Every finding on record at Lakeview Methodist Health Care Center

Based on observation and interviews the facility failed to ensure grievance forms were posted in prominent locations throughout the facility for residents and resident representatives to file grievances, and anonymously. This had the potential to affect all 66 residents in the facility. Findings include:On 11/18/25 at 10:30 a.m., during the resident council meeting, residents R7, R25, R26, R42, R43, and R62 stated they were not aware of any method to submit concerns anonymously. The residents also reported that grievance forms were not readily available and could only be obtained by asking staff. R25 further stated grievance forms had previously been available in multiple locations throughout the facility but were no longer accessible to residents without requesting them from staff.On 11/18/25 at 12:12 p.m., during a facility tour, social services (SS)-A confirmed there were no grievance forms in the designated areas accessible to all residents, which were expected at the end of each wing on first and second floor. SS-A stated grievance forms had previously been available at the end of each of the facility's two wings on both floors but was unsure when the forms were removed. SS-A stated grievance forms were also available around the corner from the front entrance and acknowledged that this location was not accessible to all residents. SS-A stated residents could submit completed grievance forms to SS-A or to any staff member and confirmed there was no designated location for anonymous submission of grievance forms.On 11/19/25 at 10:09 a.m., the administrator stated the facility was expected to have grievance forms available for the residents at the end of each wing and was unaware the grievance forms were no longer at the end of each wing as expected. The facility Filing Grievances Policy undated, indicated: Any resident, his or her resident representative, family member, or appointed advocate may file a grievance concerning treatment, medical care, behavior of other residents, staff members, missing items without fear threat or reprisal in any form.Upon admission residents are provided with written information on how to file a grievance a copy of grievance procedures is posted in the area located near the main entrance.

Based on interview and document review, the facility failed to ensure documentation for 1 of 5 residents (R65) who refused Covid-19 vaccine included education covering benefits and risks of the vaccine, and name and date of resident or representative who refused the vaccine. Findings include:R65's face sheet printed on 11/19/25, indicated R65 was admitted on [DATE], and diagnosis included Parkinson's disease.R65's admission Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, was understood and could understand, used a walker or wheelchair for mobility. R65's physician orders did not include Covid-19 immunization. During record review for immunizations, the immunization section of the electronic medical record (EMR) indicated the Covid-19 vaccine had been refused, however no additional documentation included when it had been offered, if education had been provided including benefit and risk, if allergic or contraindicated. During interview on 11/19/2025 at 8:00 a.m., registered nurse (RN)-B who was also the MDS nurse, provided documentation of refusal for R65's pneumococcal vaccine, but stated there was no documentation for refusal of the Covid-19 vaccine. RN-B stated the infection preventionist, who oversaw the vaccine program, was on leave of absence and therefore she did not know why the documentation was missing. During an interview on 11/19/25, at 11:40 a.m., the director of nursing (DON) stated she had been informed of findings by staff.In an email dated 11/20/25 at 10:57 a.m., the DON indicated the Covid-19 immunization was not on the facility standing orders as were other immunizations and was in the process of adding it. Facility Covid-19 Vaccine policy dated 9/1/25, indicated the residents medical record must include documentation that indicated, at a minimum, the resident or resident representative was provided education regarding the benefits and potential side effects of the Covid-19 vaccine, and that the resident (or representative) either accepted and received the Covid-19 vaccine or did not receive the vaccine due to medical contraindications, prior vaccine, or refusal. If there was a contraindication to the resident having the vaccination, the appropriate documentation must be made in the medical record.

Based on observation, interview and document review, the facility failed to ensure individualized activities were care planned and provided for 1 of 2 residents (R1) reviewed for activities. Findings include: R1's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R1 was admitted to the facility 10/16/25, had moderately impaired cognition, required partial to moderate assistance with transfers, and substantial/maximal assistance with shower/bathe and dressing, and required supervision with eating and oral hygiene. R1 identified it was somewhat important to do her favorite activities, keep up with the news, participate in religious services, go outside to get fresh air, have reading material, listen to music, and do things with groups of people. R1's diagnoses included anemia, heart failure pneumonia, macular degeneration (chronic eye condition that affects retina leading to significant visual impairment) and depression. R1's baseline/comprehensive care plan dated 11/3/25, did not include R4's activities, interests or interventions related to activities. R1's Care Area Assessment (CAA) dated 10/29/25, included visual impairment related to macular degeneration. R1 was at risk for complications and will monitor for changes in vision, offer examinations as needed and tell resident where to place items and keep room in order per resident preference. The CAA did not include activities. An Activity assessment dated [DATE], included R1 was content to be in her room, resting in a recliner and watching television. R1 had supportive daughters who visit when they can. R1 does enjoy music. Will continue to invite to small groups. On 11/17/25 at 3:52 p.m., R1 was observed in her room seated in a recliner asleep. The television was off and no radio or music device was visualized in the room. At 3:59 p.m., family member (FM)-A entered R4's room. FM-A stated they had just gotten back from an eye doctor appointment for R1's vision issues. FM-A stated the facility had been aware of R1's vision issues but did not think they were doing anything to address it. FM-A turned the TV on and stated the screen was not even full on the TV and R1's recliner was too far away for her to see it. FM-A stated she doesn't believe R1 goes to any activities, and it would be good for her to get out of her room. FM-A was not sure if staff had been inviting her to activities as she visits about once a week. R1 slept throughout interview with FM-A. On observation 11/18/25 at 9:31 a.m., staff assisted R1 with dressing and then assisted R1 via wheelchair to the dining room. At 9:50 a.m., R1 was assisted back to her room and asked to lay down. R1 transferred to her bed with assist of one staff . Lights were turned off. On observation 11/18/25 at 11:06 a.m., R1 was in her recliner asleep. Lights and TV were off. On interview 11/18/25 at 11:10 a.m., NA-D stated R1 has family that visits weekly but tended to stay in her room. NA-D stated R1 asked to go back to her room after meals and tended to sleep most of the time. NA-D doesn't believe R1 went to any activities and was unsure if activities is inviting her. On observation and interview 11/18/25 at 12:39 p.m., R1 was in her recliner dozing. FM-B was present and stated she doesn't think R1 attended any activities at least when she has been at the facility and is unsure if she was being asked to participate. FM-B was not aware of music this afternoon and stated she will take R1 there as she enjoyed music. FM-B did not think anyone had offered R1 a radio or CD player for her to listen to music. On observation 11/18/25 at 1:12 p.m., FM-A and FM-B wheeled R1 out of her room and was observed walking throughout the facility. At 1:30 p.m., FM-A and FM-B took R1 to the music event. R1 returned to her room at 2:30 p.m. On interview 11/18/25 at 3:03 p.m., LPN-A stated R1 tends to stay in her room and sleep. LPN-A was not sure but assumed activities staff were inviting her. On interview 11/19/25 at 9:50 a.m., nursing assistant (NA)-C stated R1 had not been at the facility long but hasn't seen R1 go to any activities. NA-C stated R1 tended to stay in her room and sleep. Review of activity participation documentation for R1 included 10/28/25: attended activity briefly this afternoon, 10/29/25: attended Bingo with family member briefly, 10/31/25: refused to attend trick or treat and 11/18/25: attended special music. No other refusals were documented. On interview 11/19/25 at 10:42 a.m., social services (SS)-A confirmed R1's plan of care did not include an activities plan. SS-A stated R1 had been sleepy since she had been at the facility, which may impact her attending activities. On interview 11/19/25 at 10:57 a.m., activities director (AD)-A stated she was responsible for assessing activity needs on admission and quarterly and developed the plan of care from that information. AD-A reviewed R1's medical record and confirmed there was not a plan of care for activities stating I must have missed that one. AD-A stated staff document in the medical record activity attendance and refusals. AD-A stated she had met with R1 and FM-B when R1 was admitted and offered talking books which they declined and the family was going to look into getting her a CD player. AD-A stated they invite R1 to activities but she frequently declines. On interview 11/19/25 at 11:55 a.m., the director of nursing (DON) stated all residents should have a care plan for activities. The DON added the facility does have resources for visually impaired residents and that should be part of the plan of care for activities. The DON stated when activities were attended, it should be documented in the medical record along with when they refuse. A facility Activity Programs/Care Plan policy was requested but not received.

Based on observation, interview and document review, the facility failed to ensure a care plan was implemented to ensure activity preferences were identified and implemented for 1 of 2 residents (R31) reviewed for activities.R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 was admitted to the facility 10/16/25, had moderately impaired cognition, required partial to moderate assistance with transfers, and substantial/maximal assistance with shower/bathe and dressing, and required supervision with eating and oral hygiene. R1 identified it was somewhat important to do her favorite activities, keep up with the news, participate in religious services, go outside to get fresh air, have reading material, listen to music, and do things with groups of people. R1's diagnoses included anemia, heart failure pneumonia, macular degeneration (chronic eye condition that affects retina leading to significant visual impairment) and depression. R1's baseline/comprehensive care plan dated 11/3/25, did not include R4's activities, interests or interventions related to activities. R1's Comprehensive Care Area Assessment (CAA) dated 10/29/25, did not include activities. An Activity assessment dated [DATE], included R1 was content to be in her room, resting in a recliner and watching television. R1 had supportive daughters who visit when they can. R1 does enjoy music. Will continue to invite to small groups. On 11/17/25 at 3:52 p.m., R1 was observed in her room seated in a recliner asleep. The television was off and no radio or music device was visualized in the room. At 3:59 p.m., family member (FM)-A entered R4's room. FM-A stated they had just gotten back from an eye doctor appointment for R1's vision issues. FM-A stated the facility had been aware of R1's vision issues but did not think they were doing anything to address it. FM-A turned the TV on and stated the screen was not even full on the TV and R1's recliner was too far away for her to see it. FM-A stated she doesn't believe R1 goes to any activities and it would be good for her to get out of her room. FM-A was not sure if staff had been inviting her to activities as she visits about once a week. R1 slept throughout interview with FM-A. On observation 11/18/25 at 11:06 a.m., R1 was in her recliner asleep. Lights and TV were off. On interview 11/18/25 at 11:10 a.m., NA-D stated R1 has family that visits weekly but tended to stay in her room. NA-D stated R1 asked to go back to her room after meals and tended to sleep most of the time. NA-D doesn't believe R1 went to any activities and was unsure if activities is inviting her. On observation and interview 11/18/25 at 12:39 p.m., R1 was in her recliner dozing. FM-B was present and stated she doesn't think R1 attended any activities at least when she has been at the facility and is unsure if she was being asked to participate. FM-B was not aware of music this afternoon and stated she will take R1 there as she enjoyed music. FM-B did not think anyone had offered R1 a radio or CD player for her to listen to music. On observation 11/18/25 at 1:12 p.m., FM-A and FM-B wheeled R1 out of her room and was observed walking throughout the facility. At 1:30 p.m., FM-A and FM-B took R1 to the music event. R1 returned to her room at 2:30 p.m. On interview 11/18/25 at 3:03 p.m., LPN-A stated R1 tends to stay in her room and sleep. LPN-A indicated she has noted the TV on in R1's room on occasion. LPN-A was not sure but assumed activities staff are inviting her to all activities. On interview 11/19/25 at 9:50 a.m., nursing assistant (NA)-C stated R1 had not been at the facility long but hasn't seen R1 go to any activities. NA-C stated R1 tended to stay in her room and sleep. Review of activity participation documentation for R1 included 10/28/25: attended activity briefly this afternoon, 10/29/25: attended Bingo with family member briefly, 10/31/25: refused to attend trick or treat and 11/18/25: attended special music. No other refusals were documented. On interview 11/19/25 at 10:42 a.m., social services (SS)-A confirmed R1's plan of care did not include an activities plan. SS-A stated R1 had been sleepy since she had been at the facility, which may impact her attending activities. On interview 11/19/25 at 10:57 a.m., activities director (AD)-A stated she was responsible for assessing activity needs on admission and quarterly and developed the plan of care from that information. AD-A reviewed R1's medical record and confirmed there was not a plan of care for activities stating I must have missed that one.AD-A stated they invite R1 to activities but she frequently declines. On interview 11/19/25 at 11:55 a.m., the director of nursing (DON) stated all residents should have a care plan for activities. The DON added the facility does have resources for visually impaired residents and that should be part of the plan of care for activities. A facility Activity Programs/Care Plan policy was requested but not received.

Based on interview and document review, the facility failed to ensure documentation for 2 of 5 residents (R65 and R5) who refused influenza vaccine included education covering benefit and risk of the vaccine, and name and date of resident or representative who refused the vaccine Findings include:R65's face sheet printed on 11/19/25, indicated R65 was admitted on [DATE], and diagnosis included Parkinson's disease.R65's admission Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, was understood and could understand. R65 used a walker or wheelchair for mobility. R65's standing orders dated 6/11/25, indicated may have annual Influenza vaccine unless contraindicated. During record review for immunizations, the immunization section of the electronic medical record (EMR) indicated the influenza vaccine had been refused, however no additional documentation indicated when it had been offered, if education had been provided including benefit and risk, if allergic or contraindicated. During an interview on 11/19/2025 at 8:00 a.m., registered nurse (RN)-B who was also the MDS nurse, provided documentation of refusal for R65's pneumococcal vaccine, but stated there was no documentation for refusal of the influenza vaccine. RN-B stated the infection preventionist, who oversaw the vaccine program, was on leave of absence and therefore she did not know why the documentation was missing. R5's face sheet printed on 11/19/25, indicated R5 was admitted on [DATE], and diagnosis included dementia. R5's admission MDS assessment dated [DATE], indicated moderately impaired cognition, clear speech, could understand and be understood. R5 did not walk and used a wheelchair for mobility. R5's standing orders dated 6/10/25, indicated may have annual Influenza vaccine unless contraindicated. During record review for immunizations, the immunization section of the EMR indicated the influenza vaccine had been refused, however no additional documentation indicated when it had been offered, if education had been provided including benefit and risk, if allergic or contraindicated. During interview on 11/19/2025 at 8:00 a.m., registered nurse (RN)-B who was also the MDS nurse, stated she could not locate documentation of refusal for the influenza vaccine. RN-B stated the infection preventionist, who oversaw the vaccine program, was on leave of absence and therefore she did not know why the documentation was missing. During an interview on 11/19/25, at 11:40 a.m., the director of nursing stated she had been informed of findings by staff.Facility Influenza Vaccination policy, undated, indicated all residents would be offered the influenza vaccine annually. Residents and family may refuse the vaccine; this would be documented under the immunization tab in the electronic medical record.

