Every finding on record at LB Broen Home

Based on interview and record review the facility failed to provide adequate supervision to prevent a hazard over which the facility has control for 1 of 1 resident (R1) while outside in extreme temperatures without protection which resulted in serious, life-threatening harm when R1 was found slumped over in a chair and unresponsive. R1 was transferred to a hospital for evaluation and treatment for extreme hyperthermia.The immediate jeopardy began on [DATE] at 4:00 p.m., when the facility failed to provide adequate supervision to R1 who notified staff he was going to sit outside at approximately 2:30 p.m. R1 required assistance from staff for ambulation, was allowed to independently ambulate out of the facility, to the pond area. The temperature outside was 95 degrees Fahrenheit (F), sunny, with no cloud coverage, or wind present (accuweather.com). R1 wore long sleeves and pants, without water or a way to call for assistance. R1 was found at approximately 4:15 p.m. slumped over in a chair and unresponsive. R1 was evaluated by emergency services (EMS), findings included: body temperature was 105.8 F, tachycardia (rapid heartrate) 100 to 120 beats per minute, and tachypnea (rapid breathing) respirations 36. R1 was admitted to hospital with diagnoses including heat stroke and pneumonia. The administrator and director of nursing (DON) were notified of the immediate jeopardy on [DATE] at 6:30 p.m. The immediate jeopardy was removed on [DATE] at 4:50 p.m., but noncompliance remained at the lower scope and severity level D (isolated, scope and severity level) which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's annual Minimum Data Set (MDS) dated [DATE], identified R1 was admitted to the facility on [DATE], from a hospital. R1 had intact cognition and no behaviors. MDS noted it was very important to R1 to get fresh air when the weather was good. R1 was independent for all cares, transfers, and walked 150 feet once standing in a corridor or similar place independently with a walker. Medical diagnoses included: debility (state of weakness due to illness or old age) due to cardiorespiratory conditions, atrial fibrillation (two upper chambers of the heart beat irregularly, too fast, quivering instead of contracting properly increasing a person's risk of blood clots), congestive heart failure (CHF), hypertension (HTN) (high blood pressure), renal failure/insufficiency, diabetes mellitus (DM) insulin dependent, asthma, macular degeneration (decreased and/or loss of central vision due visual field deficit), and muscle weakness. R1 had dyspnea (shortness of breath or trouble breathing with exertion) (e.g. walking, bathing, transferring), and on oxygen.R1's physician orders identified:-Oxygen (O2) 1 liter (L) in both nostrils every shift to keep SaO2 (arterial oxygen saturation) above 89% (1 to 5 L per nasal cannula (NC)). Titrate as able. Start date: [DATE].R1's 5/2026, electronic medication administration record (EMAR) identified O2 use was documented starting on evening shift on [DATE] through [DATE] night shift (all three shifts) set at 2L to 2.5L with SaO2 ranging from 92 to 98%. Additionally, on [DATE] during day shift R1 was documented as using oxygen at 2L with SaO2 at 96%.R1's St. Louis University Mental Status (SLUMS) (examination used to detect mild cognitive impairment and dementia) dated [DATE], identified score of 14 out of 30, to indicate dementia (less than high school education scoring used) (25 to 30 - normal, 20 to 24 mild neurological disorder, and 1 to 19 dementia).R1's Cognitive Area Assessment (CAA) dated [DATE], identified R1 had a poor memory, respiratory distress, and was administered diuretics (remove excess fluid and salt from the body by increasing urine production), anticonvulsants (taken for nerve pain).R1's care plan dated [DATE], identified:Risk for decreased cardiac output due to heart failure. Staff were directed to evaluate skin color, temperature, and characteristics and provide oxygen as indicated by condition and provider order. Date initiated/created: [DATE].Activities of daily living (ADLs) self-care performance deficit related to disease process, heart disease and muscle weakness. Staff were directed to provide wheelchair if required continuous oxygen use or experiencing increased weakness. R1 required assistance of one with dressing, transfers, and ambulation. Ensure call light was within reach. Date created/initiated: [DATE].R1 was dependent upon staff for activities for cognitive stimulation, social interaction, related to physical limitations. Staff were directed to assure the activities R1 was attending were compatable with physical and mental capabilities.R1 had the potential for fluid deficit related to diuretic use to manage CHF. Staff were instructed to ensure he had access to cold water whenever possible and monitor intake and output. Date initiated/created: [DATE].R1 was at risk for ineffective breathing patterns and impaired gas exchange related to chronic obstructive pulmonary disease (COPD) and CHF. Staff were directed to administer/monitor effectiveness of oxygen therapy as ordered and encourage fluid intake. Date initiated/created: [DATE].R1 was at moderate risk for falls related to deconditioning and balance problems. Staff were instructed to anticipate and meet R1's needs, be sure R1 had call light within reach and encourage use for assistance. R1 required prompt response to all requests for assistance. Date initiated/created: [DATE].Nursing assistant (NA) worksheet, undated, received printed copy on [DATE], identified R1 transfer/locomotion: transfer with assist of one, transfer belt, wheelchair as needed (PRN) and ambulation assist of one, transfer belt, wheelchair to follow. Special needs/requests: oxygen (handwritten in black: PRN). Nursing staff shall: revise worksheet whenever care plans are changed and follow worksheet and care plan directions when delivering care.R1's elopement assessment dated [DATE], identified low risk for elopement. R1 was able to ambulate independently on and off the unit. During the summer months he often sat outside. He was alert and oriented, made no attempts to leave the facility, and was not at risk for elopement.Occupational Therapy (OT) treatment encounter note dated [DATE] at 11:45 a.m., identified transfers with assist of one and four wheeled walker. R1 had oxygen needs and frequent rest breaks, dyspnea (shortness of breath) with exertion, and low endurance. Instructed in bilateral upper extremity exercises to increase strength for improved performance in ADLs and functional transfers. R1 complained of weakness in bilateral knees and required subsequent verbal/visual cueing throughout exercises due to poor recall of technique.R1's progress notes reviewed [DATE] through [DATE], identified: On [DATE] at 4:30 p.m., writer got a call at 4:06 p.m., R1 was not responding, and she needed to go outside. Writer promptly ran to where R1 sat behind the facility building by the pond in a stationary chair with head down. Resident color was pink and skin was warm to touch. Face appeared to be deep pink in color. R1's pulse was palpated, present and strong but irregular. Writer asked staff to call 9-1-1 and get emergency services on their way. Staff reported R1 was not wearing oxygen correctly and they reapplied it. R1's O2 tank was in the red when writer assessed it and asked staff to grab an O2 tank and oximeter. Writer was unable to get R1 to arouse to verbal stimulation, ineffective. Writer completed sternal rub to try to awake R1, he opened his eyes, moaned to writer, and was unable to talk. R1's SaO2 was 80% on 2.5L and writer titrated O2 up to 5L via NC. Writer called more staff and brought down automated external defibrillator (AED) (portable medical device used to save lives during a sudden cardiac arrest, automatically analyses the heart's rhythm and delivers an electrical shock to help the heart re-establish and effective beat) and cardiac pulmonary resuscitation (CPR) supplies. Emergency services had arrived and took over. Paperwork faxed to local area hospital. Another staff member stated they were going to call family.On [DATE] at 7:56 p.m., received phone call from local hospital. They are keeping R1 overnight for observation, he was looking better.On [DATE] at 10:25 p.m., received phone call and updated on resident status.On [DATE] at 12:04 p.m., R1 was admitted back to the facility. R1 was in good spirits and appeared to be back to baseline and getting up and moving independently from nurse to nurse. Had bowel movement and off O2 since 6:00 a.m. Orders for O2 to be PRN. R1 reported he had received insulin in the hospital one time a day and wanted that here and utilizing O2 at night.On [DATE] at 1:31 p.m., Writer talked to R1 about him going outside without alerting staff and sat out by the pond, he should have alerted staff when leaving the building and was not recommended to sit out by the pond. Resident stated, maybe I went down there to die. R1 mentioned he was upset with his family about wanting him to stay here long-term and he wanted to leave and go to Wadena. R1 reported he felt depressed lately. Writer reassured R1 that we were here for him and that we only want the best for him. R1 in agreement