Every finding on record at Lake Winona Manor

Based on observation, interview, and record review the facility failed to reassess the resident's elopement risk and revise the comprehensive person-centered care plan to reflect interventions following an elopement episode for 1 of 1 residents reviewed for elopement risk. Findings include:R1's significant change Minimum Data Set (MDS) dated [DATE] indicated R1 had Brief Inventory of Mental Status (BIMS) score of 3 indicating severe cognitive impairment. R1 had wandered and assessed that her wandering placed her at significant risk of getting to potentially dangerous places (stairs, outside the facility). R1's pertinent diagnoses were heart failure and non-Alzheimer's dementia.R1's target behaviors assessment dated [DATE] indicated R1 had behaviors observed. She had been hitting, pinching, running her wheelchair into staff and trying to leave the building multiples times through the elevator when staff walked away, she got into the elevator and was going up and down over and over in the elevator before the nurse had to intervein. R1's potential indicators of psychosis included hallucinations (perceptual experiences in the absence of real external sensory stimulation). R1 had no verbal behavioral symptoms, no rejection of evaluation of care. The interventions attempted were R1 was redirected, offered snacks, showed her to her room, and told the resident she was sleeping at the facility that night.R1's event report dated 7/21/26 indicated R1 eloped at 8:00 p.m. on 7/21/26. R1 was found quickly with no injuries she was found in someone's vehicle in the parking lot. R1 had successful and unsuccessful elopements in the past. She had been packing belongings, repeatedly opening doors/setting off alarms of secured doors, resisting redirection from staff, verbalizing statements about leaving and wandering with no intentional purpose or attempting to open doors. There were no changes with her mental status. Possible contributing factors were anxiety disorder and dementia. R1 had no new recent events of trauma, new diagnoses, or other stressors. She had recently started Seroquel (medication to decrease agitation) 12.5 milligram (mg) in the a.m. and 50 mg in the p.m. R1's interventions in place were a chair seat pad alarm, a door alarm band, and a motion detector. R1's event report lacked any documentation under the titles of:describe any measures takenoutcomes of interventionsnotification guidelinesvital signsordersA facilities list of R1's most recent observation assessments dated 5/27/26 - 7/29/26 did not indicate that an assessment was completed after R1's elopement episode on 7/21/26.R1's care plan dated 9/23/21 with a last reviewed date of 6/3/26 indicated R1 was identified as a wander related to dementia manifested by long periods of being lost with directions. Her goal was to have no elopement episodes in the next quarter. Her intervention approaches were:Due to historical events including elopement, smoking, and leaving the facility with significant other R1 was not to leave the facility with anyone but Guardian or facility staff 8/11/22.Wander guard on left wrist. Check placement every shift, and function once daily 6/19/23.Half hour visual checks 6/1/25.Offer ear plugs if she was upset regarding noise 8/24/25.Motion alarm, in place above her door to alarm when entering or exiting her room [ROOM NUMBER]/10/25.No new care plan interventions were added following her elopement episode on 7/21/26.Upon observation and interview on 7/29/26 at 10:15 a.m. R1 was seated in her room on her bed, she was not yet dressed. She had a WanderGuard bracelet on her left wrist. She stated the bracelet was an old time watch. She did not recall leaving the facility and getting into a car. She stated she was renting a room at the facility until her home was remodeled and then would be leaving. She had a door alarm in place over her door which did sound when she was wheeled out of her room by staff.Upon interview on 7/29/26 at 2:09 p.m. registered nurse (RN)-A, the nurse manager stated R1 had been an elopement risk for years and the facility had kept her safe. She reviewed R1's event documentation and agreed it was not complete however the information could be found in her progress notes or on her care plan. R1 already had multiple interventions in place that had kept her safe on her care plan. (RN)-A was not certain if a new assessment was completed or the care plan had been updated following this incident. She stated assessment information was noted on the event report indicating R1 had no injuries. (RN)-A reviewed R1's records and did not produce a completed assessment after the incident or an updated care plan.Upon interview on 7/29/26 at 2:42 p.m. the Assistant Administrator stated that there would not be a need to update her care plan because R1 was not injured during the elopement.Upon interview on 7/29/26 at 2:55 p.m. the Administrator stated since R1 had not gotten off the campus property that it was not a true elopement and she was not harmed therefore an updated care plan was not warranted.A policy regarding care planning was requested, however none was provided.

Based on interview and record review, the facility failed to maintain and clearly define a full-time director of nursing (DON). This practice had the potential to affect all 66 residents who resided at the facility.Findings include:The facility Change of Director of Nursing form dated 5/1/26, indicated the administrator, who was also an RN, was the previous DON and designated RN-B as the new interim DON.The interim DONs time card dated Friday, 7/10/26 to Sunday, 7/19/26, indicated the interim DON worked eight hours on Monday, Wednesday, and Thursday for a total of 24 hours in one week.During an interview on 7/17/26 at 1:59 p.m., registered nurse (RN)-A stated the administrator was not present at the facility this week, and the interim DON worked part-time. RN-A stated she was the nurse manager and was not filling in as an interim DON.During an interview on 7/17/26 at 4:18 p.m., the assistant administrator stated the interim DON was on a leave of absence and started to work part-time on 7/13/26 on Mondays, Wednesdays, and Thursdays. The assistant administrator stated RN-A was present in the facility and available for clinical questions.During email correspondence on 7/20/26, the assistant administrator indicated the interim DON's leave started on 5/18/26. The assistant administrator indicated the full-time DON role was covered by the full-time nurse manager, part-time interim DON, herself as a full-time LNHA (licensed nursing home administrator) assistant administrator, and the full-time RN/LNHA administrator.During an interview on 7/17/26 at 4:23 p.m., the administrator acknowledged the interim DON worked a few days a week.The facility did not provide education or documentation for RN-A to cover the interim DON role.The Facility Assessment Tool dated 6/19/26, identified a Staffing Plan which included a Total Number Needed or Average or Range of staff positions. The section Administrator/Assistant and Administrator/Marketing, identified one administrator, one interim DON, 1 assistant administrator, and one clinical administrative assistant. The section Other nursing personnel (e.g., those with administrative duties), identified one nurse manager.The facility Role Summary for Title: Nurse Manager dated 10/20/23, identified the nurse manager oversaw staff on all shifts and made recommendations and lent support to the Director.The facility Role Summary for Title: Director of Nursing dated 4/2026, identified Required Work Schedule: Typically works standard business hours. Monday through Friday 8 a.m. - 4:30 p.m. Must be flexible for occasional meetings outside of standard business hours. The role summary indicated the DON supervised the nurse manager.The facility Role Summary for Title: Administrator of Senior dated 10/21/19, indicated the role was the designated administrator of the facility and worked collaboratively with the DON.

Based on observation, interview, and record review, the facility failed to provide assistance and/or cueing with activities of daily living (ADLs), such as eating, for 2 of 2 residents (R3, R4) observed at a designated table for residents who need staff assistance with meals.Findings include:R3's significant change in status Minimum Data Set (MDS) dated [DATE], identified R3 had severe cognitive impairment, delusions, no behaviors or rejection of care. R3 was dependent on staff assistance for eating and diagnoses included non-Alzheimer's dementia and anxiety.R3's activities of daily living care plan dated 7/2/26, identified R3 had a self-care deficit and decreased ADL participation. A care plan intervention dated 9/30/25, directed staff to supervise and encourage R3 to take bites and drink. R3's dementia care plan dated 7/2/26, identified an intervention dated 10/1/25 to provide R3 with cues and supervision to eat and drink. R3's nutritional care plan dated 7/2/26, indicated R3 was a high nutritional risk related to dementia with risk for chewing/swallowing difficulties and poor oral intake. The care plan directed staff to assist R3 during mealtimes.R4's Face Sheet dated 7/17/26, indicated R4 admitted [DATE] with diagnoses which included dementia with other behavioral disturbance, lactose intolerance, major depressive disorder, anxiety disorder, prediabetes, chronic kidney disease, and low back pain.R4's ADL care plan dated 7/15/26, indicated R4 had a self-care deficit and decreased ADL participation. A care plan intervention dated 7/15/26, directed staff to cut up R4's food, supervise R4 in the dining room at meals, and cue and give spoon to R4 as needed.During observation on 7/16/26 from 12:43 p.m. to 1:10 p.m., R3 and R4 sat in their wheelchairs at a table with their lunch in front of them and were not eating. Two kitchen staff were present in the room, and trained medication assistant (TMA)-A was intermittently present at the medication cart stationed right outside the dining room. At 12:45 p.m., nursing assistant (NA)-A and another unidentified male staff entered the dining room, looked around, and left. At 12:48 p.m., R3 picked up her chicken on a bone and started to eat. R4 continued to stare and not eat. NA-A and NA-C interacted with residents at the table in conversation and did not provide meal assistance for R3 or R4. R4 had two uncut chicken legs and a serving of potatoes on her plate which appeared to have no bites taken. NA-B entered the dining room, spoke to a resident at a different table, removed the resident's tray, provided a drink, and walked out of dining room. At 12:55 p.m., R3 spilled her water which went across the table and dripped off the table near R4's shoes. Surveyor notified NA-B, and NA-B picked up water and wheeled R3 out of dining room at 12:56 p.m. R3 had eaten her dessert, one of two chicken legs, and drank one glass. At 12:59 p.m., NA-A walked by the dining room and looked in and left. NA-B brought a resident into the dining room and left. At 1:09 p.m., R4 stood up from her wheelchair and NA-B entered the dining room to assist R4 to sit back into wheelchair. At 1:10 p.m., unidentified female staff came and removed R4 from dining area. One out of two cups of R4's liquid was empty, and R4's two chicken legs and potatoes appeared untouched. R4 had eaten approximately 25 percent of small soup bowl.During interview on 7/16/26 at 1:28 p.m., NA-A stated he knew what residents required supervision or assistance with eating based on the care plan and the nurse. NA-A stated R3 was a new resident and was unsure what kind of assistance she needed. NA-A stated he would check if resident's mouth hurt, if confused, or if hands not working well if he noticed a resident was not eating.During interview on 7/16/26 at 2:56 p.m., NA-B stated R3 and R4 sat at a table designated for residents who required assistance to eat. NA-B stated R4 did not see well and assisted R4 if she needed help and was not eating by herself. NA-B stated lunch was crazy today and indicated the facility lacked staff to assist at lunch.During follow-up interview on 7/17/26 at 11:24 a.m., NA-B stated residents' care plans were printed out and available for staff to view in a binder. The care plan printed 5/25/26, indicated R3 needed supervision and cues to eat dated 10/1/25. NA-B stated supervision meant staff were supposed to be in the dining room and could sit down at the table if staff had time. The TMA was usually near the dining room. NA-B stated R3 needed more assistance with eating compared to before. R4's care plan indicated R4 needed supervision and cues to eat and her food cut up. NA-B acknowledged R4's chicken legs were not cut up on 7/16/26, and the dietary aides were supposed to cut up resident food.During interview on 7/17/26 at 11:09 a.m., NA-C verified no staff sat at the lunch table on 7/16/26 to assist R3 and R4 with eating assistance. NA-C stated she assisted residents at the designated table if the residents were not eating. NA-C stated R4 needed encouragement rather than assistance to eat, and R3 could not see well so staff usually handed food to R3.During interview on 7/17/26 at 12:16 p.m., licensed practical nurse (LPN)-A stated residents' care plans were viewable in a binder or online. LPN-A stated staff were supposed to sit with R3 during meals and hand her food. LPN-A stated R4 sat at the table who required assistance with meals and expected staff to sit near R4 to see what assistance R4 needed.During interview on 7/17/26 at 12:45 p.m., dietary aide (DA)-A stated she followed color code sheets to serve food to residents. The sheets listed residents' diets and any special dietary related requirements. DA-A stated kitchen staff and nurses were supposed to sign the color code sheet, but nursing often did not initial. DA-A reviewed instructions for R4, and the color code sheet did not indicate to cut up R4's food.During interview on 7/17/26 at 1:59 p.m., registered nurse (RN)-A, who was also the nurse manager, expected staff to sit by R3 throughout meals and assist as needed. RN-A stated R3 had dementia and a slow decline with ADLs. RN-A stated R4 was a new resident and gathered information from R4's family member about what kind of assistance R4 needed with meals. RN-A acknowledged the care plan directed staff to cut up R4's food. RN-A stated supervision meant to watch R4 to see if R4 fed herself. RN-A stated R3 and R4 sat at the meal table for residents who required staff assistance. RN-A expected the care plan book to have current care plans, and staff viewed current care plans through their online medical record system. RN-A stated the table should be served when a staff member was available to sit at the table and assist the residents.During interview on 7/17/26 at 4:23 p.m., the administrator, who was also an RN, expected staff to follow the care plan for eating assistance. The administrator stated residents who sat at the table designated for meal assistance meant staff were to provide hand over hand assistance, supervision, and actively feed residents or keep residents eating.The facility Feeding procedure dated 9/20/18, directed staff to review resident specific diet directives on the dietary sheets, and the staff who served a resident, who needed more help than serving the tray, was responsible to sit with the resident.

Based on observation, interview, and document review, the facility failed to ensure a self-administration of medication assessment (SAM) was completed for 1 of 1 resident (R8) reviewed for self-administration of medication.Findings include:R8's Quarterly Minimum Dat Set (MDS) assessment, dated 2/10/26 indicated R8 was cognitively intact. Further, R8 was independent with eating and basic personal hygiene and dependent on facility staff for mobility and transfers.R8's record lacked an assessment to self-administer medications.During observation and interview on 3/2/26 at 7:01 p.m., a Voltaren Gel (pain relief) tube was observed sitting in a basket on R8's tray table. R8 stated he used the Voltaren Gel on both his knees when he had pain. R8 stated he would use the gel throughout the day and is unsure how many times per day.R8 lacked an order for Voltaren Gel. During observation and interview on 3/4/26 at 8:54 a.m., licensed practical nurse (LPN)-A was observed administering R8's morning medications. The Voltaren Gel remained in the basket on R8's tray table. R8 again stated, he uses the Voltaren Gel on his knees when they are causing him pain. LPN-A completed R8's medication administration and left the room.During an interview on 3/4/26 at 9:01 a.m., LPN-A stated she was unsure if R8 had an order for the Voltaren Gel and if he had been assessed to administer the medication himself. Upon review, LPN-A confirmed R8 had neither an order to use the Voltaren Gel nor an assessment to be able to self-administer the medication. LPN-A stated it is important to have an order for the Voltaren Gel, so the provider team knows all the medications R8 was taking. LPN-A indicated it is important R8 have an assessment to administer his own medication to make sure he is capable to administer the medication and that he can administer the medication as directed by the order.During an interview on 3/4/26 at 11:15 a.m., nurse manager (NM)-A stated medications such as Voltaren Gel should have a provider order. Further, if the resident would like to administer the medication themself, they would need to be assessed to make sure they can administer the medication as directed by the medication order. NM-A stated if a nurse found a medication in a room, she would expect the nurse to follow up to make sure there was an order for the medication, and the resident had been assessed to have the medication in his room. NM-A stated it is important to have an order for all medications and residents are assessed to give the medication, this will ensure the providers are aware of all the medications a resident is taking, and to make sure the resident can safely administer the medication as ordered.During an interview on 3/4/26 at 2:19 p.m., the administrator/director of nursing stated all medications, even pain gels such as Voltaren Gel, need to have a prescriber order to administer. Further, if a resident would like to administer the medication, they would need to be appropriately assessed to ensure the resident can administer the medication as prescribed. The administrator/director of nursing stated if staff found medication in a resident room, she would expect them to verify the medication was ordered and remove the medication if it was not. Additionally, if the medication was ordered she would expect staff to verify if the appropriate self-administration assessment had been completed, removing the medication if it had not.During observation on 3/5/26 at 11:52 a.m., the Voltaren Gel remained sitting in a basket on R8's tray table. Additionally, an order for the Voltaren Gel had not been completed, and assessment for self-administration had not been completed.A facility policy titled Medication Administration dated 12/24, a resident may not be permitted to administer or retain any medication in his/her room unless it is so ordered by the provider and appropriate assessment is completed.

Based on observation, interview, and record review, the facility failed to ensure facility survey results were posted in an accessible location for residents, staff and visitors. This had the potential to affect all 64 residents residing in the facility as well as staff and visitors.Findings include: On 3/3/26, at 11:45 a.m. a review of the survey results binder located near the elevator was completed. Although the previous recertification survey of 12/5/24 was found within the survey binder, the Life Safety Code (LSC) 2567, completed 12/4/25, was not located in the binder.During interview on 3/3/26, at 1:12 p.m. the administrator stated she was unaware the LSC 2567 survey results were not in the survey binder. Administrator stated it was important for the survey results to be available for review by residents, staff and visitors for so they may be aware of the previous survey results.A request was made for the facility policy for posting of survey results, however, a policy was unavailable.

Based on observation, interview, and record review, the facility failed to ensure the most up to date Nursing Home Resident [NAME] of Rights (RBOR) was provided to each resident residing in the facility and displayed for residents, visitors and staff to review. This had the potential to affect all 64 residents currently residing in the facility as well as all staff and visitors.Findings include: During observation on 3/3/26, at 11:45 a.m. the Resident [NAME] of Rights poster, dated 1/2019, was observed near the entrance to the building. A second Combined [NAME] of Rights poster, dated 1/2016, was posted next to the elevator going to the second floor.During interview 3/4/26, at 3:29 p.m., administrator stated she was unaware of the newly released Resident [NAME] of Rights poster, effective 1/1/26, which was to replace any previous posters.The facility policy, effective 8/1/21, titled Resident Rights, was reviewed, and identified residents had the right to be informed by the facility of rights granted within the [NAME] of Rights, which was to also include the recourse residents had if rights were violated. The policy identified the [NAME] of Rights were to be posted in a conspicuous location within the facility.