Based on observation, interview and document review, the facility failed to provide routine passive range of motion (PROM) on a consistent basis to improve strength, mobility and improve circulation for 1 of 1 resident (R32) reviewed for ROM. In addition, the facility failed to identify and develop interventions to reduce the risk of potential complications of a hand contracture.Findings include:R32's facesheet printed on 11/19/25, included diagnoses of traumatic brain injury, Parkinson's disease, and dementia.R32's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated severe cognitive impairment, no speech, rarely/never understood, sometimes responded to simple, direct communication only. Dependent upon staff for all activities of living (ADL). R32's physician orders dated 4/13/21, indicated restorative nursing measures such as PROM, ambulation, transfers, ADL may be implemented following an assessment by a licensed nurse.R32's care plan, undated and printed on 11/19/25, indicated R32 had an alteration in musculoskeletal status related to impaired mobility and cognition. R32 would be free of complications related to immobility. Daily hand hygiene. Monitor/document/report contracture formation. PROM to be completed with am/pm (morning and evening) cares as tolerated. In addition, the care plan indicated R32 had Parkinson's affecting movement. Staff were to report a decline in ROM. The care plan did not identify right hand contracture nor interventions to reduce the risk of potential complications, such as use of a hand splint, palm protection, or focused PROM to hand. R32's TASK tab in the electronic medical record (EMR) indicated: Range of Motion Exercises: Passive Range of Motion to joints per CNA education, not a specific OT program to be done by CNA, every shift. Review of documentation for this task for the past 30 days from 10/21/25, through 11/19/25, indicated NAs were to document the number of minutes spent providing PROM. Findings indicated R32 received PROM only 30% of the time in that time frame, specifically:Number of opportunities to perform PROM was 90 (every shift x 30 days).Actual number of times PROM was documented as being performed was 27 times.Number of refusals were 10.Number of times NAs documented not applicable was 29 times (16 times on the day shift, four times on the evening shift and nine times on the night shift).During a telephone interview on 11/17/25 at 2:00 p.m., family member (FM)-C stated R32 did not receive PROM exercises to his extremities. During an interview on 11/17/25 at 2:45 p.m., licensed practical nurse (LPN)-B stated she thought R32 was on a restorative program and exercises would be posted inside his closet door. During an observation at 2:49 p.m., there were no exercises posted inside the closet in R32's room.During an observation and interview on 11/18/25 at 9:30 a.m., observed nursing assistants (NA)-F and NA-G in room with R32, wheeling R32 out of the bathroom after having a shower. While in bed getting dressed, observed fingers on right hand were clenched; fingers on left hand loosely open and knees were flexed. Both NA-F and NA-G stated R32 could not straighten his legs anymore. NA-G stated, you can pull them down, but then he bends them up again. At 9:47 a.m., when R32 was dressed and in the Broda chair (a specialized positioning wheelchair), NA-G stated R32 was not able to open the fingers of his right hand and as she was talking, she pulled the fingers open. The palm of R32's hand was still moist from the shower. Fingernails were moderately long with some dark material under some nails. NA-G cleaned nails on both hands with a wooden manicure stick and trimmed the nails. NA-G stated staff did not usually put anything in R32's right palm to protect his skin, adding sometimes a washcloth but it did not stay in place. No PROM exercises were observed as being done during this episode of care.During an interview on 11/19/25, at 9:14 a.m., occupational therapist (OT)-B stated she had not seen R32 for occupational therapy, so could not comment on his right-hand contracture or if OT had recommended a restorative program for him. OT-B stated current records only go back three years and, in that time, R32 had not been evaluated by OT.During an interview on 11/19/25 at 9:22 a.m., registered nurse (RN)-C who was also the resident care coordinator for the unit on which R32 resided stated she was aware of R32's right hand contracture. Looking in the EMR at R32's care plan, RN-C acknowledged there was nothing in his care plan specific to the contracture and stated there should have been. RN-C stated documentation of PROM to R32's joints would be found in the TASK tab in the EMR and stated PROM exercises were typically posted in a resident's closet. RN-C stated PROM exercises should be done every shift. Looking in the EMR, RN-C stated it did not look like PROM had been done every shift - more like once or twice a day, but not every day. RN-C stated R32 was not able to speak so would not be able to verbalize a refusal of PROM. RN-C could not recall if R32 came to the facility in 2017 with a right-hand contracture or if it developed over time after he was admitted . RN-C stated she would expect something to protect R32's right palm and would talk to OT about an appropriate device, adding, We need to make sure to protect his palm. Together with RN-C, went to R32's room and verified no PROM exercises were posted inside his closet or elsewhere in the room.During an interview on 11/19/25 at 9:37 a.m., RN-C presented what she referred to as standard ROM exercises that NAs learned in NA class. The pages numbered 51 and 52 of an unidentified book were titled Skill #48 PROM (Hip, Knee, Ankle) with a 10-step procedure and Skill #49 PROM (Shoulder, Elbow) with a 7-step procedure. The PROM was not specific to R32. When asked, RN-C stated she would have expected PROM exercises to be specific to R32, his needs and his ability. These documents did not include PROM exercises for R32's right hand contracture. Further, RN-C stated she had talked to NA's who told her R32's way to refuse PROM was by clenching up. RN-C stated she would expect NA staff to inform a nurse if R32 refused PROM and in turn, she be notified. RN-C stated she was not aware of refusals as no one had told her that. During record review, no documentation of PROM refusals was noted in progress notes. RN-C was not aware R32 had not had a physical or occupational evaluation for at least three years.During an interview on 11/19/25 at 10:01 a.m., NA-B stated she did PROM for R32; that his exercises where inside his closet (they were not) and NAs did it as often as they could. NA-B stated they did abduction and adduction of his shoulders, elbows, hips and knees. NA-B stated R32 often tensed up when doing PROM and that was how they knew he wanted to stop. NA-B was asked if R32 needed PROM for his hands and replied, No, his hands are good - just his joints. During an interview on 11/19/25 at 11:34 a.m., the director of nursing (DON) was informed of findings and stated RN-C was already addressing it. The DON was informed of the observation on 11/18/25, during morning cares when PROM was not done; the lack of identification and intervention for R32's right hand contracture or for palmar protection. The DON was informed that R32 had not had an OT evaluation for at least three years according to OT-B. R32's refusals of PROM exercise had not been communicated from NAs to nursing staff for follow up. The DON stated she had known R32 since his admission in 2017, and stated he had overall become stiffer and, We should have caught that, and gotten OT involved. Need to get better and look at this.Facility Restorative Nursing Care policy dated 4/30/14, indicated residents would be given appropriate treatment and services to maintain or improve his/her abilities, as indicated by residents' comprehensive assessment, to achieve and maintain the highest practicable outcome. General restorative nursing care is that which does not require the use of a qualified professional therapist to render care. Facility Range of Motion (Active, Active Assistance and Passive) policy dated 7/17/22, indicated the purpose was to move the residents' joints through as full a range of motion as possible, to improve or maintain joint mobility and muscle strength, to prevent contractures, to increase strength and activity tolerance, to reduce pain, to prevent complications of mobility. The policy included body parts, such as neck, shoulder, elbow, etc. with specific instructions for each. Inform nurse of any changes in residents' ability and/or complaints of discomfort or pain. When the resident's activity level or joint function is at risk of/or decreases, range of motion should be slated as soon as possible. Joints begin to stiffen within 24 hours of disuse.

Based on observation and interview, the facility failed to ensure basic infection control practices were followed when the tubing of a urinary drainage bag for 1 of 1 resident (R8), was observed laying on the floor of the shower. The deficient practice had the potential to cause infection.Findings include:R8's face sheet printed on 11/19/25, included diagnoses of stroke, obstructive and reflux uropathy (blockage that prevents urine from flowing, causing it to back up), bacteremia (bacteria in blood) and history of urinary tract infections.R8's annual Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, usually understood and could understand. R8 had a urinary catheter. R8 walked with supervision or touch assistance or used a wheelchair for mobility.R8's physician orders dated 2/10/25, included indwelling catheter. R8's undated care plan, printed on 11/19/25, indicated R8 had an indwelling catheter related to retention. Catheter care per facility policy. During an observation on 11/17/25 at 3:19 p.m., observed R8 wearing a urinary leg bag on her right lower leg. In R8's bathroom, observed an overnight urinary drainage bag hanging from a handicap bar in the shower. The distal end of the urinary drainage bag tubing laid on the floor of the shower with no protective cap over the insertion tip. During an interview and observation on 11/17/25 at 3:21 p.m., together with nursing assistant (NA)-A, looked at the location of the tubing. NA-A stated, Oh, that should not be there. NA-A stated the overnight bag was supposed be placed into the small clear waste bag tied to the bar next to drainage bag. NA-A collected the urinary drainage bag and discarded it, stating he would get a new one. NA-A stated the catheter bag tubing should not touch a dirty surface because it could cause an infection. During an observation on 11/18/25 at 9:57 a.m., observed R8's overnight urinary drainage bag inside a small clear waste bag tied to a handicap bar in the shower. During an observation on 11/19/25 at 8:00 a.m., observed R8's overnight urinary drainage bag hanging from a bar in the shower. The distal end of the urinary drainage bag tubing laid on the floor of the shower with no protective cap over the insertion tip. During an observation and interview on 11/19/25 at 8:26 a.m., together with registered nurse (RN)-A who was also the interim infection preventionist, observed the location of the urinary drainage bag and tubing. RN-A stated the set up was not supposed to be left like that; it should have been placed in the small clear waste bag tied to the bar. RN-A stated the floor of the shower was not clean and R8 could potentially develop a UTI if the dirty tip was attached to her urinary catheter. RN-A stated staff were trained on proper management of urinary drainage bags.During an interview on 11/19/25 at 9:12 a.m., RN-B, who was also the MDS nurse looked in R8's electronic medical record (EMR) and stated R8's last UTI's were in February 2025. During an interview on 11/19/25 at 9:29 a.m., RN-C who was also the resident care coordinator for the unit on which R8 resided stated she had been informed of the observation of the urinary drainage bag. RN-C stated NAs would have had training on proper handling of the urinary drainage bag during NA training, including the facility-specific process of tying a waste bag to the shower bar and placing the entire urinary drainage bag and tubing inside when not in use. During an interview on 11/19/25 at 10:01 a.m., NA-B stated she had disconnected R8's overnight urinary drainage bag that morning, flushed it with bleach water, then put it in the waste bag in the shower. When informed the urinary drainage bag had not been in the waste bag, she stated it may have popped out. When informed the entire urinary drainage bag and tubing had been hanging next to the waste bag, NA-B admitted it was possible she had forgotten to put the urinary drainage bag into the waste bag. NA-B stated the tubing laying on the floor of the shower created a potential risk for infection for R8. During an interview on 11/19/25, at 11:40 a.m., the director of nursing stated she had been informed of findings by staff, and stated NAs would be re-educated on proper handling of urinary drainage bags when not in use. Policy on handling urinary drainage bags was requested and not received.

Based on observation and interview, the facility failed to ensure beverageware was completely dry before storing, in order to prevent bacterial growth. This had the potential to affect all 29 residents who resided on second floor. Findings include: During an observation and interview on 10/22/24 at 1:51 p.m., observed multiple beverageware stacked on trays, sitting on an open cart located between kitchenettes on second floor. Observed stacked clear plastic cups, light blue plastic cups, and thermal coffee cups. Condensation was visible in the stacked light blue cups. Dietary aide (DA)-A was asked to pick up and separate a stack of blue cups and looking in the cups, verified moisture was present. In addition, DA-A picked up several thermal coffee cups and verified there was moisture inside the cups as well. DA-A explained when she removed beverageware from the dishwasher, she placed them on the counter on top of a piece of rubber shelf-liner to air dry. DA-A acknowledged moisture remaining in cups could lead to bacterial growth. During an interview on 10/22/24 at 2:05 p.m., dietary manager (DM)-C was present in the kitchenette area on second floor and was informed of the wet cups. DM-C stated when removed from the dishwasher, staff were to set beverageware on the rubber shelf-liner to allow time to completely air dry before storing. Further, DM-C stated staff were not to stack beverageware, but instead place cups on a single layer on a tray. DM-C acknowledged moisture in cups had the potential for bacterial growth. During an interview on 10/24/24, at 10:20 a.m., the administrator was informed of findings and acknowledged with four kitchenettes, it required monitoring by dietary leadership staff to ensure policies were adhered to. The facility Dishwashing Machine Use policy dated March 2010, indicated food service staff required to operate the dishwashing machine would be trained in all steps of dishwashing machine use by the supervisor or designee proficient in all aspects of proper use and sanitation. After running the items through an entire cycle, allow to air-dry.

Based on observation, interview and document review, the facility failed to ensure 1 of 1 resident (R264) reviewed who was observed to have medications at the bedside, had been appropriately assessed and deemed appropriate to self-administer medications. Findings include: R264's Admission Record printed 10/24/24, identified diagnoses including bloodstream infection, muscle spasm of the back, and lack of blood flow to the muscle. R264's entry tracking record Minimum Data Set (MDS) assessment dated [DATE], identified admitted [DATE], and admission from short-term general hospital stay. R264's care plan printed 10/24/24, identified R264 required extensive staff assistance for grooming, transfers, bed mobility, and dressing. Care plan further indicated R264 was at risk for ineffective coping related to health status with interventions of re-orientation, allow time to process, move slowly with cares and give simple explanations. R264's Order Summary Report printed 10/24/24, identified an order for miconazole nitrate external ointment (fungal cream) apply to fungal dermatitis topically two times a day for fungal dermatitis until healed and diclofenac sodium external gel (pain gel) apply to affected area topically four times a day. R264's record review did not include an assessment for self-administration of medication. During observation on 10/21/24 at 9:28 a.m., R264 was sleeping in her bed. Two prescription creams were observed within reach on bedside table. The creams were labeled as miconazole nitrate external ointment and diclofenac sodium external gel. During observation on 10/22/24 at 1:45 p.m., miconazole cream and diclofenac gel remained on the bedside table in R264's room. During interview on 10/22/24 at 4:41 p.m., licensed practical nurse (LPN)-B verified no assessment for self-medication administration had been completed for R264. LPN-B further stated the cream and gel should not have been in R264's room prior to there being an assessment completed for self-administration. LPN-B removed the cream and gel from R264's room. During interview on 10/22/24 at 5:12 p.m., director of nursing (DON) stated she would expect an assessment completed for self-administration of medication prior to medications being left in R264's room. DON further stated an assessment should have been completed to ensure R264 was safe to have medications at bedside. The facility Self-Administration of Medication policy revised 12/28/22, indicated: The interdisciplinary team must ask the resident during assessment whether he/she wishes to self-administer drugs. The resident has the right to defer the responsibility to the facility. If a resident chooses to self-administer drugs, the interdisciplinary team must assess the resident's cognitive, physical, visual abilities to carry out this responsibility. A physician's order will be obtained and recorded in the chart. Order to include which specific medications can be kept at bedside. Place on resident care plan, review and revise as needed.