to wait to talk to provider about his code status and concerns.On [DATE] at 2:43 p.m., DON (director of nursing) discussed with resident his comment made about maybe went down there to die, referring to sitting in the back of the building by the pond. R1 stated he was feeling disgusted and was upset with his family for wanting him to stay here and he wanted to go back to Wadena. When he was questioned further about wanting to die, denied wanting to harm himself and did not have a plan in place to cause himself harm.R1's electronic medical record vital signs identified on [DATE] at 7:04 a.m. R1's oral temperature was 98.0 F., blood pressure was 118/80 (sitting), heart rate was 66 beats per minute, oxygen saturation level (SaO2) was 96%, and respirations were 20 breaths per minute. Facility document, Transportation Drive Scheule dated [DATE], identified: resident appointments were scheduled for 6:30 a.m., 8:50 a.m., 9:00 a.m., 10:00 a.m., 10:10 a.m., 10:20 a.m., and 1:00 p.m. The driver returned to the facility around 3:30 p.m. and 4:00 p.m. to transport resident(s) back to facility. Per DON, on [DATE] the driver drove the van towards the back parking lot where R1 sat by the pond, to get to the street.Vulnerable Adult Maltreatment Report dated [DATE] at 1:15 p.m., identified a male resident [R1] was found alert to voice but unable to follow commands. Nursing staff stated the patient had been sitting outside for the last approximately 90 minutes in 95-degree weather. Staff stated they had driven by the patient a few times and saw him moving but no official checks came until about 4:05 p.m. Patient was unresponsive to all stimuli and slumped in his walker for staff. His eyes were open and attempted to track but showed no motor activity in extremities or core. Patient was extremely hot to touch and red in color. Patient was assisted to standing with EMS assistance, dead body weight, and moved to the cot. Patient began to move his arms and groan but was unable to make distinct movements or words. While in ambulance, patient would open his eyes when spoken to but had no other motor response to physical stimuli. Stroke assessment was unable to be completed. Crew initiated cooling measures with groin placed in ices packs and cooled air during transporting due to suspected heat stroke. Patient had strong radial pulse through contact, did not appear to be in any respiratory distress but was reported to have an initial SaO2 of 85% for staff. Oxygen was applied by nursing staff prior to EMS arrival which brought his Sa02 up to mid-90's. Patient was transferred to the closest local hospital ED (emergency department) and continually monitored through transport to ED where handoff report was given to nursing staff who were able to take over further evaluation and care.ED visit note dated [DATE] at 7:42 p.m., identified R1 had significant cardiopulmonary and metabolic comorbidities (two or more conditions that occur together can interact in ways that affect your approach to managing your health) with acute altered mental status after being found slumped over outdoors with extreme hyperthermia (105.8-degree F temperature), tachycardia, and tachypnea. Clinical picture is most concerning for heat stroke given environmental exposure, markedly elevated temperature and central nervous system (CNS) dysfunction. Broad work up initiated to rule out alternative etiologies (causes or origins of disease or condition) and assess for severe effects of prolonged heat exposure. Aggressive cooling measures initiated including application of ice packs, removal of patient's fluid within, IV fluid boluses, and placement of temperature sensing catheter for close monitoring of core body temperature and accurate tracking of intake/output. Elevated ventricular heart rate likely secondary to hyperthermia. Critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: cardiac failure, circulatory failure, and CNS failure or compromise.Hospital admission note dated [DATE] at 7:44 p.m., identified R1 presented to emergency room (ER) with heat related illness. He stated he was near a pond for a couple of hours, and staff found him slumped over in the chair. He felt quite unwell and had a decreased level of responsiveness and brought to ER. R1 was quite warm at that point, no fever or chills prior to this incident. R1's initial temperature in ER was 105.8 F, heart rate 100 to 120's in atrial fibrillation in rapid ventricular response (RVR) (occurs when heart rate was over 100 beats per minute, prevents the heart from filling properly, drastically reducing blood flow, and oxygen delivery resulting in a serious condition that can lead to blood clots, stroke, or heart failure if not managed) hemodynamically stable (blood flow was sufficient in the body). Respirations were tachypneic with initial respiration rate at 36 per minute. All vitals normalized (HR, temperature and respirations) after intravenous fluids (IV) and external cooling with ice packs. R1 was noted to have some diffuse wheezes upon exam. Initial lactic acid (indicate your body tissues are stressed or not receiving enough optimal oxygen) was moderately elevated at 2.5 millimoles per liter (mmol/L) (normal range: 0.7 - 2.1 mmol/L). Chest x-ray showed evidence of left lower lung infiltrate (an abnormal substance such as fluid, pus, or cells) was abnormal. Procalcitonin (a biomarker that spikes rapidly in the blood stream during serious bacterial infections and sepsis) was elevated at 0.51 nanograms per milliliter (ng/ml) (over 0.50 ng/ml: High. Serious bacterial infection, sever sepsis, or septic shock are very likely, indicating a strong need for antibiotic treatment). R1 was admitted for further management of heat stroke and pneumonia and started on Levaquin and Doxycycline (antibiotics) and IV fluids given. In patient treatment required for heat stroke, pneumonia, and COPD.Hospital Discharge summary dated [DATE] at 9:26 a.m., identified discharge back to facility with discharge diagnoses: hyperthermia likely related to heatstroke, acute heatstroke, left lower lobe pneumonia, acute COPD exacerbation. Hospital problem list: acute kidney injury (AKI), heat stroke and bacterial pneumonia. admitted on [DATE] at 9:55 p.m. from ED and discharged on [DATE] at 10:50 a.m. At this time R1 was on room air but will discharge him with 2L O2 per NC on PRN basis (his baseline) and follow-up with primary provider in one week.During an interview on [DATE] at 10:50 a.m., nursing assistant (NA)-C stated R1's memory was good, remembered most things talked about. R1 had no behaviors, accepted assistance with care, required assistance from one staff with transfers and ambulation. R1 was changed to independent with walking with walker this morning ([DATE]). NA-C was unsure if R1 had to be supervised outside, stated she would have to ask someone else. NA-C verified R1's care plan did not include whether he needed supervision while outside and /or how he could alert staff if he needed help while outside. NA-C stated residents were able to go out and sit by the pond either by going out through the basement exit door or by exiting the building from the front door, go around to the side of the building and down a slopped road. NA-C stated she had not received any education about residents going outside by the pond.During an interview on [DATE] at 11:36 a.m., R1 stated he had lived at this facility since 3/2024, a little over two years. R1 stated he was an outside person no matter what type of weather it was and the other day he passed out by the pond. Staff strapped his oxygen tank onto his walker, and he walked down to the pond from the front door, was down there for about two hours, it was hot out, he was alone and was found slumped over. Staff later told him his oxygen had run out. R1 stated he knew about the pond area because another resident who went there a lot, talked about it. R1 stated, the middle of last week, at 2:30 p.m., he decided to check it out and it was his first time going to the pond. R1 stated he had not been told he could not go down to the pond, was not asked to sign out when he went outside, did not tell anyone he was going, that he remembered, but was aware now he had to let someone know where he was going. R1 stated once he arrived at the pond, he felt warm, and his underarms were sweating with the long-sleeved shirt he had on. R1 stated he had nothing to drink and was not aware he was getting too hot. R1 stated he did not have his cell phone with him, always left it in his room, and had no way to alert staff he needed help. R1 did not remember passing out. R1 stated he remembered NA-B was getting into her car in the parking lot, unsure of what time that was, he waved at her, she waved back. He saw four or five other staff in the parking lot during the time he sat out there but was unsure of their names. R1 stated there were days he felt depressed, wanted to be outside rather than sit around inside, and was lonely. His family did not visit very often, he felt boxed in, isolated, and needed something more to do. R1 stated he was not suicidal, did not want to end his life, and did not need a counselor.During an interview on [DATE] at 12:58 p.m., EMS operations manager (OM) stated on [DATE] they arrived on scene at