Every finding on record at Heartwood

Based on observation, interview, and document review, the facility failed to ensure staff followed Enhanced Barrier Precautions during high-contact resident care activities for 1 of 1 resident (R6) reviewed for catheter care. Findings include:R6's admission Minimum Data Set (MDS) dated [DATE], identified R6 had severe cognitive impairment and diagnoses that included Alzheimer's disease and urinary retention. R6 required partial/moderate assistance with eating, was dependent on staff for all other care areas and R6 used an indwelling catheter. R6's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 5/24/26, identified R6 had a indwelling catheter. A trial reduction was attempted, however R6 was unable to void without the catheter placement. Care planned to promote safe emptying of bladder with use of foley catheter. R6 was at risk for urinary tract infection (UTI) versus risk for urinary retention.R6's care plan revised 5/27/26, identified R6 required enhanced barrier precautions due to foley catheter. Staff were directed to follow enhanced barrier precautions in addition to standard precautions: wear gown and gloves during high-contact resident care activities.During an observation on 8/18/26 at 4:24 p.m., there was a 3-drawer plastic cart outside R6's door containing disposable gowns and gloves. There was signage on R6's room door identifying Enhanced Barrier Precautions (EBP). Nursing assistant (NA)-A was standing next to R6 with the vital machine cart taking R6's blood pressure. NA-A was not wearing a gown or gloves. NA-A then moved the blood pressure cuff from R6's left arm to R6's right arm and took the blood pressure again.At 4:26 p.m., registered nurse (RN)-A stepped into the room and asked NA-A if she needed any help. NA-A stated no, that R6 had already been transferred into her wheelchair. RN-A left the room but did not remind NA-A of the need for a gown or gloves.At 4:28 p.m., NA-A assisted R6 to put on a cardigan sweater then assisted R6 to the common area. During an interview on 8/18/26 at 4:29 p.m., NA-A stated the signage on R6's door and the PPE cart meant staff needed to wear a gown and gloves when staff was working close with R6 because R6 had a catheter. NA-A clarified and stated when providing cares to R6, when giving R6 a shower, that kind of thing. NA-A was only putting a sweater on R6, so a gown and gloves was not needed. However, after reviewing the sign on the door, NA-A stated a gown, and gloves should have been worn because dressing was listed to prevent giving R6 an infection. During 8/18/26 at 4:42 p.m., registered nurse (RN)-A stated R6 did not need EBP. RN-A confirmed R6 did have an indwelling catheter and staff needed to provide really good catheter care but R6 did not require EBP. Upon reviewing on the signage on R6's room door, RN-A stated well, that's my bad. RN-A stated staff were expected to wear a gown and gloves for R6 because they were handling bodily fluid. During an interview on 8/19/26 at 8:28 a.m., NA-B stated staff would only wear a gown and gloves with R6 if touching the catheter. Staff did not need to wear gowns or gloves any other time such as transfers, dressing etc. Only catheter cares. During an interview on 8/19/26 at 8:33 a.m., RN-B stated staff were expected to wear a gown and gloves whenever they are performing direct resident care. During an interview on 8/19/26 at 8:38 a.m., RN-C stated staff were expected to wear a gown and gloves during resident care for anyone on EBP to protect the resident from possible infection.During an interview on 8/19/26 at 9:50 a.m., the director of nursing (DON) stated she expected staff to follow EBP for all resident care for a resident with a catheter to protect the residents from possible infection. During an interview on 8/19/26 at 9:56 a.m., the administrator stated she expected staff to follow EBP per CDC guidelines. The undated Centers for Disease Control and Prevention (CDC) Enhanced Barrier Precautions sign, identified providers and staff must wear gloves and a gown for the following High-Contact Resident Care Activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube or tracheostomy and wound care.

Based on observation, interview and document review, the facility failed to ensure the medications section of the Minimum Data Set (MDS) was accurately coded for 1 of 5 resident (R6) reviewed for unnecessary medications.Findings include:R6's admission Minimum Data Set (MDS) dated [DATE], identified R6 had intact cognition and included a diagnosis of type 2 diabetes. R12 received an injection of insulin one day per week.R6's Order Summary Report dated 6/30/25, identified semaglutide (a GLP-1 receptor agonist used primarily for managing type 2 diabetes and aiding in weight loss, with significant effects on appetite regulation and blood sugar control.) subcutaneous solution pen-injector 2 milligram (MG)/3 milliliter (ML) inject 0.5 mg subcutaneously one time a day every Monday for type 2 diabetes.An email from the coding department director dated 7/23/25 at 1216: p.m., identified R6's semaglutide was coded as insulin in error.During an interview on 7/23/25 at 12:37 a.m., the director of nursing (DON) stated MDS assessments should be coded correctly to ensure correct payment was received and to ensure the residents received the care they required.The facility policy Resident Assessment Instrument (RAI) Process: MDS 3.0, Care Area Assessments, Care Planning and Submission revised 3/25, identified the facility would complete the RAI in accordance with the utilization guideline set forth in the current MDS 3.0 RAI User's Manual.Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated 10/2024, identified the steps for assessment included:1. Review the resident's medication administration records for the 7-day look-back period (or since admission/entry or reentry if less than 7 days).2. Determine if the resident received insulin injections during the look-back period.3. Determine if the physician (or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) changed the resident's insulin orders during the look-back period.4. Count the number of days insulin injections were received and/or insulin orders changed.

Based on interview and document review, the facility failed to comprehensively assess for trauma informed care and identify potential triggers, to avoid potential re-traumatization for 1 of 1 resident (R6) reviewed for trauma informed care.Findings include:R6's admission Minimum Data Set (MDS) dated [DATE], identified R6 had intact cognition and included a diagnosis of post traumatic stress disorder (PTSD).R6's medical record failed to identify a Trauma-Informed Care Assessment was completed.R6's care plan revised 5/9/25, did not include R6's PTSD triggers and/or interventions specific to his PTSD.During an interview on 7/21/25 at 2:22 p.m., R6 was lying in bed in her room. R6 spoke with a flat affect and stated she liked to keep to herself in her room. R6 stated she was unaware of any traumatic events in her life and could not recall anything that would make her upset specifically. During an interview on 7/23/25 at 9:05 a.m., registered nurse (RN)-B and nursing assistant (NA)-C stated they were both unaware of R6's PTSD diagnosis. RN-B stated she heard R6 had had a rough childhood but didn't know any details. Neither were aware of any triggers for R6, but NA-C stated R6 was very withdrawn. Staff did offer activities and opportunities for R6 to get out of her room but R6 never wanted to. R6 did not like her blinds open until later in the day when R6 up and moving around. When R6's family called R6, R6 was very quiet afterwards but R6 never told why. Neither could say if there was anything that made R6 uncomfortable or anything that should be avoided.During an interview on 7/23/25 at 10:08 a.m., RN-A stated social services was responsible to complete the Trauma Informed Care Assessment and would make care plan revisions if the assessment identified a problem. RN-A stated R6 was very stoic and had never told RN-A anything about any traumatic life events. R6 knew she was on medications but could not explain to you why she was on those medications. It would be important for staff to know those things because staff wanted to keep R6 comfortable and feeling secure and safe.During an interview on 7/23/25 at 12:37 p.m., the director of nursing (DON) stated R6 was admitted at the time the facility was changing ownership and electronic medical records. Because of this, R6 was missed, and a trauma informed care assessment was not completed. The DON stated the assessment should have been completed for staff to identify and care plan triggers and interventions for R6's psychosocial needs. The facility Trauma Informed Care Policy revised 12/22, identified the facility would ensure staff assessed a resident who displayed or was diagnosed with mental disorder or psychological adjustment difficulty, or who had a history of trauma and/or post-traumatic stress disorder and facilitate appropriate treatment and services to manage the assessed problem to attain the highest practicable mental and psychological well-being. The intent of this requirement was to ensure that the facility delivered care and services which, in addition to meeting professional standards, were delivered using approaches which were culturally competent and account for experiences and preferences and addressed the needs of trauma survivors by minimizing triggers and/or re-traumatization.

Based on observation, interview and document review, the facility failed to ensure a unit refrigerator maintained a safe temperature for storage of food. This had the potential to affect all residents who received food from unit refrigerator. Findings include: During observation on 8/7/24 at 11:06 a.m., the unit refrigerator contained milk, cheese, and yogurt. A regular thermometer was not in the unit refrigerator and a request was made to the culinary director log of temperatures for the month of August 2024. During an interview on 8/7/24 at 2:12 p.m., the culinary director stated she did not know the range the unit refrigerator should be set at. When the unit refrigerator temperature was out of the set range of the automated monitoring system, an alert would be sent out to the culinary director, bio-med technician, and the executive director. The culinary director could not identify the temperature range or what temp she would be notified at. The History Detail Report for Skyview unit refrigerator dated 8/7/24, identified from 8/1/24 at 12:00 a.m. through 8/7/24 at 2:30 p.m. temperatures in the unit refrigerator were monitored every 15 minutes via an automated monitoring system. The report identified temperatures were at or above 41 degrees Fahrenheit (F) for the following times. -8/1/24 at 12:00 a.m., through 8/4/24 at 3:15 a.m, (75 hours (hr), 15 minutes (m) -8/4/24 at 5:45 a.m. through 8/4/24 at 7:45 a.m. (2 hr, 00 m) -8/4/24 at 12:45 p.m. through 8/5/24 at 1:45 a.m. (13 hr, 00 m) -8/5/247 at 2:15 a.m. through 8/7/24 at 2:30 p.m. (60 hr, 15 m) The total time the unit refrigerator was out of range was 6 days, 6 hours, and 30 minutes of a total of 6 days, 14 hours, and 30 minutes. During an interview on 8/7/24 at 2:19 p.m., the bio-med technician stated he was unaware of the temperature range the unit refrigerator was to be kept at nor did he know the temperature alert range the automated monitoring system had. An email was received from the bio-med technician identifying the automated monitoring system was set to a range of 33.8 degrees F to 48.2 degrees F. During an interview on 8/7/24 at 2:50 p.m., the director of nursing (DON) stated the unit refrigerator would be kept at a temperature below 41 degrees F to ensure safe storage temperature of food, so it does not spoil. If the food was spoiled, it could have caused illness in residents who received milk, cheese, or yogurt. Food should be stored according to the food storage policy. The facility's Food Storage policy dated 2021 identified time/temperature control for safety (TCS)foods must be maintained below 41 degrees F. Temperatures for refrigerators should be between 35-39 degrees F.

Based on observation, interview and document review, the facility failed to perform ongoing monitoring and wound care, as ordered, for a chronic reoccurring wound for 1 of 2 residents (R34) reviewed for wound care. Findings include: R34's quarterly Minimum Data Set (MDS) dated [DATE], identified R34 had diagnoses that included peripheral vascular disease (PVD) (a slow and progressive disorder of the blood vessels. PVD may affect any blood vessel outside of the heart. This includes the arteries, veins, or lymphatic vessels. Organs supplied by these vessels, such as the brain or legs, may not get enough blood flow for healthy function. The legs and feet are most often affected), high blood pressure, and coronary artery disease. R34 had one unhealed venous or arterial ulcer (a full-thickness defect of skin, most frequently in the ankle region, that fails to heal spontaneously and is sustained by chronic venous disease, based on venous duplex ultrasound testing). R34's care plan revised 7/3/24, identified R34 had a potential alteration in skin integrity related to risk factors associated with limited mobility and recent right below the knee amputation for ischemic limb, peripheral arterial disease to bilateral lower extremities and poor appetite. Interventions included: - Perform a skin assessment weekly - Wound care nurse (WCN) assessed left lateral ankle venous ulcer. Staff were directed to paint left ankle vascular wound with betadine and apply foam border dressing for protection. R34's physician orders dated 6/18/24, identified the following: Wound care: apply to left lateral ankle topically one time a day for left ankle vascular wound. Paint daily with betadine, cover with foam border for protection. Offload at all times while in bed with pillow under calf. R34's Skin/Comfort note dated 7/16/24 at 10:50 a.m., identified R34 was seen on wound rounds to follow up on vascular wound to left lateral malleolus (a bony projection with a shape likened to a hammer head, especially each of those on either side of the ankle). No drainage was noted on the old dressing. Wound measured 1.0 x 0.6 centimeters (cm). Thin, dry scab noted. Surrounding tissue blanchable erythema/redness. Foot had a purple hue while dependent. Will continue to paint scab with betadine and cover with foam border adhesive dressing for protection. R34 would be seen on wound rounds monthly. R34's Skin Observation dated 7/27/24 at 9:20 a.m., identified R34's skin integrity; however, the note failed to identify R34's left lateral ankle wound and its condition. R34's Electronic Treatment Administration Record (ETAR) dated 7/16/24- 8/7/24, identified R34 received wound care daily. Additionally, on 8/6/24, the ETAR identified RN-B signed off R34's left lateral ankle wound care as complete. During an observation on 8/7/24 at 10:36 a.m., licensed practical nurse (LPN)-A applied gloves and removed a foam border dressing from R34's left outer ankle vascular wound. LPN-A stated there was a small amount of serosanguineous (a type of wound drainage, or exudate, secreted by an open wound in response to tissue) drainage on the dressing before throwing the dressing in the trash. LPN-A stated the vascular wound was open and there was slough (dead tissue within a wound) in the wound bed.LPN-A applied betadine to the wound bed and, once dried, applied a foam border dressing. LPN-A used a marker to date and initial the foam border dressing. LPN-A stated the dressing should have been changed on 8/6/24, but the dressing LPN-A removed was dated 8/5/24. R34 should have been assessed on 8/6/24 by the wound care WCN. LPN-A stated she did not know why R34 did not receive wound care on 8/6/24. During an interview on 8/7/24 at 10:46 a.m., RN-A stated she was unaware R34 had an open wound. RN-A understood R34's wound was scabbed over and R34 was no longer followed during wound rounds. During an interview on 8/7/24 at 11:28 a.m., R34's physician stated R34 had a chronic vascular wound. Previous nursing reports identified the wound was scabbed over but had opened which was expected. R34's wound did not show signs/symptoms of infection but the WCN should evaluate R34. Staff wanted to care for the wound as best as possible to protect the leg because it was the only leg R34 had. During an interview on 8/7/24 at 12:55 p.m., the director of nursing (DON) stated RN-B did sign off R34's wound as complete on 8/6/24 and could only assume RN-B believed the WCN would change R34's dressing that day. Nursing staff were expected to follow wound care orders and document accurately. Additionally, nursing staff were expected to document a description of the wound at least weekly and/or if a change occurred. On 8/7/24 at 1:45 p.m., a phone interview with RN-B was attempted. The facilty policy Wound and Skin Care Protocols undated, identified wounds required weekly documentation at minimum and with changes in wound appearance/condition.

Based on observation, interview and document review, the facility failed to implement enhanced barrier precautions (EBP) for 1 of 2 residents (R34) reviewed for chronic wounds. Findings include: R34's quarterly Minimum Data Set (MDS) dated [DATE], identified R34 had diagnoses that included peripheral vascular disease (PVD) (a slow and progressive disorder of the blood vessels. PVD may affect any blood vessel outside of the heart. This includes the arteries, veins, or lymphatic vessels. Organs supplied by these vessels, such as the brain or legs, may not get enough blood flow for healthy function. The legs and feet are most often affected), hypertension, and coronary artery disease. R34 had one unhealed venous or arterial ulcer (a full-thickness defect of skin, most frequently in the ankle region, that fails to heal spontaneously and is sustained by chronic venous disease, based on venous duplex ultrasound testing). R34's care plan revised 7/3/24, identified R34 had a potential alteration in skin integrity related to risk factors associated with limited mobility and recent right below the knee amputation for ischemic limb, peripheral arterial disease to bilateral lower extremities and poor appetite. Interventions included: Perform a skin assessment weekly and wound care nurse (WCN) assessed left lateral ankle venous ulcer. Staff were directed to paint left ankle vascular wound with betadine and apply foam border dressing for protection. The care plan failed to direct staff to implement or follow EBP during wound care. R34's physician orders dated 6/18/24, identified the following: Wound care: apply to left lateral ankle topically one time a day for left ankle vascular wound. Paint daily with betadine, cover with foam border for protection. Offload at all times while in bed with pillow under calf. The order did not direct staff regarding EBP for R34's chronic vascular wound. R34's Skin/Comfort note dated 7/16/24 at 10:50 a.m., identified R34 was seen on wound rounds that morning to follow up on vascular wound to left lateral malleolus (a bony projection with a shape likened to a hammer head, especially each of those on either side of the ankle). No drainage noted on old dressing. Wound measured 1.0 x 0.6 centimeters (cm). Thin, dry scab noted. Surrounding tissue blanchable erythema/redness. Foot had a purple hue while dependent. Will continue to paint scab with betadine and cover with foam border adhesive dressing for protection. R34 would be seen on wound rounds monthly. The note did not identify EBP for R34's chronic vascular wound. R34's Skin Observation dated 7/27/24 at 9:20 a.m., identified R34's skin integrity, however, the note failed to identify R34's left lateral ankle wound and its condition. R34's Electronic Treatment Administration Record (ETAR) dated 7/16/24 - 8/7/24, identified R34 received wound care daily. During an observation on 8/7/24 at 10:36 a.m., R34's door contained no signage regarding EBP nor was personal protective equipment (PPE) available for use. Licensed practical nurse (LPN)-A applied gloves and removed a foam border dressing from R34's left outer ankle vascular wound. LPN-A stated there was a small amount of serosanguineous (a type of wound drainage, or exudate, secreted by an open wound in response to tissue) drainage on the dressing before throwing the dressing in the trash. LPN-A stated the vascular wound was open and there was slough (dead tissue within a wound) in the wound bed. LPN-A removed her gloves, used hand sanitizer and applied clean gloves. LPN-A did not implement EBP nor applied a gown. LPN-A applied betadine to the wound bed and, once dried, applied a foam border dressing. LPN-A used a marker to date and initial the foam border dressing. LPN-A removed the soiled gloves, removed the trash, used hand sanitizer and left R34's room. LPN-A stated she did not know why R34 was not on EBP because R34 had an open chronic wound. During an interview on 8/7/24 at 10:46 a.m., RN-A stated she did not know why R34 was not on EBP. RN-A stated she would need to look into his wound and determine what it was. - At 11:01 a.m., RN-A stated she was unaware R34 had an open wound. The last she understood was R34's wound was scabbed over and R34 was no longer followed during wound rounds. RN-A had previously set up a group email that included herself, administration, the physicians, and nursing to ensure everyone was updated with changes and staff were expected to report changes in resident conditions timely. There was signage and supplies available and nursing was expected to implement EBP as soon as possible to prevent a potential for infection transmission in chronic wounds and should have done so. During an interview on 8/7/24 at 11:28 a.m., R34's physician stated R34 had a chronic vascular wound. Previous nursing reports identified the wound was scabbed over, but had opened which was expected. Staff wanted to care for the wound as best as possible to protect the leg because it was the only leg R34 had. During an interview on 8/7/24 at 11:31 a.m., the director of nursing (DON) stated staff were expected to implement EBP for chronic wounds until healed. The facility's undated Care Center Enhanced Barrier Precautions Policy and Procedure policy, identified residents were at higher risk of becoming colonized and infection with Multidrug Resistant Organisms (MDROs) as the prevalence of MDROs was higher in this care setting. It was the policy of this facility to implement Enhanced Barrier Precautions, using PPE, as a preventative approach, to help reduce and prevent the transmission of MDROs. Enhanced Barrier Precautions involved gown and glove use during high-contact resident care activities such as wound care (any skin opening requiring a dressing).

