Every finding on record at Hilltop Healthcare Rehabilitation and Skilled Nurs

Based on observations, interviews, and record reviews the facility failed to have resident meals served within 45 minutes of the start of the posted scheduled mealtimes. This affected all 103 residents in the facility.Findings include:Signs posted throughout the facility indicated breakfast on Cedar, Elm and Spruce units started at 7:45 a.m. Breakfast on [NAME] (memory care unit) started at 8:15 a.m. Lunch on Cedar, Elm, and Spruce units started at 12:00 p.m., and lunch on [NAME] started at 12:30 p.m. Dinner on Cedar, Elm, and Spruce units started at 5:45 p.m., and dinner on [NAME] started at 6:15 p.m.During an observation at the Cedar unit on 3/9/26 at 7:45 a.m., food arrived at the kitchenette, had been placed on the steam tables and had been temperature checked. One culinary aide (CA) was in the kitchenette, and two nurse assistants (NA)s were in the dining hall. The CA and NAs were observed conversing and looking into the dining hall with residents waiting for their meals. At 8:15a.m., the CA began dishing up plates of food and the NA's began placing trays of food into meal carts. At 8:28 a.m., one aide left the dining hall with the meal cart to hallway 1. The other aide stayed in the dining hall to serve residents present. The last resident on Cedar unit did not receive their meal until 9: 03 a.m. This was 1 hour and 18 minutes after the scheduled start of mealtime.During an observation on the Cedar unit on 3/9/26 at 12:00 p.m., the food had arrived at the unit and was ready to be served. The last resident did not receive their tray until 1:02 p.m. 1 hour after the scheduled start of mealtime.On 3/10/26 at 5:32 p.m. an announcement was made that dinner service would start 30 minutes later than scheduled.During an observation on the Cedar unit of 3/10/26 that began at 5:45 p.m., residents were in the dining room along with nursing staff, waiting for food to arrive. At 6:26 p.m., food arrived and was placed in the kitchenette steam tables. Trays were set up and placed in the tray carts to go to hallway 1. At 6:39 p.m., the tray cart left for hallway one and the first resident in the dining hall received their tray. The last resident received their tray at 7:12 p.m. 1 hour and 27 minutes after the scheduled start of mealtime.During an observation on the Spruce unit on 3/10/26 that began at 5:45 p.m., (the start of dinner service). The first tray was not passed until 6:35 p.m., with the last tray passed at 7:16 p.m. 1 hour and 31 minutes after the start of mealtime.During an observation on the [NAME] unit on 3/10/26 at 5:54 p.m., food had arrived on the unit. At 6:45 p.m. nursing staff were in the dining hall with the residents, but no culinary staff had arrived. Residents had started to get restless. At 6:59 p.m., culinary staff arrived on unit, and the meal service began. At 7:25 p.m., the last resident was served. 1 hour and 10 minutes after the scheduled start of mealtime.During an interview on 3/10/26 at 6:45 p.m. registered nurse (RN)-A stated the facility had been on a streak where the dinner had been always late.During an interview on 3/11/26 at 12:52 PM CA-A stated the NA would give them the meal ticket, the CA would fill the plate and then the NA would set the tray up and deliver the meal. A lot of times there would be delays because either the food did not make it up in time, issues in the kitchen, and equipment forgotten or the CA would have to wait for nursing staff to get into the dining hall to start getting trays ready and getting them passed.During an interview on 3/12/26 at 9:35 a.m. NA-A stated several times the food would be late because staff would still be getting residents up and out of bed. When there were a lot of residents who needed assistance up it took more time.During an interview on 3/12/26 at 10:03 a.m. the culinary services manager (CSM) stated both the kitchen staff and the nursing staff worked together to make sure meals were passed timely. The times posted were the times when meal service began and passing of trays to the residents should begin at that time. An allowable amount of time would be 45 minutes for all residents to be fed, but anything beyond an hour from start of service was to long for residents to wait for meals. During an interview on 3/12/26 at 10:42 am the administrator and administrator of record both stated 45 minutes to an hour is ok for all residents on a unit to be served meals. Anything beyond one hour from start of mealtimes is not acceptable.On 3/12/26 at 11:48 a.m., an announcement was again made that the lunch service on that day would start 30 minutes late.The dining hall and service line policy was requested but not provided.

Based on observation and interview, the facility failed to ensure that proper glove use and hygiene was completed during food service. This had the ability to affect all 26 residents on the [NAME] unit.Findings include: On 03/10/2026 at 6:59 p.m., cook (C)-A arrived in dining room to begin plating meals on [NAME] unit. C-A began removing plastic coverings from food in steam table. C-A then left and went to another unit and grabbed a cart with cups. She then returned near steam table and donned gloves. No observation of hand sanitization. She grabbed a plate and ladle, placed them down, then went to the fridge and grabbed another metal tray and placed in the steam table. She then grabbed a plate and began plating food from steam table. Other staff members poured drinks and began to serve plated food. With the same gloves on, C-A went to another unit touching door handles on her way and returned carrying plates covers. With same gloved hands she placed them on the counter and grabbed another plate and began plating food. During plating of food she went to fridge, opened fridge, grabbed another metal container and placed it in the steam table with the same gloved hands. She then continued to plate food touching the bread of each sandwich with the same gloved hands and placing them on plates.During interview on 03/10/2026 at 7:26 p.m., C-A stated, that is my bad. I should have taken off my gloves, went out there, sanitized my hands, and put on new gloves prior to plating food.During interview on 03/12/2026 at 10:38 a.m., the director of nursing (DON) stated that her expectation would be that the staff would have removed the gloves, completed hand hygiene, and donned new gloves prior to plating food.

Based on interview and record review, the facility failed to ensure timely implementation of a pharmacist recommendation and subsequent provider order to help prevent unnecessary medication use for 1 of 5 residents (R83) reviewed for unnecessary medications.Findings include:R83's quarterly minimum data set (MDS) dated [DATE], identified intact cognition and diagnoses of congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), diabetes mellitus, and hypertension.R83's provider orders dated 3/25/25, identified acidophilus (a supplement with beneficial bacterium) two times per day for prevention of urinary tract infections (UTI).A document, Physician/Provider Recommendation dated 9/12/25, identified a pharmacist recommendation to consider a trial discontinuation of acidophilus to help prevent polypharmacy, excessive pill burden, and unnecessary medication. The provider responded on 10/3/25 to discontinue lactobacillus (acidophilus) due to therapy completed.During an interview on 3/12/26 at 12:02 p.m., registered nurse (RN)-E, a nurse manager, stated the pharmacy recommendations went to the providers as soon as they got to the nurse managers. RN-E added she wasn't sure what happened with this one, her expectation would be that all orders were acted on.During an interview on 3/12/26 at 2:52 p.m., the pharmacist consultant (PC)-G stated she would expect follow up on pharmacy recommendations within 30 days. A policy regarding unnecessary medications, non-psychotropic, was not received.

Based on observation, interview and document review, the facility failed to ensure the care plan was followed to prevent potential aspiration for 1 of 9 residents (R99) reviewed for accidents.Findings include:R99's Medicare 5 day Minimum Data Set (MDS) dated [DATE], identified R99 had diagnoses which included enterocolitis due to clostridium difficile recurrent (a severe infection causing inflammation of the colon [large intestine]), retention of urine, pressure ulcer, dysphagia (difficulty swallowing), and long term use of opiate (a type of medication that acts on the central nervous system to reduce pain, cause sleep, or induce feeling of euphoria). R99's MDS identified she required set up for meals.R99's Order summary identified R99 has orders for a cardiac mechanical soft texture, regular/think consistency dated 3/4/26.R99's care plan dated 2/13/26, identified R99 had actual complications with deficits with activities of daily living related to current medical/physical status. Interventions included eating; set up, ensure resident is up in wheelchair for all meals, encourage to eat in the dining room, upright at 90 degrees for oral intake and for 30 minutes afterwards. R39's swallow evaluation dated 2/24/26, identified strategies recommended by speech therapy were to have the resident alternate liquids and solids, general swallow techniques/precautions and bolus size modifications and have an upright posture during meals and for greater than 30 minutes after meals. During an observation on 3/11/26 at 8:28 a.m., room trays were being passed to residents who were eating in their rooms. R99 received her breakfast in her bed.-at 8:34 a.m., R99 was seated in her bed. The bed was elevated to about 45 degrees as she was eating her breakfast.-at 8:49 a.m., R99 remained in bed. Both hands were under the covers; she was still at about 45 degrees her tray remained on the overbed table in front of her.-at 1:22 p.m., R99 was observed in bed eating lunch. Her bed was at about 45 degrees.During an interview on 3/11/26 at 1:24 p.m., registered nurse (RN)-B looked in R99's room and verified the bed was elevated at about 45 degrees. RN-B stated the bed should be at 90 degrees when R99 declined to get out of bed and come to the dining room for her meals. RN-B stated the head of the bed at 90 degrees was important to prevent choking.A policy on dysphagia was requested but not provided.

Based on observation, interview and document review, the facility failed to monitor weights to identify possible congestive heart failure (CHF) exacerbation for 1 of 1 resident (R119) reviewed for quality of care.Findings include:R119's entry Minimum Data Set (MDS) dated [DATE], identified R119's cognition had not been assessed. R119's diagnoses included acute on chronic CHF, acute resp failure with hypercapnia, diabetes mellitus type 2 (DM2), hypertension (HTN), morbid obesity, and obstructive sleep apnea (OSA).R119's 48-hour Care Plan (paper document) dated 3/6/26 indicated R119 is cognitively intact with admission diagnoses of acute diastolic heart failure and obesity.R119's care plan dated 3/12/26, instructed:Record weights a minimum of monthly or per MD/RDN.R119's provider orders dated 3/12/26 included:Daily weight one time a day related to acute diastolic (congestive) heart failure, ordered 3/9/26.Elevate legs and prevent extended periods where legs are down, every dayshift for lower extremity edema management.Bumetanide Oral Tablet 2 MG (Bumetanide) Give 1 tablet by mouth at bedtime related to acute on chronic diastolic (congestive) heart failure.Spironolactone Oral Tablet 25 MG (Spironolactone) Give 1 tablet by mouth one time a day related to acute on chronic diastolic (congestive) heart failure.R119's treatment administration record (TAR) dated 3/12/26, instructed staff to obtain a daily weight one time a day related to CHF, with order dated 3/9/26 at 12:51 p.m.R119's Admission/readmission Tool dated 3/6/26 at 2:50 p.m., identified a most recent weight of 327.0 dated 9/23/25 while other most recent vitals were dated 3/6/26.Review of R119's weight record dated 3/12/26, identified an admission weight dated 3/6/26, a struck-out weight dated 3/10/26, and two weights on 3/11/26 (at 10:14 a.m. and 5:40 p.m.). This record was also reviewed on 3/9/26 and no weights were entered at that time.R119's nurse progress notes for 3/2026 were requested but not received.During an observation on 3/9/26 at 1:05 p.m., R119 was in their wheelchair in their room. They asked registered nurse (RN)-C to assist with elevating their legs on the bed. RN-C assisted with positioning bilateral legs on bed. R119 stated his physician wanted him to elevate his legs often to reduce swelling.During an interview on 3/11/26 at 3:39 p.m., RN-B stated staff obtain a weight on admission, residents with CHF would be weighed daily, and all residents were weighed weekly on their shower day. They stated the nurse enters the standing order when a resident with CHF is admitted . They confirmed their concern that weight gain in a CHF resident could be a sign of fluid retention, which could lead to breathing issues and the need for diuresis. RN-B stated they identified on 3/9/26 that R119 had no order for daily weights and entered the standing order. Reviewing R119's weight record, they confirmed that no admission weight was entered and R119 had a recorded weight gain of 19.1 pounds in one day (338.3 pounds on 3/10/26 to 357.4 pounds on 3/11/26). RN-B stated they were present at R119's admission, requested a mechanical lift weight, and observed it being done.During an interview on 3/12/26 at 10:11 a.m., RN-C stated vitals, including weight, would be taken immediately on admission. They stated the standing order was daily weights for three days then weekly unless there was a specific order for a resident with CHF or dietary concerns which required continuing daily weights. They confirmed they would be concerned for significant weight change in a resident with CHF. RN-C stated if there was a weight change, they would reweigh the resident and notify the physician of a significant change.During an interview on 3/12/26 at 10:15 a.m., RN-B stated they found R119's admission weight on the admission nurse's handwritten notes. RN-B stated they entered the weight historically in R119's medical record. RN-B stated the nurse that entered R119's weight on 3/10/26 thought it was entered incorrectly so RN-B struck the weight from R119's record.During an interview on 3/12/26 at 10:24 a.m., director of nursing (DON) stated vitals, including weight would be taken on resident admission, then daily weight for three days to establish a baseline, and then weekly unless the resident has CHF or malnutrition diagnoses, which may require more frequent monitoring. The DON stated if there is a weight discrepancy, the electronic medical record would flag it in red, and they expected staff to reweigh the resident for accuracy, complete an assessment, and update the provider. The facility parameters for significant weight loss was more than 2 pounds overnight or 5 pounds in a week. With weight gain in CHF residents, the DON was concerned for fluid retention, shortness of breath, edema, and CHF exacerbation.Review of undated facility document of hand-written nurse notes indicated R119's admission weight was 352.8.The facility document Standing Orders for Skilled Nursing Facilities signed and dated 6/13/25, in admission to facility, indicated daily weights for residents with heart failure unless otherwise directed.

Based on interview and document review the facility failed to investigate an accident that resulted in injuries for 1 of 8 residents (R106) reviewed for accidents. Findings include:R106's quarterly Minimum Data Set, dated [DATE], identified R106 had diagnoses which included disease of spinal cord, dementia, diabetes mellitus, paranoid schizophrenia, insomnia, nicotine dependence, tobacco use, and repeated falls. In addition, R106's MDS identified he was moderately cognitively intact.R106's current care plan report identified he was at risk for falls. Interventions included the following:Call light positioned for easy access initiated on 4/10/25Fall Review per facility protocol initiated on 4/10/25Have commonly used articles within easy reach initiated on 4/10/25Wheelchair-anti-rollbacks initiated on 5/19/25Call don't fall sign placed initiated on 5/19/25R106's care plan report identified R106 smoked. Interventions included the following:Assess for safe smoking practice upon admission, quarterly, and as needed initiated on 4/10/25Educate/remind of the facility smoking policy as needed. Has agreed to follow the policy initiated on 4/10/25Smoking material will be stored in locked drawer in room or designated safe area for example on person or in a pocket initiated on 4/10/25The facility smoking list provided on 3/9/26, listed R106 as a current smoker.The facility's investigation of R106's fall on 1/26/26, identified the following:The date the incident occurred, the location, R106's description of the incident (he was unable to say how he fell), immediate actions taken (lifted off of the ground with an assist of two, brought inside, nasal bleeding stopped, sent to the emergency department for evaluation). The explanation was Fell off his w/c (wheelchair) outside in the smoking area. Unable to explain incident. No statements gathered, no further notes on follow-up, no root cause analysis, no changes made to R106's care plan.During an interview on 3/11/26 at 2:36 p.m., registered nurse (RN)-D stated he was unsure if a root cause analysis had been completed after R106's fall. He stated they did not complete a smoking assessment after the fall citing the resident's power of attorney no longer wanted R106 to smoke. During an interview on 3/12/26 at 11:36 p.m., the director of nursing (DON) verified that a thorough investigation of R106's fall had not been documented. The DON stated there was not any education completed for staff on falls, smoking, or smoking during inclement weather. The DON stated it was important to complete a root cause analysis to figure out why the incident occurred, and to prevent reoccurrence. The facility's root cause analysis of the incident was requested but not provided. Incident Investigation Procedure dated 2/8/24, identified, All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. The policy identified any corrective action would be documented and other pertinent data as necessary or required. The policy further identified, Incident/accident reports will be reviewed by the safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities.

Based on interview and record review, the facility failed to ensure a resident prescribed an as needed (PRN) antipsychotic (AP) medication received a face-to-face visit with the provider before re-ordering the medication and failed to have documentation to support PRN AP medication use for 1 of 5 residents (R83) reviewed for unnecessary medications.Findings include:R83's quarterly minimum data set (MDS) dated [DATE], identified intact cognition and diagnoses of dysthymic disorder, anxiety, adjustment insomnia, and delusional disorder. Section N identified R83 took an AP medication.R83's care plan . Mood/behavior - observe/monitor/document behaviors/m ood and notify supervisor, SW and/or MD as needed, psych services as ordered, at risk for agitation and reassure and reapproach as needed. Risk for noncompliance.R83's electronic medical record (EMR) identified the following in 2026:1/10, an order for olanzapine (an atypical antipsychotic medication) 5 mg tablet by mouth PRN one time a day for agitation or anxiety for 14 days, discontinue on 1/23/26.1/11, a medication administration record (MAR) entry for PRN olanzapine 5 mg.1/13, a MAR entry for PRN olanzapine 5 mg.1/21, a MAR entry for PRN olanzapine 5 mg.1/23, an order for olanzapine 5 mg tablet by mouth PRN one time a day for agitation or anxiety for 14 days, discontinue on 2/26/26.1/27, a MAR entry for PRN olanzapine 5 mg.2/26, an order for olanzapine 5 mg tablet by mouth PRN one time a day, discontinue on 3/2.2/26, a MAR entry for PRN olanzapine 5 mg.3/2, an order for olanzapine 5 mg tablet by mouth PRN one time a day for agitation or anxiety, discontinue on 3/12.3/4, a MAR entry for PRN olanzapine 5 mg.Evidence of correlating behavior documentation and face-to-face provider visits weren't found in R83's EMR. During an interview on 3/12/26 at 12:11 p.m., RN-E, a nurse manager, would expect an order to be discontinued after 14 days if that is what the order was for, and stated she wasn't sure what happened. RN-E stated her expectation was for behavior charting to be done every shift and when using a PRN AP medication. During an interview on 3/12/26 at 2:59 p.m., pharmacy consultant (PC)-G would have expected the order to stop after 14 days, and for the provider to see the resident face to face if renewing an as-needed antipsychotic. A policy, Unnecessary Drugs-Psychotropic Drugs dated 2/27/23, identified residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. PRN orders for psychotropic medications will be limited to 14 days unless the physician identifies the rationale to extend the medication beyond 14 days. PRN antipsychotic drugs will be limited to 14 days and will not be renewed unless the physician evaluates the resident for appropriateness of the medication. The provider should determine and document the following:Is the antipsychotic medication still needed on a PRN basis?What is the benefit of the medication to the resident?Have the resident's expressions or indications of distress improved as a result of the PRN medication?

Based on interview and document review the facility failed to update a resident's care plan, including the resident's inability to safely smoke after a fall from wheelchair while smoking, for 1 of 1 resident (R106) reviewed for accidents.Findings include:R106's quarterly Minimum Data Set, dated [DATE], identified R106 had diagnoses which included disease of spinal cord, dementia, diabetes mellitus, paranoid schizophrenia, insomnia, nicotine dependence, tobacco use, and repeated falls. In addition, R106's MDS identified he was moderately cognitively intact.R106's current care plan report identified he was at risk for falls. Interventions included the following:Call light positioned for easy access initiated on 4/10/25Fall Review per facility protocol initiated on 4/10/25Have commonly used articles within easy reach initiated on 4/10/25Wheelchair-anti-rollbacks initiated on 5/19/25Call don't fall sign placed initiated on 5/19/25R106's care plan report identified R106 smoked. Interventions included the following:Assess for safe smoking practice upon admission, quarterly, and as needed initiated on 4/10/25Educate/remind of the facility smoking policy as needed. Has agreed to follow the policy initiated on 4/10/25Smoking material will be stored in locked drawer in room or designated safe area for example on person or in a pocket initiated on 4/10/25The facility smoking list provided on 3/9/26, listed R106 as a current smoker.The facility's investigation of R106's fall on 1/26/26, identified the following:The date the incident occurred, the location, R106's description of the incident (he was unable), immediate actions taken (lifted off of the ground with an assist of two, brought inside, nasal bleeding stopped, sent to the emergency department for evaluation). The explanation was Fell off his w/c (wheelchair) outside in the smoking area. Unable to explain incident. No statements gathered, no further notes on follow-up, no root cause analysis, no changes made to R106's care plan.During an interview on 3/11/26 at 2:36 p.m., registered nurse (RN)-D recalled the incident when R106 fell. RN-D was unsure if R106's care plan had been updated but did state his power of attorney no longer wanted R106 to smoke, RN-D reviewed the care plan and verified it had not been updated.During an interview on 3/12/26 at 11:36 a.m., the director of nursing (DON) verified there were no updates made to the resident's care plan after the incident.Incident Investigation Procedure dated 2/8/24, identified, All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. The policy identified any corrective action would be documented and other pertinent data as necessary or required. The policy further identified, Incident/accident reports will be reviewed by the safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities.

Based on interview and record review, the facility failed to meet the requirements for a bed hold notification, including having it in writing and including contact information for the area office of ombudsman for long term care, for 1 of 2 residents (R51) reviewed for hospitalization.Findings include:R51's annual minimum data set (MDS) dated [DATE], identified intact cognition and a diagnosis of chronic pulmonary edema.R51's electronic medical record (EMR) identified R51 was transferred to the hospital on 3/7/26 at 11:26 p.m. A progress note identified a resident transfer charting template which included the reason for the transfer and other questions where the writer could enter in the text. There was an affirmative response to the question does resident or power of attorney (POA) want a bed hold?.During an interview on 3/11/26 at 11:56 a.m., registered nurse (RN)-F stated bed holds were done on a form, and they would ask the resident if they wanted a bed hold but wasn't sure what the current process was because they were trying to get rid of paper, but he could find out.During an interview on 3/11/26 at 12:00 p.m., RN-B stated they would make note of whether the resident wanted a bed hold. RN-B thought there was a form the resident would sign and probably get uploaded to the chart. During an interview on 3/11/26 at 1:04 p.m., the director of nursing (DON) demonstrated the template used in the electronic medical record (EMR) when residents were transferred out of the facility indicating if they wanted a bed hold or not. The DON added they had just changed to this process, but they did go over bed hold information with residents on admit and annually. A policy, Bed Holds dated 9/8/24, identified the resident or responsible party must be notified concerning the bed hold policy of Hilltop Healthcare and sign the policy as evidence that they have been properly notified prior to being charged for any service. A copy of this policy will be sent with the resident when transferred to the hospital. At the time of transfer or therapeutic leave, staff will provide the current resident/responsible party with a copy of the policy. In case of emergency transfer, staff will attempt to provide the resident with a copy and will notify the responsible party of the transfer and policy within twenty-four (24) hours. Staff will follow up with a phone call to clarify any questions concerning the policy on the next working business day.

Based on observation, interview and document review, the facility failed to ensure the required nurse staffing information included the required information and was posted on the weekend. This had the potential to affect all 103 residents, families and visitors who would wish to review the information.Findings include:During an observation on 3/9/26 at 7:27 a.m., the nurse staffing was posted in the main hallway where visitors entered. The posting was dated 3/6/26, it had the name of the facility at the top of the page, the date and the day of the week, the census, the nursing hours and the hours per patient day. Below these were listed the roles starting with the certified nursing assistant listed as 25 with a total of 189.5 hours. Licensed practical nurses were listed as four with a total of 29.5 hours. Registered nurses were listed as 10 with a total of 84 hours. The posting dated 3/6/26 was for Friday in addition, the posting lacked nurse staffing separated out by shifts and did not include any information on trained medication aides.During an interview on 3/12/26, staffing coordinator (SC)-D stated the nurse staffing was supposed to be posted daily which would include weekends. SC-D also verified the posting was supposed to include the staff working by shift and not just a total of all hours worked in a 24-hour period.During an interview on 3/12/26 at 12:16 p.m., the director on nursing (DON) stated the staff posting was supposed to be posted for families and residents so they would be able to see how many staff were working on each shift.The Daily Staff Posting dated 10/17/25, identified the posting would include the following information: Content Requirement: Posting must include the number of nursing staff (RN, LPN, TMA, CAN) on duty per shift. Must list the total number and actual hours worked along with the current resident census. The title identified the posting would be posted daily.

Based on interview and document review, the facility failed to consistently offer and provide a nutrient and/or calorie substantive snack after the dinner meal and before bedtime, leaving 15 hours between the evening and morning meals. This had the potential to affect all 107 residents at the facility. Findings include: During interview on 4/28/25 at 7:13 p.m., R60, whose quarterly Minimum Data Set (MDS) dated [DATE] identified intact cognition, stated the facility staff do not come and deliver a bedtime snack. During interview on 4/28/25 at 1:12 p.m., R5, whose quarterly MDS dated [DATE] identified intact cognition, stated no snacks were offered in the evening. During resident council meeting on 4/30/25 at 1:30 p.m., the following residents voiced concerns about snacks: -R9, whose quarterly MDS dated [DATE] identified intact cognition, stated staff never bring snacks around to residents. R9 also stated the snacks residents have received were not substantial enough. -R39, whose quarterly MDS dated [DATE] identified intact cognition, stated staff do not bring snack around to residents. R39 also stated there was not enough snack at times, and there was not a good variety of snacks. During interview on 5/1/25 at 2:09 p.m., registered nurse (RN)-E stated snacks were available on the unit and residents have to ask for a snack. RN-E stated being unaware if there were snack carts. During interview on 5/1/25 at 2:15 p.m., certified nursing assistant (CNA)-B stated there were a good variety of snacks available to the residents at any time, and residents needed to ask for a snack. CNA-B further stated there were no snack carts brought to the residents. During interview on 5/2/25 at 10:09 a.m., licensed practical nurse (LPN)-A stated residents were able to get a snack anytime. LPN-A further identified residents would ask staff for a snack, and was not sure if there were snack carts. During interview on 5/2/25 at 1:06 p.m., director of nursing (DON) stated expectation that snacks were offered to residents before bedtime. Hilltop Healthcare Meal Cart Delivery Times undated, identified the following times for meal cart delivery on different units: CEDAR BREAKFAST- 7:45 AM- 8:05 AM LUNCH- 11:45 PM-12:05PM DINNER 4:45 PM-5:05 PM WILLOW BREAKFAST- 8:05 AM-8:25 AM LUNCH- 12:05 PM- 12:25PM DINNER- 5:05 PM- 5:25 PM SPRUCE BREAKFAST-8:25 AM- 8:45 AM LUNCH- 12:25 PM- 12:45 PM DINNER-5:25 PM- 5:45 PM ELM BREAKFAST 8:45 AM-9:00 AM LUNCH 12:45 PM- 1:00 PM DINNER 5:45PM- 6:00PM Snack Availability policy, last reviewed 6/7/24, identified the purpose of the policy was to ensure that residents have access to nourishing snacks. Policy defined a nourishing snack as a verbal offering of items, single or in combination from the basic food groups.

Based on record review and interview the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 3 of 5 residents (R26, R30, R29) reviewed for MDS completion. Findings include: R26: R26's admit MDS dated [DATE], indicated R26 was cognitively intact with the diagnosis of COPD. MDS Section O., was coded incorrectly and indicated R26 was not receiving hospice. R26's Census documentation showed R26 was admitted on [DATE], with hospice services. R26's care plan with the admitted [DATE], included care planning for hospice services. During an interview on 5/1/25 at 3:06 PM both registered nurse (RN-A) and the director of nursing (DON) were present and confirmed R26's admission MDS should have been coded to show that R26 was receiving hospice services. The facility policy Accuracy of Assessments dated 3/15/24, indicated the policy was created to ensure each resident received an accurate assessment reflective of the resident status at the time of assessment and staff were to follow the RAI manual. 48109 R30: R30's quarterly MDS dated [DATE], identified intact cognition and diagnoses of kidney failure and malignant neoplasm of the prostate. Section H, which covers bowel and bladder, identified R30 had a colostomy. During an interview on 5/2/25 at 10:21 a.m., RN-F confirmed R30 didn't have a colostomy. During an interview on 5/2/25 at 2:55 p.m., the MDS nurse stated section H of R30's MDS was marked in error. The MDS nurse stated accurate MDS' were important because it reflects how they should plan and care for him. 49878 R29: R29's quarterly MDS dated [DATE], indicated R29 was cognitively intact and with a functional limitation in movement on one side of the lower body. The MDS further indicated R29 did not use any mobility devices. R29's facesheet reviewed on 5/2/25, indicated diagnoses of secondary polycythemia (increased amount of red cells due to another medical condition), depression, anxiety, polyneuropathy (disease affecting peripheral nerves throughout the body), hypertension, acquired absence of foot, sleep apnea, and amputation of lower left leg. During observation on 4/30/25 at 10:20 a.m., R29 observed in bed with a wheelchair and prosthetic leg in resident's room. R29 confirmed using mobility devices when out of bed. During interview on 5/1/25 at 11:02 a.m., MDS coordinator explained MDS reports were done on a schedule dictated by regulations. MDS coordinator stated reports were based on documentation from nursing staff, and providers involved in the resident's care. MDS coordinator further explained parts of the MDS were done in-person with the resident. MDS coordinator reviewed R29's quarterly MDS from 4/8/25, and confirmed MDS indicated R29 did not use mobility devices. MDS coordinator stated the MDS was incorrect and R29 does use mobility devices including a wheelchair and prosthetic limb. During interview on 5/2/25 at 1:05 p.m., director of nursing (DON) stated expectation that MDS reports should accurately reflect the resident's status. DON confirmed R29's MDS from 4/8/25 was not accurate concerning mobility devices.

Based on observation, interview and document review, the facility failed to ensure weights were completed as ordered and failed to provide assessment and documentation before a visit to the emergency department for 1 of 2 residents (R3) reviewed for quality of care. Findings include: R3's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and diagnoses of congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), morbid obesity, obstructive sleep apnea, hypertension (HTN), and chronic kidney disease (CKD) stage 3. R3's care plan dated 2/4/25, identified R3 had a risk for, or actual, heart and circulation concerns related to diagnoses of hypertension and heart failure. Interventions included medications, treatments and labs per provider order and to monitor and document signs and symptoms of adverse side effects related to diagnosis and medication use. R3's provider orders identified: -4/2/24 an order for weights twice weekly. -5/6/24 an order for a 2000 milliliter (mL) fluid restriction daily. -7/16/24 an order for furosemide (a diuretic, or water pill) 120 milligrams (mg) on Mondays, Wednesdays, Fridays, and 80 mg on Tuesdays, Thursdays, Saturdays and Sundays. -4/25/25 an order for metolazone (a diuretic, or water pill) 2.5 mg, and Spironolactone (a diuretic, or water pill) 25 mg daily for CHF. -4/26/25 an order for daily weights. R3's EMR identified the following weight records for April 2025: -4/7 216.6 -4/21 223.7 -4/26 220 Review of R3's electronic medical record (EMR) for April 2025 didn't identify progress notes with R3's refusal of having weight taken, didn't identify an assessment or progress note for R3's symptoms prior to going to the emergency room the afternoon of 4/29/25. During an observation on 4/28/25 at 5:15 p.m., R3 was observed sleeping on her bed with her bare legs visible. Both of R3's lower extremities had tight, shiny skin and were reddish-purple in color from about mid-calf down. There were compression socks laying on the bed inside out. During an interview on 4/29/25 at 2:39 p.m., R3 stated her legs were hurting so bad and this happened sometimes, the nurse took her vitals, and she was going to the emergency room . At 2:42 p.m., an ambulance arrived and took R3 via stretcher. During an interview on 4/29/25 at 3:02 p.m., nursing assistant (NA)-A stated the resident weights were done by the NAs, but the nurse will tell them who needs to be done, then they get it and report back to the nurse. During an interview on 4/30/25 at 7:19 a.m., R3 was back in the facility and stated the ER treated her for pain in her legs. R3 was wearing compression socks. During an interview on 5/2/25 at 1:57 p.m., registered nurse (RN)-F stated she would expect some kind of assessment and documentation when a resident is sent to the ER. RN-F would also expect daily weights to be taken as ordered and for refusals to be documented for R3. RN-F added R3 was known to refuse weights, and they would encourage her by educating her because she had heart problems, edema and leg pain so it would be important for her to have her weight taken. During an interview on 5/2/25 at 3:31 p.m., the director of nursing (DON) stated her expectation would be for daily weights to be done as ordered. The DON would also expect documentation in the medical record when a resident went to the ER.

Based on interview, observation, and record review the facility failed to ensure competent administration of insulin occurred for 1 of 1 resident (R60) who was reviewed for insulin administration. Findings include: R60's quarterly Minimum Data Set (MDS) dated [DATE], indicated R60 was cognitively intact with the diagnosis of diabetes. R60's undated Care Plan indicated R60 had diabetes type II and instructed staff to administer medication and treatments as ordered. R60's Medication Review Report on or After 5/5/25, Orders included the following orders: Lantus Solostar inject subcutaneous 72 units at bedtime. Humalog Lispro insulin inject per sliding scale at bedtime. Blood sugars before meals and at bedtime R60's Medication Administration Record for April 2025, included the following insulin administrations: 4/25/25 Humalog scheduled time 2000 administered time at 2126 by registered nurse (RN-C), dose 1 unit. 4/25/25 Lantus scheduled time 2000 administered time at 2127 by RN-C, dose 72 units. R60's Weights and Vitals Summary 4/1/25 to 4/30/25 did not show R60 had experienced a low blood sugar the evening of 4/25/25, into the morning of 4/26/25. A progress note entered on 4/29/25, showed that R60 had reported concerns regarding an insulin administration that had occurred on 4/25/25. Note indicated an investigation had been started. The facility provided video clip dated 4/25/25, of a medication administration performed by RN-C on the evening of 4/25/25, was reviewed. The clip started with RN-C wearing gloves and handing R60 a snack at the left side of the nurse's station desk. RN-C moved to the right side of the desk, then went back to the left side, grabbed a computer mouse, returned to the right side of the desk and stood at the computer on the nurse station desk edge. With the same gloves on, RN-C opened the medication cart, removed a baggie with insulin pen(s) from medication cart, did not close the medication drawer, returned to end of nurse station, (same gloves on) removed the insulin pens from the baggie, and set them on the counter. (Same gloves on) RN-C went back to medication cart, opened the top right medication drawer and proceeded to enter both drawers with gloved hands. RN-C left both drawers open and moved out of the camera frame towards the nurse manager's office. RN-C returned in the frame wearing gloves with supplies in hand, stopped at the medication cart, partially closed the right drawer and then went back to R60 at the nurse station desk. RN-C removed what appeared to be a syringe from a wrapper and then drew insulin out of what appeared to be an insulin pen via the syringe. RN-C kept the syringe in hand, set down the pen and then grabbed a different pen and appeared to draw insulin from the 2nd pen. (Wear the same gloves) RN-C then set the pen down and administered the contents of the syringe to R60. With the same gloves on RN-C went between the medication cart and the administration area a few times and then returned to R60 at the desk with another baggie containing an insulin pen. RN-C set the pen down, can be seen putting hand in pocket and doing other actions at the desk. (With same gloves on) RN-C entered the open top left medication drawer, returned to R60 and then got a second dose of insulin ready to administer to R60. RN-C proceeded to administer a second injection of insulin to R60 (wearing the same gloves). RN-C returned items to the medication cart and touched several surface area while still wearing the same gloves. At the end of the video clip R60 wheeled away from the desk and RN-C can be seen at a computer, wearing the same gloves. During an interview on 4/28/25 at 7:16 p.m., R60 stated they were worried they had received the wrong dose of Lantus insulin over the weekend because the nurse seemed unsure of what they were doing. The nurse had drawn their insulin into a syringe from insulin pens, and R60 suspected nurse had gotten the math wrong and given them too much insulin because they had experienced a low blood sugar that night. During a follow-up interview on 4/30/25 at 1:17 p.m., R60 stated the insulin administration they were concerned with had occurred on Friday 5/25/25. R60 reported the nurse had taken a BD syringe and drawn two doses of insulin out of insulin pens, and given it to them instead of administering the insulin with the pen. R60 stated they didn't think it was okay for the nurse to draw insulin from a pen, and they were concerned the nurse had done the math wrong and given them too much insulin because of the low blood sugar they had in the middle of the night. R60 was not able to pull up the low blood sugar value on their dexacom unit (which continuously monitored blood sugar). R60 indicated they had reported the events to the nurse manager yesterday (4/29/25). During an interview on 4/30/25 at 3:54 p.m., RN-C stated they could not recall all the details from the 5/25/25 evening shift, however they did remember they had given R60 two injections of Lantus insulin to equal the ordered bedtime dose of 72 units. They had explained to R60 the two doses would not be equal amounts, but the total dose would equal 72 units, so they were not sure why R60 thought they had received too much Lantus insulin. RN-C felt they had administered the correct amount because they had also had a second staff check the total dose prior to administration. RN-C confirmed they had administered R60's insulin via a syringe after they had drawn the insulin out of R60's old and new insulin pens. During an interview on 4/30/25 at 4:43 p.m., the director of nursing (DON) stated they had talked with RN-C, and RN-C had confirmed they had drawn insulin out of insulin pens with a syringe and administered it to R60 via the syringe. During an interview on 5/1/25 at 8:03 a.m., RN-G stated they had been working the night shift on 5/25/25, into 5/26/25, and they had not been called to address a low blood sugar for R60. During an interview with the DON on 5/2/25 at 10:47 a.m., the video footage from 5/25/25, of R60's bedtime insulin administration was reviewed. The DON confirmed RN-C and R60's were the subjects being viewed in the video. The DON confirmed RN-C had opened the medication cart, removed insulin, and then had left the cart open, unlocked, and unattended during the course of the video. In addition, RN-C had also left insulin pens unattended at the desk. The DON stated the medication cart should not be left unlocked once medication is removed, and the cart and or medications should never be left unattended. The DON confirmed it appeared RN-C had not sanitized their hands or changed gloves at any point during the video and they had touched multiple surfaces, entered the medication cart and administered medications wearing the same gloves. The DON stated they expected infection prevention measures to be followed which included hand sanitization after touching dirty surfaces and sanitization and glove changes before and after insulin administrations. The DON confirmed RN-C had drawn insulin from insulin pens and indicated this was not an acceptable medication administration practice. The DON stated they were in the process of addressing identified concerns with RN-C along with the additional concern that it was likely R60 had not received their bedtime Humalog insulin dose on 5/2/25. During an interview on 5/2/25 at 1:38 p.m., the consulting pharmacist stated it was not an acceptable practice to draw insulin from an insulin pen and indicated they believed manufacturers recommend against this practice either. Insulin pens are specifically designed to administer insulin directly to a person. Pens are also designed to hold insulin for priming, so a pen may show it is empty but there may still be insulin left in the pen that was intended for priming. The excess insulin is intended to be disposed of when the pen is empty, it should not be removed from the pen with a syringe. There really is not an acceptable reason to pull insulin from an insulin pen. During a follow up interview on 5/2/25 at 2:45 p.m., RN-C stated they had given R60 their Lantus insulin at the desk so they could verify with another nurse what dose to give R60. RN-C remembered giving R60 two injections of Lantus at the nursing station desk that night and stated they should not have drawn insulin from the insulin pens into syringes, they should have administered the insulin directly from the pen. RN-C's personnel file included a completed Skills Check Off form dated 9/27/18. The insulin administration check off included insulin administration by insulin pen. The competency did not include drawing insulin from an insulin pen for administration. Hand sanitization before and after medication administration was included in administration steps. An additional interview document dated 4/30/25, indicated RN-C had confirmed they had drawn insulin out of an insulin pen for administration to R60. RN-C had also acknowledged infection prevention concerns that had occurred during R60's insulin administration. The facility policy Insulin Administration from Pen dated 6/7/24 included hand sanitization before and after administration of insulin. The policy did not include drawing insulin from an insulin pen for administration via a syringe. The facility policy Hand Washing dated 6/8/22, indicated the facility would follow CDC recommendations for handwashing the policy identified the following hand sanitization events: before and after glove use, after touching contaminated surfaces, before/after touching residents. The facility policy Medication - Storage dated 3/12/24, indicated all medications were to be stored in accordance with manufacturers recommendations and according to state and federal laws. All drugs and Biologics should be stored in locked compartments, and controlled substances should be stored with two locks.