approximately 4:30 p.m. Behind the facility, located next to a pond, R1 was in a stationary chair directly in the sun, with a walker next to him. It was 95 degrees outside, sunny without cloud coverage and no breeze. R1 was dressed in a long-sleeved button up shirt and long pants. R1's face, neck, and hands were extremely red and hot to touch. R1 did not appear to have sunscreen on. OM stated he was not aware of anything near R1 that could be used to contact staff if R1 needed assistance. EMS team was informed by facility staff, R1 had been outside in the sun/heat for at least 90 minutes, staff had driven by him in the parking lot, and no one checked on him. R1 was slumped over in the chair and was unresponsive to verbal stimuli. R1's eyes were open, he was attempting to track but showed no motor activity in his extremities or core. OM stated he would be concerned about anyone who was found unresponsive out in the heat but it was strange no one physically checked on him. The lack of supervision for almost two hours was concerning to OM. Anyone can look just fine when someone drove by but they still could have been unresponsive. OM stated with temperatures in the 90's, no protection from the sun/heat would have become a health concern within 20 to 30 minutes without access to water. R1 sat by the pond where the reflection of the sun onto the water would have made it even hotter in this situation. R1 was brought into the ER unresponsive, and the cooling process was started. R1 was in serious condition when we arrived, he was close to needing CPR and if it had been a few minutes longer he could have had a cardiac arrest.During an interview on [DATE] at 1:20 p.m., NA-B stated she usually parked in the back parking lot. NA-B stated she was very familiar with R1's past medical concerns such as his respiratory problems, received nebulizer treatments and complained of breathing problems. On [DATE] around 3:00 p.m., when she walked to her car, she saw R1 by the pond sitting in a chair in the direct sunlight, alone. NA-B stated she had no idea how long he had been out there, and the sun was hot. Residents should not have been allowed to go outside that day due to extreme heat and if they did staff would be expected to check on them at least every 15 to 20 minutes. She had seen a female resident down by that same pond on other days, thought that resident had the ok to go there. R1 had a history of not telling staff where he was going. NA-B stated it would not have been safe for R1 to walk down the slopped road to the pond area with his walker. NA-B was unsure how he managed to do that safely. NA-B stated she was in her vehicle and drove by R1, he waved at her, she waved back and kept driving. There were no other staff around at the time and she figured the staff on first floor knew he was out there. NA-B stated she should have gone over and checked on him but since he waved, she thought he was ok.During an interview on [DATE] at 1:52 p.m., licensed practical nurse (LPN)-B stated she had worked on [DATE]. The last time she saw R1 was around lunch time and assumed after that he was in his room napping. She was not made aware R1 went outside and had no idea how long he was out there. LPN-B stated it would have been concerning to have R1 outside in over 90 degrees weather with the sun shining on him. He should not have been allowed outside that day alone in the heat, activities could have sat with him if they were asked. LPN-B did not think R1 had anything to drink while outside that day. LPN-B stated R1 had COPD and was on 2L of oxygen that day. LPN-B checked R1's oxygen tank levels that morning, was unsure of what time, and the tank was 3/4 full. LPN-B stated the tank should have been ok for at least three hours. LPN-B stated she heard it was empty when they found him later that day around 4:00 p.m. LPN-B stated she was sure R1 did not have sunscreen on. R1 was wearing a cap, long sleeved shirt, and shoes or slippers.During an interview on [DATE] at 3:11 p.m., NA-D stated the last time she saw R1 on [DATE], was in the afternoon walking in the hallway with therapy with his walker. NA-D stated R1 would have been ok to be outside unsupervised, but only right outside the building. NA-D stated she was unaware R1 had gone out of building and down to the pond area. With the temperature outside over 90 degrees, it would not have been safe for him to be out there alone. It was too hot out. It placed him at risk for a heat stroke. NA-D stated residents are not told to sign the book when they go outside. There should be a way for us to know they are going out there and right now we don't have anything such as that in place. NA-D stated she was unaware of any interventions or plans in place to help avoid this from happening again.During an interview on [DATE] at 10:15 a.m., Oxygen Respiratory Services representative (R) stated a mid-thigh height oxygen tank would last about four to five hours before a resident would run out of oxygen. When the red arrow on the dial was at zero indicated low pressure, less oxygen pushed the patient due to low volume and almost empty.During an interview on [DATE] at 11:48 a.m., registered nurse (RN)-B stated on [DATE], she had received report by 3:30 p.m. At 4:00 p.m., NA-A informed her R1 was outside. RN-B thought NA-A meant R1 was right outside the front door. It was the hottest day of the year so far. [R1] had some confusion, was sleepier lately, was not his usual self, was increasingly having shortness of breath (SOB), and was on oxygen. At 4:15 p.m., RN-B was informed by LPN-A, R1 was out by the pond in the heat. Staff went to the pond area and 9-1-1 was called. RN-B stated if a resident informed staff they were going outside, they could be monitored through the windows. Those residents, including R1, were considered independent. When outside no one checked on them. The residents were unable to contact staff if they needed assistance while down by the pond or outside anywhere. RN-B stated R1 did not have fluids with him, sat in the sun unprotected, ran out of oxygen, had poor safety awareness and did not realize he needed to stay hydrated in the heat. R1 got heat stroke and was sent to the hospital via ambulance.During an interview on [DATE] at 12:50 p.m., the certified occupational therapy assistant director (COTA) stated the residents at this facility do not typically walk on uneven surfaces and are not assessed for that. R1 was assessed as needing supervision while ambulating outside. The COTA stated prior to [DATE], R1 required assistance of one staff to walk, with a gait belt and walker and should have had assistance of one when he went out the front door to be outside for safety reasons. R1 was using a four wheeled walker with an oxygen tank attached and placed him at a higher risk for falls. R1 had not been assessed for outdoor ambulation. R1 would not have been safe walking outside alone, on uneven ground, around the building and down to the pond with the walker and oxygen tank. The COTA stated she did not understand how R1 could have gotten around the building and down the slopped road to the pond safely by himself. The slopped road made the COTA nervous due to the speed going down a slope would have pushed him at an angel faster, affected his gait pattern and placed him at a higher risk for falling. Staff would have been expected to be with him, would have expected staff alert therapy of the need to assess R1 for outside ambulation. The COTA stated R1 would not have been safe out in 95-degree weather without shade and no way to call for assistance.During an interview on [DATE] at 2:24 p.m., the NA-A stated on [DATE] between 2:30 p.m. and 2:45 p.m., R1 was seen walking down the hallway independently without difficulty, Which was odd because he was supposed to get assistance from one staff. R1 had a white dog on a leash and stated, I'm going outside to sit by the pond can someone do something with this dog? R1 handed me the leash and walked out the front door with his walker. This exchange took place near the doorway by the front desk. The NA-A asked no questions of R1, did not have time to ask what pond R1 meant, and watched him walk out of the front door of the building alone. The NA-A stated her attention was not on R1, the NA-A was more concerned about what she was going to do with the dog and starting her tasks for the day. The NA-A stated normally, if not distracted by a dog and starting her tasks for the day, she would have asked R1 are you not assist of one? NA-A recalled R1 was wearing a t-shirt with arms exposed and was unsure of his pants. NA-A stated she was unsure if he had sunscreen on, did not recall if R1 had fluids with him, and R1's oxygen canister was located on the front of the walker in a holder. NA-A stated she was unaware if R1 was care planned to be outside alone, Most of the residents on first floor were independent and go out whenever they wanted to. We are expected to check on residents every twenty to thirty minutes through the day. NA-A stated at 4:00 p.m., the facility transport van driver (TA) approached her and informed her they found R1 sitting down by the pond for a while and it looked like R1 was asleep. The TA informed NA-A, they had driven back and forth through the parking lot