Every finding on record at Hillcrest Health Care, LLC

Based on observation and interview, the facility failed to maintain infection prevention and control practices in the 200 hall shower room to prevent the potential spread of infection for 1 of 2 shower rooms observed. Findings Include: On 8/23/26 at 6:10 p.m., R70 stated he had showered independently in the shower room across the hall from his room the previous day and described the shower as gross. R70 stated he found the cleanest towels he could find in the shower room, placed a towel on the shower chair, and showered himself. R70 stated there were used towels on the floor and used bandages in the shower room.On 8/23/26 at 6:21 p.m., the 200 hall shower room was observed with the interim administrator present. An open container containing multiple pieces of linen and washcloths was observed. A blue basin was also observed on the floor adjacent to the linen container. The basin contained two bandages and a tube/container of care-related product. The bandages were lying loose inside the basin. The interior of the basin had visible areas of discoloration and residue along the bottom and sides, giving the basin an unclean appearance. Multiple towels/linen were also observed in an open container in the shower room and appeared used.On 8/23/26 at 6:23 p.m., the director of nursing (DON) and interim administrator stated they would not expect dirty towels, bandages, or other linens to be left in the shower room. The DON stated used linen was expected to be bagged and removed after use. The DON stated used bandages were not expected to be present in the shower room and stated the shower room was expected to be cleaned. The DON confirmed the observed conditions could present an infection control issue.On 8/23/26 at 6:33 p.m., nursing assistant (NA)-A stated the 200 hall shower room was not known to have been used since Friday, two days prior. NA-A stated the linens, basin, and bandages observed in the shower room would have been present since that time. NA-A stated these items were expected to be removed after use and stated they would not expect these items to be left in the shower room.The facility policy Infection Prevention and Control Program dated 11/25, indicated the primary mission is to establish and maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The IPCP is a facility wideeffort involving all disciplines and is part of the quality assurance and performance improvement program (QAPI).

Based on observation, interview, and document review the facility failed to ensure proper handwashing/hand hygiene was implemented for 1 of 3 residents (R13) observed during incontinence cares. In addition, the facility failed to ensure enhanced barrier precautions (EBP) were utilized during a transfer for 1 of 3 residents (R13).Findings include:R13's face sheet dated 6/30/26, identified diagnoses of diabetes, dementia, chronic kidney disease, and retention of urine.R13's significant Change Minimum Data Set (MDS) dated [DATE], identified R13 had moderate cognitive impairment, had no behaviors, had rejection of cares that occurred 1-3 days, had limitations in range of motion on lower extremity, used a wheelchair, was dependent for toileting hygiene, substantial/maximum assistance for bed mobility, dependent for transfers, and had an indwelling catheter.R13's care plan dated 6/11/26, identified R13 was currently on EBP related to catheter care and wound care. Goal of staff to follow EBP. Interventions added on 6/11/26as follows:-Use appropriate communication to follow EBP. Explain reason for use of enhanced barrier precautions (catheter, cares, and wound cares) (dated 6/11/26).-Staff to DON (apply)/DOFF (take off) personal protective equipment per EBP policy when providing high contact cares (catheter care and wound care) (dated 6/11/26).-Follow EBP while providing urinary catheter maintenance, contact with the catheter, tubing, and collection bag, and other high contact care activities. (Must wear gowns and gloves with urinary catheter, maintenance, contact with the catheter, tubing, collection bag, and other high contact care activities) (dated 6/12/26). During an observation and interview on 6/30/26 at 10:08 a.m., R13's room had a sign outside his room indicated he needed EBP for high contact care activities. Nursing assistants (NA)-G and NA-C entered R13's room and began attaching R13 to the full body mechanical lift. NA-G stated R13 had a wound and an indwelling urinary catheter. Neither NA-G nor NA-C had on a gown nor gloves. NA-G and NA-C then transferred R13 to bed and asked assistant director of nursing (ADON) to come into R13's room to perform wound care. ADON then entered R13's room with gown and gloves on and gave instructions to NA-G that she needed to have gown and gloves on during any high contact cares. NA-G then placed a gown and gloves on without performing hand hygiene. ADON removed R13's pad and NA-G cleansed stool from R13's bottom, NA-G then removed gloves and placed new gloves on without performing hand hygiene. NA-G then applied cream to R13's bottom and applied a new brief with the same gloved hands. NA-G stated for residents on EBP staff should be applying PPE prior to performing any high contact care activities, however, she did not apply the required PPE prior to assisting R13. ADON explained staff should absolutely be using EBP prior to doing high-contact care activities such as transfers, cares, and catheter care. During an interview on 6/30/26 at 10:44 a.m., director of nursing (DON) stated it was her expectation for staff to apply gown and gloves any time they performed high contact care activities and also perform hand hygiene at the appropriate times. Review of the facility's Enhanced Barrier Precautions Policy dated 11/25, identified it was the practice of the facility to implement enhanced barrier precautions for the prevention of transmission of multidrug resistant organisms (MDRO). Definition: Enhanced Barrier Precautions refers to the use of gown and gloves for use during high contact resident care activities for a resident known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition. (e.g., residents with wounds and indwelling medical devices). Implementation of EBP:-Make sure gowns and gloves are available.-Ensure access to alcohol-based hand rub in every resident room.-Position a trash can inside the resident room for discarding PPE.The infection preventionist will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education. High-contact resident care activities include the following: Dressing; Bathing; Transferring; Providing hygiene; Changing linens/briefs or assisting with toileting; Device care or use (central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes); wound care.

Based on observation, interview, and record review, the facility failed to ensure body pillows used as positioning devices were not implemented as physical restraints for 3 of 3 residents (R5, R10 and R11) reviewed for restraints. Findings include: R5's face sheet dated 6/30/26, identified diagnoses of fracture of the right femur, osteoarthritis, dementia, osteoporosis, and history of falling. R5's admission Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment, had no behaviors, no rejection of care, had impairment on one side of lower extremity, used a walker, used a wheelchair, needed supervision/touching assistance for bed mobility, substantial/maximum assistance for transfers, had a fall in the last month prior to admission, had a fracture related to fall; in the 6 months prior to admission. Had no falls since admission. Had surgical repair of fracture of pelvis, hip, leg, knee, or ankle. R5's Fall incident report dated 5/5/26 at 9:20 a.m., identified R5 has a witnessed fall. Nursing assistant (NA) was in room and as she turned to get R5's shoes, R5 stood up and the NA was unable to catch her in time. Immediate action taken was to place a body pillow under her sheets to alleviate any further falls from self-ambulation. Predisposing physiological factors of agitation, forgetful, unsteady gait, confusion, history of falls, not able to realize limitations, and gait imbalance. R5's fall focus care plan was revised on 5/6/26 to add intervention of body pillow placed under sheets to alleviate any further falls from self-ambulation. R5's Incident Review and Analysis form dated 5/6/26, identified R5's 5/5/26 fall while ambulating was reviewed. Causal factors of fall were identified as being confused and unable to tell what she was attempting to do. Current interventions in place at the time of the fall were 15-minute checks; anti-roll backs on wheelchair; bilateral grab bars on bed. Interdisciplinary team (IDT) review added interventions to discontinue body pillow and have wheelchair locked at bedside. R5's care plan was revised on 5/8/26 to discontinue body pillow placed under the sheets and have R5's wheelchair locked at bedside. R5's incident report dated 5/23/26 at 1:45 p.m., identified R5 was found on the floor at the foot of the bed lying on her left side. R5's family had placed R5 in bed without staff assistance. Staff reported they had last checked on and toileted R5 at 1:15 p.m., where R5 was lying in bed. Immediate action taken was to send R5 to the emergency department for evaluation. R11's face sheet dated 6/29/26, identified diagnoses of hemiplegia and hemiparesis affecting left side and dementia. R11's Fall Review Evaluation dated 6/10/26, identified R11 was at risk for falls due to receiving scheduled narcotics, psychotropics, is incontinent of bowel and bladder, is alert and unaware of mobility limitations. R11's significant Change MDS dated [DATE], identified R11 had severe cognitive impairment, had no behaviors, no rejection of care, had lower extremity functional limitation, used a wheelchair, dependent with bed mobility, dependent for transfers, had no falls since admission/or retry or prior assessment. R11's fall focus care plan dated 9/6/23, identified R11 was at risk for falls related to human immunodeficiency virus, unspecified symptoms and signs involving cognitive functions and awareness, chronic pain syndrome. Goal to be safe and free from falls. Interventions included but were not limited to: -Body pillow for repositioning purposed when in bed. (dated 7/21/25) During an observation and interview on 6/26/26 at 1:10 p.m., R11 was observed lying in bed without a body pillow in place. NA-A retrieved a body pillow from a nearby chair, lifted the left side of the bed sheet, positioned the body pillow between R11 and the side of the bed underneath the sheet, and tucked the pillow securely into place. NA-A stated the body pillow was used to keep R11 in bed. R10's face sheet dated 6/30/26, identified diagnoses of hemiplegia (paralysis on one side of the body) and hemiparesis (partial weakness or loss of movement on one side of the body) following cerebral infarction (stroke). R10's quarterly Minimum Data Set (MDS) dated [DATE], identified R10 had moderate cognitive impairment, had physical behaviors directed towards other (such as hitting, kicking, pushing, scratching, or grabbing) that occurred daily, had verbal behaviors directed towards other (such as threating others, screaming at others, cursing at others) that occurred 4-6 day bud less than daily, rejection of care daily, needed substantial/maximum assistance for bed mobility and transfers, does not walk, no falls since admission/reentry/prior assessment, and no use of restraints. R10's mobility focus care plan dated 12/29/15, identified R10 had an alteration in mobility, at risk for falls and skin breakdown related to late effects of cerebral vascular accident (stroke) and hemiplegia. Goal to remain safe within the facility with no major injury. Interventions included but was not limited to -Pressure redistribution mattress to bed to prevent skin breakdown with body pillows to outline parameter of mattress (dated 12/30/15). During an observation and interview on 6/26/26 at 1:08 p.m., R10 was lying in bed and on his left side where a body pillow had been tucked under the mattress sheet on the right side of the bed. NA-C stated that R10's body pillow was placed under the sheets tight so he did not remove the pillow, and the pillow also makes sure he did not attempt to try to get out or roll out of bed. NA-C stated, that is the way we have been placing body pillows for a long time, and we put them that way, so he does not remove it. During an interview on 6/26/26 at 1:18 p.m., nurse manager licensed practical nurse (LPN)-A stated body pillows should never be placed under the sheets to try and keep residents from getting out of bed, if they are used in this way, they become a restraint. LPN-A was not aware that staff had been placing body pillows in the manner they were and would need to do some immediate education with the staff. During an interview on 6/26/26 at 3:59 p.m., director of nursing (DON) stated body pillows should never be placed under the sheets, so a resident was not able to remove them and by doing so, made the body pillow like a restraint. DON explained the facility had not completed a restraint assessment because they did not use restraints in the facility. Requested policy on restraints, but facility did not currently have a policy.

Based on interview and document review the facility failed to timely report a fall with major injury to the state agency (SA) within the required timeframe for 1 of 1 resident (R5) reviewed for falls. Findings include:R5's face sheet dated 6/30/26, identified diagnoses of fracture of the right femur (thigh bone), osteoarthritis (disorder where the protective cartilage that cushions the bones wears down), dementia, osteoporosis (a bone disease characterized by weak, brittle bones), and history of falling. R5's admission Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment, no behaviors, no rejection of care, had impairment on one side of lower extremity, used a walker/wheelchair, needed supervision/touching assistance for bed mobility, substantial/maximum assistance for transfers, had a fall in the last month prior to admission, had a fracture related to fall; in the 6 months prior to admission. Had no falls since admission. Had surgical repair of fracture of pelvis, hip, leg, knee, or ankle. R5's Vulnerable Adult Care Plan dated 4/25/26, identified R5 was categorically a vulnerable adult while resides in a skilled nursing facility. Resident was at risk due to decreased cognitive and physical abilities related to diagnosis of Lewy body dementia (a progressive brain disorder caused by abnormal protein) , disorientation, anxiety and visual hallucinations. Goal to remain free from abuse and/or neglect. Interventions as follows:-Staff will follow the facility vulnerable adult and abuse reporting policy. (dated 4/25/26)-The local ombudsman, adult protection, police, and state/financial agencies will be notified of any suspected abuse or financial exploitation as needed. (dated 4/25/25) R5's fall focus care plan dated 4/25/26, identified R5 was a fall risk related to impaired cognition, poor safety awareness, and impulsiveness as evidenced by fall history. Goal to be safe and free from injury. Interventions as follows:-15-minute checks (dated 4/29/26) R5's progress note dated 5/23/26 at 4:28 p.m., identified R5 was found at the foot of the bed lying on her left side at 1:45 p.m. R5's daughter had placed R5 in bed without assistance. Staff reported R5 was last checked on and toileted at 1:15 p.m. R5 was lying in bed when last seen. Range of motion was limited on left upper extremity. R5 unable to verbalize pain, so the FLACC Scale (an observational tool used for non-verbal or cognitively impaired individuals) and pain was 8/10 on pain scale. R5 was visibly yelling Help me. Provider called and gave order to send to the emergency department (ED). R5 was sent to the ED at 2:30 p.m. Review of R5's May 2026 Treatment Administration Record (TAR) identified a physician order for 15-minute behavioral checks every shift (dated 4/25/26 through 5/28/26). Although the TAR required staff to document only one entry per shift, it did not include documentation of the individual 15-minute checks performed throughout the shift.During an interview on 6/26/26 at 3:59 p.m., director of nursing (DON) stated during the facility investigation of R5's fall on 5/23/26 she had performed staff interviews and confirmed R5 had not been checked every 15 minutes as per her care plan fall prevention interventions nor did the facility have documentation showing that every 15 minutes someone put eyes on R5. DON explained family had been present prior to the fall and placed R5 in bed, however, staff should have checked on her every 15 minutes and according to the incident report it had been 30 minutes since R5 had been checked. DON explained R5 being impulsive and needing to be on 15-minute checks, staff should have continued to check on R5 every 15 minutes even if family was present to decrease the risk of her falling. DON further explained R5's fall on 5/23/26 did not get reported to the SA because she had been instructed by the corporate nurses that it did not need to be reported. DON could not articulate the rationale for not reporting this to the SA, however, she explained she was aware R5's care plan had not been followed at the time of the fall and per the incident report it had been 30 minutes since she had been checked on when her care plan indicated she was on 15 minute check. DON further explained this fall with serious injury should have been reported to the SA. Review of the facility's Abuse Prohibition/Vulnerable Adult Policy dated 11/25, identified the purpose to protect residents against abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends or other individuals. Incidents that must be reported to the state agency were as follows: -Mistreatment-inappropriate treatment or exploitation of a resident. -Neglect - Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident. -Injuries of unknown source - an injury should be classified as an injury of unknown source. When both of the following conditions are met: The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is in an area not generally vulnerable to trauma), or the number of injuries observed at one point in time or the incidence of injuries overtime.-All serious injuries that are determined to be a result of abuse, neglect, exploitation or misappropriation, even those considered accidental.

Based on observation, interview, and document review the facility failed to complete a comprehensive fall analysis, evaluate and revise the care plan, and failed to implement fall interventions for 2 of 3 residents (R5, R11) who had severe cognitive impairment, impulsivity, and at high risk for falls. Findings include:Findings include: R5's face sheet dated 6/30/26, identified diagnoses of fracture of the right femur (thigh bone), osteoarthritis (disorder where the protective cartilage that cushions the bones wears down), dementia, osteoporosis (a bone disease characterized by weak, brittle bones), and history of falling. R5's admission Minimum Data Set (MDS) dated [DATE], identified R5 had severe cognitive impairment, no behaviors, no rejection of care, had impairment on one lower extremity, used a walker/wheelchair, needed supervision/touching assistance for bed mobility, substantial/maximum assistance for transfers, had a fall in the last month prior to admission, and had a fracture related to fall 6 months prior to admission. R5 had no falls since admission and had surgical repair of fracture of pelvis, hip, leg, knee, or ankle. R5's Fall Review Evaluation dated 4/24/26 at 12:47 p.m., identified R5 had multiple falls within the last 6 months, was taking three medications that may contribute to falls, was incontinent of urine and unable to independently come to a standing position. Summary/Interventions: Resident admitted to facility into secure memory care unit. Past medical history of falls. Recent fall with right lower extremity fracture and repair. Currently on hourly checks (However, review of R5's record did not include a comprehensive assessment linking R5's identified fall risk factors to the implementation of hourly checks as an intervention.) Will continue to evaluate quarterly, with change of condition and as needed. R5's progress note dated 4/24/26 at 10:48 p.m., identified R1 was admitted to the facility following a fall at home on 4/21/26 that resulted in a right femur fracture with surgical repair. R5's family wanted R5 to be on 15-minute checks until R5 gets used to facility. R5's family requested fall mat on floor. to prevent R5 from falling on the floor. Oncoming shift notified. Review of R5's record revealed that, although R5's family requested 15-minute safety checks, there was no documented assessment or re-evaluation to determine whether the existing hourly safety checks remained appropriate. Additionally, there was no evidence the care plan was revised to implement 15-minute safety checks and the fall matt on the floor. R5's fall focus care plan dated 4/25/26, identified R5 was a fall risk related to impaired cognition, poor safety awareness and impulsiveness as evidenced by fall history. Goal to be safe and free from falls. Care plan interventions as follows: -Follow resident specific fall prevention plan. Hourly checks. (dated 4/25/26 through 5/6/26) -Monitor and document on safety. Review information on past falls and attempt to determine root cause of falls. Record possible root causes. Alter/remove any potential causes if possible. Educated resident/family/caregivers as to causes. (dated 4/25/26) -Follow physical therapy and occupational therapy instructions for mobility function. (dated 4/25/2/26) R5's progress note dated 4/25/26, identified R5 showed signs of agitation at 1p.m. and was attempting to stand up from her wheelchair. R5's progress note dated 4/27/26, identified R5 does try to get out of bed and staff assist her to reposition or get up depending on wishes. R5's progress note dated 4/28/26, identified R5 had been upgraded to assist of two for pivot transfers using a gait belt. R5 resting in bed, bed lowered and on 15-minute checks. Review of R5's care plan on 4/28/26 did not include bed height intervention nor identify revision to include an intervention for bed height. R5's fall focus care plan was revised on 4/29/26 to include the following interventions: -Anti-roll backs applied to wheelchair. -Bilateral grab bars applied to bed. -15-minute checks per family request. R5's Fall incident report dated 5/5/26 at 9:20 a.m., identified R5 has a witnessed fall. Nursing assistant (NA) was in room and as she turned to get R5's shoes, R5 stood up and the NA was unable to catch her in time. Predisposing physiological factors of agitation, forgetful, unsteady gait, confusion, history of falls, not able to realize limitations, and gait imbalance. Immediate action taken was to place a body pillow under her sheets to alleviate any further falls from self-ambulation. R5's Incident Review and Analysis form dated 5/6/26, identified R5's 5/5/26 fall while ambulating was reviewed. Causal factors of fall were identified as being confused and unable to tell what she was attempting to do. Current interventions in place at the time of the fall were 15-minute checks; anti-roll backs on wheelchair; bilateral grab bars on bed. Interdisciplinary team (IDT) review added interventions to discontinue body pillow and have wheelchair locked at bedside. R5's fall focus care plan was revised on 5/6/26 to include body pillow placed under sheets to alleviate any further falls from self-ambulation. Although The Incident Review and Analysis dated 5/6/26 identified discontinuing the body pillow and locking the wheelchair at the bedside; despite these recommendations, R5's care plan was revised to add the body pillow intervention and did not include locking the wheelchair at the bedside. R5's Medication Administration Record (MAR) default progress note dated 5/7/26 at 1:32 p.m., included a response for monitoring effectiveness of fall interventions which indicated that R5 does need help, and supervision while up in wheelchair due to her trying to stand up to prevent falls. R5's progress note dated 5/7/26 at 1:36 p.m., R5 needs supervision due to trying to walk alone and staff assist her to sit down. R5's progress note dated 5/8/26 identified R5 had been placed in her bed in the lowest position. Aide went to help another resident and as passing R5's room, R5 was observed sitting on the floor. R5 unable to state how she fell, neurological exams started, skin tear noted on right arm. Body pillow placed under her sheets to help alleviate any further falls from self-ambulation. Call light within reach and bed in the lowest position and fall mattress on the side of the bed. R5's incident report dated 5/8/26 at 5:20 p.m., identified R5 was found on the floor. R5's bed was in the lowest position and R5 had been placed in bed prior and after nursing assistant helped another resident, R5 was found on the floor. R5 sustained a skin tear on her right arm. Immediate action was fall matt placed on side of bed. R5's Incident Review Analysis dated 5/8/26 however signed by IDT on 5/13/26 identified a causal factor of R5 assisted to lay in bed after dinner, bed was in lowest position and R5 has a small skin tear on her right arm. IDT review and determined bed to be at appropriate height with feet touching flat on the floor when sitting at the edge of the bedside. Continuing physical therapy to improve strength and mobility and walking program initiated to ambulate twice daily for staff assist. The fall record did not include a comprehensive fall analysis that would include but not limited to R5's last known well time, pain presence, or if toileting needs were met. R5's care plan was revised on 5/8/26 identified the body pillow intervention was discontinued which had been directed to be discontinued on 5/6/26 according to the Incident Review. A new intervention was added that directed staff to have R5's wheelchair locked at bedside. However, the care plan was not revised to include the floor matt as per the progress note on 4/24/26 and was not revised to address the bed height as per the analysis and the progress note on 4/28/26. R5's progress note dated 5/9/26 at 3:54 p.m., identified R5 attempting to stand from her wheelchair. As writer approached resident she dug her nails into writer's arm. The family called to come and sit with resident and resident calmed down. R5's progress note dated 5/10/26 at 10:15 p.m., identified R5 agitated at supper time and keeps standing up to her wheelchair. R5's care plan was revised on 5/11/26 to include the interventions: bed at appropriate height [height not specified], no fall mat, no low bed, and a soft-touch call light clipped to the side of the bed. Review of R5's record revealed no comprehensive assessment or evaluation supporting the discontinuation of the fall mat and low bed interventions. R5's progress note dated 5/12/26 at 6:18 p.m., identified R5 may sit for a while but then sits and stands up, required staff member to stay with her when she was doing this. Does get up and down in bed. Monitored for safety. Anti-tip legs put on wheelchair to prevent her wheelchair from tipping over. R5's progress note dated 5/15/26 at 4:20 p.m., identified R5 was self-transferring at 8:00 a.m. across from the dining room. R5 was immediately redirected to her wheelchair and attempted to stand up from her wheelchair multiple times. R5 toileted and laid down for a nap after breakfast. R5's progress note dated 5/16/26 at 7:50 p.m., identified R5 gets up and starts to stand and walk on own, staff assist as soon as seen. R5's progress note dated 5/18/26 at 4:11 p.m., identified R5 will stand up from her wheelchair and staff assist. R5 does not comprehend that she needs help for safety purposes. R5's progress note dated 5/20/26 at 11:14 a.m., identified R5 walked with nursing assistant today and was much steadier than last week. R5 needed observation as to prevent her from getting up alone. R5's progress note dated 5/20/26 at 12:48 p.m., identified R5 sitting longer in wheelchair before trying to get up alone. Staff needed to be there to monitor and visit with her as she would get up and stand. R5's progress note dated 5/23/26 identified R5 was found at the foot of the bed lying on her left side at 1:45 p.m. R5's daughter had placed R5 in bed without assistance. Staff reported R5 was last checked on and toileted at 1:15 p.m. R5 was lying in bed when last seen. Range of motion was limited to left upper extremity. R5 unable to verbalize pain, so the FLACC Scale (an observational tool used for non-verbal or cognitively impaired individuals) was used and R5's pain was rated 8/10 on the pain scale. R5 was stating, Help me. Provider called and gave order to send to the emergency department (ED). R5 was sent to the ED at 2:30 p.m. R5's ED note dated 5/23/26, identified R5 was seen following a fall in the nursing home. R5 was having left arm and left leg pain. Imaging completed of left shoulder which revealed an acute transverse fracture (a type of complete bonce break where the line runs horizontally, perpendicular to the long axis of the bone, usually caused by high impact trauma like a fall, car accident, or direct blow.) of the left humeral head/neck junction. Family did not want any surgical interventions, so R5 was placed in a sling and will be discharged back to the nursing home. R5's incident report dated 5/23/26 at 1:45 p.m., identified R5 was found on the floor at the foot of the bed lying on her left side. R5's family had placed R5 in bed without staff assistance. Staff reported they had last checked on and toileted R5 at 1:15 p.m., where R5 was lying in bed. Immediate action taken was to send R5 to the emergency department for evaluation. Although R5's care plan identified R5 required every15-minute checks, the incident report documented R5 had not been checked for 30 minutes prior to the fall on 5/23/26 at 1:45 p.m. R5's Incident Review and Analysis dated 5/23/26, identified R5's fall on 5/23/26 at 1:45 p.m. was reviewed. Causal factors for incident are that R5 was found on the foot of the bed lying on her left side at 1:45 p.m. Family assisted R5 to bed before that. R5 was last toileted at 1:15 p.m. Other (new) inventions: bed in lowest position and body pillow for positioning and defining the edge of the bed. Although R5's care plan indicated 15-minute checks, the Incident Review and Analysis did not identify that the care plan was not followed. Review of R5's May 2026 Treatment Administration Record (TAR) identified a physician order for 15-minute behavioral checks every shift (dated 4/25/26 through 5/28/26). The TAR required staff to document only one entry per shift, it did not include documentation of the individual 15-minute checks performed throughout the shift. R5's progress note dated 9:59 p.m., identified at R5 arrived back at the facility at 6:24 p.m. and wearing a sling. Soft touch call light placed and attached to sheet. R5's care plan was revised on 5/24/26 to have bed in lowest position, body pillow for positioning and defining the edge of the bed. Do not tuck body pillow under bed sheets. During an interview on 6/26/26 at 1:18 p.m., licensed practical nurse care coordinator (LPN)-A stated after a resident has fallen, she would add the information of what events occurred during the time of the fall, however, she did not review if R5 had been checked on every 15-minutes per the care plan, had toileting needs met, and had not determined fall prevention interventions had been implemented at the time of the fall as part of root cause analysis. During an interview on 6/26/26 at 3:59 p.m., director of nursing (DON) stated during the facility investigation of R5's fall on 5/23/26 she had performed staff interviews and confirmed R5 had not been checked every 15 minutes as per her care plan nor did the facility have documentation showing that every 15 minutes check increments were completed by staff. DON explained family had been present prior to the fall and placed R5 in bed, however, staff should have checked on her every 15 minutes and according to the incident report it had been 30 minutes in between since R5 had been checked. DON explained R5 being impulsive and needing to be on 15-minute checks, staff should have continued to check on R5 every 15 minutes even if family was present to decrease the risk of her falling. During an interview on 6/26/26 at 4:07 p.m., administrator stated she had identified following R5's fall with fracture on 5/23/26 that the facility had only been documenting 15-minute checks once per shift instead of recording every 15-minute. Administrator explained on 5/23/26 the facility changed the process of documentation for staff to document every 15 minutes versus once per shift and this documentation would be on paper to ensure compliance. During an interview on 6/30/26 at 4:19 p.m., the medical director (MD) stated it was her expectation that staff ensure fall prevention interventions were implemented to mitigate the risk of falls with serious injury. The MD further stated that the facility's failure to implement those interventions for R5 resulted in a fall on 5/23/26 that caused a fracture. R11 R11's face sheet dated 6/29/26, identified diagnoses of hemiplegia and hemiparesis affecting left side and dementia. R11's Fall Review Evaluation dated 6/10/26, identified R11 was at risk for falls due to receiving scheduled narcotics, psychotropics, is incontinent of bowel and bladder, is alert and unaware of mobility limitations. R11's Significant Change MDS dated [DATE], identified R11 had severe cognitive impairment, had no behaviors, no rejection of care, had lower extremity functional limitation, used a wheelchair, dependent with bed mobility/transfers, had no falls since admission/or retry or prior assessment. R11's fall focus care plan dated 9/6/23, identified R11 was at risk for falls related to human immunodeficiency virus, unspecified symptoms and signs involving cognitive functions and awareness, chronic pain syndrome. Goal to be safe and free from falls. Interventions as follows: -Monitor and document on safety. Review information on past falls and attempts to determine cause of falls. Record possible root causes. Alter/remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes (dated 9/23/23). -Follow physical therapy (PT) and occupational therapy (OT) instructions for mobility function (dated 9/6/23). -Call light within reach (dated 9/10/23). -Dycem (anti-slip mat) to top of cushion in Broda (a specialized positioning chair) wheelchair (dated 1/26/24). -Body pillow for repositioning purposed when in bed (dated 7/21/25). -Fall mat beside bed (dated 12/15/25). R11's progress note dated 6/25/26 at 1:43 p.m., identified R11 was seated on the floor in the dining room. R11's back and head was resting against the seat and leg rest on the chair. R11's chair was in the upright position. Immediate intervention was to maintain the Broda chair in the tilted back position whenever the resident is not actively eating to promote positioning and reduce the risk of forward sliding. R11's Incident Review and Analysis form dated 6/26/26, identified R11 was observed slip down out of Broda chair and sat on bottom on the floor. Intervention to reposition with total mechanical lift after meals to ensure resident has safe body alignment within chair and must lay down after 1 hour of being up in Broda chair. R11's care plan was revised on 6/26/26 to reposition with total mechanical lift and two staff after meals to ensure resident has safe body alignment within chair. Must lay down after 1 hour of being up in the Broda chair. During an observation and interview on 6/30/26 at 1:10 p.m., R11 was lying in bed without a fall mat on the floor nor a body pillow for positioning according to the care plan. Nursing assistant (NA)-A entered R11's room where R11 was lying in bed. NA-A stated R11's fall interventions were supposed to be a fall mat in place and a body pillow on the side of the bed next to him. NA-A had placed R11 in bed after lunch, however, had not placed the fall mat on the floor next to his bed nor put the body pillow in place. NA-A then took the body pillow and placed it on the left side of the bed tucked under the sheet of R11, however, NA-A did not put the fall matt next to R11's bed. As NA-A was leaving R11's room surveyor asked NA-A if the matt was supposed to be placed. NA-A then placed the fall mat on the floor next to R11's bed and explained R11 should have had this placed as soon as he was transferred into bed to prevent injury if he were to fall out of bed. During an interview on 6/26/26 at 1:18 p.m., nurse manager licensed practical nurse (LPN)-A stated it was her expectation for all staff to ensure that the fall prevention interventions are utilized for a resident at risk for fall to mitigate the risk of injury if they do fall. LPN-A explained R11's body pillow was not supposed to be tucked under the sheet when he was in bed and was just supposed to be laid on the top of the sheet for positioning to make help define the bed. R11's fall mat should have been placed on the floor as soon as R11 was placed in bed. During an interview on 6/26/26 at 3:59 p.m., DON stated it would be her expectation for staff to ensure all fall prevention interventions are utilized at all times to mitigate the risk of falling and to try and mitigate the risk of injury if the resident does fall. Review of the facility's Fall Prevention and Management Policy dated 11/25, identified the following: Managing Falls and Fall Risk: -Facility staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. -If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on the nature of or type of fall, until falling is reduced or stopped or until the reason for the continuation of the falling is identified as unavoidable. -Staff may also identify and implement relevant interventions to try to minimize serious consequences of falling. -Staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling.