Based on interview and document review, the facility failed to develop individualized and comprehensive care plans for for 2 of 2 residents (R30, R101) reviewed for pain and wound management. Findings include: R30: R30's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and diagnoses of malignant neoplasm of prostate, chronic pain syndrome, and anxiety. Section J of the MDS, which looks at health conditions impacting the resident's functional status and quality of life, identified R30 had pain, scheduled and as-needed pain medications, and had pain that frequently affected sleep, therapy, and day-to-day activities. R30's provider orders dated 4/30/25, identified an order for morphine sulfate every two hours as needed for pain, and morphine sulfate (MS) extended release 15 mg tablet two times per day for pain. Orders for non-pharmacologic interventions were not found. R30's care plan dated 4/24/25, identified R30 had a diagnosis which can or may affect pain status. R30's care plan didn't clearly identify actual pain and lacked individualized details for R30's pain, how to assess or rate pain, a goal rating for pain tolerance, how the pain impacted sleep, ADLs, activities of leisure, mood, or behavior. During an interview on 4/28/25 at 7:24 p.m., R30 stated they didn't do a good job with pain medication, but he had signed up for hospice now. During an interview on 5/2/25 at 2:15 p.m., registered nurse (RN)-F stated the non-pharmacologic interventions in place were to try to get R30 to reposition, but he won't always do that and to encourage rest and assist to rest as able. RN-F stated R30 was a smoker and it was sometimes hard to get him to rest because he wanted to be outside. RN-F indicated she would be updating R30's care plan to be more specific about his pain, symptoms and interventions. R101: R101's admission Minimum Data Set, dated dated dated [DATE], identified intact cognition and diagnoses of bilateral lower extremity cellulitis, pain in the thoracic spine, and chronic pulmonary edema. R101's MDS identified two venous stasis ulcers, a risk for pressure ulcers but no actual pressure ulcer, and limited range of motion in both lower extremities. R101's care plan dated 2/11/25, identified a problem statement for skin integrity, but didn't clearly identify actual venous stasis and pressure ulcers. Interventions for R101 included meds/labs/treatments as ordered, incontinent care with incontinent brief changes, observe skin with AM and PM cares and report to team leader, weekly skin checks, pressure reduction cushion in wheelchair and bed, Circaid Velcro (compression wrap) to both lower extremities. The care plan lacked instruction for positioning in consideration of R101's posture, lacked a turning and repositioning program, and didn't include coordination with the outside wound care provider. R101's provider orders identified the following: -2/12/25 Elevate legs off and on throughout the day, try to keep pressure off spine as much as possible - recommend to closely monitor this area for breakdown and protect with padded foam like dressing - keep pressure off as able every shift. -2/19/25 Foam border to mid spine for protection, change every three days and as needed. -4/18/25 Wound care to mid spine: acetic wash, apply a thin layer Mupirocin (antibiotic ointment) to wound bed only, cover with Allevyn (brand name foam dressing) gentle border or equivalent, change every other day. -4/18/25 Turn and reposition every two hours - She is to stay off her back R30's Weekly Wound Round Documentation dated 4/8/25, identified an abrasion to lower back which had been slow to heal, so weekly measurements would be started. The document indicated there was a positioning plan, but didn't indicate what the plan was. During an interview on 5/2/25 at 2:28 p.m., RN-F stated turning and repositioning were important, but especially for R101 because her back is shaped differently. During an interview on 5/2/25 at 3:31 p.m., the director of nursing (DON) stated care planning was important so they can meet the needs of the residents. A policy, Comprehensive Person-Centered Care Planning Policy and Procedure dated 3/14/25, identified the facility will develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet each resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.

Based on interview and document review, the facility failed to ensure that quarterly care conferences were completed for 1 of 1 resident (R17) reviewed for care conferences. Findings include: R17's quarterly Minimum Data Set (MDS) dated [DATE], identified diagnoses of chronic obstructive pulmonary disease (COPD), depression, and pressure ulcers. During interview on 4/28/25 at 12:50 p.m., R17 stated that he had only had one care conference since he admitted that he could remember. Care plan documentation notes, undated, identified that R17 had care conferences on 8/23/24 and 11/21/24. No further care conferences were documented. During interview on 5/1/25 at 8:22 a.m., social services director (SSD) stated that the last care conference for R17 would have been on 11/21/24. I believe the last couple of times we had scheduled care conferences, R17 was in the hospital. We typically schedule care conferences every three months and it looks like R17 is due for one. Care conferences are important to address any concerns, whether it be nursing, social services, or other concerns. Missing care conferences could cause resident concerns to be missed. During interview on 5/1/25 at 11:39 a.m., the director of nursing (DON) stated care conferences should occur quarterly and following a change in condition. Care conference are important in developing an individualized plan of care and allowing the patient to have involvement in their plan of care. Care Plan - Reviews/Conferences policy last reviewed 3/6/24, identified that the community will conduct a care plan review/conference at least quarterly, and as needed, that is interdisciplinary, provides an in-depth review of the resident's plan of care, and provides an opportunity for resident and resident representative and/or family discussion/input.

Based on record review and interview, the facility failed to ensure an indication for use was connected to ordered medications for 2 of 5 residents (R88, R407) reviewed for unnecessary medications. Findings include: R88: R88's quarterly Minimum Data Set (MDS) dated [DATE], identified R88 was severely cognitively impaired, required partial to substantial assistance with activities of daily living (ADLs), and had diagnoses of cerebrovascular disease (condition that affects blood vessels supplying blood to the brain), dementia, hypertension, depression, hyperlipidemia, and a history of transient ischemic attack (temporary stroke). R88's provider orders reviewed on 4/30/25, included the following orders: -aspirin oral capsule 81 milligrams (mg), give one tablet by mouth one time a day for salicylate -atorvastatin calcium oral tablet 80mg, give on tablet by mouth one time a day for antihyperlipidemic -clopidogrel bisulfate oral tablet 75mg, give one tablet by mouth one time a day for platelet aggregation inhibitors -losartan potassium oral tablet 100mg, give one tablet by mouth one time a day for ARBs -pantoprazole sodium oral tablet 40mg, give one tablet by mouth one time a day for PPIs During interview on 5/1/25 at 10:05 a.m., registered nurse (RN)-B reviewed ordered medications in R88's chart. RN-B confirmed R88's listed medications did not have a proper indication or diagnosis for use. RN-B stated expectation of all medication orders to have an indication for use or diagnosis attached. During interview on 5/2/25 at 1:05 p.m., director of nursing (DON) stated expectation for all medication orders to have an indication for use or diagnosis attached. 49036 R407: R407's admission MDS dated [DATE], identified diagnoses of bipolar disorder, post-traumatic stress disorder (PTSD), and chronic pancreatitis. R407 was cognitively intact. R407's provider orders reviewed on 4/29/25, included the following order: -valacyclovir HCl Oral Tablet 1 gram (GM), give 1000 mg by mouth in the evening for x During interview on 5/1/25 at 11:41 a.m., the DON stated it was important and the expectation would be that there is a diagnosis for the use of R407's valyclovir. Medication Administration policy last reviewed 4/1/24, explained facility's policy to administer all medications and treatments in a safe and effective manner. Included in the procedure for administering medications was 'able to state indication.'

Based on record review and interview, the facility failed to ensure psychotropic medication orders had an indication for use for 1 of 5 residents (R29) reviewed for unnecessary medications. Findings include: R29's quarterly Minimum Data Set (MDS) dated [DATE], indicated R29 was cognitively intact and identified diagnoses of secondary polycythemia (increased amount of red cells due to another medical condition), depression, anxiety, polyneuropathy (disease affecting peripheral nerves throughout the body), hypertension, acquired absence of foot, sleep apnea, and amputation of lower left leg. R29's provider orders reviewed on 4/30/25, included the following medication orders: -duloxetine oral capsule delayed release sprinkle 60 milligrams (mg), give one capsule by mouth one time a day for 'no indication listed' -pristiq oral tablet extended release 24 hour 25mg- give 25mg by mouth one time a day for 'no indication listed' During interview on 5/1/25 at 8:51 a.m., registered nurse (RN)-D reviewed medication orders for R29 and confirmed no indication listed for duloxetine and pristiq medications. RN-D stated expectation for every medication order to have an indication or diagnosis listed. During interview on 5/2/25 at 1:05 p.m., director of nursing (DON) stated expectation for every medication order to have an indication for use listed. Medication Administration policy last reviewed 4/1/24, explained facility's policy to administer all medications and treatments in a safe and effective manner. Included in the procedure for administering medications was 'able to state indication.'

Based on observation, interview, and document review the facility failed to ensure that vitals were performed pre and post dialysis for 1 of 1 resident (R19) reviewed for dialysis care. R19's admission Minimum Data Set (MDS) dated [DATE], identified diagnoses of chronic kidney disease, atrial fibrillation, coronary artery disease, diabetes mellitus, and hypertension. Resident was cognitively intact. R19's care plan, undated, identified that R19 received dialysis and interventions included to check access site every shift to ensure dressing is clean, dry and intact, resident exhibits no signs/symptoms of infection, patency of access site palpating pulse of extremity, and checking for warmth and color of extremity. Meds/labs/treatments as ordered/accepted. The care plan did not address assessment of vitals pre or post dialysis. R19's April 2025, Weights and Vitals charting failed to show vitals assessments pre and post dialysis. During interview on 4/28/25 at 6:36 p.m., R19 stated that the facility does not check her vitals or do any type of assessment after dialysis. On 4/30/25 at 12:10 p.m., trained medication aid (TMA)-A was in room with R19 upon her return from dailysis. TMA-A had not taken resident vitals. TMA-A stated that she belived that there is not any type of assessment for R19 when she returns from dialysis. During interview on 4/30/25 at 12:21 p.m., registered nurse (RN)-D stated that the staff assesses the dialysis site for redness, infection, and/or swelling upon return from dialysis and receives a post run report from the dialysis facility. Vitals are completed at the dialysis facility. During interview on 5/1/25 at 11:44 a.m., the director of nursing (DON) stated that there should be pre and post dialysis vitals taken for dialysis residents. It is important to ensure there are no complications from dialysis and ensure that R19 is returning in a better state than what she left us in. During interview on 5/1/25 at 12:01 p.m., RN-D looked at R19's vitals assessments and stated that he did not see post dialysis visit vital signs, only documentation of signs and symptoms. Facility policy, Dialysis, last reviewed 6/7/24, failed to address vitals assessments pre and post dialysis.

Based on record review and interview, the facility failed to ensure a Level II Pre-Admission Screening and Resident Review (PASARR) reassessment after 30 days was conducted, documented, and retained to ensure mental health needs were appropriately addressed or provided for 1 of 1 residents (R22) reviewed for PASARR. Findings include: R22's significant change Minimum Data Set (MDS) dated [DATE], identified R22 had severely impaired cognition and required substantial assistance with most activities of daily living (ADLs). R22's admission record, reviewed 5/2/24, identified diagnoses including dementia with agitation, delusional disorder, bipolar disorder, morbid obesity, essential tremor (neurological disorder characterized by uncontrolled shaking movements), bilateral hearing loss, depression, and schizophrenia. R22's pre-admission screening (PAS) dated 2/4/23, indicated R22 required a Level II assessment for mental illness to be done before admission to a nursing home. PAS further indicated R22 was in assisted living with an admission to the nursing home on 2/3/23 with an anticipated length of stay listed, Less than 30 Days. R22 was also noted to have a diagnosis of schizophrenia. R22's Level II Preadmission Screening for Persons with Mental Illness Determination for Nursing Facility Admission completed on 2/7/23, indicated admission is approved for post-hospital rehabilitative services for 30 days. This person may have a mental illness and may need specialized services, by [but] meets the requirements for post hospital rehabilitation. Further assessment and service plan changes must be documented upon at change in the resident's condition or when the nursing facility (NF) stay is anticipated to exceed 30 days. The NF is responsible for alerting LMHA to such changes. During interview on 5/1/25 at 11:19 a.m., admissions clerk (AC) stated PAS and PASARR were done before a resident's admission, and coordinated with Senior LinkAge Line (responsible for PAS in Minnesota). AC reported being unaware of R22's Level II assessment being limited to a 30 day admission and needed a reassessment after that point. During interview on 5/1/25 at 11:25 a.m., social services director (SSD) stated being unaware of R22's Level II assessment being limited to a 30 day admission. SSD reviewed R22's Level II assessment and confirmed it was limited to a 30 day admission. SSD stated Senior LinkAge Line should have been contacted when R22 stayed in the nursing home past 30 days. During interview on 5/2/25 at 1:06 p.m., director of nursing (DON) stated being unaware of R22's Level II assessment being limited to a 30 day admission. DON stated expectation for all PAS and PASARR assessments to be completed with required timeframes.

Based on observation, interview and document review, the facility failed to ensure care plan interventions were implemented for 1 of 3 resident (R1) reviewed who required the use of a transfer belt during transfers reviewed for falls. R1 sustained actual harm when staff failed to implement the use of a transfer belt during a transfer. R1 fell , fractured multiple ribs, sustained a left sided pneumothorax (free air around lung causing some lung collapse), a left sided hemothorax (blood around the lung cause some lung collapse) that led to chest tube placement, and was sent to the emergency department (ED) requiring medical treatment. The facility implemented a corrective action prior to the survey so the deficient practice was issued at past non-compliance. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment and no behaviors. R1 required partial/moderate assistance with toileting hygiene, substantial/maximal assistance with personal hygiene, upper and lower body dressing, lying to sitting on the side of the bed, sit to stand, chair/bed-to-chair and toilet transfers. R1 used a wheelchair for mobility and was occasionally incontinent of bladder and always continent of bowel. Diagnoses included fractures and other multiple trauma, cataracts, glaucoma or macular degeneration (last three are diseases that affect vision). The MDS indicated 2 or more falls in the last six months prior to admission with at least one fall causing fractures. R1's care plan, undated, identified at risk for falls due to current medical/physical status and was on medications that can/may affect fall risk. Staff were directed to keep call light positioned for easy access and to have commonly used articles within easy reach. The care plan also identified a risk and/or potential for complications with deficits with activities of daily living (ADL) related to current medical/physical status. Staff were directed to transfer with an assist of 1 using walker to transfer in and out of bed and recliner with gait belt. R1's Fall Assessment Tool dated 1/25/25 at 6:02 a.m., identified a risk for falls. R1's discharge MDS dated [DATE], identified R1 had one fall since admission with major injury. R1's progress notes from 3/5/25 through 3/6/25, identified the following: -3/5/25 at 7:40 p.m., writer alerted for witnessed fall. Per nurse assistant (NA)-A was getting R1 up to use the bathroom and she had a hard time standing because R1 leans backwards. R1 stood up and turned. NA-A was holding onto R1's pants at that time and R1 fell backwards onto the ground. R1 started complaining of her back hurting. R1 stated excruciating pain in her back. Assessment completed and noted swelling upper left rib cage area that was tender to touch. R1 was Hoyer (full body mechanical lift) lift transferred to the recliner, the primary care provider was notified and orders received to send to emergency room for evaluation emergency services called and transferred R1 to the emergency room at 7:25 p.m. -3/6/25 at 3:51 p.m. follow up call to emergency department. Resident was admitted to hospital with a diagnosis of fractured ribs. R1's Emergency Department (ED) notes dated 3/5/25 at 8:30 p.m. identified chief complaint: fall. She was a [AGE] year-old female who came in after a reported fall. Patient reported she was being transferred by nursing staff and was dropped on her left side. She did not hit her head or lose consciousness. She is complaining right rib and pelvis pain. Reports she already had a couple rods placed in her hip. She stated she had left rib pain. Physical exam identified: some chest wall tenderness over the lower inferior mid axillary ribs without crepitus and no bruising. R1's computed tomography (the use of x-rays and a computer to create 3D digital images of your organs, bones, and other tissues) (CT) scan of the chest without contrast dated 3/5/25, identified a small left pneumothorax (<10% by volume of the left chest) and a small hemothorax (<10% by volume of the left chest). The CT scan also identified new minimally displace fractures of the left posterior ribs 6 through 9 and new fractures of the left transverse thoracic spine process at T7, T8, and T9. Age-indeterminate compression fractures in the thoracic spine at T3 and T9 with possible additional superior endplate deformity at T11. Critical result related to the pneumothorax and hemothorax reported to the provider. R1's hospital progress notes from 3/7/25 through 3/13/25, identified: -3/6/25 at 8:11 a.m., active problem list included closed fractures of the transverse process of thoracic vertebra, thoracic compression fracture, closed fracture of multiple ribs of left side, hemothorax with pneumothorax and fall. -3/11/25 at 9:30 a.m., hemoglobin is down to 7.2 today from 9.0 yesterday. Repeat CT scan of chest indicated a now moderate left chest hemothorax with no other signs of bleeding. Will have a chest tube placed in the left chest. -3/11/25 at 2:54 p.m., left sided chest tube placed without complication. 100 milliliters (ML) of bloody fluid sent to lab for analysis. -3/13/25 at 12:46 p.m. Chest tube still in place with 70 ML of bloody fluid out in the last 24 hours. Will keep chest tube in and continue to monitor. Facility investigation dated 3/5/25, identified R1 was an assist of one with walker and gait belt and had gait balance concerns. Staff were assisting R1 to the restroom when the fall occurred. She stood up but leaned back when she stood up. Staff had a hold of R1's pants when R1 fell backwards onto the floor. The investigation found that staff did not follow the care plan due to staff not using a gait belt during the transfer process. During an interview on 3/13/25 at 1:20 p.m., physical therapy assistant (PTA)-A stated R1 tended to lean backwards when she stood up and when she tried to walk. Therapy decided to keep use of the [NAME] (machine to assist resident when standing) because of the leaning backwards and her fear of falling again. PTA-A upgraded R1's transfer status to an assist of 1 staff member with walker and gait belt about two weeks prior to her fall. Nursing staff was updated that they needed to utilize the gait belt with R1 since she did have the backwards lean when she stood up and walked, which gave her an increased chance of another fall. The reason we tell nursing staff to use a gait belt is because the belt gives the staff more control of the resident and if there is a fall, the staff have better control to take the resident to the floor safely. During an interview on 3/13/25 at 1:57 p.m., registered nurse (RN)-A stated the staff were aware R1 would lean backwards when she stood up and first start to walk. Leaning backwards would increase a resident's risk of falls because of imbalance issues, which is part of the reason we told staff to make sure to utilize gait belts when they assist in transfers. RN-A stated that right after R1's fall was investigated, education was started with all nursing staff on the use of gait belts and following resident care plans. During an interview on 3/13/25 at 2:17 p.m., nursing assistant (NA)-B stated an awareness R1 would lean back when she stood up and this would increase the risk of falls. Because of leaning backwards, staff needed to use a gait belt to have better ability to assist R1 to stand and transfer safely. R1 would never rush or refuse to utilize the gait belt for transfers. We have received training in gait belt usage and care plan training since the fall occurred. During an interview on 3/13/25 at 2:43 p.m., NA-A stated it was close to the end of her shift on 3/5/24 when R1 placed her call light on. NA-A answered the call light to assist R1 to the bathroom. R1 was assisted to a standing position by holding onto R1's pants. Once R1 was standing, NA-A switched from R1's right side to her left side. R1 had leaned backwards slightly during the transfer. Before a step could be taken R1 fell backwards and fell on the floor hitting her left side of the body on the floor. NA-A stated the gait belt was not in place, but should have been prior to getting R1 out of bed. NA-A stated she received educational counseling related to gait belt usage and following the resident's care plan. During an interview on 3/13/25 at 2:48 p.m., registered nurse (RN)-B stated he was made aware of the fall when NA-A reported a witnessed fall in R1's room. When RN-B entered the room, found R1 on the floor laying on her left side. There was no gait belt around R1. RN-B performed assessment and noted R1 had a complaint of pain on the left side of the ribs and had swelling, notified the provider right away and received orders to transfer R1 to the emergency room for evaluation. After R1 was transferred to the emergency room RN-B educated NA-A on care plans because the care plan had not been followed. R1 did not have a gait belt on. During an interview on 3/13/26 at 2:53 p.m., the director of nursing (DON) stated R1 was supposed to have a gait belt on anytime she transferred according to her care plan. The gait belt is used to keep control and keep the resident safe when transferred anywhere. After the investigation was finished, a decision was made that the care plan was not followed since the gait belt was not utilized, which in part led to the fall. After the fall occurred and investigation was completed, staff education was started on the use of gait belts and following care plans. NA-A was educated by myself and the nurse the evening of the fall. Lastly management began audits to make sure staff would utilize gait belts and follow resident care plans. The facility gait belt policy was requested but not provided. The facility care plan policy was requested but not provided.

Based on interview and document review, the facility failed to follow a Physician Orders for Life-Sustaining Treatment (POLST) to provide cardiopulmonary resuscitation (CPR) for 1 of 3 residents (R1), who wished to have CPR in the event of cardiopulmonary arrest (absence of pulse and respirations). This resulted in an immediate jeopardy (IJ) when R1 was found absent of pulse and respiration, CPR was not initiated and R1 died . The facility implemented immediate corrective action, and was issued at past non-compliance. The IJ began on [DATE] at 8:03 p.m. when licensed practical nurse (LPN)-A found R1 unresponsive in her room and did not initiate CPR per R1's wishes. The administrator and the director of nursing were notified of the IJ on [DATE] at 4:12 p.m. The IJ was removed on [DATE] when deficient practice was corrected on [DATE], prior to the start of the survey and therefore was issued at past noncompliance. Findings include: R1's Provider Orders for Life Sustaining Treatment (POLST) dated [DATE], signed by the medical provider on [DATE], and verbal confirmation by R1's family member (FM)-A on [DATE], indicated CPR/attempt resuscitation if patient has no pulse or is not breathing. On [DATE], facility video surveillance indicated (LPN)-A entered R1's room at 8:03 p.m. and left R1's room at 8:04 p.m. LPN-A returned to R1's room at 8:06 p.m. Nursing assistant (NA)-A entered R1's room at 8:07 p.m. At 8:09 p.m. NA-A left R1's room. At 8:10 p.m. LPN-A left R1's room. At 8:24 p.m. both LPN-A and NA-B entered R1's room and both left the room at 8:25 p.m. At 8:59 p.m. Registered nurse (RN)-B entered R1's room. On [DATE] at 9:18 a.m., trained medical assistant (TMA)-A stated on [DATE] at 8:07 p.m., when she was off duty at home, LPN-A had sent her a text message asking her to call. On the phone, LPN-A told her R1 had passed away, and she did not know what to do. She told LPN-A she needed to call the on-call nurse, and check R1's CPR resuscitation status. She was confused because LPN-A was not doing anything. On [DATE] at 11:25 a.m., director or nursing (DON) stated at 8:37 p.m. on [DATE], LPN-A called her at home and told her R1 had passed away. She asked LPN-A what R1's resuscitation status was, and LPN-A stated she didn't know. She told her to go and check it now. The DON was able to check R1's resuscitation status, and saw R1 was a full CPR status. She left home to go to the facility, arriving at 8:55 p.m. She told RN-B to go into R1's room. RN-B told her R1 was not breathing, was cool to the touch, and did not have a pulse. R1 did not have any irreversible signs death (rigor mortis, dependent lividity, decapitation, transection, or decomposition). RN-B started CPR on R1. The DON called 911, and went into R1's room with the crash cart (resuscitation cart) and helped RN-B provide CPR to R1. Emergency medical services (EMS) arrived at 9:10 p.m. EMS pronounced R1 deceased at 9:15 p.m. On [DATE] at 11:53 a.m., LPN-A stated on [DATE] around 8:00 p.m., she entered R1's room to check on her and noticed she was not breathing, didn't have a pulse, but was warm to the touch. R1 did not have signs of irreversible death. She panicked and stated she did not know why she didn't start CPR or call a code. On [DATE] at 1:36 p.m., nurse practitioner (NP)-A stated R1 was a full code resuscitation status, and the staff should have started CPR when she was found with no pulse and not breathing. On [DATE] at 2:38 p.m. RN-B stated on [DATE] at 8:59 p.m., RN-B entered R1's room and checked R1 for a pulse and listened for breathing. R1 had no pulse and was not breathing. R1 had no irreversible sings of death. RN-B moved R1 to the floor and started CPR until EMS took over. On [DATE] at 2:49 p.m. NA-B stated on [DATE] at 6:30 p.m., she went into R1's room to try and see if she would eat but R1 declined. When she came back from break around 8:20 p.m., NA-A stated R1 had passed away. She asked LPN-A what the plan was and LPN-A acted like she did not know what to do. NA-B went into R1's room to confirm she passed away, then went back to the nurses station and helped LPN-A find R1's chart. NA-A found R1's POLST and saw R1 was to be resuscitated. She told LPN-A to start CPR. LPN-A did not start CPR and just looked at her. RN-B and the DON came into the facility and started CPR. The facility Cardiopulmonary Resuscitation Procedure reviewed [DATE], directed staff to identify the need for CPR (assessment, vital signs) locate resident POLST, call for help, if no pulse start compressions, give breaths, use an automated external defibrillator (AED), and place in recovery position. The past non-compliance immediate jeopardy began on [DATE]. The IJ was removed, and the deficient practice was corrected by [DATE], after the facility implemented a systemic plan that included the following actions: Reviewed their policy and procedure on CPR, and re-educated all staff on the CPR policy and procedure. Assessed all residents to ensure their POLST were completed and accurate. Conducted a mock CPR drill on [DATE] during morning and evening shift to ensure staff respond correctly. Reviewed the daily schedule to ensure each shift had at least three staff of nurses or TMAs who were CPR certified. Completed audits to ensure all crash carts had all essential equipment and supplies, and the AED was functional and will bring the results of the audits to the Quality Assurance and Performance Improvement (QAPI) committee. Verification of corrective action was confirmed by observation, interview, and document review on [DATE].

Based on observation, interview and document review, the facility failed to provide proper supervision during meals to prevent choking for 2 of 3 residents (R1, R2) who required 1:1 supervision during meals. This deficient practice resulted in an immediate jeopardy (IJ) for R1 and R2 when they were not provided 1:1 supervision during meals, and R1 had a coughing episode and R2 fell asleep with food in his mouth. The IJ began on 8/13/24 when R2 was found alone at the dining table sleeping with food in his mouth. The director of nursing (DON) and administrator were notified of the immediate jeopardy at 5:07 p.m. on 9/3/24. The IJ was removed on 9/4/24, but noncompliance remained at the lower scope and severity level of D - isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's Provider Orders dated 7/8/24, indicated R1 had a regular diet with chopped texture, and nectar mild thick liquids. R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 held food in his mouth and cheeks, or held residual food in his mouth after meals. R1 was on a mechanically altered diet, and needed limited assistance with eating. R1's care plan dated 7/2/24, indicated R1 had dysphagia (difficulty swallowing) and needed 1:1 close supervision in dining room for meals. R1 also required cues to alternate small bites and small sips, and take multiple swallows to clear food from his mouth and avoid choking. On 8/1/24 a therapy progress note written by physical therapist (PT)-A indicated trained medical assistant (TMA)-A administered R1's medications in the therapy gym. R1 became red in the face and attempted to cough, but was he was unsuccessful with clearing the medications by coughing. R1's inhalation was noted to be very wet (occurs when lungs fill with fluid and not air) PT-A provided three back thrusts to R1 when coughing, and R1 coughed up one large pill. R1 continued to have wet inhalation and exhalation with a poor cough. PT-A provided five more back thrusts, and R1 was able to clear a small amount of applesauce and one small white pill. R1 coughed intermittently throughout the session, and coughed up one more large white pill. PT-A notified licensed practical nurse (LPN)-A of the incident. On 8/1/24, at 3:50 p.m. an email from PT-A was sent to the DON, administrator, and facility nurse managers, and indicated R1 had a severe choking episode with his medications that morning. R1 needed back thrusts from PT-A several times cough up medications he was choking on. PT-A was concerned R1 aspirated (breathed liquid or food into lungs) as he continued to cough for 30 minutes. PT-A had notified LPN-A. A Therapy Note dated 8/2/24 written by speech therapist (ST)-A, indicated R1 needed 1:1 assistance/close supervision at all mealtimes due to him being a choking risk. On 8/29/24 a therapy progress note written by PT-A indicated R1 was at the breakfast table, and PT-A heard R1 coughing heavily with a mouth full of food. R1 was able to scoop food out of his mouth with his hands. Nursing staff was notified R1 needed to be on 1:1 supervision with meals, and there were no staff in the dining area with R1 when he began coughing. On 8/29/24 at 9:35 a.m. an email from physical therapy sent to the DON, administrator, and RN-A indicated R1 was on a chopped diet, and continued to have coughing episodes with eating. The note indicated R1 was not being supervised during meals. R1's meal ticket and speech recommendations indicated R1 should be on 1:1 supervision with meals which was not happening. R1's medical record lacked indicaton of the coughing episodes on 8/1/24 and 8/29/24. On 8/30/24 at 8:48 a.m., R1 was observed being given his meal of scrambled eggs, chopped coffee cake with syrup, oatmeal, and nectar thick milk. R1 was sitting at a table alone with his back towards the nurse's station. Three nursing assistants were in the dining area were passing trays, but no staff were providing R1 with 1:1 supervision. R1 was putting spoonful's of the coffee cake in his mouth before swallowing the previous bite. R1 did not cough or choke during the observation. At 8:56 a.m., nursing assistant (NA)-A was called to the nurse's station by RN-A. NA-A came back into the dining area, and sat with R1 while he was feeding himself. On 8/30/24 at 9:05 a.m., NA-A got up for the table as R1 was still eating, went out of the dining room talked with a staff member. NA-A came back to the dining room less than a minute later and patted another resident at a different table on the back to say hello, went back to R1's table and stood next to the table. R1's meal ticket indicated supervision at all meals. R2's Provider Orders dated 8/12/24, indicated regular diet with chopped texture and thin liquids. R2's admission MDS dated [DATE], indicated R2 had aphasia (disorder that affects communication), had a mechanically altered diet, no swallowing disorder, and needed supervision when eating. R2's care plan revised 8/14/24, indicated R2 needed 1:1 supervision and assist with all meals. On 8/13/24 a therapy progress note written by PT-A indicated R2 was found in the dining room hunched over toward his left side. R2's mouth was closed with visible pocketing of food in his left cheek. R2 was unarousable to sternal rub (firm rub on sternum) and trap pinch (gripping and twisting of trapezius muscle in shoulder). PT-A questioned staff on how long R2 had been like that, and staff stated he was tired. After several minutes, R2 was aroused and able to swallow the food in his mouth. The nurse manager was notified. On 8/13/24 at 1:09 p.m. an email from therapy sent to RN-D, the DON, and the therapy director asked if R2 could be placed within staff's line of sight for meals. PT-A found him at the table with food in his mouth slumped over. He required multiple sternal rubs, trap pinch, and shaking to arouse. On 8/30/24 at 8:09 a.m., R2 was observed being given his meal of chocolate milk, scrambled eggs, chopped coffee cake with syrup, oatmeal, orange juice and coffee. R2 was not being provided with 1:1 supervision. R2 was eating at a fast pace, and was not swallowing what was in his mouth prior to putting more food in his mouth. R2 was drinking fluids while eating. Four staff members (NA-B, NA-C, NA-D and one unidentified staff) were in the dining room passing meal trays, and no staff was sitting with R2, or cued him to slow down. On 8/30/24 at 12:10 p.m., R2 was observed being served his lunch. R1 had white bread with the crust cut off, parmesan zucchini casserole, broccoli, peach chunks, and milk. Staff did not provide him with 1:1 supervision. On 8/30/24 at 9:13 a.m., NA-A stated R1 needed 1:1 supervision with all of his meals, and that plan had been in place for a few weeks. R1 required staff to sit next to him because he would stuff his mouth with food, and staff would have to remind him to slow down. On 8/30/24 at 11:16 a.m., R1 was interviewed and was able to shake/nod his head with yes or no answers. When asked if staff sat with him for all of his meals, R1 shook his head no. When asked if he had ever choked on his food or medications at the facility, R1 nodded his head yes. When asked if he had choked recently, R1 nodded his head yes. On 8/30/24 at 11:24 a.m., health unit coordinator (HUC)-A stated she had never seen R2 with 1:1 supervision during meals when she worked. She sat at the 2nd floor desk and had direct vision of the dining room. On 8/13/24 she saw R1 asleep at the table with food in his mouth, and no staff were around. HUC-A did not alert any of the staff he was asleep with food in his mouth, nursing staff were aware of who needed assistance as it was listed at the desk. On 8/30/24 at 12:34 p.m., NA-B stated 1:1 supervision with meals meant staff needed to sit next to the resident to make sure they did not choke. She had never seen R2 with 1:1 supervision with meals. She had been told only 10 minutes ago R2 required 1:1 supervision, and that was why no one was sitting with him during his lunch meal. On 8/30/24 at 12:39 p.m., NA-A stated they were passing trays at breakfast time, and that was why no staff were providing 1:1 supervision with R1 at the beginning of breakfast. NA-A stated 1:1 supervision meant someone needed to be right next to R1. On 8/30/24 at 1:09 p.m., R2 stated since he was admitted to the facility, no staff had ever sat with him during meals. On 8/30/24 at 1:36 p.m., ST-A stated she recommended R1 have 1:1 close supervision at all meals, and this was not happening. When she recommended 1:1 supervision, it meant nursing staff were to sit with the resident when they received their meal until they were done eating. It also meant staff needed to provide cues while eating. R1 had swallowing impairments, had a modified diet, and would shovel food in his mouth. If R1 did not have 1:1 supervision with meals, he could choke, aspirate, or possibly die. R2 was recommended to have 1:1 supervision with all meals. She had seen R2 eating alone in the dining room without 1:1 supervision. On 8/30/24 at 1:49 p.m., NA-C stated staff does not sit with R2 during meals, he normally eats alone. On 8/30/24 at 1:55 p.m., occupational therapist (OT)-A stated R1 had not had 1:1 supervision during meals on more than one occasion, but was unable to identify dates or meal times when this had occurred. On 9/3/24 at 6:58 a.m., LPN-A stated on 8/1/24 after the choking incident with R1 in the therapy room, the facility had switched his medications to being crushed per therapy request after ST-A saw R1. She was unaware if R1's provider had given an order for crushed medications, or if pharmacy was aware. On 9/3/24 at 7:18 a.m., TMA-A stated on 8/1/24 after R1 choked on his medications, ST-A saw him right away and stated to crush R1's medications moving forward. On 9/3/24 at 8:09 a.m., RN-A stated on 8/29/24 she received an email from the therapy department in regards to R1 coughing on his food. She emailed the nurse practitioner (NP)-A, and got orders for OT/ST to evaluate and treat R1, and an order for a swallow study to be completed. She assessed R1 on 8/29/24, and he was stable with clear lung sounds. She forgot to document her assessment and the NP update in R1's medical record. On 9/3/24 at 9:07 a.m., PT-A stated on 8/13/24, R2 was in the dining room for lunch, sitting [NAME] at a table hunched over in his chair. She could see food in R2's mouth. She tried a sternal rub and trap pinch on R1, but he was not waking up. NA staff came over and they where able to arouse him. On 8/29/24 at breakfast, R1 was sitting at a table in the dining room without 1:1 staff supervision, and was shoveling food into his mouth. She tried to cue R1 to stop, and he started scooping the food out of his mouth with his hands as he was coughing. There was no staff to provide R1 with 1:1 supervision, so she stayed with him while he ate. She sent an email to management about the incident. PT-A stated the response she got from management was R2 was just tired. On 9/3/24 at 9:23 a.m., HUC-A stated on 8/13/24, at lunch time R2 was sitting at the table in and out of sleep as he was eating. No one was sitting with R2, there was a nursing assistant in the dining room at first, but then they left the area as R2 was still eating. PT-A then came to the unit and R2 was asleep with food in his mouth. PT-A tried to wake R2, she finally got R2 to open his eye after several minutes, and there were still no NAs around. On 9/3/24 at 9:30 a.m., ST-A stated R2 had a history of aspiration prior to being at the facility. On 9/3/24 at 9:31 a.m., the medical director (MD)-A stated he was aware of the concerns with 1:1 supervision during meals, and this was not being followed at the facility. Staff were expected to follow ST recommendations. If a resident was coughing on their food, a nurse should be notified to assess the resident, including putting the assessment in the resident's medical record. On 9/3/24 at 9:39 a.m., RN-E stated on 8/29/24 in the morning, therapy came to her and stated R1 had too many sausages in his mouth. When RN-E went into the dining room, PT and OT were the only ones with R1. NAs were passing trays. R1 was supposed to have supervision with him when he was eating, She was not sure how far from R1 they could be when providing supervision, so RN-E kept an eye: on him. On 9/3/24 at 9:44 a.m., DON stated staff were to follow the residents care plan and assist them per therapy recommendations. 1:1 supervision meant staff were to sit next to a resident when they were eating. On 9/3/24 at 9:56 a.m., the administrator stated staff were expected to follow therapy recommendations when it came to 1:1 supervision at meals. On 9/3/24 at 3:56 p.m., nurse practitioner (NP)-A stated R1's diagnoses and tendencies when eating put him at high risk for aspiration pneumonia. On 9/3/24 at 4:40 p.m. (NP)-B stated R2 was at a higher risk for aspiration pneumonia due to his stroke and speech therapy concerns. The facility policy Activities of Daily Living- Dining/ Meal Assistance dated 6/8/22, directed supervision means observation while eating and 1:1 direct supervision means cueing and physical assist. The immediate jeopardy that began on 8/13/24, was removed on 9/4/24 when the facility reviewed and revised their current policy on meal assistance. The facility reviewed all resident care plans/Kardex to reflect current ST recommendations. The facility implemented a new system for therapy recommendations. The facility completed staff education on the meal assistance policy with post quiz. The facility completed audits on all residents who needed assistance or supervision with meals to ensure they were being assisted or supervised. This was verified through observation, interview and document review.

