Every finding on record at Jones Harrison Residence

Based on observation and interview, the facility failed to ensure interventions to reduce the risk of falls were implemented for 1 of 3 residents (R1) reviewed for accidents. R1 fell from her bed when the nursing assistant (NA)-A repositioned her alone, R1's care planned interventions required two staff for repositioning. R1's fall resulted in a femur fracture with surgical intervention.Findings include: R1's care plan dated 12/15/26 indicated R1 required substantial assistance from two staff to assist and reposition every 2 hours. Substantial/maximum assistance of two staff for dressing assistance, bathing, and toilet use. R1 was able to determine when she has voided or had a bowel movement and would call for staff assistance when her incontinent brief required changing. R1's fall assessment dated [DATE] indicated R1 was a high fall risk. R1 was alert and oriented. R1 was chair bound and non-ambulatory. R1's quarterly minimum data set (MDS) dated [DATE] indicated R1 had a Brief Inventory of Mental Status (BIMS) score of 15 indicating she was cognitively intact. She was dependent upon staff for toileting, dressing, hygiene, rolling from left to right in bed, and chair to bed transferring. R1's pertinent diagnoses were vascular myopathies (muscle disease caused by compromised blood flow or inflammatory changes in blood vessel supplying the muscles and chronic respiratory failure with hypoxia (the lungs cannot adequately transfer oxygen into the blood stream. R1's nursing progress note dated 6/29/26 at 3:01 p.m. indicated R1 was being changed in bed. R1 stated I was pushed too far on the edge of the bed. The fall description indicated at 11:18 a.m. the social worker notified the nurse, registered nurse (RN)-A that upon entering the room R1 was on the floor on her knees crying out in pain stating, I think my leg is broken. An injury was noted as a bruise to her left knee and swelling of her right knee below the knee cap. R1 was sent to the hospital for evaluation. R1's nursing progress note dated 6/29/26 at 5:06 p.m. indicated R1 had been admitted to the hospital with a right femur fracture. Upon on 7/1/26 at 4:43 p.m. R1's family member (FM)-A stated she was at the hospital and R1 was recovering from the surgery she had after the staff at the facility pushed her out of bed. She stated a new plate was put in R1's leg, the same leg R1 had prior surgery on years ago where a rod was placed. R1 would not be returning to the facility due to feeling unsafe following the fall incident. Upon interview on 7/2/26 at 10:25 a.m. social worker (SW)-A stated on 6/29/26 she was seated at her desk and heard (NA)-A yelling for help. She ran to R1's room and found R1 on the floor crying in pain. NA-A was the only staff member in the room. Almost immediately more staff entered the room with a mechanical lift to assist R1 off the floor. SW-A stated she attended training following the incident that involved ensuring staff were aware of how to obtain each resident Kardex (a quick-reference care summary of the residents) and follow the care plan for each resident. Upon interview on 7/2/26 at 10:45 a.m. RN-B stated she was in her office and heard yelling. She responded by getting the mechanical lift and rounded up other staff members for assistance. R1 required assistance of two staff as she was a heavy woman and unable to move herself. (NA)-A was repositioning R1 alone as she was changing bowel movement and pushed her too close to the edge of the bed and R1 fell to the floor fracturing her knee. The facilities investigation concluded that R1's care plan was not followed. Retraining of how to access the Kardex in the software system and to make sure the Kardex was checked prior to administering care. R1 had required assistance from two staff since her admission date months prior. Upon interview on 7/2/26 at 12:46 p.m. (RN)-C stated she had assisted (NA)-A with R1 multiple times with morning cares and repositioning, so she was not certain why (NA)-A did not request assistance on the morning of her fall. Upon interview on 7/2/26 at 12:53 p.m. (RN)-D, nurse supervisor stated on 6/26/26 she was on the unit and heard commotion. By the time she got to R1's room staff were already assisting to get R1 back into bed. (RN)-D was part of the facilities investigation. She interviewed other residents who (NA)-A frequently worked with. She denied interviewing other residents on the unit to inquire whether other staff members followed the care plan or not. The education department was informed of the incident and the investigative findings. The education department wrote an education plan on how to access the Kardex and to remind staff to be sure to check the Kardex before providing care. She stated the facility would be completing audits; however, the management team had not yet come up with what the audits would look like. Upon interview on 7/2/26 at 1:10 p.m. the director of nursing, DON stated R1 was a bedbound resident who used a mechanical lift and required two staff members for transfers and reposition. (NA)-A did not follow the care plan, R1 fell out of bed and required surgery. (NA)-A was terminated from her position at the facility. Upon interview on 7/2/26 at 1:16 p.m. R1 stated she had a rod in her leg from another surgery about 14 years ago. On 7/1/26 she had surgery from the recent accident, and a plate was placed in her leg. The day of the incident (NA)-A had washed her face in bed and R1 needed her incontinence brief changed. NA-A did not turn on the call light or leave the room to request assistance. NA-A turned R1 on her side with hard hands and pushed R1 off the other side of the bed. R1 stated she hit her head on her oxygen tank, had instant knee pain, and later developed pain in her coccyx. R1 stated it was a common occurrence that NA-A did not have two staff for assistance, and it happened with other staff, but it was rare. Upon interview on 7/2/26 at 1:45 p.m. (NA)-A stated she was getting R1 ready for the day she had washed her hands and face and R1 had a bowel movement, so she was just changing and cleaning her. She did not believe two staff were needed to change her. She assisted R1 on her side and she rolled out of bed onto the floor. (NA)-A yelled for help immediately. She stated she was aware that R1 required two staff for repositioning, (NA)-A was aware of how to access the Kardex. Upon interview on 7/2/26 at 2:02 p.m. the Administrator stated she expected the staff to follow the care plan. She stated (NA)-A made a poor decision of not following R1's care plan. A facility policy titled Incident/Accident Reports dated 1/2024 indicated designated staff members will initiate an internal investigation as needed to determine the root cause of the incident. The staff member is designated by the Administrator and Director of Nursing. If there are allegations of abuse, neglect, or mistreatment follow internal and state abuse reporting procedures. Refer to and follow all policies on abuse and neglect. When the root cause analysis is completed, the investigator will document the findings in risk management discussed in an IDT meeting and discussed at Quality Assurance (QAPI) meetings to determine ongoing interventions and/or system changes. If reports to other agencies are made, indicate this in the documentation, along with the names or the agency representatives.

Based on observation, interview, and document review, the facility failed to ensure laundry was laundered according to standard infection control practices, with the potential to affect all 116 residents residing in the facility. Findings include:The Centers for Disease Control and Prevention's (CDC) Guidelines for Environmental Infection Control in Health-Care Facilities: Laundry and Bedding resource dated 1/8/24, indicated that damp laundry should not be left in machines overnight. During an observation and interview on 1/8/25 at 12:45 p.m., multiple (greater than ten) cloth mop heads were observed in the laundry machine. Laundry aide (LA)-A stated that the mop heads, cleaning rags, microfiber cloths, and clothing protectors would be brought down to the laundry room throughout the day. The non-laundry staff would then start the laundry machine in the evening. The non-laundry staff would not assist in moving the clothing to the drying machine. The laundry aide confirmed that the usual practice was for the laundry listed above to be cleaned, left wet in the washing machine overnight, and then she would put it in the dryer the following day. During an interview on 1/8/25 at 2:29 p.m., the infection preventionist (IP) stated she was unaware that damp laundry was being left in the washing machine overnight after being washed. The IP stated she thought this practice could be improved and not something she would do at home but was unsure what the infection control risk was. The facility's Linen Handling to Prevent and Control Infection Transmission policy, dated 11/11/24, was reviewed and did not include direction on whether laundry could be left in the machine overnight.

Based on interview and document review the facility failed to ensure residents taking psychotropic medications had an appropriate clinical rationale for not attempting a gradual dose reduction of psychotropic medications, an appropriate diagnosis for use of antipsychotic medications, and non-pharmacological interventions were attempted and documented with as needed psychotropic use. The facility further failed to ensure behaviors were observed and documented to adequately justify psychotropic medication use. This had the ability to effect 3 of 5 residents (R63, R87 and R180) reviewed for unnecessary medications.Findings include:R63R63's quarterly Minimum Data Set (MDS), dated [DATE], indicated R63 was admitted to the care facility on 6/14/25 and had mild cognitive impairment. The MDS further indicated R63 received antipsychotic medication and antidepressant medication during the look-back period without a gradual dose reduction (GDR) attempted.R63's Order Summary Reported, dated 12/2/25, indicated R63 was on several medications including Aripiprazole (an antipsychotic medication) 10 milligrams (mg) two times a day for bipolar and Mirtazapine (an antidepressant) 7.5 mg at bedtime for insomnia.R63's Consultant Pharmacist's Medication Review, dated December 2025, indicated a pharmacist recommendation for a gradual dose reduction of R63's Aripiprazole and Mirtazapine, indicating per CMS [Centers for Medicare and Medicaid] guidelines, all psychotropic medications should be considered for a trial dose reduction at least twice within the first year of use. If a dose reduction is contraindicated, rigorous risk/benefit documentation should be provided. A review of recent provider progress notes did not yield a thorough risk/benefit assessment for this patient's [R63] psychotropic medications.The providers response on the R63's Consultant Pharmacist's Medication Review, dated December 2025, lacked a clinical rationale for not attempting a GDR, instead indicated R63 had been on Abilify [aripiprazole] since [approximately] 2014 for bipolar and mirtazapine since 2022.R63's electronic medical record (EMR) lacked any further documentation to address a clinical rationale for not attempting a GDR for R63's psychotropic (i.e. antipsychotic and antidepressant) medications.An interview on 1/9/26 at 10:50 a.m., with the director of nursing (DON) confirmed there was not a documented clinical rationale for not attempting a GDR for R63's psychotropic medications.R87R87's quarterly MDS, dated [DATE], indicated R87 was admitted to the care facility on 11/3/23 and had severe cognitive impairment. The MDS further indicated R87 had received antipsychotic medication during the look-back period.R87's EMR, indicated an order, dated 1/7/26, for quetiapine (an antipsychotic medication) 12.5 mg two times a day for anxiety, order by Favoured Hospice.R87's Consultant Pharmacist's Medication Review, dated July 2025, indicated per CMS guidelines, anxiety is not a sufficient diagnosis to warrant the use of antipsychotic medications.R87's EMR lacked behaviors notes or target behavior documentation to justify the need for a new antipsychotic medication.R87's December and January medication administration records lacked any evidence R87 had received as needed quetiapine or lorazepam (an antianxiety medication ordered for as needed use for 14 days, dated 11/24/25.)During an interview on 1/9/26 at 8:21 a.m., nurse manager and registered nurse (RN)-B stated she believed hospice was in contact with the family when the decision was made to schedule R87's quetiapine and stated R8 did get agitated at times and she believed R87 was receiving as needed quetiapine. RN-B further stated the facility had guidelines to follow for what diagnoses are appropriate, confirming anxiety was not an appropriate diagnosis for antipsychotic use, stating the medication was ordered by hospice. R108R108's quarterly MDS, dated [DATE], indicated R108 was admitted to the care facility on 12/6/24 and had severe cognitive impairment.R108's EMR contained an order, dated 1/6/26, for lorazepam (an antianxiety medication) 0.5 mg every 2 hours for anxiety, ordered by hospice. The EMR also contained an order for lorazepam 0.5mg every 2 hours as needed for 14 days, dated 12/28/25 and discontinued on 1/6/26.R108's medication administration records indicated R108 had received 6 doses of as needed lorazepam in December 2025 and 1 dose in January 2026 between 1/1/26 and 1/5/26.R108's EMR to include progress notes, medication and treatment administration records for December 2025 and January 2026 and behavior task documentation lacked documentation to justify the need for scheduled lorazepam every 2 hours. The EMR further lacked evidence that non-pharmacological interventions had been attempted prior to as needed lorazepam administration.During an interview on 1/8/26 at 10:25 a.m., nursing assistant (NA)-C stated she didn't know R108 to have much anxiety, stating maybe once and awhile. NA-C stated if R108 seemed anxious, she often wanted to see her daughter or be left alone.During an interview on 1/8/26 at 9:58 a.m., nurse manager and registered nurse (RN)-B stated it would be expected that R108's behaviors and non-pharmacological intervention attempts would be documented on the medication and treatment administration record, confirming there was no documentation of resident behaviors nor non-pharmacological interventions in the month of December or January.A facility policy titled Psychopharmacologic Drug Use, revised 5/2025, indicated:1. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used: Without adequate monitoring; or without adequate indications for its use.2. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior, including antipsychotic medications and antianxiety medications. 3. If not clinically contraindicated, multiple non-pharmacological approaches have been attempted but did not relieve the medical symptoms which are presenting a danger or significant distress; and/or GDR was attempted, but clinical symptoms returned.4. Documentation in the resident's medical record will indicate the rationale for the use of psychotropic medication. The rationale must be based on sound risk/benefit analysis of the resident's symptoms and potential adverse effects of the drug.