Based on observation, interview and document review, the facility failed to ensure resident status was accurately identified in the Minimum Data Set (MDS) assessment for 1 of 2 residents (R42) reviewed for elopement devices and 1 of 1 resident (R62) reviewed for hospitalization . Findings include: R42's Face Sheet, printed 10/24/24, included diagnoses of dementia and senile degeneration of the brain. R42's quarterly Minimum Data Set (MDS) dated [DATE], section P, P0200 under alarms, did not include a wander/elopement alarm. During observation and interview on 10/23/24 at 10:58 a.m., R42 was in her wheelchair propelling herself with her feet, and approached room [ROOM NUMBER] (empty room) and opened the closed door. R42 had a wanderguard (bracelet worn to prevent elopement) bracelet on her left lower leg. R42 closed the resident room door without entering and wheeled self towards the unit exit doors, with side of door open to hallway and other door closed. R42 made it to through the door when a staff member entering had R42 turn around and go back on the unit. During interview on 10/23/24 at 11:21 a.m., registered nurse (RN)-A, also identified as MDS coordinator stated R42 does have a wander guard alarm and after reviewing R42's 8/24/24 MDS confirmed the MDS was not accurate and will correct it. During interview on 10/23/24 at 11:34 a.m., the director of nursing (DON) indicated if someone has a wanderguard she would expect the MDS to reflect that. 50764 R62's discharge MDS assessment dated [DATE], indicated R62 was admitted on [DATE], had intact cognition, no behaviors, was independent with bed mobility, hygiene, transfers, and walking, diagnoses included: femur fracture and unspecified injury of the elbow or forearm. R62's discharge MDS further indicated a planned discharge with return not anticipated, and discharge to a short-term general hospital on 8/10/24. R62's facility document titled Discharge Summary dated 8/10/24, indicated discharge date of [DATE], and discharge location as son and daughter-in-law's home with transportation provided by family, all belongings and medications sent with R62 and family. During interview on 10/23/24 at 8:40 a.m., RN-A, also know as MDS coordinator, stated the discharge MDS was coded incorrectly in error and needed to be corrected. MDS coordinator further stated R62 discharged to son's home. During interview on 10/23/24 at 11:05 a.m., DON stated she expected the MDS to be coded accurately to reflect accurate resident information. DON further stated the facility follows guidance of the Resident Assessment Instrument (RAI) manual and should have coded the MDS accordingly. Facility policy on MDS completion and accuracy was requested but not received.

Based on observation, interview and document review, the facility failed to ensure a care plan was revised to address pressure ulcer risk and preventative measures for 1 of 2 residents (R31) reviewed for pressure ulcers (PU). Findings include: R31's face sheet printed 10/23/24, included diagnosis of Parkinson's disease (progressive movement disorder), lymphedema (swelling of the leg or arm), and body mass index 36.0 - 36.9 (normal is 25-30). R31's quarterly Minimum Data Set (MDS) dated [DATE], identified one stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling.) not present on admission. Cushion on chair, air mattress on bed. R31's physician orders dated 6/28/24 included apply rolled towel to left lower leg for left lateral malleolus (bony prominence on each side of the human ankle) pressure reduction every shift for left lateral malleolus pressure area stage III. Complete skin observation assessment every shift every Tuesday, dated 5/28/24. R31's most current care plan last revised 6/28/24, included pressure ulcer injury stage III to left lateral malleolus. Treatment in place. Interventions included; Assess, monitor and record wound healing weekly. Measure length, width and depth where possible. Assess and document wound perimeter, wound bed and healing progress. Report improvements and declines to practitioner. Daily skin inspection. Report abnormalities to the nurse. Inform the resident/family/caregivers of any new area of skin breakdown. Keep skin clean and dry. Use lotion on dry scaly skin. The care plan lacked individualized interventions including air mattress, repositioning, chair cushion and foot/heel protector. During interview and observation on 10/21/24 at 9:56 a.m., R31 was lying in bed, feet were resting directly on the bed and heel/foot protector was in the Broda (positioning for comfort) chair parked in the room. R31 had an air mattress present on his bed. R31's feet were both turned outwards and laying on the mattress with no rolled towel or foot/heel protectors present. R31 stated he has a sore he thinks on or close to his heel that gets a dressing put on every day. R31 indicated he did not have this PU prior to his admission and thinks it was awhile ago when it started. During observation and interview on 10/22/24 at 11:34 a.m., R31 was lying in his bed with feet both rotated outwards. Heel/foot protector was sitting on his Broda chair. R31 stated he hasn't had his heel/foot protector on for at least a few days. During observation on 10/22/24 at 6:05 p.m., R31 remains lying in his bed, both feet rotated outwards and heel/foot protector sitting in his Broda chair in his room. During an observation and interview on 10/23/24 at 8:36 a.m., R31 was lying in bed with feet both rotated outwards, no leg wraps on and heel/foot protector in his Broda chair. R31 stated they haven't put his heel/foot protector on for a few days now. R31 stated you would think they would know by now it needs to be on there. During observation and interview on 10/23/24 at 8:53 a.m., registered nurse (RN)-B, also identified as wound care nurse entered R31's room and exposed R31's lower legs. R31 did not have heel/foot protector on or towel roll present for positioning. RN-B stated he should have a heel/foot protector on his left lower leg and foot. RN-B examined left lateral malleolus area and stated there should also be a dressing present on the PU area, which was not present. RN-B stated the malleolus pressure ulcer was discovered in June but has improved and is now healed and the dressing is more to protect the area along with the heel/foot protector. RN-B stated they had tried repositioning to try to keep the left lateral malleolus off the bed, but it was too painful for R31. R31 confirmed this and stated he just couldn't take the pain of his leg being rotated on the positioning devices. RN-B placed the heel/foot protector on R31's foot after examination and then informed the nurse it needed to have dressing placed on. A Wound Evaluation dated 6/28/24 at 10:29 a.m., indicated new stage III pressure ulcer with 60% granulation and 50% slough. Treatment included foam dressing with additional care to include heel suspension/protection device, moisture control. Wound evaluations were completed weekly with measurements and assessments with wound showing gradual improvement. A wound evaluation dated 10/22/24 at 3:15 p.m., included pressure stage 3 ulcer on left lateral malleolus, 3 months old was resolved. Wound has been closed for last three assessments. Will discontinue weekly wound assessments but continue with heel protector positioning with pillow indefinitely due to outward turn of leg. Continue with foam dressing as long as remains red. Skin assessments were not completed daily per plan of care. The following skin assessments were completed: 4/29/24: Open areas to right and left legs. Mepilex (absorbent foam dressing) treatment. 5/13/24: Open area to right lower leg. Left lower leg area is scabbed over. 7/2/24: Left ankle outer with pressure and right lateral leg with healing blister. Notes included left malleolus area is pressure. Dressing changed and being followed by wound care for measurements. Boot and rolled towel initiated. 8/2/24: Left lower malleolus pressure wound, see wound care notes. 8/20/24: Wound to bilateral lower extremity and received treatment and assessed by wound nurse today. 9/3/24: Right buttock red raised areas, right shin old scab. 10/1/24: Shower today. Barrier cream applied to buttocks. No new alteration to skin integrity. Healing wounds assessed by wound care today of right leg and left malleolus. Review of interventions and tasks for October, heel protector to left foot at all times was listed as an intervention but lacked any documentation. On interview 10/23/24 at 9:41 a.m., licensed practical nurse (LPN)-A indicated the nursing assistants (NA) are responsible for putting the heel protectors on R31. LPN-A indicated he does wear the heel/foot protector boot, but refuses to get out of bed or have his feet repositioned. LPN-A indicated they do weekly skin assessments on all residents generally on bath day. On interview 10/23/24 at 9:49 a.m., NA-A indicated she only works on the unit once a week and ensures R31 has his heel/foot boot on at all times. NA-A is unsure if they document the boot but she thought so. On interview 10/23/24 at 9:56 a.m., NA-B indicated R31 has his heel/foot protector is on most of the time but does sometimes refuse. NA-B added R31 refuses to reposition or get into his Broda chair. NA-B indicated she doesn't believe there is a place to document the boot when on or off or if he refuses. On interview 10/23/24 at 10:01 a.m., the director of nursing (DON) indicated weekly skin assessments are completed on all residents. The DON confirmed there is no documentation on the heel/foot boot for September or October. The DON after investigation stated the heel/foot boot protector was just added to the task list today, which is why there was no documentation present. The DON confirmed skin assessments were not completed daily and the heel/foot protector should be on at all times and should have been part of the care plan and the tasks for documentation. The DON confirmed the care plan should reflect the preventative measures being taken to prevent skin breakdown and was generic and not specific to R31's interventions. The facility Body/Skin Audit policy dated 4/2018, included: -Care plan for skin will be reviewed and revised. The facility Skin Safety Protocol, Pressure Ulcer Prevention policy reviewed 4/30/14, included pressure ulcer prevention is to be provided for all residents at risk of pressure ulcer development and for those individuals who have a pressure ulcer. There may be some medical or personal conditions that may impeded interventions from this protocol being implemented. Individualize the interventions as appropriate for these patients.

Based on observation, interview, and document review, the facility failed to comprehensively assess skin and/or consistently implement interventions to prevent the development of new pressure ulcers for 2 of 2 residents (R31, R48) who were reviewed for pressure ulcers. Findings include: R31's Face Sheet printed 10/23/24, included diagnoses of Parkinson's disease (progressive movement disorder), lymphedema (swelling of the leg or arm), and body mass index 36.0 - 36.9 (normal is 25-30). R31's quarterly minimum data set (MDS) dated [DATE], identified R31 was cognition was intact, needed substantial to moderate assistance for all activities of daily living except was able to eat independently. Further, the MDS indicated R31 was at risk for pressure ulcer (PU) development, currently had a stage III pressure ulcer ( (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling.) not present on admission and had pressure reducing devices for bed and chair. R31's physician orders dated 6/28/24, included apply rolled towel to left lower leg for left lateral malleolus (bony prominence on each side of the human ankle) pressure reduction every shift for left lateral malleolus pressure area stage III. Complete skin observation assessment every shift every Tuesday, dated 5/28/24. R31's plan of care dated 6/28/24, included R31 has alternation in or potential for break in skin integrity. Interventions included; a pressure ulcer injury stage III present to left lateral malleolus. Treatment in place. Additional interventions included assess, monitor and record wound healing weekly. Measure length, width and depth where possible. Assess and document wound perimeter, wound bed and healing progress. Report improvements and declines to practitioner. Daily skin inspection. Report abnormalities to the nurse. Enhanced barrier precautions due to open wound. Inform the resident/family/caregivers of any new area of skin breakdown. Keep skin clean and dry and use lotion on dry scaly skin. During interview and observation on 10/21/24 at 9:56 a.m., R31 was laying in bed, feet were resting directly on the bed and heel/foot protector was in the Broda (positioning for comfort) chair parked in the room. R31 had an air mattress present on his bed. R31's feet were both turned outwards and laying on the mattress with no rolled towel or foot/heel protectors present. R31 stated he has a sore he thinks, on or close to his heel that gets a dressing put on every day. R31 indicated he did not have this PU prior to his admission and thinks it was awhile ago when it started. During observation and interview on 10/22/24 at 11:34 a.m., R31 was lying in bed with both feet rotated outwards. Heel/foot protector was sitting on his Broda chair. R31 stated he hasn't had his heel/foot protector on for at least a few days. During observation on 10/22/24 at 6:05 p.m., R31 remains lying in his bed, both feet rotated outwards and heel/foot protector sitting in his Broda chair in his room. During observation and interview on 10/23/24 at 8:36 a.m., R31 was lying in bed with feet both rotated outwards, no leg wraps on and heel/foot protector in his Broda chair. R31 stated they haven't put his heel/foot protector on for a few days now. R31 stated you would think they would know by now it needs to be on there. During observation and interview on 10/23/24 at 8:53 a.m., registered nurse (RN)-B, also identified as wound care nurse entered R31's room and exposed R31's lower legs. R31 did not have heel/foot protector on and no wraps present. RN-B stated he should have a heel/foot protector on his left lower leg and foot. RN-B examined left lateral malleolus area and stated there should also be a dressing present on the PU area, which was not present. RN-B stated the malleolus pressure ulcer was discovered in June but has improved and is now healed and the dressing is more to protect the area along with the heel/foot protector. RN-B stated they had tried repositioning to try to keep the left lateral malleolus off the bed, but it was too painful for R31. R31 confirmed this and stated he just couldn't take the pain of his leg being rotated on the positioning devices. Upon examination of R31's left lateral malleolus, RN-B stated the area on and around the left malleolus is red, but no open areas present. RN-B placed the heel/foot protector on R31's foot after examination and then informed the nurse it needed to have dressing placed on. RN-B confirmed skin assessments should be completed weekly by a nurse. Review of R31's task list for October, included heel protector to left foot at all times but lacked any documentation of completion. R31's Wound Evaluation dated 6/28/24 at 10:29 a.m., indicated new stage III pressure ulcer with 60% granulation and 50% slough. Treatment included foam dressing with additional care to include heel suspension/protection device, moisture control. Wound evaluations were completed weekly with measurements and assessments with wound showing gradual improvement. Dates included 6/28/24, 7/5/24, 7/10/24, 7/17/24, 7/23/24, 7/30/24, 8/6/24, 8/13/24, 8/20/24, 8/27/24, 9/3/24, 9/10/24, 9/17/24, 9/24/24, 10/1/24, 10/8/24, 10/15/24. A wound evaluation dated 10/22/24 at 3:15 p.m., included pressure stage III ulcer on left lateral malleolus, 3 months old was resolved. Wound has been closed for last three assessments. Will discontinue weekly wound assessments but continue with heel protector positioning with pillow indefinitely due to outward turn of leg. Continue with foam dressing as long as remains red. Skin assessments were not completed weekly per facility order and protocol. Below were skin assessments completed: 4/29/24: Open areas to right and left legs. Mepilex (absorbent foam dressing) treatment. 5/13/24: Open area to right lower leg. Left lower leg area is scabbed over. 7/2/24: Left ankle outer with pressure and right lateral leg with healing blister. Notes included left malleolus area is pressure. Dressing changed and being followed by wound care for measurements. Boot and rolled towel initiated. 8/2/24: Left lower malleolus pressure wound, see wound care notes. 8/20/24: Wound to bilateral lower extremity and received treatment and assessed by wound nurse today. 9/3/24: Right buttock red raised areas, right shin old scab. 10/1/24: Shower today. Barrier cream applied to buttocks. No new alteration to skin integrity. Healing wounds assessed by wound care today of right leg and left malleolus. On interview 10/23/24 at 9:41 a.m., licensed practical nurse (LPN)-A indicated the nursing assistants (NA) are responsible for putting the heel protectors on R31. LPN-A indicated R31 does wear the heel/foot protector boot, but refuses to get out of bed or have his feet repositioned. LPN-A indicated they do weekly skin assessments on all residents generally on bath day. On interview 10/23/24 at 9:49 a.m., NA-A indicated she only works on the unit once a week and ensures R31 has his heel/foot boot on at all times. On interview 10/23/24 at 9:56 a.m., NA-B indicated R31 has his heel/foot protectors on most of the time but does sometimes refuse them. NA-B added R31 refuses to reposition or get into his Broda chair. NA-B indicate she doesn't believe there is a place to document the boot when on or off. On interview 10/23/24 at 10:01 a.m., the director of nursing (DON) indicated weekly skin assessments are completed on all residents. After review of documentation, the DON indicated R31's were not done weekly and went from mid May until July without being completed/documented. The DON confirmed there was no documentation on the heel/foot boot for September or October. The DON after investigation stated the heel/foot boot protector was just added to the task list today, which is why there was no documentation present. The DON confirmed skin assessments were not completed monthly and the heel/foot protector should be on at all times and should have been part of the care plan and the tasks for documentation. 50764 R48's face sheet printed 10/24/24, indicated diagnoses of type two diabetes mellitus with foot ulcer, chronic kidney disease, heart failure, and fracture of the tibia (lower leg bone). R48's quarterly MDS assessment dated [DATE], indicated R48 had intact cognition, no rejection of care, used a walker and wheelchair, required partial assistance with dressing, footwear, and hygiene, and was independent with transfers. MDS further indicated R48 was at risk for pressure ulcer development, currently had a stage III pressure ulcer not present on admission, and had pressure reducing devices for chair and bed, nutrition interventions for skin, and required pressure ulcer care, application of medications and dressings to feet. R48's physician's order dated 10/7/24, indicated an order for weekly wound assessment by wound care coordinator. Wound orders included treatment for left foot wound of cleansing wound by moistening gauze and laying over wound for five minutes, pat dry, cover wound with foam adhesive dressing, evening shift, every three days and as needed. R48's care plan printed 10/24/24, indicated R48 had an alteration in or potential for break in skin integrity with interventions listed as assess, monitor, and record wound healing weekly. Measure length, width, and depth where possible. Assess and document wound perimeter, wound bed, and healing progress. Report improvements and declines to practitioner. Further interventions included daily skin inspections, keep skin clean and dry. During observation and interview on 10/21/24 at 2:43 p.m., R48 was seated in wheelchair with no sock on left foot. A foam adhesive bandage was observed adhered to the top of R48's left foot. R48 stated she was unsure what the bandage was for and thought her wound was healed. During interview on 10/22/24 at 4:39 p.m., LPN-B stated the pressure ulcer started from R48's shoe being too tight. LPN-B further stated the wound was healed and the bandage on R48's left foot was for protection to the area. During interview on 10/22/24 at 5:37 p.m., RN-B also identified as the wound care nurse stated she thought R48's left foot pressure ulcer was healed in September and was unsure why a treatment was still ordered. RN-B stated R48's left foot pressure ulcer developed 3/5/24, was stage III at the time of discovery, and that weekly skin audits should have been completed consistently prior to discovery of R48's wound. RN-B further stated wound measurements and assessments should be completed weekly to prevent worsening of wounds. Review of R48's weekly skin audits for one month prior to discovery of the stage III pressure ulcer on 3/5/24, indicated skin audits on 2/8/24 and 2/21/24. Review of facility wound assessments indicated wound measurements and assessments were not completed weekly once the wound developed. Documented completed wound measurements occurred on the following dates: 6/4/24, 6/6/24, 6/13/24, 6/20/24, 7/17/24, 8/6/24, 8/20/24. There was no documentation to indicate the wound was resolved. During interview on 10/23/24 at 10:15 a.m., DON stated she expected weekly skin audits on bath day and weekly measurements and skin assessments of wounds to prevent pressure ulcers and promote healing of developed pressure ulcers. The facility Body/Skin Audit policy dated 4/2018 included: -All residents will have a body/skin audit performed by a licensed nurse for a head to toe skin inspection. -Body audits will be completed weekly, on admission, readmission and as needed. -Body audits will be documented by a nurse in the treatment record and by nursing assist in point of care. -Care plan for skin will be reviewed and revised.