Based on observation, interview and document review, the facility failed to protect 3 of 3 residents (R2, R3, R5) from ongoing resident-to-resident abuse when residents had multiple incidents of abuse and the facility failed to mitigate abuse risks and implement individualized behavioral interventions to prevent future resident-to-resident abuse incidents. This resulted in an immediate jeopardy for R2, R3 and R5. The immediate jeopardy began on 8/15/22 when the facility failed to implement interventions to protect residents from resident-to-resident physical and verbal abuse altercations which was identified on 8/18/22. The administrator and director of nursing were notified of the IJ at 11:17 a.m. on 8/18/22. The immediate jeopardy was removed on 8/19/22, but noncompliance remained at the lower severity level 2, and a lower scope level of a D/isolated scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 was severely cognitively impaired and displayed physical behaviors directed at others one to three days and other behavioral symptoms not directed at others one to three days. The MDS identified R2 had not displayed wandering behavior. R2's face sheet identified diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R3's quarterly MDS dated [DATE], indicated R3 was severely cognitively impaired and was free of behaviors and wandering behavior. R3's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's face sheet identified the dementia was with behavioral disturbances. R5's significant change MDS dated [DATE], indicated R5 was severely cognitively impaired and was free of behaviors and wandering behavior. R5's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2, R3, and R5's Care Plans identified all three were at risk for abuse, wandered, and required the secured memory care unit. Interventions for all three directed staff to Observe/Suspect abuse, remove resident from aggressor and relocate to safe location and to Observe and Provide Safe Environment. Facility Risk Management - Physical reports, and medical records, identified the following resident-to-resident abuse events: -4/15/22: At 6:30 a.m. the nurse was informed R3 shoved [R2] into the wall, causing him to fall to the floor. R2's progress note, dated 4/15/22, at 6:10 a.m. identified R3, who was totally unprovoked shoved R2 into the wall as R2 ambulated by the nurse's station. R2 sustained a left outer eyebrow laceration and required medical attention (four sutures). R2 returned on 4/15/22, at 1:15 p.m. from the emergency room . R3 and R2 were immediately separated and R3 was placed on one-on-one supervision. R3's Resident 15 Minute Checks flow sheet identified R3 was on one-to-one checks on 4/15/22, from 6:30 a.m. until 10:15 a.m., 15 minute location checks from 10:15 a.m. to 6:30 a.m. on 4/16/22, and then on 4/16/22, from 6:30 a.m. to 10:30 a.m. R3's 15 minute location checks continued through 4/21/22, at 2:30 p.m. -6/10/22: At 12:10 p.m. staff witnessed R3 turn and shove R2 after R2 grabbed R3's arm. R2 fell to his knees and was visibly upset based on his facial expression(s) and body language. R2 and R3 were placed on 15 minute location checks. Fifteen minute location check flow sheets, dated 6/10/22 through 6/16/22, identify R2 and R3 were provided 15 min checks; however, 6/11/22 - 6/16/22 lacked numerous location entries each day. -7/26/22: At 5:15 p.m. staff's attention was drawn by loud voices towards the [nurse's] desk while they served dinner and staff witnessed R3 shoving R2 in the shoulder. R2 stumbled, but did not fall, and R2 attempted to shove R3 in response. R3 stated, He gets in [MEDICATION(S)]! [OBSCENITY] ing cunt. Staff separated them. Both were placed on 15 minute location checks. Fifteen minute location check flow sheets were provided. From 7/28/22 - 8/5/22 and then on 8/9/22, R3's location was monitored. Three undated flow sheets for R3 were provided. From 7/28/22 - 8/5/22, R2's location was monitored. One undated flow sheet for R2 was provided. The combined flow sheet lacked numerous location entries on most days and R2 and R3's 7/29/22 flow sheets were not provided. -8/8/22: At 11:45 a.m. R2 stood up and struck R5 on the right shoulder/back three to five times while they waited for lunch. R5 conversed with other male residents prior to the incident. R2 was redirected to another area and R5 stated, He didn't mean to hit me he was trying to tell me something. Fifteen minute location check flow sheet, dated 8/9/22 - 8/15/22, indicated R2's location was monitored; however, four days lacked multiple location entries. A flowsheet for 8/8/22 was not provided; however, the flow sheet dated 8/9/22, indicated location checks were performed on 8/8/22, from 10:30 p.m. - 12:00 a.m. R2 and R3's progress notes lacked evidence of an analysis/evaluation for the discontinuation of the routine location checks after each incident. R2 and R3's progress notes, and Care Plans, lacked evidence of initiated and/or revised interventions to mitigate/prevent similar resident-to-resident altercations. R2 and R3's medical records lacked evidence their behaviors were comprehensively assessed and/or the care plan interventions were evaluated for effectiveness. Facility follow-up investigation reports forwarded to the State Agency (SA) identified the following event details: -4/23/22: The report identified [on 4/15/22] R3 attempted to get around R2 and was isolated due to the nature of the event. The facility sent out a referral for R3 to Essentia psych/behavioral health and R3 was placed on a waiting list. -6/17/22: The report identified [on 6/10/22] R2 attempted to ambulate with R3 by grabbing his arm. R2 was care planned for staff to offer him tactile items when he ambulated. R2 and R3 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] -8/2/22: The report identified [on 7/26/22] R2 and R3 were observed with both hands on each other and R3 made contact with R2's shoulder with a closed hand. Headphones with cassettes were ordered for both to assist with comfort and distraction. In addition, the report identified R2 and R3 continued to gravitate towards one another. -8/15/22: The report identified [on 8/8/22] R2 made contact with R5 with a closed fist and R2 had not shown prior physical aggression. Staff were educated to allow residents who wanted to calmly do something, to let them. R2's progress note entry, dated 7/28/22, at 2:02 p.m. identified the following entry: [R2] came up to writer, and said Go [expletive] yourself, After initiating verbal aggression, [R2] attempted to initiate physical aggression towards staff, and other residents. Staff immediately separated [R2] from others, and brought him to activity room for quiet environment. Behavior remained the same, and he came back to dining room .[R2] is currently laying [sic] in bed. [R2] remains on 15 minute checks. R2's Care Plan identified R2 displayed behavioral disturbances with paranoia, hallucinations, and delusions. Interventions directed staff to allow R2 to wander the unit, engage him with activities as needed and per his preference(s), and to remove stressors (noisy/overstimulating area or other residents in his personal space who are too close). In addition, the Care Plan intervention revised on 4/11/22 identified R2 like[d] to hold hands while ambulating, and on 6/17/22, directed staff to Offer tactile items while [R2 was] ambulating. R2's Care Plan lacked information R2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the Care Plan lacked individualized behavioral interventions to safeguard R2 from resident-to-resident abuse. R3's Care Plan identified R3 displayed behavioral disturbances with visual hallucinations and that [R3] can act out physically towards others. [R3] has hit or struck out at others. Interventions directed staff to allow R3 to wander the unit, engage him with activities as needed and per his preference(s), and to remove stressors (noisy/overstimulating area or other residents in his personal space who are too close). R3's Care Plan lacked information R3 and R2 adversely gravitated towards each other and have a history of verbal and physical altercations. In addition, the Care Plan lacked individualized behavioral interventions to safeguard R3 from resident-to-resident abuse. R5's Care Plan lacked evidence R5 was involved in a resident-to-resident physical abuse encounter and lacked individualized behavioral interventions to safeguard from resident-to-resident abuse. On 8/16/22, the following events were observed: -At 11:09 a.m. R3 was brought to a unit activity and sat on R2's left side (within arm length). Shortly after, R5 propelled his wheelchair and sat next to R3's left side (within arms length). Staff did not separate R2, R3, and R5. -At 11:40 a.m. R2, after he started to walk away from the activity, turned around and walked up to the back of a chair adjacent to R5 and just stood there (within arms length of R2). Staff did not separate R2 and R5. -At 1:15 p.m. R3 approached R2 as he stood at the nurse's station and stood adjacent to R2's right side (within inches of each other). Nurse manager (RN)-A and registered nurse (RN)-B looked at R2 and R3 from behind the nurse's station desk and neither separated R2 and R3 or engaged them in conversation. Shortly after, both R2 and R3 moved at the same time: R2 moved to his right and R3 stepped back and to his left. Both were within inches of bumping into each other. R2 proceeded down the hall and walked up to another resident in the unit who stood approximately three-forths the way down the hallway. Nursing assistant (NA)-A came around the dining room corner, observed R2 and that resident together and called out [R2]. She entered a non-resident room at the beginning of the hall and did not approach R2 or the other resident to separate. The hall was free of other staff. R2 continued to follow the resident and entered another resident's room after him. Both exited the room shortly after. A staff member exited a room closer to R2 and the other resident and initiated conversation with others (not R2). R2 passed the talking individuals and continued to walk back to the nurse's station. On 8/17/22, the following events were observed: -At 7:30 a.m. R2 sat on a bench at the end of the hall with his head down. At 7:33 a.m. R3 walked down the hall towards R3. On his way, he entered a resident's room. A staff member exited a resident room, walked by him, and kept on down the hall. Shortly after, R3 exited the room and continued toward R2. When R3 was about half way down the hall, another staff member exited a room and asked R3 how he was doing. The staff did not cue him to return to the dining room area before she walked away from him. R3 continued a few steps towards R2; however, turned around and went back to the dining room. Once R3 returned to the dining room, staff at the medication cart kept their back turned towards the residents. On 8/18/22, the following events were observed: -At 9:18 a.m. R2 walked past R3 on his way to the main dining room. Both were within arms-reach. A staff member walked by R2 and did not initiate conversation or direct him away from R3. R2 walked to the end of the dining room and turned around and walked back toward R3; however, this time he passed him within approximately a couple feet. Staff were in the area; however, their backs were turned. -At 9:22 a.m. Staff approached R3's table where he sat with another resident and removed a coffee cup. After the staff walked away, R3 stated, This is bullshit! got up and walked to the coffee pot. Staff approached him and stated she would go fill the coffee pot. R3 stood there with his hands on his hips as the staff member walked off of the unit. His mouth was down-turned and his brows were furrowed. No other staff were in the area. -At 9:28 a.m. R2 was brought to a different table adjacent to R3 and sat down. Their backs were within arms-length. From 9:33 a.m. to 9:35 a.m. (approximately two minutes), R2, R3, and the residents in their vicinity were unsupervised as the nurse at the medication cart continued to keep their back turned. During unit observations on 8/16/22, 8/17/22, and 8/18/22, R2 and R3 were observed numerous times to wander throughout the unit, either alone or directly past other residents. Both R2 and R3 were assisted to sit at tables for the noon meal, snacks, activities, and wandering rest breaks, which put them within arm's reach of each other and many other residents. At times one or both were unsupervised as staff either assisted other residents, there were no staff in the area, and/or the nurse was at the medication cart with their back turned towards them. R2 was not observed to hold tactile items and neither R2 nor R3 were observed to have headphones on. During interview on 8/16/22, at 10:57 a.m. R3 was asked if he felt safe in the facility and if he was ever physically or verbally abused by any one at the facility in which he stated, I would knock the day lights out of them if they did. He denied he had ever had to knock the day lights out of someone at the facility. When interviewed on 8/16/22, at 1:20 p.m. nursing assistant (NA)-A about a couple weeks ago she witnessed R2 push R3 on the left shoulder and chest area. When she attempted to separate them, R3 almost punched her. She denied that R3 hit R2 in response. She alerted the director of nursing (DON) and RN-A. She could not remember if new behavior/safety interventions were implemented to protect R2 or R3 after the incident. When [R2] and [R3] act up a little bit and once you get them out of the situation they are fine for a week .something has to irritate them for them to get angry. R2 would get really aggressive if something triggered him or if he did not take his medications in which he took it out on whoever is in front of him. R2 and R3 often acted out with each other as R3 often went up to R2 and explained when they walk, they walk by each other as both gravitate towards the nurse's station. When R2 and R3 appeared angry, staff attempted to keep them away from each other. When R3 first admitted to the unit, he and R2 were best friends and then R3 started acting out and he would always go after [R2]: now it was a hit and miss. Sometimes they will talk and it will go good and then it can start to go badly .depends on the day with them. She did not witness R2 and R5's event; however, she explained she heard R2 stood up and hit R5 about five times: [R2] was agitated. He wanted to walk around and someone kept telling him to sit down so he was ready for lunch. He was just irritated at that and took it out on [R5]. During interview on 8/16/22, at 1:52 p.m. NA-B stated the memory care unit was not her primary scheduled wing and the resident Kardex's did not contain enough information on behaviors and behavioral interventions: There could be more [information]. She had not witnessed resident-to-resident events with R2, R3, or R5. R2 required a lot of redirection and she had never seen him aggressive. Additionally, she had never seen R3 with behaviors. She was unaware of issues between R2 and R3 and acknowledged she was never informed she needed to keep a closer eye on them when they are within proximity of each other. If R2, R3, or R5 showed behaviors, she would try to keep them separated and keep them busy. When interviewed on 8/16/22, at 2:20 p.m. NA-C stated resident-to-resident behaviors occurred pretty often especially on this unit as the boys like to fight .they are like [NAME]. Because of this, she watched the residents close for signs, such as body language, which cued her to potential issues. She then utilized distraction, activities, food, etc. to help decrease stressors. She stated she reviewed the care plan for behaviors and behavioral interventions; however, the Kardex's could have a little more in there or be more specific to assist with behaviors on the unit. She stated R2 just wanders and she is unsure as to what triggered him to become angry and R3 appeared to get super overwhelmed when there is too much going on around him. R2 and R3 needed closer supervision when they were closer to each other; however, staff did not keep them from talking to each other as they did get along at times. NA-C stated R2 and R3 were currently on 15 minute checks in order to make sure they were okay and staff knew where they were. During interview on 8/17/22, at 9:00 a.m. R2's family member (FM)-B stated the facility updated her related to the R2 and R5's altercation and she explained the incident did not seem like a big deal. She stated R2 was not an aggressive person; however, she mentioned maybe in the beginning when they did not have his medications adjusted and he displayed verbal aggression. She added that she knew R2 was aggressive in which she believed staff just separated them. She was unaware of any other interventions to help decrease the risk of R2 being involved in resident-to-resident altercations. When interviewed on 8/17/22, at 11:33 a.m. NA-D stated [on 4/15/22] she heard R2 and R3 arguing at the nurse's desk and when she exited the room she was in, she witnessed R3 push R2 into the wall with two hands full force on his chest and shoulder areas. She heard R3 call R2 all sorts of b words .calling him an[OBSCENITY] . She stated it was reported to her from the evening shift that R3 was moody and antsy and to watch out for him. NA-D acknowledged she was unable to remember if any new interventions were implemented to protect them from each other. During interview on 8/17/22, at 2:45 p.m. RN-B stated she witnessed R3 push R2 in the shoulder on [7/26/22] and she was unable to reach them in time after she heard their raised voices. She was able to stop R2 from hitting R3 after R2 made motions as if he was going to hit R3. She stated, On this shift, when you hear loud voices you react immediately. RN-B confirmed she did not update R2 or R3's care plans with information related to the altercation nor did she update or implement any new interventions in the care plans. She denied R2 or R3 required current 15 minute checks. During interview on 8/17/22, at 7:51 a.m. trained medication aide (TMA)-A stated he was expected to follow the resident's Kardex (nursing assistant care plans) to help with behaviors and interventions. He confirmed the Kardex often lacked behavioral information and he stated, I think they should put more stuff on there and gave examples such as activity preferences, spare time enjoyments, likes when younger, etc. TMA-A stated he had witnessed events where R2 and R3 were physically aggressive with other residents and he explained R2 and R3 appeared as if they were in a relationship where they were best friends one moment and then the next one was upset with the other. R2 and R3 were allowed to wander the unit together; however, he attempted to watch them as it is hard to keep them separated and the unit had too many residents with behaviors at times, which was harder to manage when the core staff were not scheduled on the unit. In addition, there were too much male hormones over here and it was like the residents were in grade school again and because of all the different behaviors, they clashed. He confirmed R2 and R3 were not on 15 minute checks or one-on-one supervision; however, he stated R2 and R3 required one-on-one supervision to keep them safe. When interviewed on 8/17/22, at 10:16 a.m. RN-C stated when a resident-to-resident altercation occurred, staff separated the involved residents, ensured their needs were met, and provided them with distraction/activities at least for the rest of the shift. He explained 15 minute checks were often initiated. He denied any residents were on one-to-one supervision at that time and he felt R2 and R3 were on 15 minute checks; however, he was not certain as he had not seen the 15 minute check flow sheet on the clip board that morning and it was not reported off in the shift report. RN-C stated he was unsure as to the process of determining when 15 minute checks were discontinued as that was a role for the DON and RN-A. He stated when R2 grabbed his arm and twisted it, or when R3 started to raise his voice, they required increased supervision. At the start of the shift, he would first determined where R2 and R3 were and he observed them. If neither showed any signs of concerns, both R2 and R3 are good to wander and he did not keep a close eye on them. R2 and R3 used to be buddies and walked the hallways always together .that changed and I am not sure what happened. Since then, both required increased supervision and staff tried to keep them separated. In addition, he explained if R2 was seen fiddling with his fingers he has to go to the bathroom and if staff spend time with [R3] on one-to-ones and give him focus and attention, that helps him feel grounded and not so anxious. He also stated R3 was very protective of the other residents and was ready to defend someone's honor if he felt the need. RN-C was unsure if such information was present in R2 or R3's care plans and acknowledged the unit needed to have someone out in that area and by the nurse's desk and have eyes out on the floor .that is the most important thing to help prevent a problem. During interview on 8/17/22, at 10:54 a.m. hospice nurse (RN)-D stated she witnessed that R2 kept standing up and staff kept directing him to sit down as lunch would be there soon. After this direction, R2 stood up and started hitting [R5] on the back about five times with a closed fist .it was more than a pat. RN-D stated, I think [R2] was overstimulated. There was a lot going on around him. such as ring toss, popcorn, and resident conversations. When interviewed on 8/17/22, at 1:49 p.m. RN-A stated staff were expected to review the resident Kardex's. R2 and R3's Kardex's were reviewed and she confirmed both Kardex's lacked specific behavioral signs/symptoms or that either had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She explained such information should be on the Kardex, along with individualized interventions so staff watched for specific behaviors and being on top of it .instead of just watching for behaviors in general. She stated if staff were not updated on behaviors or interventions, staff may not spot them or pay closer attention to particular residents. Overall, she did not change behavior care plans as they still seem to be effective; however, recently she lacked sufficient time to make sure the care plans were accurate and acknowledged this process needed to be completed. Fifteen minute checks were a frequently used intervention and staff were expected to review a designated clip board for the flow sheets to identify the checked residents. She was unsure if any of the resident's currently required routine checks. Fifteen minute checks were not put on the Kardex or in the main Care Plan and when 15 minute checks were implemented, she was unsure of the interventions used to protect R1, R2, R3, R4, and R5 in between the check times for each incident reviewed. Fifteen minute checks were discontinued when an intervention was put into place and determined to be effective. She explained R2 was setup to assist/offer tactile items while ambulating and she expected staff to follow the care plan/Kardex interventions. She confirmed R2 should have a tactile item in his hands when he walked and when she was updated this was not observed, she commented she should have removed that and tried something different as staff attempted it and it did not work: He does not hold onto anything for very long. RN-A stated she ordered [the cassette players] maybe a week ago which had not yet arrived [documentation indicated they were ordered as of 8/2/22]. She did not implement a replacement intervention until the cassette players arrived. RN-A indicated R2 was not an aggressive resident and she did not believe R2 hit R5 to be mean, just to get his attention. R2 did not like stimulation and she stated R5 and another resident were talking loudly by R2. RN-A confirmed R3 no longer followed psych services as she wanted to have Essentia psych follow him versus Mille Lacs psych services, in which R3 was removed from Mille Lacs services and placed on a waiting list for Essentia. She indicated R3 was last seen by psych possibly sometime in April of this year [facility provided psych visit notes indicated 4/15/22 was the last visit]. She confirmed she had not contacted Essentia psych to communicate with them related to R3's wait time for psych services since he was placed on the waiting list. During interview on 8/17/22, at 3:18 p.m. the DON stated she expected immediate intervention(s) to be implemented, care planned, and followed to ensure the resident(s) remained safe, even if the intervention was a simple intervention, in order to prevent further incidence altercations. The DON stated routine review of interventions was important to ensure they were effective as interventions at times may no longer be well suited for that resident. She felt many of the resident-to-resident altercations the facility experienced recently were due to residents needing increased activity and more supervision. The facility recently hired more activity staff, adjusted available activities, and worked on camera placement on the secured unit. The DON expressed she felt R2 and R5's altercation was not a true resident-to-resident abuse situation. For R1 and R4, she stated his family came in and he left the building for a few hours and he appeared calm when he returned: Fifteen minute checks were good for him. For R2 and R3, she explained, Ever since day one, they have been friends and they gravitate towards each other. She stated initially when R2 and R3 started to have altercations, both families were talked to and family did not want them segregated. She identified R2 liked to be next to someone and that R3 did better in a less male setting and the facility attempted to keep the male census on the unit as low as they were able. The DON stated behavioral reviews with the consulting pharmacist stopped due to new ownership; however, these reviews would again start in September and until that time would be performed as needed with the IDT. A policy Altercation-Resident to Resident, revised 3/1/14, identified if was a policy to protect resident(s) and intervene on behalf of the residents to prevent further aggression. The policy directed staff to take prompt action to [NAME] the aggression and separate the residents. Preliminary prevention interventions were to be taken and the care plans were to be revised as needed and all appropriate staff were to be updated of any care plan changes and/or interventions. In addition, the policy directed the administrator was to seek guidance from the DON, the resident's physician, and the medical director to review the appropriateness of retention of the aggressor within the facility. A policy Freedom from Abuse, Neglect, and Exploitation, revised 5/2020, identified it was a policy of the facility to take appropriate steps to prevent the occurrence of abuse and defined resident-to-resident altercations as an incident that involved a resident who willfully inflicts injury upon another resident. The policy defined willful as the resident must have acted deliberately, not that they must have intended to inflict injury or harm. The policy directed if the suspected perpetrator was another resident, the staff separated the residents so they did not have access to each other until the circumstances of the alleged incident were determined. A policy Behavior Monitoring Policy, dated 6/8/22, directed the interdisciplinary team (IDT) to evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident and develop a plan of care accordingly. Safety strategies were to be implemented immediately if necessary to protect the resident and others from harm. In addition, the policy directed that interventions would be individualized and part of the overall care environment that supports physical, functional and psychological needs, and strives to understand, prevent or relieve the residents distress or loss of abilities. The policy lacked evidence of how often the IDT was to review behavioral symptoms. The immediate jeopardy that began on 8/15/22, was removed on 8/19/22 at 2:40 p.m., when the facility updated R2 and R3's care plan, to include a behavioral intervention of one-on-one supervision to monitor/observe daily habits until further appropriate interventions were identified and implemented according to their needs. In addition, R2 and R3's Kardex's were updated to reflect behavioral signs and interventions, IDT and nursing staff were educated on the updated interventions as well as Kardex use and processes, the updated abuse policy and the updated Behavior Monitoring policy; however, noncompliance remained at a lower scope and severity level of an E, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy.

Based on interview and document review, the facility failed to ensure adequate supervision in a resident smoking area which resulted in a resident falling asleep while smoking and starting on fire for 1 of 3 residents (R1) reviewed for accidents related to smoking. In addition, the facility also failed to secure assessed resident's smoking materials for 1 of 3 residents (R1). This failure resulted in an immediate jeopardy (IJ) situation when R1 was outside smoking a cigarette, fell asleep and sustained [CONDITION(S)] to both upper legs. In addition, the facility failed to ensure R1's smoking materials were properly stored and secured. The IJ began on 8/29/21, at approximately 1:00 a.m. when R1 fell asleep while smoking and started on fire. Another resident (R3) who had gone outside to smoke observed R1 on fire and put out the fire. R1 sustained [CONDITION(S)] to both upper legs. R1 who was assessed not to be safe to have smoking materials in her possession, had smoking products in her possession at the time incident, and had observable [CONDITION(S)] to both her upper legs. The administrator and director of nursing (DON) were notified of the IJ on 9/8/21, at 3:29 p.m. The IJ was removed on 9/10/21, at 3:17 p.m. but non-compliance remained at the lower scope and severity of a D, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's Admission Record printed 9/10/21, indicated R1's diagnoses included diabetes, diabetic [CONDITION(S)], history of a [CONDITION(S)] (TBI), and a history of other mental and behavioral disorders. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had intact cognition. The MDS also indicated R1 had reported feeling tired or having little energy for 2-6 days out of the week. R1's care plan initiated 1/20/20, indicated R1 was assessed to smoke independently, however, R1's smoking materials where to be stored safely by staff. R1's goals included R1 would be free of serious injuries and or complications related to smoking. R1's Smoking Safety Full Screening Tool dated 8/24/21, indicated R1 had been assessed to smoke independently, however, staff were to keep her smoking materials. On 8/29/21, at 1:09 a.m. a progress note indicated R1 was found in her bathroom attempting to wash off smoke from both hands. [CONDITION(S)] were noted on R1's jeans and on her skin. Second degree [CONDITION(S)] ([CONDITION(S)] where the top layer of skin and the layer underneath are damaged, will be bright red, swollen, and blister) were noted to her left thigh measured 10 centimeters (cm) x 7 cm. R1's right thigh [CONDITION(S)] measured at 5 cm x 10 cm. Nurse practitioner (NP)-A was notified, and wound care orders were placed. R1 tolerated the treatment. R1 received a shower to rinse off her thighs. Witness (R3) stated R1 was outside smoking, and she was trying to put out the fire in her lap, and was not successful. R3 went to assist and was able to get the fire out. R1's cigarettes and pants were bagged up and placed in the nurse manager's office. R1's smoking privileges were removed. R1's Treatment Administration Record (TAR) initiated 8/29/21, included burn wound care to both thighs, wash with soap and water apply [MEDICATION(S)] cream (medication is used with other treatments to help prevent and treat wound infections in patients with serious [CONDITION(S)]) to areas place mesh dressing on top cover with abdominal pads (ABD) apply elastic retention dressing to hold in place till healed two times a day for wound care related to chronic pain. R1's Wound Observation dated 8/30/21, at 2:41 a.m. indicated the following: Left thigh (front) - Burn: Length = 10 cm, Width = 7 cm Right thigh (front) - Burn: Length = 5 cm, Width = 10 cm R1's Wound Observation notes lacked documentation of what degree R1's [CONDITION(S)] were. On 9/7/21, at 12:56 p.m. R1 was interviewed and stated she had been out smoking and fell asleep. R1 stated when she woke up, her pants were on fire. R1 stated another resident had helped put the fire out on her legs. R1 further stated she had her own cigarettes and lighter on 8/29/21, and she always had them on her person. On 9/8/21, at 7:53 a.m. nurse practitioner (NP)-A was interviewed and stated she had been on call 8/29/21. NP-A stated she was given information by the facility that R1 had been outside smoking. NP-A stated she did not recall all the details of the conversation, but what she did recall was the facility said they were documenting so they could take away R1's smoking privileges. NP-A stated the nurse that had called her reported to her that R1 was doing okay so she gave orders for [MEDICATION(S)]. NP-A stated could not recall the nurse reporting to her possible second degree [CONDITION(S)], and had she received that information, she would have sent R1 into the emergency department (ED). On 9/8/21, at 8:27 a.m. R3 was interviewed and stated on 8/29/21, she had gone out to smoke and found both R1's legs on fire. R3 stated R1 had appeared tired and groggy. R3 stated R1 had not been able to put the fire out herself. R3 stated she physically put out the fire on R1's legs by hitting it with her hands. R3 further stated it was common practice for residents to be out smoking at 1 a.m On 9/8/21, at 10:37 a.m. the director of nursing (DON) was interviewed and stated R1 had been seen by NP-B on 8/30/21, and 8/31/21, however, there was no documentation of the visit in R1's medical record. The DON stated R1 had not been seen by a wound care doctor for the [CONDITION(S)]. On 9/8/21, at 10:44 a.m. NP-B was interviewed and stated he had not looked at R1's [CONDITION(S)] when he was rounding on 8/30/21, or on 8/31/21. NP-B stated it had not been until 9/3/21, when he had actually assessed R1's [CONDITION(S)]. NP-B stated on 9/3/21, after assessing the [CONDITION(S)] he had made a referral to wound clinic. NP-B declined to assess the degree of R1's [CONDITION(S)]. NP-B further stated he had observed R1 outside smoking on 8/30/21, even though R1's smoking privileges had been revoked following the fire. NP-B further stated he had taken pictures of R1's [CONDITION(S)] on 9/3/21, however, had not placed the photos into R1's records. On 9/8/21, at 12:48 p.m. the DON was interviewed again. The DON stated she observed R1's [CONDITION(S)] on 8/29/21, at approximately 10:00 a.m. The DON stated she had assessed R1's [CONDITION(S)] to have been third degree [CONDITION(S)] (third-degree [CONDITION(S)] occur when all 3 layers of skin are burned. The skin may be white, black, brown, or leathery. This type of burn injury is often painless because the nerves have been damaged. Bones and muscles may also be damaged). The DON stated although R1 was not to have any smoking material in her possession, and all of her smoking materials where to be locked up, R1 had access to them. The DON stated she had informed NP-B of R1's [CONDITION(S)] on 8/29/21. The DON stated NP-B should have assessed the [CONDITION(S)] wounds on the 8/30/21, and 8/31/21, and she thought he had. The DON further stated if a person suffered third degree [CONDITION(S)] such as R1 had, she would have expected them to be sent to the ED. The facility policy Accidents/Falls revised 5/20, directed the facility strives to promote safety, dignity, and overall quality of life for its residents by providing an environment that is free from any hazards for which the facility has control and by providing appropriate supervision and interventions to prevent avoidable accidents. A policy on smoking was requested, but not provided. The IJ was removed on 9/10/21, when it was verified through observation, staff interviews and document review, the facility revised the smoking policy, reassessed all smokers, increased supervision in the smoking area, and educated staff.

Based on observation, interview, and document review, the facility failed to provide care in accordance with professional standards of practice when the facility failed to provide appropriate assessment and medical treatment for 1 of 1 residents (R1) who suffered extensive [CONDITION(S)] to both upper legs. This resulted in actual harm to R1 when she received third degree [CONDITION(S)] to her legs and emergency care and burn/wound care was delayed. Findings include: R1's Admission Record printed 9/10/21, indicated R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had intact cognition. The MDS also indicated R1 had reported feeling tired or having little energy for 2-6 days out of the week. R1's care plan initiated 1/20/20, indicated R1 was assessed to smoke independently, however, R1's smoking materials where to be stored safely by staff. R1's goals included R1 would be free of serious injuries and or complications related to smoking through next review date. R1's Smoking Safety Full Screening Tool dated 8/24/21, indicated R1 had been assessed to smoke independently, however, staff were to keep her smoking materials. On 8/29/21, at 1:09 a.m. a progress note indicated R1 was found in her bathroom attempting to wash off smoke from both hands. [CONDITION(S)] were noted on R1's jeans and on her skin. Second degree [CONDITION(S)] ([CONDITION(S)] where the top layer of skin and the layer underneath are damaged, will be bright red, swollen, and blister) were noted to her left thigh measured 10 centimeters (cm) x 7 cm. R1's right thigh [CONDITION(S)] measured at 5 cm x 10 cm. Nurse practitioner (NP)-A was notified, and wound care orders were placed. R1 tolerated the treatment. R1 received a shower to rinse off her thighs. Witness (R3) stated R1 was outside smoking, and she was trying to put out the fire in her lap, and was not successful. R3 went to assist and was able to get the fire out. R1's cigarettes and pants were bagged up and placed in the nurse manager's office. R1's smoking privileges were removed. R1's Treatment Administration Record (TAR) initiated 8/29/21, included burn wound care to both thighs, wash with soap and water apply [MEDICATION(S)] cream (medication is used with other treatments to help prevent and treat wound infections in patients with serious [CONDITION(S)]) to areas place mesh dressing on top cover with abdominal pads (ABD) apply elastic retention dressing to hold in place till healed two times a day for wound care related to chronic pain R1's Wound Observation dated 8/30/21, at 2:41 a.m. indicated the following: Left thigh (front) - Burn: Length = 10 cm, Width = 7 cm Right thigh (front) - Burn: Length = 5 cm, Width = 10 cm R1's Wound Observation notes lacked documentation of what degree R1's [CONDITION(S)] were. On 9/7/21, at 12:56 p.m. R1 was interviewed and stated she had been out smoking and fell asleep. R1 stated when she woke up, her pants were on fire. R1 stated another resident had helped put the fire out on her legs. R1 further stated she had her own cigarettes and lighter on 8/29/21, and she always had them on her person. On 9/7/21, at 1:08 p.m. R1's [CONDITION(S)] were observed with registered nurse (RN)-A. RN-A removed the dressings to the [CONDITION(S)] on R1's upper thighs. Both [CONDITION(S)] were observed to have thick white and green drainage. RN-A immediately covered the [CONDITION(S)] and stated he was going to get the director of nursing (DON) to assess the [CONDITION(S)] and and assist with the dressing change. RN-A covered the [CONDITION(S)] with clean white sterile gauze, removed his gloves and exited R1's room. On 9/8/21, at 7:53 a.m. NP-A was interviewed and stated she had been on call 8/29/21. NP-A stated she was given information by the facility that R1 had been outside smoking. NP-A stated she did not recall all the details of the conversation, but what she did recall was the facility said they were documenting so they could take away R1's smoking privileges. NP-A stated the nurse that had called her reported to her that R1 was doing okay so she gave orders for [MEDICATION(S)]. NP-A stated could not recall the nurse reporting to her possible second degree [CONDITION(S)], and had she received that information, she would have sent R1 into the emergency department (ED). On 9/8/21, at 10:37 a.m. the DON was interviewed and stated R1 had not been seen by a doctor for her [CONDITION(S)]. On 9/8/21, at 10:44 a.m. NP-B was interviewed and stated he had not looked at R1's [CONDITION(S)] when he was rounding on 8/30/21, or on 8/31/21. NP-B stated it had not been until 9/3/21, when he had actually assessed R1's [CONDITION(S)]. NP-B declined to assess the degree of R1's [CONDITION(S)]. NP-B further stated he had taken pictures of R1's [CONDITION(S)] on 9/3/21, however, had not placed the photos into R1's records. On 9/8/21, at 12:48 p.m. the DON was interviewed and stated she observed R1's [CONDITION(S)] on 8/29/21, at approximately 10:00 a.m. The DON stated she had assessed R1's [CONDITION(S)] to have been third degree [CONDITION(S)] (third-degree [CONDITION(S)] occur when all 3 layers of skin are burned. The skin may be white, black, brown, or leathery. This type of burn injury is often painless because the nerves have been damaged. Bones and muscles may also be damaged). The DON stated she would have expected R1 would have been sent to the ED. The DON stated NP-A's orders and treatments for R1 were based on the information she was given by the nurse working that night. The facility policy Notification to Physician/Family/Resident Representative of Change in Resident Health Status revised 11/2016, directed, Nursing judgment is an integral part of the skilled care provided in this facility; therefore, such judgment must be applied in a case-by-case basis in keeping with acceptable nursing practice.