Based on interview and document review, the facility failed to provide and document the most recent Centers for Disease Control (CDC) education regarding the potential risks and benefits of the pneumococcal vaccine for 3 of 5 residents (R20, R39, R42) reviewed for immunizations. Findings include: R20's significant change Minimum Data Set (MDS) dated [DATE], identified R20 was [AGE] years old and had diagnoses that included diabetes mellitus, and hypertension. R20's immunization record dated 8/7/24, identified R20 refused a pneumococcal conjugate (PCV20) vaccination. R20's admission note dated 6/20/24 at 12:48 p.m., identified R20 declined when offered pneumonia vaccine. However, the admission note failed to identify what education, if any, education R20 received regarding pneumococcal vaccination. R20's Care Center Pneumococcal Immunization Consent dated 6/20/24, identified R20's signed refusal of a pneumococcal vaccination. However, the document failed to identify which pneumococcal vaccine R20 was offered and/or what education was provided. During a phone interview on 8/7/24 at 10:52 a.m., family member (FM)-A stated R20 a pneumococcal vaccination when offered by the facility but could not recall what education, if any, R20 received. R39's admission MDS dated [DATE], identified R39 was [AGE] years old and had diagnoses that included coronary artery disease, hypertension, dementia and renal insufficiency. R39's immunization record dated 8/7/24, identified R39 refused a PCV20. R39's Care Center Pneumococcal Immunization Consent dated 5/23/24, identified R39's family representative signed refusal of a pneumococcal vaccination. However, the document failed to identify which pneumococcal vaccine R39 was offered and/or what education was provided. R39's nursing progress note dated 6/6/24, identified R39's family represenative was provided education regarding a respiratory syncytial virus (RSV) vacccine, however, did not identify if R39's family representative was provided education regarding pneumococcal vaccination. During a phone interview on 8/7/24 at 11:08 a.m., FM-B stated she believed vaccinations were discussed during R39's care conference but could not recall what education had been provided. R42's admission MDS dated [DATE], identified R42 was [AGE] years old and had diagnoses that included hypertension, Diabetes Mellitus, and dementia. R42's immunization record dated 8/7/24, identified R42's family representative refused pneumococcal vaccination. R42's Care Center Pneumococcal Immunization Consent dated 6/24/24, identified R42's family representative signed refusal of a pneumococcal vaccination. However, the document failed to identify which pneumococcal vaccine R42 was offered and/or what education was provided. During a phone interview on 8/7/24 at 2:17 p.m., R42's family representative did not recall what education was provided regarding vaccinations. During an interview on 8/6/24 at 4:19 p.m., registered nurse (RN)-A stated she created a form for documentation of offering, education and acceptance/refusal of pneumococcal immunizations. However, RN-A stated nursing did not complete the forms as directed and RN-A could not confirm what education R20, R39 and R42 or their family representative had been provided. RN-A stated nursing staff were expected to fully complete the forms for documentation to ensure residents and their family representatives were fully and accurately informed. During an interview on 8/7/24 at 12:55 p.m., the director of nursing (DON) stated RN-A had been working diligently to update vaccination documenation forms to ensure correct documentation of offer, education and acceptance/refusal of vaccinations. The DON stated nursing staff were expected to complete the documentation accurately and fully. A facility pneumococcal policy was requested but not received.

Based on interview and document review, the facility failed to provide pneumococcal conjugate vaccine 20 variant (PVC20) education as directed by the Centers for Disease Control (CDC) for 5 of 5 residents (R11, R28, R36, R37, R42) reviewed for immunizations. Findings include: R11's quarterly Minimum Data Set (MDS) dated [DATE], identified a diagnosis of congestive heart failure. R11's immunization record dated 7/19/23, identified R11 received the pneumococcal 23 (PPSV23) on 10/23/14 and the pneumococcal conjugate vaccine 13 variant (PCV13) on 1/04/16. R11's medical record failed to provide evidence the PCV20 (pneumonia immunization) was offered and/or education was provided in conjunction with the provider to R11/R11's representative. R28's quarterly Minimum Data Set (MDS) dated [DATE], identified diagnoses of anemia (low blood count) and hypertension (high blood pressure). R28's immunization record from 7/19/23, identified R28 received PPSV23 on 2/4/15, and the PCV13 on 11/11/14. R28's medical record failed to provide evidence the PCV20 was offered and/or education was provided in conjunction with the provider to R28/R28's representative. R36's quarterly Minimum Data Set (MDS) dated [DATE], identified a diagnoses of Parkinson's disease, heart valve replacement, and pulmonary (lung) nodule. R36's immunization record dated 7/19/23, identified R36 received the PPSV23 on 11/12/02, and the PCV13 on 9/29/17. R36's medical record failed to provide evidence the PCV20 was offered and education was provided in conjunction with the provider to R36/R36's representative. R37's quarterly Minimum Data Set (MDS) dated [DATE], identified a diagnosis of anorexia (not eating enough). R37's immunization record dated 7/19/23 identified R37 had not received a PPSV23 or a PCV13 and education was not given by the facility. Further, R37's medical record failed to provide evidence the PCV20 was offered and education was provided in conjunction with the provider to R37/R37's representative. R42's quarterly Minimum Data Set (MDS) dated [DATE], identified a diagnosis of respiratory failure (unable to breath). R42's immunization records dated 7/19/23, identified R42 received the PPSV23 on 10/11/04, and the PCV13 on 12/9/16. R42's medical record failed to provide evidence the PCV20 was offered and education was provided in conjunction with the provider to R42/R42's representative. During an interview on 7/18/23 at 3:30 p.m., registered nurse (RN)-B stated she worked with the residents and tracked the immunizations they received. When residents were admitted to the facility their immunization record was reviewed and education was provided to the residents about the PCV 20. The residents who were in the facility prior to May 2023, were not offered the PCV 20 and no education was provided. During an interview on 7/19/23 at 3:29 p.m., the director of nursing (DON) stated it was expected the recommendations from the CDC were followed. The facility policy Pneumococcal Immunizations for Residents dated 4/28/23, identified the residents would have every opportunity to receive the recommended vaccine. The CDC guidance dated 2/9/23, identified adults 65 and older have the option to get PCV20.

Based on observation, interview, and document review, the facility failed to ensure personal intimate laundry was not left in a public area for 1 of 1 residents (R9) whose bras were observed sitting on top of the handrail outside her room door. Findings include: R9's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/16/22, at 10:34 a.m. about six shirts on hangers were hanging on the hand railing outside R9's room. On top of the hangers were two bras. Registered nurse (RN)-D exited the room. RN-D stated she hadn't heard anyone knock on the door and confirmed personal laundry should not be left outside a resident's room. On 3/16/22, at 10:39 a.m. laundry aide (LA)-A stated she knocked on the resident's door and when no one answered she left the laundry hanging on the railing outside the resident's door. LA-A verified she should not have left personal laundry (resident's bras) outside the room where anyone walking by could see them. On 3/17/22, at 9:00 a.m. RN-C stated she would see clothing left outside of resident rooms about twice a week. RN-C verified this was not a dignified practice to leave personal clothing outside of resident rooms, especially if it was underclothes. On 3/17/22, at 9:45 a.m. RN-B verified it was not dignified for residents to have their personal clothing left in the hallway for anyone to see. RN-B stated she would expect staff to knock on the door and bring the clothing into the room to be put away. If no one answered the door the clothing should not have been left in the hallway. On 3/17/22, at 10:59 a.m. the director of nursing (DON) verified personal laundry should not be left in the hallway, staff should have knocked and brought the clothing into the room. If no one answered she would have expected the clothing to be delivered later. The DON confirmed it was not dignified to have personal clothing (especially bras) left in the hallway. The facility policy titled Care Center Privacy and Dignity undated, directed staff to care for all residents in an approach that makes certain that each residents privacy and dignity was respected by staff.

Based on observation, interview and document review, the facility failed to identify two full body pillows as a restraint for 1 of 1 resident (R1) who utilized two full body pillows and was unable to move them. Findings include: R1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was severely cognitively impaired, required extensive assistance with activities of daily living, and did not have restraints in use. R1's care plan revised 9/14/21, indicated R1 was at risk for falls with a history falls and of crawling out of bed onto the fall mats. Interventions included the bed to be in the lowest position when staff were not in the room, call bell pinned to gown when in bed, and to not be left alone in her wheel chair in her room. In addition, a thick fall mat was to be placed next to the bed, then another fall mat next to the thick fall mat. On 3/15/22, at 11:10 a.m. R1 was lying in her bed on her right side facing the wall, with two full length body pillows behind her back. The two body pillows were stacked one on top of the other and were about eight to 10 inches raised above her body. Next to R1's bed was a six to eight inch mat with a second mat about two inches thick next to the first mat. On 3/15/22, at 2:50 p.m. nursing assistant (NA)-E went into R1's room, R1 was lying in her bed on her right side with the two full body pillows behind her back and the fall mats next to her bed. NA-E stated R1 could move the pillows herself. NA-E checked R1's brief (it was dry) and then tucked both body pillows under the lift sheet. On 3/16/22, at 9:19 a.m. NA-B stated the long body pillows on R1's bed were to keep R1 from rolling out of bed. NA-B stated the long body pillows were not a restraint. R1 was transferred from her wheelchair to her bed with a standing mechanical lift. When R1 was seated on the side of her bed she lifted her feet into the bed and lay down without staff assistance. NA-B tucked the long body pillows under the lift sheet, lowered the bed to the floor, and placed the thick mat next to the bed, then the second mat next to the thick mat. On 3/17/22, at 8:24 a.m. NA-A entered R1's room, R1 was calling out, both long body pillows were tucked under her lift sheet. NA-A asked R1 if she could push her pillows away, R1 did not push the pillows away as requested. NA-A stated on previous occasions she had found R1's pillows pushed off her bed when she entered R1's room. On 3/17/22, at 9:04 a.m. registered nurse (RN)-C entered R1's room. R1 was lying on her back in bed, the two body pillows were stacked one on top of the other on R1's left side. RN-C asked R1 to push the pillows off her bed. R1 smiled at RN-C and asked her for water. RN-C gave R1 some water to drink. R1 did not push the pillows off the bed. On 3/17/22, at 9:49 a.m. RN-B stated she had occasionally found R1's long body pillows at the foot of the bed. RN-B stated on 6/6/21, R1 had moved the pillows out of the way to get her shoes but then had a fall out of bed. On 3/17/22, at 10:11 a.m. NA-D stated about two weeks ago she found the long body pillows on the fall mat. NA-D verified when the pillows were tucked under the lift sheet R1 would not be able to get at them and move them. On 3/17/22, at 10:20 a.m. RN-B stated the MDS nurse looked at restraints each quarter. RN-B verified no one was having R1 demonstrate at those reviews if she could move the pillows. On 3/17/22, at 10:26 a.m. the director of nursing (DON) stated the long body pillows were for positioning and comfort. The DON went to R1's room, R1 was lying on her back in bed with the two long body pillows stacked one on top of the other on lying next to her on the bed and not tucked under the lift sheet. The DON asked R1 to push the pillows away, R1 did not push the pillows away. The DON stated the pillows were a safety risk and removed the pillows from R1's room. The DON verified the long body pillows were a safety risk because R1 could no longer move the pillows out of her way. The facility policy titled Care Center Restraint Free Environment undated, defined a restraint as any manual method, physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body.

Based on interview and document review, the facility failed to ensure allegations of abuse were reported immediately (within two hours) to the administrator and State Agency (SA) for 1 of 4 residents (R11) reviewed for abuse. Finding include: R11's Transfer/Discharge Report printed 3/17/22, indicated R11's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R11's care plan initiated 8/12/16, indicated R11 had cognitive impairments and dementia with behaviors (swearing, hitting, kicking and refusals of care), with a need for assistance with activities of daily living (ADLs) and mobility. In addition, R11's care plan indicated R11 had verbal outbursts (swearing, name calling [whores], delusions/physical aggression [hitting, biting, kicking, and refusal of cares], cognitive impairment [[CONDITION(S)] with psychotic symptoms such as paranoia and hallucinations]) A facility incident report submitted to the SA on 10/19/21, at 4:35 a.m. indicated on 10/17/21, at 4:49 a.m. R11 was yelling out during cares to call the doctor, the doctor had raped her. On 3/16/22, at 1:08 p.m. the director of nursing (DON) stated she was unsure of when she first learned of the allegation. The DON verified she would have expected staff to report an allegation of rape immediately to the charge nurse who then should have called her or the administrator at that time. The DON verified the allegation was not reported timely. The facility policy titled Abuse Prevention Freedom from Abuse, Neglect And Exploitation, undated, directed all staff to report to their immediate supervisor any suspected maltreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The supervisor would then report the incident immediately to the administrator.

Based on interview and document review, the facility failed to ensure COVID-19 vaccination policies and procedures included a process that all staff, including contracted staff, had received the COVID-19 vaccination or were granted an religious and/or medical exemption. This resulted in less than 100% staff vaccination rate which increases the potential of spreading COVID to residents who resided at the facility. Findings include: A Human Resources email dated 3/15/22, identified dietary aide (DA)-A did not receive a vaccine upon hire (2/21/22) and was granted 30 days to make a decision from her hire date. Human Resources was scheduled to follow up with DA-A on 3/21/22, but DA-A was suspended and was most likely not going to return. The facility COVID-19 Staff Vaccination Status for Providers undated, identified DA-A was a dietary employee assigned to the kitchen. The form also identified DA-A was unvaccinated and did not have a medical or non-medical exemption. The dietary staff schedule dated 2/21/22-3/20/22, identified DA-A worked 2/22/22, 2/23/22, 2/24/22, 2/25/22, 2/28/22, 3/3/22, 3/4/22, 3/5/22, 3/6/22, and 3/14/22. During an interview on 3/15/22, at 2:55 p.m. registered nurse (RN)-A stated she was responsible for tracking the employee vaccination matrix for the long-term care center, but employee health and human resources were responsible for employee vaccination and/or exemptions. RN-A was responsible for unvaccinated employee COVID testing. DA-A was listed on the provided Staff Vaccination Matrix, however, the matrix identified she was unvaccinated and had no medical or non-medical exemption. At that time, RN-A stated she needed to reach out to Human Resources for clarification. During an interview on 3/16/22, at 1:39 p.m. the administrator and RN-A provided a printed email from human resources which identified DA-A was unvaccinated and did not have a medical or non-medical exemption due to DA-A having a 30-day delay. The administrator stated Human Resources had no documentation regarding DA-A's 30-day delay besides an email dated 3/15/22, which stated DA-A did not receive a vaccine upon hire and was granted 30 days to 'make a decision' from her hire date which was 2/21/22. The administrator further stated this was identified at the beginning of survey and DA-A had been suspended from employment at that time. Additionally, Human Resource employees were educated on the vaccine mandate and the requirements that must be followed. The facility policy CMS COVID-19 Health Care Staff Vaccination Interim Final Rule Mandate Policy for Cuyuna Regional Medical Center Staff and Providers undated, identified the policy applied to all staff and all new staff were required to comply with the CMS vaccination requirements outlined in this policy as a condition of employment. Potential candidates for employment would be notified of the requirements of this policy prior to the start of employment. All new staff must show proof of COVID-19 full vaccination or approved exemption prior to orientation.