Based on interview and record review the facility failed to comprehensively assess and monitor fluid intake to ensure adequate hydration for 1 of 3 residents (R3) reviewed for dehydration. Findings include: R3's face sheet dated 6/26/26, identified diagnoses of malignant neoplasm of brain, type 2 diabetes, moderate protein-calorie malnutrition, and absence of right leg below knee. R3's significant change of status Minimum Data Set (MDS) dated [DATE], identified R3 had no memory issues. R3 had no vision or hearing impairments. R3 rejected cares 1-3 days per week, had impairment on both sides of upper and lower body, was independent with eating, moderate assistance with upper body dressing and dependent on lower body dressing. R3's nutritional care plan updated 5/23/26, identified a goal of maintain adequate hydration status. Interventions included to offer adequate fluids at and between meals beginning 11/28/25 and obtain/review labs per doctor orders. R3's Clinical Nutrition Evaluation V-5 dated 3/4/26, did not identify R3's fluid requirements however, indicated R3's daily fluid intake consumed was 1500-2000 cubic centimeters (cc) daily. The evaluation included the goal maintain adequate hydration status Consume 75% meals and supplements. R3's Fluid Intake record identified inconsistent documented individual fluid intakes consumed. However, there was no indication the 24-hour daily fluid intake was calculated and evaluated to determine whether R3 met hydrations needs even though multiple 24-hour daily consumptions documented did not exceed 1000 ml when calculated. 4/7/26: Fluid intake documented as 480 mL at 1:34 p.m., 480 mL at 1:35 p.m., and 600 mL at 7:01 p.m. The documented fluid intake entries totaled 1,560 mL. 4/8/26: Fluid intake documented as 480 mL at 10:00 a.m., 480 mL at 1:10 p.m., and 600 mL at 6:28 p.m. The documented fluid intake entries totaled 1,560 mL. 4/9/26: Fluid intake documented as 240 mL at 1:37 p.m., 240 mL at 1:37 p.m., and 600 mL at 6:24 p.m. The documented fluid intake entries totaled 1,080 mL. 4/10/26: Fluid intake documented as 240 mL at 1:11 p.m., 240 mL at 1:11 p.m., and 240 mL at 6:13 p.m. The documented fluid intake entries totaled 720 mL. 4/11/26: Fluid intake documented as Resident Refused at 6:47 p.m. 4/12/26: Fluid intake documented as Resident Refused at 6:10 p.m. R3's progress note dated 4/12/26 at 4:20 p.m., identified at 1:30 p.m., R3 had an unresponsive episode after transferring on the mechanical standing lift. R3 had complained of feeling dizzy while standing on the machine and when R3 sat down on the bed, went unresponsive. Nursing assistant (NA) reported R3 did not respond to shoulder shake or name being called. NA was unable to determine approximate length of time R3 was unresponsive and informed nurse after R3 came to. Assessed vital signs: temperature 98.2 (normal range 97.8-99.0), pulse 64 (normal range 60-100), respirations 16 (normal range 12-18), blood pressure 80/51 (normal range 90/60-120/80), oxygen 90% room air (normal range 95-100%). Physician contacted and advised sending to emergency department (ED) for evaluation. R3's Emergency Department (ED) After Visit Summary dated 4/12/26, identified R3 was seen at the ED for loss of consciousness. Testing showed signs of dehydration and R3 received intravenous fluids. R3 was to continue to increase water intake. R3's progress note dated 4/12/26 at 7:26 p.m., identified R3 returned from ED at 6:30 p.m. Diagnoses-syncope (fainting) and failure renal acute (acute kidney injury) and signs of dehydration. Continue to increase water intake. Drink less juice. Review of R3's record dated 4/12/26 identified R3's care plan was not revised to include management and/or prevention strategies for signs/symptoms of dehydration, acute renal failure, and syncope. In addition, the record did not identify re-assessment of R3's daily fluid needs and goals in conjunction with defined how much fluid staff were to encourage. R3's Treatment Administration Record (TAR) for 4/2026, identified a nursing order on 4/12/26, Per ED visit continue to increase water intake. Follow up with primary care provider in the next 1-2 weeks for re-evaluation and repeat kidney function testing. Return to ED if any new or worsening symptoms, chest pain, shortness of breath, repeat passing out or any other concerns every shift until 4/20/26. This order included a +/- and each shift marked, however, did not include a corresponding symbol key in order to ascertain meaning of documented +, -', or 0. The TAR identified on 4/12/26 night shift marked 0. On 4/13/26-4/20/26 each shift marked +. On 4/20/26, night shift marked - . Order was discontinued 4/21/26. R3's Extended Care Visit Note dated 4/13/26, identified R3 was seen for ED visit on 4/12/26, for syncope/dehydration, with a diagnosis of acute renal failure. ED had advised increased fluid intake and close follow-up with primary care provider for re-evaluation of renal function. Orders to obtain basic metabolic panel (BMP) in one week. R3's progress note dated 4/14/26 at 12:27 a.m., identified R3 came to dining area for supper. No dizziness noted. Has been drinking more water per doctor order. R3's record did not identify amounts. R3's Extended Care Visit Note dated 4/27/26, identified BMP was stable and reviewed on 4/21/26, continue current plan of care. R3's Fluid Intake record identified inconsistent documented individual fluid intakes consumed. However, there was no indication the 24-hour daily fluid intake was calculated and evaluated to determine whether R3 met hydrations needs even though multiple 24-hour daily consumptions did not exceed 1000 ml when calculated. 4/13/26: Fluid intake documented as 240 mL at 1:55 p.m., 240 mL at 1:55 p.m., and 240 mL at 6:55 p.m. The documented fluid intake entries totaled 720 mL. 4/14/26: Fluid intake documented as 240 mL at 1:26 p.m. and 240 mL at 1:26 p.m. The documented fluid intake entries totaled 480 mL. 4/15/26: Fluid intake documented as 480 mL at 1:14 p.m. and Resident Refused at 6:02 p.m. The documented fluid intake entries totaled 480 mL. 4/16/26: Fluid intake documented as 240 mL at 1:29 p.m., 240 mL at 1:29 p.m., and 0 mL at 6:38 p.m. The documented fluid intake entries totaled 480 mL. 4/17/26: Fluid intake documented as 240 mL at 1:28 p.m., 240 mL at 1:28 p.m., and 240 mL at 7:06 p.m. The documented fluid intake entries totaled 720 mL. 4/18/26: Fluid intake documented as 240 mL at 1:27 p.m., 240 mL at 1:42 p.m., and 600 mL at 7:20 p.m. The documented fluid intake entries totaled 1,080 mL. 4/19/26: Fluid intake documented as 240 mL at 1:24 p.m., 240 mL at 1:24 p.m., and 480 mL at 6:49 p.m. The documented fluid intake entries totaled 960 mL. 4/20/26: Fluid intake documented as 480 mL at 10:16 a.m., Resident Not Available at 1:00 p.m., and 600 mL at 6:38 p.m. The documented fluid intake entries totaled 1,080 mL. 4/21/26: Fluid intake documented as 240 mL at 1:40 p.m., Not Applicable at 1:41 p.m., and 240 mL at 6:18 p.m. The documented fluid intake entries totaled 480 mL. 4/22/26: Fluid intake documented as 600 mL at 6:08 p.m. The documented fluid intake entry totaled 600 mL. 4/23/26: Fluid intake documented as 240 mL at 2:03 p.m., 240 mL at 2:03 p.m., and 600 mL at 7:01 p.m. The documented fluid intake entries totaled 1,080 mL. 4/24/26: Fluid intake documented as 240 mL at 6:52 p.m. The documented fluid intake entry totaled 240 mL. 4/25/26: Fluid intake documented as 240 mL at 1:46 p.m. and 240 mL at 1:46 p.m. The documented fluid intake entries totaled 480 mL. 4/26/26: Fluid intake documented as Resident Refused at 1:17 p.m. and 440 mL at 1:17 p.m. The documented fluid intake entries totaled 440 mL. 4/27/26: Fluid intake documented as Resident Refused at 10:16 a.m., 240 mL at 1:24 p.m., and 240 mL at 5:37 p.m. The documented fluid intake entries totaled 480 mL. 4/28/26: Fluid intake documented as 0 mL at 1:24 p.m., Resident Refused at 1:24 p.m., and 240 mL at 6:38 p.m. The documented fluid intake entries totaled 240 mL. 4/29/26: Fluid intake documented as 240 mL at 1:10 p.m., 240 mL at 1:10 p.m., and 240 mL at 6:43 p.m. The documented fluid intake entries totaled 720 mL. 4/30/26: Fluid intake documented as Not Applicable at 11:59 a.m., Not Applicable at 11:59 a.m., and 240 mL at 6:56 p.m. The documented fluid intake entries totaled 240 mL. 5/1/26: Fluid intake documented as 240 mL at 1:38 p.m. and 240 mL at 1:38 p.m. The documented fluid intake entries totaled 480 mL. 5/2/26: Fluid intake documented as 480 mL at 11:20 a.m., 480 mL at 2:06 p.m., and 600 mL at 7:23 p.m. The documented fluid intake entries totaled 1,560 mL. 5/3/26: Fluid intake documented as 480 mL at 1:30 p.m. and 480 mL at 1:35 p.m. The documented fluid intake entries totaled 960 mL. 5/4/26: Fluid intake documented as 240 mL at 12:59 p.m., 240 mL at 12:59 p.m., and 240 mL at 7:03 p.m. The documented fluid intake entries totaled 720 mL. 5/5/26: Fluid intake documented as 480 mL at 1:47 p.m., 480 mL at 1:48 p.m., and 240 mL at 6:36 p.m. The documented fluid intake entries totaled 1,200 mL. 5/6/26: Fluid intake documented as 240 mL at 9:49 a.m., 480 mL at 1:27 p.m., and 240 mL at 7:30 p.m. The documented fluid intake entries totaled 960 mL. 5/7/26: Fluid intake documented as 240 mL at 6:39 p.m. The documented fluid intake entry totaled 240 mL. R3's progress note dated 5/7/26 at 4:43 p.m., identified R3 had head pain at 1:00 p.m. BP taken at 83/38 and on opposite arm 94/46. R3 rated pain 10/10. Went to get VS after 15 minutes and R3 had shallow respirations, O2 was 86% on room air. BP 91/48. R3 did not respond to questions on pain and sternal rub performed. R3 stated pain was high. R3 stated it was March and Saturday. R3 was sent to ED for evaluation. R3's ED Discharge summary dated [DATE], identified R3 went to ED for a headache. R3 had low blood pressure for emergency medical crew, fluids given and dehydration favored per medical doctor (MD). Critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: dehydration. R3's blood, urea, nitrogen (BUN) was 25 (normal range 8-24) and blood pressure prior to intravenous fluids was 88/56. R3 was provided with 1,000 mL of NaCl (normal saline) and discharge blood pressure was 133/86. Headache resolved with fluids and Tylenol and no orders were provided by ED. R3's Extended Care Visit Note dated 5/11/26, identified R3 was seen for a follow-up ED visit from 5/7/26, with a diagnosis of headache. No new orders, continue current plan of care. R3's progress note dated 5/13/26 at 3:15 p.m., identified water pass done in morning per usual. Removed three 550 mL mugs (two had juice, one had water) from R3's room. replaced with one 550 mL of ice water and one 550 mL of cranberry juice with ice. At 3:17 p.m., progress note identified R3 also orders a 550 mL mug of cranberry, apple, or lemonade at each meal and carries it with him if not done at meals. Often sits by north door with a mug of juice and ice multiple times daily. At 3:21 p.m., progress note identified R3 ordered a 550 mL mug of cranberry juice at lunch. R3 had consumed 400 mL of cranberry juice from 11:00 a.m. until 3:24 p.m. Water mug from morning water pass had 250 mL left in it. Will continue to encourage water intake. R3's progress note dated 5/23/26, indicated R3 was admitted to hospice. R3's Fluid Intake Record for between 5/13/26 through 5/31/26 identified inconsistent individual fluid intake entries with calculated or documentation a total daily fluid intake. Based on a calculation of the documented individual fluid intake entries, the resident's daily fluid intake ranged from 480 mL to 2,480 mL, with an average daily intake of approximately 1,121 mL after excluding the 18,000 mL entry documented on May 27. R3's Clinical Nutrition assessment dated [DATE], completed by registered dietician identified R3's fluid needs as 1850 cc's-2200 cc and R3 was meeting nutritional needs with a documented intervention as hospice cares. Resident to remain as nourished and hydrated as disease state allows. Goal is comfort. Food and fluids as desired and tolerated. During an interview on 6/30/26 at 8:16 a.m., nursing assistant (NA)-D stated as far as he was aware culinary services charted fluid intake for residents. NA-D could not recall ever recording fluid intake on fluids consumed outside of the meals. R3 seemed to be very thirsty, asking for water a lot. R3 had very dry skin and we had to lotion/moisturize it morning and night. During an interview on 6/30/26 at 9:00 a.m., NA-E stated she did not record fluid intake. R3 had very dry skin and did not drink a lot. Staff encouraged R3 to drink water or juice frequently. During an interview on 6/30/26 at 9:22 a.m., NA-F stated dietary staff monitor and record fluid records for residents, not NA's. NA-F thought nurses might record fluids that were not given in the dining room. During an interview on 6/30/26 at 8:30 a.m., cook (C)-A stated dietary did not record fluids consumed from the water mugs that were passed out in the morning and evening. C-A was unsure if any staff monitored a 24-hour fluid intake for residents to determine if they had enough fluids each day. During an interview on 6/30/26 at 11:47 a.m., registered nurse (RN)-A stated nurses keep track of fluid that they give for residents on fluid restriction. Nurse would record the amount in the treatment administration record (TAR). RN-A thought someone checked daily for 24-hour fluid intake but was unsure who and thought maybe it would be the nurse manager. During an interview on 6/30/26 at 1:46 p.m., RN-B stated fluid could be determined by checking daily weight. All residents require 1,000 milliliters (mL) per day. RN-B reviewed R3's fluid intakes from April-June and stated the + sign indicated that the resident received 1,000 mL that day. RN-B then stated the + meant to increase fluid but it did not specify exactly how much. RN-B stated NA's report to the nurse how much fluid the resident takes and would follow-up with kitchen and electronic record to determine fluid amount. R3 would be at risk for dehydration. RN-B stated nurses monitor what fluid is consumed during their shift but was unsure if anyone monitored total daily fluid intake. During an interview on 6/30/26 at 12:42 p.m., director of nursing (DON) stated typically dietary staff monitored fluid intakes but nursing would monitor in the TAR if needed. A checkmark or plus/minus sign would not give a good idea of fluid intake or give a specific amount of fluid consumed. DON questioned What does the + or minus mean without a corresponding progress note. DON would expect the documentation to include how many mL's were offered and how many were consumed. Sometimes, residents just needed to be encouraged to drink more fluids but occasionally the dietician or doctor would consult for goals of fluid intake. DON guessed that the interdisciplinary team (IDT) had determined that R3 had adequate fluid intake and did not need additional monitoring. However, DON was unable to find corresponding documentation that IDT had reviewed R3's fluid intake. The facility Hydration Program policy dated 6/2026, identified between meals, culinary services provides clean water pitchers or cups for between-meal hydration. The assigned department will pass water to all residents who are medically appropriate to receive it. Pitchers will be retrieved and sent to kitchen for cleaning and sanitizing at least daily. Thickened water will be passed as applicable. The facility Monitoring Food and Fluid Consumption revised 6/2026, identified all residents, including those who receive meal trays, will be monitored for dietary intake during each meal. Hospitality Services Director and Registered Dietician will review dietary intake. Recommendations will be made to improve nutritional status as necessary.

Based on observation, interview, and document review the facility failed to safely store medications by allowing medications to be removed from their original labeled containers, permitting loose and unidentified medications to remain in medication carts, failing to properly label medications after opening, and failing to remove expired medications from active stock on 2 of 2 medication carts observed. Findings include During an observation and interview on 6/25/26 at 4:17 p.m., registered nurse (RN)-A opened the top drawer of the medication cart. Inside the cart there were three white souffle cups filled with medications. RN-A stated she currently had three residents' medications set-up in the top drawer. RN-A put the resident room numbers on the bottom of the souffle cups, so she knew whose medications they were. RN-A stated she always set medications up in the top drawer, so they were ready to distribute if I am really busy at least it is ready for them or me to give it to them. It saves a lot of time for me. During an observation and interview on 6/26/26 at 8:13 a.m., licensed practical nurse (LPN)-B opened the medication cart and removed Refresh Tears eye drops. LPN-B stated the Refresh Tears were house stock so did not need a resident identifier on them or an open date as they were individual filled Tears. Another Refresh Tears was labeled with a resident name, however, did not have a date when the bottle was opened. LPN-B stated eye drops were good for 30 days from the date they were opened. Without the open date, LPN-B would not be able to identify if the eye drops were expired or not it is pretty full though. A lidocaine patch was loose in the top drawer, and a white souffle cup with medications were also in the top drawer. I don't know whose meds are in the top drawer. They were here when I got here, assuming from the night shift. LPN-B verified there were four white pills in the medication cup. LPN-B stated she would not be able to know who the medications belonged to or what they were. it is not good practice to do that. LPN-B stated she was going to destroy the medications. During an observation and interview on 6/26/26 at 10:17 a.m., trained medication aide (TMA)-A opened the medication cart she was working on and found one bottle of Refresh eye drops with no date. TMA-A stated the eye drops should be labeled with an open date and the expiration date. TMA-A was going to remove the eye drops from the cart and destroy them. TMA-A noted inhalers were together in the cart. inhalers should be separated out and in their own box. A bottle of Latanoprost eye drops had an open date of 4/27/26 with an expiration date of 6/8/26. Latanoprost should not have been used after the expiration date. During an interview on 6/26/26 at 10:34 a.m., assistant director of nursing (ADON) stated eye drops should not be used beyond the expiration date. Inhalers should be kept separate and in their own individual bag with the resident name on it. The pharmacy does a monthly audit and provides feedback on the medication carts. During an observation on 6/26/26 at 10:40 a.m., ADON went to LPN-B's medication cart. LPN-B verified with ADON that there was a cup of four pills in the cart when she came on-shift that she did not know who they belonged to either. ADON instructed LPN-B to open the medication cart so she could complete an audit on medications. Once the cart was opened, ADON found two Loperamide 2 milligram (mg) tablets in individual packages; 18 tablets of Tylenol 325 mg in a medication cup; Two Rosuvastatin 5 mg tablets not in packaging in top drawer; one 14 mg Nicotine patch with an expiration date of 5/28/26; 10 Bisacodyl 5 mg tablets loose in top drawer; two random individually filled eye drops; One tablet Bupropion 100 mg; One tablet Carbidopa-Levodopa 25-100 mg; One tablet Cymbalta 60 mg; ADON stated this is not acceptable, I am sick. One tablet Gabapentin 100 mg; One tablet Carbidopa-Levodopa 50-100 mg; One half tablet Sertraline 50 mg; one tablet Seroquel 25 mg; and two tablets Haloperidol unknown strength. ADON stated this was not okay, it was not evidence based or best practice. ADON stated the facility would be having a big conversation about this. ADON was going to destroy the medications that were just found loose in the top drawer of the medication cart. The facility Medication Storage in the Facility policy dated 2/2026, identified the provider pharmacy dispenses medications in containers that meet regulatory requirements. Medications are kept in these containers. Nurses may not transfer medications from one container to another or return partially used medications to the original container. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating. The nurse will check the expiration date of each medication before administering it. No expired medication will be administered to a resident. All expired medications will be removed from the active supply and destroyed in the facility.