Based on observation, interview and document review, the facility failed to assess and develop non-pharmacological interventions to promote comfort for 1 of 2 residents (R4) reviewed for pain management.Findings include: R4's admission Minimum Data Set (MDS) assessment, dated 12/1/25, indicated R4 had intact cognition. Diagnoses included the following: rheumatoid arthritis (chronic autoimmune disease where the immune system attacks joint linings, causing pain, swelling, stiffness, fatigues and damage to joints), Sjogren's syndrome (chronic autoimmune disease which can cause symptoms including fatigue and joint pain), arthrodesisis status (indicated that patient has undergone surgical joint fusion), muscle weakness, and chronic pain. Further the assessment identified R4 received PRN (as needed) pain medications and received non-medication interventions for pain. Furthermore, R4 identified she frequently had pain which occasionally effects sleep, interferes with day-to day activities and rated pain at a 10 out of 10 on a pain scale with 10 as the worst pain. During an interview on 1/5/26 at 3:06 p.m., R4 stated that she has chronic pain which was over the top. R4 stated I think there is more that they could do. R4 stated they do not offer any alternatives to medication such as massage, heat, ice or essential oils. R4 stated I do think it would be helpful. R4's care plan reviewed 1/6/26, identified resident was on pain medication therapy related to rheumatoid arthritis. The care plan indicated to review pain medication efficacy, assess whether pain intensity was acceptable to resident and monitor for side effects. The care plan lacked evidence of offering non-pharmacological interventions prior to administering as needed (PRN) medications, what non-pharmacological interventions have been tried, what has been effective and not effective and what non-pharmacological interventions should be used.R4's January medication administration record (MAR/TAR), printed 1/6/26, included the following orders: - acetaminophen (pain medication) 325 milligram (mg) tablet: give two tablets by mouth every 6 hours as needed for pain with a start date of 12/17/25. The medication had been administered a total of 12 times in January. A pain scale was used on administration of acetaminophen which showed pain scale rating of 3-10 and effectiveness of medication was documented. - oxycodone (opioid pain medication) 5 mg: give 5 mg by mouth every 6 hours as needed for pain with a start date of 12/19/25. The medication had been administered a total of 17 times in January. A pain scale was used on administration of oxycodone which showed pain scale rating of 0-10 and effectiveness of medication. R4's MAR/TAR lacked evidence of non-pharmacological interventions being offered prior to administration of as-needed pain medication. R4's progress notes, dated 1/1/26 to 1/6/26 were reviewed and lacked evidence of non-pharmacological interventions being offered to R4 for pain. During an interview on 1/7/26 at 8:31 a.m., nursing assistant (NA)-A stated when a resident reported they had pain, a nursing assistant asked what kind pain they were having and reported that immediately to the nurse. NA-A stated nursing assistants were not to offer any interventions as they were to report everything to the nurse. NA-A stated R4 did have pain. NA-A stated they had not offered any non-pharmacological interventions such as heat or ice to R4 to help with pain. During an interview on 1/7/26 at 9:32 a.m., licensed practical nurse (LPN)-B stated when it was reported that a resident had pain the nurse needed to assess the resident to find out where the pain was coming from, have them rate the pain, and check to see if they could get medication for the pain. LPN-B stated the nurse also needed to look to see if the resident just had medication. LPN-B stated the nurse would follow up with the provider if the pain was something new or out of the ordinary. LPN-B stated a non-pharmacological intervention might be offered depending on the resident and the situation. LPN-B stated if a non-pharmacological intervention was offered, it would be documented in the progress note. During an interview on 1/7/26 at 12:52 p.m., assistant nurse manager (LPN)-C and registered nurse manager (RN)-A stated the expectation would be non-pharmacological interventions were offered and documented prior to administering PRN pain medications. LPN-C stated the nonpharmacological interventions should be listed on the care plan. RN-A stated the nonpharmacological intervention should also be listed on the MAR and documented prior to administration. During a follow up interview on 1/8/26 at 8:13 a.m., RN-A verified there were no non-pharmacological interventions offered to R4 prior to administration of as needed pain medication. RN-A verified the care plan had been updated after interview on 1/7/26.During an interview on 1/9/26 at 11:11 a.m., director of nursing (DON) stated the expectation would be that non-pharmacological interventions would be offered and documented prior to the use of PRN pain medications. A facility policy titled Pain Medication, reviewed 8/8/25, indicated that all residents have the right for appropriate pain evaluation and pain medication. The policy indicated non-pharmacological interventions research supports physical activity and exercise as a part of most treatment programs for chronic pain.

Based on observation, interview, and document review the facility failed to develop a comprehensive person-centered care plan with goals and interventions utilizing a trauma-informed approach including monitoring of PTSD (post-traumatic stress disorder) for 1 of 1 (R2) residents reviewed for trauma-informed care.Findings include: R2's quarterly Minimum Data Set (MDS) assessment, dated 11/26/25, indicated R4 had severely impaired cognition. Diagnoses included: PTSD, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), anxiety disorder, depression, dementia (significant loss of memory, thinking and reasoning skills), and seizure disorder (condition where the brain has abnormal electrical activity suddenly that temporarily disrupts normal function). R2's Psychosocial History Assessment, dated 11/19/25, identified through a question with a radio-button answered yes that R2 experienced any significant life events that continued to affect R2's life. The assessment form disclosed R2 stated long ago and did not specify further regarding traumatic events. R2 identified smoking cigarettes once in a while helped get through difficult times. R2 did not specify any particular triggers. Furthermore, the assessment identified R2 was seen by a provider for mental health. R2's care plan, printed 1/8/26, identified R2 was resistive to care and had a history of becoming aggressive with staff during cares and accusing staff of attempting to hurt her. Interventions included: followed by psych, provide reassurance, provide consistency in care to promote comfort with ADLs and maintain consistency in timing of ADLs, caregivers and routines as much as possible. The care plan lacked evidence mention of R2 suffering from PTSD, discussing possible triggers, interventions to determine triggers, measurable objectives, interventions, and timeframes for how staff are expected to meet R2's desired goals and outcomes concerning her PTSD. During an interview on 1/5/26 at 1:56 p.m., R2 was observed lying in bed. R2 was nonsensical and repeated self. During an interview on 1/8/26 at 12:15 p.m., R2 was observed lying in bed. R2 asked what was for lunch and then said goodbye as she waiting for her lunch and declined to talk any further. During an interview on 1/8/26 at 12:20 p.m., nursing assistant (NA)-B stated if a resident had PTSD and had triggers it would be on their care plan. NA-B stated they do not believe that R2 has PTSD. NA-B stated there are no known triggers for R2. During an interview on 1/8/26 at 12:30 p.m., licensed practical nurse (LPN)-B stated if a resident had a diagnosis of PTSD, that would be listed on the care plan along with any triggers. LPN-B reviewed R2's diagnoses and verified R2 had a diagnosis of PTSD and stated this information along with any triggers should be on the care plan. During an interview on 1/8/26 at 12:36 p.m., director of social services (DSS)-A stated it's important to gather all the information possible either form the resident, medical records, family, other providers to help not retraumatize a resident when they have a history of trauma or PTSD. DSS-A stated it is important to try to identify triggers and communicate this information to all the staff. During a follow up interview on 1/9/26 at 10:25 a.m., SSD-A verified she was able to review R2's medical record. SSD-A verified there was not a trauma care plan prior to interview yesterday and should have been. SSD-A reviewed the initial assessment completed that did not identify triggers, reviewed therapist notes that did identify trauma history and how that could be related to current behaviors. SSD-A stated she updated R2's care plan to reflect a trauma history. SSD-A stated it is important to gather all this information from all sources to do their best to not retrigger a resident, even if they can't identify a trigger, and avoid further trauma. During an interview on 1/9/26 at 11:09 a.m., director of nursing (DON) stated a residents trauma history needs to be assessed and care planned so staff are aware of the trauma, so they don't retraumatize residents. A facility policy titled Trauma Informed Care, reviewed 1/22/25, identified the goal of trauma informed care is to ensure an environment that is safe and sensitive and to ensure the available of trained professionals.

Based on interview and document review the facility failed to ensure a medication order, written in error and without documented justification was appropriately questions and doubled checked before implementing and administering the medication multiple times for 1 of 1 resident (R108) reviewed for unnecessary medications. Findings include:R108's quarterly MDS, dated [DATE], indicated R108 was admitted to the care facility on [DATE] and has severe cognitive impairment.R108's EMR contained an order, dated [DATE], for lorazepam (an antianxiety medication) 0.5 mg every 2 hours for anxiety, ordered by hospice. The EMR also contained an order for lorazepam 0.5mg every 2 hours as needed for 14 days, dated [DATE] - [DATE] and a second as needed order dated [DATE] and discontinued on [DATE].R108's medication administration records indicated R108 had received 6 doses of as needed lorazepam in [DATE] and 1 dose in [DATE] between [DATE] and [DATE]. Between [DATE] and [DATE], R108 received a total of 11 doses of scheduled lorazepam.R108's [DATE] treatment administration record directed staff to monitor for side effects of the psychotropic medication Seroquel but not lorazepam.R108's EMR to include progress notes, medication and treatment administration records for [DATE] and [DATE] and behavior task documentation, lacked documentation to justify the need to scheduled lorazepam every 2 hours. During an interview on [DATE] at 12:19 p.m., R108's emergency contact and family member (FM)-A stated the facility had called her recently regarding R108's lorazepam order asking her if she was okay with them discontinuing the order. FM-A asked the staff to keep it available to her if she needed it, but not to be scheduled around the clock every 2 hours. During the interview R108 was sitting unassisted on the side of her bed, eating her lunch independently. FM-A stated she had wondered why R108 had seemed more confused today and wondered if it was the extra doses of lorazepam she had received.During an interview on [DATE] at 12:26 p.m., registered nurse (RN)-C confirmed R108 was receiving 0.5 mg of lorazepam every 2 hours scheduled but was not working when the order changed from as needed to scheduled, so was not sure why the medication was scheduled. During the interview, nurse manager and RN-B stated she would investigate where the order came from.During a follow up interview on [DATE] at 1:00 p.m., nurse manager and RN-B stated the order for lorazepam 0.5mg every 2 hours scheduled was given by the hospice registered nurse case manager (RNCM).During an interview on [DATE] at 2:17 p.m., the hospice RNCM stated the order for lorazepam 0.5mg every 2 hours as needed had expired so he wrote a new order for it yesterday ([DATE]). The hospice RNCM stated his intention was for the medication to be as needed and stated, I don't think she [R108] needs that much [0.5mg scheduled every 2 hours]. The hospice RNCM then stated he actually meant to schedule the lorazepam 0.5mg every 12 hours, not every 2 hours as every 2 hours scheduled would be a sharp increase.During a third follow up interview on [DATE] at 2:44 p.m., nurse manager and RN-B stated she would investigate where the miscommunication came from, stating FM-A should be aware R108 was receiving lorazepam every 2 hours.During an interview on [DATE] at 3:03 p.m., consulting pharmacist (CP)-A stated if R108's system was not use to that much lorazepam it would be important to monitor her for increased lethargy or confusion. CP-A further stated 0.5mg of lorazepam every 2 hours was probably not harm level dose but he would want to ensure R108 was monitored and not showing signs of sedation.During a fourth follow up interview on [DATE] at 9:58 a.m., nurse manager and RN-B stated she would expect to see behaviors and non-pharmacological intervention attempts documented on the medication and treatment administration records for R108 justifying the need for lorazepam every 2 hours, confirming the records lacked such documentation. RN-B stated she spoke with the hospice RNCM who confirmed the order for lorazepam every 2 hours was written in error, and it should have been scheduled every 12 hours, not every 2 hours.During an interview on [DATE] at 10:25 a.m., nursing assistant (NA)-C stated she didn't know R108 to have much anxiety, stating maybe once and awhile. NA-C stated if R108 seemed anxious, she often wanted to see her daughter or left alone.During a follow up interview on [DATE] at 10:46 a.m., FM-A again confirmed she did not believe that R108 needed antianxiety medication every 2 hours or even scheduled every 12 hours and she only wanted it available to R108 as needed, stating she [R108] has seemed very doped up lately.During an interview on [DATE] at 10:50 a.m., the director of nursing (DON) stated she would have expected that either the floor nurses or the nurse manager question the lorazepam order and why, without justification and without as needed dose use to support, the order went from lorazepam 0.5mg every 2 hours as needed to scheduled every 2 hours.A facility policy titled Medication Administration-General Guidelines, dated [DATE], indicated, If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnoses or conditions, the nurse calls the provider pharmacy for clarification prior to the administration of the medication or if necessary contacts the MD/NP [doctor/nurse practitioner] for clarification. This interaction with the pharmacy and/or MD/NP and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate.

Based on interview and document review, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for 1 of 1 residents (R18) reviewed for hospice.Findings include: During an observation on 1/5/26 at 1:41 p.m., R18 was observed lying in bed with her eyes closed. During a follow up interview and observation on 01/7/26 at 8:50 a.m., R18 was observed in the dining room. R18 smiled but did not answer questions. R18's quarterly MDS assessment, dated 11/1/25, identified R18 had severely impaired cognition. Diagnoses included dementia (significant loss of memory, thinking and reasoning skills), atrial fibrillation (an irregular and often rapid heart rhythm), dysphagia (difficulty swallowing), chronic pain and hemiplegia (paralysis affecting one side of the body). The MDS contained section O which contained a section hospice care which was marked no indicating R18 did not receive hospice services. R18's orders, printed 1/9/26, included the following order:-ok for hospice to evaluate, treat and accept with a start date of 8/1/24-call hospice in case of an emergency [number listed] with a start date of 10/29/25 R18's electronic medical record (EMR) contained a section titled special instructions which was listed R18's name, allergies and code status which indicated [name of hospice] hospice. R18's care plan, printed 1/6/26, indicated R18 was enrolled in hospice with a potential for knowledge deficit of hospice philosophy/program and an expected physical and cognitive decline which was last revised on 11/5/24. The care plan did contain additional information regarding R18 and hospice and interventions. During an interview on 1/7/26 at 9:20 a.m., licensed practical nurse (LPN)-A verified R18 was on hospice. During an interview on 1/8/26 at 10:57 a.m., director of MDS (MDS)-A verified R18 was on hospice. MDS-A indicated the last MDS was coded incorrectly and should have indicated R18 was on hospice. MDS-A stated a modification for R18's quarterly MDS assessment on 11/1/25 had been submitted after review. During an interview on 1/9/26 at 11:10 a.m., director of nursing (DON) stated the accuracy of MDS was important and it helps ensure staffing levels are appropriate and appropriate cares are provided to all residents. A facility policy titled MDS/Care Plan Process/Resident Assessment, revised 10/21/25. Under the section Accuracy of Assessments, the document indicated the assessment must represent an accurate picture of the resident's status during the observation period of the MDS.

