. R28 was seated in wheelchair, and received the first does of the antibiotic. FM-A and FM-B had requested R28 be evaluated in the emergency room . The charge nurse was informed of the request. -At 5:07 p.m. RN was called down R28's unit. Husband looks angry when RN walking towards him. FM-A and FM-B both requested to have R28 sent immediately to the hospital. FM-B had stated to the RN just look at her. RN explained to FM-A and FM-B that R28's physician had ordered resident to stay at facility and had also ordered an antibiotic to be started for possible aspiration. FM-A stated he did not care what the physician had ordered or said. RN informed FM-A and FM-B that if they wanted R28 sent to the hospital that it was their choice and they had every right to do so but she would not be arranging rides or taking part of the situation due to having no doctor's order. The note further indicated the RN attempted to explain to FM-A and FM-B the reasoning for keeping R28 at the facility was due to the hospital or emergency room (ER) not doing anything more that what the facility was currently doing for R28 here and now. FM-B had questioned R28's breathing and oxygen in which the RN indicated R28's oxygen level was 91% and that she would receive oxygen if her levels went below 90%. FM-A became angry, red in the face, pointing finger, and hollering at the RN. RN called the ER charge nurse to give a little heads up on the situation. The note lacked evidence an assessment of R28's condition was completed at the time of the family request and also lacked evidence of any attempts to contact R28's primary physician or an on call physician regarding the family's wishes. -6:01 p.m. R28 left facility via MediVan. RN notified the ED that the resident was on her way with family. -9:41 p.m. RN received call from the ER which informed the facility R28 was really sick, was started on an intravenous antibiotic, had a nasogastric tube inserted, and R28 was septic therefore was admitted to the hospital. Review of R28's physician's orders [REDACTED]. R28's Uniform Code Level Direction for Cardiopulmonary Resuscitation form dated [DATE], indicated the family had determined that no interventions were to be made in the event of a cardiac or respiratory arrest. Other conditions were to be treated as medically appropriate. The family had not restricted any other medical treatments in the event of an emergency. They had not refused further hospitalization s. The Hospital Triage Chief Complaint documentation dated [DATE], indicated R28 arrived at the emergency room with the family and complaints of fatigue. Family reported when they arrived at the facility, R28 was observed hanging over the side of her chair with her tongue hanging out. R28 was not responding to family and her tongue was white and dry appearing. R28 had recently been treated for [REDACTED]. The emergency room note dated [DATE], indicated R28's white blood count was elevated to 29,400 (normal number of WBCs in the blood is 4,500 to 11,000 a high number indicates the body's reaction to fight infection). R28 was admitted to the hospital with [REDACTED]. The hospital Progress Note dated [DATE], indicated R28 had [DIAGNOSES REDACTED]. R28's Hospital Discharge Summary dated [DATE], indicated R28 required hospitalization for the provisional [DIAGNOSES REDACTED]. R28 received IV fluids and antibiotics, her temperature had returned to normal, she was alert and was able to swallow food comfortably. R28 was to continue on oral antibiotics for a total of 10 additional days. On [DATE], at 7:10 a.m. licensed practical nurse (LPN)-D stated if a family member requested a resident to go to the hospital, she would check on the resident, notify the charge nurse, and make arrangements to assist to transfer the resident to the hospital. On [DATE], at 7:30 a.m. RN-A stated if a family member requested to send a resident to the hospital, the resident was to be assessed, a physician (either the resident's primary physician or the on call physician) was to be contacted and the facility staff were to assist with the transfer. RN-A stated she was aware of the concern on [DATE], when R28's family requested R28 be transferred to the hospital. RN-A stated ultimately R28 was seen in the hospital and admitted and verified it was the family's right to have the resident seen in the emergency room if they wished. On [DATE], at 8:22 a.m. RN-B stated if a family member wished to have a resident seen in the emergency room , the staff were to complete an assessment, contact the primary physician or on call physician and obtain an order to transfer the resident to the hospital for further evaluation per the family request. RN-B stated R28 had a history of [REDACTED]. RN-B stated R28 had not been physically evaluated by the primary physician on [DATE], rather due to the physician knowing R28's history or aspiration pneumonia and previous treatments, and R28 having been recently treated with an antibiotic for aspiration pneumonia, R28's physician had instructed the facility to treat R28 at the facility, had ordered an antibiotic and requested to not send R28 to the emergency room . RN-B confirmed the instructions to refrain from hospital transfer/evaluation had not been written as a physician's orders [REDACTED]. R28's primary physician and the family had discussed hospitalization s in the past and there was a verbal agreement to treat R28 at the facility versus in the acute hospital. RN-B stated she had attempted to contact R28's family on [DATE], to notify them of her deterioration however, she was unable to reach the family and did not document her attempts to contact the family in R28's record. Upon review of the [DATE] documentation, RN-B stated it would have been beneficial for RN-D to have completed an assessment of R28's condition, contact a physician and assist to transfer R28 to the emergency room per the family request. -At 8:52 a.m. the director of nurses (DON) stated if a family member wished to have their loved one evaluated by the emergency room physician, the staff were to assess the resident, contact a physician and assist with making the arrangements for transfer to the hospital. The DON stated she would not expect the staff to refuse to transfer a resident when a family requested it. -At 8:56 a.m. RN-C stated if a family member requested to have their loved one transferred to the hospital, she would complete a resident assessment, contact the primary physician or the on call physician, and make the arrangements to transfer to the hospital. -At 9:03 a.m. the DON stated R28's primary physician was notified of R28's vomiting, fever and wheezes on [DATE], and had ordered R28 a new antibiotic. The DON stated R28's primary physician prefers the residents of the facility be treated in the facility and staff were to inform him of any changes. The DON confirmed R28's medical record did not contain a physician's orders [REDACTED]. The DON confirmed RN-D's documentation lacked an assessment of R28's condition on [DATE], and verified RN-D did not attempt to notify a physician of any potential changes in R28's condition. Upon review of the progress note dated [DATE], at 6:01 p.m. the DON stated she was unaware the documentation clearly indicated RN-D refused to assist FM-A and FM-B to transfer R28 to the emergency room for an evaluation and stated that was not the facility's normal practice. The DON stated she had talked to RN-D about the actions on [DATE], and directed RN-D and the rest of the staff to assist with transfers to the hospital per families' choice. However, the DON stated she had not documented the directive nor had she provided any type of formal training to the staff. The DON stated during shift to shift report, she had directed the staff to remind each other to follow family requests. -At 9:21 a.m. the DON and State Agency surveyor attempted to contact RN-D without success. -At 9:49 a.m. the facility administrator reviewed RN-D's documentation from [DATE], at 5:07 p.m. and stated he was unaware RN-D had not assessed R28 at the time of the family's request, or that RN-D had refused to contact a physician or assist the family in transferring R28 to the hospital. The administrator stated he felt RN-D's documentation showed frustration and it was his understanding that the family had not allowed RN-D time to assess R28 prior to them transferring R28 