Based on interview and document review, the facility failed to ensure the Centers for Disease Control (CDC) guidance to prevent or minimize the transmission of COVID-19 was fully implemented. The facility failed to follow Minnesota Department of Health (MDH) and CDC guidance related to criteria for positive COVID-19 staff returning to work prior to the required quarantine end date for two staff members (NA-A and NA-B). This deficient practice resulted in an immediate jeopardy (IJ) situation which placed 125 of 143 residents, and staff at risk for serious illness or death related to potential for contracting COVID-19. The IJ began on 11/9/20, when the facility allowed a confirmed COVID-19 asymptomatic nursing assistant (NA) to return to work prior to quarantine period, and was identified on 12/15/20. The executive director (ED), assistant executive director (AED), assistant director of nursing (ADON), and clinical director (CD) were notified of the IJ on 12/15/20, at 4:30 p.m. The IJ was removed on 12/16/20, at 4:30 p.m., but noncompliance remained at the lower scope and severity level of E, which indicated a pattern with no actual harm with potential for more than minimal harm that is not IJ. Findings include: Minnesota Department of Health (MDH) guidance titled Clarification of Staffing Options for Congregate Care Facilities Experiencing Staff Shortages dated 10/12/20, identified health care workers (HCW) who have experienced a high-risk exposure to a person with COVID-19, need to be excluded from work. Further, MDH guidance identified facilities must work the State Emergency Operations Center to demonstrate that the facility is having a recognized staffing crisis and must obtain approval from the MDH Commissioner before HCW who do not have symptoms but have tested positive for COVID-19 can be asked to continue working or return to work earlier than MDH and CDC guidance dictates. In addition, this document refers to the following MDH web site: Defining Crisis Staffing Shortage in Congregate Care Facilities: COVID-19 (https://www.health.state.mn.us/diseases/coronavirus/hcp/crisis.html) where the following is indicated A facility's designation of being in staffing crisis will be initiated and discontinued at the recommendation of the assigned Long-term Care Crisis Staff Manager at the State Emergency Operations Center. COVID-19-positive staff cannot work if the facility does not have this designation. CDC webpage titled: Criteria for Return to Work for Healthcare Personnel with [DIAGNOSES REDACTED]-CoV-2 Infection (Interim Guidance) dated 8/10/20, identified, Healthcare Personnel who are not severely immunocompromised and were asymptomatic throughout their infection may return to work when at least 10 days have passed since the date of their first positive [MEDICAL CONDITION] diagnostic test. Review of staff positive line listing dated 12/14/20, indicated nursing assistant (NA)-A tested positive for COVID-19 on 11/2/20, and was asymptomatic. Review of NA-A time sheet dated 12/15/20, indicated NA-A returned to work on the designated COVID-19 unit on 11/9/20. Further review of time sheet, indicated NA-A worked 11/9/20, 11/10/20, and 11/11/20, which was day 7, 8, and 9 following positive COVID-19 test on 11/2/20. Review of staff positive line listing dated 12/14/20, indicated NA-B tested positive for COVID-19 on 12/7/20, and was asymptomatic. Review of nursing schedules, printed 12/14/20, indicated NA-B returned to work on the designated COVID unit on 12/13/20 and worked 12/13/20, 12/14/20, and 12/15/20, which was day 6, 7, and 8 following positive COVID-19 test on 12/7/20. Further review of nursing schedules, indicated NA-B worked with RN-A, RN-B, LPN-A, NA-C and NA-D on 12/13/20, who were not on the staff line list as positive staff. On 12/14/20, NA-B worked with NA-E, who was also not on the positive staff line list. In addition, on 12/15/20, NA-B worked with NA-E, NA-F, and LPN-A who were not actively diagnosed or previously diagnosed with [REDACTED]. During interview on 12/14/20, at 4:46 p.m. the ED indicated staff working in the designated COVID-19 unit are COVID recovered or volunteered to work on that unit. On 12/15/20, at 9:59 a.m. staffing coordinator (SC)-A indicated NA-B waited five days before returning to work the designated COVID unit on 12/13/20, to ensure NA-B did not develop any signs or symptoms. SC-A stated she received this direction from CD for asymptomatic staff to return to work. On 12/15/20, at 8:34 a.m. infection preventionist (IP) indicated staff currently working the designated COVID-19 unit actively have a [DIAGNOSES REDACTED]. However, IP confirmed she works in the COVID unit, but is not listed on the staff positive line listing dated 12/14/20. On 12/15/20, IP provided a list of staff who work or have worked on the designated COVID-19 unit. Review of the list provided, indicated 14 of the staff listed were not diagnosed or previously diagnosed with [REDACTED]. On 12/15/20, at 9:00 a.m. ADON indicated the facility received approval to allow asymptomatic COVID-19 positive staff to work, before they completed the required quarantine time, from MDH. ADON indicated this approval came from Infection Control Assessment and Response Program (ICAR). In addition, ADON indicated that ICAR approved COVID positive staff to return as long as they had a separate break room. It was confirmed during the survey that ICAR did not provide guidance to allow COVID-19 positive staff to work prior to the end of quaratine. On 12/15/20, at 9:56 a.m. SC-A, indicated she received approval from facility CD to schedule asymptomatic COVID-19 positive staff to work with residents who were also currently diagnosed with [REDACTED]. On 12/15/20, at 9:59 a.m. ED indicated the facility followed MDH guidance dated 10/12/20, when SC-A was directed to schedule asymptomatic COVID-19 positive staff on the designated COVID-19 unit. ED stated asymptomatic COVID-19 positive staff who were permitted to return resulted from MDH guidance. On 12/15/20, at approximately 9:59 a.m. CD stated, We are asking if people have a high risk exposure but test negative or are completely asymptomatic to work the COVID unit. In addition, CD stated, Calling back asymptomatic positive staff has been direction from MDH. Further, CD indicated she spoke with ICAR and MDH on 11/9/20, or 11/10/20, but could not recall if she asked for approval for asymptomatic positive staff to work the unit. CD stated, I don't have documentation that I did or didn't. The facility failed to produce a document that they were in contact with ICAR or MDH. On 12/15/20, at 10:49 a.m. ED indicated she spoke with the State Emergency Operations Center (SEOC) on this date, to update them regarding staffing crisis. ED indicated SEOC was meeting with the SEOC supervisor to discuss. On 12/15/20, at 11:52 a.m. ED stated they are following the guidance from MDH but did not read the section of the guidance which indicated the facility needed approval from the Commissioner before bringing asymptomatic COVID-19 positive staff back to work. ED stated she talked with SEOC on 12/15/20, unknown staff, to request approval to have COVID positive staff work the COVID unit. ED stated the facility did not receive permission from the Commissioner to allow COVID positive staff to work the COVID unit. She was told the only staff the facility was allowed to bring back were those who had a high risk exposure. Further, ED stated that the facility's company works in multiple states, Wisconsin is allowing positive asymptomatic staff to work, so I figured we do it without someone's permission. ED indicated the facility had been participating in weekly calls with the COVID Case Manager, through MDH. The calls included provided updates to their Case Manager regarding staffing difficulty and facility need. ED indicated the facility stopped participating and had not participated in a call for more than one-and-one-half months due to not receiving the assistance needed in relation to staffing difficulties. ED stated she did not update the case manager or SEOC prior to allowing staff who were confirmed COVID positive to work the COVID unit. Further, ED stated staff who work on the designated COVID unit have their own exit and entrance, and also their own break room. ED indicated there is never more than two staff in the breakroom at a time and the COVID positive staff do not take a break with the COVID negative staff. Facility document, Communicable Disease Policy, dated July 2010, indicated if a team member has confirmed positive for any communicable disease, the Health Dimensions Group (HDG) Community will follow the most recent CDC guidelines for the team member's ability to return to work. Facility document, COVID-19 Testing Policy, dated September 2020, indicated if COVID-19 is confirmed, team members should follow Centers for Disease Control and Prevent (CDC) guidelines, Criteria for Return to Work for Healthcare Personnel with [DIAGNOSES REDACTED]-CoV2 Infection. The IJ that began on 11/9/20, was removed on 12/16/20, at 4:30 p.m., when the facility reviewed their return to work policy and procedure to ensure all asymptomatic positive COVID-19 staff were quarantined for at least 10 days prior to returning to work. Staff were educated on the policy and CDC guidance for return to work criteria. The facility also completed audits to ensure positive COVID-19 staff were not scheduled to work before their quarantine period ended. This was verified through interview of staff, and staff education occurred. However, noncompliance remained at the lower scope and severity of an E, which indicated no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

Based on interview and document review, the facility failed to monitor and provide treatment for [REDACTED]. This resulted in actual harm to R1 when he developed an infection and an infestation of maggots, and required treatment at the emergency room , and R1 devoloped a new [MEDICAL CONDITION]. Findings include: R1's Admission Record printed 9/3/20, indicated R1's [DIAGNOSES REDACTED]. R1's admission Minimum Data Set ((MDS) dated [DATE], indicated R1 had a infected wound of the foot. The MDS also indicated R1 required limited assistance with activities of daily living (ADLs), and had intact cognition. R1's Care Area Assessment (CAA) dated 7/1/20, indicated R1 had a current skin wound and infection of the foot. R1's care plan initiated 6/23/20, indicated R1 had a history of [REDACTED]. Staff interventions included implementing orders/treatments per MD/wound clinic, and follow facility skin protocol. R1's facility Risk/Benefit Tool completed 6/26/20, indicated R1 was at risk of surgical wound failure, risk of infection, loss of mobility to leg, risk of falls which could lead to significant injury, and hospitalization or death. R1's wound treatment order received from wound clinic initiated 8/5/20, indicated wound care for right foot. Instructions included acetic acid (solution with antibacterial and antifungal properties) wash prior to dressing changes, rinse well and dry completely. Coat a ¼ plain packing strip with [MEDICATION NAME] (antibiotic) to tunnel near base of third toe followed by [MEDICATION NAME] to rest of wound bed covered with [MEDICATION NAME] (anti-microbial dressings) and quick pad (dressing), followed by Kerlix (wrap) and Setopress (compression dressing). R1's treatment administration record (TAR) dated 8/1/20, through 8/30/20, indicated R1 refused wound care on 8/5, 8/6, 8/9, 8/11, 8/12, 8/13, 8/15, 8/18, 8/21, 8/22, 8/25, and 8/26. Record review lacked indication R1's physician or the wound clinic was notified of R1's refusal of wound care. Review of R1's medical record including skin assessments and progress notes, indicated the facility failed to properly assess R1's wound status from 8/1/20, through 8/26/20, during the time period the facility nursing staff was responsible for R1's diabetic wound care. R1's medical record lacked documentation of an assessment of the diabetic wound status, measurements, or description from 8/1/20, through 8/26/20. On 8/26/20, a progress note indicated R1 had been sent to the emergency department (ED) due to to complaints of increased pain in the right foot. On 8/27/20, a progress note indicated R1 returned to the facility with new orders for [MEDICATION NAME] (oral antibiotic) 500 mg 3 times daily for seven days, and Zinc 50 milligrams (mg) 1 time daily to promote healing. R1's Patient Discharge Orders from the ED dated 8/27/20, at 1:30 a.m. indicated R1 was treated for [REDACTED]. The orders further indicated R1 was started on a course of antibiotics in the ED, and was to complete full course of antibiotics prescribed. Wound care clinic visit summary and wound assessment details dated 9/1/20, indicated R1's right foot trauma wound measured 4.5 centimeters (cm) in length, 2.2 cm in width and 0.1 cm in depth. R1's wound was described as having medium amounts of serosanguineous (serum and blood) drainage which was red and brown in color. The report also indicated R1 developed an additional right foot dorsal (outer) wound which measured 2 cm in length, 1 cm in width and 0.1 cm in depth. R1's second right foot wound was described as having large amounts of serous (serum) drainage, and was amber in color. Both of R1's right foot wounds were classified as Grade 1 [MEDICAL CONDITION] (superficial wounds through either the epidermis or the epidermis and dermis, but that do not penetrate to tendon, capsule, or bone). On 9/2/20, at 8:24 a.m. R1 was interviewed, and stated he had been to the ED recently, and was treated for [REDACTED]. R1 further stated he had refused dressing changes numerous times because he felt it was unnecessary. R1 stated he was previously going out to wound clinic but was not able to go out due to COVID-19 in the facility, and during that time the facility was providing wound care. R1 stated he is now going to the wound clinic for wound care twice weekly, and he would no longer be refusing wound care. On 9/3/20, at 9:35 a.m. nursing assistant (NA)-A stated if a resident had a change in condition such as increased pain or change to skin she would report the change immediately to a nurse in charge. NA-A stated only licensed nurses are responsible for providing resident wound care. NA-A had no knowledge of R1's wound care or [MEDICAL CONDITION]. On 9/3/20, at 9:35 a.m. registered nurse (RN)-A stated nurses were responsible for completing wound care. RN-A stated R1 had been previously going out to the wound care clinic, but this had change the first part of August due to COVID-19 in the facility. RN-A stated all wound care then was completed in house and residents were not going out to the wound clinic during the facility COVID-19 outbreak. RN-A stated R1 frequently refused wound care. RN-A stated R1 had refused wound care for himself, however, neither R1's physician or the wound care clinic were contacted with those refusals. RN-A stated resident refusals of cares, and correspondence to physicians related to refusals of care were to be documented in the progress notes. On 9/3/20, at 10:57 a.m. the director if nursing (DON) stated if a resident refused treatments, the physician was to be notified. The DON stated she was made aware of R1's maggot infestation to his right foot wound upon his return from the ED on 8/27/20. The DON stated she would have expected R1's physician to have been notified of R1's refusing wound care. The DON stated failure to update the physician could increase the risk of developing an infection, and worsening of the wound. The DON stated notification to R1's physician should have been completed by nursing staff with each of R1's refusal of care. On 9/3/20, at 12:15 p.m. RN-B was interviewed and stated she was the nurse manager for R1's unit. RN-B stated she personally never provided wound care or inspected R1's foot wound. RN-B stated she never provided education to R1 regarding the risks related to his refusal of care. RN-B stated she was made aware of R1's right foot maggot infestation on 8/27/20. RN-A verified the neither the wound clinic nor R1's physician were notified and updated regarding R1's wound care refusals. RN-B stated the facility failed, and they should have been letting the physician and wound clinic aware of R1's refusal of wound care. On 9/4/20, at 2:29 p.m. the wound clinic RN-C was interviewed. RN-C stated the facility had not notified them of R1's wound care refusals. RN-C stated she was updated via email by the hospital social worker regarding R1's wound condition and maggot infestation on 8/27/20. RN-C stated R1 had not been seen at the wound clinic from 7/31/20, through 8/27/20, due to an outbreak of COVID-19 at the facility. RN-C stated the facility was responsible for R1's wound care during that time. RN-C stated she would have expected the facility to notify the wound clinic of R1's refusals, and had they been updated, R1's wound infection and maggot infestation may have been prevented. The ED physician was called 9/3/20, at 8:12 a.m. and a message was left, however, there was no response or return call. The facility policy Notification to Physician/Family/Resident Representative of Change in resident Health Status revised 5/20, directed the facility will consult the resident's physician when there is a need to alter treatment significantly (i.e. a need to discontinue or change an existing form of treatment due to adverse consequences or to commence a new form of treatment). The facility policy Pressure Injury/Skin Integrity/Wound management revised 5/20, directed residents will receive treatment and services consistent with professional standards of practice to promote healing and prevent infection and prevent new pressure injuries from developing. The facility policy Treatment Record revised 5/20, all treatments provided must be ordered by the physician and documents, documentation to include reason for refusal of treatments.

Based on observation, interview and document review, the facility failed to implement appropriate COVID-19 infection control practices related to the appropriate utilization of personal protective equipment (PPE) when providing personal care and treatment to residents; and failed to quarantine 2 of 2 residents (R1, R2) who had recently returned from hospitalization s as recommended, in order to minimize or contain the spread of COVID-19. These practices resulted in an immediate jeopardy (IJ) due the potential risk for widespread outbreak of COVID-19 with the potential to affect all 133 residents residing in the facility, and all staff. The immediate jeopardy began on 8/1/20, when it was determined the facility had begun re-using one to two plastic infection control gowns per room, per resident, per day, for all staff entering a resident room to wear regardless if contaminated during the provision of cares; and when the facility failed to ensure quarantined residents remained in their rooms during the 14 day hospital return per the Centers for Disease Control and Prevention (CDC) COVID-19 guidelines even though the facility currently had an outbreak of COVID-19 within the facility. The executive director, administrator, director of nursing (DON) and the infection control nurse were notified of the IJ at 4:20 p.m. on 8/14/20. The IJ was removed on 8/19/20, but noncompliance remained at the lower scope and severity level of F: widespread which indicated no actual harm with potential for more than minimal harm that is not IJ. Findings include: On 8/13/20, at 12:30 p.m. upon entrance to the facility, the executive director stated the facility currently had twelve residents who had tested positive for COVID-19 and an additional resident test result was pending. Between 8/1/20 and 8/13/20, twelve of twenty-seven residents tested positive for COVID-19. Eleven of the twelve positive residents resided on the Birch unit; one resided on the Elm unit. The Birch and Elm units were currently under quarantine due to having had COVID-19 positive residents residing on those units. On 8/13/20, at 2:20 p.m. when asked about infection control precautions, unit manager (UM)-A stated plastic reusable gowns hung on a hook in the entrance of each resident room on the Elm unit. UM-A stated the staff were to don the gown when entering the resident room, provide care or assistance to the resident, then doff the gown when exiting the room and hang it back up on the same hook for the next staff member to use when entering the resident room. UM-A stated all staff had their own goggles which they stored in Tupperware containers in their break room when not on shift. Personal Protective equipment (PPE) On 8/13/20, at 1:57 p.m. a staff member on the Birch unit was observed to enter room [ROOM NUMBER]. Upon entrance to the room the staff member removed a gown from a hook just inside the door to the room. The staff member then put her arms into the sleeves of the gown and pulled the gown, which was already tied at the neck, over her head touching the gown to her face. In addition, R3's room was located on the Elm unit which was a quarantined unit due to another resident, who resided on the unit, having tested positive for COVID-19. R3 required transmission-based precautions for a 14 day period due to a potential exposure to the COVID-19 illness. Precautions included the staff to wear a mask, eye protection and a gown when entering R3's room. R3 did not exhibit any acute respiratory symptoms and was not COVID positive. During observations on the Birch unit on 8/14/20, at 7:56 a.m. trained medication aide (TMA)-A entered room [ROOM NUMBER] wearing a gown. Upon entrance to the room TMA-A removed a gown from a hook inside the door and placed it on over her gown. When leaving the room, TMA-A removed the gown and placed it back on the hook inside the room. -At 8:03 a.m. an unknown nursing assistant (NA) was observed removing a gown by pulling it over her head with the neck still tied and hung it on a hook outside the nurses station. The NA then took the gown back off the hook and placed it over her head, again with the neck still tied. -At 8:06 a.m. NA-D entered room [ROOM NUMBER], removed a gown from a hook in the room and pulled it over her head with the neck already tied. -At 8:12 a.m. NA-E removed a gown from a hook inside a resident room, put the gown on in the hallway while talking to another staff member and returned to the room where the gown had been. Upon leaving the room, NA-E pulled the gown, still tied at the neck over his head and hung it back on the hook in the room. -At 8:16 a.m. registered nurse (RN)-A stopped at the entrance to room [ROOM NUMBER], removed a gown from a hook in the room and pulled it over her head. Upon leaving the room, RN-A pulled the gown back over her head and placed it back on the hook. -At 8:20 a.m. NA-E stated the gowns were being shared by staff throughout the day and were changed out on the overnight shift. When asked about education related to donning and doffing PPE, NA-E stated staff were probably not doing it correctly. Shortly thereafter, UM-B stated she had been on the floor all day the previous day. UM-B stated she had seen some of the staff pulling gowns on and off over their heads and stated she had educated those staff members as to the correct way to don/doff a gown. -At 8:19 a.m. NA-A was observed on the Elm unit, pushing a mechanical standing lift into R3's room. Upon entering the shared resident room, NA-A grabbed one of two, unlabeled gowns that were hanging side by side on hooks just inside the entrance of the room. With ungloved hands, NA-A proceeded to don the gown by grabbing the outside of the gown, threading her arms into the sleeves, and tied the gown ties to secure it at the neck and waist. NA-A stated the gowns hanging were to be shared and worn by all staff who entered the room and that the night shift changed the gowns every night. R3 was lying in bed. NA-A applied gloves, and assisted R3 to a seated position on the edge of the bed, applied the lift sling around R3's waist, positioned straps around R3's calves, fastened the waist lift straps to the lift and proceeded to stand R3 up. NA-A wheeled R3, in the mechanical stand, into the bathroom and onto the toilet. NA-A obtained an unlabeled wash basin from an unidentified closet and filled the basin with wash water. While R3 was seated on the toilet, NA-A washed R3's upper and lower body and dressed R3. Throughout the cares, and with the same gloved hands, NA-A was observed to grab her gown several times and pull it up over her shoulders, as it kept sliding down off her shoulder. While applying R3's pants and shoes, NA-A's gown brushed up against R3's bare feet and calves. Once dressed, NA-A stood R3 up with the mechanical stand and provided perineal care. During the perineal care, NA-A's gown came into direct contact with R3's bare hip. Following the cares, NA-A assisted R3 into her wheelchair. With the gown on, NA-A removed R3's wet, urine soiled, bed linens and placed them into a bag, tied the bag, and rinsed the wash basin and returned it to an unidentified closet. The soiled linen and basin were not noted to have direct contact with NA-A's gown. Neither the basin nor closet were labeled with a resident's name or bed. NA-A verified the gowns and basin were not labeled to identify for which resident they were to be used. When asked, NA-A confirmed the supplies could get mixed up and used for either resident but it was common knowledge that the closet closest to the door belonged to bed one except in one room on the Birch unit were it was just the opposite. NA-A stated she was unaware of any closets having been marked or identified with a resident name. NA-A stated the wash basins were disinfected one time weekly on the resident's bath days. -At 8:59 a.m. the regional nurse consultant stated the facility was using reusable gowns to conserve on their PPE. The regional nurse consultant stated the facility had a non-COVID related outbreak a few months prior and had received direction to re-use gowns, however, had not clarified the use of re-useable gowns during a COVID-19 outbreak. The regional nurse consultant stated the facility had been stockpiling reusable gowns and were utilizing them throughout the building. The regional nurse consultant stated the facility had a mixture of disposable and re-usable gowns but they were trying to conserve. She further stated the health department had supplied the facility with gowns. The nurse consultant stated the gowns were used throughout the day and were changed out on the overnight shift or when soiled. She stated the staff should not be donning and doffing the gowns by leaving them tied and pulling them over their heads and stated the department heads and unit managers were responsible for monitoring how staff were donning and doffing the PPE. -At 9:01 a.m. NA-B was observed on the Elm unit going from room to room delivering breakfast trays to the residents in their rooms. NA-B was observed to remove a shared gown off the hook from inside a resident's room. The neck ties of the gown were tied, therefore NA-B slipped the gown over his head and threaded his arms into the gown sleeves. NA-B applied gloves and entered the resident room to deliver the tray that another NA handed to him from the hallway. NA-B placed the tray on the over bed table, set up the meal, removed the gown, hung it back up on the doorway hook with the ties remaining tied. NA-B removed and discarded his gloves, and utilized hand sanitizer. NA-B was observed to repeat this process in three additional resident rooms, on the Elm unit. Throughout the observation, NA-B was not noted to secure the gown at his waist, rather the gown flowed freely when on. On 8/14/20, at 12:23 p.m. NA-C was observed standing next to and leaning over R4's bed to take his meal tray off the bedside table. NA-C wore a mask and face shield as required, however, was not wearing a gown. NA-C's uniform brushed up against R4's bed while she was speaking to R4. NA-C utilized hand sanitizer and exited the room. When asked, NA-C stated she thought she should have put on a gown before entering R4's quarantined room, but was not sure as the facility staff was not good at informing staff about that stuff. R4's clinical record revealed R4 had been hospitalized from 8/4/20 - 8/11/20, therefore was required to be on 14 day transmission based precautions and isolated to his room due to this recent hospitalization and subsequent return to the facility. Precautions included the staff were to wear a mask, eye protection and a gown when entering R4's room and in-room isolation. R4 did not exhibit any acute respiratory symptoms and was not COVID positive. On 8/14/20, at 3:33 p.m. NA-C stated she also worked at another facility and at that facility, she would apply a new gown each time she entered a resident room and discard the gown in the garbage. NA-C stated at this facility, the staff were using the same gowns all day with multiple people. NA-C asked, What if one of the staff have COVID-19 and now I am contaminated by using their gowns. I think it is so gross. NA-C also stated she had worked a couple of hours this shift before someone stopped her and told her she also needed to be wearing goggles. NA-C stated, They [staff] are so poor at explaining stuff. NA-C also stated she worked at this facility very part time, and prior to today, had not worked in a long time. Quarantined residents R2 had been hospitalized on [DATE] through August 7, 2020, and required 14 day transmission based precautions and in-room isolation for a 14 day period due to her recent hospitalization . Precautions included the use of a mask, eye protection and gown when entering R2's room. R2 did not exhibit any acute respiratory symptoms and was not COVID positive. On 8/13/20, at 12:24 p.m. ward clerk (WC)-C verified R2 was hospitalized [DATE] through August 7, 2020 and was under 14 day quarantine following the hospitalization . On 8/13/20, at 1:27 p.m. R2 was seated in a wheelchair in the main hall near the nurse's station. R2 had a cloth face mask on that covered her mouth, however the mask was not covering her nose. A staff member was observed to pass R2 and gave her a verbal reminder to pull her mask up over her nose. R2 replied the mask made it difficult for her to breathe. The staff member instructed R2 to remain in her room if she could not wear the mask properly. On 8/14/20, at 7:45 a.m. R2 was observed self-propelling in the facility hallways on Spruce unit. R2 had a cloth face mask on, however, the mask did not cover R2's nose. Several staff were observed to walk past R2, however, none of the staff directed R2 back to her room. -At 11:40 p.m. R2 was observed self propelling her wheelchair in the hallway on the lower level of the facility near the kitchen area. R2 was wearing a cloth mask over her mouth, however, the mask did not cover her nose. -At 3:33 p.m. R2 was observed in the main hallway of the first floor near the nurse's station, seated in her wheelchair. R2 was not wearing her face mask rather was holding it out, away from her face. Two staff members were observed to pass by her, but did not redirect R2 to put her mask on properly or to return to her room. R1 had been hospitalized [DATE] through August 13, 2020, therefore was on 14 day transmission-based precautions and in-room isolation. Precautions included the use of a mask, eye protection and gown when entering R1's room. R1 did not exhibit any acute respiratory symptoms and was not COVID positive. On 8/13/20, at 2:40 p.m. R1 was observed to be outside the facility's first floor dining area between the Elm and Birch units, near to two other residents. All three residents were seated in wheelchairs about two to three feet apart from each other smoking. When done smoking, R1 re-entered the facility through the dining room door and wheeled himself through the dining area, hallway, turned onto the Spruce unit hallway, touched the elevator button, and entered the elevator in order to return to his room on the second floor. R1 stated he had just returned from the hospital that morning. Upon reaching the second floor, R2 propelled himself down the hall, past the dining area and nurse's station and to his room. On the door of R2's room was a sign that indicated he was on enhanced respiratory precautions. R1 was observed to wear a face mask when not smoking. -At 2:47 p.m. licensed practical nurse (LPN)-A stated enhanced respiratory precautions indicated R1 was under a 14 day quarantine following a hospital return that morning. LPN-A stated when staff entered the room they were to wear a gown, gloves and face mask. LPN-A was asked why R1 was off the unit if he was supposed to be quarantined and stated the nurses manager had just spoken to him about leaving his room after he returned to the unit after smoking. On 8/14/20, at 9:08 am. the regional nurse consultant stated when a resident returned from the hospital they were placed under quarantine for 14 days and staff were to treat them as if they were positive for COVID-19, wearing a mask, gloves and gown when providing care. She stated residents were educated upon return from the hospital and should not be leaving their rooms. -At 9:52 a.m. the regional nurse consultant stated all of the residents except one who had tested positive for COVID-19 had resided on the Birch unit prior to moving to the designated COVID-19 unit. On 8/14/20, at 12:15 p.m. R1 was again observed seated in his wheelchair in front of the first floor activity office door. R1 wore a face mask. R1 stated he was waiting for the activity director to return as she had purchased his cigarettes and he needed them. There were no staff members present. The social worker was asked to assist and was observed to have a brief conversation with R1 in the hall. R1 then turned to go to the elevator. R1 stated the social worker told him she would get his cigarettes for him, but he was to return to his room because he was supposed to be quarantined. R1 self-propelled to the elevator to return to the second floor. -At 3:45 p.m. the director of nursing (DON) stated new admissions and residents who returned from the hospital were placed on a 14 day quarantine and were to remain in their rooms. The DON stated the staff were directed to wear a face shield, mask, gown and gloves when entering into a quarantined/isolation room. The DON stated the staff tried to keep R2 in her room, but she was non-compliant. The DON verified the staff were aware R1 and R2 were under quarantine and were expected to redirect a resident under quarantine/isolation back to their room if they were out and about within the facility. The DON verified allowing R1 and R2 to come out of their rooms and wheel throughout the facility was an infection control concern due to the potential of spreading COVID-19 if they were to test positive for the illness. The DON verified the staff did reuse gowns in quarantined resident rooms and confirmed the gowns were not disinfected between use but were replaced daily. The DON also confirmed additional COVID-19 test results were pending. The DON confirmed the gown hooks, and closets in shared rooms, were not labeled to identify which resident it belonged to rather the hook or closet closest to the door was meant for the resident in bed one which was by the door and the other was for bed two, the bed by the window. In regard to residents who required two staff for cares the DON stated that was up to the staff going into the rooms. The DON confirmed there was a potential the virus could be spread to staff and other residents based on the current staff practices. The DON further stated she was not aware of any shortage of PPE in the building and stated, we have been pretty well stocked. An Email letter sent to the families and residents of the facility, dated August 8, 2020, indicated the facility was following all guidance from federal, state and local health officials to limit the spread of the COVID-19 virus within the facility. A facility policy titled, Infection Prevention and Control COVID-19, revised 7/23/2020, indicated upon identification of symptoms there would be strict adherence to the use of standard, contact and droplet precautions. The policy indicated residents with known or suspected COVID-19 should be placed in a private room but indicated room sharing might be necessary if there are multiple residents with known or suspected cases. In the event of an outbreak the policy outlined the following: Place residents in private rooms on standard, contact and droplet precautions, PPE to include gloves, gowns and masks. The CDC recommendations recommended healthcare workers wear a gown to protect skin and prevent soiling or contamination of clothing during resident-care activities when contact with blood, body fluids, secretions, or excretions was anticipated. Remove the gown and perform hand hygiene before leaving the resident's room, and to not reuse gowns, ever for repeated contacts with the same resident. Disposable gowns should be discarded after use. Residents may remove their face mask when in their rooms but should put it back on when around others or leaving their room. Any reusable PPE must be properly cleaned, decontaminated, and maintained after and between uses. All new admissions and hospital returns should be quarantined in room for 14 days following admission. The immediate jeopardy that began on 8/1/20, was removed on 8/19/20, when the facility implemented an infection control plan to minimize the spread of COVID-19 which included procedures for the appropriate use and reuse of PPE by facility staff and procedures to ensure staff encouraged the appropriate use of face masks by residents when outside of their room for source control, encouraged resident social distancing, and limited resident wandering between designated hot (facility COVID cohort area), warm (facility quarantine area) and cold units within the facility. The plan also included identification of additional separate smoking areas to accommodate each unit of the facility to ensure residents within the 14-day quarantine period, residents residing on a hot unit and residents residing on units not requiring quarantine restrictions did not travel through a unit with a different hot, warm or cold designation to reach their smoking area and limited potential exposure to each other. Staff were provided education regarding the infection control procedures and the facility established a daily auditing plan for PPE usage and 14-day quarantine in relation to smoking and source control.

Based on interview and document review, the facility failed to initiate timely cardio-pulmonary resuscitation (CPR) in accordance with resident wishes and physician orders [REDACTED]. This deficient practice resulted in an immediate jeopardy (IJ) when R4 was found with an absent pulse and respirations, timely CPR was not initiated, and R4 died . The IJ began on [DATE], when R4 was found with an absent pulse and respirations, timely CPR was not initiated, and R4 died . The administrator and director of nursing (DON) were made aware of the incident on [DATE], and immediately initiated corrective actions. The administrator and director of nursing (DON) were notified of the IJ on [DATE], at 3:14 p.m. The facility implemented corrective action on [DATE], prior to the onsite investigation, and the deficiency is being issued at past non-compliance. Findings include: R4's Face Sheet dated [DATE], indicated R4's [DIAGNOSES REDACTED]. R4's admission Minimum Data Set ((MDS) dated [DATE], identified R4 was cognitively intact. R4's Providers Order for Life Sustaining Treatment (POLST) dated [DATE], directed CPR/ATTEMPT RESUSCITATION and PROVIDE LIFE SUSTAINING TREATMENT. The POLST document was signed by R4's guardian on [DATE], and R4's physician on [DATE]. On [DATE], at 2:30 p.m. a progress note indicated R4's guardian requested CPR be performed, if needed. On [DATE], at 9:04 a.m. a progress note written by registered nurse (RN)-E indicated R4 died at 8:50 a.m. On [DATE], at 2:08 p.m. nursing assistant (NA)-A was interviewed. NA-A stated on [DATE], she had provided R4 a meal tray and changed the resident's incontinence product between 8:00 a.m. and 8:30 a.m. NA-A stated between 8:45 a.m. and 9:15 a.m. NA-B found R4 unresponsive, and informed her and RN-E. NA-A stated RN-E went to the nurses' station to look for R4's code status and then she saw him on the telephone. NA-A stated she was unaware if RN-E went into R4's room prior to going to the nurses' station. NA-A stated she then obtained supplies to perform post-mortem cares and placed the supplies in R4's room. NA-A stated she informed NA-C R4 had died , and then returned to R4's room. NA-A stated upon entering the room she asked NA-C how staff determined a resident's code status. NA-A stated NA-C responded you don't know, and instructed her to stay in the room and ran down a hallway towards the nurses' station. NA-A stated she then overheard a Dr. Heart (facility's [MEDICAL CONDITION] response team) called via an overhead page. NA-A stated the facility's nurse managers quickly came to R4's room and began CPR. NA-A estimated 15 minutes passed from when she was informed R4 had died , to when CPR was started. NA-A stated she heard R4's code status was supposed to be listed on a team sheet, but was not. On [DATE], at 2:26 p.m. NA-C was interviewed. NA-C stated she was in the unit dining room on [DATE], at approximately 9:00 a.m., when NA-A informed her post-mortem cares needed to be completed for R4. NA-C stated when she arrived to R4's room, the supplies were present. NA-C stated NA-A then asked her how to determine if a resident was a full-code or do-not-resuscitate. NA-C stated that made me think twice and she went to the nurses' station to look for R4's code status. NA-C stated she was unable to find R4's code status, and called a Dr. Heart via an overhead page. NA-C stated she saw RN-E at the nurses' station on the telephone and looking through a chart. NA-C stated staff came quickly once the Dr. Heart was called. NA-C stated she did not know when R4 was found unresponsive. On [DATE], at 2:49 p.m. NA-B was interviewed. NA-B stated R4 was not eating breakfast on [DATE], between 8:00 a.m. and 8:30 a.m., so she returned to R4's room at approximately 8:45 a.m. to offer her a popsicle. NA-B stated when she entered the room, R4 was lying in bed, her eyes were open, and the resident looked dead. NA-B stated she felt for a pulse on R4's neck for one minute and felt nothing. NA-B stated she then found RN-E within five minutes, and they went into R4's room together. NA-B stated RN-E checked R4's pulse and told her R4 had died . NA-B stated RN-E instructed her to clean up R4, and told her he would check for the resident's code status, and they left the room together. NA-B confirmed RN-E did not start CPR. NA-B stated she then left the room, and told NA-A R4 had died , and needed to be cleaned up. NA-B stated she saw RN-E at the nurses' station making telephone calls. NA-B stated approximately 15 to 20 minutes had passed from her finding R4 unresponsive until she overheard NA-C call a Dr. Heart via overhead page. On [DATE], at 8:59 a.m. RN-B was interviewed. RN-B stated she worked on [DATE], however, was not at the facility when R4 had died . RN-B stated the NAs reported RN-E failed to perform CPR when R4 was found unresponsive at approximately 9:00 a.m. RN-B stated RN-E had reported he started CPR and then stopped, however, this was contrary to the NAs' report. RN-B stated she did not know what time a Dr. Heart was called, but confirmed CPR was not performed continuously when R4 was found unresponsive. RN-B stated the nurse managers performed CPR once the Dr. Heart was called, and did so continuously until emergency medical services (EMS) arrived. RN-B stated she understood RN-E was having difficulty locating R4's POLST document. RN-B confirmed R4's code status was not documented on R4's team sheet on [DATE]. RN-B stated she personally placed a copy of R4's POLST in R4's medical record. RN-B stated R4's POLST was found at the nurses' station under paperwork RN-E had looked through. RN-B stated RN-E was immediately suspended pending investigation, and he was no longer employed at the facility. RN-B stated the facility expectation was to call a Dr. Heart if a resident's code status was unable to be determined. RN-B stated she instructed agency staff on the process of identifying residents' code status upon starting at the facility. RN-B stated the facility provided CPR education after the event occurred. On [DATE], at 9:11 a.m. RN-A stated she worked dayshift on [DATE]. RN-A stated she heard a Dr. Heart called at approximately 9:15 a.m., and licensed practical nurse (LPN)-C had an automated external defibrillator (AED) and was in the process of performing CPR when she arrived to the unit. RN-A stated she did not know what time R4 was found unresponsive. RN-A stated she called the ambulance and R4's guardian to let them know CPR was in progress when she arrived to the unit. RN-A stated she understood RN-E had difficulty locating R4's POLST document because the copy was made in white. RN-A stated the facility had made a process change and all POLST documents were now copied in gold. RN-A also stated all residents' team sheets were checked for accurate code statuses after the occurrence. On [DATE], at 9:21 a.m. LPN-C stated she worked dayshift on [DATE], and heard a Dr. Heart called sometime around 9:00 a.m. and grabbed an AED. LPN-C stated RN-E was near R4's room when she arrived to the unit, however, he was not performing CPR. LPN-C confirmed no CPR was in progress when she arrived to R4's room, and stated she was the first person to perform CPR. LPN-C stated she did not know what time R4 was found unresponsive. LPN-C stated since the occurrence, copies of POLST documents were to be made in gold. On [DATE], at 9:28 a.m. RN-F was interviewed and stated he worked dayshift on [DATE], and heard a Dr. Heart called between 9:15 a.m. and 9:20 a.m. RN-F stated when he arrived to R4's room, CPR was being performed by LPN-C. RN-F stated approximately five minutes after arriving to the unit, emergency medical services (EMS) arrived. RN-F stated he did not know what time R4 was found unresponsive. RN-F stated since the occurrence, copies of the POLST were made in gold. On [DATE], at 9:42 a.m. the assistant director or nursing (ADON) was interviewed. The ADON stated she did not work on [DATE], however, was responsible for education regarding the occurrence which involved R4. The ADON stated code status education was provided to all nurses, and audits on resident code status were completed. The ADON stated R4 was found unresponsive, staff performed CPR, and after the Dr. Heart was called everything was conducted as it was supposed to be. The ADON was asked what if a resident's code status was unable to be identified, and responded the POLST should just be there on two occasions. The ADON stated the facility was unable to stop CPR once it was started without a physician order. The ADON stated the facility was conducting an investigation regarding the occurrence. On [DATE], at 10:07 a.m. the health unit coordinator (HUC)-A stated she was responsible for making team sheets on the unit which R4 resided. HUC-A confirmed R4's code status was not on the team sheet on [DATE]. HUC-A stated the interim administrator went over the process of making team sheets, and provided education to her. On [DATE], at 10:40 a.m. the director or nursing (DON) was interviewed. The DON stated she worked dayshift on [DATE], and heard a Dr. Heart called at approximately 9:15 a.m. while she was in morning meeting. The DON stated the morning meeting consistently started around 9:15 a.m. The DON stated she did not know what time R4 was found unresponsive. The DON stated she interviewed RN-E, and he stated he performed CPR. The DON stated when she arrived to the unit RN-E was performing CPR. The DON stated she heard CPR was not performed timely, but she was only able to go by the fact R4 was provided CPR. The DON confirmed RN-E was suspended immediately following the occurrence to make sure everything was done. The DON confirmed it was not routine practice to suspend every nurse when a resident experienced a [MEDICAL CONDITION]. The DON stated proactive education was provided to all nursing staff. The DON stated copies of the POLST document were also to be made in orange moving forward. The DON stated the facility spent all weekend educating everybody. On [DATE], at 11:00 a.m. administrator was interviewed. The administrator stated she worked dayshift on [DATE], and was in morning meeting at approximately 9:15 a.m. when she heard a Dr. Heart called. The administrator stated all the nurses left the room at that time. The administrator stated she believed R4 was found unresponsive around 8:50 a.m., however, could only personally account for 9:15 a.m. The administrator stated she was made aware there was a concern CPR was not started timely when R4 was found unresponsive, and an investigation was started. The administrator stated RN-E was immediately suspended following the incident. The administrator stated RN-E reported he had started CPR and stopped. The administrator stated RN-E reported he was having difficulty locating R4's code status. The administrator stated R4's original POLST document was found in the physician's rounding folder, and an additional copy of R4's POLST was found at the nurses' station. The administrator confirmed a code stated was not listed on R4's team sheet on [DATE]. The administrator stated it was identified that further follow-up needed to be conducted with RN-E, however, he did not respond to further inquiries so his employment was terminated. The administrator confirmed CPR should have been started and not stopped until EMS arrived. The administrator stated the facility completed CPR education with all licensed nursing staff. The administrator stated staff was instructed CPR was to be performed continuously unless the AED directed them to stop, no exceptions. The administrator stated the facility also reviewed employee files, had an ad hoc quality assurance meeting, and two audits were conducted of all residents team sheets and POLST documents on [DATE]. The administrator stated documentation showed education was completed on [DATE]. On [DATE], at 1:57 p.m. R4's guardian (G)-A was interviewed and stated he received a call from the facility on [DATE], between 9:05 a.m. and 9:10 a.m., and was informed R4 had died . G-A stated he had told the facility R4 was a full-code status, and was told the facility worked on R4 for a long time, and she died at 8:50 a.m. G-A stated he then told the facility which funeral home he preferred to use. G-A stated he then received another call from the facility at approximately 9:25 a.m., and was told the facility was in the process of performing CPR on R4. G-A stated approximately five minutes later he received another call from the facility and was told the R4 had died . The facility implemented corrective action to prevent recurrence by [DATE]. The facility audited resident team sheets and POLST documents to ensure accuracy on two occasions, the facility educated licensed nursing staff, conducted an ad hoc quality assurance meeting, reviewed employee files, and ensured POLST documents were printed on gold paper and placed in front of resident's charts. The corrective actions were verified by staff interview and review of resident records and education logs. The facility policy Cardiopulmonary Resuscitation (CPR) revised ,[DATE], directed, Personnel provide basic life support, including CPR, to a resident requiring such emergency care. Prior to the arrival of emergency medical services (EMS), this community provides basic life support, including the initiation of CPR, to a resident who experiences [MEDICAL CONDITION] (cessation of respirations and/or pulse) in accordance with the resident's advance directives or in the absence of advance directives or Do Not Resuscitate (DNR) order. The facility policy Staff Competencies Policy revised ,[DATE], directed, It is the policy of Health Dimensions Group to assure staff have appropriate competencies and skills sets to provide nursing, food, nutrition, and related services to assure resident safety and attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident.