Based on interview and document review the facility failed to ensure an allegation of sexual abuse was thoroughly investigated for 1 of 2 residents (R81) reviewed for allegations of abuse. Findings include:R81's quarterly Minimum Data Set (MDS), dated [DATE], indicated R81 was admitted to the care facility on 7/22/23 and had severe cognitive impairment. The MDS further indicated R81 required partial to moderate assistance with most activities of daily living and required substantial assistance with toileting.R81's care plan, dated 7/16/25, indicated should resident report that she was sexually assaulted, staff should ensure resident is safe and report allegation to their supervisor immediately.R81's progress note, dated 12/14/25, indicated resident [R81] reported that she was sexually abused at night. Writer reported to daughter. Daughter ran the camera and reported two NAR [nursing assistants] changed resident and she went to sleep. Nothing wrong happened to resident as per the resident daughter. Daughter said, 'This is becoming a behavior issue.'During an interview on 1/8/26 at 11:33 a.m., registered nurse (RN)-C stated, every once and awhile she would get report that R81 told staff, Someone raped her or hurt her. RN-C stated it was expected that those allegations be reported to their supervisor because they were timeframes they needed to follow for reporting and investigating.During an interview on 1/9/26 at 8:21 a.m., nurse manager and RN-B stated R81 had dementia and had made allegations of being raped in the past but nothing credible was found, and R81 later forgot about what she reported. RN-B stated R81's family had a camera in her room the family could review when allegations were made. RN-B stated she was off in December when R81 reported she felt sexually abused, however if it was reported to her today, she would discuss it with the director of nursing (DON) so that it could be properly investigated. During an interview on 1/9/26 at 8:45 a.m., RN-D stated she recalled reading a progress note regarding R81 reporting an allegation of sexual abuse and that the camera in her room was reviewed by family. RN-D stated she would have expected that to be reported to the DON immediately to start investigating what happened.During an interview on 1/9/26 at 9:52 a.m., the director of social services (DSS)-A stated she was aware R81 had made allegations of sexual abuse, but she was just made aware of the allegation reported in December. DSS-A stated it would be expected that staff investigate to gather as much information as possible and if staff can't prove it didn't happen it should be reported. DSS-A stated the allegation made in December should have immediately been reported to the supervisor and the DON for investigation. During an interview on 1/9/26 at 10:50 a.m., the DON confirmed the allegation of sexual abuse reported by R81 in December was not reported to her and she would have expected it to be so that it could have been thoroughly investigated. A facility policy, titled Vulnerable Adult - Abuse Prohibition Plan, revised 10/2024, indicated:During the shift that the alleged abuse/neglect, unexplained injury or suspected crime is first observed, a mandated reporter/covered individual will immediately make an initial report to their supervisor, after securing the resident's safety. Steps must be taken to ensure that no resident in the facility remains in danger of maltreatment, including medical intervention if needed.If potential maltreatment is suspected or unknown, the Supervisor will immediately report to the Administrator and/or designee Director of Nursing.Immediate steps are taken to protect the vulnerable adult from harm while the situation is being investigated.The Building Charge, Nurse Manager, Director of Nursing, or Administrator will immediately institute an internal investigation of the reported allegation or incident. The investigation may include but not limited to:a. Interviews of staff and written statements from staffb. Resident interviewsc. Resident Representative interviewsd. Witness interviews and written statements of incidente. Care observationsf. Environmental review g. Resident health status/Medical record review

Based on interview and document review the facility failed to implement their written policy and procedure and ensure an allegation of sexual abuse was reported to the state agency for 1 of 2 residents (R81) reviewed for allegations of abuse.Findings include:R81's quarterly Minimum Data Set (MDS), dated [DATE], indicated R81 was admitted to the care facility on 7/22/23 and had severe cognitive impairment. The MDS further indicated R81 required partial to moderate assistance with most activities of daily living and required substantial assistance with toileting.R81's care plan, dated 7/16/25, indicated should resident report that she was sexually assaulted, staff should ensure resident is safe and report allegation to their supervisor immediately.R81's progress note, dated 12/14/25 at 11:25 a.m., indicated resident [R81] reported that she was sexually abused at night. Writer reported to daughter. Daughter ran the camera and reported two NAR [nursing assistants] changed resident and she went to sleep. Nothing wrong happened to resident as per the resident daughter. Daughter said, 'This is becoming a behavior issue.'During an interview on 1/8/26 at 11:33 a.m., registered nurse (RN)-C stated, every once and awhile she would get report that R81 told staff, Someone raped her or hurt her. RN-C stated it was expected that those allegations be reported to their supervisor because there were timeframes they needed to follow for reporting and investigating.During an interview on 1/9/26 at 8:21 a.m., nurse manager and RN-B stated R81 had dementia and had made allegations of being raped in the past but nothing credible was found, and R81 later forgot about what she reported. RN-B stated R81's family had a camera in her room the family could review when allegations were made. RN-B stated she was off in December when R81 reported she felt sexually abused, however if it was reported to her today, she would discuss it with the director of nursing (DON), and they would typically file a VA [vulnerable adult] report. She expected it to have been reported to the supervisor who was covering for her while she was off (RN-D).During an interview on 1/9/26 at 8:45 a.m., RN-D stated she recalled reading a progress note regarding R81 reporting an allegation of sexual abuse and that the camera in her room was reviewed by family. RN-D stated she would have expected that to be reported to the DON immediately to start investigating what happened.During an interview on 1/9/26 at 9:52 a.m., the director of social services (DSS)-A stated she was aware R81 had made allegations of sexual abuse, but she was just made aware of the allegation reported in December. DSS-A stated it would be expected that staff investigate to gather as much information as possible and if staff can't prove it didn't happen it should be reported. DSS-A stated the allegation made in December should have been reported to the supervisor and the DON immediately.During an interview on 1/9/26 at 10:50 a.m., the DON confirmed the allegation of sexual abuse reported by R81 in December was not reported to her and she would have expected it to be.A facility policy, titled Vulnerable Adult - Abuse Prohibition Plan, revised 10/2024, indicated:Mandated reporters in skilled nursing facilities ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported, and a report made immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do notresult in serious bodily injury, to the administrator of the facility and to other officials in accordance with State law through established procedures. The report will be made to the Minnesota Department of Health (MDH)/OHFC. During the shift that the alleged abuse/neglect, unexplained injury or suspected crime is first observed, a mandated reporter/covered individual will immediately make an initial report to their supervisor, after securing the resident's safety. Steps must be taken to ensure that no resident in the facility remains in danger of maltreatment, including medical intervention if needed.If potential maltreatment is suspected or unknown, the Supervisor will immediately report to the Administrator and/or designee Director of Nursing.Immediate steps are taken to protect the vulnerable adult from harm while the situation is being investigated.External Reporting Procedure1. The Administrator and/or Director of Nursing or their designee will complete the MDH/OHFC on-line report.

Based on observation, interview and document review, the facility failed to ensure a resident's nails were kept clean and trim for 1 of 3 residents (R90) reviewed for activities of daily living. Findings include: R90's quarterly Minimum Data Set (MDS), dated [DATE], indicated R90 was cognitively intact, had upper and lower extremity impairments on one side and required substantial to maximum assistance with activities of daily living. R90's care plan, dated 7/10/24, indicated R90 had limited physical mobility and self-care performance deficit related to hemiplegia (paralysis affecting one side of the body) and hemiparesis (weakness or reduced strength on one side of the body) following a cerebral infarction (stroke) affecting his right side, required assist of two staff with bathing/showering, and directed staff to provide nail care as needed. During observation and interview on 1/5/26 at 4:25 p.m., R90 had fingernails approximately 1/4 inch long with dark matter underneath them. R90 looked down at his nails and stated, they do need to be trimmed and cleaned. During a second observation on 1/8/25 at 10:34 a.m., R90's nails continued to extend past his fingertips with dark matter still underneath all of his nails. During an interview on 1/8/26 at 10:25 a.m., nursing assistant (NA)-C stated it was the expectation that residents receive nail care whenever it is needed but also on bath days. NA-C also stated every morning facility staff should be assisting residents with washing their hands and ensuring their nails are clean. During an interview on 1/9/26 at 8:21 a.m., nurse manager and registered nurse (RN)-B stated it would be expected that staff keep resident's nails clean and provide nail care on bath days. RN-B confirmed there were no notes in the electronic medical record regarding R90's nail care being completed. A facility policy on Activities of Daily Living was not received.

Based on interview and document review, the facility failed to submit accurate and/or complete data for staffing information based on payroll during 1 of 1 quarter (Fiscal Year Quarter 4 2025 - July 1 - September 30) reviewed, to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. This had the potential to affect all 116 residents at the facility.Findings include: The CMS PBJ Staffing Data Report for Fiscal Year Quarter 4 2025 dated 1/2/26, indicated the facility had no registered nurse (RN) hours, and lacked licensed nursing coverage for 24 hours per day on the following 25 dates: 8/1, 8/3-8/8, 8/11-8/15, 8/18-8,22, 8/24-8/31. Review of the staff schedules and time sheets indicated the facility had the appropriate licensed 24-hour nursing coverage and RN hours as required. During interview on 1/6/26 at 1:59 p.m., administrator stated she was responsible for submitting the staffing data and was not surprised the report triggered for the missing RN and licensed nursing hours. She stated she attempted to submit the August data and stayed late to complete the submission; however, she encountered technical issues and it didn't go through. During an interview on 1/9/26 at 11:04 a.m., the director of nursing (DON) stated the administrator was in charge of submitting the PBJ report and she didn't have anything to do with submitting it. The DON stated she knew the administrator was having troubles submitting the report for August. The DON stated the facility as a registered nurse in the building at all times so knows that the report wasn't accurate. The facility Payroll Based Journal - Error Report and XML Files policy revised 1/25, indicated administrators or designees will log onto the CMS website and enter data, check validation report, and verify the submitted report is accurate and complete.

Based on interview and document review, the facility failed to assess a resident timely after a change of condition for 1 of 3 (R1) residents reviewed for change in condition.Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition with diagnoses including paraplegia, urinary tract infection, and protein-calorie malnutrition. R1's care plan dated 7/4/25, indicated R1 was usually able to identify the need to have incontinent product changed and was able to utilize the call light to request assistance. R1's preference was to have incontinent product checked at 4 am only. A nurse's note written by registered nurse (RN)-A on 7/14/25 at 6:46 a.m., indicated R1 was alert and oriented to baseline with no shortness of breath or respiratory distress noted or reported. R1 slept through the night. A nurse's note written by licensed practical nurse (LPN)-A on 7/14/25 at 6:59 a.m., indicated during report the outgoing nurse (RN-A) denied R1 had a change of condition and insisted R1 was doing okay however, was sleepy. A nursing assistant (NA) (does not identify which one) had reported R1 was not doing well and was very unresponsive. Both nurses went to R1's room to check on her. R1's vital signs were: blood pressure 83/50, pulse 87, oxygen saturations 48, temperature 97.7 and respirations 14. Supplemental oxygen was started at 2 liters per minute. LPN-A was in the process of updating the provider. The Emergency Medical Services (EMS) ambulance run sheet dated 7/14/2,5 indicated a 911 call was received on 7/14/25 at 8:19 a.m. The local fire department arrived first and started R1 on supplemental oxygen at 10 liters per minute (L). EMS arrived at 8:28 a.m. At 8:32 a.m., R1's oxygen saturation was 84% on 10 L supplemental oxygen, skin was cold, breathing was rapid and labored, and lungs had crackles in all fields. Supplemental oxygen was increased to 15L and R1 was transported to the closest hospital. On 7/23/2025 at 9:45 a.m., family member (FM)-A was interviewed and stated R1 was usually easy to wake up. R1 would not have been able to sleep through a brief change and laying in bed while the nursing assistants changed the sheets on her bed. R1 was a talkative person and wanted her cares completed in a certain way. There is no way they [the nursing assistants] couldn't notice she was unconscious. On 7/23/2025 at 10:26 a.m., FM-B was interviewed and stated R1 had been complaining about how her cares were being completed so the family decided to place two motion activated cameras in her room. FM-B reviewed the videos from 7/14/25. Two male staff members entered R1's room just after 4 a.m. They called out her name however, she did not respond. R1's arm was observed falling like it was dead weight. The staff members were making noise and there was no reaction from R1. After that, no one entered R1's room until 6:30 a.m. or so when a male and female staff entered the room. The female (RN-A) was heard saying she is just sleeping, and the male (LPN-A) replied that is not sleeping. On 7/23/2025 at 12:25 p.m., NA-A was interviewed and stated around 4 a.m., NA-A and NA-B entered R1's room to check her incontinent product. NA-A noticed R1 did not look the way she usually did. R1 would usually wake up when someone knocked on her door. NA-A called R1's name a few times and she did not wake up. NA-A and NA-B changed R1's incontinent product and bed sheets then left the room. NA-A could not find RN-A right away but eventually told the RN-A R1 was not doing well. NA-A could not recall what time he notified RN-A and did not know if RN-A went to R1's room. On 7/23/2025 at 1:08 p.m., NA-B was interviewed and stated he assisted NA-A with changing and repositioning R1. NA-B called R1's name and she did not respond. NA-B told NA-A to go get R1's nurse. NA-A replied the nurse already knew about R1's condition. When they were done, NA-B told LPN-A R1 was not talking the way she usually did when she was being changed. NA-B thought there was something wrong with R1. On 7/23/2025 at 1:19 p.m., RN-A was interviewed and stated she was the nurse responsible for R1 on 7/14/25. RN-A checked on R1 about 4 a.m., by standing in the doorway or her room to check if she was breathing and if the tube feeding was still running. At that time R1 appeared to be sleeping. R1 would put the call light on if she needed anything. RN-A asked NA-A if R1 had been changed. NA-A confirmed R1 had been changed but gave no other information about R1. RN-A stated the first time she heard R1 was not feeling well was from LPN-A during nurse to nurse report at about 6:30 a.m. On 7/23/2025 at 2:41 p.m., LPN-A was interviewed and stated about 6:00 a.m., NA-B told him R1 had not been feeling well, but NA-A had stated RN-A already knew. At about 6:40 a.m., during nurse-to-nurse report, RN-A reported R1 was doing ok. LPN-A was confused because that was not what NA-B had told him, so LPN-A and RN-A went to R1's room to check on her. LPN-A could tell something was off about R1 as soon as they walked into the room and R1 did not talk to them. When R1 would not wake up, LPN-A checked her vital signs, which were abnormal, and called the on-call provider for orders. On 7/23/2025 at 4:14 p.m., nurse practitioner (NP)-A was interviewed and stated an unresponsive resident should be assessed by a nurse immediately after the resident is found unresponsive. A delay in assessment and subsequent contact with the provider could result in the resident's clinical condition getting worse and harder to reverse or the resident could pass away. On 7/24/2025 at 1:10 p.m., the director of nursing (DON) was interviewed and stated a nursing assistant should notify the nurse right away if a resident who was normally arousable was not waking up. The nursing assistant should notify the nurse anytime a resident was observed to be different than the nursing assistant expects, even if the nurse had been notified of the condition previously. The nurse should assess the resident as soon as possible. The Change of Condition Assessments policy dated 4/16/25, established standardized procedures for registered nurses to assess and manage changes in condition among patients. The purpose of a nursing-focused assessment was to collect and compare data to normal findings and the individual patient's current health status, and reporting changes and responses to interventions in an ongoing manner to a registered nurse or the appropriate licensed health care provider. The Perineal Care policy dated 11/2017, instructed staff to inform the nurse of any changes, concerns or any skin integrity issues.