Based on observation, interview and record review, the facility failed to follow the turning and repositioning care plan requiring assist of two staff for 1 of 3 residents (R1) which resulted in actual harm when R1 fell off the bed sustaining a right tibia and fibula fracture, and a distal end of left femur fracture. The facility had put corrective measures in place on 11/13/25, prior to the start of the survey, therefore, was issued at past non-compliance Findings include: R1's face sheet dated 12/17/25, identified diagnoses of multiple sclerosis (disease that causes numbness, weakness, trouble walking, vision issues, etc.), fracture of upper end of right tibia (fracture just below the knee), fracture of lower end of left femur (lower part of thigh bone), and anxiety. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 was able to understand and make self-understood to others, had no cognitive deficits, no behaviors, impairments on both sides of upper and lower extremities, dependent on staff for all activities of daily living (ADL), had a urinary catheter, was incontinent of bowels, and had almost constant mild pain. R1's care plan dated 11/16/22, included interventions informed staff R1 required assist of two with mobility and repositioning. The care plan also directed staff to ensure a pillow is under each leg lengthwise to relieve pressure on heels; use a gentle touch to reposition; prefers to roll on right side; Cross left foot over right to assist and use soaker pad to roll from side to side versus pushing on hips and arms. For toileting, R1 required full assistance, prefer not to use the toilet and alert staff when brief needs changed. The facility reported Nursing Home Incident Report (NHIR) dated 11/13/25, indicated on 11/12/25 at 9:00 p.m., nursing assistant (NA)-A was providing cares to R1 in her room. NA-A rolled R1 onto her side when R1's leg slid over the edge and NA-A repositioned R1's leg. R1's leg started to slip again and due to weight and immobility from multiple sclerosis, R1 slid and rolled out of bed. NA-A caught R1 and attempted to slow down R1's upper portion of body and lay down on the floor protecting R1's head. R1's care plan identified bed mobility and repositioning required assist of two people. R1's care plan on 11/12/25 was revised to include R1 should be a two assist for all peri cares as well as with any turning or positioning that goes along with it due to progression of multiple sclerosis and difficulty supporting herself using the side rail. R1's progress note dated 11/13/25, identified R1 returned to facility around 12:30 a.m., after emergency department visit. Right tibia/fibula fracture and right lower extremity is in a soft cast/ace wrapped. The progress note and/or record did not include details for which R1 was transferred to the hospital. R1's Emergency Department/Urgent Care-Provider note dated 11/13/25, indicated R1 presented to the ED following a fall. X-rays revealed R1 had a right nondisplaced fracture of the proximal tibia and also impacted fracture of the right fibular neck. A splint was placed from proximal thigh down to the foot overlaid with ace wraps. R1 was transferred back to the facility. R1's care plan interventions dated 11/13/25 included assess affected area every shift for skin temperature, peripheral pulses, edema, circulation, motion, sensation. Maintain body in functional alignment and prescribed position: no bending or range of motion/stretches. Monitor color, warmth, movement, sensation, pain, and interventions utilized, ensure soft cast is always in place aside from cleansing of the leg. R1's progress note dated 11/15/25 at 3:30 p.m., identified R1 offered complaints of left leg/knee pain. NA that worked with R1 also indicated during repositioning/cares, the left knee area appeared to become more disfigured and was extremely painful. The area appeared to be edematous just above the knee. R1 was transferred to emergency department. R1's Emergency Department note dated 11/15/25, identified R1 returned to the emergency department for increased left leg pain after fall in the last week that broke right leg. Diagnosis of fracture of distal end of left femur. R1's progress note dated 11/15/25 at 9:33 p.m., identified R1 returned from emergency department with a left distal femur fracture and immobilizer on left leg. R1's Event Report dated 11/18/25, identified R1 fell on [DATE] at 9:30 p.m., R1 was lying in bed on left side facing door while NA-A performed personal cares on the opposite side of the bed. R1's bilateral lower extremities slipped from the bed on the opposite side of NA-A. NA-A reached across the bed and pulled R1's bilateral lower extremities back on the bed. R1's bilateral lower extremities slipped again, and NA-A was unable to pull them back onto the bed. NA-A reached across the bed and held onto R1's torso and slowly lowered R1's upper body to the floor to prevent R1 from hitting head. R1 was laying on her back on the floor at the side of the bed with bilateral lower extremities towards the head of the bed and head and upper body at the foot of the bed. R1 had abnormal alignment and extreme pain with touch to right lower extremity. Immediate intervention was for R1 to be two assist for all peri cares as well as with any turning or positioning that goes along with it due to progression of multiple sclerosis and difficulty supporting herself using the side rail. R1's physician visit note dated 11/20/25, identified R1 was seen following a fall that resulted in a right leg fracture confirmed by emergency department imaging. Continued pain led to a second emergency visit two day later, where a left femur fracture was identified, resulting in bilateral leg fractures. R1's orthopedic visit note dated 12/3/25, identified left distal femur fracture and right distal tibia fracture from 11/12/25. R1 is non-weight bearing on left and right lower extremities. R1's care plan dated 12/8/25 included the intervention that informed and directed staff for proper positioning of lower legs the goal is to keep lower legs straight, use a pillow under both legs allowing the ankle and foot to dangle off to prevent pressure. Measure that it is off load with air space, use rolled up blankets/towels as shown in pictures in room and plan of care to keep legs, ankle, and feet straight. R1's physician visit note dated 12/10/25, identified R1 fell out of bed on 11/12/25, while getting ready for bed. R1 experienced an impacted left fibular neck fracture along with a nondisplaced transverse fracture of the proximal tibular metaphysis. Also, transverse fracture involving the proximal right tibia and slightly impacted fracture involving the proximal neck of the right fibula. About three days after the fall, R1 continued pain and swelling, further x-rays revealed a distal spiral fracture of the left femur. Currently has a cast placed on the right lower extremity below the knee to the foot and a soft leg immobilizer/splint on the left lower extremity from mid-thigh to ankle. R1 makes little if not any movements apart from turning head to look, generally unable to move body. During an observation and interview on 12/17/25 at 2:16 p.m., R1 was lying in bed. R1 explained when she fell out of bed on 11/12/25, the bed was in the highest position six feet off the ground; the kid did not wait for help and did not have [me] in the middle of the bed and just went ahead and rolled me. When she fell, she ended up with her head where her feet should be and feet where her head would be on the floor. Two different bones were broken on her right leg and the main bone on the left side was broken too. R1 stated prior to the fall she had no control of leg movements, and the second staff person was to make sure her legs were going where they were supposed to go. During a phone interview on 12/17/25 at 3:41 p.m., NA-A stated on 11/12/25, he had not worked with R1 much but was doing nightly routine cares with R1 that required her to roll to one side. NA-A rolled R1 to her side and noticed R1's legs started to slip off the bed. NA-A put R1's legs back onto the bed to a position where he thought they would not slip again, and then they slipped again. They slipped so fast and NA-A threw himself over the bed to keep R1 from hitting the ground hard. NA-A did not have enough strength to hold her up so he held onto R1's upper body so her head would not hit the ground. NA-A stated he was basically on the bed at that point and R1's legs went down first and everything else after that. R1 hit her legs on the floor but NA-A did not see if the legs were bent, mainly focused on not having her head hit the ground. NA-A stated R1 had feeling in her legs but was unable to move them, they were just dead weight and R1 did not have abdominal control. NA-A stated R1 was one assist with turning prior to the fall, and after the fall R1's care plan was updated to two assist. During an interview on 12/18/25 at 10:27 a.m., registered nurse manager (RNM)-A stated at the time of the fall, R1's care plan identified R1 was assist of one with toileting, and assist of two with turning, repositioning, and bed mobility. With care plan changes, RNM-A updates the nurses and nursing assistants through written communication in the care plan books, computer, and through verbal report. During an interview on 12/17/25 at 2:10 p.m., NA-B stated R1 did not have any trunk control. If R1 lost control, there would be no way to stop her from falling when she was rolled in bed. NA-B would not turn R1 without a second person present prior to the fall or after the fall. The second person braces R1, R1 has no motor control, only able to move head and hands. During an interview on 12/17/25 at 2:54 p.m., NA-C stated R1 did not use her hands or arms, only to press the call light. NA-C had been surprised when she heard R1 had fallen from bed with only one person assisting because she was always supposed to have two people. During an interview on 12/18/25 at 1:28 p.m., Administrator stated after review of the record it looked confusing with R1 on how many people would be required. Administrator stated with R1's size she could not anticipate anyone to turn R1 alone, and it would not be good body mechanics. The lifting policy states that if a person was going to exert more than 30 pounds, they were to get another person's assistance or use a lift. The deficient practice was issued at Past Non-compliance (PNC) after the following corrective actions were implemented on 11/13/25, and verified the facility took the following actions, prior to the start of the survey. -R1's care plan was revised and clarified on 11/12/25 to include R1 was assist of two staff for turning, repositioning, and toileting cares. -Staff were provided with education on 11/13/25 with the modifications to R1's care plan and NA-A was provided with education prior to returning to work. The facility Care Plans and Care Conference policy revised 9/2024, identified the comprehensive care plan will be updated to reflect any changes/updates since admission.

Based on interview, observation, and document review the facility failed to ensure proper food safety practices when food service workers (FSW-A and FSW-B) were observed not having hair secured, not properly disinfecting food thermometer, not recognizing need to reheat food when needed, and touching food with contaminated gloves. This practice had the potential to affect all 65 residents who received meals from 2 of 2 dining rooms observed. Findings include: During an observation and interview on 12/2/24 at 5:04 p.m., in the second-floor dining room, observed FSW-A standing behind the steam table preparing to plate food for the evening meal. FSW-A's hair which was long and curly, had not been fully secured in his hairnet -- all hair below the level of his ears was outside of the hairnet. FSW-A was asked not to proceed and to secure his hair. FSW-A stated he would try and left the dining room. FSW-A returned a few minutes later and his hair was still not fully secure. He tucked the rest of his hair into the hairnet, washed his hands and donned gloves. During an observation on 12/2/24 5:10 p.m., FSW-A touched his face with gloved hand, and opened the door to the thermal plate base warmer to remove more thermal bases. At 5:15 p.m., FSW-A handled French fries and chicken tenders with his contaminated gloved hands as he plated food for residents. FSW-A then handled multiple resident meal slips, opened, and closed equipment doors, and pushed up his eye glasses. At no time did FSW-A remove his gloves, wash his hands and re-glove. FSW-A stated he had been doing this job for over a year. At 5:20 p.m., FSW-A was observed cutting chicken tenders with a knife while holding the chicken with his contaminated gloved hand. FSW-A continued to handle meal slips, a pen, and rested both hands on the counter of steam table. At 5:28 p.m., FSW-A was again cutting chicken tenders while holding the chicken with his contaminated gloved hand. During this observation, he also latched a thermal cart, wrote on paper with a pen, and handled the food thermometer. At no time did FSW-A remove his gloves, wash his hands and re-glove. FSW-A was observed setting a food thermometer with the probe open and with visible food debris, on top of the steam table ledge. At 5:33 p.m., FSW-A wiped the thermometer probe with a paper towel and handed it to FSW-C who temped fruit with it. During an interview on 12/2/24 at 5:36 p.m., director of environment & risk management (DERM)-B with oversight over food and nutrition services, was in the dining room and was informed of observations. DERM-B stated food service workers were expected to have their hair fully covered in a hairnet when serving food. Further, DERM-B stated FSW were trained to wear gloves during meal services and were expected to remove gloves, wash hands and re-glove as they moved between tasks and before handling food. In addition, DERM-B stated staff were to place the probe of the food thermometer in a solution of food-safe QUAT (quaternary ammonium - a chemical sanitizer) to disinfect it between temping food. . During an observation on 12/3/24 at 11:46 a.m., in the second-floor dining room, FSW-B stated he had been in his role for a week. FSW-B was standing behind the steam table waiting to plate food for residents and was observed wearing gloves. While waiting, FSW-B was observed talking on the phone, opening and closing the refrigerator, cupboard and cart doors, handling resident meal slips, putting on and taking off his eye glasses that were strapped around his neck, bending over and putting his gloved hands on his knees while looking at meal slips on the lower shelf of a cart. At 11:51 a.m., FSW-B temped pureed shrimp on the steam table and verbalized the temperature was 114 degrees F (Fahrenheit). When FSW-B did not take action, he was asked if that temperature was warm enough and he replied, yes. An unidentified dietary worker standing nearby said, no and she re-temped it, obtaining 116 degrees. The pureed shrimp was taken back to the kitchen. FSW-B stated the shrimp should have been 140 degrees or greater. At 11:55 a.m., a coworker whispered to FSW-B to put on new gloves, which he did, but did not wash his hands first. Again, FSW-B put on and took off his eye glasses multiple times, plated food, handled utensils, and filled cups with water from a dispenser. At 11:58 a.m., FSW-B removed and put on new gloves without washing his hands. At 12:03 p.m., FSW-B continued to plate food and continued to put on and take off his eye glasses, bend over and place hands on knees, and open and close the warmer. During an interview on 12/3/24 at 12:17 p.m., food & nutrition manager (FNM)-C who was in the dining room, stated new food service workers were trained for six shifts before they were on their own. It was the expectation workers wore gloves during meal services and to change gloves and wash hands before handling food directly. FNM-C also observed FSW-B touch face and eye glasses, then touch edges of a grilled cheese sandwich several times. FNM-C did not intervene. 51578 During interview and observation on 12/03/2024 at 11:30 a.m., food service worker (FSW)-D did not follow proper procedure when sanitizing the dietary thermometer in between temping foods for the residents in the main dining room on the first floor of the facility. FSW-D was observed not to use a alcohol wipe on the thermometer when cleaning it in between checking food temps. FSW-D was observed using a sanitizer bucket full of QUAT (quaternary ammonium - a chemical sanitizer). This sanitizer is food safe, however the thermometer was not wiped with alcohol after the use of the quat sanitizer. During observation on 12/04/2024 at 12:26 p.m., on the second floor dining room FSW-B was checking temps of food that would later be returned to the kitchen and possibly used for other meals. FSW-B was observed taking the thermometer out of a sanitizer bucket and then took the thermometer and rubbed the thermometer on the bottom of pants to help dry off the thermometer and then temped the gravy behind the steamer. During interview on 12/4/2024 at 12:32 p.m., FSW-B was asked about the process for temping foods and the steps for cleaning the thermometer to temp the food prior to returning it back to the kitchen for later use. FSW-B stated when they are done with the lunch meal they verify which foods will be returning to the kitchen or maybe kept for further use. FSW-B explained the process for temping the foods and the use of the thermometer in the following steps 1) clean the sanitizer in either a red bucket that is next to the food on the counter or 2) use the sterilizer container each time. When specifically asked about the cleaning of the thermometer, FSW-B stated that the red bucket that was used was the same as the small container of QUAT and can be used to sanitize all surfaces and items that need to be properly cleaned to prevent food born illness. This container looked like a small salt and pepper shaker and was used on both of the dining rooms observations. The tip of the thermometer was submerged in the sanitizer container prior to temping the foods During the interview, FSW-B was aware that the thermometer was wiped on his pants and explained it was an accident. When asked, FSW-B explained that the rationale, stated because the food was not going to all be used so perhaps it was out of instinct. FSW-B verified that the normal process was to either use the red bucket full of sanitizer or the small container of QUAT. FSW-B stated they temp the food prior to sending what is left back to the kitchen for further use. During an interview on 12/4/2024 at 1:22 p.m., Director of Environment & Risk Management Services (DERM)-B verified that they have a specific process for cleaning the thermometer after each time for temping the foods. While at Kitchenette #2 on the second floor verification of the difference between the red bucket of sanitizer and the small container of sanitizer. DERM-B stated that there is the same sanitizer in the red bucket as the small container of QUAT. When asked about the process for cleaning the thermometer DERM-B explained the process for temping foods was to place it in the small QUAT container and then wipe it down with an alcohol wipe prior to temping foods and in between. The DERM-B explained that the sanitizer in the bucket was the same as the small red container however this was to be used when cleaning down the area behind the steamer and not the thermometer during temping foods. During an interview on 12/4/24 at 2:48 p.m., DERM-B reiterated the following: -- Hair nets: hair must be secure/covered for anyone behind steam table. When staff report to work, everyone goes to kitchen first to wash hands and put on hairnet. DERM-B stated there was not a mirror in this area for staff to visibly determine if their hair was fully covered. --Hand hygiene and glove use: DERM-B stated it was the expectation that dietary staff wore gloves when working the steam table and dishing up food, adding they had been doing that for [AGE] years and believed it to be best practice. DERM-B stated it was the expectation staff stayed behind steam table and if they went outside of it, to remove gloves and wash hands. --DERM-B stated it was FSW-B fifth day on the job. Day one of orientation included organization-wide training, day two included handbook, expectations, and safe food handling videos, then partnering with staff for four to six shifts and with a manager observing during meal service. Due to survey observations, DERM-B stated FSW-B had been removed from the schedule for additional training. --Regarding FSW-A holding chicken tenders with contaminated gloves, DERM-B stated that was unacceptable. --Regarding disinfecting the food thermometer probe, DERM-B stated staff were supposed to wipe the probe with an alcohol wipe to remove debris between temping foods. When not in use, DERM-B stated the thermometer probe could rest in the QUAT solution. DERM-B was unaware staff were not wiping the probe with an alcohol wipe. --Regarding pureed shrimp temping at only 114 degrees and FSW-B not taking action on his own, DERM-B stated that was something FSW-B should have known and that there were appropriate temperature references in the food temperature log. DERM-B provided a documented titled Hazard Analysis Critical Control Point Food Safety System, dated 2019. In an email dated 12/5/24, DERM-B indicated the document was not used for training or orientation, however the topics covered in the plan were in the Safe Food Handler training videos that new employees watched on the second day of employment and before they did any food service in the department. The document included the following: --Hair restraints (hairnets, hats, or caps) must cover the hair sufficiently to prevent hair from falling onto food or food equipment and to minimize hand contact with hair. --Disposable gloves must be used when handling ready-to-eat foods (foods that require no further processing and cooking/heating). Gloves must be changed before starting another job and when they are torn, dirty or contaminated. Hands must be washed before putting on gloves. --Thermometer stems must be washed, rinsed, and sanitized. Three sanitizing methods were approved: Sanitizing solution with immersion time of one minute. Hot water method (185 F or above) immersion time of three seconds, or alcohol swabs (antibacterial probe wipes containing 70% isopropyl alcohol). FSW-A's training checklist titled Food and Nutrition Services New Hire Checklist indicated FSW-A completed Food Handler Training Videos, parts 1-5 on 6/13/23, and FSW-B the same on 11/26/24. During an interview on 12/5/24 at 1:22 p.m., the administrator who had been informed of dietary findings by DERM-B, stated she expected staff to be fully trained and follow food service policies.