to the hospital. The administrator stated the DON had investigated the concern from the family however, confirmed there was no documentation related to the investigation nor indication additional staff training/coaching had been provided. On [DATE], at 4:00 p.m. RN-D stated it was her understanding R28 had been started on a new antibiotic and she was not to be sent to the emergency room as they could not do anything differently than what was being done at the facility. RN-D confirmed R28's medical record did not contain a physician's orders [REDACTED]. RN-D stated on [DATE], when FM-A had requested R28 be sent to the emergency, FM-A was angry and threatening towards her so she had to walk away from the situation. RN-D stated she did not feel she had the time to assess R28 or to help with the transfer as the family had already made the arrangements and left with R28. RN-D stated she had called the emergency room regarding R28's family request however, she had not attempted to contact a physician. The facility policy, Resident Incidents/Change in Resident Health Status dated ,[DATE], directed staff to provide continued care for a resident when they become acutely ill. The policy directed the charge nurse to assess the illness, notify family and physician of any changes, assist with transfers to the hospital as needed and update the resident's care plan as needed. R58's Care Center [DIAGNOSES REDACTED]. R58's quarterly MDS dated [DATE], indicated R58 had moderate cognitive impairment, required extensive physical assist from one staff member for bed mobility and transfers. A facility fax to R58's physician dated [DATE], revealed R28 was found to have small fluid filled blisters on her left leg which appeared to be due to lower extremity [MEDICAL CONDITION]. [MEDICAL CONDITION] is only noted in the left leg. R58 to be set up with daily weights for one week. Will also wrap left with cast padding and an ace wrap. Will update physician with any concerns. R28 continues to receive scheduled [MEDICAL TREATMENT]. Facility assessment section indicated fluid filled blisters due to lower extremity [MEDICAL CONDITION], nothing additional requested for the resident. The physician response dated [DATE], indicated agree with plan. No new orders given. R58's physician visit progress form dated [DATE], indicated R58 had been stable since last visit and had contemplated discontinuing [MEDICAL TREATMENT]. The Review of Systems (ROS) section indicated skin was negative. R58's signed physician orders [REDACTED]. R58's standing orders signed by the physician on [DATE], directed staff to apply Ted compression stockings or ace wraps, as needed. R58's Physician order [REDACTED]. -Inspect skin on bath days for reddened or opened areas. -[DATE], Left lower extremity: Apply ABD (12 x 12 inch x one inch bandage) pads, wrap with roll gauze/Kerlix, and secure with tape, twice a day. Notify the charge nurse when weeping has subsided, or when healed or worsened. Twice a day. -[DATE], Right lower extremity: Wound cleanse, pat dry, apply non-adhesive dressing pad with a dab of [MEDICATION NAME], cover lower extremity with ABD pads due to weeping, roll with gauze/Kerlix, and secure with tape, twice a day. Notify charge nurse if worsening or when healed. When weeping subsides dressing can be changed daily instead of twice daily. Review of R58's Treatments Administration Record (TAR) history dated [DATE]-[DATE], directed staff to cleanse the right shin wound, pat dry, apply a non-adherent pad with a dab of [MEDICATION NAME], roll with gauze, and secure with tape daily. The treatment was initiated on [DATE], with a discontinuation date of [DATE]. Documentation revealed the treatment was provided daily, as directed. Review of R58's TAR dated [DATE]-[DATE], directed staff to cleanse the right shin wound, pat dry, apply a non-adherent pad with a dab of [MEDICATION NAME], roll with gauze, and secure with tape, daily. The documentation revealed the the dressing was completed on [DATE], through [DATE]. Review of R58's TAR dated [DATE]-[DATE], directed staff to apply ABD pads to the left lower extremity, wrap with roll/gauze/Kerlix, and secure with tape twice a day. The TAR also directed staff to cleanse the right lower extremity wound, apply a non-adhesive pad with a dab of [MEDICATION NAME], cover extremity with ABD pads due to weeping, roll with gauze/Kerlix, and secure with tape twice a day. Both treatments were initiated on [DATE], with a discontinuation date of [DATE]. The documentation revealed both treatments were completed twice daily from [DATE], through [DATE]. R58's care plan dated as last reviewed [DATE], indicated the following: -Potential for alteration in skin integrity related to history of pressure ulcers. [MEDICAL CONDITION] (CKD) and valvular [MEDICAL CONDITION] and directed staff to maintain adequate nutrition and hydration by providing dietary decub program. -At risk for infection related to CKD and receives [MEDICAL TREATMENT]. Staff were directed to offer fluids on a regular basis with meals, medications, between meals and in the evening. Monitor for hydration, redness and breakdown. Be aware of changes in behavior, lethargy, confusion, agitation, assess changes and update physician as needed. -Potential for fluid overload and alteration in circulation status with a goal R58 would not have excess fluid. Staff were directed to send to [MEDICAL TREATMENT] as ordered, medicate as ordered, in emergency staff would give [MEDICATION NAME] as ordered if unable to attend [MEDICAL TREATMENT], and to maintain adequate nutrition and hydration by providing dietary decub program. R58's care plan failed to identify and address the actual non pressure related wound and [MEDICAL CONDITION] and care directives. R58's Checklist for Skin Risk Factors and Interventions form dated [DATE], indicated R58 had lower extremity concerns of signs and symptoms of arterial disease ([MEDICAL CONDITION]-[MEDICAL CONDITION]) such as cold extremity, thin and shiny skin and also arterial insufficiency concerns. The staff were directed to inspect skin daily, weekly skin assessment by licensed staff, moisturize dry skin, bathe with mild soap and gently dry, monitor pain and administer pain medications/treatments as ordered, involve/educate resident and/or family members, optimize blood flow to extremity, keep legs in neutral position, prevent trauma, proper fitting footwear, pressure reduction to heels, monitor weight/labs with a written note indicating [MEDICAL TREATMENT] would monitor labs, pad, protect and/or apply skin prep to fragile skin, encourage mobility and ambulation. On [DATE], at 2:42 p.m. R58 was observed seated in her recliner with her legs in a dependent (down) position with white Ted compression stockings on bilaterally. Slight [MEDICAL CONDITION] (swelling) was noted in both ankle areas. An ABD (a specific type of dressing) was visible on her right shin area. No dressing visible on the left leg. On [DATE], at 12:00 p.m. R58 was observed seated in her recliner with legs down. R58's compression stockings were not on. [MEDICAL CONDITION] was noted in both lower extremities from ankle to mid calf area. R58's left leg had large scales of dry skin on the foot and ankle. The right mid shin had an ABD dressing on secured with gauze. The left shin area had a dime size superficial wound with clear, yellow tinged fluid running down R58's leg. R58 stated her leg had been weeping all morning. On [DATE], at 6:09 p.m. R58 was observed in her recliner, both legs were noted to be [MEDICAL CONDITION] and weeping. RN-G entered the room and R58 reported to RN-G that her left leg had been weeping all day. RN-G proceeded to donne gloves and removed the right shin dressing. An approximate 2.0 inch by 0.5 inch with a depth of approximately 0.1 centimeter (cm) wound was noted on the right shin. The base of the wound was visible and a thin layer of yellow/green matter was observed in the lower area of the wound. RN-G sprayed cleanser on the wound and dried it with a clean 4x4 gauze. RN-G left the wound open, washed her hands and left the room to gather more supplies. Upon returning to the room, and without gloves on, RN-G applied a non adherent gauze directly on the wound and covered it with a ABD dressing and secured it with a gauze wrap. RN-G donned gloves, sprayed the left shin area with wound cleanser and dried it with a clean 