Based on interview and document review the facility failed to identify a resident's highest level of wellbeing, develop individualized care plan interventions, involve the medical provider to review rejection of care, and develop new goals and treatment choices, for 2 out of 3 residents (R1 and R2) when both residents refused hygiene (washing face and hands, brushing hair and teeth), peri care (washing rectum and vaginal areas after incontinence), weekly bed baths, and reducing risk for developing pressure ulcers. In addition, R1 refused to let staff check her blood pressure (BP) required prior to giving medication, and monitoring R2's weight weekly as ordered. Findings include: R1's care plan dated 11/20/24, indicated she needed two staff to change her incontinent pad when soiled and transfer out of bed with a mechanical lift. Staff would do a sponge bath when unable to do a full bath or shower. She needed one staff member to turn from side to side in bed, dress, hygiene, and oral care. No indication she refused care. R1's care plan dated 11/22/25, indicated she would decline being weighed due to pain. The intervention was not updated since. R1's care plan dated 1/23/25, indicated only one reference to refusal of care associated with taking antidepressant medication and risk for refusal to eat. R1's nursing progress notes dated 3/7/25 through 7/9/25, indicated she refused: being weighed 28 times, incontinent care five times, blood pressure (BP) checked leading to missing Midodrine (medication to elevate BP) dose nine times, and weekly bed bath three times. R1's care plan dated 3/31/25, indicated she was bed bound and required the assistance of two staff members to bathe, incontinent care, turn in bed, dress, and transfer using a mechanical lift. She required the assistance from one staff member to perform daily hygiene and eating assistance. She had impaired hearing, and difficulty communicating her needs to staff. The care plan did not address any rejection of cares and there were no individualized interventions to minimize the refusals of care. R1's Minimum Data Set (MDS) dated [DATE], indicated she had intact cognition, neuromuscular neuropathies (a disease effecting her nerves and muscles), inability to stand or walk, malnutrition, hearing loss, inability to urinate, difficulty swallowing and the history of alcohol abuse. Care Area Assessments (CAA) triggered inability to care for herself, move in bed, had a Foley catheter, impaired vision, inability to communicate, risk for falling, poor nutrition, risk for developing a pressure ulcer, use of anti-psychotropic medication to treat depression, anxiety, and Oxycodone (opioid) for chronic pain. R1's nursing assistants (NA) Kardex dated 7/8/25, indicated staff would identify risks related to refusing care, and re approach later. After 2 refusals they would notify the nurse. On 7/8/25 at 12:12 p.m., nurse manager registered nurse (RN)-A stated R1 had a history of refusing care. Staff would re-approach at a different time. If staff were unable to check her blood pressure before giving Midodrine, the dose would be held. She would expect the staff after a couple of refusals to update the medical provider for further guidance. On 7/8/25 at 1:00 p.m., director of nursing (DON) stated she expected her staff to notify the medical provider for any missed doses of medication, refusing weights, incontinent care, hygiene, medication, lab draws, and food, along with increased or decreased weights. Staff did not identify the root cause for rejection of care, including a risk benefit analysis. She also agreed R2's care plan did not identify refusal of care and lacked individualized care plan interventions. On 7/9/25 at 10:27 a.m., nurse practitioner (NP) stated staff updated her about R1 refusing BP checked prior to receiving Midodrine nine times on 7/8/25. She had been trying to adjust the Midodrine dose several times, because her blood pressure remained low. Had she known she could have educated R1 to gain compliance. She expected the staff would have contacted her in March when the behavior started not four months later. In addition, regarding activities of daily living (ADLS) refusals, she would have encouraged compliance by discussing the risk for developing pressure ulcers and infection. R2's medical record from 11/20/24 through 6/26/25, indicated in 38 weeks the facility weighed her eight times. R2's risk for altered nutrition care plan dated 11/22/25, indicated she would decline weights related to pain. No further interventions identified in the care plan to minimize the number of times she refused. R2's medical record dated 12-1-24 through 12-31-24, indicated staff would document her weight in two places. Weighing her was documented on the treatment administration record (TAR) and the actual weight under the results tab in point click care (PCC) electronic medical record. PCC documentation indicated staff weighed her, but there were no weights recorded under the result tab. R2's MD-A visit note dated 12/31/25, indicated her last weight was 203 lbs. R2's TAR dated 1-1-24 through 1-31-24, indicated staff weighed her every week, but only one weight was documented on 1/1/25. No indication the NP was notified. R2's TAR dated 2-1-24 through 2-28-24, indicated staff weighed her every week, but only one weight was entered on 2/21/25 with a gain of 37.8 lbs. from her previous weight. No indication the NP was notified. R2's Nurse Practitioner (NP)-A note dated 2/15/25, first indicated a weight gain from 202 lbs. to 240 lbs. in six weeks. During her assessment she observed edema (swelling of the feet related to fluid buildup in the tissue.) R2 told her that was not normal for her. R2's TAR dated 3-1-24 through 3-31-24, indicated staff weighed her weekly, staff documented three weights on 3/5/25, 3/12/25, and 3/26/25, resulted in weight gain of 10 lbs. since 2/19/25. No indication the NP was notified. R2's nursing note dated 3/5/25 at 11:00 a.m., indicated her weight was 250 lbs. and she developed worsening edema. NP-B was updated and would visit R2. R2's NP-B note dated 3/10/25, stated she developed edema in her lower extremities since February 2025. Review of weights showed she gained 50 lbs. since admission four months ago. Staff told her she drank a lot of fluid throughout the day. She started a diuretic (medication to pull fluid out of the tissue) on 3/6/25 had not improved the edema. Her left thigh graft (healthy skin transplanted on a wound to promote healing) currently reopened draining fluid. Likely cause was the edema in her leg. R2's TAR dated 4-1-25 through 4-30-25, indicated staff weighed her weekly, but no weight was documented for the month. No indication the NP was notified. R2's medical doctor (MD) note dated 4/14/25, indicated the edema was related to low albumin (protein cells) and taking Gabapentin (medication for nerve pain). The left leg wound infection resolved. R2's medication and treatment documented dated 4/19/25, indicated an order for daily weights and update the provider for a weight gain more than 2 lbs. in one day or five lbs. in one week. R2's administration note dated 5/21/25, indicated she needed an MDS weight on 5/22/25, since her last weight was on 3/26/25. She refused to be weighed. R2's MDS dated [DATE], indicated she had normal cognition, risk for skin breakdown, heart disease, diabetes, high blood pressure, obesity, depression, left thigh skin graft after motor vehicle incident, chronic pain, and depression. She currently took anti-depression medication along with opioid narcotics. She was incontinent of bowel and bladder. R2's result note dated 6/26/25, indicated she was weighed one time for 264.4 lbs. She gained an additional 14.4 lbs. No indication the NP was notified. On 7/8/25 at 9:20 a.m., registered dietician (D)-A stated if a residence weight increased by two lbs. in one day or five lbs. in one week, she would notify the nurse manager who would update the provider. R2 often refused to be weight related to increased pain when using the mechanical lift. On 7/8/25 at 11:00 am., NP-B stated she was not aware R2 refused to be weighed as ordered when the facility contacted her on 7/7/25. She now realized the lack of weights failed to identify her significant weight gain and diagnosing fluid buildup, edema and why her leg failed to heal. Had she known about the refusals, and weight gain she would have addressed the situation with the resident and developed different methods to monitor fluid buildup without having a current weight such as measuring the diameter of her legs and checking for shortness of breath when lying flat. On 7/8/25 at 1:00 p.m., director of nursing (DON) stated she expected her staff to notify the medical provider for any missed doses of medication, refusing weights, incontinent care, hygiene, medication, lab draws, and food, along with increased or decreased weights. Staff did not identify the root cause for rejection of care, including a risk benefit analysis. She also agreed R2s care plan did not identify refusal of care and lacked individualized care plan interventions. The facility policy Individualized Care Plan dated 1/22/25, indicated, staff would develop a comprehensive care plan after using a comprehensive assessment. Resident's needs and functional capacity would be identified on the individualized plan of care. All physician orders are included in the care plan. Interventions would be updated in the residence Kardex. Any care plan alterations would be initiated by the staff member who identified the problem.

Based on observation, interview and record review, the facility failed to test the levels of chemicals used on the three compartments sink to sanitize the pots used for meal preparation; failed to ensure dry goods removed from original packaging were stored in a manner to reduce the risk for cross contamination; and failed to properly monitor food temperatures before serving food to residents. These findings had the potential to affect all 102 residents, staff, and visitors, who consumed food prepared from the main production kitchen. Findings include: During observation and interview on 11/12/24 at 8:20 a.m., an initial kitchen tour was completed with culinary coordinator (CC) and the following items were identified: 1. A series of two white colored plastic bins were on the floor (wheeled) adjacent to the baking area. These were labeled for flour and sugar. However, the bin labeled for flour was approximately half full and a plastic, blue-colored scoop was present inside the bin and touching the flour. The handle was pointed upward from the product. CC opened the flour container and stated, that shouldn't be there. 2. The three compartments sink was filled with water. The water in two of the compartments was clear, and the third one was tinted blue. A testing log of the chemical used on this sink was not available upon request. During interview on 11/13/24 at 10:25 a.m., CC and company regional kitchen manager (RKM) confirmed the facility used a chemical sanitization process for cleaning pot and pans and stated the staff had not been testing the chemical levels used in the three-compartment sink. CC stated the pots used to prepared food were washed in the three compartments sink and the pots were never washed in the dishwasher. RKM stated a testing log was implemented that morning. During observation on 11/13/24 at 11:36 a.m., dietary staff were dishing food from a steam located next to the main cooking area. A black binder was on top of the steam table and contained daily temperature logs for the month of November. Daily logs included breakfast, lunch, and dinner. Temperature documentation of meals were as follows: 11/01/24 - Breakfast and dinner temperatures were documented. 11/02/24 - No temperatures were documented 11/03/24 - Breakfast and dinner temperatures were documented. 11/04/24 - Breakfast, lunch, and dinner temperatures were documented 11/05/24 - Breakfast and dinner temperatures were documented. 11/06/24 - Breakfast and lunch temperatures were documented. 11/07/24 - Breakfast and dinner temperatures were documented. 11/08/24 - Breakfast and lunch temperatures were documented. 11/09/24 - Breakfast and lunch temperatures were documented. 11/10/24 - Breakfast and lunch temperatures were documented. 11/11/24 - Breakfast, lunch, and dinner temperatures were documented 11/12/24 - Breakfast and lunch temperatures were documented. 11/13/24 - Breakfast and lunch temperatures were documented. During interview on 11/13/24 at 12:20 p.m., CC and RKM verified the daily temperature logs for the steam table were incomplete. CC stated the cooks used a blue colored binder to document the food temperatures when they were preparing the food, and before the food was transferred to the kitchen's steam table. CC was unable to locate the cook's binder used to log temperatures at the point of food preparation and stated she was going to contact the weekend cook and ask where the binder was. During interview on 11/14/24 at 7:20 a.m., CC stated the binder used by the cooks to document the food temperature was not found. During interview on 11/14/24 at 7:25 a.m., cook (CA) stated he did not temp or document the breakfast or lunch temperatures on 11/12 or 11/13 before he transferred the food from the kitchen to the steam table because the dietary aide checks the food temperature at the steam table. During interview on 11/14/24 at 8:32 a.m., RKM stated having two binders to document temperatures was not functional, and probably the cook and the kitchen aid were relying on each other to check the temperature. RKM stated starting immediately a single temperature log will be used by the kitchen staff. RKM stated the food temperatures needed to be monitored to assure the quality of the food, meet regulations, and prevent foodborne illnesses. Further, RKM stated leaving a scoop inside a container was a concern for cross contamination, and the chemical levels of the three-compartments sink should be tested to assure pots are properly sanitized. During interview on 11/14/24 at 1:58 p.m., the administrator stated the expectation was to check the temperature of food before it's served, scoops are not left inside food containers to prevent cross contamination, and testing of the chemicals used to sanitize kitchen equipment was done to assure proper sanitation. Facility Policy titled Meal Program, dated 03/2023, indicated the purpose of this policy was to offer a comprehensive and attractive meal program that meets the United States Department of Agriculture guidelines for the nutritional needs of the elderly and ensures compliance with 144G.41 and 144G.91. Policy also indicated the food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626. Further, policy indicated temperatures will be taken by cook after transfer any item to the steam table prior to beginning of service and logged. Facility Policy titled Food Labeling and Storage dated 11/2023 indicated the director of food and nutrition services will be responsible for providing safe foods for all individuals and knows to store food to prevent cross contamination. Facility Policy titled Food Safety and Sanitation dated 05/2024 indicated the staff will complete all necessary tasks regarding regulations for service and preparation in healthcare environment. Policy included the proper procedure to set up three-compartment sink and test water for PPM ((200-4500) for quart and (500-700) for sink and surface, record and initial in log.