Based on observation, interview and document review, the facility failed to ensure enhanced barrier precautions (EBP) were implemented for 3 of 3 residents (R27,R24,R58) reviewed for wounds, and proper donning and doffing of personal protective equipment (PPE) was completed per standard guidelines for 2 of 3 residents (R20,R27). Findings include: R20's facesheet printed on 12/5/24, included diagnosis of chronic foot ulcer. R20's quarterly MDS assessment dated [DATE], indicated R20 was cognitively intact; was usually understood and could understand. R20 was dependent on staff for most activities of daily living (ADL), and had a stage 2 pressure ulcer on her foot. R20's care plan dated 10/4/24, indicated impaired skin integrity related to left foot pressure ulcer and enhanced barrier precautions were in place. During an observation on 12/2/24 at 2:38 p.m., in hallways on the north and south units on second floor, PPE carts and doffing receptacles (metal stands with blue garbage bags) were observed lining the hallways outside multiple resident rooms. On the doorframe of these rooms were laminated signs indicating the residents were in EBP. The signs did not provide guidance as to where staff should doff - inside or outside of the resident's room. During an observation on 12/3/24 at 9:44 a.m., outside R20's room was a three shelf PPE cart, doffing receptacle and a CDC (Center for Disease Control) sign on the door frame indicating R20 was in EBP. Observed nursing assistant (NA)-A don PPE consisting of gloves and a yellow reusable gown and entered R20's room. During an observation on 12/3/24 at 10:04 am, NA-A exited R20's room, removed PPE and placed it in the doffing receptacle. NA-A stated sometimes the doffing receptacle was located inside the resident's room, and sometimes it was outside the resident's room. NA-A thought staff were supposed to doff inside the resident's room, but since the receptacle was on the outside of the room, that's where she doffed. During an observation on 12/4/24 at 7:26 a.m., doffing receptacles were still outside resident rooms on the north and south units on second floor. An undated documented titled Enhanced Barrier Precautions in Nursing Homes Algorithm located on a bulletin board on second floor identified for staff training, indicated: position trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room, or before providing care for another resident in the same room. 40614 R27's facesheet, printed 12/5/24, included diagnoses of Parkinson's disease (movement disorder), chronic myeloid leukemia (blood cancer that starts in the blood forming cells of the bone marrow), and gastrostomy status (external opening into the stomach). R27's quarterly minimum data set (MDS) assessment dated [DATE], identified R27 had moderately impaired cognition and received tube feedings for more than 50% of nutritional needs. On observation 12/3/24 11:35 a.m., R27 had a sign outside of his room indicating enhanced barrier precautions (EBP) and to gown and glove to provide cares. Upon entry into the room, registered nurse (RN)-B was present in R27's room and was flushing R27's gastric tube (GT). RN-B did not have a gown on but was wearing gloves. RN-B upon exit of the room indicated she is not aware of the exact procedure at facility but was aware of the sign on the door for enhanced barrier protection for R27. RN-B stated I wore gloves and that is what I did. A linen hamper for nondisposable gowns was located outside of R27's room. On observation and interview 2/3/24 11:38 a.m., nursing assistant (NA)-C and NA-D gowned and gloved and assisted R27 from his recliner to his wheelchair. NA-C and NA-D took R27 in his wheelchair to the doorway and removed gloves and disposed in trash in the room. NA-C and NA-D exited the room and took off non-disposable gowns and discarded in the laundry hamper outside of R27's room. NA-C stated she is not sure why the laundry hamper was outside of the door, but since it was, they wore the gowns into the hallway to discard them. R24's facesheet printed 12/5/24, included diagnoses of severe dementia, difficulty in walking, and dysphagia (difficulty swallowing). R24's quarterly MDS assessment dated [DATE], identified R24 had severely impaired cognitive decision making skills, disorganized thinking and inattention constantly present. R24 required substantial to maximum assist with bed mobility and is dependent on staff for wheelchair mobility. R24 did not have a pressure ulcer but was identified at risk of pressure ulcer development. On observation and interview 12/3/24 at 8:42 a.m., no sign was present on R24's door indicating EBP. R24's family member (FM)-A indicated R24 has had a pressure ulcer on the heel of her foot for the past few months. A Wound management Detail Report dated 10/14/24, by RN-A included unspecified left heel ulcer. Comments included newly discovered Stage 3 pressure ulcer (pressure causes a wound into the skin's fatty layer) to left heel with wound nurse assessment and recommendations for treatment. On observation and interview 12/3/24 8:42 a.m., RN-B did not gown, but gloved and completed wound care on R24's left heel. Wound measurements included 7 millimeter (mm) x 9 mm open area. RN-B indicated she is not sure what to call the wound at this time but it is still open but healing. R24's room did not have an EBP sign at the door or PPE present. R58's facesheet printed 12/4/24, included diagnoses of heart failure, dementia, and lupus erythematosus (audtoimmune system attacks the body's tissues and cells). R58's readmission MDS assessment dated [DATE], included moderately impaired cognition with delirium symptoms of inattention and disorganized thinking that fluctuates. R58 has 2 unstageable pressure ulcers (wound bed covered with slough/eschar {dead tissue}and can't be properly staged) present at the time of reentry. On observation 12/2/24 at 5:49 p.m., R58 was asleep in his bed. There was no sign present for EBP outside of the room or PPE equipment present. On observation and interview 12/4/24 at 1:22 p.m., R58 was asleep in his bed. No EBP sign was present outside of R58's room and no PPE present. RN-E completed wound care on both R58's heels wearing gloves but no gown. RN-E identified both wounds as pressure ulcers and open wounds but was unsure what stage they were presently. On interview 12/4/24 at 11:46 a.m., RN-A, also identified as infection preventionist, indicated doffing (removal of PPE) should occur in the residents room prior to exiting. RN-A indicated she was not aware the disposal hampers were outside of the rooms and stated they should be inside of the room by the door. RN-A stated she is unsure how contracted staff are trained on the facilities infection prevention policies, but would assume they are trained on EBP and hand hygiene prior to working at the facility. RN-A indicated R58 is on EBP precautions due to pressure ulcers, but upon arrival at R58's room indicated there was no sign or indication he was on EBP. RN-A indicated she is not sure what happened and why the EBP sign and equipment was removed from his room. RN-A confirmed R58 and R24 should both be on EBP due to open wound pressure ulcers. RN-A indicated EBP should be used for any wound stage 2 (one that has progressed to affect both the top and bottom layers of the skin) or higher. During interview on 12/5/24 at 1:19 p.m., the administrator, confirmed staff should doff PPE prior to exiting the room, before reaching the hallway. The administrator also confirmed anyone with an open wound should be in EBP precautions. Facility training slide deck titled Infection Control dated 8/7/24, and which according to RN-A was used for staff training, indicated PPE would be doffed before exiting the resident's room. Facility Infection Control policy dated 4/2024, indicated: A. A sign that indicates the type of precautions required will be placed outside each infectious room. B. Clean PPE needs to be applied when entering. C. Dirty PPE needs to be removed and discarded prior to exiting the room. D. PPE DON/DOFF instructions will be placed outside and inside each isolation room. E. Random audits of PPE use and placement will be conducted by the Infection Control Nurse or designee. A summary of these audits will be included in the monthly Infection Control review. Facility Infection Control policy dated 4/2024, included Multi-drug resistant organisms (MDRO) may require enhanced barrier precautions to align with nationally accepted standards. EBP's (generally gown and gloves) are recommended for certain residents during specific high-contact/high -risk activities conditions associated with MDRO transmission: Residents with indwelling medical devices regardless of colonization or infection (urinary catheter's, intravenous lines, feeding tube); Residents with open wound (does not include short lasting wounds such as small skin tears requiring a simple dressing such as a band-aid) ; High risk activities include device care or use, and wound care with any skin opening requiring a dressing. A. A sign that indicates the type of precautions required will be placed outside each infectious room. B. Clean PPE needs to be applied when entering. C. Dirty PPE needs to be removed and discarded prior to exiting the room. D. PPE DON/DOFF instructions will be placed outside and inside each isolation room. E. Random audits of PPE use and placement will be conducted by the Infection Control Nurse or designee. A summary of these audits will be included in the monthly Infection Control review.

Based on observation, interview, and document review, the facility failed to comprehensively assess wounds including measurements weekly for 1 of 3 residents (R24) reviewed for pressure ulcers. Findings include: R24's facesheet printed 12/5/24, included diagnoses of severe dementia, difficulty in walking, and dysphagia (difficulty swallowing). R24's quarterly minimum data set (MDS), dated [DATE], identified R24 had severely impaired cognitive decision making skills, disorganized thinking and inattention constantly present. R24 required substantial to maximum assist with bed mobility and dependent on staff for wheelchair mobility. R24 did not have a pressure ulcer but was identified at risk of pressure ulcer development and had a pressure reducing device in wheelchair. R24's physician orders dated 10/15/24, included left heel wound: Cut to fit Aquacel Ag (sterile dressing to cover wounds that excrete fluids and includes antimicrobial) to the wound bed, cover with 4x4 Allevyn gentle border foam (water/bacteria-proof silicone adhesive dressing) and change every other day and as needed. R24's plan of care dated 9/12/24, included R24 has a potential for skin integrity impairment with goal indicating the skin will remain intact. Interventions included weekly skin assessment. Treat skin concerns per protocol as able. Update provider with issues or concerns. Monitor every 2 hours, turn and reposition schedule. The care plan did not include pressure reducing device for heels. During interview and observation on 12/2/24 at 3:25 p.m., R24 was sitting in her broda chair (provides comfort, support and mobility) with slippers on both feet. Prevalon boot (heel protector) was on the floor next to the television. The foot rest on left side of Broda chair was off and R24 had her left heel suspended with her foot resting on on her right foot. Family member (FM)-A stated she has had a heel ulcer for the last few months. FM-A stated he removes the prevalon boot because R24 likes to kick her feet around and he doesn't think it does any good even though staff tell me it does. FM-A added the wound is doing good now and healing but is still open. During observation and interview on 12/3/24 at 8:42 a.m., R24 was sitting in her chair in her room with FM-A present. Left foot rest on Broda chair remained off and R24 had her left foot resting on top of her right foot. R24 had slippers on both feet. Registered nurse (RN)-B entered room to complete wound care and observed FM-A remove old dressing. Scant serosanginous drainage was present on old dressing. FM-A stated the wound has always been dime size and it is even smaller now. RN-B measured wound at 7 x 9 millitimeters (mm) across and stated it is healing, no tunneling present or redness or signs of infection. RN-B when questioned about the wound type, and wound bed description stated I'm unsure what to call this wound at this time. RN-B indicated wound assessments and measurements are documented in the progress notes when done. RN-B was unsure how frequently this facility requires a comprehensive wound assessment to be done. R24's completed skin assessments included: 10/3/24: Generalized self-inflicted scratches. Otherwise skin intact 10/10/24: Light redness inner buttocks, skin tear right hand and fourth finger. No mention of heel issues A Wound Management Detail Report dated 10/14/24, by RN-A for R24 included unspecified left heel ulcer. Moderate amount of serosanguineous (clear thin liquid that oozes from wounds) drainage present with no tunneling. Tissue type is slough (dead tissue within the wound). Comments included newly discovered stage 3 (full thickness skin loss with damage to subcutaneous tissue) pressure ulcer to left heel with wound nurse assessment and recommendations for treatment. Podiatry appointment is scheduled for 10/24/24. A Podiatry Note dated 10/22/24, included R24 is being seen for pressure ulcer on the posterior, plantar lateral aspect of her left heel. History of this ulcer is not known. FM-A who is with R24 today stated she had some type of callused lesion over that area for quite some time however, there is no record of any open ulceration until 10/15/24. A padded heel boot was recommended to help offload pressure at the ulcer site. Silver alginate with an Allevyn dressing was applied and this has been changed frequently since then. The day after the wound care nurse visit, the patient's primary care provider thought there was some concern of infection at the wound and prescribed doxycycline (antibiotic) 100 mg twice a day for ten days. Assessment of wound included stage 2 (one that has progressed to affect both the top and bottom layers of the skin but not fatty tissue beneath) pressure ulcer measuring 0.5 x 0.4 cm which is an improvement from 1.0 x 0.8 cm when she was seen by wound care 1 week ago. The base of the ulcer is red and granular with about 2 mm of depth at the center tapering out to 1 mm and lesser on the edges. No active drainage or sign of infection at this time. There is no necrotic (dead) or devitalized tissue surrounding or over the wound. R24's wound evaluations from 10/25/24 to 12/4/24, included: 10/25/24: Scant serous drainage on bandage. Open area posterior 0.3 cm x 0.4 cm. Wound description not completed. 10/31/24: Pressure sore to left heel open to air. Pea sized open area, not red, calloused edges have softened. Depth 0.3 mm. Scant drainage, no edema. 11/7/24: Pressure ulcer related to left heel not changed this shift, not measured, or assessed. Has been charted as improving. 11/8/24: 0.5 cm x 0.5 cm light serous drainage, 50% epithelial tissue and 50% non granulation tissue. Wound is improving. 11/18/24: No drainage from left inner heel scabbed area, is size of a pea. 11/23/2024: Left inner heel has a pea sized red shiny area, scab appears to have sloughed off. Treatment was completed with no indicators of pain. No signs of infection. Receives Aquacell AG and mepilex border with gauze wrapping. 11/27/24: Heel is open now, red and clean, appears 0.3 cm deep 1cm circular - no drainage or odor. 12/1/24: Stage 2 pressure ulcer to left heel. Minimal serosanguinous drainage. Wound is 1 cm x 0.8 cm. Comments: Stage 2 pressure injury to left heel appears to be healing well with current treatment. No surrounding pink discoloration, redness or warmth. Scant amount of drainage present. The wound assessments lacked consistent weekly measurements and comprehensive wound assessments including but not limited to wound bed description, drainage, and wound edges. During interview on 12/4/24 at 7:43 a.m., RN-D indicated wound care including assessments of the wound are required to be completed weekly. RN-D stated we do a brief note with all dressing changes. During interview 12/4/24 at 10:12 a.m., RN-A, also identified as covering nurse manager, upon review of wound documentation, confirmed wound measurements and comprehensive wound assessments were not completed weekly but should have been. During interview 12/5/24 at 1:19 p.m., the administrator indicated weekly wound measurements and wound assessment including secretions, wound base, tissue at wound bed should be documented per policy and procedure. Facility Skin Care policy dated 7/2023, included: When a skin ulcer or other wound is identified, an assessment of that specific wound will be completed and documented in the electronic medical record (EMR) by the nurse . The assessment will include: measurements of the pressure ulcer, other wound or bruising, condition of wound bed, condition of surrounding tissue and any other signs and symptoms of infection. Weekly skin assessment of the area will be added to the medication administration record.