Based on observation and interview, the facility failed to maintain a wheelchair in a clean and sanitary manner for 1 of 1 resident (R32) and ensure fans in resident rooms were kept clean for 3 of 3 residents (R2, R52 and R21) reviewed for safe, clean, comfortable, and home-like environment. Findings include:R32's face sheet received on 8/13/25, included diagnosis of Parkinson's disease (a movement disorder of the central nervous system). R32's admission Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition. R32 had unclear speech, was usually understood and could understand. R32 required substantial assistance or was dependent upon staff for activities of daily living (ADLs) and did not walk. R32's care plan did not include use of a wheelchair. During an observation on 8/11/25 at 7:18 p.m., while seated in her wheelchair at a table in the great room, observed a heavy grayish/white film over the blue brackets under and alongside R32's wheelchair. The film was hardened onto the brackets and was not able to be wiped off with a finger.During an interview on 8/12/25 at 2:08 p.m., the director of nursing (DON) stated there was not a wheelchair cleaning schedule, that staff cleaned them on a resident's bath day, and the cleaning was not documented. During an interview on 8/12/25 at 2:13 p.m., nursing assistant (NA)-E stated wheelchairs were cleaned on a resident's bath day with disposable wipes. NA-E did not know if wheelchair cleaning was documented. During an interview on 8/13/25 at 7:31 a.m., NA-C stated wheelchairs were cleaned when staff had time, or the night shift did it. NA-C was asked to look at R32's chair under the light in the hallway and stated the heavy whitish/grayish film on the surfaces of the bars alongside and under the wheelchair was from R32's food. During an interview on 8/13/25 at 7:36 a.m., licensed practical nurse (LPN)-C, who was also the care coordinator approached while speaking to NA-C. LPN-C stated R32's wheelchair was hers from her home. LPN-C stated R32 was a new resident and that was the condition of her wheelchair at the time she was admitted to the facility. R32 was admitted three months prior, on 5/13/25. During an interview on 8/14/25, at 11:05 a.m., R32 stated she was unaware her wheelchair had a film on it. The film was described to her, and she indicated she didn't know what it was from.During an interview on 8/14/25, at 11:30 a.m., the DON stated she would expect staff to notice dirty wheelchairs and clean them. Facility wheelchair cleaning policy was requested. In an email dated 8/13/25, at 5:12 p.m., the administrator indicated wheelchair cleaning would follow the residents bill of rights. DIRTY FANSR2's face sheet received on 8/13/25, included diagnosis of dementia. R2's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R2 was cognitively intact, clear speech, was able to understand and be understood.R52's face sheet received on 8/13/25, included diagnosis of dementia.R52's quarterly MDS assessment dated [DATE], indicated moderately impaired cognition, clear speech, was able to understand and be understood. R21's face sheet received on 8/13/25, included diagnoses of recurrent c. diff (clostridioides difficile - inflammation of the colon caused by bacteria), cancer of the rectum and receiving chemotherapy.R21's quarterly MDS assessment dated [DATE], indicated intact cognition, clear speech, was able to understand and be understood. R21 was ambulatory per self.R21's care plan dated 7/10/25, indicated isolation precautions related to recurrent C-diff infection.During an observation and interview on 8/11/25 at 3:18 p.m., in R2's room observed a black standing fan in operation in the corner of R2's room directed at R2's recliner where he had been sitting and where he also slept. Observed a significant amount of whitish/gray fuzzy material hanging off the front and back grates of the fan. R2 stated he had not noticed, didn't know if it had ever been cleaned and stated it should probably be cleaned, but staff were busy. During an observation and interview on 8/11/25 at 6:37 p.m., in R52's room observed a white standing fan in operation about two - three feet in front of R52's recliner where she had been sitting and where she also slept. Observed a significant amount of fuzzy whitish/gray material on the back grate of the fan and heavy dark material on edges of the fan blades. R52 stated she did not think it had ever been cleaned.During an observation on 8/12/25 at 8:40 a.m., in R21's room observed a standing white fan in operation about three feet from R21's bed as he sat on the side of the bed. The fan had a buildup of fuzzy grayish material on the front and back grates and dark material on the edges of the fan blades. R21 stated he hadn't noticed and that he thinks he brought the fan from home.During an interview and observation on 8/12/25 at 12:11 p.m., along with housekeeping manager-in-training (HM)-B and housekeeping regional supervisor (HS)-C looked at the fan in R52's room. HS-C stated housekeeping was responsible for cleaning fans, adding it was not done on a routine basis, just when housekeeping noticed them needing to be cleaned. HS-C stated they were behind on some routine work due to staffing but would make sure to address fans. Together also looked at the fans in R21 and R2's rooms. Both HM-B and HS-C acknowledged potential health concerns for residents with dirty fans blowing air in their rooms. During an interview on 8/13/25 at 8:07 a.m., registered nurse (RN)-E, who was also the assistant director of nursing and infection preventionist in training was informed of dirty fans. RN-E stated dirty fans were not good for anyone, but in particular not good for residents with allergies, respiratory issues or asthma due to the potential particles in the air getting in their respiratory tract. RN-E stated she was not aware of dirty fans and would expect housekeeping to monitor and clean the fans. Facility policy was requested for maintaining clean fans in resident rooms. On 8/13/25 at 3:33 p.m., the administrator provided a deep cleaning list that including cleaning fans, but no policy regarding regular/routine cleaning of fans.

Based on observation, interview, and document review the facility failed to identify a change in condition, comprehensively assess weight gain, monitor, and notify the physician for 1 of 1 residents (R1). As a result R1 had a total weight gain of 37 pounds over 13 days that resulted in heart attack, respiratory failure, and death. This resulted in a past non-compliance at an Immediate Jeopardy (IJ). The Immediate Jeopardy (IJ) began on [DATE] when R1 had a 7.1 pound (lb.) weight increase that was not reported to the physician nor comprehensively assessed and monitored. The Administrator and Director of Nursing (DON) were notified of the IJ on [DATE] at 5:48 p.m. The facility had implemented immediate corrective action on [DATE] to prevent recurrence, the IJ was issued at past non-compliance (PNC). Findings include: R1's face sheet dated [DATE], identified diagnoses of mild intellectual disabilities and lack of expected normal physiological development in childhood (disorder that interferes with brain development), congestive heart failure (long term condition where the heart can't pump blood well enough to meet the body's needs) (CHF), cardiomyopathy (disease of the heart muscle that makes it difficult for the heart to pump blood to other parts of the body), long QT syndrome (heart rhythm disorder that can cause fast, chaotic heartbeats), peripheral vascular disease (causes narrowing or blocking of the blood vessels outside the heart), edema (swelling caused by too much fluid trapped in the body's tissues), atrial fibrillation (irregular and fast heartbeat), hypertension (high blood pressure), and presence of automatic cardiac defibrillator (implanted device in the chest that detects and stops irregular heartbeats). R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had no cognitive impairment. R1 had no prognosis for a life expectancy of less than 6 months, did not use oxygen and weighed 248 lbs. R1's dietary care plan dated [DATE], identified R1 had alteration in cognition related to mild intellectual disabilities, included a 2 gram no added salt diet. Education provided to R1 regarding requests for large mugs of V8 juice at meals and salty snacks that he kept in his room, and R1 was angry at education provided. R1's dietary goal was to maintain current weight +/- five pounds and obtain weight per physician orders. R1's care plan did not address cardiac concerns, edema or edema management. R1's physician orders reviewed [DATE] thru [DATE] included the following orders: -[DATE], daily weights, notify physician if the weight had increased three pounds (lbs.) in one day or five lbs. in one week. - [DATE] Lasix 60 milligrams (mg) in the morning and 40 mg daily at noon. This order discontinued on [DATE]. R1's progress note dated [DATE] at 3:26 p.m., identified registered nurse (RN)-A spoke with a nurse in cardiology and informed her R1 ate salty snacks at times, the current Lasix dose was 60 mg in the a.m. and 40 mg at noon. Cardiology would check with the provider and see what can be done for testing and schedule an appointment with cardiology sooner than April. R1's cardiology communication record dated [DATE], identified R1's current dose of Lasix was 40 mg twice daily (BID) and should increase Lasix to 80 mg in the morning and 40 mg in the afternoon for three days and then resume Lasix 40 mg BID (which was inconsistent with the previous physician order and 20 mg less daily than what R1 had received since [DATE]). Update on weights requested for [DATE]. The orders also included to draw basic metabolic panel on [DATE]. A handwritten note on the bottom of this communication identified R1 was currently receiving Lasix 60 mg in a.m. and 40 mg at noon not 40 mg BID. Attempted to call cardiology five times. The handwritten note also included initials of a a nurse and was dated [DATE]. R1's record did not identify the physician order to increase the Lasix to 80 mg in the morning for three days. Review of R1's medication administration record identified R1 continued to receive Lasix 60 mg in the morning and 40 mg at noon on [DATE], [DATE], and [DATE]. R1's cardiology visit note dated [DATE], identified the facility had not received the faxed order with the updates for Lasix and basic metabolic panel (BMP) from [DATE]. A facility nurse would administer the extra dose of Lasix at noon in addition to the extra doses on [DATE] and [DATE]. BMP would be drawn on [DATE], and weights to be sent to cardiology office for review. R1's progress note dated [DATE] at 6:34 p.m., identified cardiology called and said they had new orders for R1, and to give a Lasix 20 mg at noon (to equal 60 mg for the noon dose instead of 40 mg). R1's treatment administration record (TAR) dated [DATE], directed to contact cardiology to clarify that R1 was taking Lasix 60 mg in a.m. and 40 mg at noon and should return to that dose again after the three days of taking the 80 mg in AM. Was NOT taking 40 mg BID. This was a one-time only nursing order signed by RN-B at 4:31 p.m. on [DATE]. R1's medication administration record (MAR) identified R1 was administered Lasix 80 mg in the morning and 40 mg at noon on [DATE], [DATE], [DATE], [DATE]. R1's medication administration records for January and February identified R1 was administered Lasix 40 mg twice daily from [DATE]-[DATE]. During an interview on [DATE] at 12:45 p.m., director of nursing (DON) stated upon review of R1's Lasix orders the last time R1 had an order for Lasix 40 mg twice a day was [DATE]. DON was unsure how or why the cardiologist did not have the most recent orders for Lasix 60 mg in the morning and 40 mg at noon. DON indicated the order should have been clarified because it was the last dosing used. During a return phone interview on [DATE] at 10:34 a.m., nurse practitioner (NP)-C stated she was unaware of any phone call the facility made to cardiology regarding the Lasix order decrease from 60 mg in the a.m. and 40 mg at noon to the 40 mg twice a day. R1's weight record identified -On [DATE], R1 was 247.5 lbs. This was an increase of 0.4 lbs. in one day and 10.1 lbs. in one week. -On [DATE], R1 was 255.1 lbs. This was an increase of 7.6 lbs. in one day and 8.2 lbs. in one week. R1's progress note dated [DATE] at 5:20 p.m., identified cardiology had been called (previously) for weight increase and Lasix order was updated to help with fluid. R1's weight record identified: -On [DATE], R1 was 256.2 lbs. This was a decrease of 1.1 lbs. in one day but an increase of 9.3 lbs. in one week. -On [DATE], no weight was recorded according to physician's orders. -On [DATE], no weight was recorded according to physician's orders. -On [DATE], R1 was 267.1 lbs. This was 0 lbs. change for daily and an increase of 20 lbs. in one week R1's progress note dated [DATE] at 4:53 p.m., identified NP-A was called and updated on weights. Weights have been off lately in record. Leg edema is down today, denies shortness of breath (SOB). No other assessment of edema or full respiratory assessment (oxygen saturations, respirations, lung sounds) was compelted. During an interview on [DATE] at 1:26 p.m., RN-B stated on [DATE] she thought she had casually mentioned to NP-A, while she was on the phone with her discussing another resident, that R1 was not going to bed like he was supposed to or putting his feet up in the recliner. RN-B stated R1 carried a lot of edema in the abdomen and upper thighs, and had thought they were at baseline, but could not press on his lower extremities too much because his legs were full of ulcers but had not seen any red flags. RN-B explained when someone has uncontrolled systolic heart failure, usually they decline fast. During a phone interview on [DATE] at 11:57 a.m., NP-A stated she was on-call on [DATE] (which was a weekend day) and did not receive a call from the facility regarding R1's increased weight. NP-A reviewed her call log for the day and there was not a call from the facility on the log and did not have any notes in her records of a call regarding R1. R1's weight record identified -On [DATE], R1 was 269.2 lbs. This was an increase of 2.1 lbs. in one day and 20 lbs. in one week. -On [DATE], R1 was 268.0 lbs. This was a decrease of 1.2 lbs. in one day and an increase of 20.5 lbs. in one week. R1's progress note dated [DATE] at 3:50 p.m., identified cardiology office and NP-A were notified of R1's 20.5 lbs. weight gain in one week. A list of weights and past months Lasix orders was sent to the cardiologist office. R1's physician encounter note dated [DATE], identified NP-A had a visit for wound care. Weight is up again, with a recent 20 lb. weight gain; facility reported they had a call out to cardiology. Lower extremity edema worsening. Edema was bilateral ,d+[DATE]+ edema to the pedal (foot), bilateral 2+ edema to the ankles, bilateral ,d+[DATE]+ pretibial (front lower legs and shin) edema. No new orders were noted. R1's weight record identified on [DATE], R1 weighed 264.1 lbs. This was a decrease of 3.9 lbs. in one day and increase of 9 lbs. in one week. R1's progress note dated [DATE] at 7:03 p.m., identified the nurse manager, licensed practical nurse (LPN)-A was updated on what cardiology would like and the nurse manager would speak to the director of nursing (DON). During an interview on [DATE] at 1:26 p.m., RN-B stated she received a phone call from cardiology on [DATE] asking who was in charge that could take over managing R1's fluid management. RN-B passed the information from the phone call to licensed practical nurse (LPN)-A, who was the care manager for R1. During an interview on [DATE] at 3:54 p.m., LPN-A stated RN-B told her cardiology called and wanted to talk to the DON in regard to the primary care physician taking over management of R1's care because cardiology did not see R1 often enough to write orders and monitor the effectiveness of the Lasix. LPN-A stated she wrote the information in an email to the DON, however she was on vacation until [DATE], so the facility physician was not made aware and did not take over R1's diuretic management. According to R1's weight record on [DATE], the weight was not completed per physician order. R1's progress note dated [DATE] at 3:40 p.m., identified cardiology called and set up an appointment for R1 on [DATE] at 9:00 a.m. R1's weight record identified -On [DATE], R1 weighed 265.1 lbs. This was an increase of 1 lb. and marked as not applicable (NA) for the week. - On [DATE], R1 weighed 272.2 lbs. This was an increase of 7.1 lbs. in one day and 5.1 lbs. in one week. - On [DATE], R1 weighed 270.6 lbs. This was an increase (sic) of 1.6 lbs. in one day and 5.1 lbs. increase in one week. R1's progress note dated [DATE] at 4:46 p.m., identified as nutrition review related to weight and wounds. Current weight 271 lbs. which was an increase of 27 lbs. in 30 days. Significant weight gain of 11% in 30 days. Weight gain likely related to increased bilateral lower extremity edema. Noted from NP-A's dictation on [DATE]: R1's wounds typically heal best when his weight is around 230 lbs., and he is currently significantly higher than that. R1's progress note dated [DATE] at 11:02 p.m., identified R1 had an x-ray to verify PICC line placement. Indicated stable cardiomegaly (enlarged heart) and clear lungs. R1's weight record identified on [DATE], R1 weighed 271.5 lbs. This was an increase of 0.9 lbs. in one day and 2.5 lbs. increase in one week. R1's progress note dated [DATE] at 3:33 p.m., identified R1 had been unable to urinate since 8:00 a.m. and it appeared he had only urinated 150 cubic centimeters (cc) at that time. R1 requested to go to the emergency department. Vital signs were 97.1, 51, 18, ,d+[DATE]. R1 complained of SOB with exertion and bending over at the waist. Was unable to urinate at 2:00 p.m. Discussed with medical doctor (MD)-A and recommended straight catheterization at facility first and then determine the need for emergency department. R1 was straight catheterized with some difficulty and had 450 cc's of dark yellow/orange urine with a scant amount of blood and pain but stated no pain after removal of catheter. R1 did not want to go to the emergency department anymore. MD-A recommended to bladder scan or straight catheterize R1 every 8 hours if he does not void and to continue to monitor for retention and worsening edema. R1's late progress note dated [DATE] at 10:33 a.m. for [DATE], identified for clarification: discussed with MD-A by phone about residents' inability to urinate, feeling SOB with bending at waist and the continued dependent edema surrounding entire abdomen and upper thighs, however weight had increased by only 1 lb. in one day and increased 2.5 lbs. in 7 days. During an interview on [DATE] at 1:07 p.m., RN-A stated on [DATE], R1 looked a little pale, close to baseline. RN-A also recalled R1 seemed like he was short of breath, however, he did not report shortness of breath to her. RN-A did not complete a respiratory assessment. R1 had dependent edema around his abdomen and upper thighs which seemed to be worse 2+ around those areas. Around 2:00 p.m. R1 told RN-A he was having difficulty with urinating. RN-A called MD-A and reported the difficulty with urinating and 1.2 lbs. weight gain in one day and 2.5 lbs. for the week, however, was not sure if she had told MD-A about the increase in edema and shortness of breath. During a phone interview on [DATE] at 10:19 a.m., RN-D stated when he got to work on [DATE] RN-A had straight catheterized R1 between 3:00 and 4:00 p.m. During his shift R1 had urinated just a little bit in the urinal but did not recall the amount or how the urine appeared. R1 told him he felt better. Around 6:00 p.m., R1 had asked for his inhaler for shortness of breath. R1's abdomen was slightly distended but did not look different from his baseline. RN-D did not complete a respiratory assessment, or identify the baseline of edema. During a phone interview on [DATE], RN-E stated she worked the overnight shift on [DATE]. RN-E was unaware of any issues with R1 and could not recall anything from the nurse's report that would have been concerning for R1 such as R1's recent weight gain, difficulty with urinating, and shortness of breath. If RN-E would have been aware she would have assessed respiratory, oxygen levels and edema but would not have been aware of what his baseline edema was because it was not documented. RN-E felt that if R1 had shown any signs of distress during the night, the NAs would notify her immediately. R1's weight record identified on [DATE], R1 weighed 283.2 lbs. This was identified as not applicable for both daily and week difference. R1's progress note dated [DATE], identified LPN-A informed RN-C that NP-A wanted RN-C to contact cardiology regarding R1's fluid overload. Cardiology updated at 8:45 a.m. regarding the weight gain (which had been 20 lbs. in the past 7 days and 11.7 lbs. increase since [DATE]). RN-C informed cardiology R1 had symptoms of SOB and generalized edema. Cardiology would pass the information on to the physician but stated it would be faster to get an order from NP-A to have R1 sent to the emergency department. R1's physician encounter note dated [DATE], identified the visit was for follow-up wound care. Weight had increased 11.7 lbs. since the previous day. R1 complained of increased SOB and was wearing supplemental oxygen. R1 had increased edema in abdomen and legs from thigh to toes. NP-A felt that R1 needed to be seen in the emergency department for aggressive diuresis. Also to note, cardiology had called the facility on [DATE] and had requested that R1's primary care physician take over the management of his diuretics due to them not seeing him enough and the primary care physicians more frequent visits. Physician was not contacted or aware of this request. There is also a concern that a provider was not called on [DATE] when R1's weight went from 265.1 lbs. to 272.2 lbs. Exam of pulmonary R1 at baseline had no respiratory distress and normal respiratory rhythm and effort. Currently on supplemental oxygen 6 liters per minute and was at 99%. When oxygen was decreased to 1 LPM, R1 began to have respiratory distress. Abdomen was distended due to fluid retention and was hard to the touch. Peripheral edema present, edema into bilateral thighs 3+, edema in abdomen. Bilateral 3+ edema to pedal, bilateral 2+ edema to the ankles, bilateral ,d+[DATE]+ pretibial. Review of R1's record between [DATE] through [DATE], identified R1 had gained 35.7 lbs. in 20 days. Although cardiology had been notified on [DATE], [DATE], [DATE], and [DATE], there was no indication the physician order was followed to notify the physician when R1's weight had increased by three lbs. in one day or five lbs. in one week. Further not evident the facility reconciled and/or clarified the Lasix order given by cardiology on [DATE], that directed to give R1 20 mg less a day even though R1 continued to gain weight. Further there was no indication of ongoing assessments and monitoring of edema and respiratory status were completed. R1's hospital discharge summary dated [DATE], identified on [DATE], R1 presented to the emergency department for weight gain and concern for heart failure exacerbation. While enroute from facility with ambulance R1 was talking without complaint and suddenly complained of dyspnea (difficulty breathing) and became unresponsive. Upon arrival to the emergency department, R1 was unresponsive, found to be in pulseless electrical activity (PEA) arrest, required intubation (tube inserted into trachea to assist with breathing), received one heart shock with achievement of return of spontaneous circulation (ROSC). R1 was transferred to a higher level of care for further management. On [DATE], R1 was extubated (tube removed that assisted with breathing) and was using 3 liters of oxygen via nasal cannula. On [DATE], R1 developed acute hypoxic (not enough oxygen or too much carbon dioxide in the body) and hypercapnic (too much carbon dioxide in the blood) respiratory failure. On [DATE], R1's urine output dropped and concerns for renal (kidney) failure began. R1 passed away at 6:45 p.m. During an interview on [DATE] at 8:57 a.m., nursing assistant (NA)-B stated R1 had been an assist of two people with a walker for transfers, but the staff had started using a mechanical standing lift for the last while (NA-B could not recall dates) because he required more assistance. NA-B did not recall R1 ever using his oxygen that was kept in the room. NA-B did not think R1 had ever been short of breath when she would care for him. R1 was a daily weight, and the nurses kept mentioning how his weight was going up. NA-B was unaware if weights increased or decreased and would just give the nurse a handwritten list of the weights requested each day. It was the nurses who would identify differences in the weights. During an interview on [DATE] at 9:04 a.m., NA-C did not recall R1 ever using his oxygen and could not recall him being SOB. During an interview on [DATE] at 9:12 a.m., RN-A stated at the beginning of January R1 weighed around 237 lbs. and then by [DATE] had a major weight gain he was 264 lbs. RN-A recalled R1 getting additional Lasix doses but could not remember what days that occurred. Cardiology was notified about R1 on either [DATE] or [DATE] about his 20 lb. weight gain. RN-A thought she notified cardiology on [DATE] but knew she had told NP-A in-person while she was at facility. R1 always said he was not short of breath however, he seemed to be moving slower, his respirations would be between ,d+[DATE] when RN-A would check it. His vital signs were fine every time they were checked. R1 did have oxygen in his room but his saturations were always ,d+[DATE]% (within normal limits) on room air. The oxygen was as needed mostly at night if he was laying down, which he seldom did. RN-A did not endorse assessing lungs and edema as part of her assessment. During an interview on [DATE] at 3:54 p.m., LPN-A stated on [DATE], she was in R1's room with NP-A completing wound rounds on R1. LPN-A did not notice R1's shirt being tight on him. The edema was up to his thighs. NP-A told LPN-A that R1 should be sent to the emergency department. LPN-A stated floor nurses monitored lung sounds episodically. Towards the end they should have been monitoring R1 more closely. The nurses should monitor lung sounds, difficulty breathing because the lungs could fill with fluid, blood pressure, vital signs in general should be done, monitored for edema full body such as face, hands, and abdomen and report to the physician. During an interview on [DATE] at 4:05 p.m., NP-A was not aware that cardiology requested the primary care provider take over management of R1's diuretics until after R1 was sent to the hospital when she read the progress note from [DATE]. NP-A stated R1's legs and abdomen on [DATE] were huge. R1 could not fit his shirt over his abdomen. R1 had his oxygen on at 6 liters per minute and told NP-A he put the oxygen on himself and turned the oxygen liters up until he could feel the air. R1 had been on daily weights Notification was to be made to cardiology if the weight had increased three pounds in one day or five pounds in one week. Cardiology had overseen the adjustment of diuretics and facility was encouraged to notify cardiology, not R1's primary care physicians regarding the weights. The whole point of the facility calling to notify of weight increases was so intervention could happen to prevent hospitalization . The facility failed to notify us not once, but twice with two significant weight jumps. NP-A felt that if they had been notified, they could have prevented hospitalization , given R1 more time, if they would have known sooner, and he may not have died . NP-A felt this weight increase led to R1's exacerbation of heart failure, pulmonary edema, and ultimately, for him it led to his cardiac arrest and death. During an interview on [DATE] at 11:59 a.m., medical doctor (MD)-A stated she was unaware cardiology wanted to have them take over R1's heart failure and medication adjustments. MD-A stated RN-A called her on [DATE] and told her R1's abdomen had been a little firm from the bladder but could not recall an update about a significant weight increase. R1 wanted to go to the emergency department to get straight catheterized but they could do that at the facility and MD-A told RN-A to straight catheterize R1. RN-A called back and reported R1 was straight catheterized and the amount she was able to get out. At that point, R1 did not want to go to the hospital. MD-A was not aware that R1 had felt short of breath (SOB) with bending, had dependent edema around abdomen and upper thighs, but was aware of the 1.2 lbs. weight gain in one day. During an interview on [DATE] at 11:50 a.m., MD-A stated that daily weights were ordered to monitor weight gain in heart failure patients so they can avoid heart failure exacerbations because by the time the patient shows symptoms of SOB or edema it might be too far gone, and they would have to go to the hospital. That is why they have it in the orders to notify of a weight increase of two lbs in one day or five lbs in one week, to catch the more gradual increase and get an overall assessment from the facility. Each patient is different, and some patients change quickly and some change gradually over time and we want to monitor both. First line the facility should notify us of a patient with increased weight. Residents with a weight increase that have CHF could go into heart failure and require hospitalization and it could lead to death. During an interview on [DATE] at 12:46 p.m., DON stated she would expect the nurses to call the physician to update for weight increases. The nurses should look at the whole picture and not just what the weight gain was within the week because it could be up one-to-two lbs here and there not requiring an intervention and then boom, at the end of the month the resident is up 12 lbs and in CHF overload. At 4:17 p.m., DON stated if she saw a weight gain, she would want edema, oxygen levels, and lung sounds checked. They should be charted in a progress note and in the TAR. During a return phone interview on [DATE] at 10:34 a.m., NP-C stated cardiology was getting inconsistent weights from the facility. R1 was the type of person that did not complain and would be up 20 lbs. in weight and would say he was fine. That is why it would have been better for someone to see him in-house that could look at R1 and see how he was doing. Cardiology requested MD-A take over the day-to-day care of R1's diuretic management. NP-C would expect the facility to monitor edema that would include where it was and how much he had. The facility weight policy dated [DATE], identified at the discretion of the interdisciplinary team and/or physician, residents at high risk may be continued on more frequent weight monitoring. The registered dietician shall review residents who trigger for significant weight gain or loss. Significant is defined as a person with 5% weight change over 30 days, 7.5% weight change over 90 days, or 10% weight change over 180 days. The interdisciplinary team shall review weights for significant weight changes and will be discussed to determine individualized care plan interventions and documented in the electronic medical record. The facility notification of changes policy dated ,d+[DATE], identified changed in a residents condition or treatment be shared with the resident and/or resident representative, and reported to the attending physician or delegate. Nurses and other care staff are educated to identify changes in a residents status and define changes that require notification of the resident and/or their representative, and the residents physician, to ensure best outcomes of care for the resident. The past non-compliance IJ that began on [DATE], was removed on [DATE] when it was verified the facility implemented the following: 1) New process for daily weights which included updating all daily weight orders to include what the daily weight was, the difference between that weight and the prior days weight, what the seven day look back period was. 2) Reviewed all the residents with daily weight orders on [DATE]. 3) Added another level to the morning meeting and review weights from the previous day on [DATE]. 4) Education to NA's that weights are collected prior to breakfast on [DATE]. 5) Educated nurses on daily weight process, documentation, reporting changes on [DATE]. 6) Educated leadership team on the whole process on [DATE]. 7) Education that anytime a change of condition is identified the physician is notified on [DATE]. 8) Updated care plans to reflect edema monitoring on [DATE].