Based on interview and document review, the facility failed to implement fall interventions and equipment guidelines for 1 of 1 resident (R3) reviewed for falls. This failure resulted in actual harm to R3 who fell from her recliner after it had been identified as malfunctioning which was not reported, and incorrectly using the recliner's control buttons resulting in the fall and R3 subsequently sustaining a hematoma to her forehead resulting in a visit to the emergency department (ED). Although noncompliance was present at the time of the events, the facility had implemented appropriate corrective action prior to the survey, resulting in a finding of past-noncompliance for R3. Findings include: R3's significant change Minimum Data Set ((MDS) dated [DATE], indicated she was moderately cognitively impaired and required extensive assistance from two staff for bed mobility, transfers and toileting. The MDS also indicated R3 had one fall since the previous assessment that did not result in injury. R3's Falls Care Area Assessment (CAA) dated 5/19/20, indicated on 4/5/20, staff had entered her room and found her supine on the floor in front of her recliner chair. Staff to place recliner remote (adjusts movement/position) out of reach on right side of recliner. R3's Closet Care Plan titled Fall Interventions indicated on 4/6/20, per resident and daughter request, clip recliner remote to upper right side of recliner out of residents reach. R3's care plan revised 7/20/20, identified a self care deficit related to cognitive impairment and impaired mobility. The care plan identified a risk for falls related to a history of falls, impaired cognition, impaired balance and incontinence. The care plan directed staff to place call light and commonly used items within reach and indicated R3's recliner chair was removed on 7/15/20, because it was broken. On 7/20/20, at 1:29 p.m. R3 was observed in bed with her eyes closed. R3's forehead was noted to have a large blue/black bruise on it. On 7/21/20, at 8:24 a.m. R3 was observed in bed. The right side of R3's face was bruised and was black/green in color. A review of R3's facility incident reports and correlating Progress Notes dated April 2020 to July 2020, indicated the following: Progress Note (PN) dated 4/5/20, at 8:50 p.m. indicated staff entered R3's room and found her laying supine on the floor in front of her recliner chair with fall mat partially under her. R3 indicated she was trying to sit up and had pushed the wrong button on the remote. Incident report indicated a wider fall mat was provided with non-skid strips underneath and indicated recliner remote placement to be discussed with daughter that day. PN dated 7/14/20, 6:34 p.m. indicated staff entered R3's room and found her laying on the floor on her right side with her face to the floor. Recliner was in its highest position, and remote for recliner was hanging down from chair on the floor. R3 was calling out for help. Large hematoma noted to right side of forehead extending into her hair line. Hematoma was blue/purple in color with an opening measuring 0.5 centimeters (cm) x 0.5 cm. Open area was bleeding. R3 was noted to be slurring her words and was confused as to location and situation. R3 was transferred to the ED per provider order. PN dated 7/14/20, 9:51 p.m. indicated R3 was tired, confused and complained of pain to head and neck. Pressure bandage remained in place from hospital. PN dated 7/15/20, indicated writer spoke with R3's daughter to update her on condition. R3 was complaining of pain to head and right shoulder. An incident report dated 7/14/20, indicated the interdisciplinary team reviewed on 7/15/20. The report indicated investigation initiated as to whether care plan of keeping recliner remote out of reach was followed. The report indicated R3's recliner chair had been removed from her room as nursing assistant (NA)-A reported it had not been working at the time of the fall and indicated the leg rest would not go up. The report indicated R3's remote was behind her back when the NA left the room to report the broken chair and R3 had fallen after NA-A left the room. An untitled facility document dated 7/16/20, indicated NA-A removed R3's meal tray after dinner and attempted to elevate the legs of the recliner chair, however, NA-A indicated the recliner was not working correctly. The document indicated NA-A went to find the nurse to report the chair, but did not immediately find the nurse and went to help another resident. When NA-A finished with the other resident, R3 was found on the floor. NA-A further reported not being sure where the recliner remote had been left and indicated it may have been left along side R3 in the chair. NA-A reported being aware that the remote was to be kept out of R3's reach when seated in the recliner. On 7/21/20 at 11:19 a.m. R3 was observed seated in a recliner in her room. When asked how she obtained the bruises on her face, R3 stated she had fallen but was not sure how it happened. At 12:36 p.m. the director of nursing (DON) stated at the time of R3's fall, she had been seated in her recliner chair having just finished the supper meal. The DON stated after the meal, R3's chair would not recline. The DON stated when interviewed, NA-A stated she had tried to find a nurse to report the broken chair but was unable to find the nurse. The DON stated she told NA-A broken equipment needed to be removed from use, but stated that was not what caused the fall. Rather, the DON stated R3's fall occurred because R3 was able to get hold of the recliner remote and did not know how to use it. The DON stated had the been positioned where it was supposed to be, she did not think R3 would have been able to access it, raise the chair and fall. The facility's Care Center Fall Prevention policy dated 21/20/17, indicated a fall care plan was to be placed in each residents closet and all staff were responsible to follow resident specific fall interventions identified. The facility's Equipment Related Incidents policy dated 12/21/17, indicated any employee who became aware of any information that suggested medical equipment malfunction may cause, if malfunction were to reoccur: death, serious injury or adverse experience was required to report the event immediately. The past non-compliance that began on 7/16/20, was verified during an on-site visit 7/20/20 - 7/21/20. The past non-compliance was reviewed to be corrected by 7/16/20, after the facility implemented the following action plan: - Education provided to NA-A regarding following the pan of care. - Policy and procedures related to equipment reviewed and education provided. - R3's recliner chair was removed and replaced with a facility chair until R3's chair was fixed.

Based on interview and document review, the facility failed to report allegations of abuse to the State agency (SA)within the required two hour time frame for 1 of 3 residents (R2) reviewed. Findings include: R2's Entry Tracking Record Minimum Data Set (MDS) indicated he admitted to the facility on [DATE]. R2's care plan dated 7/13/20, identified an alteration in independence related to activities of daily living. The care plan indicated R2's level of assistance fluctuated depending on his mood, behavior and willingness to participate in care. The care plan indicated R2 was at risk for feelings of paranoia/suspicious behavior related to like experiences. R2's Individualized Resident Care Plan (closet care plan) indicated on 7/7/20, female caregivers only for cares and medication pass. R2's facility Progress Note dated 7/6/20, indicated R2 continued to report that a male staff on the overnight shift was mistreating him and that he feared for his life and feared retaliation. On 7/21/20, at 11:37 a.m. R2 was observed lying in bed. When asked about the incident with the male staff member, R2 stated, the nurse manager and I have handled it now, things are better, but I am glad you came. On 7/21/20, at 12:22 p.m. the director of nursing (DON) stated when R2 reported the allegation regarding the male staff member, he had been talking about a guy on the night shift and then R2 said it was another nursing assistant (NA). The DON stated they did not report the allegation to the SA immediately because they thought R2 just wanted to get out of the facility. However, the next day, the interdisciplinary team discussed the allegation and determined it should have been reported to the SA immediately, as required. The facility's Abuse Prevention Plan policy dated 2/13/20, indicated all allegations of abuse shall be reported to the SA immediately, defined as no later than two hours after the allegation was made.

Based on observation, interview and document review, the facility failed to provide a dignified dining experience for 3 of 7 residents (R26, R18, R11) observed who required staff or set up assistance to eat. In addition, the facility failed to respond to repeated requests to use the toilet for 1 of 4 residents (R50) observed, who had the ability to request and use the toilet. Findings include: R26's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R26 was severely cognitively impaired, required extensive assistance of one staff to eat, had mechanically altered diet, and had [DIAGNOSES REDACTED]. R26's care plan provided on 11/21/19, indicated R26's behaviors included difficulty with initiating chewing and the need for assistance to eat. Speech Language Pathologist (SLP) recommended close mealtime supervision due to aspiration precautions. The care plan also indicated R26 had impaired mobility, decreased range of motion (ROM) to both arms and legs, and required total assistance with activities of daily living (ADL) including eating, provide mechanical texture foods, cut foods into 1/2 inch pieces and may offer pureed foods. R18's quarterly MDS dated [DATE], indicated R18 was severely cognitively impaired, was totally dependent on one staff member to eat, and had [DIAGNOSES REDACTED]. R18's care plan provided on 11/21/19, indicated R18 had impaired mobility, required assistance with ADL's, was, totally dependent on one staff for eating, and had a potential for alteration in nutritional status. The care plan directed staff to provide meals with pureed texture, honey-like consistency liquids, nosey glass and inner lip plate. The care plan also directed the staff to monitor R18 every shift for aspiration and to ensure precautions are in place which included R18's wheelchair to be in a full upright position, staff to provide small bites/sips, alternate bites/sips, R18 must be alert and awake, chew thoroughly, and remain upright 30-60 minutes following meals. R11's Significant Change MDS dated [DATE], indicated R11 had [DIAGNOSES REDACTED]. The MDS also indicated R11 was able to feed herself after the meal tray was set up. R11's care plan dated 5/30/19, directed staff to provide house diet, regular texture, to cut all meat into half inch bite size pieces and to set up and encourage R11 to feed self with the left hand. The staff were also directed to set R11's silverware and glasses on R11's left side. On 11/18/19, at 5:06 p.m. R26 and R18 were observed seated at a dining table with another female resident. All three residents had been served the evening meal. The third resident was independently eating the meal, however R26 and R18 meals went untouched. -At 5:26 p.m. nursing assistant (NA)-F sat at the table next to R18 and proceeded to assist R18 with the meal. R26's meal remained untouched nor was R26 assisted to eat by the staff. -At 5:29 p.m. NA-A approached the table, stood next to R26's wheelchair, fed R26 a bite of food, walked away from table, used hand sanitizer, sat down at another table, and proceeded to assist another resident with eating. NA-F remained seated next to R18, cut up another resident's food, left the table, returned to the table, sat down next to R18 and resumed assisting R18 to eat. R26 remained with her meal in front of her without assistance to eat. -At 5:33 p.m. NA-F stood up, walked around the table, gave R26 a bite of food, returned and sat in same chair next to R18 and continued to assist R18 to eat. At 5:35 p.m. and 5:40 p.m. NA-F repeated the same process. -At 5:44 p.m. NA-F walked around the table, picked up R26's dessert and gave R26 a bite. At no time was a staff member observed to sit next to R26 and assist with eating. -At 5:49 p.m. NA-E walked up to R26's table, rubbed R26's arm and asked R24, are you done? R26 did not reply. While standing next to R24, NA-E gave R26 a bite of food and a drink of water. NA-E offered R26 another bite of food, however R26 turned her head away. NA-E attempted again at which time R26 accepted the bite of food. NA-E obtained a chair and sat down next to R26. -At 6:05 p.m. NA-E asked R26 is she was done eating, proceeded to remove the clothing protector and wheeled R26 out of the dining room. R26 had consumed approximately 50% of noodles, 50% of carrots, and bites of sherbet. On 11/19/19, at 5:09 p.m. R11 was observed seated at a dining table with R26's, and R18. R11 had been served the meal which consisted of salmon and creamed peas. R11's silverware was on the table, unopened/wrapped. R11 began eating the meal with her fingers by picking up on pea at a time causing the creamed sauce to smear on her hand and fingers. The other residents' seated at the table had not been served the meal. -At 5:15 p.m. R11 continued eating her meal with her fingers. Staff were observed to approach R11's table and ask the other tablemates what they would like for the evening meal. None of the staff assisted nor responded to R11 eating her meal with her fingers. -At 5:18 p.m. NA-F served R26, R18 the meal. NA-F set the meals in front of the residents and walked away. The residents sat with the meal in front of them, untouched while R11 continued to eat with her fingers. -At 5:22 p.m. R11 continued to eat the meal with her fingers while a staff member sat down at the table and proceeded to assist another resident. R11 was not offered nor provided assistance to eat or to obtain the silverware. -At 5:30 p.m. R11 continued to eat her meal with her fingers as NA-A assisted another tablemate with eating. No offer or attempt was made to unwrap and hand R11 the silverware. -At 5:37 p.m. the director of nurses (DON) cleansed R11's hand, unwrapped the silverware, handed R11 a spoon, and assisted to straighten R11 to a more upright position for eating. R11 used the spoon without difficulty to continue to feed herself spoonful's of the peas and salmon. On 11/20/19, at 12:11 p.m. the assistant director of nutritional services (ADND) stated the staff were expected to unwrap/set up R50's silverware, as directed by the care plan. On 11/20/19, at 12:15 p.m. the DON stated it was the expectation that the staff would assist R11 with meal set up which included opening of the silverware, as directed. On 11/21/19, at 8:05 a.m. family member (FM)-C stated the residents that required assistance to eat wait, on an average, 30 minutes with the food in front of them before they are assisted to eat. FM-C stated there were usually only two staff in the dining room to assist the residents with eating. On 11/21/19 at 1:16 p.m. registered nurse (RN)-A stated it was expected for the staff to assist a resident to eat as soon as they were served their meal, and not have to wait to eat. RN-A stated all nursing staff were aware of this expectation. The facility's Care Center Privacy and Dignity policy, printed 11/20/19, indicated the residents had the right to eat with dignity by having staff sit down next to them when being assisted with meals, all residents present at one ding table will be served at the same time, meal assistance begins immediately or within 5 minutes once the food was placed in front of the resident. The facility's Care Center Dining Areas policy dated 11/15/19, indicated the residents had the right to eat with dignity and have each meal be a pleasurable experience. The policy directed staff to completely serve a table and carton/containers are to be opened and the food prepared (i.e. cut up, condiments added), prior to the next table being served. Coaching and supervision would be provided for residents as required. R50's annual MDS dated [DATE], indicated R50's [DIAGNOSES REDACTED]. The MDS also indicated R50 had moderate cognitive ability, and required extensive assistance with all ADL's. The MDS indicated R50 required extensive assistance of two staff with transfers using the mechanical EZ stand lift, R50 was non-ambulatory, and was frequently incontinent of bowel and bladder. R50's Urinary Incontinence Care Area Assessment (CAA) dated 11/7/19, indicated R50 had frequency and incontinence of urine and stool. Staff were directed to check and change R50's incontinent brief every two hours and toilet per request. R50's care plan dated 10/31/19, indicated R50 was to have incontinent product checked and changed every two hours during the night. The care plan also indicated R50 was to be checked/changed or the staff were to ask R50 if she needed the toilet to have a bowel movement. The staff were directed to place R50 on the toilet per request or for smearing stool. On 11/18/19, from 5:08 p.m. until 5:32 p.m. R50 was continuously observed in the 500 wing day room. -At 5:16 p.m. R50 was heard to ask licensed practical nurse (LPN)-A to use the bathroom. LPN-A did not respond to the request. Shortly there-after, R50 again asked to use the restroom, LPN-A did not respond to the request. -At 5:20 p.m. LPN-A asked R50 if she would like a root beer float. R50 again asked to use the bathroom. LPN-A again did not respond to the request nor call for staff assistance to take R50 to the bathroom. -At 5:28 p.m. R50 directly told LPN-A that she needed to go to the bathroom. LPN-A informed R50 that there were no staff available to take her to the bathroom and told R50 she would have to wait as LPN-A could not leave the area. R50 stated she was going to have an accident in her pants. R50 was observed to attempt to stand up from the wheelchair. LPN-A cued R50 to stay seated in the chair. -At 5:29 p.m. LPN-A stated to R50, I've let someone know you need to go to the bathroom. LPN-A was not observed to assist R50 to the restroom. -At 5:32 p.m. NA-B assisted R50 to her room and assisted onto the toilet. R50's incontinent product was reported to have been dry when assisted onto the toilet. R50 did not return to the dining room rather had been assisted to bed. R50's Progress Note dated 11/18/19, at 9:41 p.m. indicated during the evening meal, R50 had requested to use the toilet and after toileting, had refused the meal. R50 had stated to staff I just want to go to bed. On 11/21/19, at 10:06 a.m. RN-A stated when a resident requests to use the bathroom, the staff were expected to call the charge nurse for help if they were not able to assist the resident to the bathroom at the time of the request. RN-A stated the charge nurse always carried a cell phone and would be available to assist or to find assistance to take a resident to the bathroom, when requested. RN-A verified it was not dignified to not respond to R50 toileting request and make R50 wait to use the bathroom. On 11/21/19 at 1:32 p.m. the DON stated the staff were expected to assist R50 to the bathroom when the request was initially made, or find assistance, if needed. The facility's Care Center Privacy and Dignity Policy reviewed 12/15/17, directed staff to provide timely bathroom assistance, as needed, to avoid situational incontinence, because they had to wait too long. The facility's Care Center Bowel and Bladder Program Policy last review date of 3/26/19, directed staff to follow the residents toileting scheduled and report to the (LPN) when results of the schedule could not be followed, so adjustments could be made.