Based on observations, interview, and document review, the facility failed to complete a comprehensive, person-centered care plan, to promote fecal continence to the extent possible that is dignified, and per resident choice for 1 of 2 residents (R34) who were reviewed for bowel incontinence. Findings include: R34's minimum data set set (MDS) dated [DATE], indicated R34 had a Brief Interview for Mental Status (BIMS) score of 9, indicated moderate cognitive impairment. R34 required extensive assistance for mobility, transfers, and toileting. R34 had a diagnosis of diarrhea. R34 did not have an active bowel program to manage bowel continence. R34's care plan dated 10/9/2024 did not include bowel care interventions or a bowel management regimen. R34 required a two-wheeled walker, gait belt, and assist of one for transfers. R34's physician orders did not address bowel diagnosis and incontinence care and prevention. During observation on 12/2/24 1:57 p.m., R34 stated he has a full depends (disposable product used for incontinence), but nursing assistant (NA)-B is coming back to help him. R34 already had his light on. R34 stated he is uncomfortable, and stated he has crap in his depends. R34 yelled at surveyor go away cause if you can't change me then you are no help. Enhanced precaution at door (resident has catheter). No obvious smells in room. During observation on 12/02/24 2:03 p.m., R34 was yelling from his room sitting here with . [explicit language] in my pants, what are you going to do, everyone just walks out and leaves me . [female name] where are you? I need your help. Can you get me my walker? I need help. I want my walker to walk out. You aren't doing a . [explicit language] thing for me. Aren't you going to help me get clean? I have to have help. Gotta have help. Can you help me? R34 became angry, yelling can I have someone help me? During interview on 12/02/24 at 2:22 p.m., R34 stated he does not like sitting in own poop. He stated he would rather use the toilet, so he doesn't get stool all over himself. R34 stated he needs assistance getting to the toilet but once there, he could have a bowel movement without soiling himself. During interview on 12/03/24 at 10:25 a.m., NA-B stated she usually checks on R34 every 2 hours to see if his catheter needed emptying or if his brief was dirty. NA-B stated she does not offer the restroom periodically to prevent stool incontinence. NA-B stated R34 has a history of clostridium difficile (bacterial infection that can cause diarrhea and other intestinal conditions) and does have more episodes of stool incontinence than most other residents. NA-B stated R34 can be predictable; with his bowel movements mostly a short while after he eats. During interview on 12/3/24 at 01:24 p.m., registered nurse (RN)-C stated R34 should be checked for safety every hour and his catheter should be checked every two hours. RN-C stated the NA's will also check his brief for signs of a bowel movement. RN-C stated R34 was not offered periodic restroom visits to prevent stool incontinence. RN-C stated approximately 30 to 45 minutes after R34 eats, he will likely experience a fecal blow-out or large fecal incontinence episode. RN-C stated a resident with this predictable bowel pattern should have a bowel care plan or bowel management program. RN-C stated R34 did not have a current or previous bowel care plan or bowel management program. RN-C stated R34 she had not written or entered a care plan for R34 because the staff know R34's bowel pattern after eating so they assist him with cleaning after his incontinent bowel movements. RN-C acknowledged R34 should have a bowel care plan so staff know to assist R34 to the bathroom after lunch before he has a blowout. During interview on 12/5/24 at 9:43 a.m., administrator stated the current practice is to use the facility standing orders and check and change every two hours until resident orders or care plans are developed after admission. If a resident experiences a change in bowel habit, new orders and a care plan are completed. Administrator stated a resident with a predictable bowel pattern such as R34, should have a bowel care plan or bowel management plan to optimize fecal continence. Administrator verified R34 does not have an active or previous bowel care plan or bowel management program. Administrator verified the facility had a policy to assess and manage fecal incontinence. Facility Toileting and Incontinence Care Standard Work policy dated 11/18/19 stated if the resident is continent, assist with the use of the toilet per frequency indicated in their care plan.

Based on observation, interview, and document review, the facility failed to ensure side rails were comprehensively assessed to determine if they were appropriate and safe, discuss risks and benefits, and obtain informed consent prior to use of bed rails for 3 of 3 residents (R1, R27, R38), who were observed to have assist bars raised on their beds. This had the potential to affect all 48 residents who utilized an assist bar(s) for mobility. Findings include: R1's facesheet printed on 12/5/24, included diagnoses of spastic cerebral palsy and osteoarthritis. R1's annual Minimum Data Set (MDS) assessment dated [DATE], indicated moderately impaired cognition, clear speech, could understand and be understood. R1 was dependent upon staff for activities of daily living, including rolling from side to side in bed, transferring and toileting. R1 was not able to move from lying in bed to sitting on the edge of the bed. R1's care plan dated 4/12/23, indicated R1 required assistance of two staff and a Hoyer lift (mechanical lift device) for transfers. R1 used a manual wheelchair for mobility and did not walk. R1's care plan did not identify use of assist bars. R1's fall risk assessment dated [DATE], indicated R1 was a moderate fall risk. R1's electronic medical record lacked side rail assessment, documentation of informed consent and discussion of risks and benefits for use of bed rails. During an observation on 12/2/24 at 1:56 p.m., observed two cane shaped assist bars on R1's bed in the elevated position toward the top of R1's bed, near the location of her head/pillow as R1 laid in bed. R1 stated they had always been on her bed, and she had not had a problem with them. R27's facesheet printed on 12/5/24, included diagnoses of repeated falls and Parkinson's disease. R27's quarterly MDS dated [DATE], indicated moderately impaired cognition, could usually understand, and was understood. R27 was dependent on staff for most ADLs. R27 required substantial assistance to roll side to side in bed, and to move from lying in bed to sitting on the edge of the bed. R27's care plan dated 10/25/24, indicated R27 had falls related to cognitive impairment. Interventions included if tired, recommend doing pivot transfers to bed in the later evening. Care plan dated 11/15/24, indicated assist of two pivot transfer or EZ stand (mechanical assist device). Have R27 stand for a second to get bearings before taking a step. Remind him to push up using grab bars. A fall risk assessment dated [DATE], indicated R27 was a high fall risk. R27's electronic medical record lacked side rail assessment, documentation of informed consent and discussion of risks and benefits for use of bed rails. During an observation on 12/3/24 at 5:02 p.m., one assist bar on R27's bed was observed in the upright position on the side of the bed away from the wall. The assist bar was positioned toward the head of the bed and the C shape of the assist bar was facing the head of the bed. R38's facesheet printed on 12/5/24, included diagnoses of dementia, carpel tunnel syndrome (numbness and tingling in fingers), and back pain. R38's quarterly MDS dated [DATE], indicated severe cognitive impairment. R38 could be understood and could usually understand. R38 was independent with mobility and used a wheelchair. R38's care plan dated 10/11/24, indicated she was a fall risk related to dementia diagnosis. R38's care plan did not identify use of assist bars. A fall risk assessment dated [DATE], indicated R38 was a high fall risk. R38's electronic medical record lacked side rail assessment, documentation of informed consent and discussion of risks and benefits for use of bed rails. During an observation on 12/3/24 at 5:02 p.m., both assist bars on R38's bed were observed in the upright position on either side of the bed. The bars were positioned toward the head of the bed and the C shape of the assist bars were facing the head of the bed. During a telephone interview on 12/3/24 at 12:54 p.m., manufacturer technician support (TS)-F, was asked for a service manual for the Hill-Rom assist bars. TS-F stated there used to be instructions online, but they were no longer available. TS-F had a physical copy in his files and took screen shots of the installation directions for the assist bar and provided them via phone text. TS-F stated their products were designed and tested in the orientation documented to ensure proper patient and user safety. The illustration provided via text was titled: Installation Instructions - Side rail, Assist Bar and Headrail Upgrade Kits dated 10/20/09. The instructions on page 175 indicated: point the cane (A) on the assist bar assembly (B) toward the foot end of the bed (see figure 1 on page 176). The figure on page 176 illustrated the assist bar positioned at the lower half of the bed frame, and the C of the assist bar facing the foot of the bed. The assist devices at the facility were installed on the beds in the opposite location and direction -- toward the head of the bed and the C facing the head of the bed. During an observation on 12/3/24 at 5:02 p.m., 48 of 57 residents had either one or two assist bars in the elevated position on their beds. The assist bars were installed closer to the head of the bed, at the level of the resident's pillow/head, and the C shape of the assist bars were facing the head of the beds rather than the foot of the bed. A Hill-Rom brochure received via email from manufacturer representative (MR)-D on 12/4/2024 at 1:06 p.m., for the Resident(R) LTC Bed, dated 2015, indicated the bed was designed specifically for long-term care. Options were available including an optional assist bar. A picture on page two of the brochure showed side rails on either side of the bed toward the top end, and assist bars on either side of the bed toward the lower end. The assist bars were C shaped resembling a walking cane. The C was facing the foot of the bed in the picture. During a telephone interview on 12/4/24 at 11:27 a.m., MF-D was asked questions about installation of the assist bars, including the proper location and direction, and who installed them when purchased in 2017. MR-D stated he would check and call back. In addition, a photo of the assist bars on R118's bed was emailed to MR-D to illustrate current position and direction of assist bars at the facility. In an email dated 12/4/24 at 1:06 p.m., MR-D wrote: as you can see, the brochure (page 2) shows the assist bar pointing toward the foot of the bed. Also, on the cover page, you can see how they also fold down out of the way toward the foot section of the bed. I am able to confirm that an order was placed for 106 assist bars back in early June of 2017. That said, I cannot confirm if someone at the site or someone on the Hill-Rom team installed them. During an interview on 12/5/24 at 9:48 a.m., registered nurse (RN)-C, who was also a nurse manager, stated the facility did not conduct siderail assessments on residents who used a grab bar (assist bar), as they were not considered a siderail. RN-C stated residents were asked upon admission if they wanted to utilize a grab bar, but their preference was not documented. RN-C stated the facility did not do a safety risk assessment, address risk/benefits, obtain a consent, or add grab bars to the care plan because grab bars were not considered a side rail. In an email dated 12/5/24 at 11:56 a.m., MR-D wrote: in speaking internally, we do not recommend removing the upper side rails of the bed, and per our documentation, we only recommend the assist bars be used at the foot section of the bed as seen in the image in the brochure. (To clarify, the purchase proposal to the facility from Hill-Rom dated 5/19/17, included beds, assist bars and pendant controls - no side rails). During a telephone interview on 12/5/24 at 12:08 p.m., MR-D was asked if the assist bars were installed correctly based upon a photo emailed to him earlier (specifically the assist bars being positioned closer to the head of bed and C facing the head of the bed). MR-D stated it was not how we (Hill-Rom) built it or tested the bed but could not comment if the current configuration posed a safety risk to residents. MR-D stated it was the facility's bed and they could do what they wanted. MR-D stated the bed and assist bar purchase and installation was so long ago, he was not able to determine how the beds would have arrived at the facility -- with the assist bars attached, and/or if Hill-Rom personnel would have installed the assist bars on new and/or existing beds. On 12/5/24 at 1:14 p.m., the administrator was sent via email, the assist bar installation sketches received from TS-F on 12/3/24 at 1:10 p.m. which indicated the installation instruction illustrations came from a Hill-Rom document titled Installation Instructions - Siderail, Assist Bar and Headrail Upgrade Kits dated 10/20/09. The instructions on page 175 indicated: point the cane (A) on the assist bar assembly (B) toward the foot end of the bed (see figure 1 on page 176). The figure on page 176 illustrates the assist bar positioned at the lower half of the bed frame, and the C of the assist bar toward the foot of the bed. During an interview on 12/5/24 at 11:08 a.m., the administrator stated if a resident requested a grab bar, it would be added to the bed. The administrator stated she realized that a grab bar was considered a siderail and therefore the resident should be assessed for safety, risks and benefits, according to their policy. Facility policy Side Rail Use dated 1/2023, indicated typically, side rails were not used, however, if needed residents would be assessed for use on admission, prior to, or with any significant change. Before initiating use of any side rail, an assessment would be completed including consent form and discussion of risks and benefits. Risks and benefits were discussed, and the consent form given to the resident or the decision maker of the cognitively impaired resident, that has been individually assessed by a licensed nurse whose assessment determines side rails as beneficial for the resident's use and are not classified as a restraint. Admission side rail assessment documentation was to include the side rail length; number of rails; which side of the bed the railing is to be up on; reason for being up; and any other comments that pertain to side rail use. The admission assessments were documented in electronic record (EMR) under the appropriate category pertaining to the intended use of the side rail. Ongoing documentation for side rail use was done in the EMR and should include the same information as the initial admission assessment. The care plan should reflect the use of side rails and their purpose to the resident.

Based on observation, interview, and document review, the facility failed to ensure proper hand hygiene and glove use practices were maintained for 1 of 1 resident (R1) observed during peri care and full body lift transfer. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1's diagnoses included non-traumatic brain dysfunction including dementia. MDS identified R1 was usually understood and usually able to understand others. However, the cognitive patterns indicated R1 was rarely or never understood and had severe cognitive impairment with fluctuating behaviors present. In addition, R1's MDS identified R1 was dependent on staff for all activities of daily living (ADL)'s. R1's care plan revised on 1/31/24, indicated R1 needed assist of 2 staff with toileting using a full body lift due to safety concerns with the use of the standing lift. Staff to provide peri hygiene and apply barrier cream with cares. During an observation on 3/7/24 at 12:59 p.m., nursing assistant (NA)-A and NA-B entered R1's room. Both NA-A and NA-B did not wash or sanitize hands upon entering the room, grabbed gloves, and put them on after pulling the full body lift into the room. NA-A and NA-B put transfer sling around R1 and transferred R1 from the Broda wheelchair to the commode. NA-A removed the soiled brief from between R1's legs while she was on the commode and pulled the commode into the middle of the room. NA-B began using wipes and removing bowel movement from R1's bottom when R1 began to void on the floor. NA-B then removed her soiled gloves and put on new gloves without sanitizing or washing hands and pushed the commode with R1 back over the toilet in the bathroom. NA-A then grabbed some towels and cleaned the floor and continued to use the same gloves throughout cares, including putting a new brief on R1, transferring her back to her wheelchair from the commode, removing the transfer sling and brushing R1's hair. NA-A then removed her gloves and disposed of them in the trash before NA-B took the trash out of the bin, put in a new bag, removed her gloves and put them in the old bag and spun and knotted the old bag setting it aside by the door. During interview on 3/07/24, at 1:15 p.m., NA-A stated she should have washed or sanitized her hands when entering and or leaving a resident's room. NA-A stated she should have sanitized or washed her hands during cares or whenever she encountered any bodily fluids. NA-A verified she had not appropriately sanitized or washed hands during R1's cares but was unable to articulate why she hadn't. During an interview on 3/07/2024, at 1:16 p.m., NA-B stated she should have washed or sanitized her hands when she entered and exited R1's room and after changing her gloves. NA-B identified she had not washed or sanitized her hands when she had changed her gloves in the room and stated she just hadn't thought about it. During an interview on 3/12/24 at 1:59 p.m., the director of nursing (DON) stated it was an expectation staff should wash or sanitize hands when entering and exiting residents' rooms and each time they moved from a dirty area to a clean area. DON further stated staff were expected to perform hand hygiene with each glove change. The DON expressed all staff are expected to follow facility policy when it came to hand hygiene and infection control. The policy Hand Hygiene updated 9/2023, indicated good hand hygiene technique should be used to prevent the spread of infection. Several types of cleaning agents are available including surgical scrub preparations, antiseptic lotion soaps and alcohol-based sanitizers. Adequate hand hygiene facilities are available throughout the facility. Hand hygiene should occur: -Before and after a work shift. -Before and after eating, drinking, or handling food. -After using the toilet; after hand contact with mouth and nasal secretions (cough, sneezes, ect.). -Before and after significant contact with any resident. -Before and after preforming invasive procedures. Although gloves are worn for certain procedures, hand hygiene before donning gloves and after removal is necessary because of the possibility of tears or holes in the gloves. -Between care activities on the same resident involving different body sites (i.e. care of foley/IV/wound/trach). -After contact with wounds or mucous membranes, or items such as dressings, bed pans, collecting devices with may be contaminated with secretions, excretions, or blood. -When there is doubt about the possibility of hand contamination.