4x4 gauze, removed her gloves and covered the shin area with an ABD dressing and secured it with gauze wrap. On [DATE], at 6:17 p.m. RN-G stated R58's legs wept on and off, and at times, wept a lot. RN-G stated the dressings were nursing orders only and should be followed as written. RN-G stated R58's compression stockings should be applied according to the doctor's order. R58's Activities of Daily Living Flowsheet directed staff to apply the compression stockings to both legs in the morning and take them off at night. The documentation revealed R58 had not utilized the compression stocking as ordered on six occasions in [DATE], and 24 days in [DATE]. The record lacked documentation of rationale why stockings were not applied. On [DATE], at 7:09 a.m. R58 was observed seated in the recliner with her legs down. The compression socks were not on. R58 stated staff did not put them on and did not offer to put them on. Both legs were noted to be [MEDICAL CONDITION]. On [DATE], at 8:45 a.m. LPN-D was observed to complete R58's lower extremity wound care. LPN-D washed her hands, donned gloves, removed the right shin dressing, stated it looked better, and proceeded to spray wound cleanser on the wound, pat it dry, and applied an ABD dressing and gauze. LPN-D removed the left leg shin dressing and left it to remain open to air. R58's nursing progress note dated [DATE], indicated both lower extremities were swollen, weeping and R58 may have had a blood/fluid blister on her right lower extremity that had recently ruptured. treatment for [REDACTED]. Blood/fluid drainage was noted on dressing approximately 45 minutes after application. R58 was seated in her recliner with feet elevated. R58 was encouraged to elevate her legs as much as possible. The note did not include the size of the wound or indicate if R58's physician had been notified. In addition, no further documentation related to R58's [MEDICAL CONDITION] or shin wound was noted in the medical record until [DATE]. R58's progress note dated [DATE], indicated R58 had intermittently refused [MEDICAL TREATMENT] and being resident continues to receive [MEDICAL TREATMENT], hospice services were not indicated however, comfort cares could be started which included no further hospitalization s. A telephone physician order [REDACTED]. Even thought R58's current status had been identified as terminal, the facility failed to assess, monitor and document wound status and interventions/response to interventions at the onset of the wound and prior to the decline in her health status. R58's medical record lacked evidence of physician notification of the right leg wound, the increase in leg [MEDICAL CONDITION], blister formation, or wound drainage. Additionally, the medical record lacked evidence of a wound assessment as well as ongoing wound documentation and monitoring including monitoring and management of the [MEDICAL CONDITION]. The E-Z Graph Wound assessment dated [DATE], completed by RN-C indicated the right shin wound measured 5.0 cm by 1.0 cm, depth could not be determined because it was covered with slough (Slough is non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed). A progress note dated [DATE], at 3:29 p.m. indicated R58's physician was updated of the intermittent formation of blisters, the right leg wound, and [MEDICAL CONDITION]. The cause of the wound was not identified on the assessment. R58's Physician Order's revealed a telephone order which indicated 1. Havenwood Care Center comfort care standing orders. 2. Weight loss expected due to terminal status. No order indicated related to changes in wound care/management. On [DATE], at 12:10 p.m. RN-C stated R58 had a history of [REDACTED]. RN-C confirmed R58's medical record lacked monitoring of the condition of R58's legs and stated she was not aware of the wound to right leg and increased [MEDICAL CONDITION]. RN-C stated if compression socks did not fit R58's legs due to the increased [MEDICAL CONDITION], nurses were to use ace wraps per the standing physician orders. On [DATE], at 7:13 a.m. LPN-D stated R58's right shin wound was from a ruptured fluid filled blister which ruptured when R58's compression stockings were applied. LPN-D confirmed nursing had not been monitoring the amount of R58's [MEDICAL CONDITION] and stated she did not know how long R58 had the blister before it ruptured. On [DATE], at 2:25 p.m. RN-D confirmed she had applied the first dressing to R58's right shin wound on [DATE], and verified she had not measured the wound or completed a wound assessment at that time. RN-D stated the approximate size of the wound on [DATE], was approximately 3.8 cm by 0.5 cm and was very superficial with no depth. RN-D confirmed she had not notified R58's physician regarding the presence of blisters or open wound. On [DATE], at 2:35 p.m. RN-C stated R58's right shin wound base was covered with slough so the extent of the wound could not be determined however, based on the measurements obtained on [DATE], the wound had gotten larger, and probably was worse than when the wound was first discovered. On [DATE], at 8:39 a.m. the DON stated R58's [MEDICAL CONDITION] and the presence of the wound including management of the right shin wound should have been identified on the care plan. The DON stated the wound should have been assessed by a nurse and wound tracking initiated when the wound was first discovered. Additionally, the DON confirmed the nursing orders for the wound dressings and stated the Ted stockings directive should have been followed and the physician should have been notified of the changes to the skin integrity as soon as possible. The undated, Skin Care Protocol policy and procedure section titled, with onset of all ulcers directed staff to initiate wound flow sheet/EZ graph and to document on the following every week: -location -size (length, width, depth, undermining or tunneling -color -odor -exudate -skin condition around wound -wound edges -wound bed appearance -only stage pressure related ulcers. Other ulcers are considered partial or full thickness. -assess for causative factor and implement intervention to prevent an injury from occurring again -initiate Braden's scale and do weekly unit healed. Once healed do Braden every week for four weeks. -wound rounds weekly -pain assessment -review chart and discuss with physician to determine type and etiology of ulcer. Venous ulcer described as shallow weeping [MEDICAL CONDITION] with irregular wound edges. Leg hyperpigmentation, [MEDICAL CONDITION] and palpable pulses. -notify family and physician about change in skin condition and current treatment plan -obtain and review labs -assure resident receives multivitamin with zinc and vitamin C at least daily -notify registered dietician -document in nurses notes daily by LPN and weekly by the RN -if no improvement in two weeks, update physician and change plan of care. -start pressure relieving devices (wheelchair, recliner and bed) The undated Pressure Ulcers in Long Term Care policy section titled, Other Skin Concerns identified a Stasis Ulcer as a destruction of tissue resulting from the stoppage or slowing of the normal blood flow to an area. This causes a back up in fluid causing congestion. The section titled, Assessment Of Other Skin Concerns directed the documented identification of the type of wound, the site, the size (width, length, depth, and condition of surrounding tissue) in centimeters, and if exudate. The policy Appendix described [MEDICAL CONDITION] as a local or generalized condition in which the body tissues contain and excessive amount of tissue fluid. Exudate was described as fluid that leaks from injured tissue which may be oozing pus or serum. The policy went on to direct staff on how to measure for the extent of [MEDICAL CONDITION].