Based on observation, interview and document review, the facility failed to ensure a hearing assistive device was provided for 1 of 1 resident (R52) who was hard of hearing. Findings include: R52's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R52 has [DIAGNOSES REDACTED]. The MDS indicated R52 had severe cognitive impairment, required extensive assistance of two plus staff with transfers, dressing, and toileting, and extensive assistance of one staff for personal hygiene. The MDS also indicated R52 utilized a hearing aid. R50's Communication Care Area Assessment (CAA) dated 8/21/19, indicated R52 had impaired communication skills. Staff to communicate with the pocket talker. Staff to speak to R52 directly in front of him with short statements, ask yes or no questions. A referral was made to an Ear, Nose, and Throat (ENT) physician, and it was noted R52 may need a consult with an audiologist (hearing specialist). R50's Care Plan dated 11/18/19, indicated R52 had a hearing deficit and would refuse to wear hearing aids. The care plan directed staff to assist with the insertion of a pocket talker (external amplifying device) in the morning and remove it at bedtime, as he was willing. The pocket talker was to be stored in the medication cart. The care plan also directed staff to get R52's attention prior to speaking, he hears better out of the right ear and can lip read. Offer the pocket talker with activities in/out of his room, staff to use [MEDICATION NAME] and irrigation of ears, as needed. Family requested staff to try the pocket talker before using paper and pen to communicate with R50. On 11/18/19, at 6:37 p.m. family member (FM)-A stated the family would like R52 to wear the pocket talker, but they frequently noticed R52 would not be wearing it when they visited. On 11/19/19, at 4:15 p.m. R52 was observed resting in bed with the television (TV) on. R52 was not wearing pocket talker. -At 4:49 p.m. a staff member assisted R52 to the dining room. R52 was not wearing the pocket talker. -At 5:44 R52 was watching TV in the small room off nurse's station. The pocket talker was not in use. On 11/20/19, at 7:07 a.m. R52 was observed lying in bed, the room was dark. -At 7:26 a.m. R52 was greeted by staff, they stated they would be back to assist him with morning cares in a few minutes. -At 7:40 a.m. R52 was assisted by staff with morning cares. -At 7:57 a.m. morning cares were completed, but R52's pocket talker was not offered nor provided. -At 8:29 a.m. R52 was wheeled to breakfast by staff. R52 was not wearing the pocket talker. -At 9:11 a.m. R52 was wheeled from the dining room to the small TV room and placed in front of the TV. R52 was not wearing the pocket talker. On 11/20/19, at 9:31 a.m. nursing assistant (NA)-F stated the staff had not noted R52 wearing the pocket talker this week. -At 10:35 a.m. NA-C and NA-D were both interviewed. NA-D stated, R52 was hard of hearing so the staff needed to speak slowly and directly while facing R52. NA-D stated R52 had a microphone thing, but R52 did not like to use it. NA-C stated they did not offer R50 the pocket talker this morning because it falls out. -At 10:37 a.m. NA-D and NA-C proceeded to look in R52's drawers for the pocket talker and stated it could not be found and then recalled it was stored in the medication cart. NA-C exited R52's room to go see if the pocket talker was in the medication cart. R52 stated he did not hear well from his right ear, but heard okay from his left. NA-C returned and placed the ear piece in R52's right ear at which time R52 stated he could hear better with it. NA-C stated the ear piece falls out and verified R52 was not offered the pocket talker that morning. NA-C confirmed R52's family had requested the pocket talker be used daily. On 11/21/19, at 11:09 a.m. registered nurse (RN)-C reported R52's hearing had improved since the ENT visit on 11/7/19. RN-C confirmed R52's family requested the pocket talker be offered to R52 to use. RN-C verified NA-C requested the pocket talker today confirmed care plan directs staff to offer pocket talker daily and would expect staff to offer the pocket talker daily with morning cares. RN-C noted there was not an NA task to alert the NA's to offer the pocket talker. RN-C stated, the Audiologist suggested the use of a pocket talker a long time ago, when his wife was alive. On 11/21/19, at 1:31 p.m. the director of nursing stated RN-C had stated R-52 doesn't want to wear it and during a care conference the son stated he doesn't want it. The DON stated the care plan should have been updated. The facility's Communication with Deaf, Hard of Hearing and Non English Speaking Patients and Families policy reviewed on 3/11/16, indicated all Cuyuna Regional Medical Center (CRMC) would respect and assure the patient's right for effective communication and to provide appropriate aids. Assistive listening devices were listed as auxiliary aids and were to be used to engage in effective communication.

Based observation, interview and document review, the facility failed to provide timely assistance with repositioning for 1 of 7 (R24) residents observed who was at risk for pressure ulcer. Findings include: R24's annual Minimum Data Set ((MDS) dated [DATE], indicated R24's [DIAGNOSES REDACTED]. The MDS also indicated R24 had severe cognitive impairment, had hallucinations, required extensive assistance of two for transfers and toileting, was frequently incontinent of bowel and bladder, and was at risk for pressure ulcer. R24's Pressure Ulcer/Injury Care Area assessment dated [DATE], indicated R24 was confined to a wheelchair and bed most of the time. R24 required staff assist to move sufficiently in order to relieve pressure over any one site. R24 transferred with the EZ stand (standing mechanical lift) with an assist of two, and had risk factors for friction and shearing. The CAA also indicated R24 required regular repositioning assistance, had frequency and incontinence of urine and bowel with risk factor of maceration. Staff to reposition R24 every two hours when in the bed, wheelchair, and the recliner. R24 utilized a pressure relieving mattress in bed and a pressure reducing cushion in the wheelchair. R24's Braden Scale (for predicting pressure ulcer risk) dated 9/24/19, indicated R24 was at moderate risk for developing a pressure ulcer. R24's Tissue Tolerance Testing (TTT) dated 9/28/19, indicated R24 could tolerate a two hour repositioning program when in the chair. R24's care plan dated 10/3/19, directed staff to offer rest periods in the recliner or bed after meals as allowed by R24, and to use a pressure redistribution/relieving mattress on the bed and a pressure relieving cushion wedge in the wheelchair. R24's closet care plan dated 9/30/19, directed staff to turn/reposition every two hours. Float heels in bed, pillows under lower legs. On 11/19/19, from 4:18 p.m. to 7:34 p.m. R24 was continuously observed. -At 4:18 p.m. R24 was in the 500 wing day room, seated in a wheelchair. A stocking hat was on her head, a towel was draped around shoulders, and her head was down. R24 was facing the TV which had a cowboy show on. -At 4:55 p.m. R24 had remained in the same position. At this time, a staff member wheeled R24 to the dining room. -At 5:00 p.m. R24 was seated a dining room table. Two beverages, in two handled lidded cups were placed in front of her. -At 5:46 p.m. R24 had remained in the dining room, consuming the meal. At this time, R24 was wheeled out of the dining room to the 500 wing day room for medications and remained there. -At 5:55 p.m. R24 was positioned facing the TV and holding a lidded, two handled cup. -At 5:57 p.m. the director of nursing (DON) stopped and said hello to R24. R24 remained in the day room until 7:14 p.m. -At 7:14 p.m. R24 was wheeled to her room for bedtime cares. Nursing Assistant (NA)-B and registered nurse (A) provided the cares. -At 7:18 p.m. R24's brief was removed and R24 was noted to be wet. R24's skin was pink and intact. -At 7:34 NA-B stated the staff kept track of the times each resident was assisted with repositioning in a book which was located at the nursing station. The book enclosed a form titled Lakeview Toileting/Offloading. The worksheet identified the times that each resident had been assisted with repositioning. NA-B stated the book indicated R24 was last assisted with repositioning at 4:45 p.m., however, NA-B she had not completed this task at 4:45 p.m. and did not know who would have. NA-B confirmed she had last repositioned R24 at 3:30 p.m. NA-B stated there were lots of extra staff today and anybody could have done it, but it was not her. NA-B verified R24 should have been repositioned every two hours as directed by the care plan. NA-B confirmed R24 had went from 3:30 p.m. to 7:14 p.m. (3 hours, 44 minutes) without having been repositioned. -At 7:36 p.m. a registered nurse (RN) working R24's unit, and NA-A were asked if they had assisted R24 with repositioning. The RN stated she had not assisted the resident, and NA-A stated she had assisted with R24's repositioning at 3:30 p.m. On 11/21/19, at 9:54 a.m. RN-A confirmed R24 should have been repositioned every two hours as directed by the care plan. On 11/21/19, at 1:23 p.m. the DON verified R24 should have been repositioned every two hours, as directed by the care plan. The facility's policy Pressure Ulcer and Skin Injury Prevention policy dated 3/26/19, indicated at a minimum, the residents in bed would be turned and repositioned every two hours, or as directed on the care plan. Residents in sitting positions were to be repositioned every two hours, if unable to reposition self, or per care plan instructions.

Based observation, interview and document review the facility failed to provide timely assistance with toileting for 1 of 7 (R24) residents who required staff assistance with toileting. Findings include: R24's annual Minimum Data Set ((MDS) dated [DATE], indicated R24's [DIAGNOSES REDACTED]. The MDS also indicated R24 had severe cognitive impairment, had hallucinations, required extensive assistance of two for transfers and toileting, was frequently incontinent of bowel and bladder, and was at risk for pressure ulcer. R24's Bowel and Bladder Care Area Assessment (CAA) dated 9/24/19, indicated R24 was on a day and afternoon shift every two hour toileting schedule. Night shift checks and changes R24's incontinent brief every two hours per facility direction, and to toilet per request. R24's Bladder assessment dated [DATE], indicated the two staff utilize a mechanical standing lift to assist R24 on and off the toilet and to be place R24 on the toilet every two hours. If R24 refused toileting, the staff were to check and change R24's incontinent brief. Night shift are directed to check and change R24's incontinent brief every two hours and to toilet per R24's request. The assessment also indicated R24 was meeting the goal of no signs of moisture related skin conditions on the buttocks. R24's care plan dated 10/3/19, directed staff to have R24 wear a medium pull up during the day and afternoon shift, to transfer R24 via the EZ stand (standing mechanical lift) with the assistance of two staff on and off the toilet. The care plan failed to address the frequency of the toileting scheduled. In addition, the care plan directed staff to utilize an incontinent brief at noc (night) and to check and change every two hours and toilet per request. R24's Closet care plan dated 9/30/19, indicated for the day and evening shift, the staff were directed to place R24 on the toilet every two hours, if refuses to check and change incontinent product. The night closet care plan directed staff to check and change every two hours and to toilet per request. On 11/19/19, from 4:18 p.m. to 7:34 p.m. R24 was continuously observed. -At 4:18 p.m. R24 was in the 500 wing day room, seated in a wheelchair. A stocking hat was on her head, a towel was draped around shoulders, and her head was down. R24 was facing the TV which had a cowboy show on. -At 4:55 p.m. R24 had remained in the same position. At this time, a staff member wheeled R24 to the dining room. -At 5:00 p.m. R24 was seated a dining room table. Two beverages, in two handled lidded cups were placed in front of her. -At 5:46 p.m. R24 had remained in the dining room, consuming the meal. At this time, R24 was wheeled out of the dining room to the 500 wing day room for medications and remained there. -At 5:55 p.m. R24 was positioned facing the TV and holding a lidded, two handled cup. -At 5:57 p.m. the director of nursing (DON) stopped and said hello to R24. R24 remained in the day room until 7:14 p.m. -At 7:14 p.m. R24 was wheeled to her room for bedtime cares. Nursing Assistant (NA)-B and registered nurse (A) provided the cares. -At 7:18 p.m. R24's brief was removed and R24 was noted to be wet. R24's skin was pink and intact. At this time, NA-B confirmed R24 had been incontinent. -At 7:34 NA-B stated the staff kept track of the times each resident was assisted with toileting/incontinent cares in a book which was located at the nursing station. The book enclosed a form titled Lakeview Toileting/Offloading. The worksheet identified the times that each resident was had been assisted with toileting/incontinent cares. NA-B stated the book indicated R24 was last assisted with toileting at 4:45 p.m., however, NA-B she had not completed this task at 4:45 p.m. and did not know who would have. NA-B confirmed she had last provided R24 with toileting cares at 3:30 p.m. NA-B stated there were lots of extra staff today and anybody could have done it, but it was not her. NA-B verified R24 should have been checked and changed every two hours as directed by the care plan. NA-B confirmed R24 had went from 3:30 p.m. to 7:14 p.m. (3 hours, 44 minutes) without having been checked/changed or toileted. -At 7:36 p.m. a registered nurse (RN) working R24's unit, and NA-A were asked if they had assisted R24 with toileting cares. The RN stated she had not assisted and NA-A stated she had assisted with R24's toileting at 3:30 p.m. On 11/21/19 at 8:06 a.m. RN-B stated R24 should have been assisted with toileting and incontinence cares every two hours, as directed. On 11/21/19, at 9:54 a.m. RN-A confirmed R24 should have been offered toileting and/or provided incontinence cares every two hours during the day and evening shift, as directed. On 11/21/19, at 1:23 p.m. the DON verified R24 should have been offered toileting and/or incontinence care every two hours, as directed by the care plan. The facility's Care Center Bowel and Bladder Program policy dated 3/26/19, directed staff to complete a baseline assessment of the resident's bladder status and to reassess with change in incontinence status, a significant change, and with the annual MDS. A resident focused care plan would be implemented with interventions and measurable goals. Once it was determined that the resident was not able to participate in a toileting program, a check and change program would be established. If a resident's toileting plan or check and change program was outside the standard two-hour time frame, per resident or resident representative request, or as determined by assessment, this information would be documented in the clinical record and reflected in the care plan.

Based on interview and document review, the facility failed to ensure an allegation of abuse was reported immediately to the State agency for 2 of 3 abuse allegations which involved 2 of 2 residents (R1, R4) reviewed for allegations of rough handling by a staff member. Findings include: R1's progress note dated 3/2/19 at 1:51 p.m. indicated staff reported R1 had complained a staff member was rushing her in the morning when getting her up for the day and R1 was upset about this. R1 stated the staff member was rough putting on her stockings. Registered nurse (RN)-B noted she would talk with the nursing assistant to address the issue. On 4/30/19 at 2:44 p.m. registered nurse (RN)-A stated she was not aware of the 3/2/19 incident. - At 3:28 p.m. The director of nursing (DON stated they were not aware of the 3/2/19, incident identified in the progress note until the surveyor brought it to their attention. The DON contacted RN-B, the author of the 3/2/19, progress note and RN-B confirmed the incident and identified nursing assistant (NA)-A as having been involved. RN-B stated she had talked with NA-A at the time of the incident, but did not report the incident any further. Review of NA-A's performance report dated 12/7/18, revealed staff complaints of NA-A swearing in resident rooms and being rough with residents. The report indicated NA-A acknowledged he got frustrated at times and at times forgot his own strength which could appear as being rough when he was assisting residents. On 4/30/19 at 2:44 p.m. RN-A indicated the NA-A's performance report dated 12/7/18, was in response to complaints from staff regarding the care provided to R4 by by NA-A. RN-A could not remember if the reports had been reported however, stated she would expect it to have been reported, as required. Review of facility incident reports between 12/5/18, through 12/11/18, lacked any evidence the allegations of potential abuse identified NA-A's performance report had been reported or investigated by the facility to ensure it's residents were free from abuse. - At 3:28 p.m. DON-A stated the incident on 12/7/18, regarding R4 was not reported because they had not observed any bruising or injury to R4. The DON-A verified there was no documentation of an incident in the R4's medical record. On 5/1/19 at 9:00 a.m. family member (FM)-B stated she visited her mother frequently at the facility and had heard NA-A could get rough with the residents. FM-B stated he/she had received a call a little while ago about NA-A lifting on my mom's arms, pulling on her and seating her on the toilet roughly. FM-B stated she had never personally witnessed rough treatment from the staff. Review of the facility's Abuse and Prevention Plan indicated all residents residing in the facility would be protected from maltreatment and abuse. The plan indicated suspected maltreatment would be reported to the State agency no later than two hours after the allegation was made if the allegation involved abuse or injury. The plan also indicated all staff were required to report to their immediate supervisor suspected maltreatment of [REDACTED].

Based on interview and document review, the facility failed to ensure allegations of abuse were thoroughly investigated for 2 of 2 residents (R1, R4) whose allegations were reviewed. Findings include: R1's progress note dated 3/2/19 at 1:51 p.m. indicated staff reported R1 had complained a staff member was rushing her in the morning when getting her up for the day and R1 was upset about this. R1 stated the staff member was rough putting on her stockings. Registered nurse (RN)-B noted she would talk with the nursing assistant to address the issue. On 4/30/19 at 2:44 p.m. registered nurse (RN)-A stated she was not aware of the 3/2/19 incident. - At 3:28 p.m. The director of nursing (DON) stated they were not aware of the 3/2/19, incident identified in the progress note until the surveyor brought it to their attention. The DON contacted RN-B, the author of the 3/2/19, progress note and RN-B confirmed the incident and identified nursing assistant (NA)-A as having been involved. RN-B stated she had talked with NA-A at the time of the incident, but had not conducted a thorough investigation of the incident. Review of NA-A's performance report dated 12/7/18, revealed staff complaints of NA-A swearing in resident rooms and being rough with residents. The report indicated NA-A acknowledged he got frustrated at times and at times forgot his own strength which could appear as being rough when he was assisting residents. On 4/30/19 at 2:44 p.m. RN-A indicated the NA-A's performance report dated 12/7/18, was in response to complaints from staff regarding the care provided to R4 by by NA-A. RN-A could not remember if the reports had been investigated or not. Review of facility incident reports between 12/5/18, through 12/11/18, lacked any evidence the allegations of potential abuse identified in NA-A's performance report had been investigated by the facility to ensure it's residents were free from abuse. - At 3:28 p.m. the DON stated the incident on 12/7/18, regarding R4 was not investigated because they had not observed any bruising or injury to R4. The DON verified there was no documentation of an incident in the R4's medical record. The facility's Abuse Prevention Plan indicated the facility would investigate all incidents/allegations after they have been reported, as required. The investigation would include resident interview, observation, assessment, staff interviews, review of the resident's plan of care and facility policy and procedures. The plan further directed staff to report any incidents or unusual resident occurrences in the electronic reporting system and report any potential vulnerable adult situations immediately to the administrator or DON for follow up.