Based on interview and document review the facility failed to ensure 2 of 5 residents (R25, R85) were offered, educated and/or provided the pneumococcal vaccine series as recommended by the Centers for Disease Control (CDC), who were reviewed for immunizations. Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R25's annual Minimum Data Set (MDS) dated [DATE] indicated R25 was [AGE] years old, was admitted to the facility on [DATE], was severely cognitively impaired, and had the following diagnoses: peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs), hypertension (high blood pressure), Alzheimer's disease, and dementia. R25's Point Click Care Immunization, updated 11/14/24, indicated R25 had received pneumococcal vaccine (PCV23) on 4/26/17. The record did not indicate a refusal or if R25 had been offered/educated on the benefit of receiving an additional pneumococcal vaccinations. R85's quarterly MDS dated [DATE] indicated R85 was [AGE] years old, admitted on [DATE], was severely cognitively impaired, and had the following diagnoses: heart failure, diabetes mellitus (a chronic disease where the body is unable to properly regulate blood sugar levels), hyperlipidemia (high blood lipid levels), Alzheimer's disease, and dementia. R85's Point Click Care Immunization tab, updated 11/24/24, indicated R85 received PCV13 on 7/13/15 and PCV23 on 01/11/07. The record did not indicate a refusal of PCV20, or if if R85 had been offered/educated on the benefit of receiving an additional pneumococcal vaccinations. During interview on 11/14/24, at 1:40 p.m. infection preventionist (IP) stated she used the Minnesota Immunization Information Connection (MIIC) and admission paperwork to determine residents' vaccination status. IP stated R25, and R85's medical records lacked documentation of receiving the PCV20 vaccination. During interview on 11/14/24, at 1:44 p.m. director of nursing (DON) stated R25 and R85 were eligible to receive the PCV20 vaccination. DON confirmed R25 and R85 had not been offered nor had they received the PCV20 vaccination. DON stated her expectation was all residents would be educated on the risks and benefits of receiving vaccinations, as well as offered any eligible vaccinations. DON stated it is important to receive vaccinations to promote good health. A vaccination policy was requested but not provided.

Based on observation, interview and document review the facility failed to comprehensively assess past trauma and develop a comprehensive person-centered care plan with goals and interventions utilizing a trauma-informed approach including monitoring of post traumatic stress disorder (PTSD) for 1 of 1 residents (R79) reviewed for trauma-informed care. Findings include: R79's quarterly Minimum Data Set (MDS) dated [DATE], indicated R79 was [AGE] years old, was cognitively intact and the MDS further indicated R79 was widowed, suffered from feelings of depression or hopelessness several days a week, and always socially isolated. R79's diagnoses sheet, dated [DATE], indicated the following diagnoses: post-polio syndrome (a condition that causes gradual muscle weakness and atrophy), hypertension (high blood pressure), hemiplegia (paralysis or weakness on one side of the body), and schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly) and altered mental status. An Associated Clinic of Psychology (ACP) progress note dated [DATE], indicated R79's social history included an alcoholic father, had lost two siblings, had suffered the loss two sons who died as infants, and was the victim of an abusive partner. It further indicated R79 suffered from flashbacks of her traumatic experiences. ACP progress note dated [DATE], indicated R79 exhibited behavioral and emotional symptoms that affect functioning, was paranoid and lacked trust in others. R79's facility Psychosocial/History assessment dated [DATE], indicated resident had experienced life threatening or traumatic events that included: polio as a child, her first husband died at age 35, her second husband committed suicide, loss of two children in infancy, and had history of a stroke. The assessment further indicated R79 had been intimidated, hurt, manipulated, or controlled by her second husband who was verbally and physically abusive towards her. R79's care plan printed [DATE], at 12:05 p.m. lacked any information on trauma informed care or trauma triggers. A care plan printed on [DATE], at 2:15 p.m. indicated R79's care plan had been updated to include trauma informed care with an initiation date of [DATE], three days after survey entrance. During interview on [DATE], at 1:09 p.m. certified nursing assistant (CNA)-A stated he was familar with R79 and worked with her frequently. CNA-A stated he did not now if R79 was a trauma survivor but did have behavioral issues. CNA-A stated he did some online education for trauma-based care but nothing specific to R79. During interview on [DATE], at 1:21 p.m. registered nurse (RN)-F stated she was familiar with R79 and worked with her frequently. RN-F stated she would occasionally take R79 outside if she was exhibiting behavioral issues but could not identify any specific trauma informed care-based interventions for R79. During interview on [DATE] at 1:35 p.m. transitional care unit charge nurse (TCU-CN) stated when a resident is assessed by social workers the information is shared with staff, used to create the plan of care, and discussed in interdisciplinary meetings. TCU-CN went on to say the facility meets with ACP providers weekly to discuss resident care and will reach out to them for instruction, assistance, or guidance on how to treat residents with history of trauma. During interview on [DATE] at 2:40 p.m. director of nursing (DON), stated she was familiar with R79, and she required total care and assistance. DON stated R79 had trauma history including emotional and physical abuse, death of children and dealing with law enforcement. She went on to say R79 would frequently isolate herself, exhibited fear of the government and it was difficult to identify what was trauma and what was delusion. DON stated she would expect any resident who had experienced trauma would have trauma informed care addressed on their care plan and it should identify what the trauma was and how to minimize risk of retraumatizing. DON confirmed R79's care plan did not previously include trauma informed care, did not include trauma triggers or interventions but had been updated on [DATE], three days after survey entrance, to include trauma informed care, triggers and interventions. DON stated it was important to know and understand a residents trauma history to avoid re-traumatization.

Based on observation, interview, and document review the facility failed to ensure a sanitary and homelike environment for 1 of 1 residents (R55) who had dried feeding tube-like substance on their feeding tube pole, dresser, bed, and floor. Findings include: R55's quarterly Minimum Data Set (MDS) dated [DATE], indicated R55 had intact cognition and depended on staff for assistance with dressing, transferring, and bed mobility. The MDS indicated R55 received over 50 percent of her total calories through a feeding tube. R55's medication administration record (MAR) dated 11/1/24 indicated received daily feedings from 9 p.m. to 11 a.m. During an observation on 11/12/24 at 11:20 a.m., R55 was observed lying in bed on the left side of the room with a feeding pump attached to a pole to her right. To the right of the pole was a dresser and in front of the pole was a bedside table. The dresser had splatters of a light brown/yellow substance scattered over the side and front of the dresser. The light brown/yellow substance was also observed scattered over the bottom one-fourth of the feeding pump pole, the carpet on the right side of the bed, and the right bed rail/frame of R55's bed. During an observation and interview on 11/13/24 at 11:02 a.m., the light brown/yellow substance was again observed in R55's room as described above. R55 stated she did not like that the brown substance was on her furniture and floor and at home she would have cleaned it up immediately. R55 stated she had family visit her at least a few days ago, and they noticed the brown substance on the furniture and floor, and it bothered her that her room was not clean especially when she had visitors. R55 stated she assumed the brown substance was tube feeding solution. R55 stated staff cleaned it up whenever they feel like it and most of her furniture hadn't been cleaned for several months. During an interview on 11/13/24 at 11:19 a.m., registered nurse (RN)-A stated she was the nurse in charge of R55's care and had stopped her tube feeding this morning. RN-A stated she was unsure how long the tube feeding had been on R55's furniture and floor. RN-A stated it should have been cleaned by either housekeeping or nursing staff but looked like it had not been. During an interview on 11/14/24 at 11:51 a.m., the unit nurse manager (RN)-B stated she expected nursing staff to clean the resident furniture and tube feeding pole as the spills occurred and housekeeping should have been called if nursing staff was unable to clean the spill. RN-B stated staff should have cleaned the dried tube feeding to ensure R55's had a home-like environment and infection control measures were practiced. A policy regarding resident room cleaning was requested and not received.

Based on interview and document review, the facility failed to ensure the Coronavirus Disease (COVID-19) vaccination was offered and/or provided to reduce the risk of severe illness to 1 of 5 residents (R58) reviewed for immunizations. Findings include: Center of Disease Control and Prevention (CDC) Interim Clinical Considerations for Use of COVID-19 Vaccines in the United States reviewed 4/4/24, directed the following guidance: For people [AGE] years or older who are not moderately or severely immunocompromised: -unvaccinated= 1 dose of an updated (2023-2024 Formula) mRNA COVID-19 vaccine OR 2 doses of updated Novavax vaccine. -Previously received 1 or more Original monovalent or bivalent mRNA vaccine doses= 1 dose of any updated COVID-19 vaccine. -Previously received 1 or more doses of Original monovalent Novavax vaccine, alone or in combination with any Original monovalent or bivalent mRNA vaccine doses= 1 dose of any updated COVID-19 vaccine. -Previously received 1 or more doses of [NAME] vaccine, alone or in combination with any Original monovalent or bivalent mRNA vaccine or Original monovalent Novavax doses= 1 dose of any updated COVID-19 vaccine. -Special situation for people ages [AGE] years and order= People ages [AGE] year and older should receive 1 additional dose of an updated COVID-19 vaccine at least 4 months following the previous dose of updated COVID-19 vaccine. For initial vaccination with updated Novavax COVID-19 vaccine, the 2-dose series should be completed before administration of the additional dose. For people [AGE] years or older who are moderately or severely immunocompromised: -Unvaccinated= 3 homologous (i.e., from the same manufacturer) updated (2023-2024 Formula) mRNA vaccine doses OR 2 updated Novavax vaccine doses. -Previously received 1 or 2 Original monovalent or bivalent mRNA vaccine doses= Complete the 3-dose series with 2 or 1 homologous updated mRNA vaccine doses, respectively. -Previously received a combined total of 3 or more Original monovalent or bivalent mRNA vaccine doses= 1 dose of any updated COVID-19 vaccine. -Previously received 1 or more Original monovalent Novavax vaccine doses, alone or in combination with any Original monovalent or bivalent mRNA vaccine doses= 1 dose of any updated COVID-19 vaccine. -Previously received 1 or more doses of [NAME] vaccine, alone or in combination with any Original monovalent or bivalent mRNA vaccine or Original monovalent Novavax doses= 1 dose of any updated COVID-19 vaccine. -People ages 12-[AGE] year may receive 1 or more additional doses of any updated COVID-19 vaccine. -People ages [AGE] years and older should receive 1 additional dose and may receive further additional doses of any updated COVID-19 vaccine. R58's quarterly Minimum Data Set (MDS) dated [DATE], indicated R58 was admitted on [DATE], was cognitively intact, and had the following diagnoses: anemia (low red blood cells and hemoglobin in blood), hypertension (high blood pressure), hyperlipidemia (high levels of fat in the blood) and anxiety disorder(a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation). R58's Point Click Care Immunizations tab lacked any documentation for COVID 19 vaccination. During an interview on 11/14/24, at 1:40 p.m. infection preventionist (IP) stated she had reviewed R58's admission medical record and the Minnesota Immunization Information Connection (MIIC) website to obtain R58's vaccination status. IP stated R58 was eligible to receive the COVID-19 vaccination but had not been offered, nor had she refused the vaccination. During an interview on 11/14/24, at 1:44 p.m. director of nursing (DON) confirmed R58 had not been offered nor received the COVID 19 vaccination. DON stated her expectation was all residents would be educated on the risks and benefits of receiving vaccinations, as well as offered any eligible vaccinations. DON stated it is important to receive vaccinations to promote good health. A vaccination policy was requested but not provided.

Based on interview and document review the facility failed to ensure orders for PRN (as needed) psychotropic medication (mood altering medications) were time limited to 14 days. In addition, the facility failed to ensure provider assessment and documentation of rationale and duration of continuation of a psychotropic PRN medication beyond 14 days occurred for two of six residents (R70 and R40) reviewed for PRN psychotropic medication use. The facility further failed to ensure an indication for use was present for one of six residents (R40) reviewed for psychotropic medication. Findings include: R70 R70's significant change Minimum Data Set (MDS) dated [DATE], indicated R70 was moderately cognitively impaired with the diagnoses of cancer. Section O. indicated R70 was receiving hospice services at the facility. The Current Order Summary dated November 2024, included the order: lorazepam (medication which act on the brain and nerves to produce a calming effect) oral concentrate 2 milligrams per milliliter (mg/ml) Give 0.5 mg by mouth every 2 hours as needed for anxiety, sleep, severe nausea. The stop date was listed as indefinite. R70's provider order for lorazepam documented, lorazepam oral concentrate mg/ml, give 0.5 mg by mouth every 2 hours as needed for anxiety, sleep, severe nausea. provider order did not document it was time limited to 14 days or less. R70's medication administration record showed that R70 had not received a dose of the ordered lorazepam between the dates of 9/6/24 to 11/13/24. Provider notes between 9/1/24 and 11/14/24 lacked evidence to show a provider had reviewed R70's lorazepam order for discontinuation or order renewal every 14 days. The Consultant Pharmacist's Medication Review dated 9/17/24, identified R70 had been prescribed lorazepam since 9/3/20 [error lorazapam was started ordered on 9/6/24] and indicated: there was not a stop date or duration listed in the order. Written review included: Per updated CMS regulations, all new prn psychotropic medications orders must be re-evaluated within 14 days of initiation and then at routine intervals thereafter. Provider note must specify rationale for renewal of medication. During an interview on 11/14/24 at 12:17 p.m., the director of nursing (DON) stated all the prn antipsychotic/psychotropic medications such as lorazepam ordered as a PRN medication should be reviewed and evaluated every 14 days for renewal or discontinuation and they should not be ordered with a stop date of indefinitely. The Policy Psychopharmacologic Drug use dated 7/8/2024, number 11. As needed (PRN) orders subpart b. included: PRN orders for psychotropic drugs are limited to 14 days except if the provider or prescribing practitioner believes the order period should be extended. They must document in the medical record the duration of and the rationale for extension of the order. The provider must directly examine the resident to determine if the PRN is still needed. 47495 R40's quarterly MDS, dated [DATE], indicated R40 was admitted to the care facility on 2/6/23 and was cognitively intact. R40's diagnoses list, printed 11/14/24, indicated R40 had several medical diagnoses including bipolar disorder, anxiety disorder, depression, and insomnia. R40's Physician Orders contained an order, dated 10/23/24, for Compazine (an antipsychotic medication) 5 milligrams (mg) by mouth every 8 hours as needed for nausea. The order however lacked an end date or a rationale of why the medication should be continued beyond 14 days. R40's Physician Orders also contained an order, dated 6/19/24, for Trazadone (an antidepressant and sedative medication) 25 mg by mouth at bedtime. The order however lacked an indication for use (i.e. depression or insomnia). During an interview on 11/14/24 at 8:22 a.m., licensed practical nurse (LPN)-B was unable to confirm if R40 received Trazodone for depression or insomnia, stating it was for bedtime. During an interview on 11/14/24 at 9:13 a.m., assistant nurse manager and registered nurse (RN)-E stated it would be expected that an indication for use would be noted on R40's Trazodone order to ensure staff knew why they were giving the medication, stating she was usually notified when a medication was missing an indication for use. During an interview on 11/14/24 at 1:42 p.m., the director of nursing (DON) confirmed all antipsychotics should always have a 14-day end date. The DON further stated it would be expected the Trazodone order had an indication of use, stating if staff did not know what they were giving the medication for they would not be able to assess the medication's effectiveness.