Based on interview and document review the facility failed to ensure continued monitoring and surveillance for efficacy and appropriateness was completed for 2 of 2 residents (R7, R20) who were on long-term, prophylactic antibiotics. In addition, the facility failed to ensure an appropriate antibiotic was administered for 1 of 1 (R9) residents who had an infected wound and were prescribed an ineffective antibiotic. Findings include: R7's quarterly Minimum Data Set (MDS) dated [DATE], indicated R7 had severe cognitive deficits and had diagnoses that included diabetes, epilepsy, morbid obesity, and urinary tract infections (UTI's). R7's Care Area Assessment (CAA) dated 3/28/23, indicated R7 triggered for indwelling catheter, cognitive loss/dementia, and pressure ulcers. R7's care plan dated 8/17/23, indicated R7 had a self-care deficit related to alteration in urinary/bowel function. Interventions included monitoring void patterns, assess for a UTI, administering medications as ordered and observing for side effects. R7's care plan lacked indication of or interventions for R7's long-term antibiotic use. R7's order dated 10/31/22, indicated R7 received sulfamethoxazole-trimethoprim (an antibiotic) 400-80mg orally for UTI's with no end date listed. R20 R20's quarterly MDS dated [DATE], indicated R20 had intact cognition and was dependent for all ADLs. R20's diagnoses included multiple sclerosis (MS), UTI, heart disease, high blood pressure, and congestive heart failure (CHF, causing fluid in the lungs and body, and shortness of breath), obesity, neuromuscular dysfunction of the bladder, constipation, and diarrhea. R20's CAA dated 12/22/22, indicated R20 triggered for indwelling catheter and pressure ulcers. R20's care plan dated 4/12/23, indicated R20 had an indwelling urinary catheter related to a neurogenic bladder. The care plan lacked indication of, or interventions for R20's long-term, prophylactic antibiotic use related to recurrent UTI's and possible organism colonization. R20's Report of Consultation dated 6/10/22, indicated to start R20 on 250 milligrams (mg) of amoxicillin (an antibiotic) daily. No end date was indicated for the antibiotic. During an interview on 10/24/23 at 10:05 a.m., R20 stated she had not had a UTI for a few months but recently began having loose stools and did not know why. During an interview on 10/25/23 at 2:57 p.m., the infection preventionist (IP) stated she did not recall why R20 was on the prophylactic antibiotic and could not recall when R20 first began taking the antibiotic. The IP further verified neither R7 nor R20 were being tracked on the facility antibiotic surveillance log for their long-term use of an antibiotic. During an interview on 10/26/23 at 7:52 a.m., registered nurse (RN)-A who was also the nurse manager, stated she had been notified R20 had been having loose stools for the past few days. RN-A stated staff would need to obtain an order from the provider to test R20 for clostridium difficile (C-Diff-a potentially deadly bacteria that can grow as a result of long-term antibiotic use) as there were no standing orders related to testing a resident for C-Diff. RN-A also stated there was no specific guidelines indicating when a resident should have been tested for C-Diff. RN-A further stated there should have been better monitoring for the antibiotic use for both R7 and R20 to ensure they were not experiencing any complications or side effects. During an interview on 10/26/23 at 11:37 a.m., the director of nursing (DON) stated long-term, prophylactic antibiotics should have been monitored and reassessed for their efficacy and appropriateness. The DON further stated residents on long-term antibiotics should be monitored for signs and/or symptoms of complications including bowel function related to possible C-Diff, although the DON was unsure if there were standing orders related to testing residents for C-Diff. During an interview on 10/25/23 at 9:40 a.m., the consulting pharmacist (CP) stated she would have expected antibiotics prescribed for prophylactic use to be reviewed at least annually for their appropriateness and efficacy. The CP also expected staff to monitor residents who were on antibiotics, especially long-term for complications including C-Diff. R9 R9's quarterly Minimum Data Set (MDS) dated [DATE], indicated R9 had intact cognition with diagnoses including heart failure, hypertension, and debility. R9 had a venous ulcer (wound caused by poor blood circulation to the lower extremities), required moderate assistance with bathing and dressing, and was independent with transferring and bed mobility. R9's care plan dated 5/26/23, indicated R9 had intact skin but was at risk for skin integrity loss. Staff were to prevent pressure, moisture, shearing, and injury to the skin. The care plan did not address the wound on R9's right lower extremity. R9's Order History report dated 10/6/23, indicated a new order for Cephalexin 500 milligrams (mg) four times a day for seven days for cellulitis. The report indicated a lab culture of the venous ulcer was ordered one time during the period of 9/1/23 and 10/26/23, dated 10/20/23. The report indicated an order active until 10/24/23 for once-a-day wound care on the venous ulcer and did not indicate the use of special safety precautions related to antibiotic resistance organisms present in her wound. The order dated 10/24/23, indicated R9 was prescribed Levofloxacin (antibiotic) 750 mg given every other day for ten days. The order dated 10/24/23, indicated R9 received once-a-day wound care on the venous ulcer and indicated the use of special safety precautions related to antibiotic resistance organisms present in her wound. R9's progress note dated 10/6/23 at 1:23 p.m., indicated R9 had increased complaints of pain to venous ulcer. The area around the wound was reddened and the drainage was a green-yellow color. The note indicated a new order for cephalexin but did not indicate the wound had been cultured. R9's progress note dated 10/12/23 at 3:17 p.m., indicated R9 had continued pain to the venous ulcer despite antibiotic treatment. R9's progress note dated 10/17/23 at 11:15 a.m., indicated R9 had a moderate amount of drainage from her venous ulcer on her right lower extremity (RLE) as well as redness around the wound. R9's Nursing Home Note dated 10/19/23 at 3:36 p.m., indicated R9 had an opened wound on her RLE that was slow to heal. The note indicated that R9 had taken cephalexin for presumed cellulitis. Nurse practitioner (NP)-I indicated the wound was actually worse than it was prior to the antibiotic. R9's progress note dated 10/19/23 at 4:51 p.m., indicated R9 had a wound on her RLE that was worsening. During an interview on 10/23/23 at 2:52 p.m., R9 stated she had a wound that she acquired while in the facility on her right lower leg, that hurts really bad. During an interview on 10/26/23 at 10:33 a.m., medical doctor (MD)-A stated R9's wound had reopened while at the facility, so they had reached out to the nurse practitioner, who had prescribed cephalexin (a broad-spectrum antibiotic). MD-A stated after R9's seven-day course, the wound had not resolved. MD-A stated the wound was then cultured for the infectious agent on 10/20/23 and she was started on Levofloxacin, an antibiotic that would work more effectively against the bacteria in the wound. MD-A stated that R9's wound may not have progressed to the degree it had if the correct antibiotic had been utilized. The facility Antimicrobial Stewardship Program policy dated January 2018, indicated the purpose of the program was to promote the appropriate use of antimicrobials in order to improve resident outcomes while minimizing toxicity and the emergence of Antimicrobial resistance by selecting the appropriate dose, route and duration of treatment. The program committee was responsible for: demonstrating improvements, including sustained improvements in proper antibiotics use, such as through reductions in C-Diff, adherence to nationally recognized guidelines and best practices, providing ongoing healthcare practitioner education regarding Antimicrobial initiatives, and collecting, tracking, and analyzing Antimicrobial use and resistance patterns. The policy also indicated, in accordance with the CDC Core Elements of Hospital Antibiotic Stewardship Program recommendations, all prescriber's were required to document the duration of Antimicrobial therapy and to review its appropriateness after 48-72 hours from the initial order.

Based on observation, interview and document review the facility failed to ensure residents were provided a private meeting place without staff present for resident council meetings. In addition the facility failed to ensure concerns brought forward at the resident council meetings were addressed in a timely manner. This deficiency had the potential to affect all 13 residents who attended the monthly resident council meetings. Findings include: During an interview with resident council members, R3, R12, R55, R48, and R46 on 10/25/23 at 1:00 p.m., residents indicated resident council meetings were held in the open dining room and provided no privacy. The residents stated staff being present was intimidating and There are times you hate to bring up concerns in front of staff. Residents also stated follow up regarding their concerns was not there and things didn't often change. During an observation on 10/25/23 at 1:54 p.m., 13 residents, two family members and five staff members were gathered in the resident main dining room for the resident council meeting. The main dining room is located in front of a nurse's station where nurses, nursing assistants, health unit coordinators (HUCs) and other staff were working and passing through. An unknown staff member used a microphone to speak to the residents. A few residents appeared to be sleeping and one was reading a magazine. The staff member then asked if there were any concerns regarding each individual department and pointed out staff present from each department including maintenance who was walking through the dining room at the time. Two residents spoke up and consistently praised each department. Review of the Resident Council Meeting Minutes dated 9/29/23, indicated the following: -No findings to report related to the findings in the August 2023 meeting. -New business indicated new cases of COVID in the facility and testing procedures were discussed. -Concerns included an unidentified resident complained of their baked potato being hard and the kitchen would be notified, an unidentified resident complained her slippers were returned damp from laundry, and it was the chaplain's last service as they found other employment. The minutes lacked indication of who attended the meeting. Review of the Resident Council Meeting Minutes dated 8/30/23, indicated the following: -No findings to report related to the findings in the July 2023 meeting. -New business indicated the call light system had been replaced, the dentist would be coming to the facility on [DATE], and residents who wanted to see him should let the staff know, and the menus were going to a three-week rotation instead of a six-week rotation. -Concerns included an unidentified resident expressing concern about a therapeutic recreation position being eliminated. Residents were reassured outings would continue and the following month's outings were discussed and residents were informed the bus lift needed to be repaired and could impact the weekend. The minutes lacked indication of who attended the meeting. Review of the Resident Council Meeting Minutes dated 7/26/23, indicated the following: -Findings from the June 2022 meeting indicated residents were notified that necklace/bracelet type call lights were not an option with the new call light system, and that there was a short time that the laundry labeler was not working and therefore, marker was being used to label clothing-this is not fixed. -New business indicated the new call light system was being installed. -Concerns indicated residents were advised now that they had to share the activities bus with the assisted living facility, attendance would be limited, and a staff was introduced in their new role. The minutes lacked indication of who attended the meeting. During an interview on 10/26/23 at 9:40 a.m., the social worker (SW) stated the resident council meeting was always held in the dining room and often resident family members would attend also. The SW stated she believed the purpose of the resident council meeting was to allow the residents an opportunity to discuss their concerns and support each other, however; she admitted meeting in the open dining room could provide a barrier for residents feeling safe to discuss concerns about staff if those staff are present. The SW stated concerns brought up during the resident council meetings may be addressed on a one-to-one basis or with an individual department depending on what the concern was. The SW stated the expectation was for concerns to be handled immediately and either documented in the resident council meeting minutes or in a resident's progress notes in their electronic medical record (EMR), however; that was not always done, and it was possible the concern would not be documented. The SW further stated a grievance form would not be filled out for the concerns brought up during the resident council meetings. The facility Resident Council Monthly Council Meeting process dated 12/4/22, indicated a calendar invite would be sent to invite/inform staff including the administrator, director of nursing (DON), nurse managers, therapeutic recreation staff, social services, chaplain services, director of hospitality, food and nutrition manager, of monthly resident council meeting, agenda, and outcome actions. The day before the meeting all above listed staff were to receive an agenda and be asked for any other announcements. Staff were to use a microphone and designate another staff as a note taker for the meeting. The following topics were to be discussed: -introduce any new residents -read and approve previous meeting minutes -old business (review actions taken since previous meeting -new business (announcements from staff or facility news) -review 1-2 resident rights -review of departments and/or announcements related to each -other resident concerns Also included was the following: Statement Regarding Complaints: We appreciate any and all feedback, and hope that you continue to bring your concerns forward to any of our staff. Please know that if there are issues you do not wish to bring up today, you may reach out to any of our staff at any time. We also provide formal grievance forms for you located outside the SW offices and at the elevator entrance on the Transitional Care Unit.

Based on observation, interview, and document review, the facility failed to keep remote to chair within reach for 1 of 1 residents (R31) reviewed for possible restraint. Findings include: R31's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R31 had severely impaired cognition and required moderate staff assistance to transfer and walk, extensive assistance to stand, and was dependent on staff for personal hygiene. The MDS indicated a bed alarm was used for R31's care. R31's Face Sheet dated 10/24/22, indicated R31 was diagnosed with Alzheimer's disease, arthritis, and osteoporosis (a condition causing weak, brittle bones that are much more likely to break). R31's care plan dated 4/12/23, indicated R31 had a risk for falls, and to intervene, staff should ensure R31's recliner remote was not tucked into the recliner seat but left on the side of the chair. During an observation on 10/24/23 at 12:46 p.m., R31 sat in the recliner on the right side of her room with the leg rest in the extended (elevated) position. The cord for the recliner remote was observed in the pocket on the side of the recliner. During an observation on 10/24/23 at 3:29 p.m., R31 was observed lying in her recliner with the leg rest in the extended position, yelling out, Help, help, pretty please, help! No staff were observed to answer R31's calls. R31's recliner remote was observed inside the right pocket of the recliner. During observation and interview on 10/25/23 at 10:51 a.m., R31 sat in the recliner with the leg rest in the extended position. A trash can was observed immediately to the right of the recliner with the remote control panel hanging over the far side of the trash can. Registered nurse (RN)-E entered R31's room and asked R31 if she was able to reach the recliner remote. R31 leaned over the right arm rest but could not reach the remote. RN-E stated R31 was unable to reach the remote, but she was unsure if R31 was allowed to have it within reach. During observation on 10/25/23 at 10:55 a.m., trained medical assistant (TMA)-B was observed entering R31's room. R31 remained in recliner, leg rest in extended position with recliner remote placed on far side of trash can. TMA-B observed talking with R31 and then leaving the room while the recliner remote remained on the far side of the trash can. During an interview on 10/25/23 at 10:57 a.m., RN-E stated she would move the recliner remote within reach of the patient because she was concerned the recliner would act as a restraint or increase R31's fall risk. During observation and interview on 10/25/23 at 12:40 p.m., R31 sat in the recliner with the leg rest in the extended position. A pillow was observed over both the recliner's right arm rest and extending some of the trash can. The recliner remote was observed halfway down the inside of the trash can. TMA-A entered R31's room, observed the recliner remote in the trash can, and stated R31's recliner remote was out of R31's reach because she was not allowed to have it. TMA-A stated that staff do not give the recliner remote to R31 because she has fallen after putting the leg rest down in the past. During an interview on 10/26/23 at 10:28 a.m., the director of nursing (DON) stated R31 was able to use the recliner remote, and she would expect it to be within her reach. The DON stated she would be concerned that R31's movement would be restricted if the recliner remote was out of her reach. The DON stated they did not have a specific assessment for recliner use and only did an assessment if an issue was noted. The facility Restraints policy dated 11/22, indicated that when staff assisted a resident into a chair they could not get out of, it was considered a restraint. The policy indicated a restraint, such as a chair, should not be used to limit a resident's movement for the convenience of staff. If a physical restraint is used for a resident with behaviors that are threatening their own well being, it must be used with a treatment procedure designed to modify that behavioral problem. The policy indicated that if a physical restraint was used, documentation must be completed demonstrating behaviors occurring and interventions that failed prior to restraints being implemented.

Based on observation, interview and document review, the facility failed to promptly notify a change in condition to the physician for 1 of 1 residents (R55) who recently had a medication change and developed possible side effects. Findings include: R55's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R55 had intact cognition with diagnoses of Parkinson's disease and breast cancer. The MDS indicated R55 required minimal assistance with personal hygiene, dressing, and transferring and was independent with walking. R55's order summary dated 8/29/23, indicated R55 began taking entacapone 200 milligrams (mg) twice a day for Parkinson's disease. R55's care plan dated 9/12/23, indicated R55 had a diagnosis of Parkinson's disease and was unable to care for herself as well as being a fall risk, requiring hourly checks from staff. R55's neurology progress note dated 8/28/23, indicated R55's involuntary muscle movements were present but were not bothering her, interfering with her gait, or interfering with her functional activities. R55's progress note dated 9/12/23 at 12:30, indicated family member (FM)-B had informed staff of R55's worsening muscle movements and the need for additional safety checks. The progress note did not indicate the provider was notified. During observation and interview on 10/23/23 at 3:02 p.m., R55 was observed with full body muscle movements including arms that swung from side to side, sporadic movements of her chest, tongue, and jaw, and occasional sporadic movement of knees. R55 was observed attempting to put a sweater on a hanger into her closet but her arms kept swinging side to side stopping her. R55 took two side steps to her right and caught herself on a box. R55 stated these movements were uncontrollable and had almost caused her to fall multiple times. R55 stated her excessive muscle movements worsened about two months ago when her neurology doctor put her on a new medication. R55 stated staff knew about the increase in her excessive muscle movements but haven't told her doctor. During observation on 10/25/23 at 2:16 p.m., R55 was observed with sporadic muscle movements including, irregular circling of the hips and irregular arm swinging, and repetitive movements of her tongue and jaw. During an interview on 10/25/23 at 2:22 p.m., FM-A stated R55's excessive muscle movements worsened a couple months ago. FM-A stated he informed nurse manager (RN)-A because he was worried about her safety. FM-A stated R55 had increased anxiety because she was afraid of what might happen when her movements worsened, and no one was checking on her. During an interview on 10/25/23 at 2:25 p.m., RN-A stated R55's excessive muscle movements seemed to fluctuate and could occasionally be extreme. RN-A stated nursing staff had looked up the side effects of entacapone because of her muscle movements, but they had always fluctuated so the provider was not notified. RN-A stated FM-A would know and have excellent knowledge of R55's baseline and had he informed nursing staff of these muscle movements worsening, the expectation would have been to reach out to the provider so a change could have been made to the plan of care. During an interview on 10/25/23 at 12:28 p.m., nurse practitioner (NP)-I stated she was not made aware of R55's worsening gait or excessive muscle movements. NP-I stated she would have expected staff to notify her and the neurologist of these changes. During an interview on 10/26/23 at 8:51 a.m., the consultant pharmacist (CP) stated R55's excessive muscle movements could be a side effect of her entacapone. The CP stated it would be important to inform her physician because it was a fine line with Parkinson's disease. During an interview on 10/26/23 at 10:55 a.m., the director of nursing (DON) stated she would have expected staff to monitor residents for possible side effects of new medications and changes in condition. The DON stated due to FM-A's history with and knowledge of R55, he would have been more likely to notice changes in her condition, and his concern should have been relayed to the provider by nursing staff. The facility Notification of Change in a Resident's Health Status policy dated 3/23, indicated the provider should be notified if the resident shows a change in condition, including a deterioration in physical or mental health. The policy also indicates the facility should contact the provider if an alteration in treatment may have been needed, including discontinuing a medication due to adverse consequences.