Based on observation, interview, and document review, the facility failed to ensure dressing changes were completed according to physician orders [REDACTED]. This resulted in actual harm for R13 whose pressure ulcer worsened. Findings include: Pressure ulcer stages from the National Pressure Ulcer Advisory Panel (NPUAP): Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. R13's Face Sheet printed 3/5/20, identified [DIAGNOSES REDACTED]. R13's annual Minimum Data Set ((MDS) dated [DATE], indicated R13 was cognitively intact, and required assistance of staff with bed mobility, transfers, personal hygiene, and set up for toileting. The MDS also identified R13 was at risk for the development of pressure ulcers, and currently had one Stage 2 pressure ulcer. The MDS also indicated R13 had a pressure reducing device for in the bed and the chair, and had nutrition or hydration inventions to manage skin problems. R13's care plan dated 4/15/19, indicated R13 was at risk for impaired skin integrity and pressure related to the need for assistance with activities of daily living (ADLs). R13's goal was for skin to remain clean, dry and intact, and have decreased potential for development of pressure injuries. R13's care plan directed the use of pressure reducing cushions in wheelchair and on bed, medications, labs, and treatments as ordered. On 1/24/20, R13's Advanced Wound Care and Hyperbaric Center visit noted indicated R13's left heel continued to show areas of pressure and significant macerated peri-wound. The note further indicated R13 had arrived again with a soaked dressing that had not been changed from R13's shower earlier that day at the facility. The note further indicated R13 had arrived at the Advances Wound Care Center with soaked dressings in the past despite calls to the facility which instructed R13's dressing to be removed prior to shower, and gauze placed over wound until R13's wound appointment. Left heel ulcer measured 0.9 centimeters (cm) x 0.5 cm x 0.2 cm. On 1/31/20, the Advanced Wound Care and Hyperbaric Center visit noted indicated R13's left heel ulcer had significantly improved from last week. R13 did not arrive with a wet dressing, and maceration to left heal showed improvement. Left heel ulcer measured 0.9 cm x 0.3 cm x 0.2 cm. On 2/10/20, R13's Wound Assessment Flow Sheet indicated R13's left heel wound ulcer measured 0.9 cm x 0.7 cm x 0.1 cm. On 2/17/20, R13's Wound Assessment Flow Sheet indicated R13's left heel wound ulcer measured in 0.9 cm x 0.6 cm x 0.1 cm. On 2/18/20, the Advanced Wound Care and Hyperbaric Center visit note indicated R13's left heel ulcer looked good and was heading in the correct direction. Left heel ulcer measured 0.4 cm x 0.2 cm x 0.2 cm. On 2/24/20, a progress note indicated R13 complained of left ankle pain, was offered [MEDICATION NAME] (narcotic pain medication) but declined. The note further indicated R13 called 911 and Emergency Medical Services (EMS) arrived and transported R13 to St. Luke's. On 2/24/20, emergency department (ED) summary indicated R13 was seen at the ED for left heel infection with increased pain. R13's preliminary x-ray results were negative for osteo[DIAGNOSES REDACTED], and R13 was started on [MEDICATION NAME] (antibiotic), returned to the facility, and was instructed to have a follow up appointment that week. On 2/25/20, a progress note indicated R13 left at 10:00 a.m. for his wound care appointment. The Advanced Wound Care and Hyperbaric Center called the facility and stated R13 would be admitted to the hospital due to [DIAGNOSES REDACTED]. On 2/25/20, the Advanced Wound Care and Hyperbaric Center visit note indicated R13's left heel ulcer had worsened from last week's visit, and started to get some tissue necrosis (tissue death). Due to the worsened appearance and deterioration of the wound, R13 was admitted to the hospital for IV antibiotics and evaluation to make sure wound did not turn into a necrotizing type of infection and to rule out osteo[DIAGNOSES REDACTED] (bone infection). R13's pressure ulcer measured 3.6 cm x 3.4 cm x 0.4 cm. The note further indicated a registered nurse (RN) from the wound clinic spoke with RN-B at the facility to update of R13's admission, and was told there were issues to address with staff but would not elaborate. On 2/28/20, R13's hospital discharge summary indicated R13 was admitted on [DATE], from the wound care clinic for [MEDICAL CONDITION], left heel ulcer which was reddened, sore, and tender. R13 had a computed tomography (CT) scan (a medical imaging procedure allowing the user to see inside the object without cutting) showed no deep space infection or osteo[DIAGNOSES REDACTED]. R13 received a broad spectrum antibiotic intravenously with some improvement, and was seen by infectious disease. Discharge instructions to left heel wound instructed: Cleanse and dry with saline and gauze. Use skin prep to skin about the bound bed and allow to dry. Lotion to remainder of both feet and legs. Cover with [MEDICATION NAME] foam 4 x 4 and kerlix. Use heel boots at all time to both feet when sitting or in bed, and follow up with Wound Care as scheduled. On 3/2/20, R13's Wound Assessment Flow Sheet indicated R13's left heel wound ulcer measured in 0.5 cm x 0.4 cm x 0.1 cm. On 3/4/20, at 1:40 p.m. R13 was interviewed and stated staff at the facility were not changing the dressing to his left heel ulcer. R13 stated he started to experience more pain in his left heel so he told RN-B that he was going to call EMS to go the ED to be evaluated. R13 stated when EMS arrived, R13 was asked why he needed to go to the ED, and R13 stated he told EMS no one had been changing his left heel dressing, and it was getting worse and painful. R13 was observed to have his left boot protector on, cushion was on the wheelchair, and pressure relief mattress was on the bed. On 3/4/20, at 1:55 p.m. RN-C was interviewed and stated she did not change R13's left heel dressing on 02/13, 2/19, 2/20, and 2/25. RN-C stated R13's dressing were not changed because there was not enough time in the work day to get it done. RN-C stated there had been a lot of staff turnovers, and an increase in resident care levels on R13's unit, so treatments were not being done including R13's left heel ulcer. RN-C stated R13 went to the ED on 2/24/20, due to increased left foot pain. RN-C stated R13's left heel ulcer had been improving prior to R13's hospitalization . RN-C stated R13's daily wound care to his left heel ulcer not being completed for several days contributed to his foot pain, deterioration of R13's heel ulcer, and hospitalization . On 3/4/20, at 2:40 p.m. RN-B was interviewed. RN-B stated on 2/24/20, R13 called EMS for left foot pain, and she was alerted by R13 at that time his left heel dressing changes were not being completed. RN-B stated she completed a review of dressing changes for February, and determined there were blanks spaces on R13's treatment administration record (TAR) from 2/19/20, through 2/24/20, indicating R13 did not receive daily dressing changes to left heel ulcer as ordered. RN-B stated she had spoken with RN-C, and RN-C admitted she did not complete R13's dressing changes on 2/13, 2/19, 2/20, and 2/25, because it was too busy, and there was not enough time to get all the work done on the her shift. RN-B stated calls were made to the other nursing staff that worked the remaining days R13's dressing changes were not signed off as being completed, and she has had no return calls. RN-B stated she would expect staff to notify her if they were unable to get their work done during their shift, and it was unacceptable to not do the work. RN-B verified R13's medical record lacked documentation R13's dressing changes to his left heel ulcer were completed on 2/11, 2/13, 2/15, 2/16, and 2/21-2/24. RN-B stated R13 was seen at the wound clinic on 2/18/20, and his wound had been improving. RN-B stated R13's missed wound care contributed to R13's hospitalization and worsening of R13's wound. On 3/4/20, at 3:45 p.m. the director of nursing (DON) and administrator were interviewed. The DON stated R13 did not have an infection in his left heel prior to his hospitalization on [DATE], and further stated R13's left heel ulcer had been healing. The DON would only confirm 4 out of the 8 dressing changes were not completed. The DON further stated interviews with the other nurses who were involved needed to be completed to determine why R13's chart lacked documentation that R13's wound care was not completed. The DON stated if R13's dressing changes were completed daily, the nurses would have noticed any changes to R13's left heel ulcer. On 3/5/20, at 9:26 a.m. the DON and administrator provided documentation of telephone conversations between the DON, RN-D, and licensed practical nurse (LPN)-B regarding R13's missed dressing changes. The DON stated she spoke with LPN-B on the phone 3/4/20. LPN-B stated she did not change R13's left heel dressing on 2/21/20, because she did not have time, and she failed to report it to the next shift. The DON stated she spoke with RN-D on the phone 3/4/20. RN-D stated she did not have enough time to complete R13's left heel dressing change on 2/22/20, and failed to report to the next shift that R13's dressing change was not completed. The DON stated education was provided to RN-D and LPN-B on reporting to the charge nurse or DON if work was unable to be completed. The administrator stated a time study would be completed to determine why the nurses were unable to complete their workload. The facility policy Pressure Injury/Skin Integrity/Wound Management dated 11/16, directed residents with pressure injuries will received treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new pressure injuries form developing.

Based on observation, interview, and document review, the facility failed to ensure a resident was able to complete his own wound care and dressing changes for 1 of 3 residents (R14) reviewed for skin conditions. This resulted in actual harm for R14 who had a worsening skin condition. Findings include: R14's Admission Record printed 3/4/20, indicated R14's [DIAGNOSES REDACTED]. R14's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R14 was cognitively intact, required assistance with bed mobility and transfers, and required assistance with dressing. R14's MDS indicated he had one Stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister), two venous and arterial ulcers, [MEDICAL CONDITION](s), open lesion(s), and moisture associated skin damage. R14's care plan revised 2/20/20, indicated R14 was non-compliant with his plan of care. The care plan indicated staff were to observe for how often he was compliant with his care plan, and the reasons for non-compliance. R14 was identified to be at risk for impaired skin integrity and pressure related skin issues related to limited mobility, occasional incontinence, and [MEDICAL CONDITION]. The care plan also indicated staff were to follow the facility skin protocol, provide incontinence care with incontinent brief changes, provide medication and treatment as ordered, observe skin with morning and evening cares and with toileting for redness, rashes, open areas, pain, swelling, and report to team leader. The care plan also directed a weekly skin check, lotion to dry skin, review skin problems with physician, and treatment as ordered. An update to the care plan on 2/25/20, indicated R14 could perform self wound care. R14's care plan indicated he was at risk for deficit's with activities of daily living related to pain and neck pain, [MEDICAL CONDITION], and depression. He required an assist of one for hygiene. R14's orders from the Advanced Wound Care and Hyperbaric Center dated 2/28/20, indicated the following orders: Wound cleansing: may shower with wounds uncovered. Acetic acid (wound cleanser) washes prior to dressing changes. Abdominal fold needs to be washed and dried twice daily before antifungal and pillow case placed. Wound care for #45 and 46, change dressing Monday, Wednesday, and Friday. Iodosorb (ointment) to wound bed covered with [MEDICATION NAME] (dressing) secured with [MEDICATION NAME] (breathable) tape. Wound #52 and 53 change dressing twice a day. Cleanse and dry skin in abdominal fold then apply antifungal cream. Place a pillow case flat with tail exposed under the pannus (abdominal fold) and under breasts. On 2/28/20, a progress note from the wound clinic indicated R14 again with multiple open wounds to bilateral lower extremities, candidas (yeast infection) to the right groin and pannus, as well as under the right breast is significantly worse this week. Wound measurements in centimeters (cm) length by (x) width x depth taken from wound clinic provider progress notes dated 1/17/20, and 2/28/20, indicated progressive worsening of left lower leg anterior proximal, left lower leg anterior distal, and right lower leg midline anterior open areas. Wound #45 left lower leg anterior proximal measured on 1/17/20, was 2.5 centimeters (cm) length x 2 cm width x 0.1 cm depth. On 2/28/20, wound #45 measured 4.4 cm x 2.7 cm x 0.1 cm. Wound #46 left lower leg anterior distal measured on 1/17/20, was 4.4 cm x 4 cm x 0.1 cm. On 2/28/20, the wound measured 4 cm x 6.5 cm x 0.1 cm. Wound #51 right lower leg midline anterior measured on 1/17/20, was 0.2 cm x 0.2 cm x 0.1 cm. On 2/28/20, the wound measured 14 cm x 11.9 cm x 0.1 cm. On 2/25/20, a telephone order indicated R14 was okay to do his own wound care. The order was obtained by registered nurse (RN)-A from R14's regular physician, not from a provider at the wound clinic. On 3/3/20, at approximately 1:15 p.m. R14 was observed seated in a common area, his dressing was slipping off of his leg. On 3/4/20, at 11:38 a.m. R14 was seated in a common area, he pulled up his pant leg to show his dressing, it was clean, dry, and intact. R14 stated the nurse manager had completed his dressing change that morning. On 3/5/20, at 10:45 a.m. during a telephone interview with the nurse practitioner (NP)-B at R14's outside wound care clinic, NP-B stated she was not aware R14 was doing his own dressing changes. NP-B stated she did not believe R14 was capable of doing his own dressing changes. NP-B stated R14 was not making progress in wound healing on his legs. NP-B stated she had heard from other residents at the facility there was not enough staff, and they were not getting their dressing changes/treatments completed. On 3/5/20, at 1:06 p.m. R14 was observed changing his dressing. R14 made several statements that he would prefer the nursing staff to complete his dressing changes. R14 stated if they would be on it every other day, he would rather the nurses would do the dressing changes. R14 removed the sleeve dressing and threw it on the floor, then removed the old dressings throwing those into the waste basket. RN-A noted a new blister on R14's left leg mid-anterior which she measured. RN-A advised R14 not to pop the blister or place medication on the blister or on the open area that was caused by removing tape the day before. R14 did not wash his hands or use hand sanitizer after removing the old dressings. After washing his legs and allowing the area to dry, R14 used his finger to place the cream on his open skin areas, then wiped his finger on a towel. R14 opened the foam dressing, cut a piece to fit, taped over the foam dressing, and covered the blister. R14 continued to treat two other open areas, missing an open area below his knee. R14 stated he was done. R14 used his reacher to pick up the soiled sleeve dressing off the floor, and was stopped before he placed the soiled sleeve dressing onto the clean dressing. RN-A verified he should not use the dressing that had been on the floor, and left the room to obtain a clean dressing. R14 verified he had not washed his hands or sanitized his hands prior to the start of his wound care or at anytime during the process. R14 tossed the towel he had used to the floor in the corner of his room. An used washcloth was observed hanging off of his walker, the floor was littered with items that had missed the waste basket, he was observed to handle his urinal, and then put away his dressing supplies. R14 stated he had not completed his treatment for [REDACTED]. R14 stated he was unable to do the abdominal (pannus, groin, breast) wound care without help stating, I can't see it. On 3/5/20, at 10:31 a.m. RN-A was interviewed and stated she completed R14's wound measurements weekly. RN-A stated the wounds on R14's toes were healed. RN-A stated R14's wounds would start to heal, and then would start to look worse. RN-A stated R14 was not good about keeping his legs elevated, and stated he consumed unhealthy snacks (high carbohydrate content) and sugar drinks. RN- A verified on R14's February TAR that he had 13 missing treatments for cleansing his wounds (legs). R14's stated the order did not make sense to cleanse his legs every shift when the dressing change was ordered on Monday, Wednesday, and Friday. RN-A verified she would expect staff to question an order that did not make sense, and for most of February the wound cleansing was documented as completed every shift. RN-A was not able to explain how this could be possible with only Monday, Wednesday, and Friday dressing changes. R14's February TAR had missing documentation for seven missed wound care/dressing changes for his right and left abdominal folds. RN-A verified the missing treatments. On 3/5/20, at 1:59 p.m. RN-A stated, It looks like he is having a harder time doing the dressing change. RN-A stated it had been a few weeks since she had last observed R14 complete his dressing change. RN-A verified R14 did not wash or sanitize his hands at any point during the procedure, and he was going to use the sleeve dressing after picking it up off of the floor. RN-A stated she had obtained an order for [REDACTED]. the time. When she was asked if there was enough staff to complete all of the ordered dressing changes RN-A stated, Honestly, no. On 3/5/20, at 2:48 p.m. the director of nursing (DON) and the administrator were interviewed. The DON stated she would expect the nurse manager (NM) to determine a resident's ability to complete their own dressing changes by observing them. The DON stated, You can't stop someone from doing their own dressing change even if they aren't competent. The DON stated she would expect a resident's competency would be assessed quarterly or with a significant change. The DON stated if the resident's wound was getting worse, she would expect the NM to re-educate the resident, and if the resident was not competent, staff should offer to do the dressing change. The DON and administrator stated the nurse working on the medication cart was the person responsible for completing wound care and dressing changes. Both stated audits on wound care were completed, and they did not find any residents who had missed treatments or dressing changes. Both stated there was enough staff scheduled to complete wound care and dressing changes. The facility policy Pressure Injury/Skin Integrity Wound Management dated 11/16, directed staff to complete wound assessments upon admission, weekly, quarterly, re-admission or with a significant change in condition, and annually. The policy further directed staff to have the care plan reflect resistance or refusals to interventions, and to document alternatives, as well as education to the resident regarding the risks. The facility policy Infection Prevention and Control dated 11/16, directed there was a system in place for when and how isolation should be used, and on standard and transmission based precautions. A policy on enhanced barrier precautions was requested, a one page handout was provided. The untitled handout directed everyone to clean their hands upon entering and exiting the room, to wear gloves and gowns for high-contact resident care activities including wound care (defined as any skin opening requiring a dressing).

Based on interview and document review, the facility failed to ensure timely evaluation, treatment, and notification of the physician regarding newly identified [MEDICAL CONDITION] activity, decreased level of consciousness, and difficulty swallowing following a fall for 1 of 3 residents (R1) reviewed for change in condition. This resulted in an immediate jeopardy (IJ) for R1, who died two days after the resident's change of condition was identified by the facility. The IJ began on [DATE], when R1 had [MEDICAL CONDITION] and had difficulty swallowing, the facility failed to assess and notify R1's physician of the acute change. The IJ was identified on [DATE], and the administrator, director of nursing (DON), and nurse consultant were notified of the IJ at 4:40 p.m. on [DATE]. The IJ was removed on [DATE], at 1:05 p.m., however, noncompliance remained at the lower scope and severity level of G - isolated, with actual harm that is not immediate jeopardy. Findings include: R1's Admission Record printed [DATE], indicated R1's [DIAGNOSES REDACTED]. R1's Admission Record lacked indication of a [MEDICAL CONDITION] disorder. R1's admission Minimum Data Set ((MDS) dated [DATE], identified R1 had short-term and long-term memory problems. R1's MDS further identified he had clear speech, made himself understood, usually understood others, and had a severe cognitive impairment. The MDS also indicated R1 required extensive assistance walking, and used a walker and wheelchair. The MDS further indicated R1 did not have chewing/swallowing problems. R1's Activity of Daily Living (ADL) Functional / Rehabilitation Care Area Assessment (CAA) dated [DATE], indicated R1 required a front wheeled walker, gait belt, and assistance of two staff when ambulating. R1's CAA further indicated R1 was working with physical therapy and occupational therapy for strength, conditioning, and balance. R1's care plan dated [DATE], indicated R1 had [MEDICAL CONDITION], dementia with behavioral disturbance, and rapid eye movement (REM) sleep disorder (physically act out vivid and unpleasant dreams). R1's care plan further indicated he was difficult to understand and had limited verbal response. Interventions included, Observe for a change in cognition, and level of alertness. The care plan also identified R1 was provided regular textured food and thin liquids. Staff was to set up R1's meal per resident direction, and assist with eating, as needed. On [DATE], the care plan indicated R1 had deficits with ADLs, and R1 required set up and assistance of one staff, at times. On [DATE], the care plan indicated R1 had clear speech and understood and understands. R1's care plan further indicated staff, May have to increase tone and/or repeat in order for resident to understand message being delivered and ask for repeat back for confirmation message was understood. The care plan also identified R1 had a history of [REDACTED]. On [DATE], at 10:49 a.m. a progress note indicated R1 made his needs known to staff, was on a regular diet and had 240 milliliters (ml) of fluid at breakfast, and no problems were noted. R1 was provided crushed medications in pudding and regular liquids, and no problems were noted. On [DATE], at 10:48 a.m. a progress note indicated R1 had mild confusion. On [DATE], at 6:37 a.m. a progress note indicated staff was called to R1's room, and R1 was lying on his back, on a fall mat, and his head was bleeding. The progress note further indicated the back of R1's head had a hematoma (bleeding under the skin). R1 was refusing to open his eyes. An order was obtained to send R1 to the hospital. Emergency Department Provider Notes dated [DATE], at 9:47 a.m. indicated R1 was evaluated for a fall and had an abrasion on the back right side of his head. The note further indicated R1 had no change in mentation (mental activity), ambulated to a stretcher when emergency medical services (E[CONDITION]) arrived, and was nonverbal. R1 was discharged , and diagnosed with [REDACTED]. On [DATE], at 7:16 p.m. a progress note indicated a speech therapy consultation was attempted. The progress note further indicated R1 ate dinner and was not having any apparent issues swallowing. Speech therapy was unable to evaluate R1 as he was not opening his eyes, not very responsive, and was holding some water in his mouth. The speech therapist removed the water from R1's mouth, and scraped some food residue out with a tongue depressor. On [DATE], at 10:28 p.m. a progress note indicated registered nurse (RN)-A had documented R1 had two [MEDICAL CONDITION] episodes, and was sleepy for most of the shift. On [DATE], at 10:07 a.m. a progress note dated indicated R1's morning medications were syringed into his mouth. The progress note further indicated R1 swallowed the first little bit, and the remainder of the medications slowly fell out of R1's mouth as he did not swallow them. On [DATE], at 2:10 p.m. a progress note indicated R1 had full body spasms/tremor [MEDICATION NAME] ,[DATE] seconds at 12:15 p.m. The progress note further indicated R1 had a full body spasm/tremor [MEDICATION NAME] [AGE] seconds at 2:00 p.m. R1's wife was present for both [MEDICAL CONDITION]. On [DATE], at 10:14 p.m. a progress note indicated R1 was having [MEDICAL CONDITION], difficulties swallowing medications, and continued to keep his mouth open. On [DATE], at 11:07 p.m. a progress note indicated R1 has been having [MEDICAL CONDITION] for this shift, and a note was left for Eldercare (physician) for follow-up. On [DATE], at 8:12 a.m. a progress note indicated R1 died at 8:08 a.m. A physician communication form, undated, indicated R1 had changes in level of consciousness, agitated, had [MEDICAL CONDITION] twice for this shift. The document was signed by nurse practitioner (NP)-A and indicated, Need additional assessment. Does this patient need to be seen today? The provider did not date the response. On [DATE], at 12:11 p.m. trained medication aide (TMA)-A was interviewed. TMA-A stated she usually worked on the nursing unit where R1 resided. TMA-A stated R1 rarely refused medications, was a football fan and talked about football all the time. TMA-A stated R1 liked animals, was alert and orientated, and a messy eater, but could chew and swallow without difficulty prior to his fall on [DATE]. TMA-A stated she worked with R1 on [DATE], beginning at 2:30 p.m. TMA-A stated R1 was having [MEDICAL CONDITION], and hadn't come out of it. TMA-A stated R1's family member (FM)-A was present and very concerned. TMA-A stated she observed registered nurse (RN)-A working with R1, and trying to give him medication with Coca Cola. TMA-A stated she told RN-A she felt the doctor needed to be contacted as R1 didn't seem like he was coming out of a [MEDICAL CONDITION] and was glazed over. TMA-A stated Coca Cola was running out of the resident's mouth, and she expressed concern to RN-A that R1 was going to choke if she continued to give the Coca Cola. TMA-A stated RN-A continued to push the fluid, and stated R1 needed his medication because he was having [MEDICAL CONDITION]. TMA-A stated she again asked RN-A to call the physician, and RN-A got cranky. TMA-A stated she assured FM-A that RN-A would call the physician. TMA-A stated she was concerned R1 may have had a brain bleed. TMA-A stated she learned R1 had died the next day, and stated RN-A never called the doctor. TMA-A stated she told her supervisor about the incident and her supervisor was very concerned. TMA-A stated she also informed the director of nursing (DON), and was told not to worry about it. On [DATE], at 12:33 p.m. nursing assistant (NA)-A was interviewed. NA-A stated R1 was normally alert, oriented, and could answer questions. NA-A stated R1 had a little confusion every once in a while, and was a messy eater, but could feed himself. NA-A stated R1 had a fall a few days prior to his death. NA-A stated R1's death was very unexpected, and he heard R1 had a few [MEDICAL CONDITION] the during the weekend ([DATE] and [DATE]). NA-A stated he never saw R1 have a [MEDICAL CONDITION], and did not believe R1 had a [MEDICAL CONDITION] disorder. NA-A stated he worked dayshift on [DATE], and R1 was not out of bed which was very strange as R1 was out of bed by 7:15 a.m. at the latest. R1 stated he was serving breakfast on [DATE], and was told by a nurse R1 had died around 8:15 a.m. On [DATE], at 2:22 p.m. RN-C was interviewed and stated he normally did not work with R1, however, he was called to R1's room on [DATE], and found the resident deceased . RN-C was aware R1 had a fall on [DATE], however, did not know details of the fall. RN-C stated R1's family had questions about what had happened overnight. On [DATE], at 3:04 p.m. FM-A was interviewed. FM-A stated she was at the facility six days per week, and had to be on top of facility staff consistently. FM-A stated R1 had a fall at the facility, and developed [MEDICAL CONDITION] activity after the fall. FM-A stated she witnessed R1 having [MEDICAL CONDITION] following his fall, and the facility did not take the [MEDICAL CONDITION] activity seriously. FM-A stated R1 did not have a [MEDICAL CONDITION] disorder. On [DATE], at 3:27 p.m. NP-A was interviewed and stated she never saw R1, and was unsure why the resident died . NP-A confirmed she wrote the note on the undated physician communication form. NP-A stated the next time she had heard from the facility, R1 had already died . On [DATE], at 8:17 a.m. a follow-up interview was conducted with NP-A. NP-A stated she rounded on [DATE], and when she had signed the undated form, R1 was already dead. On [DATE], at 8:18 a.m. licensed practical nurse (LPN)-A stated she managed the unit where R1 resided. LPN-A stated she was not at the facility on [DATE], [DATE], or [DATE]. LPN-A stated she understood R1 was at his baseline when he returned from the hospital on [DATE], however, was having difficulty swallowing. LPN-A stated R1 did not have any previous difficulty swallowing to her knowledge, however, did have an episode of lock jaw on [DATE]. LPN-A stated R1 did not have a history of a [MEDICAL CONDITION] disorder. LPN-A stated when a resident had a change in condition she would expect staff to call family and the doctor. LPN-A stated she spoke with RN-A, and RN-A told her that FM-A said there was no point to send R1 to the hospital. LPN-A stated she was not aware of what RN-A saw or what her nursing judgement was. On [DATE], at 2:14 p.m. NA-E was interviewed and stated she worked night shift on [DATE], and R1 was not himself. NA-E stated she was told R1 had a fall on [DATE], and she needed to make frequent checks on the resident. NA-E stated it appeared like R1 was having [MEDICAL CONDITION] during the shift, and the resident shook, and then became very still. NA-E stated she reported this to the nurse, and was told this had been occurring since R1 fell on [DATE]. NA-E stated the nurse checked R1, and she was told the resident was okay. NA-E stated she had seen people have [MEDICAL CONDITION] before. NA-E did not recall what nurse she notified. On [DATE], at 2:31 p.m. TMA-B stated she worked on [DATE], and was told in report R1's pills needed to be put in water as he was not taking his medications. TMA-B was also told R1 was having [MEDICAL CONDITION] and tremors. TMA-B stated she found R1 deceased between 8:00 a.m. - 8:15 a.m. and told the nurse to come right away. On [DATE], at 2:35 p.m. NA-F stated she worked with R1 after he came back from the hospital on [DATE]. NA-F stated she worked one day, on [DATE], or [DATE], and she saw R1 have a [MEDICAL CONDITION] while he was sitting in his wheelchair, and she called for help. NA-F stated a nurse and others rushed to R1. NA-F stated the [MEDICAL CONDITION] lasted for approximately one minute. NA-F stated she thought they were losing the resident, but he came back. On [DATE], at 2:40 p.m. RN-A was interviewed and stated she worked on [DATE], and was called to R1's room after he had fallen. RN-A stated R1 was bleeding from the back of his head, and R1 was sent to the hospital. RN-A stated she also worked with R1 on [DATE], and [DATE]. RN-A stated R1 was fine on [DATE], however, grabbed his wheelchair hard while in the dining room. RN-A stated R1 was having difficulties swallowing on [DATE], and was told R1 took his medications better with Coca Cola. RN-A stated she asked a NA to bring Coca Cola, and R1 took his medications very well, at 4:00 p.m., which was contrary to RN-A's documentation. RN-A stated she asked FM-A if she would like R1 to be sent to the hospital and FM-A declined. RN-A stated she instructed staff to check on R1 every 15 minutes and inform her if there was any changes. RN-A stated FM-A left the facility at approximately 7:00 p.m., and R1 was fine, but sleepy. Contrary to RN-A's documentation, RN-A stated she did not believe R1 had a [MEDICAL CONDITION], but was tremoring. RN-A confirmed she completed the undated physician communication form on [DATE], and stated she placed it in an Eldercare folder at the nurses' station. Contrary to documentation on the undated physician communication form, RN-A stated she completed the form only because R1 kept his mouth open. On [DATE], at 3:07 p.m. NA-I stated she worked on [DATE], when R1 had died . NA-I stated she was told R1 was having [MEDICAL CONDITION], and had a locked jaw. NA-I stated another NA found her and stated she thought R1 had died . NA-I stated RN-B assessed R1, and confirmed he had died . NA-I stated R1 was very cold and stiff when she cleaned him up, at approximately 8:20 a.m., and she though the resident had been deceased for a while. On [DATE], at 3:15 p.m. a follow-up interview was conducted with FM-A. FM-A confirmed R1 had a [MEDICAL CONDITION] on [DATE]. FM-A stated the facility lacked consistency with staff, and no one offered to send R1 to the hospital. FM-A stated she would had agreed to have R1 sent to the hospital, and staff had assured her information would be passed along to the physician. On [DATE], at 8:39 a.m. the assistant director of nursing (ADON) and DON were interviewed. The DON stated she did not work on [DATE], or [DATE]. The DON stated she spoke with nurses who worked with R1 on [DATE], and [DATE], and was told R1 was not having [MEDICAL CONDITION]. The DON stated she questioned why staff would document [MEDICAL CONDITION] if the resident was not having them. The DON confirmed the facility expectation was to call a resident's physician when there was a change of condition. The DON also stated concerns surrounding a head injury should be called to the physician, whereas issues such as a skin tear should be placed in a rounding book. The IJ was removed on [DATE], at 1:05 p.m. when it was verified the facility reviewed their policies and procedures on change in condition and neuro checks, reviewed all residents with a change in condition, and educated staff. The facility policy Neurological Observation revised [DATE], directed, Notify the physician of any changes in neurological status. The facility policy First Aid - [MEDICAL CONDITION] dated [DATE], directed, Resident may become limp, muscles relaxed, respirations may stop for a few seconds, and cyanosis may be present. Do not leave resident alone, and Notify physician. The facility policy Notification to Physician/Family/Resident Representative of Change in Resident Health Status revised ,[DATE], directed, The community will consult the resident's physician, nurse practitioner, or physician assistant and notify the resident representative or an interested family member when there is: . Acute illness or significant change in the resident's physical, mental, or psychosocial status (i.e., deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications.

Based on interview and document review, the facility failed to notification of the physician regarding newly identified [MEDICAL CONDITION] activity, decreased level of consciousness, and difficulty swallowing following a fall for 1 of 3 residents (R1) reviewed for change in condition. This resulted in an immediate jeopardy (IJ) for R1, who died two days after the resident's change of condition was identified by the facility. The IJ began on [DATE], when R1 had [MEDICAL CONDITION] and had difficulty swallowing, the facility failed to assess and notify R1's physician of the acute change. The IJ was identified on [DATE], and the administrator, director of nursing (DON), and nurse consultant were notified of the IJ at 4:40 p.m. on [DATE]. The IJ was removed on [DATE], at 1:05 p.m., however, noncompliance remained at the lower scope and severity level of G - isolated, with actual harm that is not immediate jeopardy. Findings include: R1's Admission Record printed [DATE], indicated R1's [DIAGNOSES REDACTED]. R1's Admission Record lacked indication of a [MEDICAL CONDITION] disorder. R1's admission Minimum Data Set ((MDS) dated [DATE], identified R1 had short-term and long-term memory problems. R1's MDS further identified he had clear speech, made himself understood, usually understood others, and had a severe cognitive impairment. The MDS also indicated R1 required extensive assistance walking, and used a walker and wheelchair. The MDS further indicated R1 did not have chewing/swallowing problems. R1's Activity of Daily Living (ADL) Functional / Rehabilitation Care Area Assessment (CAA) dated [DATE], indicated R1 required a front wheeled walker, gait belt, and assistance of two staff when ambulating. R1's CAA further indicated R1 was working with physical therapy and occupational therapy for strength, conditioning, and balance. R1's care plan dated [DATE], indicated R1 had [MEDICAL CONDITION], dementia with behavioral disturbance, and rapid eye movement (REM) sleep disorder (physically act out vivid and unpleasant dreams). R1's care plan further indicated he was difficult to understand and had limited verbal response. Interventions included, Observe for a change in cognition, and level of alertness. The care plan also identified R1 was provided regular textured food and thin liquids. Staff was to set up R1's meal per resident direction, and assist with eating, as needed. On [DATE], the care plan indicated R1 had deficits with ADLs, and R1 required set up and assistance of one staff, at times. On [DATE], the care plan indicated R1 had clear speech and understood and understands. R1's care plan further indicated staff, May have to increase tone and/or repeat in order for resident to understand message being delivered and ask for repeat back for confirmation message was understood. The care plan also identified R1 had a history of [REDACTED]. On [DATE], at 10:49 a.m. a progress note indicated R1 made his needs known to staff, was on a regular diet and had 240 milliliters (ml) of fluid at breakfast, and no problems were noted. R1 was provided crushed medications in pudding and regular liquids, and no problems were noted. On [DATE], at 10:48 a.m. a progress note indicated R1 had mild confusion. On [DATE], at 6:37 a.m. a progress note indicated staff was called to R1's room, and R1 was lying on his back, on a fall mat, and his head was bleeding. The progress note further indicated the back of R1's head had a hematoma (bleeding under the skin). R1 was refusing to open his eyes. An order was obtained to send R1 to the hospital. Emergency Department Provider Notes dated [DATE], at 9:47 a.m. indicated R1 was evaluated for a fall and had an abrasion on the back right side of his head. The note further indicated R1 had no change in mentation (mental activity), ambulated to a stretcher when emergency medical services (E[CONDITION]) arrived, and was nonverbal. R1 was discharged , and diagnosed with [REDACTED]. On [DATE], at 7:16 p.m. a progress note indicated a speech therapy consultation was attempted. The progress note further indicated R1 ate dinner and was not having any apparent issues swallowing. Speech therapy was unable to evaluate R1 as he was not opening his eyes, not very responsive, and was holding some water in his mouth. The speech therapist removed the water from R1's mouth, and scraped some food residue out with a tongue depressor. On [DATE], at 10:28 p.m. a progress note indicated registered nurse (RN)-A had documented R1 had two [MEDICAL CONDITION] episodes, and was sleepy for most of the shift. On [DATE], at 10:07 a.m. a progress note dated indicated R1's morning medications were syringed into his mouth. The progress note further indicated R1 swallowed the first little bit, and the remainder of the medications slowly fell out of R1's mouth as he did not swallow them. On [DATE], at 2:10 p.m. a progress note indicated R1 had full body spasms/tremor [MEDICATION NAME] ,[DATE] seconds at 12:15 p.m. The progress note further indicated R1 had a full body spasm/tremor [MEDICATION NAME] [AGE] seconds at 2:00 p.m. R1's wife was present for both [MEDICAL CONDITION]. On [DATE], at 10:14 p.m. a progress note indicated R1 was having [MEDICAL CONDITION], difficulties swallowing medications, and continued to keep his mouth open. On [DATE], at 11:07 p.m. a progress note indicated R1 has been having [MEDICAL CONDITION] for this shift, and a note was left for Eldercare (physician) for follow-up. On [DATE], at 8:12 a.m. a progress note indicated R1 died at 8:08 a.m. A physician communication form, undated, indicated R1 had changes in level of consciousness, agitated, had [MEDICAL CONDITION] twice for this shift. The document was signed by nurse practitioner (NP)-A and indicated, Need additional assessment. Does this patient need to be seen today? The provider did not date the response. On [DATE], at 12:11 p.m. trained medication aide (TMA)-A was interviewed. TMA-A stated she usually worked on the nursing unit where R1 resided. TMA-A stated R1 rarely refused medications, was a football fan and talked about football all the time. TMA-A stated R1 liked animals, was alert and orientated, and a messy eater, but could chew and swallow without difficulty prior to his fall on [DATE]. TMA-A stated she worked with R1 on [DATE], beginning at 2:30 p.m. TMA-A stated R1 was having [MEDICAL CONDITION], and hadn't come out of it. TMA-A stated R1's family member (FM)-A was present and very concerned. TMA-A stated she observed registered nurse (RN)-A working with R1, and trying to give him medication with Coca Cola. TMA-A stated she told RN-A she felt the doctor needed to be contacted as R1 didn't seem like he was coming out of a [MEDICAL CONDITION] and was glazed over. TMA-A stated Coca Cola was running out of the resident's mouth, and she expressed concern to RN-A that R1 was going to choke if she continued to give the Coca Cola. TMA-A stated RN-A continued to push the fluid, and stated R1 needed his medication because he was having [MEDICAL CONDITION]. TMA-A stated she again asked RN-A to call the physician, and RN-A got cranky. TMA-A stated she assured FM-A that RN-A would call the physician. TMA-A stated she was concerned R1 may have had a brain bleed. TMA-A stated she learned R1 had died the next day, and stated RN-A never called the doctor. TMA-A stated she told her supervisor about the incident and her supervisor was very concerned. TMA-A stated she also informed the director of nursing (DON), and was told not to worry about it. On [DATE], at 12:33 p.m. nursing assistant (NA)-A was interviewed. NA-A stated R1 was normally alert, oriented, and could answer questions. NA-A stated R1 had a little confusion every once in a while, and was a messy eater, but could feed himself. NA-A stated R1 had a fall a few days prior to his death. NA-A stated R1's death was very unexpected, and he heard R1 had a few [MEDICAL CONDITION] the during the weekend ([DATE] and [DATE]). NA-A stated he never saw R1 have a [MEDICAL CONDITION], and did not believe R1 had a [MEDICAL CONDITION] disorder. NA-A stated he worked dayshift on [DATE], and R1 was not out of bed which was very strange as R1 was out of bed by 7:15 a.m. at the latest. R1 stated he was serving breakfast on [DATE], and was told by a nurse R1 had died around 8:15 a.m. On [DATE], at 2:22 p.m. RN-C was interviewed and stated he normally did not work with R1, however, he was called to R1's room on [DATE], and found the resident deceased . RN-C was aware R1 had a fall on [DATE], however, did not know details of the fall. RN-C stated R1's family had questions about what had happened overnight. On [DATE], at 3:04 p.m. FM-A was interviewed. FM-A stated she was at the facility six days per week, and had to be on top of facility staff consistently. FM-A stated R1 had a fall at the facility, and developed [MEDICAL CONDITION] activity after the fall. FM-A stated she witnessed R1 having [MEDICAL CONDITION] following his fall, and the facility did not take the [MEDICAL CONDITION] activity seriously. FM-A stated R1 did not have a [MEDICAL CONDITION] disorder. On [DATE], at 3:27 p.m. NP-A was interviewed and stated she never saw R1, and was unsure why the resident died . NP-A confirmed she wrote the note on the undated physician communication form. NP-A stated the next time she had heard from the facility, R1 had already died . On [DATE], at 8:17 a.m. a follow-up interview was conducted with NP-A. NP-A stated she rounded on [DATE], and when she had signed the undated form, R1 was already dead. On [DATE], at 8:18 a.m. licensed practical nurse (LPN)-A stated she managed the unit where R1 resided. LPN-A stated she was not at the facility on [DATE], [DATE], or [DATE]. LPN-A stated she understood R1 was at his baseline when he returned from the hospital on [DATE], however, was having difficulty swallowing. LPN-A stated R1 did not have any previous difficulty swallowing to her knowledge, however, did have an episode of lock jaw on [DATE]. LPN-A stated R1 did not have a history of a [MEDICAL CONDITION] disorder. LPN-A stated when a resident had a change in condition she would expect staff to call family and the doctor. LPN-A stated she spoke with RN-A, and RN-A told her that FM-A said there was no point to send R1 to the hospital. LPN-A stated she was not aware of what RN-A saw or what her nursing judgement was. On [DATE], at 2:14 p.m. NA-E was interviewed and stated she worked night shift on [DATE], and R1 was not himself. NA-E stated she was told R1 had a fall on [DATE], and she needed to make frequent checks on the resident. NA-E stated it appeared like R1 was having [MEDICAL CONDITION] during the shift, and the resident shook, and then became very still. NA-E stated she reported this to the nurse, and was told this had been occurring since R1 fell on [DATE]. NA-E stated the nurse checked R1, and she was told the resident was okay. NA-E stated she had seen people have [MEDICAL CONDITION] before. NA-E did not recall what nurse she notified. On [DATE], at 2:31 p.m. TMA-B stated she worked on [DATE], and was told in report R1's pills needed to be put in water as he was not taking his medications. TMA-B was also told R1 was having [MEDICAL CONDITION] and tremors. TMA-B stated she found R1 deceased between 8:00 a.m. - 8:15 a.m. and told the nurse to come right away. On [DATE], at 2:35 p.m. NA-F stated she worked with R1 after he came back from the hospital on [DATE]. NA-F stated she worked one day, on [DATE], or [DATE], and she saw R1 have a [MEDICAL CONDITION] while he was sitting in his wheelchair, and she called for help. NA-F stated a nurse and others rushed to R1. NA-F stated the [MEDICAL CONDITION] lasted for approximately one minute. NA-F stated she thought they were losing the resident, but he came back. On [DATE], at 2:40 p.m. RN-A was interviewed and stated she worked on [DATE], and was called to R1's room after he had fallen. RN-A stated R1 was bleeding from the back of his head, and R1 was sent to the hospital. RN-A stated she also worked with R1 on [DATE], and [DATE]. RN-A stated R1 was fine on [DATE], however, grabbed his wheelchair hard while in the dining room. RN-A stated R1 was having difficulties swallowing on [DATE], and was told R1 took his medications better with Coca Cola. RN-A stated she asked a NA to bring Coca Cola, and R1 took his medications very well, at 4:00 p.m., which was contrary to RN-A's documentation. RN-A stated she asked FM-A if she would like R1 to be sent to the hospital and FM-A declined. RN-A stated she instructed staff to check on R1 every 15 minutes and inform her if there was any changes. RN-A stated FM-A left the facility at approximately 7:00 p.m., and R1 was fine, but sleepy. Contrary to RN-A's documentation, RN-A stated she did not believe R1 had a [MEDICAL CONDITION], but was tremoring. RN-A confirmed she completed the undated physician communication form on [DATE], and stated she placed it in an Eldercare folder at the nurses' station. Contrary to documentation on the undated physician communication form, RN-A stated she completed the form only because R1 kept his mouth open. On [DATE], at 3:07 p.m. NA-I stated she worked on [DATE], when R1 had died . NA-I stated she was told R1 was having [MEDICAL CONDITION], and had a locked jaw. NA-I stated another NA found her and stated she thought R1 had died . NA-I stated RN-B assessed R1, and confirmed he had died . NA-I stated R1 was very cold and stiff when she cleaned him up, at approximately 8:20 a.m., and she though the resident had been deceased for a while. On [DATE], at 3:15 p.m. a follow-up interview was conducted with FM-A. FM-A confirmed R1 had a [MEDICAL CONDITION] on [DATE]. FM-A stated the facility lacked consistency with staff, and no one offered to send R1 to the hospital. FM-A stated she would had agreed to have R1 sent to the hospital, and staff had assured her information would be passed along to the physician. On [DATE], at 8:39 a.m. the assistant director of nursing (ADON) and DON were interviewed. The DON stated she did not work on [DATE], or [DATE]. The DON stated she spoke with nurses who worked with R1 on [DATE], and [DATE], and was told R1 was not having [MEDICAL CONDITION]. The DON stated she questioned why staff would document [MEDICAL CONDITION] if the resident was not having them. The DON confirmed the facility expectation was to call a resident's physician when there was a change of condition. The DON also stated concerns surrounding a head injury should be called to the physician, whereas issues such as a skin tear should be placed in a rounding book. The IJ was removed on [DATE], at 1:05 p.m. when it was verified the facility reviewed their policies and procedures on change in condition and neuro checks, reviewed all residents with a change in condition, and educated staff. The facility policy Neurological Observation revised [DATE], directed, Notify the physician of any changes in neurological status. The facility policy First Aid - [MEDICAL CONDITION] dated [DATE], directed, Resident may become limp, muscles relaxed, respirations may stop for a few seconds, and cyanosis may be present. Do not leave resident alone, and Notify physician. The facility policy Notification to Physician/Family/Resident Representative of Change in Resident Health Status revised ,[DATE], directed, The community will consult the resident's physician, nurse practitioner, or physician assistant and notify the resident representative or an interested family member when there is: . Acute illness or significant change in the resident's physical, mental, or psychosocial status (i.e., deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications.