Based on observation, interview, and document review the facility failed to follow the care plan for safe transfers for a full body mechanical lift for 1 of 3 residents (R1) who required lifts for transfers. The facility's failures resulted in harm when R1 fell out of the lift and sustained subgaleal hematoma (bleeding between the skull and the scalp) and head laceration that required three staples. The facility implemented immediate corrective actions prior to survey and is issued at past non-compliance. Findings include: R1's face sheet dated 10/16/24, identified R1 had diagnoses that included traumatic brain injury (head injury causing damage to the brain by external force or mechanism), dementia (deterioration of memory, language, and other thinking abilities), bipolar disorder (serious mental illness characterized by extreme mood swings), and presence of cerebrospinal fluid drainage device (used when the normal flow of cerebrospinal fluid in the brain is obstructed). R1's quarterly (MDS) dated [DATE], identified R1 did not have cognitive impairment. R1 was dependent for transfers, required maximum assist with cares, and R1 did not have behaviors. R1's care plan dated 7/22/22, identified R1 required the full body mechanical lift with assistance from two staff for transfers. R1's care plan dated 11/16/18, identified R1 had issues with mood and behavior that included name calling, yelling, calling out, using profanities, and refusing to allow staff to complete tasks. Interventions included encouraging resident to call family, monitoring target behaviors, putting on favorite radio station, word searches, reading car/tractor magazines, offered a warm blanket, being alert to mood, and behavior changes, using a kind, and firm approach, approach in a calm voice making eye contact and using therapeutic touch, validate feelings, provide emotional support. R1's progress note dated 10/13/24 at 8:30 p.m., identified R1 was on the floor and bumped his head. R1 had a 1-centimeter (cm) x 2.0 cm gash like area. Nurse applied dressing to site and R1 was resistive to cares. The note did not identify why R1 was on the floor. R1's emergency department after visit summary dated 10/14/24, identified the reason for the visit was fall, and laceration to head. R1 had a computed tomography (CT) completed on his head. The results identified a posterior vertex scalp [area between mid-scalp and crow] and subgaleal hematoma that required three staples to the site. R1's progress note dated 10/14/24 at 9:26 a.m., identified R1 returned from the emergency department with three staples to the back of his head. R1's Incident Review and Analysis report dated 10/14/24, identified the causal factor for the fall was R1 was agitated and moving around when nursing assistant (NA)-A attempted to transfer R1 off the commode (portable toilet). Interventions included all staff education related to lifts and safe transfers. The incident report identified R1 was transferred with one assist and R1 was to have two assist for all transfers. During an observation and interview on 10/16/24 at 10:36 a.m., R1 was sitting in his wheelchair looking out the window. R1 had 3 staples in the back of his head with dried red substance surrounding staples. R1 stated that transfer was poor operation, it was just one person and I damn near got killed in this room. R1 stated NA-A put the sling around him and transferred him without help. R1 stated this was the only time he was ever transferred with only one staff member. R1 could not recollect how far into the transfer they were when the fall occurred or what had happened that caused him to fall out of the sling. During a phone interview on 10/16/24 at 2:59 p.m., NA-A explained she was a contracted staff member and could not recall what date her first shift was, but that it was recent. On her first shift, NA-C had showed her around one of the units, how residents transferred on that unit, and where supplies were kept. NA-A indicated the orientation at this facility did not include compentency for lifts, however has used that brand of lifts at other facilities. On 10/13/24 she had been covering NA-B's hallway while she was on break but NA-B had not told her how resident's transferred on that hallway. NA-A stated when NA-B was on break R1 turned on his call light and went to answer it. When NA-A entered R1's room he was sitting on the commode yelling his back hurt and wanted to get off the commode. NA-A asked R1 if he could wait but he continued to yell that he wanted to go to his bed. Because R1 was yelling she decided she would transfer him. NA-A placed the full body mechanical lift sling underneath R1, attached the sling to the lift, and began lifting R1 even though R1 continued to display behaviors. While R1 was suspended in the air, R1 continued to yell and move his body around while in the sling. NA-A asked R1 to calm down, to stop yelling, and stop moving around but R1 did not listen. He slipped out of the sling and fell to the floor. NA-A stated she was unaware that R1 required two people to transfer and thought R1 was assist of one because NA-B said R1 could go to bed prior to going on her break. NA-A did not ask the nurse or other staff for help with the transfer. During an interview on 10/16/24 at 4:01 p.m., NA-C stated she worked with NA-A on her first day at facility but could not recall the date. NA-C explained she had been in a hurry that evening because she was leaving early so she only orientated NA-A to the building and where to find supplies. NA-C showed NA-A how to use a full body mechanical lift because she had never used one before at the facility and thought she had told NA-A she had to always use two staff to transfer residents with those lifts. NA-C stated most of the residents down the hall they were working on the evening of NA-A's first day required full body mechanical lifts however, NA-A had not assisted with a lot of those transfers. NA-A assisted the residents who only required one assist. During a phone interview on 10/16/24 at 1:30 p.m., NA-B stated NA-A came from a different hall to relieve her while she took her break on 10/13/24. R1 had his fall while she was on her break. There were two other NA's working on the other halls that were supposed to be called for transfers and/or licensed practical nurse (LPN)-A who was passing medications. During a phone interview on 10/16/24 at 1:14 p.m., LPN-A stated the evening of 10/13/24, NA-A asked her to go to R1's room. R1 was on the floor and the mechanical lift sling was attached to the machine, not on R1. NA-A told LPN-A R1 was wiggling and yelling and fell to the floor. LPN-A stated it took a long time to get R1 off the floor because he continued to yell and make demands do this, do that, give me this. LPN-A told NA-A that two people were required for full body mechanical lift transfers. NA-A had told LPN-A she was unaware of that. LPN-A stated it was very well known that full body mechanical lifts always required two staff to transfer. During a record review on 10/16/24 at 12:16 p.m., administrator sent an email identifying that the facility was unable to locate NA-A's orientation packet. Administrator provided a blank copy of what the orientation packet was, which included a competency for mechanical lifts. In a follow-up email dated 10/22/24, NA-A's first day of work at the facility on the floor was 9/29/24. During an interview on 10/17/24 at 9:16 a.m., director of nursing (DON) stated she had reviewed NA-A's completed orientation packet but was not aware of the date she had reviewed, and was not sure where the completed packet was. DON explained R1 had not had behaviors while utilizing the mechanical lift prior to the incident on 10/13/24. DON questioned if R1's diagnosis of pneumonia contributed to the behavior exhibited on 10/13/24. During an interview on 10/17/24 at 11:48 a.m., with administrator and DON, DON indicated NA-A should have called for assistance and waited for assistance prior to transferring R1 by herself on 10/13/24. The staff were expected to use two staff with full body mechanical lifts transfers. DON expected all orientation packets to be completed prior to working on the floor independently. Administrator and DON indicated the following had been implemented as a result of R1's fall prior to the survey: -NA-A was suspended pending investigation on 10/13/24, -Facility-wide education with competencies on mechanical lifts began 10/14/24. -Machine used for the transfer was locked out on 10/13/24 and inspected by facility maintenance department between 10/14/24-10/15/24, along with manufacturer inspection of all mechanical lifts at the facility the week of 10/20/24. -Identification of the system breakdown for orientation of new hires and agency staff on 10/14/24 with an ad hoc meeting attended by DON, Administrator, and nurse scheduler. -R1's care plan was updated to reflect trauma/risk of trauma from the fall from the lift. -R1's orders were updated to include treatment to head wound, monitoring of site for infection, monitoring for signs and symptoms of emotional distress, skin assessment, cognition, depression screening, and trauma questionnaires completed on 10/14/24, and on-going as needed. -Social services followed-up with R1 daily 10/14-10/16/24. EZ-Way Smart Lift Operators Instructions included: -For safe operation of the EZ Way Smart Lift, operators should watch the training video, read through this manual, complete competency checklist, and practice on fell ow staff members before use with patients. -The EZ Way Smart Lift was designed to be operated safely by one caregiver. However, depending on the situation, facility policy, and the patients condition, two caregivers maybe necessary. The food and drug administration (FDA) patient lifts safety guide identifies the use of a lift should be avoided if a patient is agitated, resistive, or combative, determine how many caregivers are required to safely lift the patient. Ensure patient is able to understand and follow directions. The facility Safe Resident Handling Program dated 3/20, identified training will be provided to direct care staff to demonstrate proper application and use of available safe patient handling equipment. Training records will be maintained and include dates of training, name and title of person conducting the training, name, and job title of employee. The records will be maintained in the employee's file. The facility Care Planning policy dated 1/6/22, identified the care plan will identify problem areas and their causes, and develop interventions that are targeted and meaningful to the resident.

Based on observation, interview, and record review the facility failed to develop a person centered comprehensive care plan was developed for 1 of 3 residents (R1) who requested no male caregivers provide care. Findings include: R1's face sheet dated 8/28/24, identified R1 had an admitted in July 2024 with diagnoses of depression, major depressive disorder, social phobia, and anxiety disorder. R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 did not have cognitive impairment. R1 required two-person physical assist with dressing and grooming, and required a total mechanical lift and two assist to transfer from one location to another. During an interview on 8/27/24 at 1:52 p.m., registered nurse (RN)-A stated he completed R1's admission assessments. During that process R1 had brought up the history of sexual abuse; RN-A immediately initiated no male caregivers to provide cares. RN-A explained he did not add the history and R1's preferences to the care plan, did not document in a progress note, and did not complete the trauma assessment. RN-A stated he only reported the information during shift to shift report. During an interview on 8/27/24 at 10:17 a.m., R1 stated Since I came to the facility, I told them [staff] about being molested and that I did not want male caregivers. During an interview on 8/28/24 at 9:46 a.m., family member (FM)-A stated R1 was always upfront with facilities and told them about the sexual trauma in her past. During an interview on 8/27/24 at 10:09 a.m., nursing assistant (NA)-A indicated R1 made it known that she did not want male care givers providing personal care since she was admitted to the facility. NA-A stated R1 had told her she had been sexually molested as a child shortly after she was admitted to the facility. During a phone interview on 8/27/24 at 12:07 p.m., NA-D stated since R1 was admitted to the facility she was only to have females for personal cares. NA-D stated R1 had been fine with a males helping transfer as long as her peri area was covered. NA-D stated R1's preferences not to have male care givers was passed down during shift to shift report. During an interview on 8/28/24 at 8:23 a.m., NA-B indicated since R1 was admitted she only could have females complete personal cares because she was sexual abused. During an interview on 8/28/24 at 9:01 a.m., RN-B stated R1 did not like male caregivers and does not want them to perform cares on her. R1's clinic visit note dated 8/27/24, identified R1 had an incident on 8/25/24 in which staff inappropriately touched her. R1 had a history of sexual abuse from her father that R1 continued to have trauma from, and current incident was making it hard to sleep at night. Although mulitple staff had awareness of R1's preferences, her care plan was not revised until 8/26/24, after R1 reported an allegation of a male nursing assistant inappropriately touched her on 8/25/24. R1's care plan dated 8/26/24, included R1 was at risk for alterations in behavior related to (r/t) trauma including self-reported history of being molested. Interventions included to speak clearly and explain steps to the cares being provided, female staff only for peri-cares, two staff present during all cares, medication pass, and treatments, psychologist referral, staff will utilize trauma informed care when working with resident, encourage collaboration with therapeutic recreation and social services to improve social connections and minimize symptomology. During an interview on 8/28/24 at 12:06 p.m., administrator in training (AIT)-A stated nurses were expected to communicate with the nurse manager or adjust the care plan as needed and bring the discussion to the interdisciplinary meeting. AIT-A stated R1 did not report sexual trauma during the admission trauma questionnaire. The facility care planning policy revised 1/6/22, identified each resident will have a person-centered care plan developed by the interdisciplinary team (IDT) for the purpose of meeting the residents individual medical, physical, psychosocial, and functional needs. The baseline care plan will be developed within 48 hours of admission. The IDT, in conjunction with the resident and the resident representative, will develop and implement a comprehensive individualized care plan no later than the 21st day after admission for the resident. The trauma informed care policy revised 2/24/23, identified staff will identify history of trauma when possible, residents with a history of trauma will have goals and interventions added to the care plan to address potential triggers and approaches to minimize or eliminate the effect of the trigger on the resident. Care plans will be updated as needed.

Based on observation, interview, and record review the facility failed to ensure an allegation of staff to resident sexual abuse was reported to the State Agency (SA) within two hours for 1 of 1 resident (R1) who reported a male staff member inappropriately touched her. Findings include: R1's face sheet dated 8/28/24, identified R1 had diagnoses of depression, major depressive disorder, social phobia, and anxiety disorder. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 did not have cognitive impairment. R1 required two-person physical assist with dressing and grooming, and required a total mechanical lift and two assist to transfer from one location to another. R1's Vulnerable Adult Maltreatment Report submitted to the State Agency on 8/26/24, identified notification of R1's accusation of sexual assault by a staff member that occurred on 8/25/24. R1 had been at the emergency room earlier in the day for a dislodged catheter after the sexual assault occurred. Facility was instructed to have two people for all cares, call police, and report incident. R1's clinic visit note dated 8/27/24, identified R1 had an incident on 8/25/24 in which staff inappropriately touched her. R1 had a history of sexual abuse from her father that R1 continued to have trauma from, and current incident was making it hard to sleep at night. During an interview on 8/27/24 at 10:17 a.m., R1 stated on 8/25/24, a male aide came up behind her and pulled her brief down while she was using the mechanical lift and ran his fingers across her butt-cheeks. He said he was sorry, and she told him to leave. Since I came to the facility, I told them about being molested and that I don't want men around me in that position. During an interview on 8/27/24 at 3:49 p.m., licensed practical nurse (LPN)-A stated she went to R1's room on 8/25/24 at approximately 9:00 a.m. to change R1's catheter. Upon entering the room R1 was visibly shaking and crying. R1 reported to LPN-A a male aide pulled her brief from behind her and ripped it out then put his fingers on that area and caressed her peri area. LPN-A immediately notified the LPN-B supervisor and was in R1's room while R1 gave the same statement to the LPN supervisor. LPN-A stated LPN-B took over the investigation and determined which male aide R1 had been talking about. LPN-A indicated while all that was going on R1 was sent to the emergency room for problems with her urinary catheter. LPN-B had left her a note on her computer to call R1's power of attorney and the physician. LPN-A explained the POA had already been to the facility and was made aware by R1, LPN-A called the nurse practitioner (NP) who told her to call the police and offer emergency room for further evaluation. LPN-A notified LPN-B of NP's orders to which LPN-B directed her not to call the police and not to tell the emergency department of the allegation until after she talked to the administrator. LPN-A stated she did not call the police as directed and was not aware if the police had been notified. LPN-B was called on 8/28/24 at 11:54 a.m., however the call was not answered, a message was left with no return phone call. During a phone interview on 8/27/24 at 11:20 a.m., NP-A stated LPN-A called approximately 3:15 p.m., on 8/25/24, LPN-A reported R1 had been sexually abused by a male staff who yanked her brief off forcibly and rubbed his fingers on her behind. NP-A told LPN-A to call and notify the police and offer R1 emergency department services. NP-A indicated later that evening she had followed-up with the police, the police informed her that a report had not been filed so she informed the police of R1's allegations. During an interview on 8/27/24 at 2:28 p.m. Administrator, DON, and Administrator in Training (AT)-A had been notified via phone by the LPN-B of the allegation however LPN-B had reported R1 did not report the incident as abuse or assault in nature. Administrator stated R1 was questioned and stated, he ran his finger across her bottom during repositioning. Administrator felt the incident was customer service related and not reportable to the SA. During an interview on 8/27/24 at 3:21 p.m., medical director (MD)-A stated she would expect the facility to follow the protocol for reporting an incident and all incidents reported would need an investigation attached. The facility Abuse Prohibition/ Vulnerable Adult Policy revised 3/2024, identified the purpose was to protect residents against abuse by anyone, including, but not limited to, facility staff , to promptly report, document and investigate all incidents of alleged or suspected abuse/neglect. Suspected abuse shall be reported to Office of Health Facility Complaints (OHFC) online but not later than two hours after forming the suspicion of abuse.

Based on interview and document review, the facility failed to implement a process for antibiotic review in order to determine appropriate indications, dosage, duration, trends of antibiotic use and resistance. This had the potential to affect any residents who had infections requiring antibiotic use. Findings include: When interviewed on 6/13/24 at 8:10 a.m., the director of nursing (DON), also identified as infection preventionist, indicated the facility uses McGeer's criteria but staff are not always completing that in the medical record and stated it is a team effort to monitor symptoms between nurse managers and herself. The DON indicated she has been doing infection prevention for the past year and when she started, they didn't even have a tracking form. The DON stated she is using the Minnesota Department of Health (MDH) Infection Control Assessment and Response (ICAR) form for documentation for infections and antibiotic use. The interim DON indicated from the ICAR report, she is able to share quarterly data at quality assurance and performance improvement (QAPI) meetings, which includes the medical director and consulting pharmacist. The ICAR form included resident name, infection type, symptoms, onset date, diagnostic test performed, results, antibiotic resistant organism (yes, no), antibiotic name, dose, start and end date, transmission based precautions and date symptoms resolved. Upon review of the ICAR form for January through May 2024 the following were found incomplete: - January 2024: 27 entries present with 18 receiving antibiotics. Symptoms were present on 13 of the 27 entries. Test, type of test, results (organism and colony counts for urine) included 12 entries for rapid nasal Covid test and all 18 receiving antibiotics was blank (5 of which were urinary tract infections {UTI}). Date symptoms resolved were documented 0 of 27 entries. - February 2024: 35 entries present with 16 receiving antibiotics. Symptoms were present on 18 of 35 entries. Test, type of test, results included 15 Covid-19 rapid nasal swabs and all 16 of those receiving antibiotics was blank (2 were UTI). Date symptoms resolved were all blank. - March 2024: 36 entries present, 17 of which received antibiotics. Symptoms were present on 1 entry. Test, type of test, results included 9 entries that included RSV (respiratory syncytial virus) and influenza (flu). Of the 17 receiving antibiotics, 1 test type included culture with organism identified as staphylococcus. The other 16 were blank. Date symptoms resolved was documented on 3 of 36 entries. -April 2024: 13 entries with all receiving antibiotics. Symptoms were documented on 11 of 12 possibilities. Test type, specimen source and results were documented on 5 of 12 possibilities. Date symptoms resolved was left blank on all 13 entries. -May 2024: 21 entries, 3 of which were prophylaxis use and 20 receiving antibiotics. Symptoms were present on 17 of 18 entries. Test type, specimen source and results were documented on 12 of 17 possibilities with 4 of those documented as results not available. 8 of these were UTI's with no colony counts present. Date symptoms resolved was blank on all 21 entries. During interview on 6/13/24 at 8:30 a.m., the DON indicated nursing staff monitor resident's culture reports to make sure resident's prescribed antibiotics are the correct medication if tests are done at the facility. The DON stated she has not gotten access to the hospital electronic medical record go look up culture results for residents that were hospitalized or had testing in the emergency department. The DON confirmed she needs to follow up on all culture results to ensure the residents are on the correct antibiotic but has not currently been completing this. The DON indicated she is getting used to the ICAR documentation form and is trying to document all necessary items including symptoms resolution. The DON stated she is educating herself to bring the infection and antibiotic stewardship program to a higher level. The facility Antibiotic Stewardship Program dated 3/13/23, included: - Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. this policy is aligned with the CDC core elements of antibiotic stewardship that includes, leadership, accountability, drug expertise, action, tracking, reporting and education. -Prior to calling provider to communicate a suspected infection, the nurse will obtain and have the following information available: Signs and symptoms of suspected infection, history of present illness, current medication list, allergies, and all pertinent lab, imaging or rest results. -If a resident is admitted to the facility with orders for antibiotic therapy, the orders will be reviewed for appropriateness and completeness. Any pertinent supporting document will be reviewed and obtained for the medical record. -Appropriate indications for antibiotic use include: Criteria met for clinical definition of active infection or suspected sepsis; pathogen susceptibility, based on culture and sensitivity to antimicrobial (or treatment begun while culture is pending) and -The infection preventionist or designee will review all antibiotic orders to determine if treatment is appropriate. Treatment is appropriate if the organism is not susceptible to the antibiotic chosen. The organism is susceptible to a narrower spectrum antibiotic. Therapy was ordered for prolonged surgical prophylaxis. Therapy was started awaiting culture but not organism was isolation after 72 hours. -The provider will be notified of the review findings and recommendations and a response will be documented in the resident's medical record.