Based on observation, interview, and document review, the facility failed to ensure 1 of 1 resident (R314) who was observed using an electric heating pad, was free of potential injury. Findings include: R314's facesheet printed on 10/22/2024, included diagnoses of rheumatoid arthritis, disc degeneration, and age-related osteoporosis. R314's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R314 was cognitively intact and was independent in most activities of daily living (ADL's). R314's MD orders included Aqua-K pad 20 minutes TID (three times a day) as needed for pain relief every 8 hours. R314's care plan dated 1/19/24, indicated to offer warm blanket, massage, cold Pak, repositioning, rest/relaxation. warm bath/ whirlpool, and/ or diversional activities for pain. R314 treatment administration record (TAR) indicted the Aqua-K pad had not been used in September or October 2024. During an observation on 10/22/24 at 10:30 a.m., a heating pad was observed laying over the arm of a recliner in R314's room. During an interview on 10/22/24 at 2:12 p.m., R314 stated she used the heating pad for lower back pain at night when sleeping in her recliner. R314 stated that she thought she had brought it from home or maybe the facility provided it to her. During an observation on 10/22/24 at 5:41 p.m., observed the heating pad plugged into a wall outlet behind the recliner. The approximately 12 x 24-inch heating pad was Walgreen's brand and covered in a tan cloth. Imprinted on the control of the heating pad was, On/off for 2 hours and included ranges of warm, low, medium, and high. An Aqua-K pad as indicated in R314's orders, was not observed in room. During an interview on 10/23/24 at 9:05 a.m., licensed practical nurse (LPN)-C stated she was not aware R314 had a heating pad in her room. During an interview on 10/23/24 at 9:15 a.m., registered nurse (RN)-C stated she was not aware R314 had a heating pad in her room. RN-C looked in the EMR (electronic medical record), stated R314 had an order for an Aqua K pad, and that electric heating pads brought from home were not allowed for use by residents in the facility due to risk of injury. During an interview on 10/23/24 at 12:51 p.m., maintenance director (MD)-A stated heating pads brought from home were not allowed in the facility due to the potential risk of fire and/or electrical shock and was not aware R314 had a heating pad in her room. During an interview on 10/23/24 at 1:15 p.m., the director of nursing (DON) stated she was not aware R314 had a heating pad in her room. The DON stated she would have expected staff to notice the heating pad and inform her. The DON stated heating pads brought from home pose a risk of burning a resident since the temperature could not be regulated. The DON stated she would have the heating pad removed from R314's room right away. A policy on the use of heating pads was requested but not received.

Based on interview and document review, the facility failed to ensure 2 of 5 resident (R36, R58) were administered the pneumococcal vaccine in accordance with the Center for Disease Control (CDC) recommendations. Findings include: R36's quarterly Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment, diagnoses included: stroke, hypertension (high blood pressure), and Parkinson's Disease (brain disorder that affects movement and other systems of the body), and was not up to date on her pneumococcal vaccinations R36's Immunization Report dated 10/23/24, indicated on 5/13/24, R36 consented to the Pneumovax (pneumococcal) vaccine. R36's record review failed to indicate the pneumococcal vaccine was administered. R58's quarterly Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment, had diagnoses of anemia, coronary artery disease, hypertension, hip fracture, dementia, and obstructive sleep, and was not up to date on her pneumococcal vaccination. R36's Immunization Report dated 10/23/24, indicated on 9/16/24, R58 consented to the Pneumovax. R58's record review failed to indicate the pneumococcal vaccine was administered. On 10/23/24 at 9:22 a.m., registered nurse (RN)-B known as the infection preventionist stated the facility followed the CDC recommendations for pneumococcal vaccinations. RN-B stated she was responsible to ensure residents were administered vaccinations and confirmed R36 and R58 did not have documentation they received the pneumococcal vaccination. On 10/23/24 at 12:11 p.m., RN-A stated when residents were admitted she reviewed the resident's immunizations, and if residents were due for vaccinations consent was obtained, and then the resident name was placed a on handwritten list and given to RN-B. RN-A confirmed herself and RN-B were responsible to ensure residents received up to date vaccinations. RN-A confirmed R36 and R58 consented to the pneumococcal vaccine and the vaccine was not administered as expected. On 10/23/24 at 12:37 p.m., the director of nursing (DON) stated the facility followed CDC guidance for vaccinations, and stated when a resident consented to the vaccination the facility was responsible to ensure the resident received the vaccination. The facility Pneumococcal 20-Valent Conjugate Vaccine (Prevnar 20) Policy Statement dated 5/10/24, indicated Upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series and when indicated, will be offered the vaccine series within thirty days of admission to the community unless medically contraindicated or the resident has already been vaccinated.

Based on interview and document review, the facility failed to ensure resident mail was delivered on Saturdays for 7 of 7 residents (R3, R12, R19, R24, R32, R41, R49) who voiced concerns with mail delivery during resident council. This deficient practice had the potential to affect all 61 residents residing in the facility. Findings include: Resident Council was held on 10/23/24 at 11:00 a.m., R3, R12, R19, R24, R32, R41, R49 attended. R3, R12, R19, R24, R32, R41, R49 stated they did not receive mail on Saturdays and received the mail on Monday through Friday. R12 stated the mail was delivered to the post office and not to the facility. On 10/23/24 at 11:18 a.m., activity director (AD)-A confirmed resident mail was not delivered on Saturdays, and further stated activity staff delivered the mail to residents Monday through Friday. AD-A stated on Saturdays activity staff were not at the facility after 1:00 p.m., and the post office delivered the mail to the facility after 1:00 p.m., so therefore mail was not delivered to the residents. On 10/23/24 at 11:21 a.m., staffing coordinator (SC)-A stated the post office would deliver the mail to the facility on Saturdays, however the facility does not have a locked location for the post office to deliver the mail. SC-A stated mail delivery had been suspended on Saturdays and the mail was held at the post office on Saturday because the facility did not want packages and personal mail left unsecured in the entry of the facility. On 10/24/24 11:23 a.m., administrator stated she was not aware the facility did not have mail delivery on Saturdays. The administrator stated residents were expected to receive mail on Saturday if the post office delivered the mail. The facility Mail and Electronic Communication policy dated 5/17, indicated: Mail and packages will be delivered to the resident within 24 hours of delivery on premises or to the facility's post office box (including Saturday deliveries).

Based on observation, interview and record review, the facility failed to follow phsycician's orders per the standard of practice related to urostomy bag changes for 1 of 1 resident (R1) who had bilateral urostomies. Findings include: R1's after visit summary (AVS) from hospital dated 8/26/24, indicated R1 was admitted on [DATE], with history of bladder cancer with cystectomy (removal of bladder) and bilateral urostomies (tube from kidney to skin for drainage or urine). The AVS directed staff to change the drainage pouches twice weekly with the following: [NAME] wafer #14904, [NAME] 7805 moldable barrier stretched and placed around the opening of the adhesive side of the wafer, [NAME] 18402 urinary pouch. R1's admission Minimum Dasta Set (MDS) dated [DATE], indicated R1 did not have cognitive impairment. R1's diagnoses included cancer, renal insufficiency, failure or end stage renal disease, diabetes, and malnutrition. R1 had a urostomy and required partial to substantial assist with activities of daily living and was dependent with toileting hygiene, transfers, and bed mobility. R1 did not walk. R1's physican orders for urostomy care dated 8/26/24, included [NAME] wafer #14904, [NAME] 7805 moldable barrier stretched and placed around the opening of the adhesive side of the wafer, [NAME] 18402 urinary pouch. Change twice weekly every day shift Monday and Friday. R1's treatment administration record (TAR), for month of August 2024, identified R1's physician orders for urostomy care. The TAR indicated R1's ostomy care was not completed on 8/30/24; the record did not identify the reason why the treatment was not completed. R1's TAR, for month of September 2024, identified R1's physician orders for urostomy care. The TAR indicated R1's ostomy care was not completed on 9/2//24; the record did not identify the reason why the treatment was not completed. R1's progress notes dated 8/31/24 at 5:07 a.m., identified the right urostomy was changed due to leaking. R1's progress note dated 9/1/24 at 4:05 a.m., right side urostomy changed due to urine not flowing into bed bag and causing it to leak. Please make sure the arrow on the urostomy bag is facing away from the body, otherwise it's in a locked position preventing the urine to flow into the bedside catheter bag. During an observation on 9/12/24 at 1:09 p.m., R1's ostomy bags were observed to be on his abdomen and attached to drainage bags on the side of R1's bed. There was no date or initials noted on the pouches. During an interview on 9/12/24 at 3:40 p.m., assistant director of nursing (ADON) stated she remembered she came over to the red unit to assist with changing R1's left urostomy pouch on 9/2/24. ADON sated she thought she signed it off but could not remember. R1 was the only one in the facility with a urostomy. ADON stated her expectation would be for all dressings and ostomy supplies to be dated and initialed as ostomies are dressing changes. The dressing changes needed to be dated and initialed to verify they were changed. During an interview on 9/12/24 at 3:17 p.m., director of nursing (DON) stated it was her expectations if there was an order for specific days pouch changes then it should be completed on day scheduled. Nurses should be signing off the treatment on the TAR when it was completed. Review of the facility's policy titled Urostomy bag change dated 8/26/24 was reviewed.