Based on interview and document review, the facility failed to ensure 1 of 4 residents reviewed (R1) for medication administration were free of significant medication errors. R1 experienced actual harm when staff administered another residents medications to R1, and R1 was sent to the hospital and experienced respiratory distress and was hospitalized for [REDACTED]. Findings include: R1's quarterly Minimum Data Set ((MDS) dated [DATE], indicated the resident had moderate cognitive impairment and required limited assistance from one staff with activities of daily living. A facility incident report indicated on 12/19/17, at approximately 8:00 a.m. licensed practical nurse (LPN)-C had returned to the medication cart after administering R1 her morning medications. LPN-C immediately realized he administered the wrong medications to R1. R1 received R2's medications, which included [MEDICATION NAME] 20mg, Calcium with vitamin D 500/200 mg, Duloxetine 60 mg, [MEDICATION NAME] 600 mg, Multivitamin, [MEDICATION NAME] 60 mg, [MEDICATION NAME] 20 mg, Potassium 40 meq, [MEDICATION NAME] 25 mg, and HCTZ 37.5/ 25 mg. LPN-C notified Registered nurse (RN)-F of the medication error, contacted R1's physician, and was directed to send R1 into the emergency room . The facility notified R1 of the medication error, checked the resident's vital signs, and R1 was transported to the emergency room by ambulance. R1 was stable when leaving the facility for the hospital at approximately 8:30 a.m. on 12/19/17. A Nurse Practitioner Progress Note dated 12/22/17, indicated R1 was being seen for a follow up visit after hospitalized from [DATE], to 12/21/17, for accidental medication overdose resulting in toxic [MEDICAL CONDITIONS], and hypercapnia [MEDICAL CONDITION]. When hospitalized , R1 developed somnolence with associate respiratory depression and required multiple doses of [MEDICATION NAME]. R1 was placed on a [MEDICAL CONDITION] machine to maintain her oxygenation when in the hospital. R1 was discharged back to the facility on [DATE], and had no ongoing effects from the accidental medication overdose and was noted to be back at her baseline health status. During interview on 1/10/18, at 9:15 a.m. R1 stated she is feeling good, and had no ongoing effects from receiving another resident's medication. R1 stated LPN-C immediately came to her and explained the wrong medications were given, and a nurse stayed with her until she was transported to the emergency room . R1 stated it was an unfortunate mistake and she feels safe at the facility and trusts all the staff. During interview on 1/10/18, at 10:00 a.m. director of nursing (DON) stated LPN-C had no history of medication errors. DON stated LPN-C immediately recognized the medication error and alerted the nursing supervisor for assistance to ensure R1 was monitored until being transported to the hospital. During interview on 1/10/18, at 10:15 a.m. LPN-C stated on 12/19/17, he prepared R2's morning medication and placed them into a medication cup. When he went into R2's room, the resident was sleeping, so LPN-C returned to the medication cart with R2's cup of medication. LPN-C stated he set R2's medication on top of the medication cart and unlocked the cart to place R2's medication back into the cart. When LPN-C was unlocking the medication cart, another resident approached LPN-C for assistance. LPN-C assisted the other resident, and then noticed R1 was awake and ready for her morning medications. LPN-C prepared R1's medications and placed them in a medication cup. LPN-C stated he locked his medication cart, and was interrupted again by another resident asking for assistance. After LPN-C assisted the other resident, he returned to the medication cart and obtained the cup with the medication in and administered it to R1. LPN-C stated as soon as he returned to the medication cart he realized he had given R1 the wrong medications, and had grabbed R2's medications instead of R1's. LPN-C stated he immediately notified RN-F of the error, and went to check on R1 and explain he had administered the wrong medication. LPN-C stated he should have placed R2's medication back into the locked medication cart, but got distracted with all of the interruptions. The facility policy titled, Medication Administration dated 11/22/17, indicated no medications were to be kept on top of the medication cart.

Based on interview and document review, the facility failed to ensure safe transfer techniques during a full body mechanical lift were implemented for 1 of 3 (R1) residents reviewed for falls, when staff failed to ensure all 4 sling loops were securely on the lift prior to lifting R1. This resulted in actual harm to R1, when R1 fell from a mechanical lift onto the floor. R1 received an abrasion to the back of the head. Findings include: R1's medical record was reviewed. R1's 9/20/16 Brief Interview for Mental Status score indicated R1 was moderately cognitively impaired. R1's 9/26/16 significant change Minimum Data Set (MDS) assessment indicated R1 transferred with 2+ person physical assist. R1's September 2016 physician orders [REDACTED]. R1's care plan on 10/6/16 indicated the following interventions related to transfers: Initiated on 12/3/14, explain what you are going to do before transfer, slowly change positions. Give the resident time to process the information. Lift, do not slide the resident. Initiated on 4/21/16, use a mesh sling with a mechanical lift and assistance of two to transfer the resident. May leave mesh sling flat under resident in wheelchair to prevent friction and shearing with removal. Staff to pull mesh sling flat as possible when in wheelchair. A 10/6/16 incident report and 10/12/16 investigative report indicated on 10/6/16, nursing assistant (NA)-B and nursing assistant (NA)-C were assisting R1 to transfer from the bed to a Broda chair using a mechanical lift. NA-B's written statement indicated she was unable to find the blue (large) mesh sling R1's care plan required and instead, used a white (medium) mesh sling. The report lacked information as to the style of mesh sling used. NA-B placed the white mesh sling under R1 and activated the call light to alert NA-C of the need for assistance. NA-B secured the bottom left sling loop to the lift hook and then realized R1's pressure reducing boots were not on. NA-B began placing the boots on R1. NA-C entered the room and secured the top right and top left sling loops to the lift hook. NA-C turned to get R1's broda chair in position, while NA-B finished applying R1's boots. Neither staff secured the bottom right sling loop to the lift. NA-B lifted R1 and began moving the lift. The report lacked information as to whether NA-B or NA-C checked to ensure all loops were secure on the lift prior to lifting R1. As NA-B was moving the lift, NA-C noticed R1's bottom was still touching the bed. NA-C moved to the side of the bed and lifted R1's legs to help guide R1's legs over the edge of the mattress. R1 then fell out of the sling. R1's back landed on the base of the lift. R1's head hit the floor. NA-B informed licensed practical nurse (LPN)-D of the fall. The resident complained of head pain and staff observed blood on a pillow, which staff had placed under R1's head after the fall. Staff called 911 and transferred the resident to the hospital. R1's medical record on 10/6/16 lacked an assessment for the style and size of mesh sling to use for R1's transfers. Although the internal investigation report indicated NA-B reported R1's care plan directed to use a blue mesh sling, R1's care plan lacked direction to use blue sling and lacked staff direction of the style and size of mesh sling to use when transferring R1. 10/6/16 hospital records indicated R1 had slight posterior scalp pain with a small abrasion to the back of the head. Hospital staff cleansed the abrasion. R1 returned to the facility the same day with directions to use antibiotic ointment to the abrasion if needed. R1's progress note from 10/6/17 to 10/13/17 were reviewed and indicated R1 received Norco 5-325 three times for complaints of headache and soreness during the 48 hours following the fall. Staff applied cold packs to the back of R1's head intermittently. R1 had no additional bleeding or treatment to the abrasion. On 10/13/16, R1's skin was clean, dry, and intact. When interviewed on 12/22/16 at 9:15 a.m., the director of nursing (DON) stated the facility uses three styles of full body lift slings; supine, amputee, and regular. Each style is available in mesh and non-mesh. The slings are available in several sizes. An interview with NA-B was conducted on 1/31/17 at 9:30 a.m. NA-B stated R1's care plan directed to transfer R1 using a mechanical lift, two staff, and a blue amputee sling. NA-B stated that on 10/6/17 she was unable to find a blue mesh amputee sling, so she used a white mesh amputee sling, which fit R1 fine. NA-B stated she had assisted with R1's transfers several times and seen other staff use a white mesh amputee, a blue mesh amputee, and a regular amputee sling with R1's transfers. On 10/6/17, NA-B stated she put the white mesh sling under R1, and then put the call light on for assistance. NA-B initially stated she attached the top left and top right loop straps to the lift, later, NA-B stated she could not remember what loop straps she attached. NA-B stated she then noticed R1's green boots were not on and started to put the boots on R1. NA-C entered the room and finished attaching the loop straps to the lift. NA-C was prepping R1's Broda chair as NA-B began lifting R1 off the bed. NA-B stated she did not check the loop straps to ensure the loop straps were securely on the lift before lifting R1, as she thought NA-C had checked the straps. NA-C came to the side of the bed and helped guide R1's legs over the beds edge, while NA-B moved the lift. NA-C yelled, Wait. NA-B stated she tried to grab the bottom right strap, but it was too late and R1 fell to the ground.An interview with NA-C was conducted on 1/4/17 at 12:15 p.m. NA-C stated R1's care plan directed to transfer R1 using a mechanical lift, two staff, and a blue amputee mesh sling. NA-C stated she had assisted transfer R1 on numerous occasions and had only used a blue mesh amputee sling. NA-C stated on 10/6/16, she responded to R1's call light. The lift sling was already under R1 when she entered the room and believed the sling used during the transfer was a blue amputee sling. NA-C confirmed she attached the top right and top left sling loops to the lift. NA-C stated it was routine for the staff near the head of the resident to attach the top two loop straps to the lift and the staff near the foot of the bed to attach the bottom-two loop straps to the lift. NA-C stated she did not check to ensure the bottom two loop straps were attached to the lift, as she believed NA-B would have done this. After attaching the two top loop straps, NA-C moved over to position R1's Broda chair for the lift. NA-C heard a noise and turned around. NA-C stated NA-B had lifted R1 and was moving the lift. The noise NA-C heard was from R1's buttocks rubbing on the mattress as NA-B moved the lift. NA-C told NA-B to stop. NA-B continued moving the lift. NA-B moved to the foot of the bed to assist R1's legs over the raised mattress edge. R1 then fell out of the lift onto the floor. After the fall, NA-C noticed the bottom right loop strap was not attached to the lift. When interviewed on 12/22/16 at 9:15 a.m., the director of nursing (DON) stated physical therapy (PT) assesses residents for the safety of the lift, which is then added to the resident's physician orders [REDACTED]. The nurses document the size of sling needed for transfers on the care plan. The nurse documents on the care plan if a supine, amputee, or mesh sling are needed. The sling style is not documented on the care plan when staff are to use a regular sling. Staff are to only use the supine, amputee, or mesh sling if care planned. If staff have any questions, staff are expected to ask the nurse for clarification prior to lifting a resident. When questioned about R1's 10/6/16 fall, The DON stated, based on wound care recommendations, staff used a mesh amputee sling when transferring R1, but confirmed R1's medical record lacked the assessment or recommendation for the use of an amputee sling. The DON confirmed at the time of the fall, R1 was not assessed for a sling size and R1's care plan lacked staff direction on what size of sling to use. The DON stated R1's care plan did not direct staff to use an amputee sling; however, staff were consistently using an amputee sling when transferring R1. The sling used by NA-B and NA-C at the time of R1's fall was a medium (beige) amputee mesh sling. The DON stated neither NA-B or NA-C checked to ensure all four loops were secure on the lift prior to lifting R1.The lift manufactures manual indicated the following related to sling styles: As patients do vary in size, shape, weight and temperament, these conditions must be taken into consideration when deciding which EZ sling is most suitable for their needs. The following are the lift manufactures descriptions of the sling styles the facility uses: -Deluxe sling: (referred by staff as the regular sling) Padded sling offers support and comfort to the patient while being lifted and transferred. -Multi-purpose sling: (referred by staff as the amputee sling) used primarily for amputee patients with large thighs or patients with delicate skin. -Both the deluxe sling and multi-purpose sling are available in mesh, which are specifically designed for bathing patients, but may also be used for regular patient transfers. The lift manufactures manual indicated the following related to sling sizes: six sling sizes are available and range from small to xxxl. The manual indicated, As patients do vary in size, shape, weight and temperament, these conditions must be taken into consideration when deciding which size of the EZ Sling is most suitable for their needs. The sling- sizing chart directs staff on how to select a sling size using weight and measurements. The size chart indicated NOTE! The size/weight designations are merely estimates and basic guidelines. A proper fit will depend on factors other than weight measurements, including the height and girth of a patient. A proper fit will involve the judgement of the caregiver. The lift manufactures manual related to LIFTING THE PATIENT directs to: 1) Push UP button on hand control. 2) Once there is tension on loops, double check the loops to make sure that they are securely in the hooks. 3) Lift the patient's knee and smooth out the sling under each of the thighs. A January 13, 2011 Mechanical Lifts and Stands policy directed staff to Obtain equipment and ensure the sling size is appropriate for the resident. Follow the lift stand instructions per manufacturer's operating instructions.

Based on documentation review and interviews, the facility failed to ensure the resident environment remained free of accident hazards when a shower chair wheel was broken for at least two weeks and caused 1 of 2 residents (R1) who use the shower chair which broke to fall and sustain a subarachnoid hemorrhage and subdural hematoma. Findings include: Review of the medical record for R1 revealed his care plan, dated September 18, 2013, indicated R1 is transferred with assistance of two staff and a mechanical lift. R1 required bathing assistance of one. The care plan also indicated R1 has [DIAGNOSES REDACTED]. R1 has long term and short term memory loss and impaired communication. Progress notes dated October 31, 2013 at 13:31 noted R1 fell from a shower chair when the shower chair wheel broke. R1 fell to the floor, striking his head on the floor of his room. Progress notes dated October 31, 2013 at 13:55 noted R1 was conscious and responded to questions by shaking his head yes or no. R1 was transported to the emergency department via ambulance. Progress notes dated November 1, 2013 noted R1 was in an observation bed at a second hospital and was readmitted back to the facility later that afternoon with his diet changed from regular texture to pureed with honey thickened liquids. On November 17, 2013 R1 was transported back to the hospital and diagnosed with [REDACTED]. The facility fall assessment documented on November 1, 2013 at 21:25 noted the fall was a result of faulty equipment.Review of the maintenance request log for 2013 revealed no repair requests were received related to shower chair wheels. An interview was conducted on November 22, 2013 at 12:18 p.m. with nursing assistant (NA)-K who stated a couple of weeks prior to R1's fall in the shower chair, NA-J assisted a R2 into the shower chair when the back wheel came out of the slot and was slanted. R2 stood back up and NA-J put the wheel back in place. NA-K stated she reported the faulty equipment to Nurse-N but did not send a report to maintenance for repair or remove the chair from the resident area. NA-K stated that shower chair was only used by R1 and R2 due to its size.An interview was conducted on November 22, 2013 at 3:46 p.m. with NA-J who stated the shower chair wheel was turned and not properly in place when R2 was going to go for a shower a few weeks prior to R1's fall. NA-J put the wheel back in place. NA-J said he did not put in a maintenance request or remove the chair from the resident area but he reported it to Nurse-N. An interview was conducted on December 12, 2013 at 9:24 a.m. with Nurse-N who stated the nursing assistant facility practice was to report equipment concerns to the team leader nurse.Interviews were conducted on November 21, 2013 at 2:44 p.m. and November 22, 2013 at 8:30 a.m. with the director of facilities management who stated there was no preventative maintenance program pertaining to shower chairs prior to R1's fall. Prior to R1's fall, shower chairs were not identified, inspected or maintained at least quarterly like other facility equipment. The director of facilities management verified there was no policy in place related to the newer maintenance request software titled Facility Dude.

Based on interview and document review the facility failed to ensure care and services were provided for 1 of 3 residents (R1) when clear parameters were not established for the resident to leave the facility independently. This resulted in actual harm to R1 when R1 was allowed to leave the facility unattended and attempted to commit suicide. Findings include: R1 had [DIAGNOSES REDACTED]. R1 was independent with dressing, bathing, grooming and ambulating. R1 scored nine on the Brief Interview for Mental Status (BIMS) assessment dated [DATE] indicating moderated cognitive impairment. R1's care plan dated 2/6/2013 indicated R1 exhibited a decline in intellectual functioning characterized by; deficit in memory, judgement, decision making and thought process related to: short term memory loss. The care plan indicated R1's court appointed guardian would be contacted for decision making. The care plan did not address leaving the facility unattended. The exit seeking/wandering assessment dated [DATE], indicated R1 was physically able to leave the facility however, indicated R1 did not have impaired decision making skills and did not exhibit persistent anger at staff, regarding family, current placement or other residents. The assessment concluded R1 was not at risk for exit seeking. Entries made in the progress notes dated 2/16/2013 indicated R1 was verbalizing strong frustrations regarding other residents and the noise levels in the facility. The progress notes dated 2/26/2013 indicated R1 had left the building, walked to a grocery store and returned independently. The notes further indicated R1's guardian was notified and the guardian preferred R1 remained in a safe environment; especially with ice and snow outside. A review of the Release from Responsibility for Leave of Absence forms (sign out sheets) from 1/1/2013 through 3/11/2013 indicated R1 had signed out of the facility 22 times. A responsible party was indicated on the sign out sheet six times, twice R1 was named as the responsible party for self and 14 times no one was named as the responsible party. On 3/9/2013 the progress notes indicated R1 was again aggressively yelling and swearing at staff regarding another resident and noise levels. R1 continued to vent anger stating no one was concerned. The notes indicated R1 refused to eat that morning but left the facility to go to the coffee shop. The Director of Nursing (DON) and Social Service Designee (SSD) were updated regarding R1's escalating frustrations and anger. R1 was moved to a new room within the facility on 3/9/2013. The progress notes dated 3/11/2013 indicated R1 was upset and feeling hopeless regarding the living situation and stated, "I just can't go on like this." R1 refused food and all medications. The documentation indicated that when asked by the Registered Nurse (RN)-B about having a "plan" R1 stated "no, not yet, but I can't do this, it is just hopeless and I don't want to live this way." The progress notes indicated RN-B initiated every 15 minute visual checks for R1, notified R1's physician and a plan was formulated to meet with R1 later in the day. On 3/11/2013 before a meeting with the physician could occur R1 expressed the desire to leave the building stating "going out for a walk - I just have to get out of here right now." R1 was asked to sign out of the facility on the sign out sheet and allowed to leave. When R1 did not return to the facility after approximately two hours; the facility notified the police department. The police report dated 3/11/2013 indicated R1 had made suicidal comments before leaving the facility. Approximately seven hours after leaving the facility unattended R1 was found out in the woods lying in the snow shivering uncontrollably. R1 stated to the police officer "I came out here to die." R1 was transported out of the woods and to a local hospital for hypothermia. The hospital record dated 3/11/2013 indicated R1 was shaking violently when brought in by emergency medical services (EMS). R1 was admitted to the Intensive Care Unit (ICU) for rewarming and treatment for [REDACTED]. On 4/25/2013 at 10:55 a.m., Registered Nurse (RN)-B was interviewed and stated R1 struggled everyday with contentment in life and placement in a long term care facility with mainly elderly people. She stated R1 frequently signed out and went for walks; sometimes everyday depending on the weather. RN-B stated she was told R1 would walk uptown to a bar and play cards with old friends but always came back. RN-B stated R1 was vulnerable related to poor decision making skills and a [MEDICAL CONDITION] disorder. When asked if it was safe for R1 to leave the facility unattended; RN-B stated she was told by the Social Service designee (SSD) it was R1's "right" to go out for walks and it was not care planned that he couldn't go. She stated this was a very uncomfortable gray area for the staff because the guardian and the staff did not like R1 leaving independently however, felt they had to let him go. On 4/29/2013 at 1:45 p.m. the Licensed Social Worker (LSW) stated R1 did not have the cognitive ability to leave the facility independently and if R1 wanted to; R1 would have had to be assessed to be able to go safely, the guardian would have to give permission and the physician would have to be notified. The LSW stated the SSD would attend care conference and should have addressed the issue and updated the care plan at that time. On 4/29/2013 at 3:05 p.m. the SSD was interviewed and stated she was not aware R1 would leave the facility unattended and that it was an issue that would have to be addressed. She stated she thought the guardian was to be notified each time R1 wanted to leave and the guardian would make the decision based on the weather. She stated she did not attend the care conference for R1. The SSD stated the care plan had not been updated to direct staff what to do if R1 wanted to leave. When asked if R1 had the right to leave the facility against the wishes of the legal guardian she stated "we can't hold someone back."