Based on observation, interview and document review, the facility failed to comprehensively assess falls in order to identify causal factors and implement fall interventions in order to minimize the risk for falls and/or injury for 2 of 4 residents (R64, R88) who had repeated falls. This failure resulted in actual harm for R64. Findings include: R64's undated Face Sheet indicated R64's [DIAGNOSES REDACTED]. R64's annual Minimum Data Set ((MDS) dated [DATE], and quarterly MDS dated [DATE], indicated R64 had severe cognitive impairment, wandered, had inattentiveness, required extensive assist with toileting and dressing, limited assist with walking in room and corridor, was frequently incontinent of urine, had functional limitations with range of motion of upper extremities bilaterally, and was not steady but able to stabilize herself without human assistance when moving from a sit to stand position and on and off the toilet. R64's Falls Care Area Assessment (CAA) dated 10/2/16, indicated R64 also had a Bi-polar [DIAGNOSES REDACTED]. In addition, R64 was at risk for falls which could result in fractures, head injury, soft tissue injury, muscle injury and discomfort. Complicated by Alzheimer's dementia and psychosis. R64's Cognitive Loss/Dementia CAA dated 10/2/16, indicated R64's unexplainable behavior may be an attempt at communication about pain, toileting needs, uncomfortable position etc. the CAA also indicated R64 had physical behaviors with other residents which may be a way of R64 communicating a need of some kind. R64 had inattention that fluctuated, was at risk for confusion, and increased behaviors, falls and isolation. Complicate by Alzheimer's disease, dementia with behavior disturbances and Bi-polar mood disorder. Staff will proceed to provide cues and supervision when decision making. R64's Urinary Incontinence CAA dated 10/2/16, indicated R64 required extensive staff assist for toileting and was frequently incontinent. The CAA does not identify an individualized toileting plan to be utilized. R64's care plan reviewed on 3/16/17, indicated R64 was frequently incontinent of urine and directed staff to provide limited assistance every 1.5-2.5 hours and to check with toileting and change as needed. R64 had a potential for pain and directed staff to medicate R64 as ordered, use (unidentified) pain scale to assess pain, assist to position for comfort and to keep physician informed. R64 had decreased physical mobility with potential for falls with inability to ambulate to specific destinations at specific times in secured unit, wheel self, transfer self or turn and reposition self, sit up, lie down or get feet and legs into bed independently, wanders on secured unit. The plan directed staff to provide limited assist of one staff to ambulate on and off the unit with walker. Provide limited assist of one staff to transfer and also transfers self at times, utilize safety halos, and to refer to nursing orders (physician orders) for further fall interventions. A hand written, undated entry indicated a manual tilt in space wheelchair was to be utilized for comfort, positioning and safety. Restorative nursing as ordered. R64's physician orders/nursing orders from 10/23/16, through 2/9/17, indicated the following fall prevention interventions were in place: -lavender oil behind ears for relaxation twice a day (initiated 11/23/15) -contour mattress with cut out (initiated 11/23/15) -30 minute checks (initiated 2/19/16) -admit to Maple Lane secure dementia unit due to wandering and elopement attempts. R64's medical record and fall assessment reports between 10/23/16, and 3/19/17, revealed R64 had sustained the following 14 falls, one which caused serious injury (fall on 3/2/17): 1. R64's Fall assessment dated [DATE], and corresponding Safety Event's - Falls note indicated R64 had fall which was witnessed in the hallway on 10/23/16, at 10:00 p.m. R64 had been wandering in the hallway and attempted to enter another resident's room when a staff member tried to stop R64 and another resident also grabbed R64 at the same time. R64 lost her balance, turned around, sat down on the floor and laid down. No injury noted with this fall. Orthostatic blood pressures were stable. The follow up fall note dated 10/24/16, at 1:06 p.m. indicated this had been R64's 17th fall this year, R64 was currently being treated for [REDACTED]. Current fall prevention interventions in place were a contoured mattress with cutout and every 30 minute checks. The Evaluation Note indicated by check marks only that a Fall Prevention Program was initiated, R64's pain was resolved and care plan was updated. Although this incident was witnessed, R64's medical record lacked documentation of any new fall prevention interventions to be implemented. 2. R64's Fall assessment dated [DATE], and corresponding Safety Event's - Falls note indicated R64 had an unwitnessed fall in the dining room on 11/27/16, at 7:45 p.m. R64 was found on the floor near the dining room after another resident had alerted staff R64 had fallen. R64 had not been using a walker. No injury was noted with this fall. Orthostatic blood pressure was stable. Plan was to check orthostatic blood pressure, blood sugar, lungs sounds, log and to monitor R64. The follow up fall note dated 11/28/16, at 10:54 a.m. indicated this was R64's 18th fall this year, R64 always wore gripper socks, R64 ambulated with a walker most often, but staff needed to remind R64 to use it. It was not noted if R64 had been using the walker at the time of the fall. R64's fall prevention interventions in place remained the same. Staff does not plan to discuss use of a wheelchair for resident as staff felt R64's risks in the wheelchair were significantly worse. Evaluation Notes indicated by a check mark only that a Fall Prevention Program was initiated, pain was resolved and care plan was updated. R64's medical record lacked documentation of a comprehensive analysis of identified causal factors which contributed to this fall and no new fall prevention interventions were identified or implemented following the 11/27/16, in order to minimize further falls and/or injury. On 3/22/17, at 1:03 p.m. the director of nursing (DON) and registered nurse (RN)-B confirmed the above fall. However, stated both were on leave during this fall event. RN-B verified the family had requested R64 remain independent and walking. The DON stated the fall process included the fall would be discussed at the morning meetings- the falls committee which included unit managers, therapy, MDS nurse. If a fall occurred the fall committee talked about it on the next day and an action plan would be made and a follow up progress note was put into place. The DON stated on the weekend, the charge nurse would put immediate interventions into place, educate staff, if needed and document. As far as determining causal factors related to this fall, the DON stated was unable to comment on this as she was not in the facility at the time of the fall. 3. R64's Fall assessment dated [DATE], and corresponding Safety Event's - Falls note indicated R64 had an unwitnessed fall in another resident's bathroom on 11/30/16, at 9:45 p.m. R64 was found in another resident's room on the floor in the bathroom. R64 sustained a bump on the back of her head. R64 had her walker with her and the lights in the bathroom had been off. Vitals were checked and R64 was assisted to bed. Staff indicated they had redirected R64 back to the TV room a couple of times prior to the fall. The follow up fall note dated 12/2/16, at 11:04 a.m. (late entry) indicated R64 had a pattern to go to the end bathroom and wander through it, she ambulated independently with her walker on the unit, however she often forgot to use and staff would have to bring it to her. The staff had noted a significant change with R64's ability to find words and follow conversations. Family also reported an overall decline in R64. Staff concerned R64's overall decline in condition would continue and R64 would continue to fall, but it depended on what the family wanted for R64. Staff to discuss with family their desire to allow resident to continue to ambulate independently with her high fall risk. No further action noted and no further indication related to other cognitive declines. Fall interventions remain the same. Plan was for staff to talk to R64's family about their desire for R64 to continue to ambulate independently. The Evaluation Notes indicated by a check mark only that a Fall prevention program was initiated, pain was resolved and R64's care plan was updated. R64's medical record lacked documentation of a comprehensive analysis of identified causal factors which contributed to this fall and no new fall prevention interventions were identified or implemented following the fall in order to minimize the risk for further falls and/or injury. On 3/22/17, at 1:19 p.m. following review of this fall, the DON confirmed no new interventions were put into place. 