Based on observation, interview and document review, the facility failed to follow Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control (CDC) guidelines to prevent the spread of Covid-19 when during a Covid-19 outbreak, failed to ensure appropriate use of personal protective equipment (PPE) when staff were observed not an wearing N-95 mask in the room of 1 of 1 resident (R51) in transmission based precautions (TBP) for Covid-19; failed to doff (remove) PPE per guidelines with staff were observed removing all PPE including N-95 masks prior to exiting the room of residents in TBP for Covid-19 for 4 of 4 residents (R51, R53, R29, R30); failed to ensure precautions posted on resident room doors (R51, R34, R29, R53, R211, R43, R22, R30, R159 and R160) were consistent and followed CDC recommendations; failed to ensure all staff were fit-tested for use of N-95 masks or respirator use for 3 of 3 employees (HSK-A, LPN-C, NA-C); failed to ensure masking occurred in public areas of the facility; and failed to ensure Covid-19 testing on residents was completed in private for 3 of 3 residents (R17, R42, R35). In addition, staff failed to wear gloves when handling food for 1 of 1 resident (R17). This had the potential to affect all 61 residents who resided in the facility. Finding include: Upon arrival to the facility on [DATE] at 11:30 a.m., a sign on the entrance door indicated masks were required and the facility currently has 14 cases of Covid-19. During the entrance conference, the director of nursing (DON)confirmed the facility was in Covid-19 outbreak status with 10 current residents and 4 staff members. During an observation and interview on 12/4/23 at 12:44 p.m., housekeeper (HSK)-A exited R51's room who was on TBP for Covid-19 with gown, gloves, face shield and regular face mask on. HSK-A discarded her gown in her trash bin on her cleaning cart. HSK-A then removed her face shield setting it face down on the top of her cleaning cart and then discarded it in trash basin on her cleaning cart. Removed her gloves and performed hand hygiene. Did not clean the top of the cleaning cart. Did not change her medical grade face mask. HSK-A indicated today is her first day on this pod and she wasn't aware she needed to wear an N-95 mask to enter R51's room. HSK-A indicated she normally takes her PPE off in the room but since she was finished cleaning the room decided to take it off outside the room instead of re-entering the room. HSK-A indicated she did do training on the computer for proper use of PPE when she started. HSK-A stated she has not been fit tested for respirator or N-95 mask. During observation and interview on 12/4/23 at 12:44 p.m., nursing assistant (NA)-C donned PPE including an N-95 mask and a took a paper sack with and entered R53's room who was in TBP for Covid-19. At 12:48 p.m., NA-C exited the room with no PPE on, completed hand hygiene and placed a new medical grade mask on. NA-C indicated they put their face shield and N-95 mask in a paper sack to save for use later and left them in R53's room. During an observation on 12/04/23 at 12:45 p.m., observed (NA)-A enter R30's room who was in TBP for Covid-19, wearing full PPE to deliver a meal tray. A few minutes later, NA-A exited R30's room with no PPE on, including her N95 mask. During observation and interview on 12/4/23 at 1:40 p.m., licensed practical nurse (LPN)-C donned PPE including N-95 mask and entered R29's room. LPN-C exited the room at 1:42 p.m. with no PPE on. LPN-C completed hand hygiene and placed a new medical grade face mask on. LPN-A indicated they do not reuse N-95 masks or face shield as they have adequate PPE supply and they discard all PPE inside the residents rooms prior to exiting. During observation and interview on 12/4/23 at 4:56 p.m., LPN-C donned PPE and entered R53's room. A paper sack was present on the counter inside R53's room with N-95 mask and face shield present. At exit, LPN-C discarded gloves, gown, face shield and N-95 mask into waste basket then exited the room and completed hand hygiene. LPN-C indicated she was told to discard all PPE inside the room before exiting and pointed out the sign on R53's door that stated Please remove your PPE before leaving the room. LPN-C indicated she has not had any fit testing since starting at the facility over two years ago. Despite CDC recommendation to remove N95 masks after exiting a room, R53, and R30's door had a facility-made sign, yellow in color and laminated that read: remove your PPE before leaving the room. During observation the following rooms had the following signs posted on their door: room [ROOM NUMBER], R34: No sign on door (tested positive for Covid-19 12/1/23) room [ROOM NUMBER], R29: Droplet precautions and donning and doffing for confirmed or suspected Covid-19. (tested positive for Covid-19 11/27/23) room [ROOM NUMBER], R53: Droplet precautions and please remove your PPE equipment before leaving the room. (tested positive for Covid-19 11/17/23) room [ROOM NUMBER], R51: Droplet precautions (tested positive for Covid-19 11/24/23) room [ROOM NUMBER], R159: Droplet precautions and please see nurse before entering (tested positive for Covid-19 11/27/23) room [ROOM NUMBER], R160: Droplet precautions (tested positive for Covid-19 11/30/23) room [ROOM NUMBER], R30: Droplet precautions and please remove your PPE equipment before leaving the room (tested positive for Covid-19 11/27/23) room [ROOM NUMBER], R22: Droplet precautions and sequence for donning PPE equipment (tested positive for Covid-19 11/24/23) room [ROOM NUMBER], R43: Droplet precautions and please remove your PPE equipment before leaving the room (tested positive for Covid-19 11/27/23) room [ROOM NUMBER], R211: Droplet precautions and please remove your PPE equipment before leaving the room and sequence for donning PPE equipment (tested positive for Covid-19 12/3/23. The resident rooms had Droplet Precautions signs on all above doors except room [ROOM NUMBER] which had no sign present. The Droplet Precautions signs indicated all PPE will be discarded prior to exiting the room, including N-95 mask or respirator. In addition, rooms 109, 125, 129 and 211 had yellow laminated facility made signs indicating to remove all PPE prior to exiting the room. During observation and interview on 12/5/23 at 9:43 a.m., NA-C donned PPE, placed his medical grade face mask in a paper sack and left it on the isolation cart and entered R53's room. NA-C exited the room with gloves on, face shield and N-95 mask on. Discarded gloves, face shield and N95 mask and placed in a paper sack outside of the room, completed hand hygiene and placed on new medical grade face mask. NA-C indicated he will dispose of the paper sack in a garbage can at the nurses station. NA-C indicated he had training for infection prevention and PPE use on the computer. He also followed another employee and learned how to don and doff (take off) PPE from other staff members. NA-C indicated he has not had fit testing to wear N-95 mask or respirator. During observation on 12/5/23 at 10:07 a.m., an unidentified visitor entered the facility lobby without a mask and spoke to the receptionist (R-H) who had her facemask below her chin. Visitor was not requested to wear a face mask. Visitor was directed to and entered social services office and continued with no face mask on. During observation on 12/5/23 at 10:12 a.m., two unidentified employees entered the lobby and at reception desk without a facemask. One employee put on a face mask and spoke with R-H. R-H continued with mask below her nose and mouth. The second employee went into an office behind reception desk without face mask on. Two unidentified adult visitors entered the lobby with strollers with 3 children. The adult visitors were not wearing a facemask and no request was made for them to wear a face mask. The visitors left at 10:18 a.m. During observation on 12/5/23 at 10:15 a.m., maintenance staff (M)-A was in facility lobby with no face mask on. M-A indicated staff were not required to wear a mask in the lobby area; only in patient care areas. During interview on 12/5/23 at 10:16 a.m., registered nurse (RN)-B, also identified as infection preventionist, indicated at a meeting with other infection prevention team members, it was determined wearing a facemask was not required in the public lobby area even during a Covid-19 outbreak but was required once you entered the pods (resident care areas). RN-B added in hind sight, residents do wait in the lobby waiting for transportation at times but are always wearing a face mask or PPE if positive for Covid-19. RN-B reviewed signs on resident doors listed above and stated the signs are confusing. RN-B stated a droplet precautions sign should be on each door along with donning and doffing PPE instructions. RN-B, after reviewing current CDC guidelines for PPE use for Covid-19, confirmed doffing should include removing PPE in the resident room but should remove N-95 mask or respirator once exiting the room. RN-B also confirmed everyone entering public areas should be wearing a medical grade face mask. During an observation and interview on 12/05/23 at 11:41 a.m., NA-A and (NA)-F stated they were instructed to remove all PPE prior to exiting a residents room who was in TBP for Covid-19, including their N95 mask. In addition, both NA's stated they had not been fit-tested for N95's at this facility. During interview on 12/6/23 at 10:22 a.m., RN-B confirmed housekeeping is required to wear N-95 face masks in Covid-19 positive rooms and following donning and doffing procedures for PPE. RN-B confirmed the facility has never done fit testing for staff to wear N-95 masks or respirators. RN-B added they have not had cooperation from the medical director for medical clearance required prior to testing. RN-B indicated time is a factor also as it takes 1/2 hour per person and there are 100 employees. Covid testing in public: During observation on 12/6/23 at 8:37 a.m., RN-B was going into resident rooms testing for Covid-19. RN-B then went to the dining area on the 1st floor, red pod and swabbed R17's, R42's and R35's nostril for testing for Covid-19 while residents were in the dining area eating. During interview on 12/6/23 at 10:22 a.m., RN-B indicated residents have never complained about being tested for Covid-19 in the dining area and she has been doing it that way for a long time. The facility PPE policy last reviewed August 2023 included: - PPE consists of items such as a face mask or shield, gloves, gown and/or goggles which are to be worn whenever there is a risk of contamination by the resident's blood or body fluids. It is a component of Standard Isolation precautions as well as part of additional isolation protection if a resident needs Contact, Droplet or Airborne Isolation for infectious issues. -See separate Centers for Disease Control poster for proper donning and removal of all PPE. Copies of this poster are provided on all isolation carts. See separate listing for tasks that require PPE to be worn. -Doffing poster included: except for respirators, remove PPE at doorway or in anteroom. Remove respirator after leaving patient room and closing the door. Food handling: During observation on 12/6/23 at 8:31 a.m., R17 was sitting in a wheelchair in dining room when NA-A approached to assist and picked up toast with ungloved hands and gave R17 a bite and set toast back on plate. NA-A again picked up toast and gave R17 another bite at 8:32 a.m., with ungloved hands. At 8:33 a.m. NA-C left and went to a closet by the nurses station and returned with gloves on her hands and continued to assist R17 with his toast. During interview on 12/6/23 at 10:45 a.m., registered nurse (RN)-B indicated she had observed NA-A touching R17's food at breakfast this morning. RN-B stated she should not be touching anyone's food with her bare hands. During interview on 12/6/23 at 4:08 p.m., the director of nursing (DON) confirmed staff should not pick up food with their hands unless wearing gloves. The facility Feeding the Resident (dependent eating) procedure undated included: - observe universal precautions or other infection control standards as approved by appropriate facility committee. 42073

Based on observation and interview, the facility failed to identify and date facility-made frozen soups stored in 4 of 4 kitchenettes, and failed to ensure dishes in the kitchen were stored dry. This had the potential to affect all 61 residents who resided in the facility. Finding include: During an observation on 12/6/23 at 9:58 a.m., observed full-sized refrigerators in each kitchenette on each of four resident units. Observed in each freezer were multiple half-pint, plastic containers of an unknown food. The containers had not been labeled with contents, nor dated. During an observation and interview on 12/6/23 at 10:40 a.m., in the kitchen, dietary manager (DM)-A picked up clean metal steam table pans that had been stacked one on top of another on a wire rack. DM-A picked up two pans that were wet inside and one pan that had dried food on it. DM-A gave all three pans to the dishmachine worker to redo and asked another dietary worker to check all pans to ensure they were clean and dry. During the same interview, DM-A was informed of frozen containers of food on the units not being identified or dated. DM-A had not been aware of that and stated they were soups and should have been identified and dated. During an interview on 12/6/23 at 12:20 p.m., DM-A stated the frozen plastic containers contained homemade soup for the always available menu. DM-A stated the soup was good for three months and staff had begun labeling and dating the containers. The facility Infection Control policy, undated, indicated foods would be clearly labeled and dated in the freezer. All dishes, silverware, etc., would be stored cleaned, dry, and upside down on storage shelf.

Based on observation, interview and document review the facility failed to provide a dignified dining experience for 1 of 1 residents (R17) who required assistance with dining. Findings include: R17's Admission Record printed 12/6/23, indicated R17's diagnoses included traumatic brain injury, Parkinson (nervous system disorder progressive movement disorder that causes tremor in one hand, stillness or slowing of movement), and dementia. R17's quarterly Minimum Data Set (MDS) assessment, dated 10/4/23, identified R17 rarely to never is understood, occasionally understands, does not speak, and is totally dependent with all care including assistance with feeding from assistance of 1 person. R17's care plan printed 12/6/23, identified an activities of daily living (ADL) self care performance deficit and requires assistance by 1 staff to eat. During an observation on 12/4/23 at 12:39 p.m., R17 was sitting in his Broda chair (positioning wheelchair) at a table in the dining room with his meal in front of him. At 1:09 p.m., nursing assistant (NA)-C sat down to assist R17 with the meal without reheating. At 1:10 p.m., NA-C went to deliver a tray to another residents room and returned to assist R17 at 1:12 p.m. At 1:15 p.m., NA-C went to deliver another room tray. At 1:19 p.m. returned and assisted R17 until he was done with this meal. During observation on 12/6/23 at 7:17 a.m., R17 was brought to the dining room and placed at a bedside table in the dining room. At 7:31 a.m., R17 had peanut butter toast on his table. At 7:35 a.m., R17 received his medications from licensed practical nurse (LPN)-A. Toast continued to sit untouched on the plate. At 7:58 a.m., toast remained on his plate on his table. R17 has made no attempt to feed self. At 8:18 a.m., R17 continued with toast on his plate on table with no attempt to feed self. At 8:29 a.m., dietary manager asked NA-A if there was someone to assist R17 with his breakfast. NA-A then stood beside R17 and picked up toast that was served at 7:31 a.m. with ungloved hands and gave R17 a bite and set toast back on plate. At 8:31 a.m., NA-A picked up toast and gave R17 another bite with ungloved hands. At 8:33 a.m., NA-C went to a closet by the nurses station and returned with gloves on her hands and continued to assist R17 with this toast. At 8:41 a.m., R17 finished eating his toast. NA-C requested oatmeal. NA-C assisted R17 with eating his oatmeal and R17 had multiple coughing spells. NA-C informed LPN-A who responded that NA-C should stop feeding R17. During interview on 12/6/23 at 9:09 a.m., NA-A confirmed she did not reheat or ask for new toast for R17. NA-A confirmed R17 had to wait for assistance this morning as the NA's were busy getting everyone up before assisting him. During interview on 12/6/23 at 4:08 p.m., the director of nursing (DON) confirmed staff should not pick up food with their hands unless wearing gloves. The DON stated food should not be placed in front of R17 until staff are available to assist R17 with the meal and staff should remain with the resident until R17 is finished with his meal. The facility Feeding the Resident (dependent eating) procedure undated included: -observe universal precautions or other infection control standards as approved by appropriate facility committee. -take tray to resident and set directly in front of resident -never make the resident feel that the meal must be hurried and but that the procedure is pleasant. Give him/her your complete attention. Sit so you are at the same level as the resident when possible.