Based on observation, interview, and document review, the facility failed to provide medically related social services to promote psychosocial well-being for 2 of 2 residents (R104, R142) who had unresolved roommate conflicts. R104 experienced actual harm related to persistent sleep disturbance, a decline in physical functioning, and the onset of new mood and behavioral problems. Findings include: On 4/18/13, at 8:54 a.m. a telephone interview was conducted with family member (FM)-A. The FM-A stated R104 had a real problem sleeping since a new roommate moved in several months prior. The roommate reportedly watched television (TV) all night long and it "really bothered" R104. R104 had resided in the same room for several years without roommate problems. Although R104 was offered a room change to the secured dementia unit, R104 did not want to move. The FM-A stated R104 was more angry and had lost weight since his new roommate arrived. FM-A did not feel facility staff were working hard enough to resolve the situation, because it had been going on for several months and nothing was resolved. R104's significant change Minimum Data Set ((MDS) dated [DATE], and subsequent quarterly MDS dated [DATE], indicated the resident had moderate cognitive impairment and displayed no behavior or mood indicators. The corresponding Care Area Assessments (CAA) were requested, but not provided by the facility. R104's plan of care (POC) dated 3/26/13, indicated he was occasionally confused and required some assistance making daily decisions, but independently chose how to spend his day. He was hard of hearing, but able to make self understood and sometimes understood others. Staff was to minimize background noise before speaking with R104. The nursing assistant (NA) care plan dated 3/26/13, indicated the resident refused a hearing aid. A Nurse's Note (NN) dated 10/29/12, at 9:57 p.m. indicated R104 was agitated with the arrival of his new roommate. He was tapping the side of his head and avoided the room until after supper when brought in by staff for assistance with evening cares. The following day the resident had only been in his room to use the toilet since staff had assisted him up that morning. When asked to use the toilet R104 stated "I do not want to go in there!" He complied when told it was only going to take a few minutes. At 4:02 a.m. the resident had a blanket over his ears and his roommate's TV volume was turned up loudly. The roommate angrily refused to lower the volume, stating he could not hear his TV over R104's TV. R104's TV could not be heard by staff, but the resident appeared "nervous" and turned down his TV volume further. Staff explained that he did not have to turn his TV off, and later the roommate decreased his TV volume. On 11/6/12, at 6:25 a.m. a NN indicated R142's TV was "'blaring.'" R104 was seated in his wheelchair with a slightly hunched over posture, right hand over his right ear, left hand twitching, fingers moving nervously, head was shaking in a jerking type motion, and was rocking back and forth. On 11/23/12, at 4:59 a.m. R104 had been up most of the night and wanted to watch TV, so staff turned the volume on low. R142 then turned his TV volume up and refused to lower the volume. The NN dated 12/5/12, at 3:08 p.m. indicated the social service designee (SSD) was notified about R104's inability to sleep due to R142's loud TV at night. Staff reported R104 was displaying increased behavioral issues and was ripping papers. The note indicated the SSD would notify R142's family to request earphones. The NN dated 12/6/12, at 4:15 p.m. indicated R104 was quite a "night owl" the past several months. His new roommate was resistive to keeping the volume of his TV turned down. Night staff reported it was causing R104 to display increased restlessness, agitation, plugging his ears, and tearing papers when the TV volume was higher. At other times slept soundly despite the TV and he was "somewhat" hard of hearing. He required increased assistance with transferring "when annoyed" with his roommate. The note indicated staff would be supportive and attentive to R104, address issues as they occurred, and promote a healthy relationship between R104 and R142. A dietary significant change NN dated 12/31/12 at 1:42 p.m. indicated R104's intake had declined a bit with a gradual weight loss noted. The care conference NN dated 1/8/13, indicated staff had also noticed a decline in R104 when sometimes the resident communicated and other times would not. SSD was to be notified regarding the possible use of a hearing amplifier device. The NNs dated 1/11/13, at 3:35 a.m. 1/12/13, at 4:58 a.m. 1/13/13, at 5:49 a.m. and 1/14/13, at 5:50 a.m. indicated R104 was awake most of the night. R104 was seen tapping his head when R142's TV was loud. On 1/15/13, at 4:13 a.m. was awake during the night and appeared agitated, throwing popcorn on the floor, loudly mumbling to himself and tapping the side of his head. The NN dated 1/15/13, at 8:24 a.m. indicated R104 was asked to try the new room so he could sleep better, but R104 stated, "I don't want to move." At 8:30 a.m. R104 was in and out of other residents' rooms on the transitional care unit (TCU) looking for a place to sleep. The resident appeared frustrated, tearful and began crying. The assistant director of nursing (ADON) and the director of nursing (DON) were informed. Later at 9:23 a.m. NN indicated R104 required redirection out of others rooms and was in tears, looking for a place to lie down. At 9:30 a.m. the SSD requested a physician's orders [REDACTED]. The resident's brother agreed to the move as long as it was not permanent. R104, however, said he did not want to move and reported he was sleeping fine. The SSD told R104 if he changed his mind, he could move. The NN dated 1/17/13, at 4:01 a.m. and again on 1/18/13, at 3:39 a.m. reflected R104's wakefulness most of the night and dozing off a few times. On 1/19/13, at 4:08 a.m. R104 was awake, throwing things on the floor, and used call light frequently with no requests. On 1/21/13, at 5:36 a.m. R104 was agitated, throwing things around his room, spilling things on the floor and when asked if he needed anything R104 replied "'nope.'" He kicked a chair and then laughed stating, "'I didn't kick that.'" On 1/23/13, at 3:01 p.m. he was swearing and hitting himself, waving his arm toward his roommate, who was asked to turn down his TV. R104 continued to fiddle with his hands and mumble, so was brought out of the room for a snack. On 1/25/13, at 2:38 p.m. the resident was clapping his hands and fidgeting when asked to use the toilet, "'That damn man, that damn man! I'm not going in there, that damn man!'" He agreed to go to his room after staff promised to remove him from the room when finished. R104 was found sleeping in another resident's room the previous evening according to a NN dated 2/8/13, at 1:30 p.m. He started swinging at the staff, rambling and staff were unable to understand him. He had not spent any time in his own room that shift. On 2/12/13, at 12:48 p.m. indicated R104 was leaning way to the left and was unable to feed himself, but accepted staff assistance with eating. A NN dated 2/18/13, at 3:57 p.m. indicated R104's brother had contacted the SSD regarding concerns related to R104's overall health. R104's brother was provided with the charge nurse's phone number so his concerns could be addressed. Staff spoke to R104's brother who was concerned the resident had suffered a "'stroke.'" The nurse assessed the resident and determined he was in stable condition. The NN dated 2/20/13, at 12:07 p.m. indicated staff had reported R104's behaviors had worsened. The note also indicated R104 had become more resistive to cares, swearing recently and was not sleeping well due to R142's loud TV. The note indicated the SSD was notified of the concerns. On 2/22/13, at 8:43 p.m. the resident was very sleepy and not being his own weight with transfers. On 3/5/13, at 9:32 p.m. and 3/6/13, at 8:22 p.m. R104 was alert with an undeterminable orientation level as he would not respond to questions and required the EZ stand lift for transfers. On 3/10/13 displayed visible signs of stress such as tapping his head when R142's TV volume was high. A dietary note dated 3/19/13, at 10:23 a.m. indicated [REDACTED]. The resident was consuming 50% or less of meals and although nutritional supplements were offered, he occasionally refused them. A care conference (CC) summary note dated 3/26/13, at 11:45 a.m. indicated R104's brother and sister were in attendance. R104 did not express any concerns regarding his roommate, and did not wish to move from his room. At 12:28 p.m. it was noted R104 had been offered a room change, but declined, and expressed no concerns regarding his roommate. It was noted, however, that R104 was displaying some changes in mood and behaviors, but was easily re-directable. Staff would continue to observe for changes. On 4/17/13, at 8:26 a.m. nursing assistant (NA)-E was interviewed, and thought R104 had declined since R142 had moved into the room a couple months ago. Although R104 had always shredded paper, it had escalated quite a bit and he was shredding paper constantly. NA-E stated R104 used to be "the nicest man" and now angered easily and was more uncooperative. He used to watch TV, but now he could not hear it. The NA added it was "really very sad," and that morning R104 was clearly upset and muttering, "That man! That man!" NA-E stated the staff were very concerned with R104's mental and emotional well being, they had reported their concerns to management staff, and wanted the issue resolved. R104 had been offered and declined a room change, however, the NA stated R104 was in the room first. On 4/17/13, at 1:48 p.m. NA-G reported R104 spent most of his time on the west side of the building, and had been "going down hill" since R142's move into the room. R104 was more agitated, shredding more papers like it was "Mardi Gras" and refused to spend time in his own room. Although the resident used to sit in his room, read books, and snack, he now stayed out of his room once he was up for the day. R142's TV blared all night long, and when R104 was offered a room change, he declined because that was his room. The resident was swearing under his breath when assisted with morning cares. NA-G said management staff were made aware of the resident decline, and it was tough to see the resident "go down." The NA said R104's emotional status had been more affected than his physical status. On 4/17/13, at 9:47 a.m. registered nurse (RN)-C stated R104 displayed behaviors such as ripping paper. RN-C verified R104 was offered a room change and refused to move, however, stated R104 had been in the room first and was probably most comfortable with it. RN-C also verified R104 had spent the majority of time out of his room. R104 had declined since R142 had moved in. The RN was aware of staffs' concerns, but again stated the facility had offered him a different room. In addition, RN-C verified the management staff had been informed "more than once" of staffs' concerns related to R104's decline. On 4/17/13, at 10:14 a.m. a telephone interview was conducted with the SSD/activity director. The SSD verified R104 had spent majority of his time out of his room, and said the resident was frustrated, but did not act out. The SSD verified R104 had lived in the same room since his admission, and was offered, but declined a room change. The SSD was unaware of a physical or psychosocial decline in the resident, and did not believe the resident had changed since R142's move to the room. Although staff had voiced concerns about R142's TV, she was unaware it was still a concern, especially at night time. The SSD stated she did not know what else to do. R142 had not been offered a room change, but the SSD thought he would also refuse to change rooms. On 4/17/13, at 12:14 p.m. the surveyor along with NA-G attempted to interview R104. R104 did not respond to questions. NA-G stated when agitated R104 would slap his head. NA-G stated taking R104 out of his room calmed him the best they could. NA-G also stated R104 used to watch TV, movies and have snack time in his room but would no longer do that anymore. NA-G also stated R104 had even been observed sitting in the smoking room watching TV where it was quieter. On 4/17/13, at 12:19 p.m. the ADON concurred with staff reports regarding a decline in R104's mood since R142's admission. Although R104 was in the room first, he was offered and declined a room change. R142 had not been offered a room change, and a private room was unavailable and the waiting list was over three years. On 4/17/13, at 12:37 p.m. the DON said R142 turned up the volume on his TV, particularly if he heard another resident yelling. When talked to about it, he became angry, however, if asked nicely she could get him to lower the volume. R104 did not seem to care about watching TV any longer, and was more into doing things with his fingers. The DON said neither resident wanted to change rooms. The DON said she had not noted changes in R104's mood, but the ADON interjected and reported his mood had declined since R142 was admitted . On 4/18/13, at 9:09 a.m. licensed practical nurse (LPN)-A stated R104 had been the sweetest, most pleasant and cooperative man until he received a new roommate. LPN-A stated R104 had started hitting and slapping self, refused to go into own room, was more frustrated and constantly ripped/shredded newspapers and/or magazines. LPN-A stated she had observed R104 shredding papers that morning. LPN-A verified R104 now spent majority of the time out of his room, and stated prior to R142 moving in, R104 would sit in the recliner or lie in bed, watch TV, eat a cookie, drink coffee and now R104 entered room only to use the bathroom or change clothes. Additionally, LPN-A stated staff had informed the SSD, who overseen all residents on the long term care unit, several times in the past regarding staff concerns in which R104 was offered a room change but had declined it. LPN-A verified R104 had been in the room since admission several years ago. LPN-A stated R104 had declined emotionally, physically and had lost weight since R142 moved into the room. LPN-A verified R104's weight loss has begun just prior to R142 moving in, however, stated roommate status had escalated the situation. LPN-A stated there had been times the staff were so upset with high frustration levels over R104's decline and inability to resolve it for him. LPN-A verified staff had reported it to the SSD, ADON and the DON to get R142 moved to a more appropriate place and stated staff felt like their hands were tied. Lastly, LPN-A again stated staff had approached the SSD several times with their concerns. On 4/18/13, at 9:03 a.m. activity aide (AA)-A stated R104 was "big" on attending activities such as watching TV in his room, wheeling around the facility, and the shopping cart. AA-A also stated she was aware of some "debate" about the TV in R104's room, and AA-B concurred with AA-A's statement. Shortly thereafter, the activity coordinator (AC) stated R104 liked to "putz" on things, shred items likes newspapers into pieces. AC stated R104's shredding of items had not changed in frequency or intensity. The resident also used to like to doodle and draw pictures, but now just drew lines and no pictures. R104 enjoyed watching TV in his own room in the evenings, however, the AC was unsure if he continued with this activity or not. R142's significant change MDS dated [DATE], indicted he was cognitively intact and displayed daily behaviors including verbal and physical abuse, hoarding, and refusal of cares. The MDS also indicated R142 refused to get out of bed, accept assistance with personal hygiene cares, refused to dress, and was unable to walk. A summary of R142's nurse's notes was as follows: On 10/29/12 R142 moved from the TCU to the long term care (LTC) unit. The following day notes reflected the start of what became a pattern of blaring the TV volume and refusing to lower the volume, as well as a plan to obtain a headphone set for the resident's use. Notes, however, continued to reflect ongoing issues with the TV volume, anger at "everyone" with yelling and screaming at staff and roommate, intolerance of other residents as evidenced by mocking and yelling in response to a cough or sneeze, ramming roommate's furniture, etc. Specific examples were cited in notes dated 2/3, 12/6, 12/9, and 12/17/12, 1/14, 1/21, 2/5, 2/7, 2/8, 2/18, 2/19, 2/22, 2/23, 2/25, 3/4, 3/8, 3/9, 3/10, 3/11, 3/12, 3/15, 3/17, 3/24, 3/25, 3/26, 3/29, 4/6, 4/12, 4/15/13, 4/17, and 4/18/13. In addition, R142 staff documented frequent refusal of cares and offensive body odor on 2/18, 2/19, 2/22, 2/24, 3/4, 3/8, and 4/2/13. A care conference was held on 1/3/13. R142 was identified as displaying mood and behavioral changes at times, but had refused a psychiatric consultation. No concerns were expressed with his room or roommate. The Initial Psychiatric Evaluation Extended Care Centers form dated 2/27/13, indicated R142 had been declining cares, hoarding, and playing his TV loudly after 10:00 p.m. It was noted the resident appeared to enjoy seeing the response of individuals when he acted socially inappropriate. Recommendations were for staff to draw up a POC with the resident, allowing him to choose how he would like to have his needs met, with the understanding not all things would be possible, but he needed to be reasonable such as not blasting the TV after 8:00 p.m. One of the notes in R142's record dated 3/17/13 described loud TV volume and screaming that was heard down the hallways and only stopped to catch his breath. Interventions attempted included speaking to R142 in calm voice, allowed to voice feelings, acknowledged concerns, educated that screaming and TV volume exceeded that of other resident TVs, and was upsetting to other residents. The resident was provided emotional support, reassurance, and was told staff was working with him regarding keeping the volume to a reasonable level--TV volume lowered after given the explanation of how he was perceived by others and the awkward predicament all the staff were in in trying to meet this needs. The Behavioral Symptoms CAA dated 3/19/13, indicated R142 had daily outbursts which included verbally abusive to staff, yelling, screaming and threatening to throw himself out of bed, refusing basic daily care and was "most of the time" not re-directable. In addition, R142 disrupted the environment and his roommate with loud TV volume. A psychiatric referral and in house counseling were not beneficial and were stopped. R142 was alert and oriented, refused psychoactive medications, bathing and personal hygiene assistance, and get out of bed. The resident hoarded items, played his TV loudly and refused to turn it down, and yelled and screamed inappropriately. The plan was to set up a care guideline which included "no blasting the TV after 8:00 p.m." The Psychiatric Evaluation Extended Care Centers form dated 3/26/13, indicated R142 was informed he needed to work with staff to care for him or an alternative psychiatric-oriented setting may be required in order to work on behavioral modifications. The form also indicated although R142 had agreed to lower the TV volume, he turned it up again once staff left the room. On 3/27/13 the care meeting notes indicated R142 had denied refusing cares, verbal abuse, and loud TV volume, and the resident declined headphones. A care agreement was made with R142 to accept staff assistance with personal cares. However, the following day he remained in bed all day and refused all care. Copies of R142's POC and CCP were requested but were not received. The Daily Behavior Observation Tool forms for 4/13, identified daily behaviors which included yelling, swearing at staff, and hoarding. The forms also indicated interventions which included redirection, re-approach, provide cares slowly, allow R142 to vent feelings, assist in organizing room items, educate on infection control practices and to contact the social worker if behavior was a problem. On 4/15/13, at 4:46 p.m. the surveyor entered R142 and R104's room. R142's TV was blaring. R104 was observed seated in the wheelchair with his head down. R142 emitted a foul oral odor detectable from several feet away. R142 lowered the TV volume to complete an interview, and then turned up the volume loudly when the interview was completed. On 4/17/13, at 8:26 a.m. NA-E reported R142 did not like it when R104 watched his own TV, therefore, he turned his up as loud as it would go. On 4/18/13, at 9:09 a.m. LPN-A stated staff had reported roommate issues to the SSD, ADON and the DON to get R142 moved to a more appropriate place and stated staff felt like their hands were tied. Lastly, LPN-A again stated staff had approached the SSD several times with their concerns. On 4/18/13, at 9:47 a.m. RN-C verified R142 was very loud and his TV was very loud. The RN stated R142 had the right to refuse to turn his TV down. RN-C added, it was a difficult, challenging situation and "We do what we can. It's their right." On 4/18/13, at 10:14 a.m. a telephone interview was conducted with the SSD/activity director. Although staff had voiced concerns about R142's TV, she was unaware it was still a concern, especially at night time. The SSD stated she did not know what else to do. R142 had not been offered a room change, but the SSD thought he would also refuse to change rooms. On 4/18/13, at 12:19 p.m. the ADON reported an awareness of conflicts over the TV and stated they just never knew how R142 was going to react. R142 had not been offered a room change, and a private room was unavailable and the waiting list was over three years. On 4/18/13, at 12:37 p.m. the DON said R142 turned up the volume on his TV, particularly if he heard another resident yelling. When talked to about it, he became angry, however, if asked nicely she could get him to lower the volume. The DON said neither resident wanted to change rooms. On 4/19/13, at 10:42 a.m. the LSW stated she was unaware and not involved in R104's and R142's roommate concerns, and she was responsible for the TCU only. The facility Room Transfers policy and procedure (reviewed 6/29/12), indicated the facility would attempt to accommodate residents' needs at the time of admission or when complaints occurred. In addition, room transfers would be assessed and implemented based on a resident's medical and behavioral need which took priority over a resident's personal preference.