4. R64's Fall assessment dated [DATE], and corresponding Safety Event's - Falls note indicated R64 had an unwitnessed fall in the TV/day room on 12/4/16, at 4:40 a.m. Staff were in the dining room and heard a thud noise. R64 was found flat on her back on the floor of the TV/day room. R64 appeared to have hit her head and had a bump on the back of her head. In addition, R64 had some bruising noted on her right shoulder, however it was unclear if these injuries were from this fall or the fall R64 sustained on 11/30/16. The follow up fall note dated 12/8/16, at 11:19 a.m. (late entry) indicated staff was unsure of what could be changed to assure R64 could make it into the chair. The chairs were contrast with the flooring and R64 frequently sat in these larger recliner chairs. The note also indicated this was resident's 20th fall this year, Family wanted R64 to continue to ambulate as this helped with R64's overall anxiety. Family also felt R64 would fall from the wheelchair since she would not remember any safety techniques related to the wheelchair use. It was not noted if R64 had been utilizing the walker or not. The current fall prevention interventions remain unchanged. The family was concerned that R64 had a UTI at this time so staff would monitor R64 for signs and symptoms of a urinary tract infection (UTI). The Evaluation Note indicated by a check mark only that a Fall prevention program was initiated, pain and injury were resolved and care plan was updated. R64's medical record lacked documentation of a comprehensive analysis of identified causal factors which contributed to this fall and no new fall prevention interventions were identified or implemented following the fall in order to minimize the risk for further falls and/or injury. 5. R64's Fall assessment dated [DATE], and corresponding Safety Event's - Falls note indicated R64 had an unwitnessed fall in the TV room on 12/23/16, at 6:04 a.m. Staff heard a loud thud and found R64 sitting on the floor in front of the Christmas tree. R64 stated she fell . The staff felt R64 had attempted to sit down and missed the chair. R64 had a contusion to the middle back of her head, area was red and sore to the touch. Pain medication was given for headache. A drop in orthostatic blood pressure was noted and blood sugar was elevated so staff would recheck both. R64 was unable to state what happened other than she fell . The note does not identify if R64 was utilizing the walker or not. The follow up fall note dated 12/23/16, at 10:05 a.m. indicated this was R64's 21st fall this year, current interventions remained the same. A physician order [REDACTED]. R64's physician was on site and discussed R64's falls, current dementia status, UTI treatment and also overall condition. The physician indicated R64 could be at her maximum medication treatments so suggested a reduction even though R64 displayed symptoms of depression and anxiety. An order to reduce Klonopin (antianxiety with known side effects of dizziness and lowering the blood pressure) from 0.5 milligrams (mg) three times a day to 0.5 mg twice a day. No further documentation related to the increased blood sugar or change in orthostatic blood pressure was noted. Staff also talked to the family about having R64 use a wheelchair, however, the family stated the physician and rest of the family felt R64 was not ready to use a wheelchair and would fall from it. The Evaluation notes indicated by a check mark that a Falls prevention program was initiated, pain was resolved, injury was resolved, and R64's care plan was updated. Although R64's medical record identified R64's antianxiety medication (Klonopin) as a causal factor which could have contributed to R64's fall, the medical record lacked new interventions to be implemented in order to minimize the risk for further falls and/or injury. 6. R64's Fall assessment dated [DATE], and corresponding Safety Event's - Falls note indicated R64 had an unwitnessed fall in the TV/day room on 12/24/16, at 10:50 p.m. A visitor had seen R64 on the floor and alerted staff. Staff found R64 seated on the floor in front of a chair in the TV/day room and staff assumed R64 had missed the chair when attempting to sit down. No injury was noted with this fall, however, R64 stated her feet hurt. The follow up fall note dated 12/26/16, at 1:12 p.m. (late entry) indicated R64 had quite a history of falls, this was R64's 22nd fall of the year, R64 always wore gripper socks, and Occupational and Physical therapy were not needed because R64 was stable on her feet and unable to benefit from education due to memory loss. R64 had been participating in the restorative nursing program, a family conference was scheduled for 12/28/16, to discuss options, and staff were waiting the results of a urinalysis which had been sent on 12/24/16. Current fall prevention interventions remained the same, unchanged. The Evaluations Notes indicated by a check mark that a Falls Prevention Program was initiated, pain was resolved, injury was resolved and care plan was updated. Staff are assuming R65 missed a chair when she was going to sit down. Family was aware of R64's fall risk and wanted R64 to continue to be able to ambulate. R64's medical record lacked documentation of a comprehensive analysis of identified causal factors which contributed to this fall and no new fall prevention interventions were identified or implemented following the fall in order to minimize the risk of further falls and/or injury. 7. R64's Fall assessment dated [DATE], and corresponding Safety Event's - Falls note indicated R64 had an unwitnessed fall on 12/26/16, at 1:20 p.m. R64 was found in R64's bathroom on the floor. R64 stated she had slid off the toilet and R64's pants were down to the knee. R64 had some bruising on R64's right upper leg. The follow up fall note dated 12/27/16, at 1:51 p.m. indicated this was R64's 23rd fall this year. Staff had just assisted R64 to the bathroom at 1:00 p.m. prior to the fall, R64's physician felt R64's body was at maximum level of medication tolerance and that something might be causing her falls related to her medications. R64 tired quickly and was encouraged to take frequent rest periods. Current fall prevention interventions included remained unchanged. R64 was stable with walking with her walker most often. However, the medical record indicated R64 did not remember to take the walker with her and required reminders or staff to bring the walker to her. Staff were waiting on the results of the urinalysis and culture (UA/UC) which had been obtained. (Based on the results of the UA/UC, R64 was not treated for [REDACTED].>Evaluation Notes indicated family wants R64 to continue to ambulate until family conference is held. Urine culture recently obtained, orthostatic blood pressures stable. Check marks indicated a Falls Prevention Program was initiated, Pain was resolved, and care plan was updated. No mention of R64's blood sugar was noted. R64's medical record lacked documentation of a comprehensive analysis of identified causal factors which contributed to this fall and no new fall prevention interventions were identified or implemented following this fall in order to minimize the risk for further falls and/or injury. R64's Event report note dated 1/1/17, indicated a conference was held with four of R64's family members to discuss R64's falls. Family was given an update on R64's activities of daily living abilities/status and activities. R64 had an eye appointment set up for the month of 1/17, however, family did not feel R64 had any visual changes at this time. Staff would be adding activities on Maple Lane in which family felt would be beneficial as R64 enjoyed activities and liked to stay busy. The staff discussed with R64's family two overall options for R64 which was mainly to continue to ambulate as she currently was or to try a wheelchair for R64. Family's main concern was that a wheelchair be customized for R64 with a tilt mechanism. Discussion held on R64's frustration level if unable to get out of the wheelchair independently. Family feels R64 would not be able to get out of the wheelchair and they are Ok with this as long as R64 might be safer. Family asked about using the wheelchair on an as needed basis, however, staff informed the family that R64 was not a good resource to say if she was tired and needed to sit down and could not always