between 2:30 p.m. and 4:00 p.m., and saw R1 sitting by the pond numerous times. The NA-A stated she was not sure who was responsible for checking on R1 or if someone was already out there, the NA-A became busy with her tasks and did not think about it. The NA-A verified she did not see anyone go outside with R1 when he left the building but thought there could have been someone waiting outside for him. The NA-A stated it was a hot day and sunny out. As far as the NA-A knew, no one checked on R1. The staff nurse instructed the NA-A and the TA to go down to the pond area, check and see if R1 was ok and tell him to come back into the building. The NA-A and the TA took the van to the back parking lot, where R1 sat by the pond. There were no trees, R1 was in the direct sunlight without protection, with a hat on his head, arms were red, and his oxygen canula was on the back of his neck and not in his nose. NA-A stated R1 did not have a way to contact staff for help while by the pond. The oxygen tank was empty, this was verified by the nurse once she arrived. R1 sat hunched over in a chair located next to the pond and looked like he was sleeping. NA-A rubbed R1's shoulder and he moved his arm. The NA-A tried to apply the gait belt to get him up and noted he was unable to move and was limp. NA-A stated she checked his pulse on his neck, it was faint. NA-A could hear his irregular breathing; it was slower and louder than normal. R1 had no movement in his shoulder and the rest of his body, his chin was to his chest, and his bottom lip was above top lip. The TA called the staff nurse to come down, indicating R1 was not looking good. LPN-A came to the pond and started yelling R1's name. LPN-A tried to do a sternal rub to get R1 to respond. R1 moaned like he could hear LPN-A but did not open his eyes. Staff called 9-1-1, NA-A left when the ambulance arrived. NA-A stated staff met at the nurse's station and talked about the incident. NA-A told the LPN-A, R1 informed her he was leaving the building earlier to go to the pond and NA-A was made aware of where he was.During an interview on [DATE] at 4:00 p.m. front desk staff/confidential secretary/human resource assistant (HRA) stated she was aware of who R1 was and had seen him go outside without assistance/supervision in the past. The HRA stated she left the front desk frequently to assist staff and residents, the HRA did not remember seeing R1 exit the building on [DATE]. R1 usually sat outside in front of the building by himself or with other residents. The HRA was expected to stop a resident if they had a wander guard, the HRA was aware those residents could not be left alone or leave the facility. There was not a binder and/or pictures of residents to refer to at the front desk for those residents at risk of elopement or safety concerns going outside. The HRA stated she had not seen staff walking with R1 inside or outside the building for a while now and was unaware of his recent care plan. If R1 came to the front door to exit out of building, the HRA would not have responded unless she saw R1 walk away from the facility. The HRA stated she did not have a good view from the front desk, could only see a small section outside, was unable to see people coming down the parking lot and only a little part of the front entry door. The HRA stated she had never been told which residents were able to go outside without supervision or assistance, aside from those residents with a wander guard bracelet on. The HRA stated she had seen a specific female resident go out the door on several occasions and did not pay attention as to whether she walked around the side of the building or sat out front.During an interview on [DATE] at 5:00 p.m., the DON stated R1 was hospitalized three times: [DATE] through [DATE], for acute carbon dioxide (CO2) retention; [DATE], for chronic hypoxic respiratory failure and [DATE] through [DATE], for heat stroke and pneumonia. R1 was on oxygen due to increased respiratory difficulties due to COPD, CHF, and SOB. Additionally, he was in the hospital for one week [DATE] to [DATE], with acute hypoxic respiratory failure, exacerbation of COPD, concern for pulmonary embolism (PE), and pneumonia. The DON stated she was unaware of any signs or symptoms R1 had of pneumonia prior to the [DATE] incident. DON stated she was unaware of a facility policy/protocol addressing staff responsibility when a resident wanted to go outside independently. The DON stated all residents who were alert and oriented were allowed to go outside to the pond. If the residents ha

Based on observation, interview, and document review, the facility failed to provide services in a dignified manner for 1 of 1 residents (R31), reviewed for dignity.Findings include: R31's quarterly Minimum Data Set, dated [DATE], identified R31 was cognitively intact and had diagnosis which included renal insufficiency, diabetes mellitus (DM), and hypertension (elevated blood pressure). MDS further identified R31 was continent of bowel and bladder and required staff assistance with activities of daily living (ADL's) which includes bed mobility, transfers, and toileting. Review of a bowel and bladder assessment dated [DATE], identified R31 was continent (has control of ) bowel and bladder. Review of R31's care plan revised 1/30/26, identified R31 was aware of the need to void or defecate and would request to use the toilet as needed. During an interview on 5/17/26 at 11:54 a.m., R31 stated staff put diapers on me, I know when I need to use the bathroom and I am not incontinent. R31 stated I have told staff it makes me feel like a baby when they put a diaper on me. During an observation on 5/18/26 at 8:20 a.m., nursing assistant (NA)-A excited R31's room and wheeled R31 to the dining room and returned to the hallway. R31 motioned for surveyor to come over to his table. R31 pulled his pants outward slightly and grabbed at his brief and stated she just put this on me a few minutes ago. During an interview on 5/18/26 at 8:45 a.m., NA-A verified she placed a brief on R31 this morning even though R31 was not incontinent of his bowel or bladder. NA-A stated she was unsure why she placed a brief on R31 but was aware that R31 did not like to wear briefs and stated R31 would take the brief down and place it around his ankles.During an interview on 5/18/26 at 9:27 a.m., registered nurse (RN)-A verified R31 was continent of bowel and bladder. RN-A stated staff puts a brief on R31 out of habit. R31 stated her expectation was that staff not place a brief on any resident that is continent to maintain resident dignity. During an interview on 5/18/26 at 9:27 a.m., director of nursing (DON) stated her expectation was that staff not place a brief on residents that are continent. DON stated it was important to maintain R31's dignity. Review of a document / facility policy titled Combined Federal and State Resident [NAME] of Rights dated 12/22/25, identified a facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each residents individuality. The facility must protect and promote the rights of the resident.

Based on observation, interview and document review, the facility failed to ensure staff were using personal protective equipment (PPE) according to the Centers for Disease Control for 2 of 2 residents R35, R13 who tested positive for COVID -19.Findings include:The CDC Interim Infection Prevention and Control Recommendations for Healthcare Personal During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated May 8, 2023, identified when using a NIOSH approved respirator or facemask is indicated for personal protective equipment (PPE) (e.g., NIOSH Approved particulate respirators with N95 filters or higher during the care of a patient with SARS-CoV-2 infection, facemask during a surgical procedure or during care of a patient on droplet precautions), they should be removed and disgarded after the patient care encounter and a new one should be donned. FACILITYInfection ControlLaundry tour 07/08/25 10:02 AM [NAME] Supervisor - laundry comes down in carts. we wear yellow gowns and gloves and goggles when sorting laundry. Any infectious bags are sent out to west central linen. One washer broken . 2 gas dryers . dryer vents get cleaned every shift. Use a covered cart to deliver laundry. Yellow gowns are reusabel and gets washed in hot water. 07/08/25 05:27 PM [NAME] - LPN I checked the res blood sugar and then washed it with alchohol and sani wipe -Reviewed IC policies no concerns Reviewed IP credentials no concerns07/09/25 09:39 AM [NAME] NA/TMA - we get tested for Covid every day that we work. 07/08/25 02:00 PM [NAME] RN IP - I use the Mcgeers criteria the nurses alert me to infections charge nurses can right in infection - [NAME] the DON is my back up as well. I email staff and post things in nurses station or through mass text to educate and do in person a well. We do antibiotic stewardship we do antibiotic timeout that alerts the charge nurse. If uc comes back and its not an infection we alert the MD's. [NAME] is on a phrophalactic and its reviewed with primary and risk verus benefits gets done every 6 months. Covid outbreak - started on 6/27/25 a res tested positive he was on hospice and passed since. That day we contact traced all staff that had worked with him the prior 48 hrs . Then we got a second res positive the next day so we started to test everyone. Then that sunday 3 more residents. Staff get tested everyday. Residents get tested twice a week. We have signs on the door of what PPE to wear and should remove PPE before they leave the roo. Should wear a gown, N95, gloves and face shield or the goggles. When Doffing they should be throwing away the N95's. Staff should be throwing away the N95's not reusing. Verified we are not in crisis PPE and staff should not be reusing the N95's Expectation is they should not be reusing the N95. Staff should not be putting the N95 over a face mask. Reviewed infection log no concerns. 