Based on observation and interview, the facility failed to ensure 4 of 5 vents in the 400 hallway, and 5 of 5 vents in 500 hallway were clean when they had a black substance present on the 3 tiered vents. This deficient practice had the potential to affect all residents, staff, and visitors on the 400 and 500 wings. In addition, the facility failed to ensure resident rooms were maintained in a clean, sanitary manner for 13 of 60 residents (R7, R163, R16, R29, R39, R57, R2, R4, R162, R260, R37, R45, R22) whose rooms and/or bathrooms lacked upkeep, and who were reviewed for environment. Findings include: Hallway Vents During an observation on 6/10/24 at 3:29 p.m., the 500 unit hallway was observed to have five vents that had a black substance present on the rungs of the 3 tired vents. The maintenance director (MD)-A indicated it appears like dust buildup and the vents need to be taken down and cleaned. MD-A added it likely due to moisture after starting the air conditioning units causing the dirt to stick. MD-A indicated housekeeping staff are responsible to clean the vents using a duster which he thought was weekly. MD-A indicated he has not taken down and cleaned the vents since he started at this facility a few years ago. During interview and observation 6/10/24 at 4:06 p.m., MD-B indicated the vents have dirt and dust present and was not sure if it was mold or not. During interview on 6/10/24 at 3:45 p.m., environmental services director (EVSD)-E indicated the vents are very dirty and and when questioned if it could possibly be mold she stated yes. On 6/10/24 at 3:46 p.m., the director of nursing (DON), also identified as infection preventionist, indicated she thought the vents were covered in dirt but couldn't say for sure if it was dirt or mold. The DON indicated she would have to go ask some questions for further information. During observation and interview on 6/10/24 at 4:30 p.m., MD-A had one of the vents in hallway 500 down and was cleaning the vent with bleach. MD-A indicated the administrator instructed him to clean them. MD-A when asked if it was possible mold stated he didn't think so as it easily wiped off. During interview on 6/10/24 at 4:34 p.m., the administrator indicated maintenance staff had looked at the vents and didn't believe it was mold so she instructed them to clean the vents. The administrator indicated they have had similar issues in the past with black debris on the vents and it was determined at that time it wasn't mold. The administrator indicated she has not had any complaints of odor of mold down the hallway from staff members or residents. During interview on 6/10/24 at 5:18 p.m., MD-A indicated he looked into the air conditioning vents when taking down the vents and stated everything was clean and dry. Both MD-A and MD-B indicated the dirt/grime washed off easily and it has been likely years since the vents were taken down and cleaned. MD-B indicated housekeeping takes a dust mop to get some of the dirt off weekly, but apparently aren't getting the top tiers of the vents. During interview on 6/11/24 at 10:01 a.m., the maintenance director for the corporation (MDC)-C indicated he had looked at the vents today with MD-A and was told it was just dirt and grime present. MDC-C indicated the dust mops stir up dirt and it sticks to the vents. MDC-C indicated with mold you can't wash off with soap and water. MDC-C indicated he is 100% certain it was dirt and not mold present. During interview and observation on 6/11/24 at 11:30 a.m., EVSD-E showed dusting tool used to clean the vents. The tool had a long handle and fuzzy end that is designed to trap dirt. EVSD-E indicated the staff have a difficult time reaching the vents even with this dusting tool. Review of hallway vent cleaning schedule received 6/11/24, indicated 400 and 500 wing vents were last cleaned 1/16/24 by housekeeping. During observation on 6/13/24, down the 400 hallway, 4 of 5 vents were covered with a black substance on the top tiers of the vents. The bottom of the vents were clean. The facility Daily Cleaning Procedure undated, indicated housekeeping would empty trash, dust all high surfaces including vents and all corners, disinfect flat surfaces and high touch items, spot clean walls, clean restroom including high dust and toilet; and dust mop and damp mop the entire floor. 42073 Resident Rooms/Bathrooms/Hallways During an observation on 6/10/24 at 12:29 p.m., R7's room smelled of urine. Observed a small wastebasket next to the bed with soiled briefs open/overflowing. R7 who was lying in bed, stated she could smell the urine too and had not noticed the wastebasket with soiled briefs in it. R7 stated NA's usually removed the trash when they left the room. During an observation on 6/10/24 at 1:27 p.m., R163's toilet was heavily soiled with dark brown streaks of rust coming from under the rim and a rusty toilet bowl. During an observation on 6/10/24 at 1:49 p.m., in R16's room, the floor was dull and appeared dirty with scuff marks and shoe prints, small white paper debris on the floor, and dusty floor underneath the bed. The overbed table had gray paper stuck to it which appeared to be the bottom of a tissue box that was initially stuck to the surface and then removed, leaving gray paper residue behind. A small wastebasket was observed with soiled briefs open/overflowing. During a second observation on 6/12/24 at 2:30 p.m., R16's room was unchanged from the initial observation on 6/10/24 at 1:49 p.m., except the small wastebasket was empty. During an interview and observation on 6/10/24 at 5:11 p.m., family member (FM)-D expressed concerned about cleanliness of R29's room and pointed out dead ants on the windowsill - stating they had been there for weeks. FM-D stated the floor generally wasn't clean, the bed wasn't moved to clean under it, and a small fan in the room was usually dusty. During an observation on 6/11/24 at 8:30 a.m., in R39's room, observed three full urinals sitting on an overbed table with strong smell of urine permeating the room. Multiple white tissues on the floor, small brown piles of tobacco chew/spit on the floor, empty beverage bottles and food containers observed on flat surfaces. The floor was dull and appeared dirty with many dark scuff marks. During an observation on 6/11/24 at 10:03 a.m., while standing in the hallway near R57's room with the door ajar about three inches, the stench of urine permeated the hallway. During an observation on 6/11/24 at 10:14 a.m., R57's floor was sticky. Surveyor shoes were tacky when walking in or near R57's room. A strong odor of urine permeated room R57's room; bed linens were stained yellow/brown when R57 got out of bed. During an observation on 6/12/24 at 7:09 a.m., on the wall of a short hallway leading to the resident shower room on the 200 wing, were multiple, horizontal areas above and below the chair railing where paint had been scraped off. Further, below the chair rail -- the wall appeared darker with dirt or dust, and had other small nicks of paint. During an observation on 6/12/24 at 07:37 a.m., observed the call light above R39's room was missing the white cover over the light on the outside of the door, above the door frame. The cover helps to illuminate he light to see it from a distance. During an observation on 6/12/24 at 9:45 a.m., observed a potential trip hazard on the floor near the main entrance reception desk. Metal strips were between flooring types, and the middle of the three metal strips, each about three feet long and about four inches wide -- was lifting on both ends. During an interview on 6/12/24 at 10:27 a.m., R39 stated he notified nursing assistants (NAs) when his urinals were full as they were too busy to empty them after each use. R39 stated housekeeping had tried to get the scuff marks off his floor the day before. R39 stated the facility was short housekeepers so he only had them clean his room once a week. During observations on 6/13/24 at 8:15 a.m., observed rusty toilet bowls in the following rooms: --R2, toilet bowl was stained rust colored and the ceiling exhaust vent had thick, gray debris on the slats. --R4, toilet bowl was stained rust colored and ceiling exhaust vent in the bathroom had fuzzy gray debris on the slats. During an observation on 6/13/24 at 9:44 a.m., the following rooms had approximately eight inches by five inch sections of the wall where a previous wall-mounted hand sanitizer dispenser had been, which were unpatched and unpainted: R260, R27, R45, R35, R39, R22, and R57. INTERVIEWS During an interview on 6/11/24 at 10:57 a.m., with environmental services director (EVSD)-E (who had oversight over several long-term care facilities in the city) and corporate director of operations (DOO)-F for EVS, EVSD-E stated a housekeeper was expected to clean every resident room, every day. If not able to get to all the rooms, housekeepers let EVSD-E know and if she was not able to get to those rooms, housekeeping staff would do those rooms first thing the next day. EVSD-E stated the expectations of a housekeeper included cleaning the bathroom, walls, mirror, restock paper towels, empty trash, move beds and clean underneath; everything should be clean and odor-free. EVSD-E stated in a perfect world, three full-time and two part-time housekeepers would be able to accomplish cleaning every room, every day, but the facility was short two housekeepers. EVSD-E stated they had been interviewing and hiring -- looking at pay and offering a bonus. Some potential candidates scheduled for an interview had not shown up; some new hires started but quit right away. EVSD-D stated one resident in particular -- R39 -- would only allow housekeeping into his room once a week. EVSD-E stated R39's room took a good 20 minutes to clean .housekeeping had to clean up chew/spit off the floor; that R39 didn't bathe, and his room smelled awful. EVSD-E was informed of rusty toilets in various rooms in the facility and stated she was aware of it and aware some had been approved for replacement. During an interview on 6/11/24 at 11:59 a.m., NA-B stated when NA's changed a residents brief, they were to place the soiled brief in the wastebasket and then remove the garbage bag from the room upon exiting. NA-B stated staff were expected to do this even if there was only one soiled brief in the wastebasket. NA-B stated staff removed soiled briefs right away so rooms wouldn't smell of urine or feces. During an interview on 6/11/24 at 2:56 p.m., EVSD-E stated two EVS directors from other facilities were coming 6/12/24, to help catch up with resident room cleaning. During an interview on 6/12/24 at 7:33 a.m., EVSD-E, stated once she was informed of the condition of some resident room, started cleaning rooms herself on 6/11/24. EVSD-E stated due to workload, she had not been able to monitor the performance of the housekeepers and stated in the past, managers had been assigned to monitor cleanliness of rooms, but that was no longer the case. During an interview on 6/12/24 at 1:09 p.m., EVSD-E stated she will have a meeting with her staff to talk about expectations, adding, I thought they were doing better. During an interview on 6/13/24 at 8:28 p.m., with maintenance director (MD)-A, MD-A was aware of the rust-stained toilet in room [ROOM NUMBER] and stated it was on his list to replace. MD-A was aware of rust stains in toilet bowls of other resident toilets and stated he had started to replace some on them on the 200 wing. MD-A was reminded rusty toilets had been cited two years ago but MD-A was not able to say what the plan had been at that time to improve the condition of resident toilets. With MD-A, looked at the metal floor strip that was lifting by the main reception desk, and the missing call light cover outside of R39's room MD-A had not noticed the metal strip lifting and would fix that. MD-A stated he had ordered call light covers and would replace it. Together, looked at resident rooms where patching and painting had not been completed after changing hand hygiene dispensers. MD-A stated he was not working the day the dispensers were switched out and couldn't recall how long ago it had been done. Together also looked at the areas of scraped paint in the short hallway on the 200 wing and MD-A stated he was aware of that. During an interview on 6/13/24 at 10:06 a.m., with MD-B, asked about the facility plan after the State survey two years ago for improving the condition of resident toilets. MD-B stated MD-A had a list of toilets to be replaced; she didn't know where the list was and stated they do what they can, when they can -- there was no set schedule to replace the rust-stained toilets. MD-B stated, 100% - the toilets look terrible. MD-B did not recall how long ago hand sanitizer dispensers had been changed out -- that the maintenance department had started to patch and paint, then heard all the rooms were going to be repainted eventually, so didn't continue. During an interview on 6/13/24 at 10:43 a.m., the administrator stated lack of staff was prohibiting them from adequately cleaning resident rooms and added they have had performance issues with some housekeepers. The administrator stated managers used to do room cleanliness audits, but that stopped and they would be taking a different approach to doing that. The administrator was informed of other findings including rusty toilets, paint missing from walls in resident rooms and a hallway, and the condition R36's room. The administrator was aware of R36 refusing to allow staff to clean his room and stated they have tried having various staff talk to him -- adding, it has been a struggle finding what would work for him. Facility policy on room repair and maintenance was requested and the administrator indicated there was no policy. The facility Daily Cleaning Procedure undated, indicated housekeeping would empty trash, dust all high surfaces including vents and all corners, disinfect flat surfaces and high touch items, spot clean walls, clean restroom including high dust and toilet; and dust mop and damp mop the entire floor.

Based on observation and interview the facility failed to ensure a mechanical transfer lift was cleaned after resident use for 3 of 3 residents (R9, R45, R26) and that appropriate sanitizer was used to clean the lift observed for infection control practices. Findings Include: R9's Face Sheet printed 6/13/24, included diagnoses of obesity, bipolar disorder, difficulty in walking and unsteadiness on feet. R9's significant change Minimum Data Set (MDS) dated [DATE], indicated R9 was dependent on staff for all transfers and required assist of 2 and a lift. During observation on 6/11/24 at 3:36 p.m., nursing assistant (NA)-E and NA-F with the assist of a mechanical lift (device utilized for transfer) transferred R9 from her bed to her wheelchair. NA-F removed the lift from the room and moved it to another hallway and parked it in room [ROOM NUMBER]. NA-F left the room. NA-F confirmed he did not clean the lift and should have. During observation on 6/13/24 at 8:39 a.m., NA-A was observed in R45's room cleaning a hoyer lift. NA-A was observed using Mckessen Stay Dry disposable washcloths. NA-A confirmed he was using resident wipes and should have been using disinfectant wipes. NA-A indicated they were told not to use bleach wipes anymore as it was staining residents clothing and all he could not find anything but bleach wipes. 50761 R26's MDS dated [DATE], included diagnoses for traumatic brain injury, dementia, and hip fracture. MDS indicated R26 used wheelchair. MDS indicated R26 was dependent on staff for transfers. During observation on 6/12/24 at 8:03 a.m., NA-A exited R26's room with a mechanical lift. NA-A placed the lift in an empty room and failed to disinfect the lift. On 6/12/24 at 8:05 a.m., NA-A confirmed the lift was not disinfected and stated the lift was expected to be cleaned after use. NA-A stated he was not aware of the policy for cleaning resident lifts. NA-A stated the lift was used for multiple residents and that's why we should be cleaning it. During interview on 6/13/24 at 8:18 a.m., the director of nursing (DON) confirmed lifts should be cleaned after use and before placing them in a hallway or empty room. The DON confirmed resident wipes are not sanitizing wipes and are not appropriate for cleaning a patient lift. The DON indicated they had just completed training with staff to talk about bleach and non-bleach wipes and necessary contact time. The facility Infection Prevention and Control Program policy dated 3/13/23 included: - Important facets of infection prevention include: -Identifying possible infections or potential complications of existing infections; -instituting measures to avoid complications or dissemination; -enhancing screening for possible significant pathogens; -immunizing residents and staff to try to prevent illness; -implementing appropriate isolation precautions, when necessary; -following established [NAME] and disease-specific guidelines such as those of the Centers for Disease Control.

Based on observation, interview, and document review, the facility failed to ensure staff were educated and following the fall risk interventions for 1 of 2 residents (R42) identified at risk for falls to prevent further falls. Findings include: R42's Face Sheet printed 6/13/24, indicated R42 had diagnoses of age related cognitive decline, disorientation, obstructive and reflux uropathy (blockage of urine flow), Epilepsy (seizures) and Parkinson's disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves). R42's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R42 had a moderate cognitive impairment, had inattention behavior continuously present, and behaviors of rejection of care that occurred 4-6 days out of 7. Activities of daily living (ADL's) included R42 uses a wheelchair and dependent on staff to wheel 50 feet, has impairment on both side of lower extremities for range of motion and requires substantial to maximal assist for transfers, bed mobility, toileting and personal hygiene. Eating requires setup or clean up assist. R42's Care Area assessment dated [DATE], indicated R42 was at risk for falls. See plan of care for fall interventions. Fall assessment last completed 1/16/24, identified R42 was at risk for falls and has had 3 falls since last assessment. R42's plan of care last updated 4/17/24, indicated R42 was at risk for falls related to generalized weakness, impaired mobility and decline in cognition. Interventions included; clip call light to overbed light to prevent resident from needing to reach over bed for the cord, Dycem in recliner, grabber (reacher mechanical tool used to increase the range of a persons reach and grasp objects) for use when reaching items, hourly checks when in recliner, offer to lay down in the afternoon as resident allows, place garbage can next to recliner, call light within reach, proper footwear to be worn at all times and monitor and document on safety. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Facility Incident Review and Analysis dated 4/17/24, indicated R42 experienced a fall from chair at 8:00 p.m Incident Analysis included resident slid from recliner and stated he was throwing something away and slid. Contributing factors included R42 not always able to realize limitations. Possible interventions was left blank with implementation of interventions including staff education if applicable, intervention care planned and appropriate assessments completed. Signed by licensed practical nurse (LPN)-A. A progress note dated 4/16/24 at 11:18 p.m., by registered nurse (RN)-C included R42 slid out of his recliner at 8:00 p.m. R42 stated he was throwing plastic cup away and slid. No injuries noted. Transported from the floor to bed via hoyer lift by 2 staff. Sister notified. Facility Incident Review and Analysis dated 4/29/24 at 4:40 p.m., indicated R42 had a fall from chair. Causal factor included patient was on the ground laying anterior attempting to get himself up from the ground. Patient stated that he was trying to reach for something and slipped out of his chair. R42 denied hitting his head or being hurt. R42 stated his shoes were slippery which might have caused him to fall from his chair. Follow up interventions included resident was given a grabber with instruction on how to use it. Implementation of interventions included staff education if applicable and interventions were care planned. Signed by LPN-B. Facility Incident Review and Analysis dated 4/29/24, at 11:40 p.m., indicated R42 had a fall from the bed. Casual factor included nursing assistant (NA), unidentified, found resident on the floor in his room on his knees with arms on bed. R42 was calling out and stated he just wanted to get up. R42 was assessed for injury and transferred to his bed. Follow up interventions included checked his report for bowel movements (BM) as R42 stated he hasn't pooped for 7 days. Intervention added to care plan to check BM list to make sure resident has BM. Encourage fluids. Provider to review bowel medications. Implementation of interventions included staff education if applicable, interventions care planned, interventions to resident care lists and appropriate assessments completed. Signed by LPN-B. A progress note by LPN-C dated 4/30/24 at 1:55 a.m., indicated R42 was found by aide, kneeling on the floor with his hands over his bed at 11:40 p.m. He stated not hitting his head and did not have injury noted to head. He wasn't able to say exactly why he was getting up, just stated he wanted to get out of bed. He was visually agitated and was having verbal outbursts, not like his baseline. Writer looked back at when resident had his last BM, it stated 7 days prior was the last time. Writer had offered Senna (stool softener), Milk Of Magnesium (laxative), and suppository (small solid objects used to deliver medicine). He had refused all at first but around 12:10 a.m., agreed to a suppository. He had medium results, BM was hardened. He became restless during the night, trying to get out of bed several times. Stated he needed to use the commode again around 2:15 a.m.,with small BM results. Resident had fall earlier during evening shift. Found on body was bruises to his left forearm, an old bruise to right hand. Both knees were reddened due to him being on them. No other injuries noted at time. Intervention put in place is to check and see if resident has had a BM every shift. Also, put in provider book for either MiraLAX (laxative solution that increases the amount of water in intestinal tract to stimulate BM's) scheduled or suppositories. He has been refusing his medications, which includes his Senna (stool softener), making it harder for him to have a BM. Facility Incident Review and Analysis dated 5/27/24, indicated R42 was found on the floor at 8:30 p.m. Causal factors included R42 was attempting to put the foot of his recliner down and slid out of his recliner. Follow up interventions included clip call light to overbed light, Dycem (nonskid pad) in recliner, grabber for use to reach items, lay resident down in the afternoon. Implementation of interventions included care planned, and appropriate assessments completed. Additional notes indicated the incident has been reviewed and will continue with the current plan of care. Signed by LPN-A. A progress note dated 5/27/24 at 10:01 p.m. by LPN-D included family member was notified of incident and no injuries. R42 was continually observed on 6/11/24: 12:34 p.m., R42 was transferred from his recliner to wheelchair and taken to a table in living area for lunch. Staff did not check brief for incontinence during this time. 3:03 p.m., bingo finished and R42 pushed himself back from the table. Staff assisting other residents to their rooms. 3:31 p.m., R42 continues to attempt to move himself in his wheelchair and stated he is going to his room because his lower back hurts and he wants to go back to his room. 3:44 p.m., staff still have not approached R42. Staff were informed R42 requested to go back to his room. Throughout continuous observation, staff failed to approach R42 and offer to toilet, assist him to his room, offer to lay him down or place him in his chair in his room. During observation on 6/12/24 at 7:11 a.m., R23 was in his bed. Call light was laying on the floor next to his bed. During observation and interview on 6/12/24 at 8:09 a.m., trained medication assistant (TMA)-B indicated R42 sleeps in some days and other days he is up and about by 7:30 a.m. TMA-B indicated staff will check on R42 periodically but unsure how often and deferred that to NA-A working today. TMA-B indicated R42 will holler out sometimes when he is ready to get up. TMA-B picked call light up off the floor and attached to the bed prior to leaving the room at 8:17 a.m. During observation and interview on 6/12/24 at 9:25 a.m., NA-A and NA-C went into R42's room and provided ADL care. R42 was taken out to breakfast. R42 stated he is tired this morning. During observation on 6/12/24 at 11:45 a.m., R42 is in his room in his chair. No reacher/grabber or garbage can is present next to his chair. During observation and interview on 6/13/24 at 9:02 a.m., R42 was in his chair in room and stated he is not sure where his grabbing deal (reacher) is, but thought it was around his room someplace. NA-A indicated he hasn't seen R42's grabber since he moved to wing a few weeks ago. NA-A was asked what R42's fall prevention interventions included and he stated Dycem to the chair, Velcro material on the floor and no skid shoes. When questioned about grabber in reach and garbage can next to chair, NA-A stated he wasn't aware of those interventions. NA-A looked around room and indicated he is unsure where the second garbage can is and the one by the door needs to stay there as R42 is on enhanced barrier precautions. During interview on 6/13/24 at 9:05 a.m., NA-D stated she was not aware the garbage can or grabber were current interventions for fall prevention for R42. During interview on 6/13/24 at 9:06 a.m., TMA-B indicated she was unsure of what R42's fall preventions are currently but can find out. TMA-B indicated NA's should be following the current plan of care that was observed with LPN-A to be on the back of R42's door dated 4/17/24, with current interventions. During interview on 6/13/24 at 9:13 a.m., LPN-A indicated R42 has had his grabber since he moved to this unit. LPN-A indicated all staff including NA's should be aware of all fall interventions in place and should be ensuring they are completed. LPN-A stated R42's grabber should be with him and his garbage can by him when he is in the chair as care planned. LPN-A indicated new interventions put into place is generally shared at shift hand offs and reports. The care plan is also posted on the back of resident's room door. During interview on 6/13/24 at 10:14 a.m., the director of nursing (DON), indicated she would expect the care plan including fall interventions in place be followed. The DON indicated R42 has had more recent confusion so he was moved to another wing for closer observation. The DON indicated R42 should be checked on every hour. During observation on 6/13/24 at 11:20 a.m., R42 was in his room in recliner with chair reclined back. Garbage can remains next to the door and not next to recliner and no grabber present. The facility Fall Prevention and Management policy dated 2/2024, included; -Facility staff will identify interventions related to the resident ' s specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. -If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. -If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on the nature of or type of fall, until falling is reduced or stopped or until the reason for the continuation of the falling is identified as unavoidable. -Staff may also identify and implement relevant interventions to try to minimize serious consequences of falling. -Staff will monitor and document each resident ' s response to interventions intended to reduce falling or the risks of falling. -The interdisciplinary team will review falls daily at morning meeting. -The staff will continue to collect and evaluate information until they either identify the cause of falling or determine that the cause cannot be found.