Based on interview and document review, the facility failed to notify a provider of a significant physical change for 1 of 1 resident (R10) reviewed for notification of change. Findings include: R10's face sheet printed on 12/6/23, included a diagnosis of congestive heart failure, and new diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (partial paralysis on one side of the body) following a stroke, affecting right dominate side with aphasia (loss of ability to understand or express speech) dated 12/1/23. R10's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R10 was cognitively intact, had clear speech, was understood, and could understand. R10 had been independent with most all activities of daily living (ADL's). R10's care plan dated 12/4/23, indicated R10 had a stroke affecting her right dominate side and expressive aphasia, and would show improvement to maximum potential with mobility and cognition. R10's physician orders dated 11/4/21, included a standing order for urine specimen for UA (urinalysis) with reflex to culture if protocol criteria were met for signs and symptoms of UTI (urinary tract infection). During an interview on 12/4/23 at 1:53 p.m., family member (FM)-F stated R10 had recently had a stroke on 11/27/23, and had difficulty speaking in the days prior to that stroke and had not been acting her usual self. FM-F thought R10 had another UTI causing the behavior changes and took R10 to the emergency room (ER) herself to have R10 checked on 11/24/23. During an interview on 12/5/23 at 1:26 p.m., licensed practical nurse (LPN)-D stated she had been working when R10 had experienced the first stroke symptoms on 11/23/23. LPN-D stated on 11/23/23, R10 became very confused, couldn't speak, and shook her head yes or no in answer to questions. LPN-D admitted she had not notified a provider despite observing R10's inability to speak. LPN-D looked in the electronic medical record (EMR) to see if she had documented R10's inability to speak and stated she had not, and should probably enter a late note. LPN-D stated she didn't document R10's changes because she was going out the door at shift change and had just stayed long enough to help do the neuro (neurological) assessment. LPN-D stated R10's neuro assessment had been okay, and she informed on-coming nurse, (LPN)-I of the results. LPN-D stated she assumed LPN-I would document the changes in R10's condition and notify the provider if symptoms continued. Progress note dated 11/23/23 at 5:47 p.m., written by LPN-I indicated: family member (FM)-F stated R10 was out of it, doesn't readily answer questions unless yes or no and was sleepy. FM-F had been adamant R10 had a urinary tract infection (UTI) though R10 denied pain or burning on urination. Vital signs were stable. Progress note dated 11/23/23, at 6:47 p.m., written by LPN-I indicated: nurse practitioner (NP)-F was called and stated FM-F had texted her regarding R10 and concern she has a UTI. Confirmed R10 did not fit criteria for a UA/UC (urinalysis and urine culture) but [a UA] could be done at the family's insistence. Progress note dated 11/23/23, at 9:00 p.m., written by LPN-I indicated FM-F stated she didn't know why she had to wait for a [urine] culture report -- she knew R10 had a UTI and said she just might take R10 to the ER herself. Twenty minutes later, R10 was observed being taken down the hallway by FM-F to the ER. LPN-I up-dated the on-call RN (registered nurse). Progress note dated 11/23/23, at 10:45 p.m., written by (LPN)-G indicated R10 had returned from the ER with an order for an antibiotic [for diagnoses of UTI]. During an interview on 12/5/23 at 3:35 p.m., registered nurse (RN)-A who was also the nurse manager stated no one had informed her about R10's inability to speak on 11/23/23, adding staff should have called the on-call nurse, registered nurse (RN)-F. During an interview on 12/5/23 at 3:47 p.m., RN-F stated she had received a call regarding R10 on 11/23/23, and the family wanting a urinalysis believing R10 had been experiencing symptoms due to a UTI. RN-F stated she instructed staff to call the on-call provider. RN-F stated staff did not report anything about R10 not being able to speak; but did say something about confusion. During an interview on 12/5/23 at 3:51 p.m., nurse practitioner (NP)-D stated on 11/23/23 at 5:46 p.m., FM-F had texted her, noting R10 had been disoriented today, urine [NAME] strong, using fingers to eat. NP-D stated she had not been the on-call provider, but FM-F had her phone number and texted her. NP-D stated she was unaware R10 had been unable to speak; FM-F did not indicate that in her text message - she was focused on a possible UTI. NP-D stated R10 could have been having a TIA on 11/23/23, with the inability to speak and behavior changes. NP-D stated she had reviewed the ER visit note from 11/23/23, and the ER provider had not noticed stroke symptoms. NP-D stated if R10 had been sent to the ER earlier on 11/23/23, it might not have changed the outcome, however it was always good practice to notify a provider anytime a resident experienced a change in condition. ER visit note dated 11/24/23 at 9:24 p.m., indicated the reason for R10's visit was urinary problems. Per FM-F's report, incontinent x3 today, confusion yesterday, today fatigue and weakness and R10 not acting like herself. The ER visit note indicated R10 presented to the ER with confusion yesterday and intermittent abdominal pain. R10 had clear speech, poor recall and moving all extremities. A urinalysis was notable for infection which could explain R10's urinary symptoms, abdominal discomfort, and confusion. The ER provider note indicated they would hold off on radiological studies at that time. Final diagnosis, UTI. According to progress notes and ER visit note, the facility had failed to inform the ER provider of R10's inability to speak on 11/23/23. During an interview on 12/6/23 at 8:33 a.m., the DON was informed of interviews with staff and the failure of a nurse to notify the on-call provider on 11/23/23, when R10 was not able to speak, nor did a nurse document R10's inability to speak. The DON was aware from the ER visit note that the ER provider had not thought R10 was having a stroke as he didn't order imagining tests. The DON acknowledged that communication from the facility to theER on [DATE], in the form of an SBAR (situation, background, assessment, recommendation) focused on UTI symptoms, and nothing about R10's inability to speak earlier that day. The DON stated he would have expected nurses to inform a provider when there was a change in a residents condition and to document the findings. The DON stated, yes - there had been an opportunity to notify the provider. The facility Physician Notification policy dated 9/13/23, indicated in the event of a significant change in a resident's physical, mental or psychosocial status in either life-threatening conditions or clinical complications, the facility RN or LPN would inform the resident, consult with the resident's physician or on-call physician. When a resident complained of an acute onset of new, severe pain, difficulty breathing, visual disturbances, increased weakness, difficulty swallowing, dizzy, has behavioral changes or any abnormal feeling, more information must be obtained. After all information was gathered, the physician needed to be contacted. Conditions in which to notify a physician immediately included sudden change in mental status including confusion.

Based on observation, interview, and document review, the facility failed to comprehensively assess and implement pressure ulcer interventions for 1 of 1 resident (R9) reviewed for risk of pressure ulcer development. R9 was harmed when he developed one, stage 3 pressure ulcer after admission to the facility. Findings include: Pressure Ulcer stages defined by the Minimum Data Set (MDS) per Center Medicare/Medicaid Services: Stage III pressure ulcers (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling.). R9's facesheet printed on 7/13/22, indicated R9 was admitted on ,d+[DATE]; admission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated severe cognitive impairment, clear speech, was understood when he spoke and was able to understand others. R9 required extensive assistance of two staff and a mechanical lift for moving in bed and toileting; was totally dependent upon two staff and a mechanical lift for transfers. R9 did not walk. The MDS assessment indicated R9 was at risk for pressure ulcer, but had no pressure ulcer over a bony prominence. In addition, the MDS assessment indicated a pressure reducing device in chair and bed was not used and there was not a turning/repositioning program in place for R9. R9's care plan dated 8/5/21 - 9/27/22, indicated R9 was at risk for an alteration in or potential for break in skin integrity. A goal indicated R9 would have no break in skin integrity through review date of 7/5/22. Interventions included daily skin inspections by a nursing assistant (NA) and to report abnormalities to the nurse, and to keep skin clean and dry. In addition, R9's care plan indicated he had an activity of daily living (ADL) self-care deficit related to post-polio syndrome and required extensive assistance of one to two staff to turn and reposition in bed as necessary. The care plan did not include measures to prevent a break in skin integrity, including, but not limited to, how often R9 should be turned and repositioned when in bed R9's care plan did not address off loading the heel and feet or device to protect ankles. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview on 7/12/22, at 8:12 a.m., family member (FM)-J stated R9 recently developed a pressure injury on left outer ankle, adding that R9 slept on his back with his left leg turned outward lying on the bed. Progress note dated 6/25/22, at 9:55 p.m., indicated licensed practical nurse (LPN)-B observed a stage 2 pressure area on R9's outer left malleolus (a bony projection on either side of the ankle). Noted while R9 in bed, laying on his back with left ankle rotated outward with outer ankle pressed into mattress. Weekly skin and wound evaluations for all of June and July were requested. No evaluations were received for 6/6 and 6/13. Others indicated: 6/20/22: No skin concerns noted. 6/25/22: Left outer ankle, pressure type injury, measuring in centimeters (cm): length 14.6, width 4, depth 0.1, stage II. In addition, the assessment indicated R9 was observed in bed, laying on his back with his left ankle rotated outward. 7/4/22: Left outer ankle, pressure type injury, measuring in cm: length 1.1, width 0.9, depth 0.1, stage II. 7/6/22: Left lateral malleolus 1.3 cm area; 1.3 cm length, 1.3 cm width. 7/11/22: R9 refused skin audit. 7/12/22: Left outer ankle, pressure type injury, measuring in cm: length 1, width 0.7, depth 0.1, stage III. Nurse practitioner (NP)-H visit note dated 6/28/22, indicated R9 had a reddened warm area on left ankle, painful with open area. Treatment being done. Open wound to left lateral malleolus. Scant drainage. No s/s [signs or symptoms] of infection. Keep heels elevated in bed. Referral to physical therapist (PT)-I to evaluate and treat wound. PT-I note dated 7/12/22, indicated R9 was seen for a stage 3 pressure injury to left mall [malleolus]. Current measurement 1 x 0.7 x 0.1 cm. Dressing change every two days with xeroform gauze and [MEDICATION(S)] boarder dressing. Off-loading boot (blue) to be worn whenever in bed to off-load ankle. Recheck 10-14 days, sooner if wound size increases. During an interview on 7/12/22, at 2:23 p.m., license practical nurse (LPN)-C was aware of the pressure injury to R9's left ankle, stating it rotated outward when he laid in bed. LPN-C looked in the electronic medical record (EMR) to find first observation of pressure injury and stated it was on 6/25/22, at 9:55 p.m., when LPN-B observed a stage two pressure area on R9's outer left ankle. LPN-C was unaware of preventive measures that had been taken to prevent a pressure injury to R9, adding skin checks were done weekly on bath day. During an interview on 7/13/22, at 8:35 a.m., nursing assistant (NA)-E provided an untitled document she called a bath sheet. The document had five columns, including day of week, room number, resident name, skin audit day and bath day. NA-E stated R9 skin audits were done by NA's on the evening shift on Thursdays when R9 had a shower. NA-E stated NA's inform the nurse of any findings and the nurse documents findings in the EMR. NA-E had not given R9 a shower, as he preferred male staff. During an observation on 7/13/22, at 11:23 a.m., R9 was laying in bed supine (on back), covered with a towel following a shower. Left lateral ankle was covered with a dressing and left ankle was externally rotated with bony prominence directly resting on mattress. During an interview on 7/13/22, at 11:29 a.m., (LPN)-A stated R9's pressure injury was first noticed by a evening shift nurse on 6/25/22. LPN-A stated it was not noticed sooner because R9 refused skin audits. LPN-A stated if R9 refused, they would ask him again, but he had the right to refuse skin audits. LPN-A stated NA's looked at R9's skin daily as allowed and reported abnormalities to the nurse. LPN-A confirmed the only intervention on R9's care plan to prevent a pressure injury were daily skin checks by a NA. LPN-A acknowledged that would not prevent a pressure injury but might catch it before the skin broke. During a telephone interview on 7/13/22, at 12:29 p.m., PT-I confirmed she saw R9 on 7/12/22, and that he had a stage 3 pressure injury. PT-I stated that due to R9's history of polio, he lacked internal rotation of his left leg and was a high risk for a pressure injury because of that. PT-I could not say if the pressure injury was preventable, as she was unaware if the facility had been using preventive measures prior to discovering the wound. PT-I stated she gave R9 a off-loading boot for his left foot on 7/12/22. During an observation on 7/13/22, at 1:30 p.m. with LPN-A, observed R9's pressure injury to left lateral ankle. Visually, wound appeared to measure approximately .25 x .25 inches, pale yellow in center, no scab, no drainage. Skin surrounding wound was slightly red. LPN-A stated it was healing and looked better. Wound was flushed and dressed by LPN-A. A pressure reducing mattress on bed and pressure reducing cushion in wheelchair were observed; neither were noted on R9's care plan. During an observation on 7/14/22, at 7:50 a.m., R9 was laying in bed, supine. Off-loading boot noted on left foot. During an interview on 7/14/22, at 8:17 a.m., (NA)-D stated R9 depends on us for everything. NA-D stated R9 might be able to turn onto his side in bed by himself, but would need a pillow behind his back to keep him on his side. We are supposed to reposition him every two hours, but he usually refuses. In the EMR, in the section where NA's documented cares, NA-D displayed tasks for the surveyor to review, it identified repositioning every two hours and for skin observations. Skin observations were marked as red areas five times prior 6/25 (6/16, 6/18, 6/19, 6/22, 6/23), when the pressure injury was discovered. NA-D stated a NA could only checkmark red area, but not indicate where the red area was located, but if she observed a red area, she would tell a nurse. NA-D stated she had never observed redness on R9's outer left ankle when bathing or dressing him. During an interview on 7/14/22, at 8:56 a.m., registered nurse (RN)-E looked in the EMR to determine R9's pressure injury was first observed on 6/25/22. RN-E indicated she did not hear much from staff about things like this (pressure injury). RN-E did not know what preventative measures had been in place to prevent a pressure injury to R9's ankle, stating, Honestly, I'm not sure. RN-E looked at R9's care plan in the EMR and stated there were no interventions to prevent pressure injury over bony prominence's .only daily skin inspection and to keep R9's skin clean and dry. RN-E acknowledged she was aware of R9's post-polio syndrome diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-E stated the facility used a program that automatically populated care plan interventions, and as staff got to know a resident better, they added more interventions. RN-E acknowledged that had not been done with R9's care plan regarding pressure injury prevention. RN-E stated skin audits were done by nurses and that ankles were a part of the audit, adding that nurses were supposed to go through each body part noted on schematic body drawings on the audit form. RN-E stated she did not know how R9's skin condition on his ankle was overlooked before becoming a stage 3 pressure injury. While looking at the NA task list in the EMR, RN-E stated NA's were to shift and reposition R9 in bed or chair every two hours to reduce pressure, and stated this had not been added to R9's care plan and therefore nurses might not have been aware of it. On the same task list, NA's were to observe R9's skin for scratches, red areas, discoloration, skin tears, and open areas. In the days prior to 6/25, there were checkmarks made by NA's on six days for red areas, but no corresponding documentation indicating whether or not a nurse had been informed of this, or where the red areas were located. RN-E acknowledged the pressure injury on R9's ankle was probably preventable, adding they could have floated his heels; he could have had heel boots. During an interview on 7/14/22, at 10:21 a.m., the DON confirmed he was aware of R9's pressure injury to his left ankle. Discussed the lack of measures initiated to prevent pressure injury over bony prominence's, as well as NA's checking red areas in their documentation for skin observation, but no correlating progress notes to indicate a nurse was informed and the location of the red area. The DON acknowledged both were accurate. When asked if the pressure injury could have been prevented, the DON replied, Ultimately, hindsight is 20/20 probably could have been prevented .we've prevented a pressure injury for a long time, considering how often R9 refuses cares. Other than a pressure relieving mattress, there was no evidence that pressure reducing measures were in place to protect R9's skin over bony prominence's prior to discovery of a pressure injury on 6/25/22. While there were multiple notation in progress notes regarding refusals of care or of activities, none were observed regarding refusals to reposition in bed. Facility policy titled Skin Alteration Management, undated, indicated the facility would identify and review residents whose clinical conditions increase the risk for skin breakdown. To ensure necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and new injuries from developing. On admission, and quarterly, each resident would have a Braden assessment. Appropriate interventions would be implemented based on assessment and would be placed on resident care plan. Resident's skin would be observed daily with cares and as needed.