Based on observation, interview and document review, the facility failed to ensure care plan interventions were followed and new interventions were implemented in a timely manner when resident pain goals were not met for 1 of 1 residents (R44) to ensure comfort and reduce the risk of complications. Findings include: R44's quarterly Minimum Data Set (MDS) dated [DATE], indicated R44 had intact cognition. The MDS indicated R44 was on a scheduled and as-needed (PRN) pain medication regimen and received non-pharmocological interventions for pain. The MDS indicated R44 had pain almost constantly over the past five days and it made it hard for R44 to sleep constantly and occasionally limited day-to-day activities. R44's care plan dated 6/5/24, indicated R44 had pain related to multiple factors including lumbar spinal stenosis (narrowing of the spinal canal causing pressure on the nerves) with radiculopathy (a pinched nerve), osteoarthritis (a joint disease that can cause pain stiffness or swelling), osteoporosis (weak and brittle bones), and failed back surgery syndrome (pain following back surgery). The care plan indicated staff should give pain medications per schedule to maintain therapeutic levels, offer non-pharmacological interventions, and notify the provider of inadequate pain relief. R44's pain interview and evaluation dated 9/23/24, indicated R44 rated her pain at a seven out of ten and had non-verbal signs of pain such as moaning and grimacing. The assessment indicated R44's pain goal was zero out of ten. The assessment indicated R44's pain management plan included diclofenac gel (pain gel) and 1000 milligrams (mg) of Tylenol three times a day. R44's provider progress note dated 10/8/24, indicated R44 had a left arm fracture requiring surgery with ongoing discomfort to the left elbow area. The note indicated R44 currently had 50 mg of Tramadol (a narcotic pain medication) available every eight hours PRN but R44 stated her pain was not well-controlled with this schedule. The provider agreed to increase the medication to every six hours PRN. The note also indicated R44 had lumbar spinal stenosis (narrowing of the spinal canal causing pressure on the nerves) with radiculopathy (a pinched nerve). R44's medication administration record (MAR) dated 10/1/24 through 11/11/24, indicated R44 had orders for the following medications: - 1000 mg of Tylenol three times a day dated 1/15/24 - 400 mg of gabapentin daily at bedtime dated 5/3/24 - two lidocaine patches (pain patch) daily dated 7/23/24 - 100 mg of gabapentin (medication used for nerve pain) two times a day dated 8/15/24 - one percent diclofenac gel available every eight hours PRN dated 8/26/24 - 0.2596 mg total daily dose of hydromorphone (narcotic pain medication) through an implanted pain pump dated 9/3/24 - 50 mg of PRN tramadol available every eight hours dated 9/17/24 through 10/8/24 - 50 mg of PRN tramadol available every six hours dated 10/8/24. - 30 mg daily (10/19/24-10/24/24), 20 mg daily (10/25/24-10/27/24), and 10 mg (10/28/24-10/30/24) of prednisone (a steroid) ordered for gout (a form of arthritis that can cause severe pain, swelling, and joint tenderness) R44's progress notes, order administration notes, pain scores, and MAR dated 10/27/24 through 11/11/24 were reviewed and indicated: - On 10/27/24 at 2:24 a.m., tramadol was given for six out of ten pain. A follow-up pain score was assessed at 7:01 a.m., an eight out of ten and the medication was documented as being ineffective. The note did not include what new pain interventions were implemented and if needed, the provider was notified. - On 10/27/24 at 10:13 a.m., tramadol was given for eight out of ten pain. At 12:43 p.m., left elbow elevation, and a cold compress were applied to the left elbow for swelling, pain, and slight warmth. The note indicated this information would be reported to the oncoming nurse. A follow-up pain score was assessed at 1:17 p.m., at eight out of ten and the medication was documented as being ineffective. The note did not include what further pain interventions were completed at that time or if the provider had been notified. - On 10/27/24 at 4:36 p.m., tramadol was given for eight out of ten pain. A follow-up pain score was assessed at 5:19 p.m., at seven out of ten and the medication was documented as being effective. - On 10/28/24 at 1:24 p.m., tramadol was given for seven out of ten left elbow pain. A follow-up pain score was assessed at 2:07 p.m., at five out of ten and the medication was documented as being effective. - On 10/29/24 at 9:56 a.m., R44 requested a physical therapy evaluation as she thought that might help with her pain, so the nurse left a message for the nurse practitioner. At 10:58 a.m., the nurse left a message for nurse practitioner who was in the building, but the note did not indicate what the message was regarding. - On 10/30/24 at 8:03 a.m., tramadol was given for six out of ten left leg pain. A follow-up pain score was assessed at 1:01 p.m., at eight out of ten and the medication was documented as being ineffective. The note did not include what further pain interventions were completed at that time or if the provider had been notified. - On 10/30/24 at 8:06 p.m.,tramadol was given for eight out of ten left leg pain. A follow-up pain score was not documented. - On 11/1/24 at 9:19 a.m., tramadol was given for eight out of ten left elbow pain. A follow-up pain score was assessed at 10:12 a.m., at four out of ten and the medication was documented as being effective. - On 11/2/24 at 8:58 a.m., tramadol was given for eight out of ten left elbow pain. A follow-up pain score was assessed at 9:40 a.m., at four out of ten and the medication was documented as being effective. - On 11/4/24 at 9:30 p.m., tramadol was given for seven out of ten pain. A follow-up pain score was not documented. - On 11/6/24 at 2:04 p.m., the nurse stated she had talked to the nurse practitioner, and she was working on the order. - On 11/8/24 at 7:43 a.m., tramadol was given for seven out of ten pain. A follow-up pain score was not assessed until 12:55 p.m., and was seven out of ten and the medication was documented as being ineffective. - On 11/8/24 at 1:12 p.m., tramadol was given for seven out of ten pain. A follow-up pain score was assessed at 3:22 p.m., at six out of ten and the medication was documented as being effective. - On 11/9/24 at 6:09 a.m., tramadol was given for eight out of ten pain. A follow-up pain score was not assessed until 1:16 p.m., and was eight out of ten and the medication was documented as being ineffective. - On 11/9/24 at 1:16 p.m., tramadol was given for eight out of ten pain. A follow-up pain score was assessed at 7:28 p.m., at six out of ten and the medication was documented as being effective. - On 11/9/24 at 7:28 p.m., tramadol was given for eight out of ten pain. A follow-up pain score was assessed at 8:39 p.m., at six out of ten and the medication was documented as being effective. - On 11/10/24 at 8:00 a.m., tramadol was given for eight out of ten pain. A follow-up pain score was not assessed until 12:55 p.m., and was seven out of ten and the medication was documented as being ineffective. The note indicated the resident stated this medication only helps a bit. - On 11/10/24 at 4:43 p.m., tramadol was given for eight out of ten pain. A follow-up pain score was assessed at 7:09 p.m., at six out of ten and the medication was documented as being effective. - On 11/11/24 at 8:23 a.m., tramadol was given for eight out of ten in the left elbow pain. A follow-up pain score was assessed at 10:09 a.m., and was five out of ten. The medication was documented as being ineffective and an ice pack was offered. The note did not indicate if a pain follow-up assessment was completed to ensure the non-pharmacological intervention was effective. During an interview on 11/14/24 at 8:51 a.m., nurse practitioner (NP)-A stated she was R44's primary care provider and managed her pain plan. NP-A stated R44 had pain related to a broken elbow that did not heal correctly and chronic back pain. NP-A stated she had not gotten any reports in the last few weeks from nursing staff indicating the current pain plan was not effectively managing her pain. NP-A stated she had gotten a report and had worked on orders regarding getting R44 physical therapy per her request but R44 had not qualified for this. NP-A stated if she had gotten a report from nursing staff indicating R44's pain was inadequately managed, she would have followed up with R44 to evaluate possible interventions but stated she doubted her pain would ever be under a seven out of ten. During an interview on 11/14/24 at 10:21 a.m., R44 stated she did not feel like her pain was well controlled and would like her pain at a maximum of 3 out of 10. R44 stated her pain was usually in her back or her left elbow and lately had been sitting at a seven or eight out of ten. R44 stated she did not feel like the staff believed her pain was as bad as it felt to her and were not providing adequate pain interventions even when she was telling them her pain was still higher than what was tolerable for her. R44 stated she feels like the facility does not listen to her when she tells them she still has pain and the pain interventions that have been attempted didn't help. During an interview on 11/14/24 at 10:28 a.m., registered nurse (RN)-C stated the trained medication aides (TMA) were responsible for asking residents what their pain levels were and then following up later to ensure the medication was effective. RN-C stated he thought R44's pain goal was zero out of ten. RN-C stated if a resident did not meet their pain goal after a PRN medication was given, then the TMA would offer a non-pharmacological intervention. RN-C stated he expected the TMA to complete this follow up assessment to determine if the residents pain goal was met after administering PRN pain medications or non-pharmacological interventions. RN-C stated if the pain goal was not met, he expected to be notified and then he would call the NP to determine what further interventions could be attempted and then that would be documented in the progress notes. During an interview on 11/14/24 at 10:58 a.m., RN-D, the unit nurse manager, stated she would expect the TMA to alert the nurse if the resident is reporting pain so the nurse could assess the resident and determine appropriate interventions. RN-D stated she would expect the nurse to follow up with the resident to determine if the resident's pain goal had been met after the pain intervention had been implemented. RN-D stated if they had already attempted the PRN medications available as well as non-pharmacological interventions she would expect nursing staff to notify the NP that the resident's pain goal was not being met so they can see if pain medication regimen needs to be updated, such as scheduling pain medications, ensuring they are using the right medication and it is being dosed effectively. RN-D stated she was unsure what the expectation was for how long after a pain medication was given, nursing staff should re-evaluate pain levels, but thought it would be around an hour. A policy regarding resident pain management was requested and not received.