verbalize needs in general, appropriately. The family confirmed this was a noticeable decline for R64 as she was unable to voice wants/needs and family often had to assume what R64 was trying to say to them. Staff talked about R64 continuing to ambulate with her walker as she currently was with the risk of her falling and breaking something as she had done in her past. Family agreed R64 was at high risk for injury and did not feel R64 would ever be able to pull through surgery to repair an injury and if R64 did require surgery, she would not return to her baseline status. Staff also discussed R64's medication changes like Aricept and also other psychotropic medications as well as possible side effects of stopping some of the medications that increased R64's fall risk. At this time, R64's family wants her to continue to ambulate with her walker and staff to watch out for her as best they could. Family also requested the facility move forward on ordering a customized wheelchair with leg rests and tilt function and to utilize it only on an as needed basis so R64 could still move as best as possible. Staff educated family on their inability to know when R64 would need the wheelchair due to her memory problems and also her inability to communicate accurately when she might need it. Staff informed family they would not know when R64 would be falling and when the wheelchair would need to be used. Staff could still ambulate R64 with assistance, however, the wheelchair would be the primary mode of transportation. Family was OK with this and understood the risks of placing R64 into a wheelchair. R64 was to be fitted for a customized wheelchair. On 12/29/16, family reported they wanted R64's Aricept stopped and R64's physician was notified. On 12/30/16, R64's physician was on site and discussed R64's falls in which he stated he did not have any suggestions on how to prevent further falls for R64. Also agreed with family's request to stop Aricept, however, requested staff notify R64's psych physician as well. Physician also reported R64's recent urine culture did not require treatment. 8. R64's Fall assessment dated [DATE], and corresponding Safety Event's - Falls note indicated R64 had an unwitnessed fall on 12/28/16, at 5:45 p.m. R64 was found on the floor in another resident's room. R64 had been walking without the walker. No injury was noted with this fall. The follow up note dated 12/29/16, at 1:11 p.m. indicated this was residents 24th fall this year, R64 had been walking without her walker and current fall prevention interventions remained unchanged. Following the 12/28/16, care conference the family agreed to have R64 fitted for a customized wheelchair which had been requested. Staff assist R64 with locating her walker when noted R64 was walking without it. The plan for this fall was to update the provider because R64 had been displaying more aggressive behaviors towards peers. The Evaluation Notes indicated staff are thinking she either tripped or slipped and this caused the fall. R64 was not using the walker and was unable to tell staff what caused her to fall. R64 was ambulatory with use of the walker and usually did quite well but does not always remember to use the walker and would leave it in various places on the unit. Continues to be followed by physician from the behavior center due to her use of psychotropic medications as well as her behaviors. Since the decrease in Klonopin, staff have noted an increase in aggressive behaviors which has impacted other residents on the unit. Falls Program initiated, R64's pain was resolved, injury resolved and care plan was updated. R64's medical record lacked documentation of a comprehensive analysis of identified causal factors which contributed to this fall and no new fall prevention interventions were identified or implemented following the fall in order to minimize the risk for further falls and/or injury. 9. R64's Fall assessment dated [DATE], and corresponding Safety Event's - Falls note indicated R64 had an unwitnessed fall on 1/22/17, at 12:54 a.m. R64 was found kneeling down on the floor and leaning on a chair in the TV/living room area. R64 could not tell staff what happened. No injury but did state her knee hurt. Falls are occurring at night. The follow up note dated 1/22/17, (untimed) indicated R64 was unable to tell staff what happened, R64 complained of her knee hurting, R64 had not used her walker, however, the walker was located nearby. Continue with the same fall prevention interventions. Plan was to request a scheduled Tylenol or ibuprofen for the knee pain which may have contributed to R64's fall. The medical record did not reveal if R64 had chronic complaints of knee pain. Evaluation Notes indicated this was R64's first fall this new year and did not address history of numerous falls prior to new year however indicated It had been almost a month since R64's last fall which was an improvement for her. The same interventions continue. A check mark indicated a Falls Prevention Program was initiated, Pain was resolved, injury was resolved and care plan was updated. R64's medical record lacked documentation of a comprehensive analysis of identified causal factors which contributed to this fall and no new fall prevention interventions were identified or implemented following this fall in order to minimize the risk for further falls and/or injury. 10. R64's Fall assessment dated [DATE], and corresponding Safety Event's - Falls note indicated R64 had an unwitnessed fall on 1/22/17, at 9:20 p.m. (second fall on this day). R64 was found on the floor in another resident's bathroom doorway. R64 was unable to tell staff what she was doing at the time of the fall. No injury was noted with this fall. The follow up note dated 1/22/17, (untimed) indicated since R64 had been found in the bathroom and had been toileted less than an hour before this fall, post void residual checks would be completed to ensure R64 was emptying her bladder. Orthostatic blood pressure checks would be done and current fall prevention interventions included the use of a contour mattress with cutout, reminders for R64 to use her walker, every 30 minute checks, lavender oil and gripper socks. Although post void residual was identified as possible causal factor for this fall, a comprehensive analysis was not conducted to identify causal factors of R64's repeated falls or interventions implemented in order to minimize the risk for further falls and/or injury. 11. R64's Fall assessment dated [DATE], and corresponding Safety Event's - Falls note indicated R64 had an unwitnessed fall on 1/31/17, at 2:55 a.m. staff heard a loud noise and found R64 lying on the floor in the TV/living room area. R64 stated she was just trying to wake up. A fist sized bump was noted on the back of her head, right side. A hand written entry indicate read ? if weak legs r/t (related to) increased leg swelling could have contributed to fall. The follow up note dated 1/31/17, at 2:16 p.m. indicated this was R64's 3rd fall this year. Current fall prevention interventions in place included the use of a contour mattress with cutout, every 30 minute checks, lavender oil twice a day, reminders to use the walker, and gripper socks. The Evaluations notes indicated R64 was not using her walker at the time of the fall rather it was noted to be next to the chair she had been sitting in. Vital signs were stable. Had an elevated blood sugar. Occupational therapy was consulted for possibility of [DIAGNOSES REDACTED] treatment due to significant lower extremity edema which was implemented on 2/27/17. Staff had noticed R64 was having dysuria and cloudy, sediment filled urine therefore a urine culture was obtained. No further analysis was identified. Fall interventions remained the same. A check mark indicated a Falls Prevention Program was initiated, Pain was resolved, injury was resolved and care plan was updated. R64's medical record indicated causal factors which may have contributed to R64's fall on 1/31/17, was R64's increased swelling in R64's legs, however, a complete analysis of the effectiveness of the interventions was not completed. 