Based on interview, and document review, the facility failed to implement the care to provide restorative range of motion (ROM) for 1 of 1 resident (R5) reviewed for range of motion. Findings include: R5 was admitted to the facility on [DATE] with diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (one sided muscle weakness) following cerebral infarction (stroke) affecting right dominant side and contracture of muscle, unspecified upper arm. R5's quarterly Minimum Data Set (MDS) assessment, dated 09/14/23, indicated Impairment on one side for both upper and lower extremity. R5's care plan, dated 8/11/23, identified R5 has a functional maintenance program with a goal to maintain joint mobility. R5 was at risk for decline in ROM related to diagnosis of hemiplegia. Care plan indicates for upper and lower extremities: 5 reps and hold count for 5 seconds to provide short stretch to bilateral wrists, elbows, shoulders, knees, ankles, feet, and toes. M-W-F. To be performed by aide. During an interview on 10/25/23 at 1:09 p.m., RN-A stated R5 is a long-term resident of facility, suffered a stroke, and his care plan and orders includes maintain joint mobility. RN-A stated the stretches/exercises are to be attempted and completed at morning and evening cares. RN-A stated R5 can be resistant to exercises and stretches for joint mobility and this resistance had increased. During an interview on 10/26/23 at 9:45 a.m., NA-A stated R5 has orders to complete ROM during morning and evening cares. NA-A stated she completed the stretches/exercises at morning and evening cares, depending on her shift, and if the resident did not refuse, but there is currently no place in the facility's EMR [electronic medical record]to chart completion or resident refusal. During an interview on 10/26/23 at 12:33 p.m., RN-A stated currently there are no posted graphics/depictions of the types of stretches to be performed in R5's room. RN-A stated she demonstrates the stretches/exercises to the aides so they know which ones to be attempted and performed. RN-A stated aides are to complete these stretches/exercises twice daily, at morning and evening cares. RN-A acknowledged there had not been a proper area in the facility's EMR to chart completion or resident refusal to stretches/exercises for R5. RN-A stated in the past this was put in progress notes. Upon review of R5's progress notes, no charting of stretches/exercises noted since 12/08/22.

Based on interview and document review, the facility failed to ensure care conferences were conducted every quarter for 1 of 1 resident (R39). Findings include: R39's face sheet indicated R39's diagnoses included cerebral infarction (stroke), dementia, schizophrenia, and diabetes. During an interview on 10/23/23, at 4:02 p.m., R39 indicated he does not remember having a care conference or a meeting about any goals. R39 indicated that they include me sometimes on what I want to work on. During an interview on 10/25/23, at 12:54 a.m., R39 indicated he meets with the social worker every 6 months or so. R39 indicated will talk about activities occasionally and nurses will talk about medications at times. During an interview on 10/26/23, at 10:30 a.m., social worker (SS-A), indicated care conferences are held upon admission, quarterly, before discharge and as needed. SS-A indicated always the resident, resident's POA/guardian if applicable, social worker, nurse manager, nutrition services, activities, dietary, and therapy (if applicable) would all attend care conference. SS-A indicated care conference notes are found in Matrix (Electronic Medical System), under care plan then go to care conference. During an interview on 10/26/23, at 1:13 p.m., SS-A confirmed upon record review R39's last care conferences were 2/8/23 and 10/9/23. SS-A stated a care conference would not be done without R39's POA as it would not be appropriate. SS-A confirmed R39 was due for a care conference in May which had not been done. SS-A indicated they sent an email to POA 6/12/23 to schedule with no response. Document was reviewed. SS-A indicated care conference typically follows the Minimum Data Set (MDS) schedule. Care conference notes indicated conferences completed 2/8/23 and 10/9/23. The facility policy for Care Plans and Care Conference revised 5/23, indicate quarterly conferences are to review and address alterations in standard of care by identifying goals and individual preferences. Discuss any consequences of interventions which do not align with standards of care. Resident and family are encouraged to attend the quarterly conferences.

Based on interview, and document review, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS) within fourteen (14) days after the facility determined, or should have determined, that there had been a significant change in the resident's physical or mental condition for 2 of 2 residents (R15 and R20). Findings include: The Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.18.11 dated October 2023, Chapter 2, page 2-25, indicated a significant change in status assessment (SCSA) is required to be performed when a resident is receiving hospice services and then decides to discontinue those services (known as revoking of hospice care. The current RAI manual indicates on page 2-26: The MDS completion date must be no later than 14 days from the assessment reference date (ARD) (ARD + 14 calendar days) and no later than 14 days after the determination that the criteria for an SCSA were met. This date may be earlier than or the same as the CAA(s) completion date, but not later than. The CAA(s) completion date must be no later than 14 days after the ARD (ARD + 14 calendar days) and no later than 14 days after the determination that the criteria for an SCSA were met. This date may be the same as the MDS completion date, but not earlier than MDS completion. The care plan completion date must be no later than 7 calendar days after the CAA(s) completion date (CAA(s) completion date + 7 calendar days). R15's quarterly MDS dated [DATE], indicated R15 had diagnoses of non-traumatic brain dysfunction, hypertension (high blood pressure), dementia, anxiety disorder, depression, visual hallucinations (seeing items that are not visible to others), chronic pain, and edema (swelling). A MDS significant change of status assessment (SCSA) had been started for R15 with an ARD date of 10/19/2023. A progress note dated 10/4/23 at 11:37 a.m., stated that resident was discharging from hospice services on 10/6/23 as patient no longer considered terminal. On 10/2/23, an event report note generated from provider visit indicated discussion of discharging R15 from hospice services as R15 remains stable. During interview with RN-B, on 10/24/23, at 3:26 p.m., verified they assist with completion of MDS for the campus indicated that a significant change in status assessment (SCSA) would be completed if a resident is not responding to treatment or coming on and off hospice. They verified R15 had discharged from hospice services on 10/6/23. They indicated the ARD [assessment reference date] is set within 14 days after identifying the significant change. They have 14 days to complete the MDS/care plan from the ARD. They indicated that the ARD was chosen for R15 as 10/19/23 as discharge from hospice was 10/6/23. They indicated this would be within the 14-day window and must have a 7 day look back period. They indicated that you have 14 days to complete the MDS from the ARD date. MDS completion date would be 14 days from 10/19/23 [ARD date]. Reviewed the RAI OBRA - required Assessment Summary which they acknowledged and indicated this is how we have always done it. During interview with RN-B on 10/24/23, at 4:06 p.m., indicated after review of RAI assessment tool that if you look at it that way, it makes sense. During interview with RN-C on 10/25/23, at 8:20 a.m., verified they complete MDS' for the campus indicated that they interpreted the rules differently regarding the ARD date. They indicated the concerns with not having MDS done according to timeframe given it would affect payment, the residents care plans would not be up to date which could affect care. RN-C acknowledged that the significant change in status assessment for R15 had not been completed in the timeframe required. During interview with administrator on 10/26/23, at 2:01 p.m., indicated that R15 should have had a SCSA completed. She indicated a SCSA should have been completed for R15 in the timeframe allotted as this can have an impact on the resident and payment. 44658 R20 R20's quarterly MDS dated [DATE], indicated R20 required setup or cleanup assistance for eating and oral hygiene, and was dependent for all other activities of daily living (ADLs). R20's diagnoses included multiple sclerosis (MS), heart disease, high blood pressure, anxiety, insomnia, and congestive heart failure (CHF, causing fluid in the lungs and body, and shortness of breath). R20's quarterly MDS dated [DATE], indicated R20 had intact cognition and was dependent for all ADLs. R20's care plan dated 9/20/23, indicated R20 had an indwelling urinary catheter. Interventions included encouraging fluids. R20 was also on a functional maintenance program to maintain joint mobility. Interventions included assisting R20 with stretches. R20 was also at risk for nutritional status with a goal to consume adequate fluids. Interventions included serving food in bowls and fluids in covered mugs. The care plan also indicated R20 had a self-care deficit related to impaired mobility. Goals included to maintain her current level of participation related to washing her face. Interventions included the use of an adaptive touch call light due to increased difficulty with a standard call light. The care plan further indicated R20 required only setup for grooming/oral hygiene and eating. R20's progress notes indicated the following: -8/8/23, indicated R20 had continued worsening of hand dexterity and difficulty feeding herself. Although a referral was made to occupational therapy (OT), R20 refused to be seen by OT, but was agreeable to meeting with dietary services regarding the use of adaptive devices. -8/9/23, indicated after meeting with registered dietician (RD)-B, R20 will have food served in bowls, sausage and gravy in a bigger bowl, covered mugs with straws for hot liquids and mugs for soup. -10/13/23, provider note indicated We have noticed some worsening of R20's physical mobility, more specifically her hand dexterity. Her fluid intake has decreased due to her hand dexterity and she is requiring more assistance from nursing with feeding. -10/13/23, R20 noted to be hollering and reported she was unable to press her call light. A touch pad call light was provided and R20 was able to activate. Staff were to continue to monitor R20 due to poor hand dexterity. During an interview on 10/24/23 at 10:01 a.m., R20 stated she noticed a decrease in her hand mobility approximately six weeks prior and believed it was due to the progression of her MS. R20 stated she was also a big water drinker but was now unable to drink by herself and had to call staff to assist her. During an interview on 10/25/23 at 11:42 a.m., RD-B stated R20 was having difficulty moving her arms and was becoming more limited with what she was able to do so registered nurse (RN)-A, the nurse manager, asked RD-B to assess her. During an interview on 10/26/23 at 8:06 a.m., RN-A stated R20's hand mobility had been decreasing over the previous few months and had been requesting more help with eating, so RN-A referred R20 to RD-B. RN-A also stated she recently switched R20's call light to a touch pad because she was having trouble activating the button. During an interview on 10/26/23 at 10:51 a.m., MDS RN-C stated she was aware R20's hand mobility had declined, causing her to require assistance with eating and other related tasks, however; she thought R20 was receiving occupational therapy to address the concern and therefore did not complete a significant change assessment for her. RN-C stated had she known R20 had refused occupational therapy she probably should have done one. RN-C also stated she was unsure of the cause of R20's decline in mobility but assumed is was related to her diagnosis of MS. The facility provided the Resident Assessment Instrument Omnibus Budget Reconciliation Act (RAI OBRA) Required Assessment Summary dated October 2023, as guidance for completion of MDS assessments. The RAI indicated a significant change assessment was to be completed 14 calendar days after a significant change had occurred in a resident's health status. No further policy was provided related to MDS assessments or significant changes in resident health status.

Based on observation, interview and document review, the facility failed to operationalize their abuse prohibition policy to identify and protect a resident(s) following witnessed verbal and physical abuse by staff for 1 of 1 residents (R1) reviewed for staff to resident abuse allegations. This resulted in an immediate jeopardy (IJ) for R1 and potential to affect 12 of 35 residents with behaviors who resided on the Sugar Loaf unit. The IJ began on 7/16/22, when three staff members witnessed licensed practical nurse (LPN)-A covering R1's mouth to stop R1 from yelling, and made demeaning comments. LPN-A finished her shift on 7/16/22 and worked on 7/17/22 with R1 and other resident who were cognitively impaired with behaviors. The administrator, DON, and licensed social worker (LSW) were notified of the immediate jeopardy on 7/27/22, at 10:10 a.m. The facility implemented corrective action and the deficient practice was corrected on 7/19/22, prior to the survey and was issued at Past Noncompliance. Findings include Facility reported incident (FRI) submitted on 7/19/22, at 2:09 p.m. identified that on 7/16/22, at 9:00 a.m. R1 was screaming, licensed practical nurse (LPN)-A was getting frustrated. LPN-A put her hand on R1's mouth and told her, To stop screaming there are other residents here not just her. R1 just kept on screaming. LPN-A then tried slamming R1's jaw to shut her mouth to try and make her stop screaming. NA-B told LPN-A that it wasn't right of her to put hands on R1's face. The report indicated LPN-A made other comments during the day such as 3 days is too long listening to her [R1], I need to put myself in a psychiatric hospital Report identified that police were contacted and came to the facility on [DATE]. LPN-A was removed from the schedule pending the investigation. R1's Face Sheet indicated R1's primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's quarterly, minimum data set (MDS), dated [DATE], identified R1 had severe cognitive impairment and other behaviors not directed towards others that occurred daily which included screaming and disruptive sounds. R1 required supervision with eating and extensive assist of 2 with transfers and extensive assist of 1 with all other activities of daily living (ADL)'s. R1's care plan dated 3/23/22, indicated that R1 behaviors related to MDD, GAD and major neurocognitive disorder due to Alzheimer's disease with behavioral disturbance. R1's behaviors were manifested by excessive loud yelling for help, irritability with staff, swearing and verbalizing to staff, don't you be rough, even before they start to help her. Crying, holding her hand over her mouth, hitting her mouth when yelling out, physical aggression attempting to hit out at staff assisting her, restiveness with cares, and refusal to change clothing even when soiled. Goal: Staff will be able to redirect R1 when agitated and yelling out and she will not become flushed with shortness of breath due to agitation. R1's care plan identified multiple appropriate person-centered interventions to manage R1's behaviors. R1's care plan did not identify R1's risk for abuse. R1's Physician notes, dated 6/20/22, included R1 continues to have multiple adverse behaviors, primarily attention seeking, she enjoys having 1 on 1 attention. She spends a lot of time in her chair by the nurse's desk and continues to be quite confused. R1's medical record did not have an entry for 7/16/22, for the incident between LPN-A and R1. R1's psychiatric note dated 7/18/22, identified that R1's anxiety with periods of yelling out when not by staff, but her periods of yelling out have been easier to redirect. The behavior charting identified her behaviors are more when some staff work versus other staff. Her pain reports have improved with the use of [MEDICATION(S)]. No changes made at this time. During an observation on 7/26/22, at 4:26 p.m. R1 was seated in a recliner inside the nurse's station was seated next to the clinical manager (CM) who was sitting at her computer. R1 was smiling and talking with CM. At 4:28 p.m. R1 very loudly yelled, help me!, when CM asked what she needed help with R1 wanted to call her husband and CM stated shall we call family member (FM)-A, CM gave R1 the phone and there was no answer. R1 started yelling then put her hand over her mouth several times in a rapid succession (normal behavior). CM redirected R1 using appropriate interventions which calmed R1. During an interview on 7/26/22, at 1:34 p.m. NA-B stated she worked the day shift with LPN-A on 7/16/22. NA-B stated R1 had yelling behaviors, which meant she had to go to the bathroom or wanted something, and sometimes it took awhile to figure out what she wanted. Because it was the weekend the charge nurse who usually did 1:1 with NA-B was not there, so R1 was yelling. NA-B indicated around 9:00 a.m. she had just taken R1 to the bathroom and was going to put R1 in the recliner. LPN-A came to assist with transfer and as R1 continued to yell LPN-A put her hand over R1's mouth. LPN-A told R1 there are other residents here not just you. R1 kept on screaming, LPN-A put her hand under her mouth to close her mouth, R1 still screamed. LPN-A then poked R1 in the head and said, you need to use your brain that is what controls your mouth. During an interview on 7/26/22, at 3:17 p.m. with NA-A, she stated she worked on 7/16/22 and was training in NA-C. NA-A indicated at 9:00 she saw LPN-A use her hand to cover R1's mouth, followed by LPN-A telling R1 that her brain was not breaking while tapping her finger on R1's forehead. NA-A had never seen LPN-A respond like that to another resident. NA-A explained on 7/17/22. R1 was screaming, LPN-A told us (NA-B, NA-E, and NA-C), after working with R1 she would have to check herself into a psych ward. During an interview on 7/26/22, at 3:28 p.m. NA-C stated she worked on 7/16/22 and R1 was screaming a lot that morning. NA-C observed LPN-A put her hand under R1's chin to close her mouth. LPN-A then started tapping R1's forehead and said, this isn't broken and don't act like its broken. R1 kept screaming and looked upset. During a phone interview on 7/26/22, at 4:03 p.m. LPN-A verified she worked 7/16/22 and 7/17/22 on the Sugarloaf unit during the day shift and had worked with R1. LPN-A stated, on 7/16/22 R1 was screaming. LPN-A stated when you try and ask R1 what she needs she will tell you she doesn't know. When you offer 1:1, like the Price is Right or a snack, she doesn't want these. LPN-A did not remember assisting with R1 to the recliner or placing her hand over R1's mouth or tapping her head. LPN-A indicated she had worked on 7/17/22, on the sugar loaf unit. During an interview on 7/26/22, at 1:05 p.m. with administrator and DON, indicated they had received an email on 7/19/22, from NA-B that reported the allegations of abuse between LPN-A and R1. Upon investigation they substantiated the verbal and physical abuse allegation that occurred on 7/16/22, at 9:00 am. They reviewed camera footage and completed staff interviews that confirmed the event. This camera footage revealed that LPN-A touched R1 three separate times, first tapped R1 on the head, then is seen putting her hand over R1's mouth, lastly LPN-A was seen pushing upwards on R1's chin, and R1 swung out at LPN-A. Administrator stated, they realize this was reported late and have given the witnesses verbal coaching and education. They implemented facility wide mandatory education on abuse and abuse reporting starting on 7/19/22. DON stated, LPN-A was immediately suspended on 7/19/22, and was terminated on 7/21/22, due to the substantiation of resident abuse. LPN-A was also reported to the board of nursing yesterday. The facility policy, Vulnerable Adult Abuse Prevention Plan, reviewed/revised 7/2022, identified a purpose that our facility has established and shall enforce an ongoing abuse prevention plan. The facility has a designated a team to review all complaints/concerns involving a resident who is suspected of, or has been abused or neglected, or has sustained a physical injury which is not reasonably explained. The team or designated members of the team will complete a thorough investigation of these cases and assure appropriate prevention action. Section V. Reporting Procedure. A. Upon discovery of the vulnerable adult situation, staff are required to notify the charge nurse and administrator on call immediately of the situation. The notified party will act to ensure the safety of the residents and that the vulnerable adult policy is being followed. The past noncompliance immediate jeopardy began on 7/16/22. The immediate jeopardy was removed, and the deficient practice corrected by 7/19/22, after the facility implemented a systemic plan that included the following actions: -Review of the facility investigation dated 7/19/22 identified LPN-A was immediately suspended on 7/19/22. -Review of R1's progress notes 7/16/22 to 7/26/22 identified monitoring/assessing for R1's behaviors for any changes as a result of the abuse. -NA-A, NA-B, and NA-C's personal files identified on 7/19/22 they were provided with comprehensive training on identification of abuse and abuse reporting procedures. -Facility developed training plan on 7/19/22 which included definitions of abuse, abuse reporting, review of abuse policy, and competency test that staff had to complete. The training was implemented on 7/19/22 with continuation for all staff to complete prior to the start of their next shift. -During staff interviews on 7/26/22, between 1:05 p.m. and 5:15 p.m. identified all direct care staff NA-A, NA-B, NA-C, TMA-A, LPN-B, and RN-A were able to articulate what constituted abuse and the facility's abuse reporting policy and procedure. -LPN-A's personal record notation identified she was terminated on 7/21/22 and reported to the Board of Nursing on 7/25/22.