Based on observation, interview and document review, the facility failed to comprehensively assess falls in order to identify appropriate fall interventions to minimize the risk of falls and injury for 1 of 3 residents (R2) reviewed for falls. This failure resulted in actual harm for R2 when R2 sustained a [MEDICAL CONDITION] following a fall. In addition, the facility failed to provide ongoing education and increased supervision for 1 of 1 resident (R3) with known incidents of intoxication while out in the community, unsupervised. This failure resulted in actual harm to R3 when he sustained a fall while intoxicated in the community and sustained a neck fracture. The facility implemented corrective related to R3's fall on 1/3/20, therefore this is issued at past non-compliance. Findings include: R2's annual Minimum Data Set ((MDS) dated [DATE], indicated R2 had severe cognitive impairment and [DIAGNOSES REDACTED]. The MDS indicated R2 required extensive assistance with all activities of daily living and had sustained falls during the assessment period. R2's Fall Care Area Assessment (CAA) dated 10/9/19, indicated R2 had a history of [REDACTED]. The assessment indicated R2 was not receiving therapy at the time of the assessment. R2's Care Plan dated 1/3/20, indicated R2 had severe cognitive impairment and directed the staff to anticipate needs and to observe for non-verbal cues which could identify needs. R2 was at risk for falls related to previous history of falls and extensive assistance needed with transfers and mobility. The care plan directed the staff to ensure the call light was positioned for easy access, check for unmet needs, ensure the environment was free of clutter, review falls per facility protocol, provide non-skid shoes, utilize a full body mechanical lift for transfers and R2 was to be non-weight bearing. R2's care plan also indicated R2 had bowel and bladder incontinence and directed the staff to provide toileting upon rising, before and after meals, in the evening, at night, observe for any changes in frequency and report to the physician. On 1/7/20, at 8:51 a.m. R2's room was observed empty. Registered nurse (RN)-C stated R2 had been transferred to the hospital due to a potential infection. Review of R2's Incident Reports revealed the following: - On 9/9/19, at 7:18 p.m. R2 was observed by a staff member self transferring herself into the bathroom. R2 fell and hit her head against the bathroom door and sustained a golf ball sized bump on the back of her head. R2 was sent to the emergency room for a medical evaluation. The Falls Risk Post Fall assessment dated [DATE], regarding the fall on 9/9/19, indicated R2 had attempted to self ambulate from the recliner and an anti-skid matt had been placed in front of the recliner. The IDT (interdisciplinary team) root cause review of the fall dated 9/19/19, (ten days post fall) regarding the 9/9/19, fall indicated the new/different interventions in place related to the root cause included a medical work up at the emergency room . However, following the emergency department evaluation, no further interventions were put into place. A re-assessment of R2's toileting needs was not completed. - On 9/12/19, at 1:45 a.m. R2 was found on the floor in front of her recliner. No injuries were noted. The staff placed an anti-skid matt in front of her recliner. The Falls Risk Post Fall assessment dated [DATE], directed the staff to ensure R2's room remained free of clutter, close the bathroom door when being used by neighboring resident and offer toilet to ensure no self transfer attempts. The IDT Root Cause Review form dated 9/19/19, (seven day post fall) regarding the 9/12/19, fall indicated the new interventions for both the 9/9/19, and 9/12/19 falls included the use of an anti-skid mat in front of the recliner and educate R2 to call for assistance even though the facility had identified the resident with severe cognitive impairment. -On 10/25/19, at 9:50 p.m. R2 was found lying on the bathroom floor on her left side. R2 stated she was trying to use the toilet. The facility initiated frequent checks and neurological assessments. The Fall Risk Post Fall assessment dated [DATE], following the 10/25/19, fall indicated R2 was to receive frequent checks and to ensure R2 used the call light. The IDT Root Cause Review dated 10/28/19, (three days post fall) indicated R2 was to have a medical work up (face to face physician visit). However, review of R2's clinical record lacked evidence of a medical work up having been completed or interventions implemented following the work up and there was no indication of a bowel and bladder assessment completed to identify a change in potential bowel and bladder needs. -On 12/28/19, at 10:30 p.m. R2 was heard calling for help and was found on the floor next to her bed. R2 had been in bed prior to the fall and was sent to the emergency room for evaluation. The Falls Risk Post Fall assessment dated [DATE], (five days post fall) regarding the fall on 12/28/19, indicated R2 was to receive more frequent safety checks. The IDT Root Cause Review dated 1/2/20, regarding the fall on 12/28/19, indicated R2 was hospitalized with left [MEDICAL CONDITION] and urinary tract in infection. R2 was being treated in the hospital and the staff were to reassess R2 upon return from the hospital. R2's Progress Note dated 12/30/19, indicated R2 had had left hip surgery on 12/29/19, and was also being treated for [REDACTED]. R2's Progress Noted dated 1/3/20, indicated R2 had returned to the facility at 1:00 p.m. R2's clinical record lacked evidence of a fall re-assessment and potential interventions identified following the surgical repair of the [MEDICAL CONDITION]/hospital return. R2's Progress Noted dated 1/7/20, at 8:33 a.m. indicated R2 had been transferred to the emergency room with a high white count, low potassium, increased lethargy and elevated heart rate. On 1/7/20, at 1:27 p.m. nursing assistant (NA)-A stated R2 was unable to ambulate; however, did not remember that she could not walk. NA-A could not recall any type of special interventions (prior to her [MEDICAL CONDITION]) related to falls other than checking on R2 every two hours. NA-A stated any new interventions after a fall would be identified and implemented by the registered nurses. -At 1:30 p.m. NA-B stated R2 did not have any type of special interventions related to fall prevention. -At 1:42 p.m. RN-D stated R2 was wheelchair bound and was to wear non-slip socks or shoes. RN-D stated when a resident had a fall, the nurses were to assess the resident, monitor for environmental factors which may have contributed to the falls, and implement interventions. NA-D stated R2 had memory impairment and did not follow or remember any new verbal instructions including to use the call light to ask for help therefore, reminding R2 to use her call light was ineffective. -At 1:50 p.m. RN-A stated when R2 fell on [DATE], R2 had stated she was on a boat. R2 had memory deficits and upon return to the facility, R2's physician had evaluated her and ordered labs to be drawn on 1/3/20. RN-A confirmed the facility did not reassess R2 at the time of the hospital return to ensure appropriate fall interventions were in place in order to minimize falls and prevent potential injuries. On 1/8/20, at 9:00 a.m. the director of nurses (DON) reviewed R2's falls. The DON stated the facility had completed medical work ups (face to face physician visits) following three of the falls, but the work up evaluations had not been reviewed nor had new interventions been implemented following each work up. The DON stated the staff should have documented the results of each of the medical work ups, and identified new/alternative interventions following each fall. The DON confirmed R2 was not comprehensively reassessed following each fall and upon return from the hospital following surgical repair of the [MEDICAL CONDITION] on 12/28/19. The DON added, at this time, R2 had since been readmitted to the hospital and would need further evaluation upon her return to the facility. R3's quarterly MDS dated [DATE], and annual MDS dated [DATE], indicated R3 was alert and orientated and had [DIAGNOSES REDACTED]. The MDS indicated R3 required extensive assistance with bed mobility, transfers and activities of daily living. R3 was not able to ambulate and did not have a history of falls at the time of the assessments. R3's Falls CAA dated 4/27/19, indicated R3 required the use a full body mechanical lift for transfers, received antidepressant medications and had a history of [REDACTED]. R3's Care Plan dated 5/6/19, indicated R3 had a history of [REDACTED]. The staff were to reinforce education why he was not to drink alcohol while out of the facility. The Nursing Home Incident Report (NHIR) dated 12/2/7/19, at 10:53 a.m. indicated R3 had [DIAGNOSES REDACTED]. The report indicated after a regular wound care appointment (at a local wound clinic), R3 had met a friend and went to a bar. After leaving the bar, R3 fell out of his wheelchair while in the community and required a transfer to the local emergency room where he was admitted . The NHIR did not identify the [DIAGNOSES REDACTED]. On 1/7/20, at 8:40 a.m. R3 was observed in his room, seated in a high back wheelchair, and wearing a cervical collar (hard stiff neck brace). R3 stated he had tipped his wheelchair backwards while attempting to wheel up a city bus ramp. R3 stated the accident did not happen while he was at the facility and directed the surveyor not to worry about it. R3 stated he had to wear the neck brace for six weeks. R3 denied drinking alcohol while out of the facility. At 9:26 a.m. R3 was observed independently propelling his wheelchair from his room to the smoking area located on the outer grounds of the facility. R3's Medication Review Report dated 10/10/19, included an order to hold [MEDICATION NAME], Tylenol, [MEDICATION NAME] and [MEDICATION NAME] if under the influence of alcohol. R3's Long Term Care Visit (primary physician progress notes [REDACTED]. R3 had no concerns regarding his alcohol use other than being banned from utilizing a community bus due to report of R3 being intoxicated on the bus. R3 drank alcohol once a week (generally when returning from wound care visits when he had access to transportation). R3 was not interested in cessation of alcohol. R3's Progress Notes revealed from 6/5/19, to 11/29/19, R3 had returned from the wound care clinic intoxicated, eleven times. One occasion also included marijuana use. R3's physician had been notified and R3's medications were held following each occasion. However, R3's clinical record lacked evidence of increased supervision when out in the community or R3 having been educated on the risk vs. benefits of drinking when out in the community, unsupervised. R3's Progress Note dated 12/26/19, at 5:34 p.m. indicated the facility was informed by the hospital emergency room department that R3 had been transferred there by ambulance. R3 was intoxicated and had fallen from his wheelchair. A second note at 9:21 p.m. indicated the facility was informed R3 had been admitted to the hospital for fractures of cervical (neck) spine C2- C6. R3 had been admitted into the hospital for further treatment. R3's Progress Note dated 12/27/19, at 2:38 p.m. indicated R3 had returned to the facility. R3's Emergency Department Note dated 12/26/19, indicated R3 had fallen in the community, had a blood alcohol level of 136 milligrams/deciliter (mg/dl) and was diagnosed with [REDACTED]. R3's clinical record contained an undated paper signed by R3 and RN-A which indicated R3 had been advised to remain sober while at the facility. The facility plan was to ensure an escort would be provided to accompany R3 to weekly wound clinic appointments to ensure R3 returned safely to the facility. The paper also read: This letter severs as documentation of this education we have previously provided verbally to you regarding the risks of alcohol use. R3's Care Plan was updated on 1/3/19, to include the identification that R3 had signed the aforementioned paper/contract and would try to stay sober. R3 was to have an escort for all medical appointment and R3 had received education regarding the escort was for his own safety. Review of R3's clinical record lacked evidence of social service involvement/interventions related to repeated alcohol use. On 1/7/19, at 1:23 p.m. NA-A stated R3 would frequently not return to the facility after wound clinic visits and would drink alcohol while out of the facility. NA-A had not seen R3 intoxicated, but stated the next day after drinking, he would frequently have loose stool. NA-A stated R3 would admit to drinking alcohol at times and at other times, would deny it. NA-A stated since R3 fractured his neck, a staff member had to go with him to appointments. NA-A stated she was unaware of any type of interventions to deter R3 from drinking while in the community. -At 1:36 p.m. RN-D verified R3 would leave the facility and go to the bar after wound clinic appointments. RN-D stated when R3 was intoxicated, his prescribed pain medications and blood thinners were to be held, and since he fractured his neck, staff were to escort him to appointments. RN-D stated prior to the neck injury, she was unaware of any type of preventative interventions to deter R3 from drinking. On 1/7/19, at 1:53 p.m. RN-A stated R3 had a long history of [MEDICAL CONDITION] and returning to the facility intoxicated. The care plan indicated he was not to drink at the facility and staff were to educate him on this and verified the facility had not implemented additional, supervisory interventions until R3 had sustained the neck fracture. RN-A stated all of the staff were aware of R3's alcohol problem. RN-A stated she had initiated the contract between R3 and the facility on 1/3/20, however, had not dated the contract and since his hospital return, R3 was to have an escort accompany him to all appointments outside of the facility. RN-A confirmed the facility was aware of R3's alcohol tendencies; however, interventions to minimize injury while intoxicated in the community had not been implemented until after he had fractured his neck. RN-A confirmed R3 had sustained harm while intoxicated as he had sustained a neck fracture. -At 2:40 p.m. licensed social worker (LSW)-A stated she was aware R3 had returned to the facility while intoxicated and the nurse managers had been aware of the concern and had been in communication with R3's physician. LSW-A stated she had not been asked to assist with R3's behaviors or alcohol dependence and had not been involved with his care. LSW-A stated she was aware the nursing staff had discussed R3's drinking during interdisciplinary team meetings and had met with R3. The nurses had a plan, therefore, she had not been involved with R3's care and had not provided R3 with alcohol cessation education or offered assistance to provide alcohol cessation community support resources. LSW-A stated she had not been asked to be involved with R3's care since he returned to the facility. LSW-A stated R3 was his own decision maker, and if R3 was not at the facility, he would be homeless. -At 2:53 p.m. the DON stated R3 had been discussed during morning interdisciplinary team meetings' every time he returned to the facility intoxicated. The DON stated R3's physician, and care team were aware of his drinking problem and verified R3 was still allowed to be in the community on his own, unsupervised. The DON confirmed R3 consumed alcohol following clinic visits and the facility had not implemented increased supervision when out in the community until R3 had sustained the neck fracture. The Accidents/Fall policy dated 2/2014, directed the staff to provide appropriate supervision and interventions to prevent available accidents. The policy directed the staff to complete post fall assessments and implement interventions. The resident care plans were to be updated to include the new interventions. The past non-compliance that began on 6/5/19, was verified during the 1/6/20/- 1/8/20, onsite visit and determined to have been corrected on 1/3/20. Verification of correction action was confirmed by interviews with a variety of nursing staff, observations and document review. Training and education of the staff had been completed on 1/3/20. Nursing staff were directed to escort R3 while out of the facility to ensure safety and sobriety. The action plan implemented included: -Education provided to R3 about remaining sober. -Updating R3's individualized care plan. -Providing staff escorts to medical appointments. -Notification of R33's primary physician when substance abuse occurred. -Withholding medications as directed by R3's physican. -Staff education.

Based on interview and document review, the facility failed to immediately identify, report, investigate, and implement interventions to protect 1 of 1 resident (R71) whom reported his roommate (R154) had sexually molested him. In addition, the facility failed to remove the alleged perpetrator's (R154's) access to other residents, which had the potential to affect all 37 residents residing on the Cedar unit. This failure to protect R71 and 37 other residents on the Cedar Unit from abuse resulted in an immediate jeopardy (IJ) when R154 was allowed to wander throughout the Cedar unit going in and out of other residents rooms, unsupervised. The IJ began on 7/31/19, at 10:08 p.m. when R71 reported R514 would come over to his bed at night, reach over and inappropriately touch his bottom and groin area. When R71 requested to sleep in the solarium and not his room, he was redirected by staff back to his room against his repeated requests not to sleep there. The allegation was not reported, investigated, nor was protection provided for all 37 residents in the Cedar unit as R514 continued to wander unsupervised throughout the unit during his entire stay at the facility. The facility administrator and director of nursing (DON) were notified of the IJ on 9/17/19, at 6:34 p.m. The IJ was removed on 9/18/19, at 5:30 p.m. but noncompliance remained at the scope and severity of Level E, more than minimal harm that is not immediate jeopardy. Findings include: R71's Admission Record dated 9/13/19, indicated R71's [DIAGNOSES REDACTED]. R71's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R71 had minimal cognitive impairment, had not exhibited behavioral symptoms, and required supervision with some activities of daily living (ADL)'s. R514's Admission Record dated 7/26/19, indicated R514's [DIAGNOSES REDACTED]. R514's admission MDS dated [DATE], indicated R514 had severe cognitive impairment, wandered 4 to 6 times a week, was independent with all mobility but required limited to extensive assistance with dressing, grooming and toileting. Review of R71's Progress Notes (PN) revealed the following: -PN dated 7/31/19, at 10:08 p.m. indicated R71 was carrying blankets and pillows down the hallway and when asked by staff what he was doing, R71 stated, I am sleeping in the solarium. When asked why, R71 replied, I don't want to be molested by my roommate. When asked to explain what he meant by that comment, R71 replied, my roommate comes over and touches me at night The writer called the evening supervisor and informed her of R71's comment who instructed the writer to document on the incident and to allow R71 to sleep where he wanted to and to reapproach R71 later to see if he would like to go back to his room or if the same statement was made again. -PN dated 8/5/19, at 11:21 p.m. indicated writer noted R71 avoids returning to his room at bedtime. Writer asked R71 if something was wrong and R71 stated he did not like his roommate and wanted a private room. R71's PN's lacked any evidence of follow up/investigation related to his molestation allegation, his reluctance to sleep in his own room, or his request for a private room. Review of R514's PN's revealed the following: -PN dated 7/31/19, at 5:23 p.m. indicated R541's family member (FM)-A was requesting R514 to discharge to another facility to be closer to family, with possible discharge date on 8/2/19. -PN dated 8/1/19, at 1:59 p.m. indicated R514 was confused, forgetful and had been wandering into other resident's rooms but was easily redirected. Ambulated independently throughout unit with a slow, steady gait. -PN dated 8/7/19, at 11:07 a.m. indicated R514 was to be accepted at another facility and discharge was planned for 8/8/19. A subsequent PN at 11:29 a.m. indicated R514 wandered, would go up-down the hall, and occasionally into other residents' rooms. R514's PN's lacked any documentation related to R71's molestation allegation or staff response to it. On 9/13/19, at 10:01 a.m. R71 stated he got along well with everyone at the facility, but could not remember the reported allegation. -At 10:53 a.m. social services director (SSD) stated she remembered R514 was confused and would walk over and stand over his roommate and she also remembered hearing about R71's molestation allegation, but she was unable to find any documentation regarding this accusation. On 9/17/19, at 1:20 p.m. during a telephone interview, registered nurse (RN)-H verified R71 and R514 shared a room and due to R514's confusion, he would wander over to R71's side of the room. RN-H confirmed R71 avoided being in his room and would stay in the solarium until late at night because he did not feel comfortable in the same room with R514. When asked why R71 felt uncomfortable with R514, RN-H stated she was aware of R71's molestation allegation against R514. RN-H stated she had discussed R71's allegation and his reluctance to not sleep in his room with a trained medication assistant (TMA) who also worked the unit. They both felt it was not appropriate for R71 to sleep in a public area such as the solarium. Therefore, RN-H stated she would redirect R71 back to his shared room to sleep (with R514). RN-H stated when directing R71 back to his room at night, he would be apprehensive about going back, and would hem and haw and say I don't really want to go back in that room with that guy, but she (RN-H) knew R71 was not in any danger so insisted he go back into his room to sleep. RN-H stated R71 did not like to have to go back to his room but he would with my direction. When asked, RN-H stated she had not offered nor provided R71 another room to sleep in. RN-H stated resident to resident incidents were to be documented in the nurse's notes and staff were to possibly notify the social worker or help the resident file a grievance form. RN-H confirmed she had not reported this to the social worker nor assisted R71 with a grievance form because she thought that being R514 was not in the room a lot and resident to resident incident reports were only completed for incidents of violence or injuries, she did not need to report or assist R71. On 9/17/19, at 1:38 p.m. during a telephone interview, licensed practical nurse (LPN)-D confirmed she was working 7/31/19, when R71 verbalized his molestation allegation at which time she had questioned him for further information. R71 stated his roommate (R514) comes over to his bed and touches him. R71 frequently slept with his back towards R514 and R71 stated when he was sleeping, R514 would come over to him and touch his bottom or reach over and touch his groin area. LPN-D could not remember if R71 had told her how often this occurred, but at the time, she had offered R71 another room to sleep in but he declined and stated he would just sleep in the solarium. LPN-D stated she reported the allegation to her supervisor that evening and was directed to write a note on it and let him sleep where he wanted. LPN-D stated she had asked her supervisor about filling out an incident report and was told she did not need to fill out any forms. On 9/17/19 at 2:00 p.m. the director of nursing (DON) stated she was not aware of any molestation/sexual abuse allegations between R71 and R514 and she should have been contacted by the nursing supervisor when the allegation was made and an incident report should have been completed. The DON confirmed she was aware of R514's wandering behaviors and the roommate issue, but was not aware of the sexual part. The DON stated sexual abuse was when anyone said or felt like they had been abused. The DON also stated the staff should have immediately relocated R71 to a different room, and an abuse complaint should have been reported within the required two hour time frame and an investigation started. The DON verified it was the administrator or her responsibility to file the abuse complaint to the appropriate State agencies. On 9/17/19, at 2:43 p.m. the administrator stated she would have expected the staff to call either herself or the DON upon receiving the resident molestation allegation. In addition, the administrator confirmed the response of redirecting R71 back to his shared room to sleep, was not an appropriate intervention. The administrator confirmed it was the responsibility of herself and the DON to report incidents/allegations of abuse to the State agency as quickly as possible and within the required reporting timeframe of two hours. The facility Freedom from Abuse, Neglect, and Exploitation -HDGR policy revised 4/2019, defined sexual abuse as non-consensual sexual contact of any type with a resident. The policy directed the facility to take steps to ensure all alleged violations of federal or state laws which involved mistreatment, neglect, and abuse are reported immediately, but not later than two hours after the allegation was made. The staff who knew or had reasonable cause to suspect that a resident had been or was being abused, to immediately report such knowledge or suspicion to the administrator. The administrator, DON, or designee would notify the appropriate regulatory, investigative, or law enforcement agencies immediately. Allegations of abuse would be thoroughly investigated and residents would be protected from harm during the investigation. If the circumstances required it, the administrator, DON, or designee would remove the resident suspected of being the subject of an alleged violation to an environment where the resident's safety could be protected. If the suspected perpetrator was another resident, the DON or designee would separate the residents so they did not have access to each other until the circumstances of the alleged incident could be determined. The IJ that began 7/31/19, at 10:08 p.m., was removed on 9/18/19, at 5:30 p.m., when the facility completed the following interventions which were verified through interview and document review: -immediately investigated to identify support needs and follow up for R71. -investigation of all other residents on the unit to determine if abuse had occurred during their stay. -reviewed all nurse's notes in order to identify if other instances of abuse may have occurred without having been reported/investigated or followed up on from (MONTH) 20, 2019, to present. -all residents with wandering behaviors were identified and person centered interventions added to their plans of care. -abuse reporting procedure requirements were posted on each unit. -provided education to all employees currently working and to all oncoming employees as they arrived to work and prior to working the floor. -education included emphasis on report timing and staff's responsibility to protect other residents. -all allegations of abuse will be investigated. -staff were interviewed to identify their understanding of the timeframe for reporting as well as interventions that could be used to protect other residents from abuse. -additionally, abuse training and policy review will be provided with each staff member every quarter for four quarters. -staff understanding of the abuse policy and procedure will be audited and audits will be reviewed through the QAPI (quality assurance and performance improvement) process.