Based on interview and document review, the facility failed to initiate cardiopulmonary resuscitation (CPR) in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in an immediate jeopardy (IJ) situation when CPR was not initiated when R7 was found without a pulse and respirations. The deficiency was identified as past noncompliance and issued at Immediate Jeopardy (IJ). The IJ began on [DATE], when the facility failed to provide CPR for R7 after R7 was found unresponsive and later died . The administrator and director of nursing (DON) were notified of the IJ at past noncompliance on [DATE] at 5:50 p.m Corrective action was taken prior to the survey. The facility corrected the deficient practice on [DATE]. Findings include: R7's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R7 had no cognitive impairment, required extensive assistance with transfers, dressing, toileting, personal hygiene, and bed mobility. R7 was diagnosed with [CONDITION(S)] (a condition in which the flow of urine is blocked that causes urine to back up and injure one or both of the kidneys), [CONDITION(S)], gait instability, and [CONDITION(S)]. R7 was expected to be discharged to the community after his stay at the facility. R7's facility admissions orders dated [DATE], identified R7's advance directives as Full Resuscitative Measures. R7's admission progress note dated [DATE], indicated Advance Directives: Full Code (Full attempts at resuscitation including intubation). Review of the [DATE], facility investigation and interviews with staff identified: 1) Nursing assistant (NA)-A answered R7's call light between 10:,d+[DATE]:30 a.m. on [DATE]. R7 requested his cell phone be plugged into his charger. NA-A then left the room. At about 10:45 a.m., R7's roommate pressed the call light and stated he pressed it for R7 who was wrestling around. NA-A discovered R7 was not responsive and left immediately to tell the nurse licensed practical nurse (LPN-A). 2) LPN-A acknowledged she was notified R7 was unresponsive by NA-A and did not check on R7 for about 10 minutes. 3) LPN-B stated she was approached by LPN-A at approximately 10:55 a.m. to assess R7. Both LPN-A and LPN-B entered R7 room and reported R7 had no pulse or respirations. LPN-B left room to call 911 and notify the house supervisor (HS). Neither LPN-A or LPN-B started CPR. The HS arrived to R7 room with crash cart and did not perform CPR shortly before the paramedics arrived. The paramedics did not perform CPR due to their assessment. 4) No resuscitation measures were attempted. R7 pronounced dead. 5) LPN-A stated she determined that R7 had no respirations or pulse when she first arrived to his room. When asked about her knowledge of R7 code status, LPN-A replied, I didn't even think about that. During interview on [DATE] at 2:07 p.m., the house supervisor (HS) identified she was working on [DATE] and was notified by the facility scheduler that R7 had died . HS arrived on the unit and asked LPN-A what R7's code status was. LPN-A informed HS that R7 died , a long time ago and did not know his code status. HS obtained the crash cart and ran to R7's room and determined his condition was irreversible by cold skin temperature and mottled appearance of lower extremities. R7 had also lost all bowel function (commonly occurs after death) and as a result had a bowel movement. Paramedics (EMS) arrived and did not perform CPR. HS stated EMS asked LPN-A why CPR was not performed. LPN-A continued to state R7 had died a long time ago without elaboration. HS identified CPR was supposed to be performed per R7's code status and, I was so emotional and sad because we did not do what we should have done. HS indicated R7's code status was present and visible in the code status banner of the electronic medical record for R7 and on his face sheet. Interviewed on [DATE] at 11:21 a.m., with the administrator identified R7 code status was full code. The administrator stated CPR was not performed when R7 became unresponsive and delayed life saving treatment, resulting in R7's death. Interview on [DATE] at 10:28 a.m., with the DON identified R7 was considered a full code. The DON stated LPN-A was suspended immediately after event on [DATE], and terminated by the facility on [DATE] due to her failure to immediately act when NA-A reported to LPN-A, R7 was unresponsive and failed to immediately assess and intervene and begin CPR. Interview on [DATE] at 6:15 p.m., with the medical director (MD) identified a resident whose Advance Directives indicated a full code should receive necessary lifesaving treatment including CPR. The February 2021, CPR and Automated External Defibrillator Policy identified when a resident is found unresponsive, yell CODE BLUE and the location down the hall, determine code status by looking at the code status banner in the electronic medical record, perform CPR for resident who have requested CPR, continue CPR until cardiac status returns or staff is relieved by another employee trained in CPR or the paramedics have arrived and asked you to stop CPR. The immediate jeopardy past non-compliance that began on [DATE], was verified during the [DATE] through [DATE] survey to have been corrected by [DATE]. Corrective action was taken prior to the survey when the DON and HS immediately educated all staff currently working that same day on [DATE] to the CPR policy following the incident. Staff not working were emailed notification to check in with the DON or HS prior to work and a notice was placed in the time clock computer that flashed a message notifying staff to see the DON and HS to re-educate them to CPR policies and procedures. Verification of corrective action was confirmed by the interviews with a variety of nursing staff, management, the medical director, and review of documentation of staff training. In addition, facility polices were reviewed and audits had been scheduled.

Based on observation, interview and document review, the facility failed to assess and evaluate causal factors for falls, and failed to ensure adequate interventions were implemented to reduce falls, for 2 of 3 residents (R4 and R3) reviewed who both sustained falls resulting in actual harm. Findings include: R4's nursing note dated 10/8/18, indicated R4 was admitted on [DATE], from the hospital with a right [MEDICAL CONDITION] from a fall at home. R4 had a 14 day admission Minimum Data Set MDS completed on 10/15/18. The MDS indicated R4 had a score of 9 on a cognitive assessment (BIMS) indicating moderate cognitive impairment. Section V of the MDS, CAA and care planning, indicated R4 triggered the following areas for development of a care plan: Cognitive loss, rehab, urinary incontinence and catheter, psychosocial well being, activities, falls, pressure ulcer and pain. CAA for falls dated 10/24/18, indicated R4 was at risk for falls related to impaired mobility, was continent of bowel and able to summon staff and wait for assistance. The goal was to be free from falls. The care plan, dated 10/24/18, indicated a problem for falls and safety related to: a history of falls, impaired mobility, debility, self transfers, cognitive deficits and medications. The goal was for R4 to have minimal falls or fall related injuries. Interventions listed were low bed with mat, anticipate toileting needs and assist as needed, observe for medication side effects, physical therapy (PT) for strengthening and endurance to improve mobility. The care plan had one hand-written comment dated 1/17/19, indicating, Fall - unsafe with transfers. There were no additional interventions written on the care plan to correspond to the comment. Progress notes on 10/8/18, indicated R4 had a fall at 5:00 p.m. while trying to get up to the bathroom. R4 had not used the call light. R4 was found sitting in front of the recliner. R4 agreed to use the call light in the future. The record lacked evidence of any other immediate actions or interventions at the time of the fall. On 10/9/18, progress notes indicated R4 was found at 6:45 a.m. lying next to the bed and stated she was trying to go to the bathroom. The right leg appeared shorter than the left and the foot was turned in. A low bed with floor mat was initiated and was reminded to use the call light. R4 had no complaints of pain. A right hip X-ray was ordered and showed no evidence of fracture, per physician notes dated 10/17/18. On 10/11/18, (two/three days post falls) the IDT met to review R4's falls. Documentation indicated R4 had post operative [MEDICAL CONDITION] following hip surgery. R4 was independent at home and not accustomed to needing to ask for help and believed she was still able to to to the bathroom independently. R4 was in a room near a nursing office. The plan was to make frequent checks and remind to use the call light. PT was consulted, a low bed was initiated, continue therapy to strengthening. The note indicated the care plan was reviewed and current. However, there was no indication toileting needs were evaluated at the time of the fall, even though R4's two falls on 10/8/18 and 10/9/18 were related to her needing to use the bathroom. A fall risk data collection was completed on 10/24/18. The data indicated R4 had a fall related fracture, was unsteady, used a diuretic (medicine to reduce fluid in the body). The record lacked an assessment of the data. A bowel and bladder evaluation (BBE) was competed on 10/28/18. The BBE indicated R4 was continent of bowel and bladder, and woke in the night to use the toilet. R4 was able to identify the need to toilet and was able to use the call light. The BBE had no written summary of findings or interventions indicated. The toileting care plan dated 10/31/18, indicated a goal to maintain level of continence. The interventions were to provide pericare after each incontinent episode, provide assistance with toileting, toilet per facility protocol, offer assist to the toiled at night if awake, administer medications and observe for signs or symptoms of urinary tract infection. The toileting care plan made no reference to R4's risk for falls. On 11/19/18, at 10:29 a.m. documentation indicated R4 was found on the floor in a kneeling position with top half of body on the bed and knees on the floor mat. R4 had a laceration above the eye due to the fall. R4 stated a need to use the bathroom and could not wait for help. R4 had not put the call light on. At 8:26 p.m. documentation indicated R4 had been in bed all day with a headache rated a pain level of 8 out of 10. The record lacked indication any new or revised interventions had been initiated related to self toileting. The IDT reviewed the fall on 11/22/18 (three days post fall). The documentation indicated R4 was forgetful of limitations, tends to be fiercely independent, low hemoglobin, declined in therapy and was placed on hospice. Additionally noted was R2's feeling of not being able to wait for help. Interventions were unchanged with low bed and floor mat, frequent safety checks (no frequency parameter indicated). However, there was no evidence resident's bathroom use needs were re-assessed, and related interventions developed and implemented. On 12/4/18 at 10:23 p.m., it was noted R4 tried to self-transfer from unlocked wheelchair to the toilet, was too weak to accomplish the task and fell to the floor. At the time of the fall R4 stated had hit head on the floor. The IDT reviewed the fall on 12/6/18 (two days later). Documentation indicated the call light was on at the time of the fall, desired to be independent, had weakness, used wheelchair in room, had low bed with mat, continue to encourage call light use, hit head on the floor and ice was applied, care plan reviewed and revised. However, the toileting care plan lacked evidence any revisions had been made. The falls and safety care plan also lacked evidence new or revised interventions had been implemented. On 12/15/18, R4 had been caught self-transferring to toilet three times and said the urgency to go was so strong and could not wait. The record lacked evidence of any new or revised interventions related to R4 self-transferring. A fall risk data was collected on 1/9/19. The summary indicated R4 was at risk for falls, was fiercely independent and attempted to do as much for self as possible, used the call light to get help for toileting, and mostly continent of bowel and bladder. Physical and occupational therapy were requested for strengthening and mobility. Additionally noted was R4 had begun to attempt to self-transfer and continued to be weak. Plan was to have staff check frequently for any needs. On 1/17/19, a nursing note indicated R4 had an unwitnessed fall. The falls/safety care plan up-dated on 1/17/19, indicated a fall occurred due to unsafe transfers. There were no additional interventions added to the care plan to correspond with the fall notation. On 1/22/19 at 11:24 p.m., a nurse progress indicated R4 had been exhibiting confusion and hallucinations related to family members in the room and mother in the bed. The nurse practitioner was notified and felt the confusion could be related to dementia and not a urinary tract infection. Later, a loud noise was heard and R4 was found on the roommates side of the room wedged between the wall and roommates night stand. R4 had a skin tear on left wrist, pain in both hips and left arm. The fall happened at 10:40 p.m. R4 left the facility by ambulance. R4 was admitted to the hospital with [REDACTED]. R4 returned to the facility from the hospital on [DATE], at 7:10 p.m., per nursing documentation. The IDT reviewed this fall on 1/23/19. The IDT documentation indicated R4 had a history of [REDACTED]. R4 sustained a left femoral fracture and was sent to the hospital but no surgery performed. R4 spent the night in the emergency room and returned to the facility the next day with pain medication. The documentation noted comfort is the goal. A temporary care plan was developed on 1/22/19, for alteration in mobility related to fracture from fall in room. The goal was for R4 to participate in mobility skills with assistance and regain increased independence; participate in activities of daily living (ADL), incisional area will heal without infection and will remain comfortable. The interventions developed were: assist with ADL, mobility and transfers; encourage to be as independent as possible; praise efforts; observe for changes in range of motion; keep physician and family notified; therapy as ordered' monitor incision site; implement safety measures as necessary. No specifics of the safety measures to be implemented were noted. On 1/29/19, at 1:20 p.m. R4 was observed lying in a low bed. The nursing assistant (NA)-H was interview and stated R4 no longer tried to get up since hurting her hip. Registered Nurse (RN)-E (also nurse manager) was interviewed on 1/30/19 at 10:30 a.m. and verified R4 had been admitted with a [MEDICAL CONDITION] and did have a fall injuring the other hip when R4 tried to get up on her own during the night, NA-I was interviewed on 1/30/19 at 10: 45 a.m. NA-I verified she would check and change and re-position R4 every 2 hours which was standard protocol and had changed R4 about hour ago and would be back in to care for R4 in about and hour. NA-I verified R4 no longer used the toilet. The Fall Risk Assessment (FSA) policy, revised 7/2016, indicated fall risk data was collected on admission, quarterly and after 3 consecutive falls. The assessor would evaluate and analyze the hazards and risks and assign a risk range of minimal, moderate or high risk. Additionally, the care plan would be updated to reflect interventions, and the interventions would be monitored for effectiveness and modified by IDT. R3 had a significant change Minimum Data Set (MDS) comprehensive assessment completed 10/24/2018. The MDS, dated [DATE], indicated R3 had experienced 2 falls with injury since admission and 2 falls without injury since admission. The Care Area Assessment (CAA) summary, listed care areas that had triggered from the MDS for inclusion in the care plan. The MDS indicated R3 scored a 5 on a cognitive abilities test (BIMS) indicating significant cognitive decline. The CAA summary identified problem areas of: Cognition, communication, activity of daily living, urinary incontinence, and behavioral symptoms, falls and nutritional status. The worksheet also indicated possible contributing factors to increase the risk for falls of: cognitive impairment, depression, incontinence, [MEDICAL CONDITION], and impaired balance during transitions. The care plan for falls and safety, initially developed on 7/17/17, showed no up-dates during the months of September, (MONTH) and (MONTH) of (YEAR), and one update for (MONTH) dated 12/31/18, to initiate a low bed and floor mat. A hand written notation on the care plan indicated a fall had occurred on 11/27/18, but lacked new interventions to correspond to the fall. Listed interventions included roam alert in place; monitor falls per protocol; maintain clutter free environment; observe for changes in gait; anticipate needs for safety; grip tape to bathroom floor. The care plan for behavior/dementia had a goal dated 4/18/19, indicated R3 was at risk for challenging behaviors related to dementia and depression. R3 had a history of [REDACTED]. The goal was for R3 to respond to behavior approaches. The approaches listed were to: evaluate effectiveness of medications, administer medications, use calm firm approach, explain procedures, allow time for comprehension and response and offer reassurance and validation. Also to monitor for wandering and guide to specific destination. R3 received an antidepressant medication. The care plan lacked personalized interventions to address all the specific problem areas indicated. High risk for falls was not addressed on the behavior/dementia care plan. Nursing progress note documentation in R3's medical record indicated: - On 9/5/18, R3 was found on the floor at 3:15 p.m. with a large bowel movement (BM) on the floor. - On 9/6/18, R3 was found on the floor in front of the bed at 2:45 p.m. The interdisciplinary team (IDT) meeting documentation, dated 9/6 /18 indicated R3 appeared to fall related to trying to pull pants down to use the toilet. R3 was independent with toileting and often refused care. The documentation indicated the care plan had been updated. - On 9/12/18, R3 stood up, took one step and fell . No injuries were noted. - On 9/30/18, R3 was found on the floor with BM in pad, on carpet and in bathroom. IDT documentation on 10/1/18, indicated no injuries from the falls, but did have a left knee abrasion from a previous fall. R3 was independent with ambulation and transfers, but can be unsteady at times and move at a fast pace. Staff assist as needed an as R3 will allow. R3 often refused care and staff were to re-approach to assist with cares and toileting. R3 had BM incontinence. Will add gripper strips to bathroom floor and additional support bars to toilet. A bowel and bladder evaluation (BBE) dated 10/18/18, indicated R3 had dementia, was continent of bowel, incontinent of bladder with one continent episode each shift. Was able to identify the need to toilet, was resistive to cares. The approach was to toilet per facility protocol and as needed to promote continence. However, there was no evidence the facility assessed causal factors related to toileting needs to develop individualized interventions. - On 11/27/18, R3 was seen getting up from the wheelchair and starting to walk. A staff went to assist, R3 pulled away and fell . No injuries were noted, R3 was helped back into the wheelchair and monitored. The IDT documentation, dated 11/28/18, at 9:31 a.m., indicated R3 was receiving physical therapy (PT), had improved mobility, pain was managed medically, and wore a knee brace on right knee. Additionally, R3 could not remember to wait for assistance due to dementia. There was no evidence of root-cause analysis of contributing factors and the documentation did not address specific interventions initiated to reduce the risk for falls other than PT. - On 12/2/18, at 8:12 a.m., a bruise was reported on R3's left hip and buttock down the side of thigh measuring 17 centimeters (cm). The medical doctor (MD) was notified and an X-ray taken. The X-ray results showed non-displaced pelvic fractures. The IDT met on 12/3/18, at 10:00 a.m. to discuss the bruising. The documentation indicated the following: R3 was getting PT, would refuse cares and ice packs; Due to cognitive impairment does not ask for assistance and was resistive; attempts to walk unattended; fracture may have been from fall on 11/27/18. R3 was placed on non-weight bearing on left leg. The record lacked evidence causal factors had been assessed by the facility to develop individualized interventions to reduce the risk for further falls. A progress note dated 12/3/18, at 9:36 p.m., indicated R3 continued to self-transfer and walk from bed to bathroom. R3 was instructed to use the call light for help. The documentation noted at 9:00 p.m. R3 was seen walking from bedroom to dining room with a walker. R3 was re-directed back to bedroom. R3 was offered juice. A progress note dated, 12/18/18, at 3:30 p.m., R3 was found sitting on the floor by the bathroom door. R3 had a skin tear below the left knee but no other sources of injury. The IDT note dated 12/20/18, at 10:51 a.m., indicated R3 had a skin tear to left knee and bruising to buttocks after the fall on 12/18/18. The note indicated the care plan had been reviewed and revised. However the care plan for falls and safety, dated 7/17/18, lacked evidence additional interventions had been added on 12/20/18. A progress note dated 12/29/18, at 8:41 p.m., indicated R3 was seen falling to the floor, but had no complaints of pain. On 12/30/18, at 9:35 p.m. it was noted the housekeeper heard a loud noise from R3's room and found R3 sitting on the floor with pants down. At 11:00 p.m. on 12/30/18, R3 was found on the floor by the bed lying on left hip and trying to get up. R3 explained he had transferred into the wheelchair to use the bathroom. R3 went back to bed after using the bathroom, but fell as he walked around the wheelchair to get into bed. The nurse was bringing in medication and hot tea for a cough and found R3 on the floor. Although R3 had short term memory loss and dementia, the note indicated R3 was encouraged to use the call light and staff would continue to monitor and check on R3 frequently throughout the night. The IDT met on 12/31/18, to review the three falls that occurred between 12/29/18 and 12/30/18. The documentation indicated R3 was unsafe to transfer or ambulate per self, but due to dementia did not remember to ask for assistance. R3 had a healing pelvic fracture from a previous fall and lower extremity [MEDICAL CONDITION] that contributed to an unsteady gait. The IDT decided to implement a low bed and floor mat to minimize attempts of self-transfers. The staff were to increase monitoring of R3 in the great room. The record lacked evidence the IDT had reviewed or discussed interventions related to R3's need to use the bathroom. A progress note, dated, 12/31/18, at 9:20 p.m., indicated R3 was found on bedside mat crawling to the bathroom. The note indicated R3 had been sitting in bed when checked 15 minutes prior. R3 said he lowered himself to the mat. A progress note, dated 1/2/19, at 8:30 p.m., indicated R3 was found crawling from bed to bathroom at 9:30 p.m. on 1/1/19. IDT documentation from 1/2/19, at 2:54 p.m. indicated R3 had fallen on 12/31/18 and 1/2/18. R3 was crawling to the bathroom. R3 was encouraged to use the call light for assistance, but was very forgetful related to dementia. A low bed and floor mat were initiated. A progress note, dated 1/6/19, at 10:15 p.m.,. indicated R3 was found lying on floor off the mat. R3 said he was crawling to the bathroom and fell asleep. Documentation on 1/5/19, at 19:16 p.m. indicated R3 was found on the floor mat sleeping. IDT met on 1/7/19, at 11:00 a.m. to discuss fall on 1/5/19. The documentation indicated, current intervention is low bed with floor mat due to unsafe transfers, which was in place . Will continue current plan of care. The care plan did indicated the addition of a tilt back wheelchair, and attempt to keep in dining room as much as possible on 1/7/19. A progress note, dated 1/8/19, at 5:20 a.m, indicated R3 was found on his knees and hands on the floor at the entrance to the bathroom. On 1/12/19, at 5:57 a.m. R3 was found lying next to the bed, resident had been with a staff prior to last rounds. IDT met on 1/9/19, at 11:00 a.m. to discuss fall on 1/8/19. It was noted R3 had a bruise on left side of back, was on blood thinners, was in low bed with mat but can self-transfer unsafely. Had a pelvis fracture from previous fall, and did not remember to ask for assistance with mobility. No further interventions were mentioned. A progress note, dated 1/14/19, at 2:50 p.m., indicate R3 was found sitting on the floor in the bathroom and said he was trying to use the bathroom. The note indicated R3 appeared sleepy, tired and weak. IDT met on 1/14/19 at 12:00 p.m., to discuss the fall that occurred on 1/12/19. The documentation indicated R3 was found on the floor 20 minutes after a previous check, and had a low bed with mat in place as current intervention due to history of falls. Additionally, the note indicated R3 was impulsive and did not ask for assistance with mobility, required assistance with mobility, current interventions would be continued, and the care plan was reviewed and revised. A quarterly bowel and bladder review was completed on 1/16/19. The document indicated the bowel and bladder management program was effective as evidenced by the goal effective and no skin breakdown. Additionally the document was blank for interventions implemented. The bowel and bladder care plan, reviewed on 1/18/19 had one hand-written update of a change from supervision to assistance with pericare (undated). The goal was for R3 to be clean dry and odor free. The interventions were to assist with pericare, encourage fluids, monitor BM's assist of 1 with toileting, toilet per facility protocol, re-approach calmly. The care plan lacked evidence the facility had developed individualized toileting interventions beyond facility protocol for toileting. R3 was observed on 1/30/19, at 10:30 a.m. R3 was in a tilt back wheelchair with head rest, leg rests and pedals. R3 had a paid personal care attendant present. R3 was talkative and in pleasant mood, but could not be interviewed due to cognitive disabilities. The personal care attendant (PCA) hired by R3's family said he works 4-6 times per week between 9:30 a.m. to 11:30 a.m. The PCA stated R3 was not attempting to get up as before. During interview on 1/29/19, at 11:25 a.m. Licensed Practical Nurse (LPN)-B explained the current interventions for R3 were a low bed with matt, frequent checks and anticipate needs. LPN-B said R3 had not fallen for a while now as R3 did not have strength to self-transfer as before. Additionally, staff tried to keep R3 in sight and put in bed when tired and R3 could be resistive with cares. Nursing Assistant (NA)-C and NA-E were interviewed on 1/29/19, at 11:30 a.m. NA-C said the unit R3 resides on is staffed with 2 NA's for 12 residents. NA-C said she was able to get her work completed and watch over the residents. NA-C said she tries to keep a close eye on R3 and offer to take to the bathroom even thought R3 could also say when he needed to go to the bathroom. NA-C verified R3 could be very resistive to cares and strike out. NA-E said they try to keep R3 in the dining room or where he could be seen. NA-E verified If R3 was left in his room alone, he might try to get up. NA-E thought the night shift also tried to keep R3 in sight in the reclining wheelchair and just do frequent checks when in the bedroom. The unit nurse manger, registered nurse (RN)-B was interviewed on 12/29/19, at approximately 1:00 p.m. RN-B explained, R3 was walking independently initially and was trying to get up from the bed. R3 declined in mobility and would stand up but was not safe to walk independently. The IDT which included the physical therapist decided a low bed and mat would be a safer option for R3 than risking a fall from a standing position. RN-B said R3 was not safe independently transferring from the bed to a wheelchair. RN-B verified R3 did not know to ask for assistance due to cognitive decline and was not progressing in therapies. When asked about investigation additional interventions for R3 related to toileting or being resistive and impulsive. RN-B said she felt there were not many options for interventions. Concerning interventions related to R3's need for help with toileting, RN-B verified R3 was on a diuretic (a medicine to remove excess fluid from the body) that could cause an increased need for toileting. Additionally, R3 was resistive to help and would attempt to go by himself right after staff offered help. RN-B said staff were to check on the need to go to the toilet per normal protocol. RN-B explained the usual protocol was before and after meals and as needed. During the night shift, the protocol was to check every 2 hours. RN-B said staff were to do frequent checks but did not give a specific time line for the frequency. RN-B verified R3 was a very active and independent person, but currently was not attempting to walk. DON was interviewed on 1/30/19. at 1:36 p.m. and stated if a resident was restless or awake, the staff would bring them to a common area and offer food and fluids and keep an eye on them until they wanted to go back to bed. The DON said one to one interventions would be documented. Additionally, DON explained, before the fracture, R3 would go to his room independently and would get up shortly after staff had left the room. The DON verified a more thorough review of R3's falls needed to develop more specific interventions. The policy, Fall Risk Assessment (FSA), revised 7/2016, indicated each resident was to receive adequate supervision and assistance devices to prevent accidents. Additionally, it was important for facility staff to ensure the safest environment possible for residents. The policy, Comprehensive and Baseline Care Planning, revised November, (YEAR), indicated a comprehensive care plan would be developed within 7 days of the completion of the comprehensive person-centered assessment and reviewed throughout the resident's length of stay. The interdisciplinary team prepared the comprehensive individualized person-centered care plan.