Based on observation, interview and document review the facility failed to provide timely repositioning for 1 of 1 resident (R42) who was dependent upon staff for repositioning and high risk for pressure ulcers. Findings include: R42's Face Sheet printed 6/13/24, included diagnoses of disorientation, malnutrition, Parkinson's disease (progressive disorder that affects the nervous system and parts of the body controlled by the nerves), and epilepsy (seizures). R42's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R42 had a moderate cognitive impairment, inattention behavior continuously present, and behaviors including rejection of care that occurred 4-6 days out of 7. Activities of daily living (ADL's) included R42 uses a wheelchair and dependent on staff to wheel 50 feet, has impairment on both side of lower extremities for range of motion and requires substantial to maximal assist for transfers, bed mobility, toileting and personal hygiene. R42 is at high risk for pressure ulcers, has pressure reducing device for bed and chair and has no current pressure ulcers. R42's Care Area Assessment indicated R42 is at high risk for skin breakdown and requires staff assist for transfers and ADL's. Staff offer toileting and repositioning per plan of care. R42's Braden Scale for Predicting Pressure Sore Risk dated 1/16/24 had a score of 17 indicating R42 is at risk for skin breakdown. R42's care plan dated 2/7/22, indicated R42 had a self-care deficit related to impaired mobility, generalized weakness, and decline in cognition. Interventions included please assist with all ADL's, staff to complete pericare after each elimination/incontinent episode every shift. If resistive with cares, leave and return in 10 minutes. Another care plan included alteration in mobility related to generalized weakness and decline in cognition dated 1/19/22. Interventions included; use EZ stand and assist of 1 to 2 for transfers. Encourage and assist with repositioning for pain. No more than 2 hours in wheelchair no matter tilting, repositioning. A plan of care dated 2/7/22 indicated R42 has a potential for skin breakdown related to impaired mobility and generalized weakness. Interventions included call bell within reach, answer promptly, turn and reposition resident every 2 hours and as needed. A separate plan of care dated 1/19/22, indicated alteration in elimination related to urinary tract symptoms and obstructive and reflux uropathy (blockage of urine flow). Interventions included monitor Foley catheter output, and assist of one with toileting every 2 hours and as needed using the EZ stand. May use assist of 2 as needed. Pads/briefs in use to aid in keeping skin dry. R42 was continually observed on 6/11/24: 12:34 p.m., R42 was transferred from his recliner to wheelchair and taken to the dining room for lunch. Staff did not check brief for incontinence or reposition during this time. 1:02 p.m., R42 remains at table with meal in front of him. 1:32 p.m., Remains at table in the living room area. 1:46 p.m., remains at table, watching television and occasionally putting his head down. 2:00 p.m., activities staff pushed him into dining room to play bingo. 2:30 p.m., continues in dining room, playing bingo with other residents. 3:03 p.m., bingo finished and R42 pushed himself from the back away from the table but stayed in the dining room. Staff assisting other residents to their rooms. 3:11 p.m., R42 remains in the same place in the dining room. All other residents have left the area. R42 attempting to move self using his arms to propel wheelchair, but ending up going in a circle. 3:31 p.m., R42 continues to attempt to move himself in his wheelchair and stated he is going to his room because his lower back hurts and he wants to go back to his room. 3:44 p.m., staff still have not approached R42 so staff were informed R42 requested to go back to his room. R42 throughout continual observation was never approached by nursing staff, or offered to be toileted or assisted to be repositioned or taken back to his room. During interview on 6/12/24 at 9:25 a.m., nursing assistant (NA)-A indicated R42 sometimes leaks around his catheter and doesn't always let staff know if he has had a bowel movement so R42's pad should be checked every few hours to ensure he is dry and clean. NA-A indicated R42 does not have any bed sores currently but is at high risk. During interview on 6/12/24 at 1:38 p.m., licensed practical nurse (LPN)-A, also identified as care coordinator, indicated R42 is a high risk for skin breakdown and should be offered to be repositioned every two hours. LPN-A stated I was not aware that wasn't done yesterday. During interview on 6/12/24 at 1:40 p.m., registered nurse (RN)-B indicated R42 has a urinary catheter but has leaked around tubing, plus he is high risk for skin breakdown so should be repositioned and checked to ensure he is dry and clean every two hours. During interview 6/13/24 at 8:14 a.m., the director of nursing (DON) indicated R42 does have a catheter but he still needs to be repositioned and checked to make sure he is clean and dry and doesn't develop any pressure ulcers minimally every 2 hours per plan of care.

Based on observation, interview and document review the facility failed to provide timely incontinence care for 1 of 2 residents (R42) who was dependent upon staff for assistance with activities of daily living (ADL). Findings include: R42's Face Sheet printed 6/13/24, included diagnoses of disorientation, malnutrition, Parkinson's disease (progressive disorder that affects the nervous system and parts of the body controlled by the nerves), and epilepsy (seizures). R42's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R42 had a moderate cognitive impairment, inattention behavior continuously present, and behaviors including rejection of care that occurred 4-6 days out of 7. Activities of daily living (ADL's) included R42 uses a wheelchair and dependent on staff to wheel 50 feet, has impairment on both side of lower extremities for range of motion and requires substantial to maximal assist for transfers, bed mobility, toileting and personal hygiene. Eating requires setup or clean up assist. R42's Care Area Assessment indicated R42 is at high risk for skin breakdown and requires staff assist for transfers and ADL's. Staff offer toileting and repositioning per plan of care. R42's Braden Scale for Predicting Pressure Sore Risk dated 1/16/24 had a score of 17 indicating R42 is at risk for skin breakdown. R42's care plan dated 2/7/22, indicated R42 had a self-care deficit related to impaired mobility, generalized weakness, and decline in cognition. Interventions included please assist with all ADL's, staff to complete pericare after each elimination/incontinent episode every shift. If resistive with cares, leave and return in 10 minutes. Another care plan included alteration in mobility related to generalized weakness and decline in cognition dated 1/19/22. Interventions included; use EZ stand and assist of 1 to 2 for transfers. Encourage and assist with repositioning for pain. No more than 2 hours in wheelchair no matter tilting, repositioning. A separate plan of care dated 1/19/22, indicated alteration in elimination related to urinary tract symptoms and obstructive and reflux uropathy (blockage of urine flow). Interventions included monitor Foley catheter output, and assist of one with toileting every 2 hours and as needed using the EZ stand. May use assist of 2 as needed. Pads/briefs in use to aid in keeping skin dry. During observation on 6/10/24 at 2:48 p.m., urine smell noted in room with wet brief on the floor next to the garbage can and window. During observation on 6/10/24 at 5:04 p.m., R42's soiled brief remains on the floor with urine smell noted in room. During interview on 6/10/24 at 7:06 p.m., family member (FM)-G indicated she has found R42 in wet pants, smelling like urine when she arrives for visits. FM-G stated he should not be leaking from his urinary catheter and plans to schedule a care conference to find out why the catheter is leaking. R42 was continually observed on 6/11/24: 12:34 p.m., R42 was transferred from his recliner to wheelchair and taken to the dining room for lunch. Staff did not check brief for incontinence during this time. 1:02 p.m., R42 remains at table with meal in front of him. Ate 25% of meal and drank a can of Pepsi. 1:32 p.m., Remains at table in the living room area. At 1:46 p.m., remains at table, watching television and occasionally putting his head down. 2:00 p.m., activities staff pushed him into dining room to play bingo. 2:30 p.m., continues in dining room, playing bingo with other residents. 3:03 p.m., bingo finished and R42 pushed himself from the back away from the table but stayed in the dining room. Staff assisting other residents to their rooms. 3:11 p.m., R42 remains in the same place in the dining room. All other residents have left the area. R42 attempting to move self using his arms to propel wheelchair, but ending up going in a circle. 3:21 p.m., R42 continues to attempt to move himself in his wheelchair. R42 is going the opposite direction of his room and has made it approximately 10 feet towards exit to another hallway. 3:31 p.m., R42 continues to attempt to move himself in his wheelchair and stated he is going to his room because his lower back hurts and he wants to go back to his room. 3:44 p.m., staff still have not approached R42 so staff were informed R42 requested to go back to his room. R42 throughout continual observation was never approached by nursing staff, or offered to be toileted or assisted to be repositioned or taken back to his room. During interview on 6/12/24 at 9:25 a.m., nursing assistant (NA)-A indicated R42 sometimes leaks around his catheter and doesn't always let staff know if he has had a bowel movement so R42's pad should be checked every few hours to ensure he is dry and clean. During interview on 6/12/24 at 1:38 p.m., licensed practical nurse (LPN)-A, also identified as care coordinator, indicated R42 is a high risk for skin breakdown and should be offered to be repositioned every two hours. LPN-A stated I was not aware that wasn't done yesterday. During interview on 6/12/24 at 1:40 p.m., registered nurse (RN)-B indicated R42 has a urinary catheter but has leaked around tubing, plus he is high risk for skin breakdown so should be repositioned and checked to ensure he is dry and clean every two hours. During interview 6/13/24 at 8:14 a.m., the director of nursing (DON) indicated R42 does have a catheter but he still needs to be repositioned and checked to make sure he is clean and dry every 2 hours per plan of care. The facility Activities of Daily Living (ADLs)/Maintain Abilities policy dated 5/9/24 included: - It is the policy of the facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident ' s quality of life by ensuring all staff, across all shifts and departments, understand the principles of quality of life, and honor and support these principles for each resident; and that the care and services provided are person-centered, and honor and support each resident ' s preferences, choices, values and beliefs.- -The facility will provide care and services for the following activities of daily living: a. Hygiene -bathing, dressing, grooming, and oral care, b. Mobility-transfer and ambulation, including walking, c. Elimination-toileting, d. Dining-eating, including meals and snacks, e. Communication, including: i. Speech, ii. Language, and iii. Other functional communication systems. -A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview and record review, the facility failed to update the care plan and the Kardex with behavioral interventions for 1 of 1 resident (R39) reviewed for care plans. Findings include: R39's facesheet printed on 6/13/24, included diagnoses of metabolic encephalopathy (a chemical imbalance in the brain which can lead to personality changes), bilateral below the knee amputations, and depression. R39's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R39 was cognitively intact, had clear speech, could understand and be understood, was independent with eating and toileting, refused oral care and bathing. Due to bilateral below the knee amputation, R39 used a wheelchair. R39's physician orders dated 8/22/23, and 3/20/24, included psychotropic, antipsychotic, and anti-depressant medication monitoring for side effects. Orders did not include mood and behavior monitoring. R39's care plan dated 6/2/22, indicated the potential for alteration in mood and behavior related to diagnoses of bilateral below the knee amputations and major depressive disorder. Interventions included: be alert to mood and behavioral changes and monitor and document mood state/behaviors upon occurrence. The care plan failed to include interventions for behaviors and how staff were to address them. R39's Kardex (separate from the care plan; an abbreviated reference commonly utilized by nursing assistants [NA's]), printed on 6/12/24, included, under the section titled Behavior included: R39 enjoyed collecting trading cards, animal movies, shows on TV. Independent activities and will chose when would like to socialize. The Kardex failed to include interventions for behaviors and how staff were to address them. Under a section titled Grooming - the Kardex failed to indicate interventions for refusing showers and oral care. R39's progress notes from January 2023, to current, indicated a pattern of behaviors including being argumentative, rude, yelling at staff, refusals to listen to staff, refusals of medical care including dressing changes, refusals of weights, oral care, bathing; spitting nicotine chew on the floor, refusing to allow housekeeping to clean his room, and inability to redirect R39. During an interview on 6/11/24, at 1:55 p.m., the director of nursing (DON) stated R39 was his own worst enemy; he was affecting other residents with body odor and smell emanating from his room. R39 was discussed at morning IDT (interdisciplinary team meetings) but admitted tactics and interventions discussed regarding behaviors were not always added to the care plan or Kardex. During several conversations with R39 on 6/12/24, in and outside of his room, R39 was open to talking and expressing feelings; was pleasant and articulate during the conversations. During an interview on 6/12/24, at 1:50 p.m., licensed practical nurse (LPN)-A who was also the nurse manager for the unit on which R39 resided, stated R39 refused a lot of cares and would cuss, swear, and scream at staff. Together in her office, reviewed R39's care plan. While several types of refusals were care planned, the care plan lacked tactics and intervention to guide staff when R39 refused cares or exhibited behaviors. When asked how current staff, new staff and agency staff would know about R39's behaviors (argumentative, cussing, swearing, screaming and refusals) prior to caring for R39 and what interventions to deploy, LPN-A stated it was okay for staff to care for R39 without being informed of his behaviors because there were always other employed staff they could ask if they had concerns. LPN-A stated R39 would tell staff to get out of his room and staff just needed to get out and not engage with him. Further, there was nothing in R39's Kardex about R39's behaviors and interventions. LPN-A stated she had not been a nurse manager very long and when she had reviewed R39's care plan, thought it looked okay, and had not identified behaviors were missing. LPN-A stated updates to a care plan were generally done when changes were made to the MAR (medication administrator record) or TAR (treatment administration record), or when a new therapy order was received. LPN-A stated care plans were also updated after quarterly care conferences. LPN-A stated R39's care plan and Kardex should address mood and behaviors with interventions to guide the staff, and admitted they did not. During an interview on 6/12/24 at 2:20 p.m., the DON stated she would expect to see mood and behavior identified on a resident's care plan and that nurse managers and social services would add behaviors and interventions to a care plan. The DON stated licensed nurses utilized a care plan to guide them in a resident's care and NA's used a Kardex. The DON was informed R39's care plan and Kardex didn't address his behaviors and outbursts, or how to manage them. The DON admitted that information would be important for staff to know how to effectively approach R39 and should include de-escalation tactics. The DON admitted R39's behaviors should be care planed so that communication was the same among all staff, including agency. During an interview on 6/13/24 at 10:43 a.m., the administrator stated her understanding of a care plan was to ensure staff were doing resident checks that were needed, to help with communication for staff and family, and to guide the staff in providing care to residents. The administrator was informed of R39's care plan and Kardex lacking identification of mood and behavior, and interventions to guide the staff. The administrator was aware of R39's behaviors - they were discussed at IDT - and stated they had tried multiple staff talking to him and it had been a struggle to find what works for him. During an interview on 6/13/24 at 11:10 a.m., the DON stated the purpose of a care plan was to tell the residents story and to identify their specific needs as each resident was different. The DON stated R39's care plan and Kardex could be improved; how to approach, what to do with refusals such as refusing a shower - what are alternatives options. The facility Care Planning policy dated 1/6/22, indicated residents would have a person-centered care plan developed by the interdisciplinary team for the purpose of meeting the resident's individual medical, physical, psychosocial, and functional needs. The goal of the person centered, individualized care plan is to identify problem areas and their causes, and develop interventions that are targeted and meaningful to the resident. The care plan shall be used in developing the resident's daily care routines and will be utilized by staff personnel for the purposes of providing care or services to the resident. The care plan is to be modified and updated as the condition and care needs of the resident changes.

Based on observation, interview and document review, the facility failed to ensure 1 of 1 resident (R16) who was observed to have medications in his room, had been appropriately assessed and deemed safe to self-administer medications. Findings include: R16's facesheet printed on 6/13/24, indicated history of a stroke. R16's annual Minimum Data Set (MDS) assessment dated [DATE], indicated severe cognitive impairment, clear speech, could usually understand and be understood. R16 was dependent upon staff for activities of daily living. R16's physician orders included: 1. Calcipotriene external ointment 0.005 %, apply to affected area on right leg topically two times a day every Saturday and Sunday for psoriasis, dated 10/25/23. 2. Aspercreme arthritis pain external gel 1 % (diclofenac sodium topical), apply to left hand and finger joints topically every morning and at bedtime for contracture pain, dated 4/18/24. 3. Systane solution 0.4-0.3 %; instill 1 drop in both eyes every morning and at bedtime for dry eyes, dated 3/24/23. 4. Latanoprost solution 0.005 %; instill 1 drop in both eyes at bedtime related to dry eye syndrome, dated 8/6/22. R16's care plan dated 7/2/15, indicated R16 was inappropriate for self-medication administration except for Icy Hot balm at bedside for wife to administer prn (as needed). During an observation on 6/10/24 at 1:44 p.m., in R16's room, observed two bottles of eye drops on top of a dorm-size fridge: Latanoprost 2.5 ml (milliliters) and Systane 15 ml. On the dresser were tubes of prescription diclofenac gel and calcipotriene ointment. R16 did not have a self-administrator order nor did his care plan indicate R16 could self-administer medications. During an observation on 6/11/24 at 10:40 a.m., the eye drop bottles were no longer visible in R16's room; the ointment and gel remained on the dresser. During an interview on 6/12/24 at 7:06 a.m., family member (FM)-C in room with R16, stated she administered eye drops and ointments to R16. FM-C stated the medications belonged to the facility. During an interview on 6/12/24 at 10:02 a.m., trained medication aide (TMA)-A stated R16 did not have a self-administration order for eye drops, ointment and cream and stated R16 would not be capable to self-administer medications either. TMA-A was informed of finding medications in R16's room and stated she had heard FM-C came in the morning to give R16 his medications as R16 was resistant to staff giving him medications. TMA-A stated FM-C may be putting his eye drops in too; that a nurse may have dropped them off in his room and had not gone back to pick them up. TMA-A stated medications can only be left in a resident's room if the resident had a self-administration of medication order. TMA-A opened the medication cart and R16's eye drops were in the cart. During an interview on 6/12/24 at 12:09 p.m., the director of nursing (DON) was informed of findings with eye drops, ointment, and a cream in R16's room. The DON was unaware of this and stated if a resident did not have a self-administration order, they were not able to keep medications in their room. The DON stated she would remove the ointment and gel from R16's room. The DON was aware FM-C assisted in giving R16's his medications but admitted FM-C had not been evaluated for safe administration of medications for R16. During an interview on 6/13/24 at 9:36 a.m., registered nurse (RN)-A stated R16 was resistant to staff giving him his medications and wanted FM-C to give them, therefore staff brought in the eye drops for FM-C to administer to R16. RN-A stated she was aware the ointment and cream were left in his room. RN-A stated R16 could get aggressive when cares were provided, which was why FM-C provided some of R16's cares. The facility Self-Administration of Medication policy dated 2/2024, indicated: Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party.

Based on observation, interview and document review, the facility failed to comprehensively assess and implement interventions to prevent worsening and prevent additional pressure ulcers (PU)'s from developing for 1 of 1 resident (R28) who had two unstageable PU's (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar) and one stage 2 PU (partial thickness skin loss of the dermis) This failure resulted in actual harm when R28's pressure ulcers worsened and additional PU's were acquired. Findings include: R28 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation and interview on 2/14/22, at 1:38 p.m. R28 reported to the surveyor she had a sore bottom. R28 was sitting in her wheelchair in her room. R28 stated she had a PU on her buttocks that was not healing and she was unsure why. R28 thought she had the sore for a month but was unsure. R28 indicated she she did not recall being repositioned every 2 hours. R28's quarterly minimum data set (MDS) assessment dated [DATE], identified R28 as having a baseline interview for mental status (BIMS) of 14 (cognitively intact). R28 required extensive assistance with activities of daily living (ADL's) that included mobility. R28 required extensive assistance with toileting and repositioning. The MDS identified R28 as being at risk for PU's and identified one stage 2 PU. Interventions; pressure reducing device on chair and bed, turning and repositioning program, PU care and nutritional intervention. The MDS indicated R28 did not exhibit any behaviors. R28 utilized a wheelchair for mobility. Review of the Braden scale dated 12/15/21, indicated R28's risk factor was mild for skin breakdown. The assessment indicated R28 continues to have an open area on the right buttock as well as a new area that is dry near the open area, that looks like it may open. Triad hydrophilic treatment dressing applied as ordered. Encourage the resident to avoid sitting no longer than 1 hour in the wheelchair without repositioning. Repositioning at least every 2 hours in bed/chair to prevent skin breakdown. Limit chair sitting to 2 hours. Avoid the resident falling asleep on the toilet. Wheelchair cushion on chair from pressure applying, staff to monitor skin daily with cares and weekly with skin inspection. Review of the Weekly Pressure Wound Evaluations; -10/20/21- right buttock measures 0.3 centimeter (cm) in length by 0.3 cm. width. The center of the wound is slightly orange in color and surrounded by whitish skin. Unstageable. -12/1/21-right buttock measures 0.1 cm length by 0.1 cm width. The wound bed is dry with no drainage. Unstageable. -12/15/21-right buttock measures 1.3 cm length by 1.5 cm width with 100% granulation tissue( new connective tissue for healing of wounds). Unstageable. -12/29/21-right buttock measures 1.5 cm length by 1.3 cm width. The wound bed had a scant amount of serous (thin and clear) drainage. Unstageable. -2/2/22-right buttock (distal) measures 0.5 cm length by 0.5 cm width. 100% granulation tissue. Pain with treatment. Unstageable (newly acquired PU on 12/29/22 and measured 0.5 cm length by 0.6 cm width ) right buttock (proximal) measures 1.7 cm length by 1.2 cm width. 100% slough slough (necrotic/dead) tissue. Pain with treatment. Unstageable. left buttock measures 1.2 cm length by 0.5 cm width. 100% slough tissue. Pain with treatment. Unstageable. (newly acquired on 1/2/22 with measurements of 0.7 cm length by 1.0 cm in width) 2/9/22-right buttock (proximal) measures 1.0 cm length by 1.4 cm width. 100% slough tissue. Unstageable right buttock (distal) 0.8 cm length by 0.6 cm width. 100% slough tissue. Unstageable. left buttock measures 1.8 cm length by 0.9 cm width. 100% slough tissue. Unstageable. The weekly Pressure Wound Evaluation from 10/20/21 to 2/9/22, indicated R28 obtained a new unstageable PU to the right distal buttocks and a newly unstageable PU to the left buttock during this time. The right buttock (proximal) PU went from granulation tissue to slough tissue and increased in size from 0.3 centimeter (cm) length by 0.3 cm. width to 1.0 cm length by 1.4 cm width. The right buttock (distal) PU increase in size from 0.5 cm length by 0.6 cm width to 0.8 cm length by 0.6 cm width. The left buttock increased in size from 0.7 cm length by 1.0 cm in width to 1.8 cm length and no change in width During review of the weekly wound assessments, it was noted the above PU's were not thoroughly being completed. Review of the current physicians orders dated 2/16/22, included an order to encourage R28 to avoid sitting for longer than 1 hour in the wheelchair without repositioning every shift (order date 2/9/22). The physicians orders also included an order to reposition R28 at least every 2 hours in bed/chair to prevent pressure to bottom. Limit chair sitting to 2 hours. Review of the care plan dated 2/16/22, identified R28 as having at risk alteration in skin integrity related to history of venous statis ulcer, skin [CONDITION(S)], [CONDITION(S)] and open area to right buttock (resolved on 3/17/21). Interventions listed; do not use perfume soaps, wheelchair cushion on wheelchair, weekly pressure would assessments, keep skin clean and dry, encourage mobility, inspect skin daily and report concerns to charge nurse, weekly skin assessments by licensed staff and treatment cream interventions as needed (PRN). The care plan indicated R28 has alteration in mobility related to [CONDITION(S)], left knee pain, CHF and [CONDITION(S)]. Interventions listed; independent with bed mobility, monitor skin integrity, routine preventive skin cares with lotion and powder, ultrafoam pressure redistribution mattress to bed and wheelchair. The care plan indicated R28 is independent with toileting and transfers and continent of bowel and bladder. R28 has a history of sitting on the toilet for hours. Staff to remind R28 every 15 minutes to finish. Interventions listed; resident was educated to call for assist when transferring to toilet, encourage good peri cares, encourage adequate fluids and monitor skin integrity. -The comprehensive care plan did not include R28's PU's on the buttocks nor the repositioning interventions per physicians order Review of the nursing assistant (NA) care sheet dated 2/9/22, indicated R28 is assisted to bed and with all transfers. Offer toileting and repositioning every 2-3 hours PRN and peri-cares PRN. Offer R28 to sit in the recliner at night, if refuses to sleep in bed. When finding R28 in the bathroom stay with her until finished. Check R28 for safety (related to fall risk) every 1 hour to make sure the resident is sleeping during the hours of 10:00 p.m. to 6:00 a.m. -The NA care sheet did not reflect the current physicians orders for repositioning. Review of the NA hourly safety checks from 1/1/22 to 2/15/22, (10:00 p.m. to 6:00 a.m.) for R28, did not include repositioning. The checks only included the whereabouts of where R28 was during this time. Continuous observations on 2/15/22 and 2/16/22, from 8:00 a.m. to 10:30 a.m. (2 1/2 hrs) and from 1:00 p.m. to 3:30 p.m. (2 1/2 hrs). R28 was not offered repositioning or off-loading. During this time, staff were observed to walk by the residents room. Observation on 2/16/22, at 10:30 a.m. R28's PU treatment was done by registered nurse (RN)-D. R28's wound dressings were removed with saline. There was a scant amount of brownish drainage on the dressings. R28 was observed to have 2 PU's on the right buttock and 1 PU on the left buttock. When RN-D cleansed the wounds R28 flinched and complained of pain. The PU's were measured by RN-D, at this time. Measurements: Right buttock-(proximal) 1.1 cm length by 1.7 cm width by 0.1 cm depth (increase in size from most recent measurements on 2/9/22) Right buttock (distal) 1.3 cm length by 0.7 cm width by 0.2 cm depth (increase in size from most recent measurements on 2/9/22) Left buttock- 1.2 cm length by 1.2 cm width by 0.1 cm depth (increased in length and depth from most recent measurements on 2/9/22. The skin around all 3 pressure ulcers was slightly reddened. Triad hydrophilic (absorbs wound exudate) wound dressing was applied to all 3 PU's R28 stated she tries to off-load, lay down during the day and stay off of her bottom as much as she can. R28 had a pressure reduction mattress on her bed and a pressure reduction cushion on her chair. Interview during this time with RN-D, stated she usually does not provide wound care for R28 and was unsure if the wounds had improved or not, but did indicate the nurse practitioner provides wound care every 2 weeks. Continued observations on 2/17/22, from 9:00 a.m. to 12:15 p.m. R28 was not repositioned or off-loaded. R28 remained in her room and slouched in her wheelchair. Facility staff were observed to go in and out of her room administering medications, delivering dinner tray, answering call lite and putting clothing away. The staff also walked by her room several times without offering to reposition or off-load. Review of a physicians visit progress note dated 1/5/22, indicated R28 was seen for wound care evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R28 expresses frustration that wounds are not healing. R28 is having pain with wound care. R28 is compliant with treatments. The right buttock wound measures 1.2 cm by 1.5 cm by 0.1 cm with a smaller area next to it that measures 0.4 cm by 0.3 cm by 0.1 cm. The wound has increased in size with a scant amount of drainage. 100% slough and unstageable The left buttocks measures 1.0 cm by 0.6 cm. No drainage. Unstageable The progress note indicated to encourage R28 to avoid sitting for longer than 1 hour in the wheelchair without repositioning and to encourage increased protein at meals and multivitamin. Occupational therapy (OT) for wheelchair positioning and overlay to bed. Review of a physicians visit progress note dated 2/9/22, indicated R28 was seen for wound care evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The progress note indicated R28 continues to have a dressing application over her buttock wounds, but the resident indicates they do not stay on. The right proximal buttocks ulceration measures 1.0 cm by 1.4 cm by 0.1 cm. The wound has increased in size, no odor or drainage. 100% slough and unstageable. Surrounding skin is tender. Right distal buttocks ulceration measures 0.8 cm by 0.6 cm by 0.1 cm. The wound has increased in size. There is no odor and scant drainage. Unstageable and surrounding skin is tender. The left buttocks ulceration measures 1.8 cm by 0.9 cm by 0.1 cm. Wound has increased in size. No odor or drainage. 100% slough and unstageable. Surrounding skin is tender treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Make sure resident is receiving peri care. Padded toilet seat is recommended and encourage resident to avoid sitting for more than an hour without repositioning. Interview on 2/16/22, at 11:15 a.m., RN-D indicated R28's PU's were re-occurring and do not seem to get better. RN-D stated R28 should be turned and repositioned every 2 hours, but confirmed she was not aware of any order for repositioning or off-loading the resident every 1 hour. RN-D further indicated R28 requires assistance with repositioning and transferring, but will often attempt to transfer self. Interview on 2/16/22, at 11:30 a.m. NA-D stated R28 will at times refuse to off-load or lay down when offered. NA-D indicated R28 should be repositioned or off-loaded every 2 hours. NA-D stated he was not aware of R28 being off-loaded or repositioned every 1 hour. NA-D further indicated when staff get busy, it is difficult to get residents repositioned timely. Interview on 2/16/22, at 1:30 p.m. trained medication assistant (TMA)-A indicated she follows the NA's care sheet for repositioning and off-loading R28. TMA-A confirmed the NA plan of care directed staff to reposition R28 every 2-3 hours PRN. TMA-A further indicated R28 will independently transfer self, but verified R28 requires assistance. Interview on 2/16/22, at 3:30 p.m. nurse manager (NM)-D indicated R28's care plan should have been updated to reflect the current physician orders for repositioning. NM-D indicated she thought the NA's were repositioning R28 while providing hourly safety checks, but later verified the staff were just visualizing R28's whereabouts. NM-D also confirmed weekly skin assessments were not always complete by the licensed nursing staff. NM-D indicated the NP was monitoring and providing treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Interview on 2/16/22, at 3:00 p.m. the facility nurse consultant (NC)-A and director of nursing (DON) confirmed R28's plan of care should have been updated to reflect the current physicians orders of repositioning (at least every 2 hours and to encourage sitting for no more than an 1 hour). NC-A stated the facility nursing staff had been trained on how to manage PU's and implement interventions per individualized care plan Review of the facility policy Skin Assessment and Wound Management dated 7/2018, included upon a significant change in a residents skin such as a development of a pressure related skin impairment, the following actions will be taken;; a tissue tolerance observation and evaluation will be completed, to determine skin tolerance and implement interventions to prevent breakdown and to promote healing, update the plan of care, update the NA care sheets and complete education with the resident including risk/benefits. Document refusals in the medical record.