07/08/25 03:22 PM [NAME] DON - Verified res had covid N95's staff should be disposing of the masks after each use. Not in shortage of masks. Staff should only be using the N95 Staff should not be wearing 2 masks. area to hang stuff to dry07/07/25 11:42 AM 2 staff are gowning. glove for EBP in room [ROOM NUMBER] 07/07/25 11:44 AM 2 staff are gowning, glove, N95 and face shield. to go in room [ROOM NUMBER] Covid positive room. Hand hygiene very good removing PPE 07/07/25 01:44 PM Passing laundry cart is covered delivered a hanger with pants and a07/07/25 01:45 PM bin with personal items closed cover on the cart and placed clothes in room sanitized hands 07/07/25 07:31 PM [NAME] NA- gowned gloved to go in EBP room [ROOM NUMBER]/08/25 08:27 AM NA put on gown, gloves, N95 eyewear on and delivered room tray to room [ROOM NUMBER] covid positive resident07/08/25 08:34 AM NA came out of room and put used N95 mask in a brown paper bag.07/08/25 09:14 AM [NAME]took N95 out of brown paper bag put on a gown, gloves and eyewear after sanitizing hands, and entered Res room07/08/25 0918 am verified used the same N95 just for that res thats why the brown paper bags are by their room . Immunizations:1.) [NAME] Covid 10/2/24 and 4/3/25, influenza 10/2/24, PCV 13 = 01/13/2016Pneumo-PCV 20 (Pneumo-conj) 4/3/25, step 1 mantouz = 01/03/2025 step 2 = 1/13/252.) [NAME]Covid dose 1= 01/05/2021Dose 2 = 02/02/2021Dose 3 = 09/15/2022 Dose 4 = 04/03/2025 influenza = 10/14/2024 PCV 13 = 10/13/2016 PCV 20 =04/04/2024 mantouz step 1 = 12/19/2017Negative (0 mm)System mantouz step 2 = 12/31/2017Negative (0 mm)3.) [NAME] Covid dose 1 = 03/19/2024 Dose 2 = 10/14/2024 dose 3 = 04/03/2025 influenza = 10/17/2023 PcV20 = 03/19/2024 mantoux step 1 = 04/02/2024Negative (0 mm)SystemStep 2 =04/02/20244.) [NAME] Covid dose 1 = 09/27/2023 dose 2 = 04/04/2024 Dose 3 = 10/14/2024 refused covid = 4/3/25 influenza = 10/14/2024 was education done Pneumo 13 = 10/08/2015 pneumo 23 refused on 1/30/23 pnumo 20 done 04/04/2024 mantoux 1st step = 11/22/2019Negative (0 mm)second step = 12/01/2019Negative (0 mm) I called her cousin and She wants her to take vaccine. I gave education. 5. ) [NAME] covid dose 1 = 02/02/2021 dose 2 = 10/14/2022 dose 3 = 05/19/2023 dose 4 = 04/03/2025 influenza = 10/14/2024 pneumo 23 = 10/10/2005 pneumo 13 = 07/22/2015 pneumo 20 = 04/04/2024 MAntouz step 1 = 10/25/2022 negative step 2 = 11/04/2022 negative 07/08/25 05:37 PM [NAME] MDH - it is not ok to wait up to 12 months to do the second step . We do a 2 step TST instead of 1 step first step boosts the immune system so you get a more acccurate result on the fist step. If negative test in past 12 months then they only need to do the one step . All I say if they dont come back in the 3 weeks they just dont need to start over. Most should be done in the 3 weeks after the first step. R13R13's quarterly MDS dated [DATE], identified R13 was cognitively intact, and had diagnoses which included: end stage renal disease (kidney failure), chronic obstructive pulmonary disease (lung disease that limits airflow) and diabetes mellitus. R13's care plan dated 7/9/25, identified R13 had limited physical mobility and required assistance with dressing, grooming and transferring with a EZ stand mechanical lift. R13's care plan also identified R13 had COVID-19, and staff were to observe for signs and symptoms of COVID-19 and implement infection control measures. R13's Point Of Care (POC) Test Result Reporting form dated 7/1/25, identified R13's test of SARS-CoV-2 (COVID-19) was positive.During observation on 7/7/25 at 4:45 p.m., NA-E assisted R13 to transfer from her wheelchair to her recliner using the EZ stand mechanical lift. NA-E wore a gown, gloves, eye protection and wore a N95 mask, over the top of a blue medical mask. NA-E removed her gown, gloves, then sanitized her hands and left R13's room. During interview on 7/7/25 at 7:19 p.m. NA-E indicated R13 had COVID, and they were expected to wear a gown, gloves, N95 mask and protective glasses or face shield. NA-E verified she had worn the N95 mask over her blue medical mask. NA-E stated she had observed others wear their masks that way, so she did it too. NA-E indicated they kept their N95 mask and eye protection glasses in a brown paper bag. NA-E stated they reused their N95 masks and glasses, one for each resident, one for each shift. NA-E showed surveyor the bags with her name on them, outside resident's rooms who were COVID positive. The bags contained a pair of protective glasses and a N-95 mask. NA-E indicated she wiped off the glasses before and after they were worn.During an interview on 7/8/25 at 2:00 p.m., infection preventionist (IP) verified eight residents including R36 and R13 on the third floor had tested positive for COVID-19 which placed the facility in an outbreak. IP verified the facility had adequate PPE supplies and was not in a shortage. IP stated her expectation was that staff would use a clean N95 each time they entered a Covid-19 positive room and then dispose of the N95 after each use. IP further stated staff should only be wearing an N95 when they entered a Covid-19 positive room to ensure they had a proper seal of the N95.During an interview on 7/8/25 at 3:22 p.m., director of nursing (DON) verified R36 and R13 had tested positive for COVID-19. DON stated her expectation was staff would use a clean N95 each time they entered a positive Covid -19 room. DON further stated staff should not be wearing a face mask with the N95 to ensure a proper seal of the N95.Review of a facility policy titled COVID-19 Infection Prevention and Control revised 6/24, identified the facility would adhere to Federal and State/Local recommendations to minimize the spread of COVID-19. Identified. Health Care Personnel( HCP) who entered the room of a resident with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a NIOSH-approved particulate respirator with N95 filters or PAPR, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face).Policy lacked information regarding when an N95 should be changed.

Based on interview, and document review, the facility failed to notify the resident representative promptly following provider order changes for 1 of 1 residents (R5) who received an order for antibiotics for a urinary tract infection (UTI). Findings include: R5's quarterly Minimum Data Set (MDS) dated [DATE], indicated R5's cognition was severely impaired. R5 had diagnoses that included cancer, Alzheimer's disease (cause of dementia), and arthritis. R5 needed maximal assistance for transferring, personal hygiene, and dressing. R5's care plan, last revised on 7/8/25, indicated R5 had an activities of daily living (ADL) self-care performance deficit related to Alzheimer's dementia, and a right hip fracture. Interventions included: Toileting schedule every two hours and check on nights, continent and incontinent of both bowel and bladder. R5's signed physician order dated 6/20/25, indicated Cipro (antibiotic for bacterial infections) 500 milligrams (mg) twice a day (BID) for five days. R5's medication administration record (MAR) dated June 2025 identified R5 received Cipro 500 mg starting 6/20/25 at 8:00 p.m., and received the last dose on 6/25/25 at 8:00 a.m.R5's progress notes lacked the resident representative being notified of R5's order for Cipro 500 mg for five days.During an interview on 7/7/25 at 11:25 a.m., R5's family member (FM)-A indicated there was no notification that R5 started on an antibiotic. FM-A indicated the clinical manager only provided an update when the antibiotic was completed. During an interview on 7/9/25 at 7:59 a.m., clinical manager (CM)-A indicated the normal practice would be to update family representatives of clinic visits, changes in conditions, and antibiotic orders. CM-A normal practice was to make a note of the update to the family representative in the progress notes. CM-A confirmed that R5's family representative had not been updated before the administration of the antibiotic. During an interview on 7/9/25 at 9:57 a.m., director of nursing (DON) indicated her expectation would be for the family to be aware of the start of antibiotics, as it was important for the continuity of care. Review of the policy titled change in condition, physician notification: physician notification of resident change in condition guidelines Resident, Legal Representative or Interested Family Member Notification, dated 11/19, identified LB Broen Home would notify Physicians, residents and legal representatives or interested family members of change in condition according to regulation.