Based on observation, interview and document review, the facility failed to minimize the presence of pain prior to dressing changes for 1 of 2 residents (R124) whose pressure ulcer treatments were observed. This resulted in harm for R124. Findings include: R124 did not receive the proper care and services to minimize the pain during wound cares. The resident's [DIAGNOSES REDACTED]. R124's wound dressings were observed to be changed on 4/17/13, at 9:47 a.m. by licensed practical nurse (LPN)-A with assistance from nursing assistant (NA)-E who held R124's limbs. R124 moaned with the initial light touch to the right heel. When the wound was cleansed R124 cursed and struck out and kicked at the staff hollering, "Get the (expletive) out of here!" NA-E explained R124 cursed and hollered out "a lot" during dressing changes. During the dressing change to the right mid-buttock R124 yelled, "God that hurts! God (expletive)!" R124 continued to curse, yell, and hit at the NA and LPN throughout the treatments. LPN-A stated she would finish the remaining two wound dressing changes later due to R124's poor tolerance of the procedure. The resident was not provided pain medication to minimize the pain prior to or after the dressing changes. On 4/17/13, at 1:10 p.m. LPN-A was observed to provide wound dressing changes to R124's left heel and right lower buttock crease. R124 hollered out when moved. The LPN stated the resident experienced "definite pain" with dressing changes, but again was not provided pain medication prior to or after the dressing changes. R124's Pain Interview and Assessment form date 1/13/13, indicated the presence of pain related to lumbago, [MEDICAL CONDITION], wound to left heel and right buttock. The form indicated R124 received Tylenol (a mild [MEDICATION NAME]) 650 milligrams (mg) daily and every four hours as needed (PRN). The written summary indicated R124 had two new possible sites that had the potential to cause pain: heel and buttock. The summary also noted R124 often became combative during cares and transfers due to pain, versus behaviors related to dementia. The Pain Interview and Assessment form dated 2/8/13, indicated [REDACTED]. The form indicated R124 displayed no non-verbal indicators of pain. Additionally, the form indicated R124's acute pain at that time would be most likely related to circumcision. The form also indicated R124 had frequent pain with inability to rate the severity, however, indicated the pain interfered with personal cares, especially peri cares. R124 was provided [MEDICATION NAME] (narcotic) on a regular basis since recent circumcision with good results, and staff needed to use non-verbal indicators such as agitation, swearing etc. to gage pain and discomfort. Additionally, the summary indicated R124's pain regimen was adequate/effective. The significant change Minimum Data Set ((MDS) dated [DATE], indicated R124 had severe cognitive impairment, required extensive assist of one to two staff for all activities of daily living, and he did not walk. R124 had indicators of pain including non-verbal sounds, vocal complaints, facial expressions, protective body movements and/or posturing one to two days per seven day period. Scheduled PRN pain medication was prescribed. In addition, the MDS noted the presence of an unstageable (necrotic tissue) pressure ulcer and a surgical wound which required ointment application and/or dressing changes. The Care Area Assessments dated 2/16 to 2/20/13 indicated R124 had severe cognitive impairment, needed supervision with daily decision making, rarely communicated needs, and at times talked in another language. He had a had a recent circumcision on 2/5/13 due to chronic inflammation, a pressure ulcer on the left heel with daily dressing changes, and an open area to the right buttock. R124 was resistive to care, swore, kicked, and hit. The resident was on an every four hour pain monitoring regimen and was prescribed Tylenol 650 mg at 5:00 p.m. for evening agitation and a history of arthritis, and PRN [MEDICATION NAME] had relieved his pain and was used for non-verbal signs of pain. The plan of care (POC) dated 2/21/13, indicated R124 had impaired cognition and decision making skills with the inability to express emotion and share information. Staff was to modify the environment to prevent situations that triggered inappropriate behavior, encourage non-verbal communication, anticipate needs, and use the pain scale due to the resident's inability to communicate appropriately, administer medications as ordered, use PRN pain medications for breakthrough pain, acknowledge the present of pain and discomfort. In addition, the plan indicated pain was present related to frequent falls while at home with bruising to buttocks, and low back pain. Staff was to administer medications as ordered, including PRN pain medications for breakthrough pain, acknowledge the presence of pain and discomfort, and to listen to R124's concerns. The POC did not specify the presence of pain and pain management interventions related to R124's wound care. The nursing assistant (NA) care plan dated 2/21/13 did not address the resident's pain. R124's physician's orders [REDACTED]. 70% saturated. physician's orders [REDACTED]. - On 8/22/11, an order for [REDACTED]. - On 12/2/11, an order for [REDACTED]. - On 2/22/13, another order for pain management was given and the goal for pain was a rating of "0." - On 3/19/13, the orders also indicated pain scale rating every four hours related to Alzheimer's dementia and [MEDICAL CONDITION]. The physician's orders [REDACTED]. The 3/13 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Pain Scale documentation did not reflect the presence of pain or the use of PRN pain medication. Dressing changes were noted to the left heel daily and right buttock every three days through 3/17, and daily from the 3/17/13 to 3/31/13. Dressing changes to the left lower buttock crease were provided daily from 3/16/13 through 3/31/13. Dressing changes to the right heel were not identified on the MAR. The physician order [REDACTED]. The left heel Wound Record Weekly Wound Assessment documentation form dated 1/7, 1/21, 2/13, 2/25, 3/4, 3/13, and 4/1/13, indicated the wound ranged from unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar) to a stage three ulcer (full thickness of skin lost, exposing subcutaneous tissues), and finally on 4/1/13, was described as unstageable. The right buttock documentation dated 2/25, 3/18, 4/1, and 4/15, indicated the wound was a stage two (partial thickness loss of skin layers). The left lower buttock crease entries dated 3/18, 3/22, 4/1, and 4/15/13, indicated the wound was unstageable. The right heel documentation dated 4/1 and 4/15/13, indicated the wound was blistered. Documentation entries for each wound revealed R124 experienced wound pain. The 4/13 MAR indicated [REDACTED]. R142 had 42 different dressing changes during the month which were completed in the mornings by day shift staff. The Pain Scale documentation indicated [REDACTED]. The Pain Management Flow sheet dated 8/29/12, through 4/17/13, indicated R124 had last received PRN Tylenol 650 mg for right leg and heal pain on 2/26/13. The Nurse's Notes (NN) from 1/13 through 4/13 revealed the following: - On 1/28/13, at 10:21 a.m. pain by grimacing and cursing during the dressing change. The Pain Management Flow sheet indicated R124 had not received pain medication prior to or after the treatment. In addition, pain, pulling away from source of pain, and/or striking out at staff were noted on 3/18, 3/22, 3/24, 3/25, 3/30, 4/1, 4/3, 4/8, and 4/13/13. On 4/15/13, at 10:54 a.m. a nurse's note indicated R124 had the following wounds: Wound #1: right buttock cheek which measured 2.0 x 2.0 centimeters (cm) with thick, brown, eschar (dead tissue) in the center of the wound bed with pink edges. Additionally, the note indicated R124 had "definite pain with dressing changes" as resident yelled and pulled away when the wound was cleaned and dressed. Wound #2: left lower buttock measured 1.0 x 1.0 cm with a pink wound bed with whitish edges along with scant serous drainage. The note further indicated R124 yelled out in pain and yelled at writer to "'Stop that!' and 'Get away from there!'" Wound #3: left heel measured 2.0 x 1.0 cm. Wound bed slightly moist with scant amount yellow drainage with white/yellowish surrounding tissue. Wound #4: right, lateral heel measured 6.0 x 4.0 cm with a blister like appearance with an open area on the inner area with moderate amounts serious, yellow drainage dripping from the wound bed. The wound is open. The inside of the right heel measured 4.0 x 4.0 cm with a dark intact blister. R124 yelled throughout the application of new dressing changes. Several small scabs on the left foot toes were noted. On 4/18/13, at 10:41 a.m. the wound care nurse debrided (process of removing dead tissue) a large amount of non-viable tissue which measured 7.0 x 8.1 cm and new dressings were applied. On 4/19/13, at 8:02 a.m. NA-G was interviewed and stated R124 hollered out in pain with every dressing change and anytime his heels were touched. It was also painful whenever his pant legs brushed/touched his heels. Additionally, NA-G was unsure whether the resident received any pain medication prior to dressing changes. On 4/19/13, at 8:07 a.m. LPN-B verified R124 did not have pain medication ordered specifically for wound pain. LPN-B stated the resident was "not typically" pre-medicated prior to the dressing changes, and the last time PRN medication was used had been on 2/26/13. R124 "sometimes...seemed" to have pain during the dressing changes and pulled away and cursed during dressing changes. When asked if pre-medication eased his pain prior to dressing changes LPN-B replied, "Yes." On 4/19/13, at approximately 8:30 a.m. registered nurse (RN)-E stated it would depend on physician orders [REDACTED]. When asked if R124 should have been pre-medicated prior to dressing changes the RN responded, "I would hope so." On 4/19/13, at 8:27 a.m. during a telephone interview, the wound nurse (RN-D) verified that on 4/18/13, she had performed the wound dressing changes and debrided one of R124's heel ulcers. RN-D stated she was unaware when the resident had been administered pain medication, and stated that due to a conflict in time, she "forgot" to ask R124's nurse on 4/18/13. RN-D said she had not addressed the resident's pain level each time she provided treatments, which was every one to two weeks. RN-D stated the facility staff knew R124 better than she did. On 4/19/13, at 9:07 a.m. the assistant director of nursing (ADON) stated if a resident was having pain during wound care, the nurse would be expected to assess the pain and ensure a plan was put in place for medication administration prior to performing the treatment. On 4/19/13, at 9:19 a.m. the director of nursing (DON) stated if a resident was having pain with dressing changes they should have been pre-medicated prior to performing treatments. When the DON was informed of R124's lack of pain medication prior to the wound treatments, the DON stated, "That should not be!" and said staff should have been automatically thinking of potential pain when providing wound care. On 4/19/13, at 10:29 a.m. NA-E verified R124 had pain with dressing changes. The facility's Pain Assessment and Management policy and procedure revised 6/29/12, indicated all residents would have the right for appropriate pain assessment and pain management to ensure a pain free existence as much as possible. The policy also indicated all residents would be assessed for the presence and/or absence of pain on admission, quarterly, with a significant change in status and with any new onset of potential pain or discomfort. The policy directed staff to observe for verbal or vocal signs of distress, changes in body movement, facial expressions or touching/holding the affected body parts and to contact the physician or other appropriate health care provider regarding a pain management program. In addition, the policy directed staff to notify the physician or appropriate health care provider in a timely manner if the current pain management program was ineffective.