12. R64's Fall assessment dated [DATE], and corresponding Safety Event's - Falls note indicated R64 had a witnessed fall on 2/9/17, at 9:45 a.m. R64 was walking out of the TV/Living room area without walker, turned around, wobbled, and was guided to the floor by a nursing assistant, however, it was not a controlled lowering to the floor. Urine was noted on the floor, unsure if the urine was there first but R64 was wet. No injury was noted with this fall. The follow up note dated 2/9/17, (untimed) indicated this was the R64's 4th fall this year, R64 had a UA/UC which was positive and was treated for [REDACTED]. Current fall prevention interventions were not noted. Evaluation Notes indicated by a check mark that a Falls Prevention Program was initiated, pain was resolved and care plan was updated. Although causal factors were identified as [DIAGNOSES REDACTED] and UTI. A complete analysis including the evaluation of current interventions in order to determine appropriateness was not completed. R64's Fall Risk assessment dated [DATE], indicated R64 was at high risk for falls as R64 had had three or more falls in the past three months, had taken more than three medications which could increase the risk for falls, and had predisposing diseases such as seizures which could also increase R64's risk for falls. No new fall interventions were identified and staff were directed to continue with the current fall interventions with no changes at this time. Although a fall risk assessment was completed, it failed to identify what could be done about the risk factors placing R64 at high risk or evaluate the efficacy of the current interventions as they related to those identified risk factors. 13. R64's Fall assessment dated [DATE], and corresponding Safety Event's - Falls note indicated R64 had an unwitnessed fall on 3/2/17, at 2:05 a.m. Staff had assisted R64 into the bathroom by the TV/Living room area. The staff member told R64 she would be right back and left R64 unattended in the bathroom to retrieve a new brief from R64's room. Staff heard R64 calling for help and found R64 laying on the floor. R64 was unable to state what happened to cause her to fall. Staff felt R64 either tipped off the toilet or attempted to get up from toilet and fell . R64 was sent to the emergency room and was found that have sustained a nose and wrist fracture (and later identified a rib fracture). Gripper socks were on at the time of the fall. Similar falls occurred at night time. R64's sleep issues were reported to the physician. Staff had been discussing plans in regards to R64's falls with her family. The follow up note dated 3/2/17, 3:31 p.m. and Evaluation Notes dated 3/2/17, indicated a customized wheelchair had been ordered for R64 which had not yet arrived. R64 was treated for [REDACTED]. R64 has had significant falls over the last year. Staff had been updating her physicians' related to falls and discussion had been held with family related to R64's falls. R64 remained on every 30 minute checks for quite some time and utilized a contour mattress with cutout. Staff monitor for pain signs and symptoms every four hours. R64 ambulates on the secured unit with the assistance of a walker. R64 had been started on daily weights and had been placed on a short course of increased diuretics because of the concern with the fluid in R64's feet and legs which placed R64 at increased risk for falls. R64 had received [DIAGNOSES REDACTED] treatment. R64's vital signs and orthostatic blood pressure, blood sugar and lungs sounds were to be checked however the results of these checks were not indicated. New fall prevention interventions identified and implemented included R64 should have someone close by her at all times, R64 was not to be left alone on the toilet, R64 was to use a wheelchair when moving about, anti-rollback's should be on R64's wheelchair, and R64 should use the manual tilt and space wheelchair for positioning, comfort and safety. R64's medical record lacked a correlation of the number of falls surrounding toileting and a toileting plan assessment was not noted following the falls. R64's physician orders [REDACTED]. If R64 was walking with her walker, she should have assistance close by at all times due her high risk for falling, and orthostatic blood pressures daily. Evaluation Notes indicated by a check mark that a Fall Prevention Program was initiated, pain and injury was resolved and care plan was updated. No further information noted related to new fractures and pain control. Causal factor was speculated to be due to R64's increase in swelling in R64's legs, however, a comprehensive root cause analysis was not completed and interventions leading up to the fall were not evaluated for effectiveness. 14. R64's Fall assessment dated [DATE], and corresponding Safety Event's - Falls note indicated R64 had an unwitnessed fall on 3/19/17, at 2:20 a.m. R64 was found sitting on the floor in another resident's room. A few minutes prior to the fall, R64 was seated on a chair by the nurse's station. Staff had assisted R64 to the bathroom at 2:15 a.m. R64 was unable to tell staff what she was trying to do at the time of the fall and facility staff were unable to determine cause of fall. Vitals signs were stable. No injury was noted with this fall. R64's customized wheelchair had been received and staff were working with R64 on use. R64 was noted to have troubles adjusting to th

Based on observation, interview, and document review, the facility failed to ensure that residents fed by a paid feeding assistant (PFA) did not have any complicated feeding problems according to the facility policy and procedures for the safe utilization of PFAs. This practice resulted in an Immediate Jeopardy situation for 1 of 10 (R34) residents assisted to eat by PFAs. R34 was identified with a history of [MEDICAL CONDITION] (strokes) and dysphagia (difficulty swallowing) with a history of aspiration pneumonia. Based on these findings, the administrator and director of nursing were informed of the Immediate Jeopardy (IJ) at 4:20 p.m. on 12/19/11. The Immediate Jeopardy was removed at 10:55 a.m. on 12/21/11, reducing the scope and severity to a no actual harm with potential for no more than minimal harm. pattern. Findings include: On 12/18/11, during the entrance conference the director of nursing (DON) stated the facility used PFAs. At approximately 4:45 p.m. the DON provided a list of residents who could be fed by PFAs. R34 was not included on this list, On 12/18/11, from 5:20-5:30 p.m. PFA-A fed R34 a pureed diet. At 5:30 p.m. PFA-A stated R34 did not want to eat anymore and wheeled the resident to the lounge area. No coughing or difficulties with eating or drinking were observed. On 12/18/11, at 4:55 p.m. PFA-A stated she could feed certain residents and R34 was one. At 5:20 p.m. PFA-A stated she fed R34 approximately 4 times a month. PFA-A stated R34 had been on pureed diet "as long as I've been here" (since October 2011). She stated R34 received regular fluids and added she could feed residents who were on pureed diets, but not those on thickened liquids. At 5:55 p.m. PFA-A stated R34 coughed once or twice a month when feeding the resident and added R34 usually coughed 2-3 times and cleared the throat. The undated Paid Feeding Assistant Policy indicated a PFA must have completed a State approved training course. The resident selection to be fed by a PFA would be based on the charge nurse's assessment, the resident's latest assessment, and care plan. PFAs would only assist residents who had no complicated health problems related to eating or drinking, such as residents who used thickened liquids or had a known choking problem. The procedure instructed the PFA to "observe and report significant changes in residents eating and report to LPN or RN." R34 had [DIAGNOSES REDACTED]. Although not listed on the [DIAGNOSES REDACTED]. The MDS indicated R34 required extensive assistance with eating and was on a mechanically altered diet. No swallowing disorder was identified. The Nutrition Care Area Assessment (CAA) dated 11/7/11, identified R34's mechanically altered diet as dysphagia level 1/puree. The CAA indicated the diet texture was related to the resident's stage in dementia and that R34 accepted the texture with no issues. The CAA also included as noted by the physician, R34 was at increased risk for aspiration with no dysphagia and "see annual nutr. review for further info 11/7/11." The current physician's orders [REDACTED]. The current plan of care (POC) dated 11/9/11, directed staff to feed R34, provide ADA diet/Dysphagia level 1, FMP (functional maintenance