Based on observation, interview and document review, the facility failed to ensure multi use glucometers (blood sugar monitoring machines) were disinfected between use according to the manufacturer's guidelines which had the potential to affect 4 of 5 diabetic residents (R149, R151, R131, R60) who utilized the community glucometer on 1 of 5 units (Cedar). This resulted in an immediate jeopardy (IJ) for 4 of 4 residents (R149, R151, R131, R60) whom used the same community glucometer without adequate disinfection that R29's used whom had known [DIAGNOSES REDACTED]. The lack of disinfection between resident use increased the risk of blood born pathogen transmission to these four residents who utilized the same glucometer as R29. In addition, the facility failed to ensure hand hygiene was performed and personal protective equipment (PPE) was utilized during wound care for 1 of 1 resident (R141) whom was diagnosed with [REDACTED]. Furthermore, the facility failed to ensure housekeeping staff utilized personal protective equipment (PPE) while cleaning a room for 1 of 1 resident (R134) whom had identified contact precautions related to MDRO infection. Lastly, the facility failed to develop and implement an infection surveillance program to track and trend potential infections within the facility. This practice had the potential to affect all 163 residents at the facility. The IJ began on 4/15/19, when R29 who had [DIAGNOSES REDACTED]. The facility failed to provide a glucometer which was dedicated for use solely by R29 in order to prevent exposure to four other residents who utilized the glucometer on the Cedar unit. The facility administrator and director of nursing (DON) were notified of the IJ on 9/11/19, at 2:27 p.m. The IJ was removed on 9/13/19, at 11:35 a.m. but noncompliance remained at the lower scope and severity level of an E-pattern , no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: On 9/9/19, at 7:18 p.m. trained medication aide (TMA)-A was observed to prepare evening medication for R149. In addition to the medications, TMA-A removed a community glucometer from the top drawer of the Cedar unit, cart one, medication cart. At 7:28 p.m. TMA-A stated the facility utilized one glucometer per medication cart which was used to obtain blood sugar readings for all residents who received medications from the medication cart. Shortly there-after, without disinfecting the glucometer, TMA-A entered R149's room, administered R149's medications, obtained R149's blood sugar reading via the glucometer, returned to the medication cart, and without disinfecting it, placed the machine in a basket, in the top drawer of the medication cart for other residents to use. On 9/10/19, at 8:10 a.m. TMA-B was observed to prepare morning medications for R29. TMA-B removed the glucometer from the top drawer of the Cedar unit, cart one, medication cart and without disinfecting the glucometer, proceeded to obtain R29's blood sugar reading. R149's name was written on a piece of paper which was adhered to the front of the machine R29 was using. TMA-B returned to the medication cart, obtained a Mico-Kill alcohol-based disinfectant wipe and wiped the machine off. The machine was noted to remain moist for approximately 15-30 seconds and was returned to the top drawer of medication cart one for other residents to use. -At 8:20 a.m. TMA-B reviewed the back of the Micro-Kill container and reported the dwell time of the product required to kill communicable disease was two minutes. TMA-B stated she was not aware the glucometers were to remain wet/moistened with the disinfecting wipe for any specific length of time in order to be effective. TMA-B removed the glucometer from the cart and wrapped it in a disinfecting wipe. TMA-B confirmed awareness of R29's communicable diseases [MEDICAL CONDITION] status and [MEDICAL CONDITION]. She stated the facility utilized only one glucometer for each medication cart which was to be used for all residents receiving medications from that cart who required blood sugar checks. When asked, TMA-B stated she was unsure why cart one's community glucometer had R149's name on it. R29's [DIAGNOSES REDACTED]. In addition, R29's laboratory results dated [DATE], indicated R29 was reactive (positive) for Human Immunodeficiency Virus ,[MEDICAL CONDITION]. laboratory results dated [DATE], indicated R29 was positive for Syphilis (highly contagious bacterial infection which can be spread through contact with blood of an infected person). R29's Physican Orders dated 7/31/19, indicated R29 was receiving medications for the treatment of [REDACTED]. R29's Medication Review Report, included a physican's order dated 4/15/19, for daily fasting blood sugars. R29's care plan dated 6/19/19, lacked identification of R29's communicable diseases and also lacked interventions which directed staff regarding the required care of a resident with a communicable disease. In addition, the care plan lacked interventions regarding the care of R29's diabetes. R149's Medication Review Report, included a physican's order for blood glucose monitoring twice a day for the treatment of [REDACTED]. R151's Medication Review Report, included a physican's order dated 8/20/19, for sliding scale (progressive increase in the pre-meal or nighttime insulin dose, based on pre-defined blood glucose ranges) insulin coverage four times a day for the treatment of [REDACTED]. R131's physican order dated 9/10/19, directed the staff to complete blood glucose monitoring once a day. R60's Physican Order dated 7/6/19, directed the staff to complete blood glucose monitoring four times per day. R60 was hospitalized during the survey. On 9/10/19, at 8:23 a.m. registered nurse (RN)-I stated when a glucometer was utilized between residents, the staff were to disinfect the machine with the Micro-Kill disinfecting wipes by wiping the machine off and wrapping it in the wipe for up to five minutes. RN-I stated about a month ago, she had identified the facility had been utilizing community glucometers at which time she had directed an unidentified staff member to assign a glucometer to each individual diabetic resident. However, RN-I had identified on 9/9/19, after the State Agency (SA) staff had left the Cedar unit, the glucometers had not been assigned to individual residents, as directed. Therefore, RN-I stated she had dispensed individual glucometers for the residents on the Cedar unit on 9/9/19. RN-I stated she preferred each diabetic resident to have their own machine. At this time, RN-I requested TMA-B to open the Cedar unit, medication cart one and RN-I removed three glucometers from the cart. R29, R149 and R131 were noted to have individual glucometers assigned. TMA-B stated she was unaware individual glucometers had been assigned to each diabetic resident. On 9/11/19, at 7:22 a.m. RN-I confirmed R29's [DIAGNOSES REDACTED]. RN-I confirmed R29 was currently receiving medications for the communicable diseases and verified R29 continued to utilize the community glucometers as of 9/10/19. RN-I stated she would expect the staff to utilize the individual glucometers or disinfect the glucometers in accordance with the disinfecting wipe directions/dwell time to ensure adequate disinfecting. -At 9/11/17, at 7:37 a.m. RN-J stated each diabetic resident was expected to have their own glucometer and an indivual glucometer should have been assigned to R29 in (MONTH) 2019, when the order for fasting blood sugars was first received. -At 8:53 a.m. licensed practical nurse (LPN)-A stated the glucometers were to be wrapped with a disinfecting wipe for five minutes, however, LPN-A stated she did not like the facility's Micro-Kill wipes as they were too harsh on her hands. LPN-A removed a bottle of hand and face wipes from the side of the medication cart and reported that she just utilized the hand and face wipes to clean the community used glucometer. However, the hand and face wipes did not contain the disinfecting agents needed for adequate disinfecting of the glucometer. LPN-A stated she did not know there was a difference between the two wipes. The facility's Glucometer Infection Control Guidance dated 3/2014, directed the staff to ensure the glucometers were disinfected between each resident use with an approved disinfectant wipe. The undated manufacturer (Medline Evencare G3) Blood Glucose Monitoring System User's Guide indicated the monitor could be used for multiple patients in a clinical setting by healthcare professional as an aide to monitoring levels in diabetes. The instruction manual directed the user to clean and disinfect the machine between each patient use with a disinfecting wipe and identified the Medline Micro-Kill wipes as approved disinfectant wipes to be used. The guide also indicated the glucose ammoniating system shoud be considered potentially infectious and are capable of transmitting blood-borne pathogens between patients and healthcare professional. -At 7:45 a.m. the director of nursing (DON) confirmed she was aware R29 had active communicable diseases. The DON stated the facility glucometer policy was not up to date; however, she expected each individual diabetic resident to have their own individual glucometers. The DON stated the facility had been in contact with the medical director and individual resident medical providers to identify a plan for exposure testing for the diabetic residents who had utilized the same community glucometer utilized by R29. -At 9:50 a.m. the DON provided a fact sheet prepared by the Minnesota Department of Health /Centers for Disease Control and Prevent (CDC) for the following disease processes: -[MEDICAL CONDITION] virus could be spread by the sharing of personal care items that could be contaminated with blood. -[MEDICAL CONDITION] virus could be spread though contact with the blood of an infected person. -HIV cold be spread through contact with the blood of an infected person. On 9/11/19, at 11:07 a.m. RN-I stated there were a total of five residents on the Cedar unit that required glucose monitoring: three residents on Cedar cart one and two residents on Cedar cart two. RN-I stated all of the residents had been given their own individual glucometers and staff education was being provided to each staff member on the unit to ensure individual glucometers were being utilized. -At 11:25 a.m. RN-J stated he had previously worked on the Cedar unit with R29 and would have had a glucometer assigned to her when the order for blood glucose monitoring was initially received. Upon review of R29's clinical record, RN-J confirmed R29's record lacked documentation of when an individual glucometer had been assigned to R29. On 9/11/19, at 2:27 p.m. the administrator, nurse consultant (NC)-A and DON were informed of the IJ related to lack of infection control practices. R29 was known to have communicable diseases and utilized a community glucometer. The facility staff had failed to disinfect the glucometer in accordance to the manufacturer directions which potentially exposed the other diabetic residents to communicable disease. The IJ that began on 4/15/19, was removed on 9/14/19, at 11:00 a.m. when the facility had completed the following interventions: -The facility identified residents who could have been potentially exposed to the communicable disease and offered blood testing for potential communicable disease. -The medical director and infectious disease physicians were consulted regarding an exposure plan. -Each diabetic resident was given an indivual glucometer. -The admission process was updated to ensure newly admitted diabetic residents received individual monitors upon admission to the facility. -The facility glucometer policy was updated to encourage individual glucometers for all diabetic residents. -All staff were educated on the revised policies and procedure. -The facility established an audit system to ensure compliance. R141's Face Sheet printed 9/13/19, indicated R141 had [DIAGNOSES REDACTED]. The undated, Spruce Team 1 nursing assistant care sheet indicated R141 had an infected right hip, but did not address interventions required [MEDICAL CONDITION] infection. R141's Infection Control Temporary Care Plan dated 9/9/18, Indicated R141 [MEDICAL CONDITION] and the interventions/approaches checked off were: to monitor vital signs per protocol, meds as ordered, treatments as ordered, update MD per protocol, monitor labs as ordered and encourage fluids. The isolation precautions protocol section was blank, not checked off. R141's Progress Note (PN) dated 9/5/19, indicated copious amount of serosanguineous drainage on right hip area noted. On 9/9/19, at 6:10 p.m. an isolation cart was observed on R141's door which contained gowns, gloves, masks, and a Contact Precautions informational guide which directed the use of gown and gloves during direct patient care or during contact with infectious materials. Without applying a gown or gloves, nursing assistant (NA)-K entered R141's room he shared with with R144. When asked about the contact precautions sign/directive on the door, NA-K stated he was not sure which resident in the room was on contact precautions or why. NA-K stated the isolation cart on the door meant staff were to wear a mask and gloves when entering the room or it may indicate that staff only needed to wear a gown when working with R141's wounds, but he was not sure what the Contact Precautions cart being on the door actually meant. On 9/9/19, at 6:14 p.m. RN-D stated she believed both residents in R141's room were on contact precautions due [MEDICAL CONDITION], one in the urine and one in his wounds; however, [MEDICAL CONDITION] was contained (Containment is an intricate process that requires the careful filling of any holes, penetrations, gaps, or spaces that could be a potential path for the spread of disease or other airborne contaminants). On 9/9/19, at 7:08 p.m. RN-L stated a gown and gloves were always required to be applied upon entering a residents room who was on contact precautions. A PN dated 9/11/19, indicated R141's previous hip dressing was 100% saturated with serosanguineous drainage. An additional PN dated 9/11/19, indicated wound drainage unable to be contained on right hip, R141 agreed to move to another room for infection control reasons. On 9/11/19, at 8:12 a.m. R141 was observed lying bed with the head of the bed elevated to 30 degrees. R141 stated he had a bed sore on the left hip and another sore on the other hip that were draining and would just not heal. R141 also stated the nurse had told him he needed to redo the dressing and put some kind of tape in it or on it because of the continuous drainage. On 9/11/19, at 9:13 a.m. NA-B stated when contact precautions were required, she only wore a gown whenever she was going to work with anything infected. NA-B proceeded to apply a gown while passing meal trays. When asked why she applied a gown to pass meal trays, NA-B stated she put the gown on because she did not know if she was going to come into contact with anything infectious. NA-B proceeded to pass meal trays into four rooms including R141's room, then removed the gown. On 9/11/19, at 9:18 a.m. without applying a gown or gloves, RN-D was observed to enter R141's room and administer medications. While in the room, RN-D picked up R141's finished meal tray from his overbed table and with it touching her uniform, carried it out to the soiled dish cart in the dining room, and then performed hand hygiene. On 9/11/19, at 11:52 a.m. without applying a gown or gloves, or washing her hands, RN-D entered R141's room to set up dressing change supplies. RN-D proceeded to clear off R141's belongings from R141's overbed table, and without washing it or placing a barrier on top of it, placed a gray basin with wound dressing supplies on top of it and set a box of gloves and a chux pad on the bed. At this time, RN-A entered R141's room with a Dixie cup of vinegar (acetic acid). At this time, RN-D stated she needed to use the bathroom before starting the dressing change and without washing her hands, exited the room. RN-A proceeded to pull R141's bed out away from the wall, picked up R141's IPad from the floor, and set the Dixie cup of vinegar on R141's bedside stand. RN-A applied gloves and without touching anything, removed them. -At 11:56 a.m. RN-D returned to the room and applied a gown. Without a gown on, RN-A assisted R141 to turn to his left side during which time R141's linens and hands/arms touched RN-A's uniform. Once turned, a large amount of bright red wound drainage was noted on R141's chux and lift sheet in an approximately five inch in diameter area. RN-A began to remove R141's saturated wound dressing at which time RN-D reminded RN-A to apply a gown and gloves. Without washing hands/arms, RN-A applied a gown and gloves and proceeded to remove R141's right hip dressing which consisted of an ABD (thick, absorbent dressing which disperses fluids in order to keep them from accumulating upon the wound site) pad which was saturated with serosanguinous drainage. RN-A tucked R141's soiled soaker pad under R141 in order to remove it from the bed when R141 rolled back. -At 12:01 p.m. RN-A removed his gloves, used hand sanitizer, applied new gloves, removed the sacral dressing, and applied vinegar soaked gauze to the wounds to soak per physician order. -At 12:08 p.m. RN-L entered the room and was informed of R141's wound drainage not being contained to the dressing as it had soiled R141's bed linens. -At 12:12 p.m. RN-A removed his soiled gloves, used hand sanitizer, applied new gloves, and proceeded to remove the soiled vinegar soaked gauze. RN-D began packing R141's right hip wound with [MEDICATION NAME] gauze, removed her gloves, used hand sanitizer and applied new gloves. -At 12:14 p.m. RN-D obtained a small Iodosorb (a sterile antimicrobial dressing) with a sterile cotton swab and applied the Iodosorb to R141's right hip wounds followed by three ABD pads on top of each other over R141's right hip wound. RN-A applied comnifix tape to cover the ABD pads. With the same gloved hands, RN-A used a Sharpie marker to write the date on the new dressing, reached under his gown, placed the sharpie marker into his uniform pocket, removed his soiled gloves, and used hand sanitizer. After using the sanitizer, RN-A again reached under his gown and pulled a pair of new gloves from his uniform pocket, the same pocket he had placed the sharpie marker in. RN-A obtained a handful of gloves from the glove box sitting on R141's bed and placed the gloves into the same uniform pocket to replenish the supply he kept on his person. RN-A applied a new pair of gloves, tucked a clean brief under R141's hip, assisted him to roll to his right side, removed the soiled chux pad, lift sheet, and brief, and placed the brief and pad into a clear trash bag, and the lift sheet into a separate clear trash bag. RN-A and RN-D removed their gloves, applied hand sanitizer, reapplied gloves and proceeded to dress R141's other wounds. On 9/11/19, at 2:17 p.m. RN-D verified R141's wound drainage had saturated through the dressings and onto the bed linens which indicated R141's infectious wound drainage was not contained within the dressing therefore R141's room environment was contaminated. RN-D verified a gown and gloves should be applied at all times when entering the room. In addition, RN-D stated having R141 share a room was concerning as this was not the first time R141's infectious wound drainage had saturated through his dressings and seeped through onto the bed linens. RN-D stated she should have recognized R141's wound drainage was not contained thereby required additional precautions. On 9/11/19, at 2:25 p.m. RN-A confirmed R141 was on contact precautions which required the use of a gown and gloves when in contact with R141, and stated he should have applied a gown prior to entering the room. RN-A also verified he had pulled gloves out of his soiled pocket and had not thought about the potential for contamination and stated he should have. RN-A confirmed R141's soiled linens had came into contact with his uniform as well as his arms and hands and he should have washed the areas. RN-A stated he had made a mistake. A PN dated 9/12/19, indicated R141 continued [MEDICAL CONDITION] precautions due to wound drainage and was residing in a private room. On 9/12/19, at 12:13 p.m. RN-L stated normally staff would report the status of R141's wound drainage and should have reported that the drainage was not contained as the interdisciplinary team (IDT) would make a decision regarding the correct type of isolation of precautions needed. RN-L stated isolation precaution education was provided to staff by the assistant director of nursing (ADON), and the staff should have asked questions if they were unsure of what to do when infection control precautions are in place. RN-L verified R141's wound drainage was not contained and the staff's contaminated skin and clothing represented a mode of disease transmission throughout the facility. On 9/13/19, at 9:33 a.m. the DON verified the staff needed to monitor infectious wound drainage in order to maintain containment and should also follow contact precautions, as directed. The DON confirmed there was a potential for the transmission of infectious disease due to the failure of staff to wash their hands as well as not utilizing personal protective equipment as directed. A PN dated 9/14/19, indicated minimal amount of serosanguineous drainage noted. A PN dated 9/16/19, indicated moderate serosanguinous (blood and serum) drainage was noted during the right hip surgical wound dressing change. The facility Pressure Injury/Skin Integrity/Wound Management HDGR policy revised 11/16, defined an infected wound as the presence of micro-organisms in sufficient quantity to overwhelm the defenses of viable tissues and produce the signs and symptoms of infection. The policy further indicated a skin monitoring interdisciplinary team (IDT) met weekly and would discuss and review documentation to assist in the development of a comprehensive prevention and wound management plan for each resident who had a non-pressure wound. The policy also indicated re-evaluation of the treatment plan including determining whether to continue or to modify the current interventions was also indicated. A policy regarding Contact Precautions was requested and was provided a Minnesota Department of Health printout titled Contact Precautions. The printout indicated Contact Precautions were used in the care of patients known or suspected to have a serious illness easily transmitted by direct patient contact or by indirect contact with items in the patient's environment. The printout also indicated illnesses requiring contact precautions may include, but were not limited to draining wounds, pressure ulcers, and/or draining body fluids. The printout further indicated additional PPE for Contact Precautions included gloves when touching the patient and the patient's immediate environment or belongings, a gown when substantial contact with the patient or their environment is anticipated (and to not wear the same gown for the care of more than one patient). Additionally, the printout indicated a private room was prioritized for patients with incontinence, draining wounds and/or uncontrolled secretions. A policy [MEDICAL CONDITION] was requested, but was not provided. R134's Face Sheet printed 9/13/19, indicated R134 had [DIAGNOSES REDACTED]. R134's Admission Minimum Data Set ((MDS) dated [DATE], indicated R134 required extensive assist of 2 staff persons for all activities of daily living (ADLs) and was frequently incontinent of urine. On 9/10/19, at 8:42 a.m. RN-L stated R134 was on contact precautions due to ESBL in her urine. On 9/11/19, at 9:21 a.m. a Contact Precautions cart containing gowns, gloves, masks and a Contact Precautions informational guide was observed hanging on R134's door. R134 was observed in her room, seated in a wheelchair while housekeeping (HSK)-B, with gloves and no gown on, was mopping her floor. HSK-B stated she sprayed the bathroom down with Virex (an EPA approved one-step, all-purpose cleaner, sanitizer and disinfectant) because that's pretty good on anything. HSK-B stated she was not instructed to do anything different as far as cleaning in R134's room nor to do at any special time during the day. When done mopping R134's floor, HSK-B took her cart to the Spruce unit housekeeping closet, dumped the bucket of water, refilled the bucket with fresh water, HSK-B stated she changed the water and mop head after every four rooms and R134's room had just happened to be the 4th room otherwise she would not have necessarily changed the water and mop head after mopping her floor. On 9/13/19, at 10:46 a.m. the Environmental Services Director (EVSD) stated if there was an isolation box on a resident's door the housekeepers were required to put on gown and gloves at the door. The EVSD stated the mop water was dumped and the mop head changed after each contact isolation room was cleaned. The EVSD verified housekeepers were alerted to transmission based precautions by the isolation cart on the door, but may not be aware of what organism was in the room unless it was [MEDICAL CONDITION] (C. diff) infection which required different chemicals. The EVSD verified housekeeping staff was expected to wear PPE and follow the housekeeping guidelines in order to prevent the spread and transmission of disease within the facility. The facility undated, Isolation document indicated contact isolation was used for residents that had bacteria in their urine, stool, lungs or blood and directed the staff to utilize face masks, gowns, and gloves as needed for isolation. Infection Control Program: On 9/13/19, at 9:09 a.m. the infection control program was reviewed with the DON who stated she and the ADON currently performed the infection control duties. The ADON stated she was currently working through the free infection control education provided by the Center for Disease Control and Prevention (CDC). Upon request of the infection control policies and procedures, a policy titled Infection Prevention and Control: Antibiotic Stewardship Program was provided and the DON stated this policy was the facility's entire infection control program, and they did not have any other policies to include. However, after being asked, the DON also provided printouts from the CDC Appendix A (guideline for Isolation Precautions: preventing transmission of infectious agents in healthcare settings) and Appendix B (protocols for initiation of antibiotic therapy). During review of the facilty's infection surveillance, the DON stated those residents receiving antibiotics were kept on a monthly log by unit and this data would be collected by the herself or the ADON, and entered into the tracking log. The log would then be reviewed at the Quality Assurance and Performance Improvement (QAPI) meeting to determine if changes needed to be made regarding policies or current practices. Review of the log revealed documentation included the resident name, room number, body system of infection, community onset yes/no, facility onset yes/no, onset date, device type, collection date, type of test, results (organism colony counts for urine), antibiotic prescription, start date, end date, and symptoms resolved days (1). However, no organisms were identified and symptoms were identified only if the resident received antibiotics, but the log did not identify the organism and less than 50% of the entries included the identified symptoms. The DON verified there were no non-antibiotic infections listed on the log and provided three additional, separate logs: -The first log titled, Infectious Outbreak Monitoring tool dated 3/29/19-4/3/19, from the Willows unit, indicated the resident name, room number, date of onset, symptoms (fever, emesis, loose stools etc) and date resolved. At the bottom of the log staff were directed to perform: frequent hand washing, frequent disinfection of hard surfaces, resident to remain on unit, activities on unit and monitor staff for symptoms. -The second log dated 3/25/19 - 4/2/19, from the Spruce unit, indicated resident name, room number (all were blank), date symptoms started, symptoms, MD notified, treatment and date resolved. At the bottom of the log, staff were directed to perform frequent hand washing, frequent disinfection of hard surfaces, resident to remain on unit, activities on unit and monitor staff for symptoms. -The third log handwritten title Elm Line List dated 4/4/19 - Norovirus, indicated resident name, symptoms, date of onset and 24 hours free of symptoms. However, the log did not indicate what actions staff implemented to prevent the spread of infection within the unit. The DON stated [MEDICAL CONDITION] infectious symptoms were tracked by the unit manager or in the progress notes and a non-antibiotic infection log was only created when there were at least three residents with the same symptoms. The DON clarified three residents with the same symptoms would identify an outbreak at which time an outbreak log would be created. The DON stated individual residents with symptoms such as a cough, fever, etc., would be documented in the resident's progress notes, but no log was needed to track these residents. Upon request of the past six months of infection control logs, the DON stated the facility knew what they were doing and she knew changes could be made, but asked if review of the logs was really needed, at which time the DON stated there were only the three non-antibiotic logs reviewed and no additional logs were available. The DON stated nursing always discussed symptoms at their morning meetings which occurred Monday through Friday and there were no morning meetings on the weekends or holidays. The DON stated whenever she had questions regarding infection control/prevention she would always reach out to her consultants, or the Minnesota Department of Health for guidance. -At 9:20 a.m. the DON stated they had previously conducted routine hand hygiene audits but had quit in (MONTH) 2019. The facility also provided regular hand hygiene education upon hire and yearly thereafter with staff demonstration required following the education. If concerns arose regarding hand hygiene, they also provided the staff with additional education. The DON stated at all times, the entire staff should be aware of infection control practices, and the unit managers should be especially aware. The facility followed the universal standard precautions for all residents and the staff would follow all isolation precautions, as needed. Isolation cart boxes would be placed on the identified resident's room door which included personal protective equipment (PPE) such as masks, gowns, gloves, and instructions for use. The DON stated PPE was required whenever staff believed they would come into contact with infectious materials such as wound drainage, but would not be required for in room activities such as delivering a food tray or answering a call light. The DON verified the resident room (TRUNCATED)

Based on interview and document review, the facility failed to ensure insulin was adminsitered according to physician orders without error for 3 of 6 diabetic residents (R564, R565, R50) whom had significant medication errors. This failure resulted in actual harm for R564 after being administered incorrect insulin resulting in a hypoglycemic event and hospitalization . Findings include: R564's Medication Error Report dated 4/10/19, indicated Trained Medication Aide (TMA)-E had drawn up 135 units of [MEDICATION NAME] (fast acting insulin) instead of 135 units of [MEDICATION NAME] (long acting) insulin to be administered to R564. Registered nurse (RN)-H identified the error after she had administered the incorrect insulin. The report indicated TMA-E received additional education after the medication error had occurred. R564's Admission Record dated 4/16/19, indicated R564 was diagnosed with [REDACTED]. R564's Physician Order dated 4/2/19, directed the staff to administered 20 units of [MEDICATION NAME]with meals and 135 units of [MEDICATION NAME] twice a day. Physician's Order dated 4/10/19, directed the staff to send R564 to the emergency room . R564's electronic Medication Administration Record (eMAR) dated 4/10/19, indicated TMA-E had signed off R564's insulin as having been administered by her. R564's progress notes (PN) lacked any documentation of the medication error on 4/10/19. R564's emergency room History and Physical dated 4/11/19, indicated R564 had received the incorrect dose of insulin at the facility. The facility administered orange juice and called the emergency medical services (EMS/ambulance). While in route to the hospital, the ambulance staff administered 3 grams of oral glucose. Upon arrival to the emergency department, R564's blood sugar was 60 milligrams/deciliter (mg/dl) but did drop to 41 mg/dl despite giving R564 ice cream. R564 required intravenous fluids (IV) of D5 1/2 normal saltine. Upon arrival to the inpatient hospital unit, R564's blood sugar was 37. R564 reported feeling anxious, but denied palpitations or diaphoresis. PN dated 4/11/19, at 9:53 p.m. indicated R564 had returned to the facility at 3:30 p.m. R564's blood sugars and vitals had been stable. On 9/17/19, at 10:12 a.m. RN-J stated he was aware of the medication error on 4/10/19, which resulted in R564 requiring hospitalization . RN-J confirmed the TMA had drawn up the incorrect insulin, signed it off as having administered it, and gave it to RN-H to administer. RN-J stated the RN should have drawn up the insulin, administered it and signed the eMAR and the TMA-B should not have been involved with the administration of the insulin. At 10:19 a.m. the director of nurses (DON) stated the TMA staff had not been trained to administer insulin and they were not to prepare insulin for administration nor sign it of as having administered it. The DON confirmed R564 had received 135 units of the incorrect insulin which was a significant medication error resulting in R564 requiring hospitalization . The Insulin Administration policy dated 4/1/08, directed the staff to administer medication by injection to be administered following professional standards of practice by a licensed professional. The policy directed the staff to ensure the correct dose of medication was measured, document the date, time, type of, strength and dosage of the insulin and injection site on the medication sheet. In addition, any unusual observation and resident reactions were to be documented in the nurse's notes. A Medication Error Report dated 6/23/19, indicated R565's sliding scale insulin coverage had been placed on hold however, the staff had also incorrectly held R565's routine non sliding scale [MEDICATION NAME]dose causing R565 to have an evening blood sugar of 480 mg/dl and required additional physician intervention. R565's admission Minimum Data Set ((MDS) dated [DATE], indicated R565's [DIAGNOSES REDACTED]. R565's admission orders [REDACTED]. The scale identified coverage from 161 mg/dl - 610 mg/dl. and the amount of insulin coverage ranged from 1 unit to 32 units of [MEDICATION NAME] to be administered four times per day. In addition, R565 was to receive 10 units of Humalog (fast acting) insulin four times per day and 45 units of Insulin [MEDICATION NAME] (long acting) at bedtime. R565's Physican's orders dated 6/23/19, indicated the physican had placed the sliding scale on hold and directed the staff to continue to administer the 10 units of [MEDICATION NAME] with meals. The Insulin was also to be held if R565's blood sugar was less than 120. PN dated 6/23/19, at 6:15 a.m. indicated R565 had sustained a fall in her room and blood sugar was 44 mg/dl at the time of the fall. R565 was noted to be lethargic and confused at the time of the fall. R565 was given orange juice and ice cream. At 3:40 a.m. R565's blood sugar was 51 and at 4:30 a.m. blood sugar was 105. The on call physican was notified and ordered to hold the sliding scale and continue to administer the 10 units of [MEDICATION NAME]at meals. PN dated 6/23/19, at 6:00 p.m. indicated R565 had received 10 units of [MEDICATION NAME] insulin. PN dated 6/23/19, at 9:38 p.m. indicated R565's blood sugar was 525 mg/dl. The physican had ordered an additional 5 units of [MEDICATION NAME]to be administered. On 9/18/19, at 11:40 am. RN-J reviewed R565's record and confirmed the [MEDICATION NAME] order had been placed on hold on the morning of 6/23/19, in error which resulting in R565 missing two doses of insulin (breakfast and lunch) causing R565 to have elevated blood sugars in the evening. RN-J stated the medication error occurred due to a transcription error. RN-J stated any medication error related to insulin would be considered a significant medication error. On 9/19/19, at 1:35 p.m. the consultant pharmacist (CP) was interviewed via telephone and stated he was not aware the facility had concerns with significant medication errors related to insulin administration. The CP stated only licensed staff were to be administering injections and the facility had not requested him to review any of their medication error reports. The CP stated he would discuss the medication errors with the facility and assist with a plan to prevent/minimize future insulin errors. R50's annual MDS dated [DATE], indicated R50 [DIAGNOSES REDACTED]. R50's Medication Review Report dated 8/28/19, indicated the physician had hand written the following orders: 1. No sliding scale with supper. 2. Change [MEDICATION NAME] to 12 units every 12 hours starting 8/30/19. R50's Physician Orders dated 9/9/19, included an order which started on 8/30/19, directing no sliding scale with supper and to change [MEDICATION NAME] to 12 units every 12 hours starting. R50's EMAR dated 9/18/19, directed staff to administer the following: -[MEDICATION NAME] pen Inject 12 unit subcutaneously every 12 hours. The order start date was 9/4/19 at 8:00 p.m. -[MEDICATION NAME] solution per sliding scale until 9/3/19 at 5:00 p.m. This resulted in R50 receiving the incorrect dose of [MEDICATION NAME] on 8/31/19, 9/1/19, 9/2/19, and 9/3/19. R50 also received the incorrect dose of [MEDICATION NAME] on 8/31/19, 9/1/19, and 9/2. On 9/18/19, at 9:54 a.m. RN-M stated verbal or telephone orders are entered into a resident's hard chart, then either a nurse or the unit coordinator (HUC) would enter the order into the electronic medical record (EMR). Physician hand written orders were entered by the HUC, or after hours, by the nurse. RN-M verified the facility required two nurses to confirm the order prior to the order being identified on the EMAR for nurses to administer and she expected all orders to be entered as soon as possible. RN-M reviewed R50's hand written physician dated 8/29/19, and verified there was no documentation evidence that any staff had reviewed this order on 8/30/19, and the order was not entered into the EMR on 9/3/19. RN-M stated this was not the expected process, but was not unexpected because she was aware of orders taking many days to process. RN-M verified there was no process to ensure all orders were processed timely when the physician made nursing home rounds. RN-M stated a Medication Review Report was printed on the day prior to physician rounds and concerns would have been hand written on the report by nursing staff, for the physician to review. However, if a physician placed the resident's chart back into the chart cupboard without telling anyone he/she had written orders, no staff would check the charts in the cupboard for new orders. RN-M stated she believed this was how R50's [MEDICATION NAME] and [MEDICATION NAME] orders were missed and not entered until 9/3/19. RN-M stated she was unaware of these medicaiton errors had occurred. On 9/18/19, at 10:33 a.m. the DON stated the process for many years has been that the physician was to write orders on the hard, carbon copy form and not on the medication review form and after the physician had rounded, the unit manager was to check for any order changes and contact the physician if they had any questions. The DON stated she was unaware of R50's medication error and confirmed waiting five days to enter a new physician order was unacceptable and resulted in R50 having received the incorrect insulin dosage, medicaiton error. A medication error report was requested, but not received. Review of the facility policy title Medications - Error dated 4/1/18, directed staff to: 1. report all medication errors to the attending physician and the director of nursing or designee 2. Assess the resident for side effects: vitals signs, physician assessment, etc. 3. Complete medication error report. Do not reference the error report in the medical records. 4. Contact family as indicated. A physican order transcription policy was requested, but not received.

Based on interview and document review, the facility failed to ensure staff provided emergency care for one of one residents (R1) reviewed who requested cardiopulmonary resuscitation (CPR) and did not receive CPR when R1's heart stopped and respirations ceased. R1 died . The failure of four nurses of facility to identify the need for CPR placed 45 residents who requested CPR at risk of Immediate Jeopardy. The facility was not in compliance on (MONTH) 20, (YEAR), when the facility failed to ensure staff provided emergency care for one of one residents (R1) reviewed who requested cardiopulmonary resuscitation (CPR) and did not receive CPR when R1's heart stopped and respirations ceased. R1 died . The facility corrected the noncompliance on (MONTH) 31, (YEAR) when it was verified during the onsite investigation the completion of education to all nurses on the topics of CPR and emergency response. In addition to the retraining, the facility conducted two mock Dr. Heart codes (emergency response) with nine nursing staff. Findings include: R1's medical record was reviewed. R1 admitted to the facility due to heart failure [MEDICAL CONDITION]. R1's care plan dated (MONTH) 4, (YEAR) indicated to provide CPR and aggressive medical care including advanced life support measures and other reasonable medical interventions. R1's provider orders for life sustaining treatment (POLST) dated (MONTH) 3, (YEAR) indicated R1 requested CPR/attempt resuscitation. R1's brief interview of mental status dated (MONTH) 8, (YEAR) indicated R1 had no cognitive impairment. R1's (MONTH) (YEAR) MAR indicated [REDACTED]. An incident report dated (MONTH) 21, (YEAR) at 6:08 p.m. indicated NA-A found R1 in bed at approximately 11:00 a.m. with no pulse or respirations and notified a nurse. The incident report further indicated three additional nurses responded, and in spite of R1's POLST that indicated do CPR, none of the nurses initiated CPR on R1. During an interview on (MONTH) 12, (YEAR) at 1:05 p.m. NA-A stated R1 reported not feeling well on the day of the incident, so NA-A helped R1 lay down in bed. NA-A stated she checked on R1 about 40 minutes later and R1 did not move in bed. NA-A stated she could not feel a pulse on R1, so NA-A ran to the nurse's station to notify LPN-C. During an interview on (MONTH) 12, (YEAR) at 1:24 p.m., RN-B stated he assessed R1 to have no pulse or respirations. RN-B stated he checked R1's POLST that indicated do CPR, but did not start CPR on R1. During an interview on (MONTH) 12, (YEAR) at 1:40 p.m., LPN-C stated on the day of the incident NA-A approached her and said, I think (R1) is dead. LPN-C stated she went to R1's room and assessed R1 to have no pulse, no respirations, and no response to a sternal rub. LPN-C stated she did not know what to do; she paged the nursing supervisor and got no response. LPN-C asked RN-B for assistance. LPN-C stated she and RN-B checked the chart and realized R1's POLST indicated do CPR. Neither LPN-C nor RN-B started CPR. LPN-C stated two additional nurses arrived to R1's room and did not start CPR. LPN-C stated one of the other nurses called the on-call nurse practitioner, and LPN-C stated she received an order (unknown time) from the nurse practitioner to not perform CPR. During an interview on (MONTH) 12, (YEAR) at 2:50 p.m., RN-D stated she received a call regarding R1. RN-D stated she and RN-J ran to R1's unit and checked R1's chart which indicated do CPR. RN-D stated she and RN-J went into R1's room and looked at her, but neither started CPR. During an interview on (MONTH) 12, (YEAR) at 3:25 p.m., registered nurse manager (RNM)-F stated she worked as the on-call supervisor the day of the incident. RNM-F stated she received a call around 11:17 a.m. from LPN-B who inquired about the death process. RNM-F stated she received a second call around 11:30 a.m. from RN-J who informed her that R1's POLST said CPR but no staff performed CPR. During an interview on (MONTH) 13, (YEAR) at 9:32 a.m., nurse practitioner (NP)-G stated she received a call from a nurse (unknown name) who said R1 passed away. NP-G stated the caller indicated R1 had no heart rate, was cold, stiff, and had been dead for a while. NP-G stated she gave an order to not start CPR based on the caller's request. During an interview on (MONTH) 13, (YEAR) at 11:40 a.m. medical doctor (MD)-H stated R1 had intact cognitive ability and the POLST indicated she wanted CPR. MD-H stated the POLST was a physician order [REDACTED]. During an interview on (MONTH) 13, (YEAR) at 1:37 p.m., medical director (MD)-I stated he never met R1, never spoke with R1's primary physician, and had not reviewed R1's chart. MD-I acknowledged R1's POLST indicated CPR, and stated that more often than not CPR is performed if that is the resident's request. A review of personnel files revealed RN-B, LPN-C, RN-D, and RN-J completed CPR training on (MONTH) 9, (YEAR). The advance directives and rights regarding treatment policy dated (MONTH) (YEAR) indicated a resident has the right to formulate an advance directive, which included the resident's choices related to life sustaining treatment (such as CPR). The policy directed to communicate the resident's choice to all direct care staff. The CPR policy dated (MONTH) (YEAR) indicated staff are to initiate CPR when a resident has no pulse and requested CPR. The freedom from abuse, neglect, and exploitation policy dated (MONTH) (YEAR) defined neglect as the failure to provide services to a resident necessary to avoid physical harm. The emergency preparedness manual dated (MONTH) (YEAR) indicated in the event of a medical emergency staff should call emergency medical services and call personnel trained in CPR. The medical emergency document titled Dr. Heart dated (YEAR) indicated in a medical emergency staff should call 911 and call personnel trained in CPR to the location of a medical incident. The past noncompliance that began on (MONTH) 20, (YEAR) was verified to be corrected on (MONTH) 31, (YEAR) during an onsite visit. Verification of corrective action confirmed with review of documentation and interviews. Seven records of residents who passed away after the incident with R1 reviewed for verification of POLST orders, indicated six resident's records contained POLST orders that directed 'do not resuscitate' in the event of lack of heartbeat and respirations. One of the resident's records indicated a POLST order to do CPR in the event of lack of heartbeat and respirations, and when that resident had an incident of lack of heartbeat and respirations, documentation indicated the staff did CPR until emergency medical providers took over. Two residents interviewed about their POLST status confirmed the medical record accurately reflected a discussion held on the day of admission regarding their wishes to receive CPR. Three RN's, one LPN, and two trained medication aides (TMA) confirmed education provided since the incident with R1 directed staff to check the resident's code status on the team sheet and follow the POLST order until emergency medical providers took over. Two mock CPR codes conducted with nine nurses revealed that the response time varied from 18 to 22 seconds and all nine nurses accurately described the steps to take in an incident with a resident who had no heartbeat or respirations. Descriptions paralleled the facility policy.