Based on observation, interview, and document review, the facility failed to ensure that each resident was provided with the necessary adaptive eating equipment, to maintain safety and prevent avoidable accidents, in 1 of 3 residents reviewed (R1), who sustained a second-degree burn when staff gave the resident hot coffee in a regular styrofoam cup, instead of a sippy cup with a lid. Findings include: R1's care plan, dated 02/15/13, established that R1 has left-sided weakness as the result of a stroke. R1's left hand is contracted and s/he does not have functional use of the left arm. R1 is totally dependent on staff for care but is able to eat independently with the aid of adaptive equipment. R1 drinks all fluids from a sippy cup with a lid. This information was consistent with the investigator's observations conducted on 05/20/13 at 7:20 a.m. and 8:10 a.m. in the Cedar Bay Memory Care dining room, where R1 was observed drinking fluids independently from a sippy cup with a lid. An Incident Report, dated 04/26/13 at 4:00 p.m., indicated that RN/(D) gave R1 a cup of coffee and when R1 reached for the coffee, it spilled on R1's left arm and lap. R1 sustained a second-degree burn to the left lower arm measuring 17cm x 7 cm. The area of burn also contained two small blisters (size not documented). In addition, R1 sustained three sites of redness on the left upper thigh measuring 11cm x 3cm, 5cm x 1cm, and 10 cm x 2 cm, and three sites of redness on the lower abdomen measuring 6cm x 4cm, 5cm x 3cm, and 5cm x 2cm.The progress notes, dated 04/29/13 at 9:22 a.m., indicated that Nurse Practitioner (NP)/(K) ordered application of Silvadene cream to R1's left arm wound twice daily with a nonstick dressing wrapped in kerlix. This treatment protocol was initiated on 04/29/13. RN/(D) was interviewed on 05/23/13 at 10:25 a.m. RN/(D) stated that R1 has used adaptive eating equipment for approximately two years. R1 consumes all fluids from a sippy cup with a lid, due to his/her physical limitations. R1 likes to have coffee in the afternoon. On the day of the incident, RN/(D) was in the dining room with several residents, including R1, who requested a cup of coffee. RN/(D) poured hot coffee in a styrofoam cup that did not have a lid and placed it in front of R1. When R1 reached for the coffee cup, s/he knocked it over and it spilled on his/her arm and lap. RN/(D) was several feet away from R1 and saw the incident occurring but could not stop it. RN/(D) stated she gave R1 coffee in a styrofoam cup because there were no extra sippy cups in the unit cupboard. R1 had large areas of redness on his/her lap, leg, and left forearm. The left forearm also had "two or three blisters." R1 complained of discomfort in the areas of redness on his/her leg and lap area, but R1 had no complaints of discomfort in the reddened area on his/her left arm. RN/(D) applied ice to all the reddened areas and placed a nonstick dressing on the area of blistering. Afterward, RN/(D) left a voice-mail message for the Nurse Practitioner (NP) about R1's injuries.Dietary Technician/(C) was interviewed on 05/20/13 at 9:10 a.m. S/he explained that dietary staff are responsible for setting the resident tables prior to the meal. Dietary staff utilize a seating map for each dining room, which designates all adaptive equipment required for each individual. The adaptive equipment is set up at each resident's place setting before the meal is served. When the steam table arrives in the dining room, each resident has a computer-generated meal ticket that identifies the type of diet to be served and any speical equipment the resident utilizes during the meal. Extra sippy cups are avialble in dining room cupboards on the units, if needed throughout the day. In the event that the unit supply of sippy cups is depleted, more sippy cups are available in the main kitchen. Observations in the Cedar Bay Memory Care dining room on 05/20/13 at 7:20 a.m. revealed that staff had already prepared place settings at tables for ten residents. One of ten place settings contained a sippy cup (R1's). LPN/(E) and Nursing Assistants (G and H) stated that the dietary department sets the tables and places any adaptive eating equipment needed by the residents. RN/(J)/Nurse Manager was interviewed on 05/30/13 at 11:05 a.m. S/he stated that all staff are to adhere to each resident's plan of care. If no sippy cups were available in the unit cupboard on the afternoon of 04/26/13, RN/(D) should have gone to the main kitchen and obtained one, prior to serving R1 coffee. It was not acceptable for RN/(D) or anyone to provide fluids to R1 in the wrong receptacle.