Based on interview and document review, the facility failed to ensure the appropriate use of an air mattress for 1 of 3 (R2) residents identified at risk for falls. This deficient practice caused actual harm, a left [MEDICAL CONDITION], when R2 fell out of bed due to the placement of an air mattress on top of the existing mattress on a bed. The facility had implemented corrective action on [DATE] therefore, the deficient practice is being issued at past non-compliance harm. Findings include: R2's admission Minimum Data Set (MDS) assessment dated [DATE], indicated the resident had severe cognitive impairment with [DIAGNOSES REDACTED]. An incident report submitted to the state agency (SA) on [DATE] at 6:48 a.m. identified a fall R2 sustained; Date and time of incident [DATE] at 22:20 (10:20 p.m.). Description of incident: At 10:20 p.m. on [DATE], resident was found on the floor in his room, laying on his left hip at bedside. Resident had been toileted 20 minutes prior at 10 p.m. and had voided at that time. Following toileting, resident had been left with his bed in low position, body pillow outlining outside edge of bed and call light within reach, per care plan. Resident appears to have rolled out of bed and onto the floor. All care plan interventions had been followed. Resident is on hospice for terminal [DIAGNOSES REDACTED]. Resident was immediately assessed for injury. Upon assessment, resident reported he fell straight onto his buttock and was noted to have complaints of left leg pain. Facility staff stayed with resident while on call hospice provider was updated at 10:35p.m. with orders to send to ER (emergency room ) for evaluation. Gold Cross ambulance was called at 10:40 p.m. Administrator Designee was updated of incident at 10:50 p.m. Facility staff was notified by daughter at 3:50 a.m. that resident was being admitted (to hospital) for left [MEDICAL CONDITION]. Administrator Designee was updated of confirmed left [MEDICAL CONDITION] [DIAGNOSES REDACTED].>The investigative report submitted to the SA dated [DATE] at 20:18 (8:18 p.m.) included: During investigation it was discovered that an air mattress had been applied over a standard facility mattress. This is not the standard procedure and the expectation is that air mattresses will be placed directly on the bed frame. Changes were not made to the policy and procedure as the procedure was not followed, but immediate re education was provided to staff involved in decision to place air mattress over a standard facility mattress .(registered nurse (RN)-C) completed causal factor investigation following fall and noted resident to have hospice air mattress on top of facility standard mattress. (Director of Nursing (DON)) spoke to (RN-D) with Moments Hospice and confirmed this resident's particular air mattress was not to be used as an air overlay mattress, and should've been placed directly on the bed frame. Interviewed (RN-E) Nurse Manager who reports being unaware an air mattress had been delivered for resident. Interviewed (Licensed Social Worker (LSW)) who reports being in resident's room while air mattress was being applied to resident's bed by (maintenance staff (MS)-B) on day of admission. Discussion occurred between LSW and (MS-B) with decision that mattress appeared to be an air overlay mattress, which was placed on top of facility standard mattress for this reason. Immediate re-education was provided to LSW and (MS-B) of standard procedure to place air mattresses directly on the bed frame and not on top of another mattress. Staff must consult with the air mattress provider or the manufacturer's directions for clarification on the proper placement of mattresses .Resident was assessed for injury and was sent to the ER for evaluation. Immediate re education was provided to staff involved in decision to place air mattress over a standard facility mattress, education was provided to staff involved in decision to place air mattress over a standard facility mattress, education was provided to nursing and environmental services staff of appropriate placement, monitoring and care of resident beds and mattresses and immediately removed standard mattress from under air mattress so that only one mattress remained on the bed frame-this decreased the bed height by 6 (inches). Care plan updated to include fall precautions to be implemented upon resident's hospital return: low bed, body pillow to outline outside edge of bed, call light within reach, floor mat when in bed, room rearranged to increase resident supervision from doorway, position resident in center of the bed and away from the outside edge of the bed and top of the hour checks. House audit completed to ensure no other beds had a similar set up with no other concerns noted and education provided to nursing and environmental services staff of appropriate placement, monitoring and care of resident beds and mattresses. When interviewed on [DATE] at 3:30 p.m., family member (FM)-C stated being very very upset with the negligence of the facility. FM-C stated R2 was admitted [DATE], had a fall the evening of [DATE], and died on [DATE]. FM-C stated R2 fell while he was in bed. FM-C stated the maintenance person had not removed the original mattress when putting the air mattress, and further expressed being unaware whether the bed had been placed in the lowest position. FM-C stated, I know when I visited with him (R2) through the window, it wasn't in the lowest position. The nurse that did the fall assessment didn't catch that he had 2 mattresses on the bed. The aides didn't catch it either. On Tuesday ([DATE]) they let me come into the facility as he was end of life. When I saw him on Tuesday he was in a Broda chair, had a catheter the hospital had put in and his leg looked terrible and was really swollen. He seemed comfortable when in his chair but anytime they repositioned him you could tell he was in terrible pain. When interviewed on [DATE] at 9:03 a.m., the LSW confirmed she had helped get R2's room set up after admitting the resident. The LSW stated R2's daughter had brought his belongings in tubs and stated, She told me when the mattress came in it was an air mattress. When (MS-B) looked at the mattress he thought it looked like an overlay and I did too. It didn't look any different than any of our other mattresses that are overlays. (MS-B) helped me fill it up then myself and a nursing assistant made the bed. When I made the bed I didn't have to stretch down over it to get the sheets on so I didn't notice that it was higher than any of the other air mattresses. The LSW confirmed she was educated on the protocol related to resident air mattresses, and stated setting up the resident's bed was something she wouldn't usually do but the resident was on hospice and the daughter was struggling with not being able to be in the room with the resident due to Covid 19 restrictions. The LSW stated the daughter was outside the facility by R2's window when they were setting up his room, directing where she wanted things. The LSW stated, We knew prior to her (the daughter) coming, that she would be bringing equipment used at (R2's) prior assisted living placement. When asked, the LSW confirmed R2's daughter was not outside the room when the air mattress was being set up. When interviewed on [DATE] at 9:46 a.m., MS-B confirmed he had placed R2's air mattress on the bed when the resident was admitted to the facility. MS-B stated R2 had been admitted from an assisted living facility, was on hospice, and stated everyone told him it (the airmattress)was an overlay. So I filled it up and put it on the bed and strapped it down. If I would have looked at the tag we might have been ok. He (R2) was tired from the ride and I wanted to get it done. Even our social services said it was an overlay. If they'd said it was a mattress I would have put it on as a mattress - but it didn't look that thick, and I haven't seen any other hospice ones that looked like that. When asked if the mattress was thicker than the other overlay mattresses he'd put on other resident beds MS-B stated, yea, maybe. MS-B confirmed that following R2's incident, all resident air mattresses in the facility had been audited to ensure they were applied properly. When interviewed on [DATE] at 10:31 a.m., the DON confirmed hospice had brought an air mattress for the resident to utilize. The DON acknowledged the LSW and maintenance staff both thought is was an air overlay and not an air mattress so had put it over the regular mattress. The DON stated normally hospice would have brought the mattress in and applied to the bed, but with covid they were not allowed to come into the facility to do that. The DON confirmed their post fall investigation of R2's fall revealed the causal factor of the fall to be the air mattress. R2's hospital orthopedic surgery consult note dated [DATE], identified the resident sustained [REDACTED]. The consult notes indicated R2's daughter consulted with the on-call surgeon and a decision was made to proceed with non-operative management with the goal being R2's comfort. The facility's ,[DATE] policy, Falls Prevention and Management Protocol, included: Facility staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. The facility's corrective actions identified in the facility's post fall investigation, were verified as having been implemented as of [DATE] through interviews and record review.

Based on observation, interview and document review, the facility failed to provide the recommended diet texture of mechanical soft for 1 of 4 residents (R276) reviewed with mechanical diet texture which caused R276 harm when he had a [MEDICAL CONDITION] food impaction (food items caught in tube which connects from throat to the stomach) requiring hospitalization and surgical removal of food from the esophagus. 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 R276. Findings include: R276' face sheet, dated 2/8/19 included [DIAGNOSES REDACTED]. R276's Mankato Clinic Note, dated 2/4/19 indicated he had a history of [REDACTED]. R276's discharge Minimum Data Set ((MDS) dated [DATE], identified R276 was cognitively intact, and required assist of 1 for setup for eating. The MDS identified R276 coughed or choked during meals or medications and had complaints of difficulty or pain when swallowing. R276 received a mechanically altered diet. R276's care plan dated 12/27/18 indicated impaired swallowing .speech therapy did bedside swallow study and found he needed mechanical soft diet. Interventions included mechanical soft diet and honey thick liquids as ordered and to sit at supervised table for all meals related to impaired swallowing and risk of aspiration. Incident report dated 1/27/19, at 11:30 a.m., indicated that R276 had an episode of choking while in dining room for lunch and nurse noted resident coughing up phlegm and choking on a piece of meat. Contributing factors included the resident is at risk for aspiration due to impaired respiratory system, status [REDACTED]. Due to compromised respiratory system resident has difficulty with coordinating swallowing with breathing. A Facility Health Regulation Division - Nursing Home Incident Reporting form submitted by the facility on 1/28/19, by the administrator stated: Resident was given a meal that was not mechanical soft per resident's care plan. Resident got piece of meat getting stuck in throat. Resident was unable to cough the meat up at facility. Resident was alert, conscious and able to breathe. Nurse was unable to visualize anything in resident's throat. Resident was transferred to emergency department via ambulance for evaluation. A progress note dated 12/26/18, by nurse practitioner (NP) indicated resident was on dysphagia 2 diet (consists of moist and soft foods avoiding foods that are very dry, coarse and difficult to chew) with honey thick liquids per speech therapy recommendations. Video swallow showed deep penetration with thin and nectar thick [MEDICATION NAME]. A speech therapy evaluation and plan of treatment dated 1/2/19, bedside assessment of swallowing, indicated R247 was on a mechanical soft diet and showed clinical signs and symptoms of dysphagia. Resident noted to be slow to manipulate, some pocketing, increased shortness of breath with intake. A nursing progress note dated 1/27/19, at 12:41 p.m., indicated the resident began to cough at the dinner table. The resident began to spit up large amounts of phlegm. The resident was removed from his table and taken to his room. The resident continued to cough and spit up phlegm. The resident stated that the had a piece of roast beef stuck in his throat. Resident asked to open his mouth, nursing was unable to visualize anything in the residents throat. Resident encouraged to cough. Resident offered a small drink of thickened water. The resident was unable to swallow the water past the meat and he coughed the water back out. The resident continued to cough and then stated he would like to go to the hospital to get the meat removed the ambulance arrived at 12:40 p.m. The resident was assist on to the gurney and they left the facility at 12:45. At that time the resident was still alert and talking. R276's order summary report indicated R247 was receiving a regular no added salt diet, mechanical soft texture, honey consistency as he allows. The diet type report dated 2/5/2019, indicated R276 was on a regular, no added salt, mechanical soft diet with honey consistency. A discharge summary dated 2/1/19 indicated that R276 was transferred .for management for [MEDICAL CONDITION] food impaction (steak). He underwent EGD (Esophagogastroduodenoscopy is a diagnostic endoscopic procedure that visualizes the upper part of the gastrointestinal tract down to the duodenum), disimpaction. Active issues requiring followup included adhere to dysphagia diet to prevent recurrent aspiration and food impaction and was to return on a dysphagia 2 diet. A nursing progress note dated 2/2/19, at 10:52 p.m., indicated dietary had R276 signed a risk VS benefit sheet after he refused to eat his mechanical soft diet and stated I don't want that crap, give me some ice cream and normal food. and attempted to pour himself thin liquids even though he was educated on the risks associated with not following his diet. During interview 2/04/19, 3:08 p.m., R276 indicated he ate some meat and it got stuck in his throat about a week ago. R276 further stated It really hurt when it was stuck. R276 rated his pain at 10 throughout the time the meat was stuck. R276 indicated he still has a sore throat from the incident and from the tubes. On observation and interview 2/05/19, at 12:51, p.m., R276 was sitting in his room in his wheelchair with oxygen on at 3 liters per nasal cannula. R276 indicated he had just returned from the dining room and stated he had ice cream and tomato soup for lunch and was following his prescribed diet. Corrective action implemented: During interview 2/06/19, at 8:32 a.m., culinary services director (CSD) indicated she had a new employee training with a seasoned person the day the incident occurred. She indicated the seasoned person went into kitchen to get something and the new employee served R276 the wrong consistency diet that included steak uncut or mechanically altered. R276 then started coughing and nurse came over and assisted him to his room. The CSD indicated she was not here when the incident occurred, but arrived shortly after. The CSD indicated she immediately started educating all staff present on mechanically altered diets. The CSD stated I spoke to the employee and she received a correction redirection. There has been no incidents since then. She further indicated the correction plan included further education from speech therapy on diets, orientation changes to immediate education on diets and special diets versus throughout a thirty day period, changing the resident diet card system to include showing the diet card to the cook before placing food onto the plates, and a change to the diet sheets that is shorter, easier to read and understand, which all staff are required to sign and date. During interview on 2/06/19, at 10:00 a.m., licensed practical nurse (LPN)-A indicated she was passing pills the day of the incident and could hear R276 coughing and it sounded different than his normal cough. LPN-A checked on R276 and he was spitting phlegm. R276 then indicated he had something stuck in his throat. LPN-A indicated she gave him water to drink and he was unable to swallow it and spit it back out. LPN-A further indicated that R276 stated he needed to go to the hospital. LPN-A took R247 back to his room and began making arrangements for transfer to the emergency department. LPN-A indicated his vital signs were within normal limits for R276 and his oxygen saturations stayed between 89 to 90%. During interview on 2/06/19, at 10:15 a.m., Registered Nurse (RN)-E, indicated she was alerted on Monday from the charge nurse that R276 had choked on his food. RN-E further indicated a team was formed of the DON, CDM and herself to review the incident. During interview on 2/06/19 2:04 p.m., the DON indicated she wasn't present at the time of the incident stating I'm relying on what is documented. The DON indicated that LPN-B told her R276 had choked on his food and she had filled out an internal report. The DON indicated once documentation was reviewed a vulnerable adult report was submitted and interventions were immediately put in place so this didn't happen to another resident. The DON further indicated the interventions included training by speech therapy for all dietary, nursing staff and feeding assistants that included what constituted thickened, honey consistency, and modified diet consistencies. During interview on 2/08/19, at 8:53 a.m., dietary aide (DA)-A indicated that education was recently completed on different diets and what resident could have for each diet category. DA-A further indicated they changed from dietary aide only looking at the resident dietary card to handing it to the cook prior to serving the food onto the plate. DA-A further indicated the cards were always by where the cook could look at them, but everyone is more alert to them now. She further stated accidents happen. During interview on 2/08/19, at 9:01 a.m., DA-B indicated that the card system changed from the DA's ordering the food to handing the cook the card and then ordering the food. It is a double check system now. She further indicated they had additional training on mechanical soft diets from speech therapy but they also went over all diet consistencies. DA-B further indicated that orientation for new staff now includes training on the first day of employment on diet types and training takes about 2 weeks. If new staff are comfortable and they feel ready, they will be on their own. DA-B further indicated she felt she had adequate training upon hire for therapeutic diets. I think this was a fluke accident. Review of the inservice education completed on therapeutic and mechanically altered diets sessions occurred 1/27/19, 1/31/19 and 2/6/19 and included all dietary staff members (dietary aides and cooks), nursing staff and paid feeding assistants. The CDM is monitoring dietary aides and cooks for compliance three to five times weekly in regard to the change in card system verification to ensure residents receive the appropriately prescribed diets. The Monarch diet orders guidelines dated 5/18 indicated the guidelines for mechanical soft meats were to be ground if not already in ground form. Exchange soft and bite sized ground meat, chopped or dental soft. The nutrition and menu planning competencies for food and nutrition services employees included: - Understands and follows prescribed diet orders. - Understand therapeutic diets and fluid restrictions and is able to follow menu spreadsheets, recipes and written orders for corresponding diet restrictions (ask cook). The past non-compliance that began on 1/27/19, was verified during the 2/7/19 onsite visit to have been corrected by 2/6/19. Verification of corrective action was confirmed by interview with a variety of nursing and dietary staff, observation and document review. Chart audits conducted verified diet orders were being followed an no other residents had failure to provide proper diet texture. Nursing and dietary staff were re-educated to the facility policy and revisions were made to the meal serving process to help prevent future incidents. This was verified as well upon onsite observation of meal service. Orientation process changes were put into place for new dietary staff to include orientation to modified diet textures on day 1 of employment, which was verified through training record review at the time of the visit.