Based on observation, interview and document review, the facility failed to complete comprehensive hydration/nutritional assessment and monitoring, prior to and/after discontinuation of tube feeding, in order to prevent dehydration for 1 of 1 resident (R56) reviewed for hospitalization . The facility's failures caused harm for R56 who becaming severely dehydrated and sustained acute [MEDICAL CONDITION]. Findings include R56's [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED]. On 9/18/18, a [DIAGNOSES REDACTED]. R56's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R56 had severe cognitive impairment, and required supervision with eating. The MDS indicated during the assessment period, R56 had complaints of difficulty or pain with swallowing, weighed 184 pounds, had no weight loss, had a physician prescribed diet for weight gain, had a feeding tube and also had orders for a mechanically altered diet. The MDS also indicated R56 received 51% of total calories and averaged 501 cubic centimeters (cc) or more of fluid via the feeding tube. R56's annual MDS dated [DATE], indicated R56's cognitive skills for daily decision making were severely impaired and R56 required supervision for eating. The MDS also indicated the resident had no difficulty with chewing or swallowing, a weight of 179 pounds, was not on a physician prescribed diet for weight gain, did not receive tube feeding, and received a mechanically altered and therapeutic diet. R56's nutritional care plan dated 9/21/18, identified R56 had been hosptalized on [DATE], related to dehydration and urinary tract infection, and had swallowing difficulty. The care plan goals included: weight will remain above 170 pounds (lbs) and would consume adequate intake to meet his needs. The care plan further included directives for staff to ensure adequate fluid intake, not use straws, and to give strawberry Ensure at 10:00 a.m. and chocolate Ensure at 2:00 p.m. (8 ounces) for additional calories. The care plan did not include any goal for fluid intake. R56's hospital discharge summary dated 9/17/18, indicated R56 was admitted to the hospital on [DATE]. The hospital note included: R56 had long-standing history of [MEDICAL CONDITION], who just recently had his percutaneous endoscopic gastrostomy (PEG) tube removed on 8/24/18. He was admitted with obvious dehydration, [MEDICAL CONDITION] (high sodium) and acute kidney injury. The discharge summary also indicated during the hospital course R56 was diagnosed with [REDACTED]. R56's nutritional assessment dated [DATE], indicated R56 had been working with speech therapy to progress to eating by mouth and that at time the diet was mechanical soft textures. The assessment further indicated R56's oral intake had increased however, R56 continued to refuse breakfast on most days and may improve with further tube feeding reduction. Tube feeding was decreased on 6/18/18, to promote increased intake at meals. The note indicated another decrease in amount of tube feeding would begin. The [MEDICATION NAME] 1.5 would be decreased to three hours per day to run at 130 cc (cubic centimeters)/hr (hour) from 9:00 p.m. to 11:00 p.m., with continued 400 cc water flushes four times a day because oral intake remained inadequate. The assessment indicated R56 required 2590 cc's of fluid daily. The note also indicated a calorie count would be started for 5 days. R56's nutritional assessment dated [DATE], indicated fluid intake at meal times was inadequate as well as between meals, and therefore R56 continued to receive water flushes between meals to prevent dehydration. The note also indicated the [MEDICATION NAME] 1.5 feeding would be held for one week to see if he continued to eat well and to determine if he could maintain weight between 185-190 lbs.; current weight was 189 lbs. and because fluid intake was inadequate water flushes would continue to be provided and fluid intake would be re-evaluated in one week. The assessment further indicated staff would monitor his fluid intake on a daily basis. The goal was to wean R56 from the tube feeding and need for fluids and medications via the tube. R56's next nutritional assessment was dated 7/23/18, and indicated R56 was recently upgraded to a regular diet with ground or cut up meats, whereas he had previously also had a tube feeding. The assessment indicated he had been doing well with food intakes from 50-100% for lunch and dinner with some refusals for breakfast, because he liked to sleep in late. The assessment also indicated R56 received Ensure when he get up in the morning and his current weight was 197 lbs, however also indicated: Oral intake of fluids remains inadequate. R56's (MONTH) (YEAR), Medication Administration Record [REDACTED]. The MAR further indicated the previous order that started on 6/29/18, which included [MEDICATION NAME] 1.5, 130 cc's an hour times three hours was discontinued on 8/5/18. R56's progress note dated 8/13/18, included: no longer receives tube feeding; does receive 120 ml flush daily before supper. A subsequent progress note dated 8/13/18, indicated the nurse practitioner was updated on constipation since diet change and a new orders were obtained. R56's record lacked assessment to determine fluid intakes were sufficient according to assessed needs. R56's subsequent nutritional assessment was dated 8/14/18, and included: weight has decreased 8 lbs. in 30 days, on 7/25/18, the Mighty Shake supplement was changed to give only at dinner. Current weight 186 lbs. The note indicated a decrease in minimum weight; 180-190 lbs. The note further included; Resident is consuming 100% of breakfast in the last 3 days, refused x 2 days, consumes 75-100% at lunch, 50-100% at dinner, no problems with swallowing and current textures provided, no [MEDICAL CONDITION]. Will review weight weekly. The assessment did not include evaluation of fluid intake. R56's progress note dated 8/14/18, indicated R56 continued to be eating and drinking well at meals and did not have indicators of dehydration. R56's next nutritional assessment was dated 8/17/18. The assessment indicated the purpose of the note was due to the resident's weight fluctuating. The additional comments section of the note included: resident is on a regular diet, is eating at a supervised table and uses a divided plate, gripper mat, gets his meats chopped or ground up. His fluids continually improves. He receives Might Shake at dinner daily. His goal weight is 190-195 lbs. Staff continues to encourage intake of food and fluids. He will be followed monthly. R56's next nutritional note was dated 8/21/18, indicated a weight of 183.2 lbs., decrease of 2.8 lbs. in one week, continue to monitor weight weekly. R56's daily fluid record from 8/20-8/24/18 reflected the following: 8/20/18: breakfast= 370 cc, lunch=zero (resident refused lunch), dinner=290 cc, daily flush 120 cc. (Total 780 cc) 8/21/18: breakfast= 370 cc, lunch=180 cc, dinner=480 cc, daily flush 120 cc (Total 970 cc) 8/22/18: breakfast= zero (resident does not want breakfast), lunch 180 cc, dinner=510 cc. (Total 810 cc) 8/23/18: morning=180 cc, lunch=370 cc, dinner=300, daily flush 120 cc (Total 970 cc) 8/24/18: breakfast=180 cc, lunch=160 cc, dinner 120 cc. (Total 580 cc) R56's surgery note dated 8/24/18, indicated reason for visit is to have PEG removed. The note indicated R56 had been able to eat a general diet, and had been thoroughly evaluated by a speech pathologist. The note also indicated the PEG tube had not been used for at least three months. The note further indicated R56's blood pressure was low and that findings had been communicated to the nurse at Lake Winona Manor to do more frequent checks to make sure it was stable. R56's progress note dated 8/24/18, indicated R56 was incontinent twice with dark concentrated urine with hematuria (blood in urine) and staff would encourage fluids between meals. No further hematuria was indicated in progress notes until 8/28/18. R56's record reflected the following daily fluid intake totals after PEG removal; the record continued to lack evidence of comprehensive evaluation of daily fluid intake, and failed to identify current hydration needs after removal of the PEG. 8/25/18: breakfast=180 cc, lunch=zero, dinner=340 cc. (Total 520 cc) 8/26/18: breakfast=zero resident does not want, lunch resident does not want, dinner 370 cc's. (Total 370 cc) 8/27/18: breakfast= 360 cc, lunch=zero, dinner=280 cc. (Total 640 cc) 8/28/18: breakfast=360 cc, lunch=not recorded, dinner=360 cc (total 720 cc) R56's progress note on 8/28/18, indicated R56 was incontinent twice with urine that was dark orange in color. 8/29/18: breakfast=150 cc's, lunch=zero resident does not want, nothing recorded for dinner (Total 150 cc) 8/30/18: breakfast=zero resident does not want, lunch resident does not want, dinner=360 cc. (Total 360 cc) R56's progress note dated 8/30/18, indicated R56 was not feeling well but demonstrated no outward symptoms. A progress note later that day at 3:35 p.m. indicated no further concerns with hematuria or concentrated urine, continued to drink fluids well, and had no indicators of dehydration. 8/31/18: breakfast=zero refused, lunch=160 cc, dinner=330. (Total 490 cc) 9/1/18: breakfast=zero refused, lunch=zero refused, nothing recorded for dinner. (Total zero cc) 9/2/18: breakfast=420 cc, lunch=zero refused, dinner=zero refused. (Total 420 cc) 9/3/18: breakfast=360 cc, lunch=180 cc, nothing recorded for dinner. (Total 540 cc) 9/4/18: breakfast=420 cc, lunch=zero refused, dinner 300 cc. (Total 720 cc) R56's next nutritional note dated 9/4/18, lacked an evaluation of the daily fluid deficit, however, indicated a weight loss over the prior two weeks; 8/27/18, weight was 181 lbs., 9/4/18, weight was 175.4 lbs., The note indicated R56 agreed to drink Ensure supplement at all meals. R56's record from 9/5 through 9/7/18, continued to reflect fluid deficits even with the addition of Ensure supplement. 9/5/18: breakfast=610 cc, lunch=190 cc, dinner=420 cc. (Total of 1220 cc) 9/7/18: breakfast=420 cc, lunch zero resident refused, dinner 460 cc. (Total 880 cc) R56's progress note dated 9/7/18, indicated R56 had cloudy urine with no burning and to push fluids. R56's record revealed no nutritional assessment was conducted immediately after the PEG tube was removed (8/24/18) until 9/7/18. The 9/7/18, assessment indicated R56's daily fluid requirements was reduced from 2590 cc per day to 2390 cc, indicating R56 consumed 1500-2000 cc/day, and was at LOW RISK for dehydration even though, the daily fluid intake monitoring between 8/24 through 9/7/18, reflected a daily average liquid consumption of only 495 cc per day. The assessment further indicated R56's weight was 175.4 lbs. with an ideal body weight of 128-161 lbs. Nutritional needs required: KCAL 1450-2190, protein 58-73 grams, and was given nutritional supplement with meals. The note further indicated R56 was refusing dinner and lunch often however, was drinking 100% of Ensure, was walking more, and was not snacking as much. The assessment further indicated R56 was a high nutrition risk-class 4, and weight was reviewed weekly. R56's intake record from 9/8 through 9/11/18, continued to reflect fluid deficits following the nutritional assessment on 9/7/18. The total daily assessed fluid intake needs identified 9/7/18 =2390 cc. On 9/8/18 the resident's fluid intake included: breakfast other=250 cc, lunch 420 cc, dinner 180 cc. (Total 850 cc) R56's progress note dated 9/8/18, indicated R56 was having difficulty swallowing his pills earlier in day; R56 told staff that he had been having a hard time swallowing recently. A subsequent progress note indicated later that evening R56 again had a hard time swallowing pills, however, eventually was able to get them down. R56's intake 9/9/18 included: breakfast=zero refused, lunch=zero refused, dinner=300 cc. (Total 300 cc) R56's progress notes from 9/9/18, indicated R56 did not eat breakfast or lunch, and did not each much for supper. A progress note indicated he took his medication slowly like he was remembering how to swallow. R56's intake 9/10/18 included: breakfast=240 cc, lunch=190 cc, dinner=200 cc. (Total 630 cc) R56's progress notes from 9/10/18, indicated he did not eat well for breakfast or lunch and was slow to swallow water and medications. The progress notes indicated at 4:05 p.m. on 9/10/18, the nurse practitioner (NP) was updated related to occasional periods of holding medications in mouth, as well as not wanting as many snacks as in past. In addition the NP was informed that although R56 was eating his meals, he had noted weight loss. R56's intake 9/11/18 included: breakfast 120 cc, lunch=zero resident did not want, dinner 20 cc. (Total 140 cc) R56's progress notes dated 9/11/18, from a Provider Visit included: past two days had been verbalizing sore throat and had increased difficulty swallowing at times. A progress note at 4:00 p.m. indicated a discussion with R56's power of attorney and included: although is still drinking and eating well for meals, past three days has verbalized sore throat at times although upon assessment no noted redness. R56's nutritional assessment note from 9/11/18, did not include a comprehensive evaluation of fluid intake. The assessment indicated R56's weight on 9/10/18, was 173.4 lbs., down two pounds in one week. The note indicated Ensure had been started with meals, but R56 had some swallowing problems noted so would be evaluated by speech therapist. R56's intake 9/12/18 included: breakfast=zero refused, lunch=zero refused, dinner=zero refused. (Total zero cc) R56's progress note dated 9/12/18, indicated R12 had not had a bowel movement in five days, had been complaining of abdominal discomfort, a suppository was given and R56 expelled an extra large amount of sticky stool that required digital assistance. Progress note at 4:09 p.m. indicated R56 was seen by MD (medical doctor) related to weight loss, periods of refusing to eat, and recent concerns of constipation: MD ordered labs. R56's physician visit note from 9/12/18, included: He had a feeding tube for many months but his oral intake was much better and the tube was discontinued. Recently he has not been eating as well and has been complaining of abdominal discomfort. Nursing felt that this was related to constipation. He is much more sedated than he has been in the past. The physical exam indicated no qualifying data for vital signs and measurements, less alert than he previously has been, and had active bowel sounds. The assessment and plan included: it is apparent that his status is changed considerably since last seen and labs will be ordered to see if there is anything reversible here. R56's intake 9/13/18 included: breakfast=360 cc, lunch=zero refused, dinner= resident was not there. R56's progress note dated 9/13/18, at 1:24 p.m. indicated his physician had called with orders to transfer R56 to the emergency room for intravenous fluids because his lab work reflected severe dehydration. R56's emergency department visit dated 9/13/18, indicated nursing staff had reported decreased intakes over the past week, labs had been ordered related to weakness, and R56 had been sent to the emergency department for further evaluation. The [DIAGNOSES REDACTED]. The notes included: dehydration/acute kidney injury: patient was sent from Lake Winona Manor for further evaluation. Patient had PEG tube removed on 8/24/18, likely unable to keep up fluid needs. The note indicated the patient presented with blood pressures between 99/61 and after intravenous fluids given blood pressure improved to 115/71. The note further indicated the patient reported constipation and had a distended abdomen with no complaints of pain; imaging study would be decided after hospital admission. Physical exam indicated ears, nose, mouth, and throat had dry mucous membranes. Labs on 9/13/18, at 11:05 a.m. included: sodium of 149 mEq/L (high), BUN 77 mg/dl (high), and Creatinine 2.42 mg/dl (high). During an observation on 10/31/18, at 7:55 a.m. R56 laid in bed with his eyes closed. Nursing assistant (NA)-G stated she had already provided morning cares however, R56 refused to get out of bed. NA-G stated somebody would take him in a nutritional supplement and offer him that for breakfast. During an observation on 11/1/18, at 7:50 a.m. R56 sat in his wheelchair at the dining room table. R56 stated ever since they took out the PEG tube he had been struggling with constipation. During an interview on 10/31/18, at 4:46 p.m. registered nurse (RN)-J stated R56 was eating and drinking ok. RN-J stated the nursing assistants documented the amount of fluid intake after each meal. RN-J indicated an unawareness if total daily fluid intake was assessed and was not aware of who was assessing the total amount of fluid intake in order to ascertain deficits that could lead to dehydration. RN-J stated if R56 had a decrease in fluid intake, or was not drinking, RN-J would encourage fluids. RN-J further stated the documentation should indicate a deficit and interventions attempted or used to replace the fluid deficit. RN-J was asked about R56's change in urine integrity; RN-J stated usually they would not call the doctor unless there were three symptoms of urinary tract infection. However, RN-J also stated it would also be dependent on nursing judgement. During an interview on 11/1/18, at 7:57 a.m. RN-A stated R56 had been admitted to the facility with the PEG tube; the reason for PEG tube was not certain. RN-A stated R56 had worked with speech and R56 worked really hard to eat so the PEG could be removed. RN-A stated R56's intakes were monitored by dietary and he was weaned off the formula when his intakes were sufficient to sustain daily recommended nutritional needs. RN-A stated the [MEDICATION NAME] formula started being held on 7/30/18, with 400 cc's flushes three times a day until 7/30/18, then the flushes were decreased to 150 cc's once per day. RN-A reviewed R56's nutritional assessments and verified the record lacked evidence of a nutritional assessment prior to or immediately following the PEG tube removal to identify daily fluid intake requirements. RN-A also confirmed R56's record lacked evidence of daily fluid intake totals and evaluations to determine fluid deficits even after the 9/7/18, nutritional assessment that that identified R56 required daily fluid amount of 2390 cc. RN-A stated prior to R56's hospitalization , R56 had seemed to drink and eat less than he had been. RN-A stated R56 did not have an order for [REDACTED]. During an interview on 11/1/18, at 10:23 a.m. nutrition specialist (NS) reviewed the record and confirmed neither the registered dietian, nor dietary supervisor had completed a comprehensive assessment of R56's daily fluid intake requirements prior to, or immediately after, the removal of the PEG. The NS said the assessment dated [DATE] did not reflect fluid intakes as documented. The NS also verified nutrition progress notes prior to, and after removal of the PEG tube, lacked evaluation of daily fluid requirements and deficits. The NS also stated she was unsure whether nursing was evaluating daily fluid intakes. During an interview on 11/1/18, at 11:42 p.m. director of nursing (DON) stated the expectation that nutritional assessment should have been completed prior to, and/or immediately following the PEG removal, to identify daily fluid requirements. The DON further stated R56's fluid intakes should have been monitored and evaluated daily. The facility's Hydration Management policy dated 6/2017, indicated the purpose was: To ensure risk factors for dehydration are identified and steps are taken to determine that a resident has sufficient fluid intake to maintain proper hydration and health status. The policy included the following risk factors for dehydration: weight loss, tube feedings, resident dependent on staff for intake, diuretic use, cardiovascular agents, [MEDICAL CONDITION], history of refusing fluids, limited fluid intake, resident lacking sensation of thirst. -Nursing assessment: A) Residents' dehydration risk is assessed on admission, quarterly, and as needed thereafter. B) Nursing should update provider if dehydration is suspected so resident may be evaluated further. C) Some common symptoms include: thirst, dark urine, headache, tenting of skin. -Care Plans: risk factors for dehydration should be identified by nursing assessment, appropriate care plan and interventions should be documented. The facility's Nutrition Risk Protocol dated 5/6/17, identified nutritional risk categories, and included and/or identified categories of risk specific for dehydration.