Based on interview and document review, the facility failed to accurately code the Minimum Data Set (MDS) correctly for 2 of 2 residents (R17, R ) reviewed for resident assessment.Findings include:The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated 10/2023, identified Section N, record the number of days during the 7-day look-back period that the resident received any type of medication, antigen, vaccine, etc., by subcutaneous, intramuscular, or intradermal injection. Check B, antianxiety: if anxiolytic medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Section O Hospice care: Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions. The hospice must be licenses by the state as a hospice provider and/or certified under the Medicare Program as a hospice provider. R17's significant change MDS dated [DATE], identified R17 on hospice serves under the section O for hospice care. R17's quarterly MDS dated [DATE] and quarterly MDS dated [DATE] , failed to identify R17 receiving hospice care under section O for hospice care R17's MDS dated [DATE] identified a diagnosis of anxiety disorder, Section N, which covers medications received during the assessment period, identified R17 was not given an antianxiety medication during the look back period.R17's Signed provider order dated [DATE] , identified an order for Ativan 0.5 milligrams (mg) every three hours as needed for agitation/ restlessness and scheduled every Wednesday at 7:00 a.m., for comfort during bath and hygiene, give at 7:00 a.m., before bath. Start date [DATE] with no end date. Orders also identified as R17 admit to Knute [NAME] Hospice state date [DATE] with no end date. R17's Signed provider order dated [DATE] , identified an order for Ativan 0.5 milligrams (mg) every three hours as needed for agitation/ restlessness for 365 days, and scheduled every Wednesday at 7:00 a.m., for comfort during bath and hygiene, give at 7:00 a.m., before bath. Start date [DATE] with no end date. Orders also identified as R17 admit to Knute [NAME] Hospice state date [DATE] with no end date. R17's signed provider orders dated [DATE], identified R17 Admit to Knute [NAME] Hospice start date [DATE] with no end date. R17's orders also included resident to have bed bath only, no tub baths, one time a day every Wednesday. Attain 0.5mg by mouth every three hours as needed for restlessness/anxiety start date [DATE] end date [DATE]. R17's [DATE] medical administration record (MAR) identified R17 received Ativan 0.5mg of Ativan every Wednesday morning at 7:00 a.m. Start date of the order [DATE] and was discontinued [DATE]. R17's February 2025 MAR identified R17 received Ativan 0.5mg of Ativan every Wednesday morning at 7:00 a.m. Start date of the order [DATE] and was discontinued [DATE]. R17's MAR identified R17 received Ativan 0.5 mg every Wednesday during the month of February. Start date of the order [DATE] and was discontinued [DATE].R17's significant change CAA dated [DATE] indicated R17had a Terminal illness, CAA lacked information regarding receiving an antianxiety medication.R17's care plan revived on [DATE], identified Coordination of care needs with Vivie (formerly Knute [NAME]) Hospice, admitted to Knute [NAME] or Vivie hospice services on [DATE]. Interventions listed Vivie hospice contact information. Care plan identified R17 uses antidepressant medication related to depression and anxiety and receives Remeron and citalopram daily, Interventions are to notify hospice of any medication changes. During an interview on [DATE] at 2:14 p.m., trained medical assistant (TMA) verified R17 was on hospice. The hospice nursing assistant would come in two to three times a week in the morning around breakfast time. During an interview on [DATE] at 22:22 p.m., nursing assistant (NA)-D verfieied R17 was on hospice. During an interview on [DATE] at 8:39 a.m., licensed practical nurse (LPN)-A verified R17 was on hospice. During an interview on [DATE] at 7:49 a.m.,clinical manager (CM)-A verified R17 was on hospice and had been admitted to hospice [DATE]. DON verified the quarterly MDS dated [DATE] and quarterly MDS dated [DATE] , failed to identify R17 receiving hospice care under section O for hospice care. CM-A verified the MDS for [DATE] and [DATE] should have been marked as receiving hospice under section O. CM-A verified R17 has an order for Ativan and was receiving Ativan once a week before baths from [DATE] until [DATE]. CM-A indicated Section N, was coded correctly as Ativan was being used for anxiety but needed to coded as the classification on medication and Ativan was classified as an antidepressant. During an interview on [DATE] at 8:47 a.m., pharmacy consultant vifeifed Ativan would be considered as a benzodiapine, which would be put on an anxiety ansxiety classification. Pharmacy consultant indicated a psychotropic medication sheet was given to the facility with a list of medications and classifications to post in the facility. Pharmacy consultant gave surveyor a copy of psychotropicd medication date sheet. The pharmacy consultant indicated she would resend the sheet to the facility and will review it with the facility. During an interview on [DATE] at 9:56 a.m., director of nursing (DON) indicated Ativan would be coded as an antianxiety on the MDS. DON's expectation would be for corrections to be made to the MDS for [DATE] and [DATE] to capture what was going on with the resident during the look back time to ensure the case mix was correct. Psychotropic medications data sheet dated 2022 had Lorazepam/Ativan listed under the anxiolytics category. Policy titled MDS assessment dated 2010, indicated all dependents/ disciplines involved in MDS completion and care planning conferences will be trained in the use of softwear, be responsible for completing MDS's sections according to deadlines in procedure, participating in care planning conferences as assigned.

Based on observation, interview and document review, the facility failed to ensure a pressure relieving device was implemented to prevent skin breakdown for 1 of 3 residents (R25) reviewed for pressure ulcers.Findings include:R25's quarterly Minimum Data Set (MDS) dated [DATE], identified R22 had severe cognitive impairment and diagnoses which included stroke, dementia, and arthritis. Identified R25 required extensive assistance with activities of daily living (ADL's) which included bed mobility, transfers, and toileting. Identified R25 was at risk for pressure ulcers. R25's annual Care Area Assessment (CAA) dated 7/5/24, identified R25 required total assistance from staff with repositioning and was at risk for skin breakdown. Identified R22 was incontinent of bowel and bladder. R25's care plan dated 4/29/22, identified R22 had self care deficits and was at risk for skin breakdown related to stroke, history of pressure ulcers and need for staff assistance with repositioning in bed and wheelchair. Identified R25 was to wear bilateral heel protectors when in bed.R25's Braden Scale for Predicting Pressure Ulcer Risk dated 5/9/25, identified R25 was at high risk of developing a pressure ulcer.R25's treatment administration record (TAR) for the month of July 2025, identified R25 was to wear bilateral heel protectors while in bed. During an observation on 7/7/25 at 1:10 p.m., R25 was lying in bed on her back wearing a heel protector on her left foot and only a gripper sock on her right foot. R25's right heel was lying directly on the mattress. During an observation on 7/8/25 at 8:05 a.m., R25 was lying on her right side with only gripper socks on her feet. Both of R25's heels were lying directly on the mattress. One heel protector was lying on a bedside table across the room. During a joint interview on 7/8/25 at 8:15 a.m., nursing assistant (NA)-A and registered nurse (RN)-A verified R25 was at risk for pressure ulcers and was to have heel protectors on both feet while in bed. NA-A stated she was unsure why R25's heel protectors were not on her feet. RN-A stated the expectation was R25 should have had heel protectors on both feet to prevent pressure ulcers. During an interview on 7/8/25 at 3:11 p.m., director of nursing (DON) verified R25 was at risk for skin breakdown. DON stated her expectation was that staff would have applied the heel protectors on R25's feet when in bed per the care plan to prevent skin breakdown. Review of a facility policy titled Skin Care program dated 7/24, identified a resident who entered the facility without pressure sores did not develop pressure sores unless the individuals clinical condition demonstrated that they were unavoidable. Identified preventative skin care used individualized approaches specific to the condition. Identified the interventions. Identified residents with pressure ulcer risk would have identified preventative interventions placed on their care plan.