Based on observation, interview and document review, the facility failed to assess and evaluate causal factors for falls, and failed to ensure adequate supervision and interventions were implemented to reduce the risk of falls and serious injury for 1 of 6 residents (R217) reviewed for accidents. This resulted in an immediate jeopardy for R217, who was recently admitted to the facility with a history of falls and a [CONDITION(S)], sustained a fall at the facility requiring transfer to the local emergency room for evaluation, and lacked individualized interventions and assessment to prevent further incidents. The immediate jeopardy began on 1/7/19, when R217 hit her head during a fall and the facility failed to conduct an assessment of contributing factors to R217's fall, and failed to implement interventions to reduce falls to prevent serious injury or death. The immediate jeopardy was identified on 1/8/19, and the administrator and director of nursing were notified of the immediate jeopardy at 3:10 p.m. The immediate jeopardy was removed on 1/9/19, but noncompliance remained at the lower scope and severity level of D isolated, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R217 was admitted to the facility on [DATE], following surgical repair of a fractured right hip related to a fall that occurred prior to admission. R217's medical history identified diagnoses which included: Diabetes type II, [CONDITION(S)], [CONDITION(S)] with long term use of anticoagulants (blood thinning medication), [CONDITION(S)], [CONDITION(S)] (a lung disease) with use of oxygen, and a history of falls. No Minimum Data Set (MDS) or Care Area Assessments (CAA) had been conducted for reference since R217i's recent admit. A Brief Interview for Mental Status (BIMS), cognitive assessment tool, was completed on 1/4/19 and indicated severe cognitive impairment. R217's initial care plan, initiated date 1/4/19, was not complete or individualized. Focuses included risk for falls with interventions that included: (1) Be sure call light is within reach and encourage resident to use it for assistance; resident needs prompt response to all requests. (2) Encourage resident to participate in activities that promote exercise. (3) Ensure appropriate footwear is being used when ambulating or mobilizing in wheelchair. (4) Follow facility fall protocol. (5) Physical therapy evaluate and treat as ordered or as needed. (6) Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter or remove any potential causes. Educate resident, family, caregivers, interdisciplinary team. (7) Resident needs safe environment. R217's care plan failed to identify individualized information including: (1) Level of assist for activities of daily living (ADL's). (2) Need for assist with decision making. (3) Level of risk for falls. (4) Specific safety needs for her environment. A Morse Fall Scale assessment for R217 dated 1/4/19, revealed a score of 75 indicating R217 was at high risk for falls. The assessment indicated R217s risks included: (1) Falls before admission. (2) More than one diagnosis. (3) Used crutches, cane, or walker. (4) Impaired gait: difficulty rising from chair, uses chair arms to get up, bounces to rise; keeps head down when walking, watches the ground; grasps furniture, person or aid when ambulating. Cannot walk unassisted. (5) Knows own limits. Although the Morse Fall Scale identified data putting R217 at risk, the assessment did not included a summary of the risks or how to prevent falls. Review of R217's incident reports indicated: (1) 1/7/19 at 10:28 p.m., R217 was sitting in her wheelchair visiting company. When company left she attempted to self-transfer to the bathroom and fell . The incident report identified the following items: (1) no injuries (2) pain level four out of ten according to the PAINAD (a nonverbal pain scale) (3) alert (4) ambulatory with staff assist (5) oriented to person (6) no predisposing environmental factors (7) predisposing physiological factors included confused, gait imbalance, and impaired memory (8) predisposing situation factors included attempting to self-transfer, ambulating without assist, denies abuse (9) no witnesses to fall (10) notification to husband and NP (11) vulnerable adult incident filed (12) order for video monitoring. The incident report failed to identify where R217's pain was and did not include a summary of the incident. (2) 1/8/19 at 11:12 p.m., indicated R217 was found lying on her left side on the floor, unable to determine if she hit her head due to fall last evening. The incident report identified the following items: (1) no injuries (2) no pain (3) alert (4) wheelchair bound (5) oriented to person (6) no predisposing environmental factors (7) predisposing physiological factors included confused (8) predisposing situation factors included attempting to self-transfer, ambulating without assist (9) no witnesses to fall (10) notification to husband, son, and NP. The incident report included a note that interventions included re-arranging furniture, 30 minute checks, two hour toileting, 24 hours of 1:1 supervision, updated care plan, pharmaceutical review by consulting pharmacist, medical review by medical director. Review of physician orders and treatment records indicated: (1) 1/7/19 11:32 p.m., video monitoring for increased falls every shift for confusion (2) Review of January 2019 treatment administration record (TAR) indicated video monitor for increased falls every shift for confusion with a start date and time of 1/8/19 at 7:00 a.m. Review of progress notes dated: (1) 1/4/19 at 4:11 p.m., indicated family had concerns regarding R217's confusion and self-transfer attempts with a history of falls. Family voiced need for frequent monitoring. (2) 1/4/19 at 4:14 p.m., indicated R217 required assist of one with all ADL's, pivot transfers with assist of two and use of transfer belt and walker. The progress note indicated baseline confusion, impulsive, and may attempt to self-transfer. (3) 1/4/19 at 5:45 p.m., indicated R217 had frequent falls, was alert, orientated to self, always confused and could verbalize to use the call light but did not use it in the hospital. The progress note further indicated video monitoring had been used during R217's hospital stay. (4) 1/5/19 at 3:23 a.m., R217 repeatedly attempted to self-transfer and video monitoring was used during the night. (5) 1/5/19 10:56 a.m., R217 was found trying to self-transfer from the recliner to the bathroom. (6) 1/5/19 at 2:24 p.m., the occupational therapy assistant (OTA) had left R217 in the bathroom and told her to pull the call light when she was done. R217 was found standing up in the bathroom. (7) 1/7/19 at 10:28 p.m., indicated R217 was sent to the emergency room via ambulance following a fall. The progress note failed to identify if immediate interventions were implemented prior to the ambulance arriving. (8) 1/7/19 at 11:39 p.m., indicated R217 returned from the emergency room with no injuries, but was complaining of buttock pain. The progress note failed to identify any revised or updated interventions. The progress notes did not include evidence of increased supervision or monitoring of the resident due to R217's falls risk. On 1/7/19 at 2:35 p.m., registered nurse (RN)-D provided a copy of the 3rd floor south wing care sheets utilized by the nursing assistants (NA). R217, who had been recently admitted was not listed on the care sheets. During interview on 1/7/19 at 3:27 p.m. with R217 and her family, the family voiced concerns of R217 being left in the bathroom alone. The family stated R217 stood by herself and would try to pull her pants up by herself. During chart review at the nurse's station on 1/7/19 at 6:49 p.m., a loud thump was heard, followed by a yell. Upon entering R217's room, R217 was lying on her back on the floor in front of the bathroom door. Staff assessed for bleeding, movement, and pain. R217 complained of back pain, was moaning and was breathing rapidly. RN-D stated she would stay with R217 until someone else was available to sit with her. R217 was noted to have hit her head on the floor during the fall, and her current physician's orders including medications to prolong her blood clotting times, increasing the risk for bleeding inside the head after a fall with head strike. R217 was to be transferred to the hospital due to fall with head strike and anticoagulant use, for imaging tests to rule out head trauma. During interview on 1/7/19 at 6:58 p.m., nursing assistant (NA)-I stated R217 had been sitting in the recliner with her call light in place the last time he'd checked on her. NA-I stated R217 had removed her nasal cannula and was self-transferring to the bathroom when she'd fallen. During interview on 1/7/19 at 7:06 p.m., RN-D stated fall interventions for R217 included: (1) room closest to nurse's station, (2) check on resident every two hours, (3) they were waiting for an order to place a video monitor to aide in supervision of R217, and RN-D stated the video monitor sat behind the nurses' station, and would make a beeping sound with any movement. During continuous observation on 1/7/18 at: (1) 7:10 p.m., RN-C notified R217's husband and the nurse practioner of the fall. (2) 7:11 p.m., R217 was placed on the bed pan and left alone, although she had just fallen and was exhibiting signs of pain and possible injury, and was being transferred to the emergency department for evaluation. (3) 7:13 p.m., staff entered room, then left leaving resident unattended (4) 7:16 p.m., staff entered room, then left, leaving resident unattended (5) 7:17 p.m., staff entered room (6) 7:20 p.m., staff left the room leaving resident unattended (7) 7:22 p.m., R217 was attempting to get up out of bed and go to the bathroom, the surveyor summoned staff to return to the room to assist the resident. During interview on 1/7/19 at 7:27 p.m., a copy of the initial care plan was received. RN-C verified the orange triangles on the care plan indicated the care plan had not been completed or individualized, and was still in progress. During observation on 1/7/19 at 7:29 p.m., the ambulance arrived to transport R217 to the emergency room . During interview on 1/7/19 at 7:35 p.m., RN-C stated the facility's fall protocol required staff to assess a resident who fell for bleeding, pain, range of motion, and position of extremities. RN-C confirmed immediate interventions placed for R217 were for staff to stay with her until the husband or ambulance crew arrived. During continuous observations on 1/8/19, R217 was not consistently observed to receive supervision to prevent further attempts at self transfer: (1) 8:15 a.m., the video monitor was on the bottom counter at the nurses' station, beeping occasionally however, no staff was in the vicinity of the desk to see or hear it. (2) 8:17 a.m., staff entered R217's room. (3) 8:18 a.m., staff left the room, leaving resident unattended. (4) 8:25 a.m., Physical Therapy Assistant (PTA)-I was in R217's room and was heard to remind R217 to use the call light when she needed anything, and to remind R217 she couldn't be up on her own. (5) 8:28 a.m., staff left the room, R217 was sitting up in her wheelchair with a transfer belt on and no call light within reach. (6) 8:32 a.m., staff entered the room. (7) 8:35 a.m., R217 was taken to the therapy room. During interview on 1/8/19 at 8:40 a.m., LPN-A stated staff had to watch the video monitor in order to see what R217 was doing. LPN-A stated the video monitor does not really alert staff when there is movement, so she would be taking the monitor with her when R217 returned to her room. During further observation on 1/8/19 at: (1) 8:50 a.m., LPN-A took the video monitor and placed it on her medication cart. (2) 8:55 a.m., R217 returned from therapy. PTA-I reminded R217 not to get up by herself and to always use her call light. PTA-I assisted R217 to transfer from the wheelchair to her bed. During an interview on 1/8/19 at 8:57 a.m., PTA-I indicated therapy was working with R217 to improve strength, standing tolerance, and walking. PTA-I stated R217 was only able to ambulate 30 feet related to increased fatigue and pain with activity. He further indicated he was not aware of R217's Tinetti (a balance and gate assessment) and had not provided recommendations for falls. During an interview on 1/8/19 at 9:00 a.m., R217 denied falls at home prior to admit. When the surveyor asked R217 how she'd broken her hip R217 said, I still don't know. R217 also denied having had any falls at the facility. During interview, R217 was sitting in the electric recliner with her feet elevated and the control lying on floor beside the chair, not within reach of R217. During observations on 1/8/19 at: (1) 9:19 a.m., LPN-A was at the medication cart, video monitor was placed on top of cart. (2) 9:25 a.m., the video monitor remained on the medication cart however the cart was unattended. (3) 9:28 a.m., LPN-B went to R217 room and checked her vital signs. (4) 9:33 a.m., LPN-B went to R217's room, came out to get the video monitor off the medication cart, and returned to the room. (5) 9:55 a.m., R217 was sleeping in the recliner with her legs elevated. During an interview on 1/8/19 at 9:56 a.m., LPN-A stated R217 had fallen that morning while self-transferring. Record review at this time indicated an entry dated 1/8/19, at 7:02 a.m., indicating family and the physician had been notified of another unwitnessed fall for R217. LPN-A stated she was not totally sure what immediate interventions had been put in place. In addition, LPN-A further indicated the night nurse reported to her that he had mentioned a sensor alarm to the director of nurses (DON), but hadn't heard anymore about it. LPN-A stated interventions to prevent further falls on her shift included: video monitoring and 1/2 hour checks. LPN-A confirmed there were no other interventions in place. She stated the other thing she could think of doing would be for staff to check on R217 more frequently but confirmed that was not currently being done. During observation on 1/8/19 at: (1) 9:58 a.m., LPN-A walked away from the medication cart and left the video monitor unattended. (2) 10:03 a.m., LPN-A returned to the medication cart. (3) 10:04 a.m., LPN-A walked away from the medication cart and left the video monitor unattended. (4) 10:08 a.m., LPN-A entered R217's room. (5) 10:09 a.m., R217 was sleeping in the electric recliner with her legs elevated. During an interview on 1/8/19 at 11:35 a.m., the Nurse Practitioner (NP) stated she would expect care planning to start at pre-admission by including: (1) fall precautions, (2) residents with dementia need extra close monitoring for the first couple of weeks, (3) someone coming in with history of falls should be monitored more closely (such as hourly), (4) video monitoring if indicated. NP stated further expectations following a fall would include: (1) re-evaluation of interventions to figure out what needs should be changed, (2) increase checks to 15 minutes, (3) add video monitoring, in addition to 15 minute checks. The NP confirmed R217 should never be left alone in the bathroom without staff. During observation on 1/8/19 at 12:50 p.m., R217 was sleeping in the electric recliner with her feet elevated. During interview on 1/8/19 at: (1) 12:52 p.m., NA-A stated staff are made aware of residents with falls risks through verbal communication. NA-A said any resident could be a fall risk, and all residents should be treated the same in regards to fall risks. NA-A stated if a resident falls, she would get the nurse. (2) 12:52 p.m., NA-D indicated staff are usually notified of resident falls through the dashboard on the computer system. She indicated when changes to resident are made, they are written in the communication book. She also indicated if something new was implemented during the shift, nurses would generally communicate that verbally. NA-D also stated all residents are checked on every one to two hours, and residents who fall frequently (more than once a week) are checked on every 30 minutes to one hour, or have a sensor alarm placed. (3) 12:54 p.m., NA-C stated if a resident fell , she would get the nurse. NA-C confirmed they receive both verbal and written communication through report, computer, and worksheets. NA-C stated facility fall interventions would include: Tabs alarm, sensor alarm, and video monitoring. Further, NA-C stated most residents are checked on every two hours, depending upon the resident's level of independence. NA-C had nothing further to add. Although, interventions had been identified following the second fall, a comprehensive assessment of causal factors, and review of effectiveness of interventions had not been conducted to reduce the risk of further falls for R217. Review of the facility's undated Fall policy, indicated all actions should be taken to provide residents with the proper safety tools to reduce and prevent falls. The policy further indicated a complete fall evaluation should be completed following a resident fall. The immediate jeopardy that began on 1/7/19 was removed on 1/9/19, when the facility re-arranged R217's furniture to facilitate nursing view of R217, initiated 30 minute checks and every two hour voiding checks, ensured 1:1 staffing for 24 hours, updated R217's care plan with individualized interventions, requested a pharmaceutical review by the consulting pharmacist, requested a medical review by the medical director, ordered laboratory values, and provided staff re-education.