Based on observation, interview and document review, the facility failed to assess and evaluate causal factors for falls, and failed to ensure adequate supervision and interventions were implemented to reduce falls, for 1 of 1 resident (R12) reviewed who sustained multiple falls. This deficient practice resulted in an immediate jeopardy (IJ) with the potential risk of serious harm, injury or death. In addition, the facility failed to comprehensively assess and ensure adequate supervision and interventions were implemented to reduce falls for 1 of 2 additional residents (R6) who sustained a humerus fracture resulting in harm that is not immediate jeopardy. The immediate jeopardy began on 10/22/17, when R12 first hit her head during falls and the facility failed to conduct an assessment of factors contributing to R12's falls, and failed to determine and implement effective interventions to reduce falls to prevent serious injury or death. The IJ was identified on 1/26/18, and the administrator and corporate clinical nursing staff were notified on 1/26/18, at 2:46 p.m. The immediate jeopardy was removed on 1/28/18, but noncompliance remained at the lower scope and severity level of G - isolated, which indicated actual harm that is not immediate jeopardy. Findings include: R12's significant change Minimum Data Set ((MDS) dated [DATE], indicated an admission date of [DATE], and identified [DIAGNOSES REDACTED]. The MDS further indicated R12 had moderate cognitive impairment and depressive symptoms, required extensive assistance with bed mobility, transfers, dressing, toilet use, personal hygiene, limited assistance with locomotion on/off the unit, and supervision with walking in room/corridor. The MDS also identified the resident was frequently incontinent of urine, experienced occasional pain (rated as moderate), utilized antipsychotic, opioid, and diuretic medications, and that R12 had experienced 2 or more falls with injury, and 2 or more falls with no injury since the prior assessment. R12's corresponding Care Area Assessment (CAA) completed 10/31/17, indicated R12 had been recently discharged from hospice services (on 10/13/17) related to (r/t) stability; had short and long term memory impairment; was frequently incontinent of urine; and was at risk for falls. CAA interventions related to incontinence included for staff to approach R12 every 2-3 hours and prn (as needed); fall interventions indicated staff were to provide 1-2 person assist with transfers and/or to utilize the EZ stand (a mechanical lift device) as needed for weakness. In addition, CAA interventions indicated R12 was to attend therapies for evaluation, and to increase strength/balance/endurance with transfers/ambulation; Antipsychotic meds (medication) use: [MEDICATION NAME] and [MEDICATION NAME] per orders for delusional/agitation behaviors; and implementation of body pillow, low bed, fall mat, non skid strips to floor and bright tape to call light. R12's current care plan, dated as last reviewed 11/9/17, identified R12 as a potential fall risk r/t frequent self transfers with unstable gait and transfer technique, history of falls, antipsychotic and narcotic medication use, and [DIAGNOSES REDACTED]. Care plan interventions included: (1) Anti lock brakes to w/c (wheelchair). (2) Body pillow to both sides of bed r/t fall prevention measures. (3) Bright tape to call light. (4) Concave mattress for bed r/t fall prevention measures to help res (resident) identify edges of mattress. (5) Essential oil [MEDICATION NAME] offered when repeatedly standing/unable to ambulate with staff in PM. (6) Floor mat at bed side when in bed (res does self transfer and is not always in place r/t constant self transfers.) (7) If res falls and refuses to get up off floor; ensure res is safe and leave until res cooperative with getting up off floor. (8) Keep call light placed within reach at all times. (9) low bed; (res self transfers into bed and might not have bed in low position r/t this.) (10) May have transfer belt on when out of bed (to allow staff to approach with attempted self transfer and assist with transfer). (11) Offer coffee and or snacks when in DR (dining room). Provide music in DR. (12) PT (physical therapy) to eval (evaluate) and treat. (13) Self transfers frequently; offer assist of 1 but do not force the issue. Allow res to self transfer at her pace. Offer assist to walk if she is walking in room/halls. (14) Trial of light touch call light when available per maintenance. A current Fall Risk Evaluation dated 12/18/17, revealed a score of 21 indicating R12 was a moderate risk for falls. The evaluation summary included: Fall risk assessment completed with moderate risks identified. Res has had multiple falls in facility since admission. History of falls prior to hospitalization undetermined. Res requires extensive assist 1-2 and EZ stand with transfers. Antipsychotic medications [MEDICATION NAME] & [MEDICATION NAME] per orders for delusional/agitated behaviors and narcotic [MEDICATION NAME] scheduled for control of back pain. Meds may add to risks for falls. Orthostatic BP's (blood pressure) & TD (tardive dyskinesia) monitored per policy. Vision and hearing within normal limits. Multiple falls from w/c & from bed as well while attempting to self transfer/ambulate. Dx (diagnosis) of severe dementia with delusions, limits res thought processes for safety and consequences of actions. Implementation of body pillow both sides of bed, low bed, concave mattress/raised edges, floor matt on both sides, soft touch call light, bright tape to call light, night light, anti lock brakes on w/c. Physical therapy working with resident and have requested to evaluate for ambulation program as recent falls with res attempting self transfers &/or ambulation. NP/MD (nurse practitioner/medical doctor) updated on falls and interventions as well as guardian. Staff continue to provide 1:1 interventions when res having agitation or repeated attempts to stand. The Resident Care Sheet utilized by the nursing assistants (NA) included these interventions: Every 2-3 hour toileting and repositioning. Fall prevention measures: low bed & floor mat at bedside. Night light added for fall prevention measure-ensure light is on. Anti-roll backs on w/c. Body pillows to each side of bed as fall prevention measure. May leave transfer belt on to res tolerance if attempting ambulation/self transfers. A revision 10/19/17 included: Staff to provide 1:1 & assist to calm/quiet area if res yelling/pacing when others enter/exit secure doors (disruptive to res cognition) believes people are entering her home. Bright tape to call light. A revision 11/7/17 included: soft touch call light. If res falls and refuses to get up off floor; ensure res is safe and leave until res cooperative with getting up off floor. If res sitting up on side of bed do not leave unattended. Assist res to lying position, or walkie (call), for assistance if need EZ stand to assist to w/c. This is for safety r/t falls out of bed. Raised edge mattress. A progress note on the date of R12's admission 9/6/17, documented at 11:02 a.m. indicated: Resident screaming, agitated, combative. Swinging at staff and threatening. Resident wanted out of bed and attempting to self transfer. Aides were trying to assist while resident combative. Nurse approached and asked resident if she would like to transfer to W/C or needed anything. Explained staff was there to help her. Resident screamed Get out of my room with vulgar language. After being approached again by the nurse, the resident screamed, I will beat the[***]out of you. Instructed staff to leave the room and give resident time to calm down to prevent injury. There isn't enough staff to do a 1:1 with resident at night. Floor mat in place. R12 had a total of five falls in September 2017 for which incident reports were reviewed: -9/7/17 - 3 falls total - (1) 3:31 a.m. - Fall from bed, found lying on left side on floor on floor mat. NA called for assistance at 1:00 a.m. (2) 8:30 a.m. - Fall from bed, found sitting next to her bed on floor mat; bed was in low position. Interventions: Implemented low bed and floor mat at bedside for resident fall and increased monitoring. R12 went back to sleep. (3) 1:00 p.m. - Fall from chair in resident room. Resident found on the floor on her right side with wheelchair several feet behind her. She was attempting to stand up stating, Whoosh, my feet slid out from under me. The report indicated the resident had initially said she had slight pain in her right elbow. A few minutes later resident c/o increasing pain and she stated her arm was swelling up. No swelling or noticeable deformity was present. Interventions identified post fall included: Request PT (physical therapy) to do evaluation of w/c for potential adjustments to minimize risks of falls from w/c eg (example) anti lock brakes or intervention determined appropriate per therapy. R12 was sent to hospital later in day with potential symptoms of stroke/tia (trans ischemic attack) for evaluation. Therapies to determine intervention and inform staff of decision regarding wheelchair. Review of R12's progress note dated 9/7/17, at 2:45 p.m., indicated R12 had experienced a non-responsive episode and when she awoken she'd had garbled speech and right sided weakness. The note indicated when R12 had been assessed, she'd had right eye drooping, was unable to smile on right side and had no hand grasp on the right side. The NP was updated and R12 was sent to the emergency room for evaluation. Resident was hospitalized from [DATE] - 9/13/17, and returned to the facility on [DATE] with hospice services in place. Review of R12's hospital discharge summary dated 9/13/17, indicated R12 had sustained a fall during the night of 9/8/17. The hospital discharge summary further indicated the resident liked to wander, was a fall risk, and for safety purposes required a sitter (a specifically designated person to stay with her at all times). -9/16/17, at 4:07 a.m. - The incident report indicated an NA had reported attempting to assist R12 into a recliner chair when R12 refused and slid from the bottom of the chair onto the floor. Follow-up interventions indicated: Res has been allowed to transfer and ambulate independently despite obvious poor balance and stability. The incident progress note indicated an interdisciplinary team review had been conducted however, no new interventions or assessment of R12's fall risk factors were identified. -9/27/17, at 12:20 a.m.- An incident report indicated R12 had been found sitting on the floor with her feet straight out touching the wall, sheets from another bed in the room that did not belong to her were pulled down as though she was going to crawl into the other bed. The report indicated R12 had reported she'd gotten dizzy and fell . Causal factors indicated the res reported dizziness with attempted self transfer. The report indicated the resident had been asleep in bed prior to occurrence; may have been sleepy yet and night time darkness may have contributed to confusion. Significant advanced dementia with poor insight into personal safety, consequences and physical limitations. No further interventions were identified or implemented as a result of this fall. R12 had a total of 12 falls in October 2017: -10/7/17, at 4:45 p.m.- dietary staff entered Whispering Hills (the dementia unit) and called for the nurse when they saw A resident (R12) on the floor. The incident documentation indicated R12 had been observed sitting on the floor in front of her wheelchair in the lobby near near the TV (television). At that time, R12 had stated, I just sat down here and had denied any pain or injury. The incident documentation indicated R12 had been assisted back into her w/c via Hoyer lift (a mechanical lift), had been examined for signs of injury, and none were noted. -10/7/17, at 4:58 p.m. resident is agitated after speaking to her husband. Observed resident sitting on the floor in front of her w/c out in the dining area. Insists she has a car here and was leaving to pick up her spouse. -10/12/17, at 10:12 p.m. fall from bed; an intervention identified in incident documentation was to offer resident warm blanket at bed time to promote sleep. -10/14/17, at 10:45 p.m. - found on floor next to bed attempting to get up, R12 was tying to find some socks as she reported cold feet; Intervention to ensure grippy socks are on. -10/15/17, at 11:40 p.m.) - found on floor in room, sitting with one leg bent underneath her, a clothes hanger was underneath her. R12 stated I was trying to get up and slid out of the bed. New interventions: will request to have maintenance place non skid strips to floor near foot end of bed and closet. -10/19/17, at 9:10 p.m. - found on floor in room, leaning up against bed with no clothing on, was unable to state what she was doing. New intervention: Call placed to PAC (physician assistant-certified) to provide update and review medications. Received order for scheduled pain med per PAC. -10/20/17, at 4:45 p.m. - sitting on the floor in her room at bedside foot of bed, right leg extended in front of her with left leg crossed underneath her at the knee. R12 stated, I tried to get up from bed. -10/22/17 - (2) falls - (1) 5:00 a.m. - found sitting on floor in room with back leaning against rocking chair; w/c to the right of body. The report identified immediate intervention: resident observed one to one until 6:00 a.m. (2) 5:45 p.m. - found on floor in room, lying on left side. The report indicated R12 reported she'd hit her head. the report further indicated the resident was very emotional stating she was scared. New interventions identified as a result of the fall: nurse practitioner to review meds and will have physical therapy evaluation. NP updated and reviewed res falls and condition with noted changes. -10/24/17 at 5:15 p.m. - fall from bed, R12 had recent changes in her narcotic and psychoactive medications this day. Interventions included placing non skid strips on the floor closer together and/or wider non-skid strips at bedside, physical therapy evaluation and bright tape on call light. - 10/28/17 at 7:40 a.m. - found on floor in room kneeling next to bed on fall mat. NP contacted for med review, no changes or further interventions put into place. -10/31/17 at 7:30 p.m.- found on floor next to bed. No further interventions to prevent falls were indicated. R12 had 17 falls in November 2017: -11/1/17, at 1:14 a.m. - found on floor- sitting on floor mat with back up against bed. New intervention: Body pillow to right side of body; will add larger body pillow to cue res to have assist with getting out of bed. -11/4/17, at 10:16 p.m. - found on knees in room with no shirt on, yelling at staff when trying to help resident off floor, extremely agitated and hitting out at staff. Immediate action - Nurse attempted to redirect and deescalate resident for 40 minutes. Resident on 1:1 staffing with nurse and aide. R12 was agitated and required intramuscular [MEDICATION NAME] (an antipsychotic medication) for her behaviors. -11/5/17 - 2 falls - (1) 8:40 a.m. - kneeling on floor mat beside bed. (2) 9:00 a.m. - fall from w/c. Nurse was in resident's bathroom getting a washcloth to get resident washed up and dressed for the day. Resident was sitting in her wheel chair and had reached into her closet to grab some clothes and fell out of her wheelchair into the closet. Resident's head was up against the wall. Resident stated she hit her head and felt where it was. There was no bump, bruise or redness on her head. Interventions: Call to NP to provide update and request review of meds and res overall condition. Request NP to see res on rounds 11/6/17. -11/6/17 (2) falls -(1) 5:20 a.m. - found on floor next to bed. No injury. (2) 8:10 a.m.- found on the floor in the dining room sitting next to a chair by the window with her wheelchair approximately 5 feet from her. Nurse conducting assessment remained with resident an additional 15 minutes to monitor mood and delusional status. Call to NP to update on condition and falls this am and through weekend per charge nurse. Education provided to staff to provide drink and include a snack while waiting for breakfast in lobby. -11/8/17 - 9:00 a.m. - fall from bed, body pillow noted on floor next to resident. New intervention: Implement left side body pillow in addition to pillow on right side currently in place -11/10/17 - 2 falls - (1) 2:50 a.m.- found on the floor sitting next to bed, appeared to have slid off the bed onto floor, did not hit head, floor mat in place, bed in low position and call-light in place. No injuries, no new interventions. (2) 7:00 a.m. - sitting on floor mat beside her bed, R12 reported she slid off bed. New intervention: Will trial light touch call light when available per maintenance. -11/14/17 - 4:30 p.m. - found on floor by bed in resident's room, on knees with wheelchair behind her, holding onto bed with right arm. Interventions included educating staff to identify if resident was tired and needed assist to bed. - 11/21/17 - 8:00 a.m. - found on the floor kneeling next to her bed on the floor mat, was seen several minutes earlier sitting on her bed with feet on her floor mat. New intervention to not leave resident alone on side of bed, NA had been obtaining supplies for morning cares when R12 fell . - 11/22/17 - 2 falls - (1) 4:15 a.m. - found on floor next to bed with her knees bent; appeared to have slid out of bed. Floor mat was in place as well as call light, no injuries. No further interventions. (2) 6:40 a.m. - Heard loud metal sound, R12 calling Help me from nursing office, lying on her right side with head next to file cabinet drawer. Kleenex lying next to her on the floor. I was reaching for my Kleenex and fell out of my chair. R12 complained of pain, and acknowledged she did hit her head against the outside of the closed file drawer. No signs of abrasions or bruising. New interventions: body pillow to one side of bed and bed pillow to other side. Will request to have 2nd body pillow for bed. 11/22 fall; will have staff cont (continue) to provide monitoring and to anticipate needs ongoing. Will request NP to review meds, falls and condition on rounds next visit. -11/24/17 - 2:00 a.m. - found on knees on floor next to bed. New intervention: Staff to monitor res with Q2h (every 2 hours) + toileting schedule when in bed at night and monitor needs ongoing for assistance as needed. -11/25/17 - 2 falls - (1) 1:45 a.m.- found on knees on floor mat beside bed. (2) 3:12 a.m.- found sitting on floor on mat beside bed, leaning against bed; resident was incontinent. The incident documentation indicated R12 had been assisted to the toilet at that time, but had refused during 1:45 a.m. rounds. - 11/27/17 - 9:16 p.m. - R12 was yelling her husband's name, found in the dining room on her stomach on the floor with her hands in front of her. Her wheelchair was near her feet. R12 hit her head. A raised red area on the right side of her forehead was noted. It measured 3 1/2 x 2 1/2 cm (centimeters). Rated pain for head at a 3/10. New intervention: Will request OT (occupational therapy) to do an eval (evaluation) for wheelchair positioning and comfort, continue with physical therapy. R12 had 7 falls in December 2017: - 12/8/17 - 9:30 p.m. - kneeling beside bed with upper torso leaning toward bed with arms resting on bed. No injury noted. Denied hitting head. Refused to have vital signs completed. She was hitting out at the nurse. - 12/12/17 - 7:30 a.m. - sitting on floor. The incident documentation indicated a new intervention: will request maintenance to place raised edge mattress to bed to further define edges of bed for resident to cue. - 12/14/17 - 1:45 p.m. - found on the floor in the dining room sitting on both of her knees and the wheelchair right behind her, attempting to remove the bracelet from her ankle, denied hitting her head, c/o pain on her right side. Assessed area and no injury noted with slight redness. - 12/16/17 - 5:15 p.m. - lying on right side next to wheelchair in front of dinner table, wheelchair breaks unlocked. Incident report documentation indicated R12 had stated, I stood up, I said 'I'm gonna go find the manager', and she came over, and then bam I hit the floor. The back of my head kind of hurts. The documentation indicated the incident happened during the supper meal with staff present in the room. The documentation indicated staff who had witnessed the fall had reported the resident did not hit her head. Following the fall, interventions identified included: Resident wears [MEDICATION NAME] to tx (treat) pedal [MEDICAL CONDITION]; res removes frequently per self ([MEDICATION NAME] cover the Wanderguard). Staff directed to assist res to reapply [MEDICATION NAME] or socks when noted as being off, as may become distracted with Wanderguard and fidget with it. Have requested therapies to assess for ambulation program if indicated for resident at this time. - 12/18/17 - 9:15 p.m.- yelling for help from her room. Upon entering resident room, found resident sitting on her bottom on the floor mat next to her bed. No further interventions listed. - 12/19/17 - 7:50 p.m. - laying on the floor in front of her wheelchair in the dining room, looked like she was sleeping. New intervention: Will add essential oil [MEDICATION NAME] to pm (evening) and hs (hour of sleep) schedules to provide for relaxation and restfulness. - 12/26/17 - 6:47 p.m. - found sitting on the floor in the hallway. Staff education provided to continue to provide monitoring of res location and provide intervention when attempting to stand. Ambulation program initiated per therapy. R12 sustained 11 falls in January 2018: - 1/3/18 - 7:15 a.m.- Incident documentation indicated R12 was sitting on a body pillow which had slid towards the floor and res feet on the floor. At that time, the call light was on and was noted to have been pulled out of the wall unit. - 1/4/18 - 3:45 p.m. - Fall from bed. At 2:15 pm nurse was called to room, R12 was sitting on the floor mat in front of her bed with right leg bent to the right. Her back was against the bed and she was facing the closet. Resident was able to move all extremities without difficulty or pain except for right knee. Did complain of pain with movement. She rated the pain at a 10/10. Right knee was not red or swollen. Refused ice to be applied. Scheduled pain medication [MEDICATION NAME] was given at around 3:50 p.m Documentation on the Medication Administration Record [REDACTED]. Following the incident, interventions identified included: PT to see resident for evaluation have staff offer ambulation prior to naps to allow res restful period of time in bed. - 1/11/18 - 3:50 p.m. - Incident documentation indicated R12 had been found on the floor in the hallway outside of room [ROOM NUMBER] (nursing office) next to her wheelchair. She had been standing up and sitting down at the grab bar only several minutes earlier, and had complained of pain initially in her right shoulder but the pain subsided in 5 minutes. The incident report included causal factor identified as: res attempted self transfer due to delusional thoughts and believing she had the ability to stand/ambulate per self. Resident is not able to realize physical limitations and personal safety concerns due to severe cognitive deficits. Interventions: Will have staff utilize [MEDICATION NAME] oil when noting res to be repetitively standing and unable to ambulate. Reviewed and discussed with SE (southeast) charge nurse and in agreement. - 1/14/18 - 3 falls - (1) 4:30 p.m. - found on floor, kneeling on her hands and knees in the hallway down the 100 wing. Had been standing and sitting for quite some time. I was picking up my slippers. (2) 6:45 p.m. - found on floor, lying on her right side in front of her wheelchair. Says she was going to make supper. (3) 10:00 p.m.- found on floor in room kneeling next to bed. Interventions following the three falls were identified to include: staff to offer assist with donning/doffing items; staff to provide verbal offers of assistance to meet needs when aware of focus,will have staff check in next hour for toileting need to meet need prior to incontinence/self transfer. Additional notes indicated the resident had a dx (diagnosis) of dementia with delusional thoughts and hallucinations, res alert to self and immediate family, general surroundings limits res ability to make safe choices, unaware of physical limitations and does not have ability to comprehend consequences of choices. Identified goal included: to provide interventions to prevent injury when falls occur. - 1/15/18 - 4:55 p.m.- found sitting on her knees in the dining room in front of her wheelchair. Causal factor identified as res attempted self transfer with belief she could physically do this, staff to provide conversation with resident during meal. - 1/16/18 - (2) falls - (1) 12:25 a.m. - found sitting on floor next to bed on the floor mat. Resident stated that she woke up and wanted to get out of bed. (2) 7:18 a.m. - found sitting on floor next to bed on floor mat, stated she wanted to go to the bathroom and got out of bed. Causal factors: 2 falls on this day, both on floor mat beside bed. The incident documentation indicated R12 had likely awakened and may have believed it was time to get up and attempted self transfer. At 7:15 a.m. the resident had been wet, and documentation indicated the resident had last been toileted at 6:50 a.m. and had urinated. The documentation further included: R12 Has impaired ability to perceive physical limitations, consequences of actions and personal safety. Delusions are very real to resident. [MEDICATION NAME] oil provided a.m. and 8 p.m. Will adjust time for administration to be three times daily to aid for sleep through night. Fall interventions in place are effective for goals of no major injury. - 1/19/18 - 11:00 p.m.- Incident documentation indicated R12 had fallen from bed and the NA had heard her yelling. R12 was on the floor sitting on a bed mat on the left side of bed with feet pointing toward window. Denied hitting head. No injury noted, kept asking if everything was off the stove. Reassured her it was. Causal factor identified as dx of dementia with delusional thoughts leading res to attempt to get up 'to turn the stove off'. Dx of dementia is severe with delusions and hallucinations. Res believes she is able to self transfer. Does not comprehend personal safety or physical limitations. Does not understand consequences of own actions. The post fall intervention note indicated interventions in place are effective for goals of no major injury when res does fall . no injury noted with falls. MD (physician name) updated 1/18/18 and in agreement this is an appropriate goal for resident. - 1/26/18 - 5:16 a.m. - incident documentation indicated R12 had been found on floor, call light went off when staff were walking by room, resident was kneeling next to her bed holding the call light. At that time, the resident stated that she couldn't get her light to turn on, was awake and ready to get up. R12 had experienced 47 falls since admission in September of 2017. The record indicated R12's [DIAGNOSES REDACTED]. Although numerous interventions were attempted post falls, there had been no comprehensive evaluation of the resident's falls, response to interventions, and or evaluation of medication use in relationship to falls. In addition, with the exception of limited 1:1 monitoring post falls, no additional monitoring or supervision had been implemented. During a supper observation on 1/23/18, at 5:00 p.m. in the dining area of the Whispering Hills memory care unit, R12 was not present during the meal. The Whispering Hills memory care unit was observed to consist of a large common dining and day room area, which opened up to a long corridor of resident rooms. Residents who were in their rooms were not visible from the common area. When interviewed on 1/23/18, at 6:30 p.m. NA-A confirmed R12 had been sleeping during supper and did not want to come out to the dining room. When interviewed on 1/23/18, at 6:57 p.m. licensed practical nurse (LPN)-A stated R12 had been very tired that day and stated they kinda go with her schedule. LPN-A stated the resident has times when she has a lot of energy and during those times she is up more. LPN-A stated then she rights herself with respect to her sleep needs. LPN-A stated once R12 gets up she'll be hungry and they will feed her supper at that time. During observation on 1/24/18, at 8:49 a.m, R12 was standing up in front of her w/c in the hallway; another male resident was seated in his wheelchair near R12. Prior to this, R12 had been observed with her hand on the arms of the w/c trying to push herself up. R12 was observed to stand up for approximately 10 seconds then sat back down in her w/c; no staff were present in the area at that time. Instead, staff were observed to be in the dining room assisting other residents with breakfast; R12 had not yet eaten breakfast. During observation on 1/24/18, at 3:06 p.m. R12 was lying in bed with eyes closed and appeared to be sleeping. R12's bed was in the low position with a fall mat on the floor next to the bed on the right side. A call light was clipped to the covers near R12's left hand. The call light was noted to be a push button call light (not soft touch with colored tape which had been identified as appropriate on R12's care plan). A body pillow was observed to have been placed on the left side of the resident. During observation on 1/25/18, at 10:05 a.m., R12 was being transported by wheelchair to the dining room by the activity director (AD) to participate in an exercise activity. R12 was observed to stand up several times after the AD had parked her wheelchair. At one point R12 indicated she wanted something thrown away for her. R12 appeared unsteady on her feet. When interviewed on 1/25/18, at 4:42 p.m. NA-B stated R12 is toileted every two hours and if she refuses, staff will reapproach about 15 minutes later and ask her again. NA-B confirmed the resident would sometimes crawl out of bed at night. NA-B stated if R12 does this, nursing assistant staff try to look in on her more frequently than every two hours. NA-B also said R12 likes to hold onto the hand rail and stand up for a bit and then sit down. NA-B said when R12 does this staff will put the brakes on on her w/c so it doesn't roll away, but will stay within site of the resident. NA-B did not indicate there was any additional monitoring or supervision in place for R12, outside of standard every two hour checks. When interviewed /26/18, at 9:45 a.m. registered nurse manager (RN)-A stated R12 was no longer receiving therapy. When interviewed on 1/26/18, at 9:55 a.m. NA-F stated R12 was on a walking program twice a day and when attempting self transfers. NA-F did not indicate any additional supervision or monitoring in place for R12. When interviewed on 1/26/18, at 10:04 a.m. NA-C stated staff try to keep the residents in the hallway where they can see them while they're charting. NA-C stated the nurses will also help by having the residents sit with them in the nurses' station. NA-C did not identify R12 as having any additional supervision or monitoring. When interviewed on 1/26/18, at 10:16 a.m. NA-G confirmed she worked full-time overnights but also picked up other shifts on the Whispering Hills unit. NA-G stated she worked in the unit at least once a week. NA-G confirmed that night staf (TRUNCATED)