Based on interview and document review, the facility failed to prevent a significant medication error for 1 of 4 residents reviewed, R1, when a staff person administered another resident's medication to R1. R1 experienced adverse symptoms due to the medication error, which required evaluation in the emergency department (ED) and inpatient monitoring. R1's care plan, dated (MONTH) 15, (YEAR), indicated R1 had an alteration in vision. The care plan specified a goal to maintain safety, including administering medications as ordered and observing for side effects and effectiveness. Review of the facility's schedules, dated (MONTH) 31, (YEAR) and (MONTH) 1, (YEAR), indicated Registered Nurse (RN)-D worked from 11 p.m. to 7 a.m. (MONTH) 31 - (MONTH) 1, and was scheduled to work on the day shift until 8:15 a.m. Review of R1's face sheet with diagnoses, dated (MONTH) 1, (YEAR), indicated R1 does not have a [DIAGNOSES REDACTED]. Review of R1's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Review of the ED provider's notes from (MONTH) 1, (YEAR), indicated R1 presented with chest pain, vomiting, and dizziness. The notes indicated R1 was erroneously given another resident's medication at Lake(NAME)Manor, three tablets of [MEDICATION NAME] 25-100 milligrams at 8:15 a.m., and shortly thereafter started to feel nauseous with several episodes of emesis, chest pain, and shortness of breath. At 9:11 a.m., R1's blood pressure was 142/71, with a pulse of 109. Since R1 was still complaining of chest pain, the ED provider saw new changes on her electrocardiogram, and poison control recommended a 4-6 hour observation period, the provider decided to admit R1 to an inpatient floor. In the ED, R1 received a bolus of fluid and a dose of anti-nausea medication. On the inpatient floor, R1's medical records indicated the provider discharged R1 back to Lake(NAME)Manor on (MONTH) 1, (YEAR) at 6:15 p.m. The provider noted R1's symptoms completely resolved and R1 was stable. A Final Opportunity Agreement, dated (MONTH) 7, (YEAR) and signed by RN-D, the Director of Nursing, and a human resources staff, indicated on (MONTH) 1, (YEAR) RN-D gave the wrong medications to a resident. The agreement indicated RN-D's medication error caused the resident to experience unwanted side effects and be sent to the ED for evaluation. The agreement also indicated the facility has safety checks in place to avoid this type of error, the six rights of medication administration, and had RN-D performed those safety checks prior to administering the medications, she would not have committed the error. Observations on (MONTH) 22, (YEAR) at 7:05 a.m. indicated R2 was not wearing a name band. When interviewed on (MONTH) 22, (YEAR) at 7:08 a.m., family member (FM)-E stated when the staff administers medications, they do not ask R2 her name or check her identification. FM-E stated staff say hi to R2, using her name, and they are familiar with her. During observation of a medication pass by trained medication aide (TMA)-F on (MONTH) 22, (YEAR) at 7:44 a.m., TMA-F stated to verify it is the right person, check the name band. The resident was wearing a name band and TMA-F acknowledged she only said the resident's name. TMA-F stated she does the medication rights when she pulls the medication from the cart. During observation of a medication pass by RN-G on (MONTH) 22, (YEAR) at 8:30 a.m., RN-G said the resident's name but did not check their name band. RN-G acknowledged not checking the resident's name band before administering medications, and stated if she is not familiar with the resident, she will check their name band. RN-G also stated that some residents have their picture in the electronic MAR (eMAR). When interviewed on (MONTH) 22, (YEAR) at 8:40 a.m., nursing assistant (NA)-H stated she had observed some staff talk with residents before administering medications, but without checking their name band. NA-H stated sometimes staff checks the resident's name band first. During an interview on (MONTH) 22, (YEAR) at 9:08 a.m., R3 was not wearing his name band. R3 stated his name band was in the bedside table drawer, that he did not like wearing the name band because it was too tight, and he pulled it off about a year ago. R3 stated he would wear a name band if it were less tight. R3 stated he had not seen anyone check his name band, rather staff say his first name and identify the medications. When interviewed on (MONTH) 22, (YEAR) at 9:17 a.m., R4 stated staff sets her medications on a table and do not usually say her name. R4 stated some staff could answer questions about her medications. During an interview on (MONTH) 22, (YEAR) at 9:26 a.m., R5 stated staff usually checks her name band before giving her medications, but not always. R5 stated staff usually say her name, and occasionally ask for her birthdate. When interviewed on (MONTH) 22, (YEAR) at 9:50 a.m., R6 stated staff sometimes checks her name band before administering medications. R6 stated if it is a new medication, staff ask her name and check her name band. R6 stated if it is a regular medication, staff says her name when they enter her room. During an interview on (MONTH) 22, (YEAR) at 10:03 a.m., R1 stated she took the wrong medication before eating breakfast. R1 stated she thought she had taken two pills, not three, but found out she had taken three pills in the hospital. R1 stated the round white pills she took were for [MEDICAL CONDITION] and looked very similar to Tylenol. R1 stated she was halfway to the dining table and the staff person touched her on the shoulder, said, There you are, I've been looking all over for you, and pushed her the rest of the way to the table. R1 stated at the table the staff person gave her a medicine cup, sat on the stool beside her, and R1 took the medication. R1 stated she started eating and everything got blurry, things started swirling around, and she got sick to her stomach. R1 stated she said she did not feel good and staff wheeled her to her room. R1 stated she threw up in the bathroom and staff decided she should go to the hospital. R1 stated she returned to the facility from the hospital after supper. R1 stated she did not know if the staff who gave her the medication said her name, but the staff did not ask her name or birthdate or check her name band. R1 stated she thought the staff was going to put the medications on a spoon for her, but R1 told the staff she did not need to do that, and then took the medications out of the medication cup. R1 stated she started feeling badly less than 30 minutes after taking the medication. R1 stated she was nervous and shaky but fully recovered. R1 stated usually staff say Hi (R1), and then administer her medications. R1 stated staff do not check her name band and do not ask for her name and birthdate. R1 stated one staff, who does not regularly work at the facility, checks her name band and asks for her name first. When interviewed on (MONTH) 22, (YEAR) at 12:11 p.m., RN-A stated RN-D had stayed over from the night shift to give medications. RN-A stated RN-D told her she thought she had given the wrong medication to R1. RN-A stated she questioned RN-D, and RN-D told her R1 was throwing up and RN-D thought she gave R6's medication to R1. RN-A stated when she went to assess R1, R1 was very flushed and sitting on the toilet. RN-A stated R1's pulse was elevated. RN-A stated after she figured out R1 had been given [MEDICATION NAME], she called the ED for advice, and then went back to R1's room where R1 was dry heaving. RN-A stated staff got R1 into a gown and prepared her for transfer to the ED. RN-A stated RN-D told her R1 was on her way out to the dining room in her wheelchair, and RN-D had already put R6's pills into a medication cup. RN-A stated RN-D said she pushed R1 the remainder of the way to the dining table and put the [MEDICATION NAME] next to R1, and later R1 told RN-D she felt funny after taking the pills RN-D gave her. RN-A stated RN-D realized she had not administered R1's medications yet. RN-A stated she did not see the medication error occur. RN-A stated when staff administer medications, they can identify residents by the name bands on their wrists, asking the resident's name and date of birth (DOB), and often by a photo in the eMAR. RN-A stated staff are not checking the resident's name band every time because staff know the resident, and they do not ask the resident's name and DOB every time either. RN-A stated the facility has medication errors, but this incident was an exception as far as the severity. RN-A stated since the incident the facility has posted the medication administration policy and staff have been reviewing it in their daily huddle. During an interview on (MONTH) 22, (YEAR) at 12:50 p.m., TMA-B stated on the morning of the incident she noticed RN-D appeared down, whereas usually RN-D is very peppy and outgoing. TMA-B stated she asked RN-D what was going on, and RN-D told her she thought she gave R1 the wrong medication. TMA-B stated R1 took three tablets of R6's [MEDICATION NAME], had an emesis, and was taken to the ED for evaluation. TMA-B stated on the eMAR there is a photo of each resident so staff knows what they look like, but also every resident has a name band. TMA-B stated she usually checks the resident's name band, it contains the resident's name and DOB, but she does not check the name band every time. TMA-B stated she is familiar with resident faces and when she calls their names, they respond. TMA-B acknowledged what should formally occur is staff should check the resident's name band and/or ask the resident for their name and DOB. TMA-B stated if a new resident comes, she makes sure to check their name band. When interviewed on (MONTH) 22, (YEAR) at 2:11 p.m., the Director of Nursing (DON) stated she talked with RN-D immediately following the incident. The DON stated RN-D said she was going to give R6's medication when R1 asked RN-D to take her to the dining table. The DON stated RN-D sat R6's medications on the table, sat down, and had conversation with the residents there. The DON stated RN-D had gotten up from the table and walked away, and could not remember where R6's medications were. The DON stated RN-D went back to the medication cart, got R6's medications, and gave them to her. The DON stated RN-D had heard R1 was not feeling well, checked on her, and R1 told RN-D she was feeling fine until RN-D gave her those medications. The DON stated that is when RN-D realized what happened with R6's medications. The DON stated RN-D seemed unsure about what happened. The DON stated that after talking with R1, it appeared RN-D had administered R6's medications to R1, rather than leaving them on the table for R1 to take. The DON stated RN-D said she did not remember giving the medications but that it was possible. The DON stated her understanding was RN-D probably gave the medications to R1. The DON stated residents have a photo in their eMAR, and they have a name band on their wrist. The DON stated staff administer medications to one resident at a time, and to confirm they have the right resident, staff have the eMAR photo, and besides that staff ask the resident's name or check the name band. The DON stated a clear photo would be enough to identify a resident, if the resident did not have a name band and the resident could not speak. During an interview on (MONTH) 22, (YEAR) at 3:10 p.m., RN-D stated on the day of the incident she stayed over to work from the previous nightshift, and she only needed to stay for an hour or two. RN-D stated that morning as she administered medications, another resident and staff, with different requests, kept interrupting her. RN-D stated she got R6's medication, three tablets of [MEDICATION NAME] 25-100 mg, and put them in a medication cup. RN-D stated she saw that R6 was not in her usual spot at the dining table, possibly made contact with another nursing assistant, and then came walking back to the dining table after having more resident contact. RN-D stated she wheeled R1 to the dining table with R6's medications in hand, and did not remember the specifics after that. RN-D stated she thought she left R6's medications at the table, but it was possible she fed them to R1. RN-D stated R1 is credible, alert, and oriented. RN-D stated she talked to the residents at the table, maybe sat or knelt down, talked to R6 and R1, and walked back to the medication cart. RN-D stated she started preparing medications for another resident, saw R6 was at the dining table, and could not find her pills. RN-D stated she knew she had not given R6 her [MEDICATION NAME], so she administered the medication to R6 at the dining table. After that, RN-D stated she got R1's morning medications ready in a medication cup, noticed R1 was not at the dining table, and walked to her room where a staff said R1 was not doing well. RN-D stated she was positive she administered R6's medication to R1; she gave her the cup of medications. RN-D stated residents have a name band, but if you are familiar with the resident, you call them by their first name and not ask their name. RN-D stated she generally does not ask for the resident's DOB, but looks at the name band. RN-D stated she did not remember if she said R1's name that morning, and she was pretty sure she did not look at R1's name band or ask for R1's name and DOB. RN-D stated R1 was in the bathroom and said she did not feel good, and she was flushed and nauseous. RN-D stated while she checked R1's vital signs, R1 said she started feeling unwell after taking the medication that RN-D gave her. RN-D stated she was then confident she had given R6's [MEDICATION NAME] to R1. RN-D stated she notified the unit leader, who tried to contact the provider. RN-D stated R1 continued to be flushed, and dry-heaved and vomited, so staff decided to have R1 evaluated in the ED. RN-D stated she was tired from working the previous night shift, and then had multiple distractions of leaving the medication cart to address other resident's concerns. RN-D stated she did not focus on one person and give their medication, and tried to do multiple things at once. RN-D stated in the past she has checked the resident's name band, especially when she was not familiar with the resident, but it was fair to say that sometimes she administers medications by greeting the resident by their name. The facility's Medication Administration Competency, undated, under the title Medication Administration, indicated Medication is administered to right resident (check arm band). A facility policy, dated (MONTH) (YEAR) and titled Medication Administration, indicated: The guidelines of administration are the right dose of the right medication to right person by the right route at the right time and recorded in the right place with the right response.

Based on interview and document review, the facility failed to supervise 1 of 4 residents reviewed (R1), when facility staff left the resident alone, connected to a mechanical ceiling lift, and seated on a commode. This resulted in actual harm to R1 when R1 fell off of the commode and sustained bilateral leg fractures. The resident died several days later. Findings include: R1's care plan dated [DATE], indicated an admission [DIAGNOSES REDACTED]. R1 required assistance of two staff with all aspects of mobility. The Quarterly Minimum Data Set ((MDS) dated [DATE], indicated R1 was totally dependent for transfers and toileting. Progress notes dated [DATE] at 2:17 p.m., indicate R1 was toileted on the commode in her room. When staff entered the room, they found her with her bottom touching the floor, but still connected to the ceiling lift. When R1 was asked if the commode slid out from under her, she responded yes. The commode chair was found unlocked. R1 had a skin tear on the left shin and complained of increased pain in the left knee. X-rays were ordered. Progress note dated [DATE] at 4:42 p.m. notes that a family member accompanied R1 for x-rays and results showed both of R1's legs were fractured. During an interview on [DATE] at 2:15 p.m., certified nursing assistant (CNA)-B stated that R1 was transferred to the commode in the middle of the room, and stayed in the sling connected to the lift while on the commode. R1 was given the call light and staff left the room. It was R1's routine to be left alone to give privacy, and this is how the staff had routinely performed the care for R1. Per interview dated [DATE] at 2:44 p.m., CNA-E stated he heard R1 scream and immediately went to her room. CNA-E saw R1 suspended in the lift sling with R1's bottom touching the floor. The commode was near the door and the wheels were not locked. CNA-E stated that leaving R1 alone while on the commode was R1's normal privacy routine, which could last up to thirty minutes. Per interview dated [DATE] at 9:37 a.m., registered nurse (RN)-A stated that R1 complained of left leg pain immediately after the fall. The provider was notified and x-rays were ordered. During this time, RN-A noted swelling in R1's right leg. R1 refused an emergency room evaluation. RN-A stated R1, when on the commode, was given privacy, the lift bar to hold on to, the wheelchair pedals to set feet on, and had become a comfort measure while R1 was seated on the commode, but it was not reflected in her care plan. During interview on [DATE] at 10:10 a.m., the director of nursing (DON) stated that for R1, it was standard to use the commode in the middle of the room as the lift does not go into the bathroom. It appeared the commode was not locked, based on the 'found' position. The DON also stated that the lift manufacturer's guidelines suggest not to leave the resident alone in an upright position in the lift. The use of the mechanical lift for transfers or level of supervision while on the commode was not specified in R1's care plan. The physician was interviewed on [DATE] at 10:05 a.m. and stated R1 had refused further treatment after the fall, therefore comfort measures were initiated. The resident had a broken femur that occurred during the fall which caused significant swelling and pain in the leg. The resident was put on a morphine pump for comfort. R1 died several days later, and the death was related to the fall. During an interview on [DATE] at 2:30 p.m., CNA-F states the resident was toileted per her routine. This routine included transferring R1 to the commode, giving R1 the hand controller for the lift and the call light. Staff then left the room to give R1 privacy per her request. The commode did not roll back at that time, but CNA-F does not remember looking at commode wheels to know if they were locked. The Liko brand mechanical lift product description lists under safety instructions, to Never leave a patient unattended in a lifting situation. There was not a facility policy that specified the amount of supervision required related to mechanical lift connection while using the commode. The facility did have a policy that all mechanical lifts require two staff to be present at the time of the transfer.