Based on observation, interview and document review, the facility failed to conduct ongoing comprehensive fall assessments to determine causal factors for 1 of 1 resident (R180) with a history of falls and continued pattern of self transfers and ambulation. This failure resulted in an immediate jeopardy (IJ) due to R180 sustaining cervical (neck) fractures as a result of a fall on 2/2/16. In addition, the facility failed to implement their smoking policy related to safe smoking practices and / or the safe storage of tobacco products and fire materials for 2 of 2 residents (R136, R95) observed to have their smoking and fire materials unsecured or unsafely extinguishing / disposing of the cigarettes. Findings include: The immediate jeopardy related to falls began on October 15th, 2015, when the facility assessed R180 to have increased from a low risk for falls to a high risk for falls due to R180's increased mobility and unsafe independent transfers / ambulation and failed to assess for causal factions related to R180's independent mobility in order to prevent and / or minimize falls, injury and / or death. The administrator and the director of nursing (DON) were notified on 2/3/16, at 7:25 p.m. of the IJ. The IJ was removed on 2/5/16, at 2:05 p.m., however, non-compliance remained at a scope and severity level of G, which indicated actual harm for R180 due to a neck fracture sustained during a fall which required medical interventions. R180 was identified as high risk for falls related to cognitive impairment, impaired gait and mobility, history of falls and unpredictable behaviors. However, the facility failed to comprehensively assess R180's risk factors related to falls which would include possible causal factors related to attempts at unsafe independent transfers. R180's Essentia Health Interagency Referral Form dated 4/23/15, completed prior to admission, indicated R180 received hospice services related to end stage dementia and sepsis. The form also indicated R180 was impulsive, had poor safety awareness, poor attention/concentration, limited left lower extremity movement, and serious difficulty with walking and had sustained a fall. R180 had a right arm hematoma (bruise) and a skin tear to the left arm. The activity instructions directed staff to ambulate with one staff assistance and walker. R180's Falls Risk Assessment (admission) dated 4/29/15, indicated R180 had impaired cognition, 3 or more falls in the last 6 months, mobility was weak and unsteady and utilized a wheelchair for mobility. The written summary indicated R180 was at risk for falls due to unsteady gait and R180's lack of safety awareness. A nurse progress note dated 4/29/15, indicated R180 stood and walked down the hallway independently for several feet and was slightly unsteady. A follow up note dated 4/29/15, indicated the resident was up in the wheelchair and got out of the wheelchair once, and the, alarm sounded. There was no corresponding assessment indicating the resident had an alarm on the wheelchair. A nurse progress note dated 5/22/15, indicated R180 had removed the safety alarm and was up and ambulating independently. Staff ambulated R180 and attempted to seat her back in her wheelchair. R180's care plan printed on 5/13/15, indicated R180 had advanced dementia with falls and anxiety, was admitted with bruises to the left knee, right hand, left hip, red area and superficial open area behind right knee and skin tear to left hand. R180 was to reside on the locked dementia unit due to dementia / delirium, was not able to use the call light, was frequently incontinent of bladder, and required two staff extensive assistance to toilet and ambulate. The care plan directed staff to keep the call light within reach with reminders to use it to call for staff assistance, to utilize a PSD (personal safety device), non-skid footwear, do not leave unattended in the bathroom, required two staff assist for transfers and bed mobility, and required extensive assist with wheelchair locomotion. R180's Fall Risk Assessment quarterly review note dated 8/4/15, indicated R180 was at low risk for falls due to resident compliance with chair fast ability, and resident choice not to attempt to independently ambulate 90% of the time. The update indicated the directive was to continue with current plan of care. However, R180's attempts to independently ambulate was not assessed, nor interventions developed or implemented related to R180 independently ambulating. R180's care plan printed on 8/13/15, indicated R180 was at risk for falls R180 was at risk for falls due to being in a new facility, end of life care, dementia, and had a history of [REDACTED]. bed mobility, one assist for transfers, utilized the wheelchair for locomotion, was incontinent of bladder, and utilized an incontinent brief. A hand written entry on the care plan dated 8/25/15, directed staff to use a communication board to ask R180 if she needed to use the bathroom, desired to go to bed, was hungry, thirsty or in pain. A Resident Incident Report dated 8/23/15, at 1:15 p.m. indicated at 1:10 p.m. an unidentified nursing assistant (NA) was in R180's room and found R180 to have been incontinent of urine with soiled linens. The NA briefly stepped out the room to gather supplies and additional assistance. Upon re-entering the room at 1:15 p.m., R180 was found lying on the floor between the bed and the radiator. R180 was noted to have two cuts to the outside of the right eye measuring 0.8 centimeters (cm) by 0.1 cm and 0.3 cm by 0.1 cm., a skin tear to the lower right arm which measured 5.0 cm by 4.2 cm, and also had a bump on the forehead which measured 2.3 cm by 4.0 cm The RN supervisor reviewed the report on 8/23/15, indicated R180 was incontinent of bladder and the resident's bed was wet, therefore the NA had left the room to gather fresh linens and upon returning to the room, R180 was found on the floor. The fall investigation / assessment completed at the time, did not identify assessments or alternative interventions implemented at the time of the fall to minimize the risk for further falls from bed. Nor did the investigation include documentation of consideration of any further safety interventions that could be utilized when R180 attempted to get out of bed unassisted. R180's significant change Minimum Data Set ((MDS) dated [DATE], which was completed due to discontinuation of hospice services, indicated R180 had severe cognitive impairment, displayed physical resistance to cares, required extensive assistance of two staff for ambulation, transfers and bed mobility. The MDS also indicated R180 had unsteady balance during transitioning and walking, and required staff assistance to stabilize. R180 had sustained one fall with injury during the MDS assessment period. R180's Falls Care Area Assessment (CAA) dated 10/20/15, indicated R180 was at risk for falls, fractures, and soft tissue injuries. R180's Falls Risk Assessment form dated 10/15/15, indicated R180 had sustained 1-3 falls in three months, had unsteady mobility, utilized a wheelchair, had dementia, was incontinent of bowel and bladder, was sometimes able to communicate her needs, required staff assistance for transfers and was unable to use the call light. The written summary indicated R180 was at greater risk for falls due to cognition impairment, lack of safety awareness, and the resident attempted to walk independently. Although R180 was identified as going from low risk of falls on 8/4/15, to higher risk on 10/15/15, and continued to self transfer but was unsteady, the assessment lacked documentation of any further assessment to determine if any additional interventions were required to ensure resident safety such as causal factors related to self rising due to her lack of safety awareness. R180's Communication CAA dated 10/20/15, indicated R180 was diagnosed with [REDACTED]. R180 was not to be left unattended in the bathroom and wore non-skid footwear, and required extensive assist of one staff with all ADLs. The CAA also indicated R180 had diminished ability to express emotions and decreased ability to listen to others and share information. A Resident Incident Report completed on 12/2/15, indicated R180 was found with bruises which measured 4.0 cm x 4.5 cm in the middle of the back, and a left hip bruise which measured 7.0 cm x 7.0 cm. R180 was unable to state how the bruises occurred. The nurse investigation indicated, Res (resident) may have very well fallen and may have gotten up independently. Further, the form indicated R180 had become more ambulatory and would be beginning physical therapy. However, the report lacked documentation of any further assessment of causal factors or environmental factors to determine interventions to be implemented to ensure R180's safety. R180's Physical Therapy Discharge Summary Recommendations dated 12/17/15, indicated R180 was referred to physical therapy (PT) for a walking assessment. The discharge [DIAGNOSES REDACTED]. The PT recommendation form included a directive for a nursing ambulation program which consisted of hand hold assistance during ambulation, otherwise the resident was to utilize a wheelchair. R180's quarterly MDS dated [DATE], indicated R180 was diagnosed with [REDACTED]. The MDS indicated R180 required extensive assistance of one staff with bed mobility and transfers, required extensive assist of two staff for ambulation in her room, and limited assist of two staff for ambulation in the corridor. The MDS also indicated R180 had unsteady balance during transitioning and walking and required staff assistance to stabilize. The MDS indicated R180 displayed wandering behaviors and R180 had not sustained a fall during the MDS assessment period. R180's Falls Risk Assessment quarterly review dated 1/14/16, indicated R180 was at risk for falls, had no safety awareness and attempted to independently ambulate. Staff were to walk with R180 using a gait belt and a wheelchair. However, R180 continued self transfer attempts and interventions related to self-ambulation attempts / monitoring for self-ambulation were not identified. R180's care plan printed on 1/19/16, indicated R180 had advanced dementia with falls and anxiety, was at risk for falls due to dementia and history of falls, was unable to use the call light, was incontinent of bladder, required extensive assist of one to two staff for ambulation and gait belt, extensive assist of one to two staff to boost up in bed, extensive assist of one staff to toilet, staff utilized a dry erase board for communication, extensive assist of one staff for transfers and wheelchair assistance for greater distances otherwise independent for shorter distances while in the wheelchair, and to allow R180 to sleep in. On 2/2/16, at 11:35 a.m. registered nurse (RN)-A stated R180 had sustained a fall the morning of 2/2/16, resulting in a large goose egg on her forehead. A Resident Incident Report dated 2/2/16, indicated at 8:00 a.m. a staff member had witnessed R180 ambulating independently in the hallway. R180's incontinent brief began to fall down, R180 attempted to pull up the brief and fell forward onto her face. R180 had sustained a bruised and swollen forehead. A cold compress was applied. The RN supervisor note dated 2/3/16, (unable to determine if dated 2/2 or 2/3), indicated a pull up (underwear style) incontinent product was to be used. The Falls Risk Post Falls assessment dated [DATE], indicated R180 had dementia and was last seen in bed prior to the fall. The assessment indicated R180 was occasionally able to communicate her needs, did not have any changes in her pain status, nor had expressed symptoms of depression or been recently hospitalized . The interventions to be implemented following this fall was to change R180's incontinent brief to a pull up style incontinent product and R180 was sent to the emergency room (ER) for evaluation. Although the form indicated R180 was last seen in bed prior to the fall, there was no assessment of R180's continued attempts to self transfer, increased mobility status, nor did the facility reassess R180's safety while self transferring / rising from bed to ensure no further interventions were needed. The Root Cause analysis form indicated the nurse manager and DON had met on 2/3/16, at 6:45 a.m. to discuss R180's 2/2/16, fall. The form also indicated the interdisciplinary team (IDT) also discussed this fall on 2/2, 2/3, and 2/4/16. The documentation indicated interventions in place at the time of the fall were to ensure R180's environment was free from clutter, commonly used items placed within reach and laminate or dry erase board utilized for communication. About an hour prior to the fall, staff had observed R180 in bed sleeping. Causal factors reviewed indicated R180 was independently ambulating and the incontinent brief she was wearing was hanging down and sliding to the floor (witnessed fall). The root cause of the fall was determined to be R180's brief was too large causing it to slip down and R180 bent down to pull up and fell forward. However, the root cause analysis only documents what occurred but fails to comprehensively assess the resident's risk factors including R180's pattern of self transferring and other factors to attempt to minimize further falls or injury for R180 and failed to identify why R180 had been ambulating independently prior to the fall. The documentation indicated new interventions put in place on 2/2/16, were staff to utilize a pull up incontinent product and on 2/3/16, following the fall review, staff were encouraged the use of a neck collar for comfort and a pharmacy review would be performed, however, there was no indication when this would be completed. Although R180 sustained significant injury, her mobility had increased, she had last been seen in bed, there was no corresponding assessment to determine if these risk factors required further safety interventions to be in place related to self rising from bed and independent ambulation. The care plan printed on 1/19/16, included hand written entries dated 2/2/16, indicated R180 was to utilize a pull up incontinent product and bladder scan daily. A hand written entry dated 2/5/16, indicated R180 was to utilize a pressure alarm in bed, use a wheelchair, and 15 minutes checks were initiated to monitor for impulsivity. However, observations/interviews indicated the pull up intervention was not consistently implemented. During a follow up interview on 2/3/15, at 10:10 a.m. RN-A confirmed R180 had a sustained neck fracture during the fall on 2/2/16. On 2/3/16, at 7:34 a.m. R180 was observed resting in a low bed. R180's eyes are completely blackened with bruising. On 2/3/16, at 11:42 a.m. NA-B stated he was not aware of any new concerns or new interventions implemented for R180. On 2/3/16, at 11:43 a.m. R180 was observed in her room, in bed. On 2/3/16, at 11:44 a.m. NA-C stated he had been informed R180 had fallen on 2/2/16, and had been diagnosed with [REDACTED]. NA-A stated he was not aware of any changes made to R180's care plan following the fall on 2/2/16, and stated he was just to monitor R180. On 2/3/16, at 12:26 p.m. R180 was wheeled from her room to the dining room. R180 informed her tablemate I hurt my neck. On 2/3/16, at 12:40 p.m. RN-A stated the facility was to put interventions in place which were to be discussed at the 9:45 a.m. morning meeting, and they were to attempt to find the root cause of R180's fall. RN-A stated the morning meeting had not yet taken place, however, she believed the reason why R180 had fallen was due to R180 self-ambulating and the brief slipping down. RN-A indicated she had changed R180's incontinent product from a brief to a pull up style. On 2/3/16, at 1:00 p.m. NA-A stated R180 had sustained a fall on 2/2/16, and was to wear the neck collar, however, there were no other changes made to R180's plan of care that she was aware of. On 2/3/16, at 1:03 p.m. RN-A confirmed the fracture R180 sustained during the fall, was a significant fracture. She confirmed the new intervention put in place after the fall was to use a pull up and a neck collar was to be used. RN-A did not offer any further interventions to be utilized for R180. On 2/3/16, at 1:43 p.m. the director of nurses (DON) stated the usual facility practice when a resident fell was for the staff to assess the resident, complete an interdisciplinary report, evaluate the scene and remove any areas of concerns. The staff were then to complete vitals, review the care plan, and evaluate if the care was being implemented correctly. The staff were to bring up the concern at the morning falls committee meeting following the morning interdisciplinary meeting. The DON stated she understood the plan at this time was to ensure R180 wore the neck collar. On 2/3/16, at 1:53 p.m. the DON reviewed R180's record and confirmed clinical record indicated R180 had returned from the ER with the neck fractures. DON stated the direct care staff should have been made aware of the changes related to the type of incontinent products for R180. On 2/3/16, at 7:13 p.m. during the provision of cares, R180 was observed to have approximately two inch bruises on both knees. On 2/4/16, at 10:28 a.m. R180 was observe din the dining room, attending an activity. R180's bruising to the face was noted to be a deep purple color on her face, forehead, both eyes and upper checks. The Accidents/Fall policy dated 4/1/08, and updated on 2/2014, directed staff to provide emergency care, complete neurological observations (neuro's) following any incident of a resident suspected of hitting their head. The staff were to investigate the incident to determine the cause of the episode, complete post fall assessments, update the resident care plan and to complete continued follow up charting for 72 hours to assess for possible injuries as well as to further evaluate the interventions put into place. The IJ that began on 2/2/16, was removed on 2/5/16 at 2:05 p.m. when the facility completed the following interventions which were verified through observation, staff interviews and record review: -comprehensive fall assessment - implemented new interventions including a personal alarm system while R180 was in bed or the wheelchair. -changed R180's incontinence product to a pull up - the nurse practitioner, R180's primary MD and the medical director along with the consultant pharmacist reviewed R180's medical record. The primary physician ordered R180 to receive a bladder scan daily to rule out urinary retention. Drug regimen review was conducted. -the nursing assistant care sheets were updated with care plans - R180 was placed on every 15 minute checks to determine the root cause of R180's impulsivity when standing/ambulating independently - the facility provided education to all staff members responsible for R180's care. R133 was a smoker and the staff failed to ensure R133's tobacco products and fire materials were kept secure for the safety of all residents and failed to ensure safe smoking practice was maintained related to R133's putting out the cigarette on her electric wheelchair control panel and placing the butts in her jacket pocket. On 2/2/2016, at 9:10 a.m. R133 was observed to leave the facility through the main entrance, via an electric wheelchair, to smoke. R133 stated the resident smoking shelter was located around the corner to the left of the entrance. However, R133 stated she had been banned for life from smoking there. R133 stated licensed social worker (LSW)-A banned her from smoking due to smoking while an oxygen tank was attached to her electric wheelchair which created a safety risk. At this time, an empty oxygen canister storage sleeve was observed attached to the back of R133's electric wheelchair. R133 stated she knew she was not to smoke with her oxygen on or the tank attached to her chair. R133 proceeded down the sidewalk located directly in front of the entrance to a location on the sidewalk at the end of the building. R133 stated she was supposed to smoke across the parking lot but stated she would not go over there because of the snowbank. R133 gestured at a snowbank approximately four feet high which covered the end of the sidewalk. R133 stated she must smoke by herself at the end of the sidewalk. The area R133 smoked at lacked receptacles for the extinguishment of smoking materials. R133 proceeded to light a cigarette with a disposable lighter and smoke it. When asked what she did with the cigarette when she had completed smoking it, R133 stated she stubbed it out on the arm of her electric wheelchair and placed the butt into the pocket of her jacket. R133 again stated she was not allowed near the smoking area where the cigarette receptacle was located so she snuck over to that area when no one was there and disposed of her cigarette butts in the receptacle. R133 stated she kept her own smoking supplies in her possession and had a locked drawer in her nightstand where she kept her cigarettes and lighter. R133 proceeded to smoke the cigarette to within approximately 1/4 inch of the filter, flicked the lit cigarette back and forth several times along the right outer edge of the control panel on the right arm of her electric wheelchair. The control panel was scraped, marred and pock-marked for approximately three inches along the right outer edge where R133 was observed to flick her lit cigarette. R133 stubbed the cigarette vertically onto the upper right surface of the control panel and placed the stubbed cigarette into the left breast pocket of her jacket. The right upper surface of the control panel was observed smudged with white ash. In addition, R133's left corner of her seat cushion was observed to have an approximate 1 inch cut in the upholstery with exposed foam cushion. R133 drove her electric wheelchair to the smoking receptacle (located around the corner on the left side as the building was exited), removed two cigarettes butts from her left breast jacket pocket and disposed of them into the receptacle. R133 stated she kept the butts in her pocket until she was able to dispose of them unseen. R133 further stated she did not have many to throw away at that time as she had emptied her pocket the previous night. R133 entered the building via the main entrance. R133's Minimum Data Set (MDS) Quarterly Note dated 4/11/15, indicated R133 had cognition that fluctuated due to chronic obstructive pulmonary disease (COPD) and was able to communicate her needs and make her own decisions. R133 was a smoker and was assessed as independent. R133's quarterly MDS dated [DATE], indicated R133 was cognitively intact, had [DIAGNOSES REDACTED]. The MDS also indicated R133 required supervision for bed mobility and transfer, required extensive assist of one for dressing and was independent with locomotion on and off of the unit. R133's Smoking Safety Assessment (SSA) dated 4/14/15, identified R133's cognition skills for decision-making were independent, indicators of delirium were not present, and R133 had clear speech. The SSA identified R133 used an electric wheelchair as the primary mode of locomotion, had no visual or range of motion limitations and had no disease/[DIAGNOSES REDACTED]. The SSA also indicated no devices or restraints were used by R133. The SSA further indicated R133 was able to use an ashtray to self-extinguish a cigarette, could use a lighter safely and had no history of smoking-related incidents. The SSA identified interventions as independent, with no assistive devices needed and indicated R133 was instructed and understood the facility smoking policy. No care plan concerns were identified. R133's Social Services Progress Note dated 6/18/15, indicated R133 was in violation of smoking policy by being in smoking area with oxygen on which was discussed with R133. R133 was informed of a three day loss of onsite smoking privileges due to this violation. Nursing was informed. The note further indicated following R133's notification of the three day lost privileges, R133 was found by social services in the resident smoke area, smoking. R133's room was searched. All cigarettes and lighters were taken and locked up. Son informed of situation. Son would prefer R133 not smoke at all. R133's Quarterly Smoking Safety Review dated 6/18/15, identified a change to the initial smoking assessment to include a three day loss of privilege due to smoking with oxygen and facility storage of tobacco products and fire materials. No Smoking Safety Assessment was completed. R133's Nurse's Progress Note dated 7/23/15, indicated staff found R133 outside in a non-smoking area smoking with oxygen tank on her chair. RN manager and social worker talked to R133. R133 was informed her smoking privileges were revoked and was no longer to smoke on the premises. However, no Smoking Safety Assessment was completed. R133's Social Services MDS Annual Note dated 9/28/15, indicated R133 was a smoker and had bummed cigs and was aware that is was against the rules. R133 was allowed to smoke off the premises only. R133's Quarterly Smoking Safety Review dated 9/28/15, identified a change to the initial smoking assessment to include smoking off premises only. No Smoking Safety Assessment was completed. R133's Care Plan dated 10/19/15, identified a focus area of Mood / Behavior which indicated R133 became shaky and talked fast when anxious due to shortness of breath. R133 was a smoker and lost her privileges to smoke on the premises of the facility due to being seen in a non-smoking area smoking a cigarette with and oxygen tank on her chair. The Care Plan directed staff R133 had signed facility smoking rules/guidelines, had lost her privileges to smoke on the premises of the facility and to remind R133 as necessary. The Care Plan also identified a Cognition focus area which indicated R133's cognition fluctuated during the day due to hypoxia. In addition, a Smoking focus area indicated R133 was as smoker and directed staff R133 was an unsafe smoker and was no longer able to smoke on the premises. R133 utilized a flag on the wheelchair when she went outside. R133's Social Service Progress Note dated 10/22/15, indicated a care conference was held and R133 chose not to attend. The note indicated R133 smoked on the premises outside. No smoking assessment was completed at this time. R133's Quarterly Smoking Safety Review dated 12/20/15, identified a change to the initial smoking assessment to include smoking off premises only. No Smoking Safety Assessment was completed to determine where R133 smoked off premises as well as how R133 disposed of smoking material. On 2/3/16, at 12:51 p.m. R133 was observed eating lunch in her own room. R133 stated she had been out smoking several times and was not able to dispose of her cigarette butts at first due to the snow but had since been able to. At this time R133 removed two smoked cigarette butts out of her pocket and showed them to the surveyor. On 2/3/16, at 3:46 p.m. licensed practical nurse (LPN)-C confirmed R133 was a smoker. LPN-C stated R133 left the oxygen tank in her room when out smoking, but she was not sure what R133 did once she was outside. LPN-C stated there was a smoking shack that other residents could use but she was not sure where R133 smoked. LPN-C stated she thought R133 was supposed to be 20 feet from the building or in the smoke house but was not sure if R133 was banned from the property. LPN-C stated R133 kept her own smoking materials and she was not sure where R133 kept them. LPN-C was also not sure how often R133 smoked but stated when it was cold outside she had seen her go out about twice per shift. On 2/3/16, at 3:52 p.m. NA-F stated R133 was independent with her smoking and staff didn't do anything regarding her smoking. NA-F stated R133 went out to smoke a couple of times per day and she usually saw R133 by the end of the building. NA-F confirmed R133 was not allowed to smoke in the smoking shack but stated she was not sure why. NA-F indicated R133 had smoking materials in her room but had no idea where R133 kept them. NA-F also indicated R133 was not supposed to use her oxygen when out to smoke. NA-F stated there had been no problems with R133 smoking that she knew of. On 2/3/16, at 3:55 p.m. NA-G stated R133 went outside to smoke 4-5 times on her shift. NA-G indicated R133 went out to the main area/smoker's shed or to the end of the sidewalk to smoke. NA-G stated the only responsibility staff had regarding R133's smoking was to remind her to take her oxygen tank off of her wheelchair and use a flag on her wheelchair. NA-G stated she knew of no issues with R133 smoking. On 2/3/16, at 4:02 p.m. RN-F stated quarterly safety assessments were performed for all smokers. RN-F also stated R133 smoked independently, without supervision and on an average shift R133 was out 1-3 times to smoke. RN-F indicated R133 was to smoke at the end of the sidewalk. RN-F indicated R133 was not allowed to smoke in the smoker's shed as she had a history of [REDACTED]. RN-F indicated the requirements for R133 to smoke were to take the oxygen tank off of her chair and use a flag on her electric wheelchair. RN-F stated she had no idea where R133's smoking materials were kept but that R133 had them. RN-F stated R133 had not had any problems with burns that she was aware of. On 2/3/16, at 4:10 p.m. licensed social worker (LSW)-A stated she didn't really have any control of R133's smoking or what she did. LSW-A stated R133's privileges had been taken away due to an incident when R133 was smoking in non-smoking area next to a running diesel truck. LSW-A indicated the physician had been contacted at that time and had discontinued R133's oxygen for a time. The physician had indicated R133 should be allowed to continue to smoke if she desired. LSW-A indicated R133 continued to smoke and they allowed her to smoke off the premises. LSW-A stated she did not know what was done now to keep R133 safe, however, R133 had been good about removing the oxygen tank from her wheelchair now. -At 4:16 p.m. LSW-B stated he became R133's social worker in 11/2015, and to his knowledge she could smoke on the premises and in the smoking shack as long as her oxygen canister was off of her wheelchair. LSW-B stated there had been no issues related to smoking since he had started working with R133. LSW-A and LSW-B both agreed the practice of R133 placing cigarette butts into her jacket pocket and stubbing out her cigarette on the control panel of her chair were not safe practices which put R133 at risk for injury. Both stated they were not aware she had been doing it. LSW-A confirmed the Resident Smoking Agreement required the storage of smoking materials at the nurses' station. However, LSW-A indicated R133 was an exception to the rule. LSW-A indicated it was agreed R133 could keep her smoking materials in a locked drawer in her room to try to prevent R133 from picking used cigarette butts out of the cans and bumming cigarettes and lighters. LSW-A indicated the smoking policy should reflect storage of smoking materials were addressed on a case by case bas

Based on observation, interview and document review, the facility failed to complete a timely comprehensive assessment following the identification of a stage two pressure ulcer in order to prevent and / or promote the healing of pressure ulcers and failed to provide every one hour turning and repositioning as directed by the care plan for 1 of 3 residents (R183) admitted with intact skin who developed three stage two pressure related ulcers following admission to the facility. This resulted in actual harm to R183. Findings include: R183's Nurses' Admission Notes form indicated R183 was admitted [DATE], was independent with bed mobility and was forgetful with repetitive speech. The note directed the reader to refer to R183's skin assessment for status of skin condition. R183's Skin: Admission Skin Examination / Evaluation form dated [DATE], indicated R183 had a skin tag on left outer knee, skin was cool, warm and had bilateral pitting ankle/feet [MEDICAL CONDITION]. The form also indicated R183 had soft heels. No mention of a pressure ulcer noted. R183's Nurse's Record and Progress Notes (NRPN) dated [DATE], titled Admit indicated R183 was non-ambulatory and required the use of a mechanical lift for transfers. There was no mention of a pressure related ulcer. R183's NRPN dated [DATE], at 10:30 p.m. indicated R183 was alert but very forgetful with repetitive speech and had bilateral [MEDICAL CONDITION] in the feet and ankles. Elevate feet in bed. No mention of a pressure related ulcer noted. R183's Short Term Care Plan dated [DATE], indicated R183 utilized a pressure reducing mattress in bed and pad in wheelchair. The plan directed staff to provide repositioning every two hours in bed and wheelchair, elevate heels off bed with pillows and heel protectors to be worn when in bed. R183's Nursing Home physician visit note dated [DATE], indicated R183 was diagnosed with [REDACTED]. The note indicated under the SKIN section, R183 had actinic (precancerous patch of thick, scaly or crusty skin) changes on the hands and face. No mention of a pressure related ulcer noted. R183's NRPN dated [DATE], indicated R183 was alert and confused, transferred with mechanical lift and one staff assistance required with bed mobility. R183's Braden Scale (tool used to predict risk for pressure ulcers) dated [DATE], revealed a score of 17. The form indicated a resident with a score of 16 or less was to be considered at risk for developing pressure ulcers. R183's NRPN dated [DATE], indicated nursing assistant (NA) found a blister on R183's left outer heel during morning shower. The note indicated the blister measured 2.8 centimeters (cm) X 2.7 cm and was fluid filled. R183's NRPN dated [DATE], at 12:30 p.m. indicated soft boots were ordered for R183 to wear while in bed to prevent further blisters. R183's NRPN dated [DATE], at 10:00 p.m. indicated left outer heel blister dry and intact, blue pillow boots in place at HS (hours of sleep). R183's admission Minimum Data Set ((MDS) dated [DATE], with an assessment reference end date of [DATE], indicated R183 had severe cognitive impairment and required extensive assistance of two staff with bed mobility and toileting, extensive assist of one staff for transferring and personal hygiene. In addition, The MDS indicated R183 had a stage two (partial thickness, loss of skin with a red-pink wound, without dead tissue) pressure ulcer, was at risk for pressure ulcers, utilized a pressure relieving device in the bed and chair, was not on a turning and repositioning schedule and received pressure ulcer care. The MDS did not indicate where the stage two pressure ulcer was located. R183's Pressure Ulcer Care Area Assessment (CAA) dated [DATE], indicated R183 was at risk for the development of a pressure ulcers / skin issue due to dementia and was noted to have a fluid filled blister on [DATE]. The CAA also indicated R183 was dependent on staff to meet his needs, was frequently incontinent of bladder, always incontinent of bowel, needed reminders to off load (relieving the pressure to an area) and reposition, was to wear blue boots while in bed and utilized a pressure relieving cushion in the wheelchair and bed. In addition, wound care would assess R183's wound weekly. R183's Nutrition Status CAA dated [DATE], indicated R183 was found to have a left outer heel blister and nursing to apply soft pillow boots to prevent further blisters. R183's Tissue Tolerance (Bed) algorithm assessment form (used to determine the skin's ability to withstand pressure without position change) dated [DATE], (completed four days following the identification of a stage two ulcer) indicated this assessment tool was to be completed upon admission, annually and with any significant change in status, upon emergence of pressure ulcers and with changes in pressure surfaces. The form indicated R183 was not independent in mobility/positioning and directed staff to follow the identified algorithm. The form directed staff to inspect R183's skin after R183 had been in the same position for two hours. The form indicated R183 had skin redness which did not blanch and directed the assessor to re-exam the skin after one hour. The next checked area indicated R183's skin was no longer reddened and to consider care plan directive to reposition R183 every two hours. The form also indicated determination of a positioning schedule should be conducted in conjunction with a Comprehensive Skin Risk Collection Tool, the Braden Assessment, and resident's preferences and were to be included in the analysis. R183's Comprehensive Skin Risk Data Collection form dated [DATE], (completed four days after the identification of a stage two ulcer) indicated R183 preferred to lay supine (on back) in bed and was to be provided offloading every two hours in bed and wheelchair, heels elevated, heel protectors and incontinence cares. In addition, this Data Collection form indicated R183 had a Rest Q pressure relieving mattress on his bed. The note further indicated R183 had soft heels, with no actual open areas identified and a trace of lower extremity [MEDICAL CONDITION]. A hand written analysis indicated R183 had cognitive and mobility impairment, was non-ambulatory, utilized mechanical lift for transfers, was dependent on staff for cares, offloading and repositioning, and peri cares were to be provided after each incontinent episode. There was no mention of a pressure related ulcer noted. R183's Short Term Preventative Skin Care Plan dated [DATE], indicated R183 required assistance with repositioning in the bed and chair, was unable to walk or transfer without assistance and was incontinent of bowel and bladder. The plan directed staff to change R183's position every two hours, wear heel protectors, elevate heel off of bed and to utilize a pressure relief mattress and wheelchair pad. R183's 14 day MDS dated [DATE], indicated R183 required extensive assist of two staff for bed mobility, extensive assist of one staff for transfers, did not walk in room and walked ,[DATE] times in the corridor, was at risk for pressure ulcers, had one stage two pressure ulcer which was present on admission (refer to admission skin assessment which indicated R183 skin was intact with soft heels), utilized a pressure reducing device in the bed and chair, was not on a turning and repositioning schedule and received pressure ulcer care. R183's current comprehensive care plan for Nutritional/Hydration/Dental initiated on [DATE], revealed a hand written entry dated [DATE], which indicated R183 had an intact left heel blister and indicated R183 was to utilize blue boots on both feet at HS. R183's current comprehensive care plan indicated a high risk for pressure ulcers / skin issues was initiated on [DATE], related to impaired mobility, dementia, weakness and incontinence. The plan indicated R183 was admitted to the facility with a stage 2 pressure ulcer on left heel. A hand written entry dated [DATE], indicated R183 had an open pressure sore on left heel and intact blister on right heel. In addition, an undated, hand written entry indicated R183 also had an open sore on the coccyx /sacral area (tail bone). The plan directed staff to administer meds / treatments as ordered, assess/record/monitor wound healing during rounds and to assess and document wound healing. The plan further directed staff to reposition / boost up in bed with two assist and use of draw sheet, to turn and reposition at least every two hours or more often as needed, follow facility policies / protocols for the prevention / treatment of [REDACTED]. A hand written updated entry dated [DATE], directed staff to turn and reposition R183 every one hour when in bed and keep heels elevated. R183's 30 day MDS dated [DATE], indicated R183 required extensive assist of two staff for bed mobility, extensive assist of one staff for transfers, and did not walk. The MDS also indicated R183 was at risk for pressure ulcers, had one stage two pressure ulcer which was present on admission, R183 utilized a pressure relieving device in the bed and chair, was not on a turning and repositioning schedule and received pressure ulcer care. R183's wound assessment flow sheets revealed the following on each pressure ulcer: Sacral pressure ulcer was acquired at the facility with an onset date of [DATE]. No stage of the ulcer was noted on this form. There were no nurse's note related to the identification of this wound. The measurements of the sacral pressure ulcer were documented as: -[DATE], 1.3 cm x 0.7 cm x 0 cm -[DATE], 0.5 cm x 0.5 cm x 0 cm -[DATE], 0.5 cm x 0.5 cm x 0 cm -[DATE], 1.5 cm (an increase of 1 cm from last measurement and an increase of 0.2 cm from when acquired) x 1.2 cm (an increase of 0.7 cm since last measurement and an increase of 0.5 cm from when acquired) -A hand written progress note on the Wound Assessment Flow Sheet dated [DATE], indicated new orders written and new mattress ordered. An additional note dated [DATE], indicated wound looks same, measurements same. -A hand written progress note dated [DATE], indicated NP observed wound and changed treatment. Right heel pressure ulcer was unstageable (wound with full thickness tissue loss in which the base of the ulcer is completely covered with slough (dead tissue or eschar (dry dark scab) in the wound bed) and had been acquired at the facility (unknown date of onset). The measurements of the right heel pressure ulcer were documented as: -[DATE], 2.5 cm x 2.5 cm x 0 cm -[DATE], 2.5 cm x 2.5 cm x 0 cm -[DATE], 2.7 cm (.2 cm larger) x 2.8 (0.3 cm larger) x 0 cm Left heel pressure ulcer was a stage 2 (partial thickness, loss of skin with a red-pink wound, without dead tissue). The admission notes indicated R183 had soft heels upon admission to the facility. The onset date of the blister was [DATE]. The measurements of the left heel pressure ulcer were documented as: -[DATE], 3.0 cm x 3.0 cm -[DATE], 3.0 cm x 3.0 cm -[DATE], 4.0 cm x 4.0 cm -[DATE], 4 .0 cm x 3.5 cm x 0 cm -[DATE], 3.0 cm x 2.0 cm x 0 cm -[DATE], 2 cm x 2 cm x 0 cm -[DATE], 2.1 cm x 3 cm x 0 cm -A hand written progress note on the Wound Assessment Flow Sheet indicated on [DATE], the fluid was drained from the blister and skin flap debrided. New dressing order obtained, wound bed beefy red, granulation 100%, surrounding skin intact with no signs of infection. A special pressure reducing mattress on bed and staff to elevate heels and ensure heel boots are in place. -A hand written progress note dated [DATE], indicated wound measurements are slightly bigger, wound edges macerated and a heavy amount of serosanguinous (serum and blood) drainage. No signs of infection. -A hand written progress note dated [DATE], indicated wound looking better, appears to be getting smaller. -A hand written progress noted dated [DATE], indicated wound getting smaller. -A hand written note dated [DATE], indicated NP debrided wound and changed treatment. A Tissue Tolerance (Bed) algorithm form dated [DATE], (completed two days after the identification of the sacral ulcer and three days after the first documentation of the right heel pressure ulcer) indicated this assessment tool was to be completed upon admission, annually and with any significant change in status, upon emergence of pressure ulcers and with changes in pressure surfaces. The form indicated R183 was not independent in mobility/positioning and directed the assessor to inspect R183's skin after R183 had remained in the same position for two hours. The form indicated R183 had no change in skin discoloration after two hours without repositioning and directed the assessor to reposition R183 and re-exam the skin after R183 had remained in the same position for three hours. The rest of the form was blank. There were no follow up notations indicated. The form also indicated determination of a positioning schedule should be done in conjunction with a Comprehensive Skin Risk Collection Tool, the Braden Assessment, and resident's preferences were to be included in the analysis. R183's nursing assistant care guide dated February 3rd 2016, directed staff to assist R183 with bed mobility and to reposition R183 every one hour and to ensure R183 had a pressure relieving mattress, heel protectors with heels elevated off the bed with pillows and pressure reducing cushion in the wheelchair. On [DATE], during continuous observations from 7:05 a.m. until 9:08 a.m. the following was observed: -At 7:05 a.m. R183 was observed lying in bed positioned on his right side. -At 7:33 a.m. nursing assistant (NA)-I entered R183's room with a sit to stand lift and gathered towels and morning care supplies. R183 stated he was thirsty and NA-I obtained a fresh cold glass of water and after raising the head of the bed up slightly handed the glass to R183 which he drank. R183 remained on his right side. NA-I offered to wash R183 up and get him up out of bed. R183 refused at this time. NA-I tidied up R183's room, took out the garbage and dirty laundry, placed call light within R183's reach, washed her hands and at 7:50 a.m. exited the room. R183 remained positioned on his right side. During this encounter NA-I had not offered R183 to have his brief checked, toileted or repositioned. Nor where the risks and benefits of not being repositioned explained to R183. -At 7:55 a.m. licensed practical nurse (LPN)-D entered room and assisted R183's roommate -At 8:25 a.m. the director of nursing (DON) poked her head in the doorway and stated she was just checking on the residents. -At 9:08 a.m. (two hours and 3 minutes without being repositioned) NA-I and LPN-D entered R183's room, moved R183 up in bed, rolled him from side to side and checked his brief (which was dry), applied a new brief, assured R183's blue foam boots remained in position on both heels and placed a pillow under R183's feet and then exited the room. On [DATE], at 10:56 a.m. LPN-D, nurse practitioner (NP)-A and registered nurse (RN)-B were observed to provide wound care and obtain measurements of R183's three active pressure ulcers. They confirmed the current measurements of R183's three existing pressure ulcers were: -Right heel pressure ulcer - 2.7 centimeters (cm) in length by 2.8 cm in width by 0 cm depth -Left heel pressure ulcer - 2.1 cm by 3.0 cm x 0 cm -Sacral pressure ulcer - 1.5 cm x 1.2 cm x 0 cm A Tissue Tolerance (Bed) algorithm assessment form completed during the survey on [DATE], indicated this assessment tool was to be completed upon admission, annually and with any significant change in status, upon emergence of pressure ulcers and with changes in pressure surfaces. The form directed the assessor to inspect R183's skin after R183 had remained in the same position for two hours. The form indicated R183 had skin redness present but was blanchable and directed the assessor to reposition R183 and re-exam the skin after R183 had been in the same position for three hours. The documentation missed a step in the algorithm procedure with the next identified area indicating R183's skin had redness and to consider to care plan directive to reposition R183 every three hours. The form also indicated determination of a positioning schedule should be done in conjunction with a Comprehensive Skin Risk Collection Tool, the Braden Assessment, and resident's preferences were to be included in the analysis. On [DATE], at 9:19 a.m. NA-I confirmed according to R183's care guide he should be repositioned every one hour and verified R183 was not repositioned hourly and had went longer than one hour before being repositioned. On [DATE], at 9:54 a.m. RN-B confirmed R183 was at risk for the development of pressure ulcers and verified R183 was to be repositioned every one hour also and verified both R183's care plan and care guide directed staff to reposition R183 every one hour. RN-B verified R183 had three current pressure ulcers. RN-B stated once R183 acquired the sacral pressure ulcer, the care plan had been changed from an every two hour to an every one hour turning / repositioning schedule. RN-B stated it was absolutely her expectation that R183 be repositioned every one hour and that waiting over two hours to reposition, was too long. RN-B confirmed R183's skin assessment had not been re-evaluated after the acquired pressure ulcers had been identified and normally RN-B would expect for this to be done. On [DATE], at 6:31 p.m. RN-B confirmed R183's sacral wound measurement from today ([DATE]) indicated R183's wound had worsened and was even larger in size then what it was when it was first acquired. At the same time, the director of nursing (DON ) also confirmed R183 was to be repositioned every hour which was implemented when R183's sacral wound was identified. The DON also stated waiting two hours to be repositioned was too long for R183. On [DATE], at 8:41 a.m. the DON confirmed it was her expectation for staff to follow R183's care plan with regards to pressure ulcer care which included the every one hour turning and repositioning schedule. On [DATE], at 11:18 a.m. NP-A verified R183's sacral wound was a stage 2 pressure ulcer. Pressure Ulcers/Skin Integrity/Wound Management policy dated [DATE], indicated the facility had in place a system for the prevention, identification, treatment and documentation of pressure and non-pressure wounds. The policy indicated a head to toe skin assessment would be completed on admission or within 24 hours of admission and a Tissue Tolerance test (both lying and sitting) and a Braden skin assessment would also be conducted within 24 hours of admission. All residents' were preventatively placed on a pressure reduction mattress and cushion in the wheelchair based on the skin assessment and an appropriate turning and repositioning schedule would be put in place and the care plan updated. Residents who have a loss of skin integrity would receive the appropriate treatments/services which included a repositioning or off-loading plan. Also all interventions and treatments should be evaluated for efficacy and modified/changes as needed. Care plans should be revised if there was a lack of progress towards healing or when a resident acquired a new ulcer.

Based on observation, interview and document review, the facility failed to re-evaluate a resident's ambulation ability after a decline in ambulation was identified for 1 of 3 residents (R156) in the sample. The resident's decline in ability to ambulate resulted in actual harm. Findings include: R156's admission MDS dated [DATE], indicated R156 was diagnosed with [REDACTED]. The MDS also indicated R156 had severe cognitive impairment and required extensive assistance of two staff for bed mobility, transfer and ambulation in his room and the corridor. The MDS also indicated R156 was unsteady with transitions and ambulation and required staff assistance to stabilize. R156 utilized a wheelchair for mobility, had no functional limitation in range of motion impairment and R156 and staff believed R156 was capable of increased independence in at least some of the activities of daily living. R156's quarterly MDS dated [DATE], indicated R156 required extensive assistance with two staff for bed mobility, transfers, R156 did not walk in his room or corridor, utilized a walker and wheelchair for mobility and had no functional limitations in range of motion impairment. R156's discharge summary from a previous facility dated 9/2/15, indicated R156 was able to transfer and ambulate short distances. He had the ability to use a wheelchair and did not attempt to self -transfer. R156's Nurse's Record and Progress Notes (NRPN) dated 9/15/15, indicated R156 was independently ambulating, staff gave R156 walker and followed R156 with the wheelchair. R156 ambulated to the dining room. R156's care plan dated 9/23/15, directed staff to ambulate R156 with extensive assistance of two staff, as needed. The plan also indicated R156 displayed physical aggression and exiting seeking behaviors and was not easily directed. Staff were directed to redirect R156 as able, encourage activities of choice and 1:1 conversation. The plan indicated R156 was to remain on the secured dementia unit. R156's Nursing Rehab program / Functional Maintenance program form, established by physical therapy to be implemented following the discontinuation of physical therapy, dated 10/5/15, and to begin on 10/6/15, directed the nursing assistants to please ambulate R156 one time per day, five days a week using a front wheeled walker with a wheelchair to follow 100 plus feet with minimal assist of one staff for steering the walker as resident pushes walker to the right. R156's goal of the program was to maintain ability to ambulate at least 100 feet daily with staff. The form directed staff to report resident status to the physical therapist. R156's Physical Therapy Discharge Summary dated 10/8/15, indicated R156 had received therapy for increasing functional ability, increasing independence and increase lower extremity strength by the use of therapeutic exercises from 9/4/15-10/8/15. The discharge summary indicated R156 required minimal staff assistance to ambulate on level surfaces, had decreased gait ability and generalized weakness. R156's NRPN dated 11/3/15, indicated R156 ' s walking program was reduced due to lack of resident participation. R156 was to be ambulated 25 feet three times a week. R156's NRPN dated 11/11/15, indicated R156 had refused ambulation program regularly. R156's ambulation program was discontinued, however, staff directed to ambulate R156 if he became anxious or attempted to stand several times. Staff to continue to attempt to walk R156. R156's NRPN dated 12/10/15, indicated walking program initiated but discontinued due to lack of resident participation. Staff to walk R156 with extensive assist of two as R156 allowed. R156 ' s NRPN ' s revealed aggressive behaviors during the provision of cares but did not address / specify aggressive resistive behaviors related to ambulation services. R156's ambulation program documentation revealed the following information: -October 2015, Restorative Nursing documentation form directed staff to ambulate R156 with two staff 100 feet or more five times per week. The dates of 10/1/15, through 10/16/15, were crossed out. From 10/17/15, through 10/31/15, R156 ambulated six times with a distance ranging from 10 to 475 feet. R156 had refused to ambulate three times. The rest of the form was blank. -The October 2015, Documentation Survey Report revealed staff signatures for walking in the corridor on either the day, evening or night shift but did not indicate whether R156 ambulated or not. The same form also revealed a section related to ambulation in the room which also indicated staff signatures but not if R156 had ambulated or not. - November 2015, R156 was to ambulate with two staff 25 feet as tolerated. The documentation indicated R156 was offered to ambulate on five different occasions in which R156 refused each time. The rest of the form was blank. The record did not indicate why R156 refused to participate or interventions attempted to promote participation. On 11/11/15, RN-A reviewed the ambulation program and indicated R156 refused to participate. She indicated R156 would become combative with staff when ambulation was attempted. Therefore, RN-A discontinued R156's ambulation program and directed staff to ambulate R156 if he was anxious or attempting to independently stand. There was no documentation related to a status report to physical therapy or re-evaluation by physical therapy. However, R156 ' s November 2015, Follow Up Question Report indicated on 11/1/15, 11/3/15, 11/7/15 (x2), 11/9/15, 11/12/15, 11/13/15, 11/15/15 (x2), 11/16/15, 11/19/15, 11/21/15, and 11/27/15, R156 ambulated with extensive assistance, R156 was involved in the activity and staff provided weight bearing support. On 11/23/15, limited assistance only was provided with R156 highly involved in the activity. - December 2015, R156 was to ambulate with two staff 25 feet, as needed. The documentation indicated R156 ambulated zero feet on 10 different occasions, however the documentation did not indicated if R156 had refused or ambulation was not offered. The rest of the form was blank. There was no written analysis by the RN indicating R156's ambulation was reviewed. -The January 2016, Documentation Summary Report indicated R156 ambulated with extensive assist six days during the month. Distance was not documented. -February 2016, no ambulation program documentation was available for review. On 2/3/16, at 8:00 a.m. R156 was observed in his room, seated in a Rock and Go (reclining / rocking) wheelchair. RN-A was observed to attempt to push R156's wheelchair, however, R156 put his feet on the ground and refused to allow the chair to move. RN-A tipped the chair back enough for R156's feet to come off of the ground and wheeled him into the dining room. -At 9:30 a.m. nursing assistant (NA)-A was observed to transfer R156 from the wheelchair to the toilet via a standing mechanical lift. R156's knees were shaky but was able to stand and maintain balance while in the lift. On 2/9/16, at 9:45 a.m. NA-T stated R156 did not have the ability to ambulate. She stated R156 was assisted to transfer via a mechanical standing lift. On 2/9/16, at 9:47 a.m. RN-A stated R156 did not have the ability to ambulate well so the ambulation program was discontinued and was changed to an as needed program and if staff noted R156 was anxious or trying to stand alone they were directed to attempt to walk with him. RN-A stated she had not reassessed R156's walking ability. On 2/9/16, at 10:00 a.m. RN-A and nurse consultant (NC)-C were interviewed. RN-A stated R156 was not able to ambulate and verified this was a decline in ability. RN-A stated attempting to ambulate R156 would be dangerous for R156 and the staff. When asked if R156 had been re-evaluated by physical therapy or assessed by nursing following the decline in ability to walk, RN-A stated, no. NC-C stated when therapy discontinued a resident from services and established a therapy program to be transferred to nursing staff to follow, those discharge instructions were just recommendations for care, not a formal directive at the time of discharge. NC-C stated once a resident was in the care of nursing staff, the RN could decide how to care for the resident related to therapy / exercise program needs. NC-C also stated the physical therapist would not be contacted for further evaluation or screening of the resident ' s ambulation ability because the RN was responsible for adjusting resident therapy goals. On 2/9/16, at 11:00 a.m. physical therapist (PT)-A stated if a resident was refusing to participate in the walking program and had previously received therapy services, she would expect nursing staff to consult with physical therapy prior to changing / decreasing a resident's program. PT-A stated this coordination was to ensure the therapist's input and knowledge was included in order to assist the resident in maintaining ambulation abilities. PT-A stated if a resident declined and was no longer able to participate in the restorative or functional maintenance program which had been established at the time of discharge from physical therapy, she would expect the staff to contact her for a re-evaluation / screening. PT-A verified physical therapy was not contacted to re-evaluate R156's decline in ambulation. In addition, PT-A stated when a resident was discharged from physical therapy and the therapist identified a walking program, that program was considered a directive as to how to care for the resident related to walking. PT-A stated the program was a directive not a suggested recommendation. On 2/9/16, at 11:20 am. the director of therapy stated the unit managers should have been reviewing each residents' therapy program monthly. The director stated if the managers noticed a resident was not participating in the established program, she would expect the therapy department to be contacted so the therapist could be consulted or they could screen the resident to determine if additional therapy services were needed. The therapy director stated the nursing staff should have consulted with physical therapy prior to discontinuing R156's therapy services. On 2/9/16, at 11:30 a.m. RN-A confirmed R156's ambulation program was established on 10/5/15, by physical therapy following the discontinuation of therapy services and set up a program for nursing staff to follow which included R156 was to ambulate 100 feet daily. R156's medical record revealed on 11/11/15, RN-A had reviewed R156's walking program which indicated R156's walking program was an as needed basis only. R156's record lacked documentation / re-assessment as to why the program had been decreased from 100 feet to 25 feet. RN-A stated R156 did not have the ability to ambulate 100 feet and he was not safe to attempt to ambulate. A policy related to ambulation was requested and none was provided.