plan) as ordered, and set up with nosey cups for all liquids. The POC did not address whether R34 had been assessed as safe to be fed by a PFA, had a history of [REDACTED]. On 12/18/11, at 5:06 p.m. the DON stated assessments are completed to determine if a resident is safe to be fed by PFAs. At 6:00 p.m. the DON verified they did not have Feeding Assessment (FA) in R34's medical record. At 6:13 p.m. the DON found an assessment in a thinned record and stated that the assessment from 2/28/10, would still be in effect. However, the assessment was not accurate related to F34's current status. The Feeding Assistant assessment dated [DATE], indicated the resident was on a mechanical soft or pureed diet, did not have thickened liquids, required assistance with meals, and had no condition that put the resident at risk (such as [MEDICAL CONDITION], dysphagia.) A hand-written note at the bottom of the form identified R34 was OK to be fed by a feeding assistant. No further feeding assessments were documented since 2/28/10. Nursing notes dated 4/20/11, identified staff had noted that resident sounded congested or that fluid in lungs was due to possible aspiration. Staff noted resident had been coughing last night on occasion. The physician's assistant (PA) clinic note dated 4/20/11, identified recent acute congestion may be on the basis of aspiration. The note also included R34 seemed to have some difficulty swallowing and staff were also concerned about possible stroke. The PA identified R34's history of [MEDICAL CONDITION] and as a result indicated R34 "has had dysphagia with a history of aspiration pneumonia." The physician's note dated 4/21/11, indicated R34 was seen for follow-up after noted aspiration. The physician noted the chest x-ray was negative and R34 had been started on an antibiotic. The Assessment and Plan section indicated R34, "is at increased risk of aspiration now... Explained to the patient that his condition, particularly the aspiration, will recur." A PA note dated 5/31/11, identified R34's problems of progressive dementia, increased aspiration risk, and [MEDICAL CONDITION]. A nursing note dated 7/16/11, identified R34 had noted difficulty eating the mechanical soft diet and a speech therapy screen was requested. The Rehabilitation Screen form dated 7/21/11, indicated "change in swallow status" and identified R34's poor intakes, extended mastication (chewing), and an evaluation was indicated for dysphagia. The Speech Therapy Swallowing Evaluation dated 7/21/11, included [DIAGNOSES REDACTED]. The evaluation identified moderate impairment with R34's oral phase which included weak oral motor function, delayed/extended mastication, and pocketing of food with no oral awareness and residue on lips. In addition, the section Pharyngeal/Laryngeal Phase indicated swallow reflex time was extended, that R34 was unable to follow compensatory behaviors, and had mild impairment of airway protection with a "weak cough". A physician's orders [REDACTED]. A PA note dated 7/28/11, continued to address R34 being at increased risk for aspiration and that R34 "has recently had a diet change to pureed due to dysphagia." A Therapy Weekly Progress Report dated 8/4/11, indicated short term goals were to decrease s/s (signs/symptoms) of aspiration with pureed diet and thin liquids. The objective status included R34 "needs adequate time between bites to complete swallow" and R34 "tolerates small sips of liquid via straw or cup". However, those approaches were not included in the current plan of care. The Nutritional assessment dated [DATE], identified the resident's diet as ADA dysphagia level 1 with the use of a nose cup (glass with a cut-out area around top rim) for liquids. The note identified R34 had no chewing or swallowing problems and no referrals were indicated. On 12/19/11, at 8:03 a.m. PFA-B was observed assisting R34 with regular consistency milk and orange juice, pureed eggs, hot cereal, and pureed toast. PFA-B was continuously observed while feeding R34 from 8:03- 8:27 a.m. and again from 8:34-8:48 a.m. when R34 finished the meal. PFA-B did not alternate solids and fluids as physician orders [REDACTED]. R34 was observed to cough 4 times throughout the meal. On 12/19/11, at 8:52 a.m. PFA-B stated she worked 2-3 shifts a week and verified she fed R34. PFA-B stated R34 coughed once in awhile while eating. In regards to special instructions for R34, PFA-B stated every couple bites, she tries to have milk or juice in between to alternate liquid with food. PFA-B stated she could not feed anyone with thickened liquids. PFA-B stated there was no list for PFAs to refer to. They just know who they can assist by looking at the resident's menu card and if the resident received thickened fluids she cannot assist them. On 12/19/11, at 10:07 a.m. the DON verified all the PFAs had completed the approved PFA course. She added assessments to determine if PFAs could safely assist residents were done by RNs. The DON explained that if residents had thickened liquids, PFAs cannot feed them. She added if residents had a stroke or dysphagia PFAs would not feed them if they had continued swallowing difficulties. The DON verified PFAs are notified of who they can assist by looking at the residents' dietary ticket, because they know they cannot assist anyone on thickened liquids. The DON verified none of the residents' care plans addressed if residents were assessed as eligible to be fed by a PFA . The DON stated she was aware that PFAs were assisting R34. She stated R34 was on a pureed diet, "I think related to chewing" and was spitting out pieces of food. At that time, RN-B stated she thought R34 had been holding food. The DON verified that with R34's history of aspiration and [DIAGNOSES REDACTED]. The DON stated the physician's orders [REDACTED]. The DON verified the speech therapy intervention that R34 "needs adequate time between bites to complete swallow" and "tolerates small sips of liquid via straw or cup" were not on the dietary ticket. The DON then verified neither the order nor the speech therapist's intervention was on the care plan. The DON stated she was not aware that R34 was having any coughing during meals and stated the PFAs should let the RN or LPN know if that was happening. On 12/21/11, at 9:00 a.m. the speech language pathologist (SLP)-A stated she had not been aware of any issues with R34 until she did the screen last evening and added she would be doing a swallow evaluation to determine R34's current eating and drinking abilities. The facility's development and implementation of the following plan was verified for the removal of the immediate jeopardy situation related to paid feeding assistants: The PFAs were immediately taken off the schedule until they were re-educated by an RN. Education was completed on 12/21/11, for all PFAs. A new Feeding Assistant Assessment was completed for R34 and identified the resident should not be assisted by a PFA. R34 was screened by the Speech Department. All residents assisted by PFAs were re-assessed by an RN to ensure they were safe to be fed by a PFA. If a resident had complicated eating problems, such as, but not limited to: a pureed diet, difficulty swallowing, recurrent lung aspirations, and tube or [MEDICATION NAME] feedings, a PFA would not be allowed to assist at meal times. These assessments would be kept in the resident's chart, and would be updated on a quarterly basis and with any change in condition. All residents assisted by a PFA would have this listed on their care plan., and would have a statement added to their dietary ticket "Res. may be assisted at meals by feeding assistant." PFAs would not be allowed to assist a resident at meal times unless they had this statement on their dietary ticket. An audit was put in place to assure Feeding Assistant Assessments were updated on a quarterly basis. These audits would be brought to the Quality Assurance Committee for review and recommendations. The DON (Director of Nurses) was responsible for compliance. Surveyors conducted multiple observations and interviews on 12/21/11, between 8:00 a.m. and 10:30 a.m. of residents being assisted with eating, and interviews with PFAs who verified they had received the training. The administrator and director of nursing were notified on 12/21/11, at 10:55 a.m. the Immediate Jeopardy was removed as a result of these interventions.