Based on observation, interview, and document review, the facility failed to comprehensively assess, attempt alternatives, ensure dimensions were appropriate and follow manufacturer's recommendations for installing prior to use of bed rails for 1 of 2 residents (R41 ) reviewed who were observed to have bed rails.Findings Include: R41's quarterly Minimum Data Set (MDS) dated [DATE], identified R41 was cognitively intact and had diagnoses which included: diabetes mellitus, arthritis and anxiety. R41's MDS further identified R41 was independent to roll left and right, and required supervision or touching assistance for lying to sitting, sit to stand and chair and bed transfers. R41's care plan dated 7/9/25, identified R41 had an activities of daily living (ADL) self-care performance deficit and indicated R41 was able to turn self and sit up in bed on own. R41's care plan interventions included to assist with transfers with gait belt and front wheeled walker. R41's care plan identified R41 had positioning rails bilaterally to assist with bed mobility. R41's Bedrail/Bed Positioning Device Assessment And Informed Consent form dated 9/22/23, identified R41 had bilateral positioning rails to aide in bed mobility and define parameters of bed. R41's Bedrail/Positioning Device assessment dated [DATE], identified R41 had 1/4 positioning rails on both sides of bed. R41's medical record lacked a comprehensive assessment of R41's bed rail including: appropriate use and installation of bed rail, measurements to assure safety and attempted alternatives prior to the use of the bed rail. During observation on 7/7/25 at 4:34 p.m., R41 had a personal twin bed with a black round bed rail on the right side. R41 indicated she had purchased the bed from a friend, and her family had installed the bed rail. R41 stated she used the bed rail to get in and out of bed. During observation on 7/8/25 at 10:47 a.m., R41's bed continued to have a black round bed rail on the right side of her bed towards the door. During interview on 7/8/25 at 3:09 p.m., nursing assistant (NA)-F indicated R41 often transferred herself to her bed. NA-F stated when assisting R41, she used a gait belt for transfers. NA-F indicated R41 did use her bed rail. NA-F stated R41 had her own bed, that her family had brought in for her. During interview on 7/8/24 at 3:17 p.m., licensed practical nurse (LPN)-B indicated R41 had her own bed for about the last month or two. During interview on 7/8/25 at 3:45 p.m., maintenance assistant (MA)-A verified R41 had a bed rail on her bed. MA-A stated family installed the bed rail. MA-A stated he was present the day they brought the bed and bed rail in, but did not assist with installation. During interview on 7/9/25 at 8:21 a.m., maintenance engineer (ME)-A stated the beds used by the facility all were the same and had the same bed rails. ME-A stated they had inspected the bed rails a few years ago. ME-A stated they do not routinely check bed rails, but if it became loose or a problem, the nursing staff would write a ticket for them to inspect it. ME-A confirmed he was not aware R41 had a different bed or bed rail. ME-A stated they had not obtained the manufacturer's instructions for R41's bed rail and was not aware if R41's bed rail was installed correctly. ME-A indicated he would inspect R41's bed and bed rail. During interview on 7/9/25 at 8:49 a.m., unit coordinator registered nurse (RN)-B stated the facility's usual practice was to inspect the bed rails to assure they were safe and inform the resident or representative of risks and benefits of their use. RN-B stated she completed the assessment and risk versus benefit consent form on admission. RN-B stated they completed quarterly bed rail assessments also. RN-B confirmed R41's Bedrail/Positioning Device assessment dated [DATE], was not accurate and needed to be modified, because R41 had obtained a new bed in May 2025. RN-B stated R41 had not been happy with mattresses they tried, so family brought in a bed for R41. RN-B confirmed she had not completed an assessment for R41's new bed rail, and they had not obtained the manufacturer's instructions for the bed rail. R41 stated R41's Bedrail/Bed Positioning Devise Assessment And Informed Consent form should also be updated. During interview on 7/9/25 at 9:25 a.m., director of nursing (DON) stated her expectation was that when a resident was admitted , they ask residents if they would like a positioning rail. DON indicated they then completed the Bedrail/Bed Positioning Devise Assessment And Informed Consent form. DON stated they usually did not attempt alternatives first. DON stated her expectation would be that R41's bed rail would be assessed to assure it was safe and appropriate. DON confirmed an assessment had not been completed yet of R41's new bed rail. The facility's Bedrail/Bed Positioning Device policy dated 2/2017, identified a bedrail/bed positioning device would not be used without assessment and informed consent. The policy identified the facility would attempt to use appropriate alternatives prior to installing a bedrail/bed positioning devise, and an assessment and informed consent would be completed.

Based on observation, interview, and document review, the facility failed to ensure a resident's call light was within reach from the bathroom floor in a resident bathroom for 1 of 1 residents (R7) reviewed for call light accessibility.Findings include:R7's quarterly Minimum Data Set (MDS) dated [DATE], identified R7 was cognitively intact and had diagnoses which included: diabetes mellitus, arthritis and anxiety. R7's MDS further identified R7 used a walker and was independent with walking, transferring and toilet hygiene. R7's care plan dated 7/8/25, identified R7 had an activities of daily living (ADL) self-care performance deficit with interventions that included, ensure call light was within reach. R7 was independent with toileting. During observation on 7/7/25 at 11:27 a.m., R7's bathroom call light box was on the wall approximately three feet off the floor. It had a short blue string attached with a knot on the end. The string hung approximately three to four inches below the call light box. R7 indicated she used the bathroom independently. During observation on 7/8/25 at 12:31 p.m., R7's bathroom call light box continued to have a short blue string, approximately three to four inches hanging from the call light box. R7 indicated she used her bathroom independently and if she fell on the floor, she would not be able to reach the call light. R7 stated she had fallen one time before in the bathroom. During observation on 7/8/25 at 2:14 p.m., maintenance assistant (MA)-A confirmed R7's bathroom call light was not accessible from the floor and was approximately three feet off the floor. MA-A did not know the actual length the call light cord should be. During interview on 7/8/25 at 2:27 p.m., administrator indicated she had been notified of R7's short call light cord in R7's bathroom. Administrator stated her expectation was that they be about two to three inches off the floor so the resident would be able to reach it from the floor. Administrator stated MA-A was replacing it now. During interview maintenance engineer (ME)-A stated call light cords must be accessible from the floor. ME-A stated this was important because if a resident fell on the floor and needed help, they needed to be able to reach the call light. ME-A indicated he was made aware R7's bathroom call light cord was too short. ME-A stated some of the cords become worn or break. ME-A stated he ordered a spool of cord and will be inspecting all the call light cords and replacing them as needed. On 7/8/25 at 8:48 p.m., health information manager (HIM)-A's e-mail indicated the facility did not have a specific call light policy.

Based on observation, interview and document review, the facility failed to implement appropriate donning/doffing of personal protective equipment (PPE) practices to prevent the spread of infection for 3 of 5 residents (R2, R16, R34) observed for enhanced barrier precautions (EBP) (an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). In addition, the facility failed to ensure equipment was sanitized between 2 of 2 residents (R24, R34) observed during transfers by nursing staff. Further, the facility failed to implement hand hygiene for 5 of 5 residents (R1, R29, R32, R37, R43) observed during medication administration. Findings include: Review of Centers for Disease Control (CDC) guidance dated 4/1/24, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) indicated examples of high-contact resident care activities requiring gown and glove use for EBP included: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care: any skin opening requiring a dressing. R16 R16's quarterly Minimum Data Set (MDS) dated [DATE], identified R16 had severe cognitive impairment and had diagnoses which included: hypertension (high blood pressure), dementia, anxiety. Indicated R16 required extensive assistance of staff for transfers and toileting. R16's care plan created 3/21/19, identified R16 required assistance with activities of daily living (ADL's) related to dementia, unsteadiness and anxiety. Indicated staff were to assist with transfers and had interventions of EBP. R16's care plan lacked documentation of a stage three ulcer to the left buttock. R16's resident condition report to physician dated 8/11/24, identified R16 had an area to the left buttock measuring nine centimeters (cm) by seven cm with an open area measuring 0.2 cm with drainage. R16's wound assessment dated [DATE], identified R16 had a stage three ulcer to the left buttock measuring 1.5 cm in length by 1 cm in width by 0.5 cm in depth. A stage two ulcer to left buttock measuring 1 cm in length by 0.8 cm in depth. A hard boil/lesion to the left buttock measuring 5 cm in length by 4 cm in width. R16's hospital report dated 8/21/24, identified R16's wound culture grew both Methicillin-resistant Staphylococcus Aureas (MRSA- a type of staph bacteria that's resistant to many antibiotics) and Escherichia coli (E. coli- a bacteria that could cause infections in the gut, urinary tract and other parts of the body). The hospital report further identified the growth of four different organisms and to treat with Bactrim antibiotic along with wound treatments. The report instructed staff to change the dressing every four days or as needed if saturated. R16's nursing progress note dated 8/22/24, identified EBP initiated due to positive wound culture of buttock for MRSA. During an observation on 8/27/24 at 10:57 a.m., nursing