Based on observation, interview, and document review, the facility failed to ensure 2 of 2 residents with pressure ulcers (R124, R25) and for 1 of 1 resident reviewed who had a history of [REDACTED]. R124 sustained actual harm when avoidable pressure ulcers (PUs) developed. Findings include: R124 had current PUs, but was not repositioned every two hours as directed by the plan of care (POC) for 2 hours and 55 minutes on 4/16/13, and for 2 hours and 45 minutes on 4/17/13. In addition, R124's bilateral pressure relieving boots were incorrectly applied. On 4/16/13, at 9:15 a.m. R124 was in the dining room eating breakfast. Bilateral foam boots were on his feet, however were on sideways, and no pillow was underneath his lower legs. At 9:34 a.m. he remained in the wheelchair adjacent to the nurses' station with his feet and legs in the same position. During continuous observation on 4/16/13, from 1:50 p.m. until 4:45 p.m. R124 remained in his wheelchair, adjacent to the nursing station. Although the foam boots were on the resident's feet, they were loosely fitted. The resident's lower legs rested on the leg rests without pillow support and a wide, black strap was fastened around the leg rests. At 3:26 p.m. the right boot remained sideways with the Velcro boot strap lying over the inner lateral lower leg. His left foot was sticking out of the boot. Throughout the observational period, several staff persons walked by and/or were seated near the resident. At approximately 4:35 p.m. the surveyor intervened and inquired about R124's repositioning schedule. The nursing assistant (NA)-F reported he should have been repositioned every two to two and one half hours, and verified the resident was last repositioned at 1:50 p.m. NA-F said the resident would be repositioned just prior to supper, at around 5:00. The NA-F also explained R124 tended to move his legs a lot which loosened and wore down the Velcro boot straps causing the boots to turn to the side, and staff repositioned and re-fastened the boots whenever he was repositioned in the chair or bed. The NA-F verified his feet had not been offloaded, and explained that it was "really hard" to do so. NA-F said a pillow had been used to offload the resident's feet, but about a week and one half ago the black strap was added to the foot rests. The NA-F also said R124 had a sore on his back. The NA-F was unsure if he had heel ulcers, but assumed he did since he wore foam boots. After the interview NA-F assisted another resident and then returned to repositioned R124. On 4/17/13, from 6:45 a.m. until 9:30 a.m. continuous observations were conducted. R124 was seated in a wheelchair adjacent to the nurses' station. The right foot was turned outward and foam boot was on sideways with the heel resting on the foam. At 8:04 a.m. he was assisted to the dining room. The boot remained on sideways and loosely fitted. R124 was in direct visual view of the several staff working in the dining room. At 9:17 a.m. R124 was assisted from the dining room to an area near the nurses' station. The right foam boot was on sideways. At approximate 9:30 a.m. staff assisted R124 into bed. The Care Center Note dated 9/21/12, indicated R124 was seen by the physician for a routine visit. R124's feet were warm and well-perfused. The presence of PUs was not documented. R124's Tissue Tolerance Testing for Offloading in a Chair (to determine the skin's ability to withstand pressure) dated 10/28/12, indicated he could tolerate every two hour repositioning/offloading without causing skin damage. The Tissue Tolerance for Repositioning Schedule while in bed dated 10/30/12, indicated R124 could tolerate every two hour repositioning while in bed. A Care Center Note dated 11/19/12, indicated R124 was seen by the physician for a routine visit, and the resident's family member was present. The family member expressed concern about R124's heel skin breakdown. It was noted R124 had been seen by the wound care nurse, wore heel protectors, and the heel wounds seemed to be healing. A Care Center Note dated 1/7/13, indicated R124 was seen by the physician to assess an open area on the right buttock. A small shallow open area on the buttock measured approximately 1.0 centimeter (cm) in diameter and approximately a 10.0 cm indurated, firm area surrounding the open area. R124 was to be referred to general surgery for [REDACTED]. A General Surgery Trns (sic) Consult form dated 1/15/13, indicated R124 had an ultrasound of the right buttock area which revealed a small amount of skin thickening with no evidence of underlying abscess or mass noted. Staff was directed to continue observation of the area with routine care of the PU and to follow up with surgery as needed. The physician progress notes [REDACTED]. A Care Center Note form dated 1/18/13, indicated R124 was seen by a physician for a routine visit at which time the physician noted the resident had some open areas on the buttocks and heel with dressings on the heels "perhaps to prevent further sores." The physician had not examined the buttock PU. Staff was to continue with the current treatment plan and wound care per wound care nursing. The Braden Scale form (for predicting PU risk) dated 2/8/13, revealed R124 was at risk for PU. R124's [DIAGNOSES REDACTED]. A significant change Minimum Data Set ((MDS) dated [DATE], indicated R124 had severe cognitive impairment, required extensive assist of one to two staff for all activities of daily living, and the resident did not walk. R124 had an unstagable PU (unable to fully visualize due to scab or dead tissue). The PU Care Area Assessment (CAA) dated 2/16/13, indicated R124 had a current PU to the left heel which required daily dressing changes and directed staff to offload this area with foam boots and pillows. R124 could tolerate every two hour repositioning. The resident had the potential for friction and shear, had an open area on the right buttock, and staff was to keep pressure off the area when the resident was in bed. The Cognitive Loss/Dementia CAA dated 2/20/13, indicated staff was to anticipate needs. The POC dated 2/21/13, indicated R124 had open area on both heels and the left and right buttock. Two staff were needed to transfer and reposition the resident every two hours with pressure off open areas. The resident was to be up for meals only. The POC further directed staff to apply foam boots and a pillow underneath the resident's feet, and to refer to the Closet Plan of Care (CCP for nursing assistants) for additional care needs. The CCP dated 2/21/13, indicated R124 did not walk and required two staff assist for transfers and repositioning every two hours in bed. The resident was to wear bilateral foam boots with a pillow under his lower legs at all times. The CCP directed staff to keep pressure off left heel when in the wheelchair or bed and to keep pressure off open area to the right buttock. An written update dated 3/16/13, indicated R124 was to be up for meals only, keep pressure off the open area on the left heel and right buttock and to turn from side to side when in bed. A physician note dated 3/15/13, written by registered nurse (RN)-D indicated R124's left lower buttock crease pressure ulcer was a Stage 3 with 85% non-viable tissue. The note indicated the wound measured 2.3 x 1.4 x 0.1 cm. The left mid-buttock wound measured measured 1.7 x 1.0 x 0.1 cm. R124 had an alternating air mattress and the resident would be off-loaded and in bed as much as he would tolerate. A physician order [REDACTED]. A subsequent physician order [REDACTED]. A physician note dated 3/26/13, written by RN-D indicated R124's right heel wound measured 6.5 x 10.0 cm and was non-blanchable with some area of fluctuants. The left heel was cleansed of non-viable tissue and the dressing would be modified to maintain light moisture. Staff was to continue to offload and continue with pressure relief. RN-D wrote a subsequent note on dated 3/29/13, directing staff to continue with offloading/free floating heels. On 4/9/13, RN-D wrote R124's right heel wound measured 9.0 x 6.0 x 0.1 cm and had a moderate amount of serosanquanous drainage. Staff was directed to free float the heels. The 4/13 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The 4/13 Treatment Administration Record (TAR) indicated R124 required wound treatment/dressing changes to wounds on the right mid buttock, left, lower buttock crease and the left and right heels. The TAR also directed staff to keep pressure off left heel with foam boot and pillows. The 3/13 TAR indicated R124 had a left heel, right buttock and a left lower buttock crease wound. The TAR also directed staff to keep pressure off the left heel with a foam boot and pillows, and the right heel wound was not identified. The 4/13 NA record directed staff to apply a foam boot to bilateral heels with a pillow underneath when in bed or in the wheelchair and to make sure the right heel was well placed in offload area of the boot. A nurses' note (NN) dated 4/15/13, at 10:54 a.m. described R124's PUs as follows: 1) Right buttock wound measured 2.0 x 2.0 cm with thick, black eschar (dead tissue) in the center of the wound bed and had pink edges. The area around the wound was swollen and hard with scant yellow/brown drainage with definite pain noted with dressing changes, and the wound had increased in size since the last assessment. 2) Left, lower buttock crease wound measured 1.0 x 1.0 cm and had decreased in size. The wound bed was pink with whitish edges with scant serous drainage. R124 yelled out in pain and yelled at nurse, "Stop that and get away from there!" 3) Left, lower heel PU measured 2.0 x 1.0 cm with a slightly moist wound bed with scant amount yellow drainage, surrounding tissue was white/yellow in color and the area was improving. R124 had several scabbed area over the left foot toes. 4) Right, lower heel PU measured 6.0 x 4.0 cm with a blister like appearance inside the open area with a moderate amount of serous yellow drainage dripping from the wound bed. A small amount of white tissue was covering a dark, blue wound bed, and the wound was open. The right heel was dark, intact, blistered area measured 4.0 x 4.0 cm. R124 yelled out throughout the dressing changes. On 4/17/13, at 9:47 a.m. wound care was provided by licensed practical nurse (LPN)-A. NA-E assisted LPN-A with R124's weight bearing support and the following was observed: 1) Right heel: gauze wrap was removed and was saturated with serosanquanous drainage. Skin was observed peeling on the right lateral heel which extended into two areas. The right lateral heel open area measured 2.0 centimeters (cm) x 2.0 cm, a blackened area measured 4.0 x 3.0 cm, and the open area on the heel measured 1.0 x 0.4 cm. The left lateral portion of the right heel measured 1.0 x 0.2 cm and appeared blister-like. LPN-A applied separate Vaseline gauze pads directly on heel and lateral heel wounds and wrapped heel with a gauze wrap. R124 was observed hollering/cursing, striking and kicking out throughout the treatment. NA-E verified R124 cursed and hollered "a lot" during wound cares. LPN-A stated the "whole" heel was a very large, pressure related blister which was ruptured and debrided. 2) Right middle buttock: foam dressing was removed with minimal drainage. An approximate 50 cent-sized blackened area was in the center of the wound, and the skin surround the blackened area was open. R124 was restless, cursed and stated, "God that hurts!" throughout the treatment. LPN-A stated the wound started out at as a lump and was unsure if the pressure from sitting/rubbing on it while in the wheelchair could have irritated it. When clean foam dressing was reapplied R124 attempted to hit at NA-E who was holding his limbs during the treatment. R124 tolerated the dressing changes poorly, therefore the remaining wound dressings were not changed at that time. At 1:10 p.m. LPN-A was observed to provide the remaining wound treatments. 3) Left heel open area: dressing was removed and observed to have a minimal amount yellow drainage. The open open area measured 1.3 x 0.3 x 0.4 cm depth. The surrounding tissue was dry and peeling. The wound was cleansed and dressing reapplied. LPN-A stated the wound started out as a large blister. LPN-A stated the wound had been a Stage 3 (full thickness tissue loss), however, was now unstagable. R124 hollered during the treatment. 4) Left lower buttock: dressing was removed. The open area measured 1.2 x 1.3 cm with slough covering the wound bed. A dressing was reapplied. R124 was observed to curse throughout the treatment, and LPN-A stated the resident experienced definite pain with the dressing changes. On 4/17/13, at 1:40 p.m. NA-G stated R124's sore on the right mid buttock started about four months ago. The wound started as a hard area and turned into a blister which was then treated and resolved. However, the wound reappeared about one and a half months ago and was being treated since then. The heel ulcers began about three months ago, and stated as "big" blisters. The resident used to sit in a recliner with his feet up and heels resting on the foot rest, and pushed down with his heels. When the first blister on the right heel appeared, staff laid the resident in bed instead of the recliner in between meals. NA-G reported that the resident continued, however, to push down on his heels in the bed, and therefore, the foam boots were initiated. The NA believed the boots fit adequately, but the Velcro straps were worn out and no longer kept the boots in place. The NA thought new ones had been ordered. The NA went on to state that the left heel blister was discovered at the time of R124's bath and was a complete surprise. Staff then quit using the foot pedals on the wheelchair and instead used the wide black strap around the leg rests to prevent the resident from pushing down on them. NA-G verified staff were directed to follow the CCP and that the resident was supposed to be up for meals only. In addition, NA-G stated the resident required turning and repositioning every two hours and the CCP and POC had not been followed. R124's right heel was debrided of large amount of non-viable tissue according to a NN on 4/18/13, and the area measured 7.0 x 8.1 cm. On 4/18/13, at 9:09 a.m. LPN-A verified R124 should not have been up between meals and stated she had "issues" with staff for not following that direction. LPN-A said it put the resident at risk for further development of PUs and delayed the healing of current PUs. The LPN reported R124's wounds could have been prevented, and explained that the nursing staff had been going through a "transition" and things got lost in the shuffle and/or did not receive follow up. The resident's lacked consistent care, which contributed to R124's development of PUs. In addition, LPN-A verified R124's foam boots were ineffective in providing offloading/pressure relief. On 4/18/13, at 9:37 a.m. RN-A verified the facility was currently in a nursing staff transition and reported she was just filling in. RN-A stated she was "not too familiar" with R124 however, stated she would have expected the POC and CCP be followed. On 4/18/13, at 9:47 a.m. RN-C stated she believed R124's mid-buttock wound was moisture related. It was the expectation that staff kept pressure off the wounds to promote healing. On 4/18/13, at 10:05 a.m. RN-D stated R124's heel wounds/blisters and lower buttock crease wounds were related to shearing pressure. RN-D also stated R124's left heel was "doing good" and the right heel required debridement. The cause of the mid-buttock wound was unknown, but stated she did not believe it was related to pressure. Nursing staff had voiced concerns that the wound had worsened, and the wounds need to be covered and offloaded. Because of R124's body movements, she was not 100% sure the wounds could have been prevented. RN-D stated staff needed to ensure the heel boots were applied correctly and were fastened. She would have expected staff to follow the POC/CCP. On 4/18/13, at 12:19 p.m. the assistant director of nursing (ADON) stated R124's wounds were preventable and that staff should have followed the POC/CCP. R124 moved his feet a lot and she had seen the heel boots spun around. The boots required readjustment and stated she would have expected staff to readjust them when needed. On 4/18/13, at 12:37 p.m. the director of nursing (DON) stated R124's left heel wound started first. The DON was unsure if the cause was the recliner foot rest or the constant motion of R124's legs and feet, as the recliner foot rest padding was pulled back and exposed a hard surface. A foam boot was initiated for pressure relief. The left lower buttock crease wound was caused from the hard surface of the anti-roll back device that was attached to R124's wheelchair. A ROHO (pressure reduction seat cushion) was then placed on R124's wheelchair seat. The DON stated R124's right foot wound developed due to issues with the foam boots as R124 was constantly moving his legs/feet which caused heel friction. She thought new pressure relief boots had been ordered. When the boots moved, she expected staff would readjust them, and expected the POC/CCP would be followed as directed. R25 was at risk for the development of PUs and the facility failed to provide repositioning and offloading assistance as directed by the POC for 2 hours and 55 minutes on 4/16/13, and for 3 hours and 22 minutes on 4/17/13. In addition, the facility failed to ensure R25's bilateral pressure relieving boots were positioned correctly in order to provide optimum pressure relief. On 4/16/13, continuous observation was made from 1:50 until 4:45 p.m. At 1:50 p.m. R25 was observed seated in the wheelchair next to the nurses' station. Bilateral foam boots were applied loosely and were partially turned. R25 remained in the same manner throughout the observations, and several staff were observed walking past and/or were sitting near R25. At approximately 4:35 p.m. the surveyor intervened and asked NA-F about how often R25 required repositioning assistance. NA-F stated every two to two and a half hours. The resident had last been repositioned at approximately 1:50 p.m. and stated staff would assist the resident again just prior to supper around 5:00 p.m. NA-F stated R25 did not have PUs, but thought she had a foot infection. On 4/17/13, continuous observation was made from 6:45 a.m. through 10:07 a.m. At 6:45 a.m. R25 was observed seated in the wheelchair next to the nurses' station. R25 was wearing bilateral foam boots, and the right boot was on sideways and turned outward. R25's heel was resting on the foam. At 7:45 a.m. R25 remained in the same position with the right heel boot loose and almost positioned backward on the right leg. When the resident was assisted into the dining room at 8:04, the boot was in the same position and remained that way throughout the meal. Several staff were in direct visual view of R25. At 9:17 a.m. R25 was assisted back the area next to the nurses' station and the boot remained on sideways. At approximately 9:30 a.m. R25 was assisted into his room and wound care was provided. R25 remained in the wheelchair throughout the treatment. At 9:43 a.m. R25 was assisted back to the same area next to the nurses' station. At 10:07 a.m. NA-G and NA-H was observed to assist R25 onto the commode via a standing Pal (mechanical) lift. R25's incontinent brief was wet and the coccyx was red. At 10:14 a.m. R25 was assisted off the commode and the coccyx was no longer red. The Braden Scale assessment form dated 1/29/13, indicated R25 was at high risk for the development of PUs. R25's [DIAGNOSES REDACTED]. A significant change MDS dated [DATE], indicated R25 had severe cognitive impairment, required two staff extensive assistance with transferring and bed mobility, was non-ambulatory, and was at risk for PU development. The CAA dated 2/3/13 and 2/5/13 revealed R25 had severe cognitive impairment, required assistance in daily decision making, and staff was to anticipate needs. Lower leg [MEDICAL CONDITION] and chronic pain with [MEDICAL CONDITION], and R25 was at high risk for skin impairment, had a potential for friction and shearing, required every two hour repositioning and foam pressure relieving boots on at all times. The CAA noted the R25 required every two hour , and was at high risk for skin impairment. The Tissue Tolerance Testing for Offloading in a Chair dated 2/5/13, indicated R25's skin could tolerate every two hours repositioning. The section titled Tissue Tolerance for Repositioning Schedule in Bed dated 2/9/13, indicated R25's skin could tolerate every two hour repositioning while in bed. The POC dated 2/12/13, indicated R25 had an activities of daily living and mobility impairment and referred staff to the CCP for care needs. The POC also indicated R25 had a [MEDICAL CONDITION] stasis ankle wound, [MEDICAL CONDITION] and a history of PUs. The POC directed staff to turn and reposition R25 every two hours. The CCP dated 2/12/13, indicated R25 did not walk and required extensive assist of two staff and the standing lift for transfers, reposition every two hours, to keep pressure off the left inner ankle at all times, reclining wheelchair with seat cushion, and bilateral foam boots at all times. The current Physician orders [REDACTED]. The physician orders [REDACTED]. The NN dated 4/11/12, at 10:32 p.m. noted redness to the front of the left shin related to rubbing on the foam boot, and a [MEDICATION NAME] dressing was applied. The Wound Record Weekly Wound Assessment form indicated on 4/17/13, R25 had a left ankle stasis which measured 3.3 x 1.9 x 0.1 cm. and was granulated. On 4/17/13, at 1:46 p.m. NA-G verified R25 should have been repositioned every two hours. On 4/18/13, at 9:09 a.m. LPN-A verified R25 was to be repositioned every two hours as the POC directed. LPN-A also stated R25's foam boots were not effective "at all" because they did not stay on correctly and staff was expected to be aware and readjust them as often as needed. At 9:37 a.m. RN-B stated she was unfamiliar with R25's POC, however, stated she would have expected staff to follow it as directed. RN-B also verified R25 was to wear the foam boots at all times with readjust as needed. At 9:47 a.m. RN-C stated she would have expected staff to follow the POC as directed. RN-C verified the foam boots were used a pressure relieving option and staff were expected to readjust them as needed. At 10:05 a.m. RN-D verified she followed and monitored R25's stasis ulcer. RN-D also stated she would expect staff to have followed the POC and if unable to then, then the plan should have been modified. All staff should have had an awareness of the foam boots when they passed a resident to see they were applied correctly, and reposition them if needed. At 12:19 p.m. the ADON verified R25 required every two hour positioning and stated staff were expected to follow the POC. The ADON also stated R25 moved his feet a lot and required readjustment of the foam boots, and it was expected they were be readjusted as needed. At 12:37 p.m. the DON stated R25 should have been repositioned as the POC directed and the foam boots should have been adjusted. A policy and procedure related to pressure ulcer interventions and implementation of was requested, but was not received. The facility Care Planning and Conferences policy and procedure revised 6/29/12, indicated each resident will have an individualized overall POC which emphasized the care and development of the whole person. The policy also indicated the facility was to ensure each resident received the care and services most appropriate to meet his/her needs. R85 had a history of [REDACTED]. R85's [DIAGNOSES REDACTED]. R85's POC dated 1/29/13, indicated an alteration in skin integrity because of [MEDICAL CONDITION] disease requiring [MEDICATION NAME] (steroid) dependence and history of stage II pressure ulcer. Staff were to observe for bilateral lower extremities skin breakdown because history of history of open areas [MEDICAL CONDITION] (antibiotic resistant infection). Staff were also directed to the CCP. The CCP also dated 1/29/13, indicated R85 needed extensive assist of two staff with bed mobility and total assist of one for wheel chair mobility. Staff was to keep pressure off coccyx area, turn from side to side in bed, and to be very careful with skin. Repositioning was to be completed every two hours. On 4/17/13, at 7:10 a.m. R85 was up in a wheelchair in her room until staff assisted her to the dining room at 8:23 a.m. The resident was assisted back to her room at 9:02 a.m. R85 dozed in the wheelchair until at 9:45 a.m. NA-A assisted her to use the toilet using the standing lift, and then assisted her to lie down at 9:58 a.m. The following morning NA-A stated R85 had been assisted out of bed the previous day at 7:00, and was toileted at 9:45 a.m. The NA explained that they had "issues" with other residents, therefore she got behind in assisting R85 back to bed. RN-A stated on 4/19/13, at 9:15 a.m. stated that R85 needed to be repositioned every two hours because of risk for redevelopment of PUs, the use of [MEDICATION NAME], and fragile skin.