Based on observation, interview and document review, the facility failed to provide appropriate care and treatment including comprehensive assessment, prescribed treatment, and resident education, for 1 of 3 residents (R21) reviewed with a current pressure ulcer. This resulted in actual harm for R21. Findings include: According to documentation of a body audit assessment conducted 12/16/14, R21 had current pressure areas to his heels, and was at risk for development of pressure ulcers. A Braden Scale for Predicting Pressure Sore Risk had been conducted 12/30/14, and R21 had been identified as at high risk for pressure ulcer development with a score of 19 out of 24. The Care Area Assessment (CAA) regarding pressure ulcers dated 12/30/14, identified R21's risk for breakdown and current heel ulcers, but did not identify any other pressure ulcers. A Resident Incident Report dated 12/30/14 at 11:30 p.m., indicated staff had identified a reddened area on the resident's coccyx and purplish-black areas on the resident's buttocks bilaterally with observed skin slough. Subsequently, a physician's visit note dated 12/31/14, indicated the resident had been seen at the clinic for evaluation of the areas on her buttocks. The physician's documented plan from the visit note included: "PLAN 1. Stage 1 pressure ulcer of the buttocks...I did discuss with her in detail that there is not an open wound...I did discuss with her that the mainstay of treatment will be attempting to relieve the pressure on her buttocks. She did seem very reluctant to have any type of movement at all. She did become concerned once I discussed that these particular issues can get progressively worse if she does not follow wound care instructions..." R21 required hospitalization on [DATE], after she was noted to have a stage IV pressure ulcer on the coccyx. The hospital discharge summary indicated she had been readmitted to the facility on [DATE], with the use of a [DEVICE] (VAC) system to treat the stage IV pressure ulcer. Although R21 had developed the stage IV pressure ulcer and had to be hospitalized , the facility had not completed a comprehensive reassessment of the resident's tissue after R21's return to the facility in order to determine what interventions to implement to promote healing of the pressure ulcers, and to help prevent further pressure ulcers from developing. An admission Minimum Data Set ((MDS) dated [DATE], identified R21 as cognitively intact, required extensive assistance with transfers and bed mobility, had one current stage II pressure ulcer (the outer layer of skin and part of the underlying layer of skin is damaged or lost), and as remaining at risk for pressure ulcer development. Additional information documented on the CAA for pressure ulcers dated 12/30/14, indicated R21 had an "existing ulcer" on her left heel, required a special mattress, regular turning and repositioning, and needed staff assistance to move. In addition, the CAA documentation included: "Res (resident) is at risk for pressure areas r/t (related to) overall health issues, poor tissue perfusion, hx (history) of CA (cancer) / [MEDICAL CONDITION]." The CAA identified no need for referrals but directed staff to "proceed to care plan." The Resident Incident Report dated 12/30/14, further included: "Res. (resident) has poor tissue perfusion, often refuses to lay (should be lie) down during the day, prefers to sit up in w/c (wheelchair). Often refuses to turn/repo (reposition) when prompted. Educated res. on importance of relieving pressure to bottom, educated staff to document refusals consistently." R21's Nurse's Notes from 12/31/14 at 4:51 a.m. identified; "Resident interviewed regarding buttocks wound. Resident states that she does sit too much and admits to not laying down when she should. Observed area (with) nurse and aide. Purple area approximately 8 cm X 4 cm (with) a slightly open draining area at the top... Wound flow sheet was filled out and education to resident and staff about its condition and importance of relieving pressure while up in chair and in bed. Will apply new cushion to chair and air mattress to bed as interventions to help relieve pressure areas." When nursing assistant (NA)-D was interviewed about the pressure ulcer on 4/15/15 at 10:03 a.m. she stated, "It just showed up, shortly after she got here." NA-D also stated the staff help R21 reposition every two hours or as she requests. However, during a subsequent interview on 4/15/15 at 10:54 a.m., NA-D stated R21 had been resistive to repositioning since she had been admitted to the facility. Record review indicated the first time staff had addressed any reluctance with repositioning, and risks/consequences associated, had been on 12/31/14 after the coccyx ulcer had been identified. Additional documentation on the physician's progress report from 12/31/14, included: "...The patient will also be encouraged to stay out of her wheelchair and at times lying in her bed with turning every 2 hours to keep pressure off this affected area. We will also see if we can get her a cushion that will help also prevent direct pressure on this area..." The progress note also indicated to "return to clinic in approximately 3 weeks for repeat assessment unless any acute issues develop before hand." A History and Physical (H&P) dated 1/6/15, indicated R21 had been admitted to the hospital on [DATE] for intravenous antibiotics and wound care. The note included: "She was seen here in clinic on 12/31, with a reddened area on her coccyx. Apparently no ulceration, her breakage of skin surface was noted at that time...she has developed an ulceration in the coccyx area...The patient has developed since 12/31, a deep coccyx ulceration with apparent probable undermining and a purulent malodorous discharge. There is surrounding [DIAGNOSES REDACTED]. There has been some discomfort associated with this. Apparently the patient has been very difficult to regarding-position." A consultation note from a consult conducted by a surgeon on 1/8/15, included: "...Patient has a poor medical condition. She has had [MEDICAL CONDITION] for her tumor and one has to assume that the skin in this area is compromised. Following her surgery, the patient was in the nursing home and developed an ulceration on her coccyx which has gotten considerably worse. Following R21's readmission from the hospital, a 5 day PPS (prospective payment system) MDS, dated [DATE], identified R21 now had moderate cognitive impairment, continued to require extensive assistance with transfers and bed mobility, and now had one stage II pressure ulcer along with one stage IV pressure ulcer. R21's care plan, dated 1/28/15, identified R21 had fragile skin, a "heel ulcer present on admission", and "often refuses to lay (should be lie) down, get off bottom thru the day when staff prompt her to do so." A goal was identified of, "Resident will have area on heel + (and) coccyx healed by next review." Further, the care plan identified interventions which included, "Float heels when in bed", "Pressure reducing mattress & (and) cushion in w/c (wheelchair)", and "follow treatments for L/heel (left heel) + coccyx as per current orders - see tx (treatment) sheets." R21's medical record was reviewed, there was no indication a comprehensive pressure ulcer reassessment was completed despite R21 being hospitalized for [REDACTED]. The facility only completed a Braden Scale, which only identifies a numerical rating of low or high risk. There was no indication the facility changed their pressure ulcer interventions from the admission Braden Scale of 12/30/14, even though R21 had developed a stage IV ulcer on her coccyx. On 4/15/15, at 11:08 a.m. registered nurse (RN)-E and RN-F were interviewed regarding R21's pressure ulcer. They confirmed R21 had routinely refused repositioning since her admission however, the facility had not completed any education regarding risks of not being repositioned, until the breakdown on her coccyx. RN-F also stated R21 should have been comprehensively reassessed for pressure ulcer risks when she'd returned from the hospital. R21's Surgery progress note, dated 1/20/15, identified, "The patient (R21) underwent a complex debridement of a coccyges decubitus ulcer (pressure ulcer) on January 12, 2015. Following this procedure, a VAC wound care device (uses medical foam and a small vacuum to create negative pressure on a wound or pressure ulcer which facilitates healing), was placed." A further Surgery progress note, dated 2/5/15, identified R21 was seen for "a stage 4 decubitus ulcer located in her coccygeal area", and, "The patient (R21) was last evaluated in Surgery Clinic on January 27, 2015 when she was noted to have an inadequately placed VAC unit, along with a small sponge within the large coccygeal decubitus ulcer." Further, the note identified, "additional instructions were given to the wound specialist at patient's (R21) nursing home." The dressing was not removed at the appointment, so the ulcer was not evaluated for undermining. A subsequent Surgery progress note, dated 3/23/15, identified R21's ulcer "is at the deepest along the left lateral and left inferior aspect of the wound", and, "No fistulas, tunneling or undermining noted." Further, the note identified, "I (nurse practitioner (NP)-A) did contact nursing home staff and talked with (LPN-B) in regards to the wound dressing...they had been advised approximate 2 weeks ago by (PT), to obtain a foam roping to place in the wound as the foam they have was not completely filling the open wound." A Medical Information Exchange Form, dated 3/30/15, identified R21 had been seen in the clinic on 3/30/15 for a "coccyx ulcer", and included a treatment which identified, "Continue (with) wound vac. Make sure to pack deep into left deep aspect of wound." R21's condition was identified as "stable" by the NP-A. A review of R21's Wound Flowsheets identified the following information: On 4/2/15, the pressure ulcer measured 4 cm X 3 cm X 1 cm in size, was "healing", and listed a treatment of [REDACTED]." On 4/3/15, the pressure ulcer measured 4 cm X 3 cm X 0.8 cm in size, was "healing", and continued to identify, "Continue current treatment." On 4/8/15, the pressure ulcer measured 3 cm X 2 cm X 1.5 cm in size, continued as "healing", and for staff to "Continue current treatment." On 4/10/15, the pressure ulcer measured 4 cm X 2 cm X 1.5 cm in size, remained identified as "healing", and for staff to, "Continue current treatment." No undermining was identified on the flow sheets for R21's pressure ulcer. During observation of pressure ulcer care, on 4/15/15 at 1:29 p.m. RN-D removed a non-coil type wound VAC dressing and exposed a stage IV pressure ulcer on R21's coccyx. The wound was symmetrical in shape, with granulation tissue (beefy red tissue indicative of healing) and approximately 50 percent (%) slough tissue (necrotic tissue). The pressure ulcer had undermining on all sides of the wound. RN-D measured the wound using a paper tape measure that had been included in the new wound VAC kit. RN-D measured the opening of the wound at 3 cm (length) X 2 cm (width) X 1.5 cm (depth). However, RN-D did not measure the depth of the wound at its deepest point or use any measuring tool to identify the depth and degree of the pressure ulcer's undermining. RN-D opened a new VAC [MEDICATION NAME] Silver dressing kit and cut the foam down to the size of the ulcer opening, and applied it into the opening of the pressure ulcer. RN-D did not use a foam coil dressing, or pack the foam into the undermining of the ulcer. RN-D cut a new clear film, draped the ulcer using the film, and applied a new central disc piece that attaches the dressing to the vacuum device. When interviewed immediately after the observation of pressure ulcer care, on 4/15/15 at 1:43 p.m. RN-D stated she last observed R21's pressure ulcer on 4/6/15 and it did not have any undermining at that time. RN-D cut the new piece of foam to better fit the wound today, but verified she did not pack the foam into the undermining of the wound as the physician had instructed in the progress notes. On asking RN-D if she had any education on the use and application of the wound VAC system she replied she had no formal education on the wound VAC system, only having knowledge of the device and dressings from, "What we learned in school." When R21 had the wound VAC placed, a physical therapist (PT)-A had come and performed education on how to complete R21's dressing change; however RN-D was unable to attend the demonstration. Further, RN-D stated she completed the dressing change as she had been shown by other nurses. During interview on 4/15/15, at 2:50 p.m. PT-A stated she had last seen the wound about a month prior when R21 had come to the clinic for an appointment with NP-A. The NP-A had written specific instructions for the nursing home staff to follow regarding the pressure ulcer treatment, including packing the undermining and tunnels of the wound using the VAC foam. PT-A stated R21 had come into the clinic (1/27/15) from the nursing home before with the dressing not completed correctly (in regards to the VAC wound dressing), so she (PT-A) had went to the nursing home and completed a demonstration for two nurses on how to complete the pressure ulcer dressing change using the VAC foam and device. Further, the staff were left with instructions to call her or KCI (the manufacturer of the VAC system) if they had questions. An interview was attempted with the NP-A on 4/15/15, at 2:59 p.m.; however she was, "out of the office for a period of time." During interview on 4/15/15, at 3:01 p.m. R21's surgeon's nurse, LPN-O was interviewed regarding R21's stage IV pressure ulcer. R21 was last seen on 3/30/15 by NP-A and the nursing home staff was advised to pack the ulcer and place the foam dressing "into the deepest aspect of the left inferior portion of the decubitus wound." When interviewed on 4/16/15, at 9:53 a.m. RN-E stated she had never changed R21's VAC dressing herself, but last observed R21's pressure ulcer in late March 2015 and at that time had not gotten a clear look at it. RN-E then added that R21 ' s pressure ulcer undermining should be packed with the VAC foam, "To heal from underneath, to the bottom up." RN-E was unaware what formal education had been completed for the staff regarding R21's dressing changes, but that staff should be measuring the wound from the deepest part. Further, RN-E stated the measurements collected of R21's pressure ulcer at the facility which were documented on the Wound Flowsheets were likely not accurate especially if the dressing changes were not completed as directed by the physician, it could have worsened R21's pressure ulcer, "Possibly, yea." The director of nursing (DON) was off campus on 4/16/15, and unavailable for interview regarding R21's pressure ulcer care and treatments. A facility Wound Care policy, dated 4/30/14, identified a purpose of, "To prevent or minimize transmission of microorganisms during wound care procedures." The policy lacked any guidance for staff regarding when to explain the risks of failing to reposition timely, conduct assessment of a resident's risk for pressure ulcers, or for following physician guidance for wound care.