assistant (NA)-B applied a gown and gloves outside of R16's room and entered R16's room. Registered nurse (RN)-A was sitting on R16's bed next to R16 applying a gait belt to R16's waist. NA-B and RN-A held onto the gait belt on each side of R16 and assisted R16 to stand and transfer to the wheelchair. RN-A sanitized her hands and left the room. RN-A was not wearing a gown or gloves during the entire observation. During an interview on 8/27/24 at 2:06 p.m., NA-B verified R16 had a wound and was on EBP. NA-B confirmed EBP were in place to prevent the spread of infection. During an interview on 8/27/24 at 11:16 a.m., RN-A verified R16 was on EBP because of a wound on R16's buttock. RN-A stated staff were to wear a gown and gloves when doing cares for residents on EBP. 37905 R34 R34's admission MDS dated [DATE], identified R34 had moderate cognitive impairment and diagnoses which included: Parkinson's disease, arthritis, and anxiety. R34's Indicated R34 required partial/moderate assistance with dressing, personal hygiene and sit to stand transfers. R34's care plan printed 8/27/24, identified R34 had ADL self-performance deficit, and required assistance with dressing, grooming, bathing and transferring. R34's care plan identified R34 had a foley catheter for urination. R34's care plan lacked documentation related to EBP. During an observation on 8/27/24, at 8:12 a.m., R34 was lying in bed, while NA-C and NA-B were in R34's room, NA-B wore a gown and gloves, while NA-C had only gloves on. R34's doorway had a sign identifying R34 was on EBP and a covered cart was located outside R34's room which contained gowns and gloves. NA-C gave R34 drinks of water from glass and straw while NA-C stood on the left side of R34's bed. NA-B removed gown and gloves and left R34's room. At 8:16 a.m., NA-B returned to room wearing a gown and gloves, with mechanical lift, and began to attach the sling under R34 to the lift with NA-C, then NA-B and NA-C transferred R34 to his wheelchair. NA-B removed the mechanical lift from the room to the hallway without sanitizing the lift, and returned to the room. NA-B and NA-C continued to assist R34 with dressing and grooming, then NA-C made R34's bed. NA-C remained in R34's room not wearing a gown from 8:12 a.m. until 8:34 a.m., when NA-B transported R34 out of room. During an interview on 8/27/24 at 9:52 a.m., NA-C indicated R34 was on EBP and staff were to wear a gown and gloves when in R34's room performing cares. NA-C stated NA-C had forgotten to wear a gown and when starting to assist NA-B with R34's cares, had then remembered during the cares, however did not want to leave the room. NA-C confirmed NA-C had helped R34 with dressing, grooming, transferring, and made R34's bed while not wearing a gown. During an interview on 8/27/24 at 10:06 a.m., NA-B indicated NA-C did not wear a gown while assisting R34, who was on EBP. NA-B stated following EBP for R34 was important to protect the staff, the resident and the next resident they took care of. NA-B stated they had not sanitized the lift when removed from R34's room, because they had forgotten. NA-B indicated usual process was to sanitize the lift after each resident use to prevent the potential for infection transmission. During an interview on 8/27/24 at 10:38 a.m., licensed practical nurse (LPN)-B, stated all nursing staff were to wear a gown and gloves when working with R34's catheter, or completing transfers or cares. LPN-B confirmed the mechanical lift was not usually sanitized between resident use, however should have been to prevent the potential spread of infection. R24 R24's significant change in status MDS dated [DATE], identified R24 had severe cognitive impairment and diagnoses which included Alzheimer's disease, dementia and arthritis. Indicated R24 was dependent on staff for dressing, personal hygiene and transfers. R24's care plan printed 8/27/24, identified an ADL self-care performance deficit and R24 was dependent on staff for dressing, bathing and transferring with a mechanical lift. During an observation on 8/27/24 at 8:54 a.m., NA-D removed the mechanical lift from room [ROOM NUMBER], then moved the lift to R24's room. NA-D began to attach the sling under R24 to the mechanical lift, and at 8:56 a.m. NA-A entered the room and began to assist NA-D to transfer R24 to bed. NA-D pushed the mechanical lift out to the hallway, then both sanitized hands and NA-D took the garbage to the soiled utility room. During an interview on 8/27/24 at 9:06 a.m., NA-D stated NA-D had taken the lift from room [ROOM NUMBER] and brought to R24's room. NA-D stated the usual process was not to sanitize the lift between residents unless they were on transmission based precautions, and confirmed staff had not sanitized the mechanical lift that day. NA-D stated the night shift usually sanitized the lifts. During an interview on 8/27/24 at 10:26 a.m., NA-A stated NA-A had not sanitized the mechanical lift that day. NA-A indicated housekeeping usually sanitized the lifts. During an interview on 8/27/24 at 10:31 a.m., housekeeper (HSK)-A stated housekeeping staff cleaned lifts when noticed they were soiled. HSK-A indicated housekeeping did not have a routine to sanitize the lifts. During an interview on 8/27/24 at 11:09 a.m., registered nurse unit coordinator (RN)-C stated lifts should have been sanitized between resident use and it was important for infection control purposes. 48740 R2 EBP R2's quarterly MDS dated [DATE], identified R2 had mildly impaired cognition and diagnoses which included hypertension (high blood pressure), seizure disorder and anxiety. R2's care plan updated 8/22/24 identified R2 was on EBP due to infection control. R2's lab culture results from 8/18/24 revealed that R2 had MRSA, in a wound located on the right breast. During an observation on 8/27/24 at 1:57 p.m., NA-A entered R2's room to answer the bathroom call light. R2 had a sign above her name beside the door indicating R2 was on EBP. A plastic bin was next to the door which had gloves and gowns. NA-A applied gloves, however did not apply a gown. NA-A assisted R2 in standing up and performing perineal cares. NA-A changed gloves and assisted R2 with pulling up her underwear and pants. NA-A removed gloves and washed hands. During an interview on 8/27/24 at 2:03 p.m., NA-A stated she was unaware of R2 being on EBP. NA-A verified there was a EBP sign by R2's door. NA-A stated the process was to wear gowns and gloves when working with a resident on EBP. During an interview on 8/27/24 at 2:12 p.m., RN-A stated R2 was on EBP as R2 had a wound on her breast. RN-A stated she expected staff would wear a gown and gloves when assisting with toileting care. 49014 HAND HYGIENE/MEDICATION PASS During an observation on 8/26/24 at 6:40 p.m., LPN-A entered the dining room, lifted R29's shirt and administered R29's insulin with her bare hands. LPN-A returned to the medication cart and discarded the insulin pen needle into the sharps container and placed the insulin pen back into the medication cart. LPN-A gathered medications and eye drops for R1, while touching the medication cart, computer mouse, and drawers. LPN-A walked to the sitting area where R1 was seated and administered eye drops to R1 wearing one glove on her left hand, touched both of R1's eyes with gloved left hand, removed glove from left hand and disposed of it into the garbage on the medication cart. LPN-A then put R1's eye drop bottle back in the medication cart and proceeded to gather medications for R32, touching the medication cart drawers, computer mouse, and cups on the medication cart LPN-A handed medications to R32 and noted R32 did not have anything in her glass. LPN-A proceeded to open the refrigerator on the unit and poured a glass of juice and handed it to R32. LPN-A returned to the medication cart to gather medications for R43. LPN-A administered medications to R43, picked up R43's glass and provided a drink of juice between each medication administered. LPN-A returned to the medication cart and gathered R37's medications. LPN-A stated medications needed to be crushed and proceeded to crush seven medications and placed them in a medication cup. Two medications were unable to be crushed; LPN-A opened the two capsules with bare hands and sprinkled them into the medication cup containing the other crushed medications. LPN-A mixed applesauce into the crushed medications. LPN-A handed R37 their glass while administering the crushed medications to R37. LPN-A did not sanitize her hands during the entire medication pass. During an interview on 8/26/24 at 7:27 p.m., LPN-A verified that she had not performed hand hygiene during the medication pass. LPN-A stated it was not her normal process to perform hand hygiene during her medication pass. LPN-A indicated she should have performed hand hygiene after every resident contact and medication pass. During an interview on 8/27/24 at 1:44 p.m., infection preventionist (IP)-A stated her expectation was that staff would have performed hand hygiene before and after medication pass, between resident contact, and entering in and out of resident rooms. During a follow-up interview on 8/27/24 at 1:51 p.m., IP-A indicated the facility had an expectation for all staff to sanitize all lifts with a Sani-wipe (germicidal cleansing wipe) after each use. IP-A stated it was important to sanitize the lifts after each use to prevent cross contamination. During a follow-up interview on 8/27/24 at 1:52 p.m., IP confirmed EBP were utilized for high resident contact cares; toileting, transferring, dressing and bathing or anytime a staff would come in direct contact with a resident. IP verified the expectation of staff were to be wearing a gown and gloves with cares. IP further stated EBP were in place because staff did not know what germs could have been present on clothing and staff wanted to protect our residents. During an interview on 8/27/24 at 3:06 p.m. director of nursing (DON) confirmed the expectation lifts were to be wiped down with Sani-wipes after the lifts were removed from a resident's room to prevent the spread of infection from one resident to another. During a follow-up interview on 8/27/24 at 4:32 p.m., director of nursing DON confirmed EBP were put in place to prevent the spread of potential infections's to other residents and staff. DON verified the expectation of staff was to wear a gown and gloves with any close personal contact with residents on EBP. DON confirmed it was important to stop the transmission of infections from staff and residents and from room to room. During a follow-up interview on 8/27/24 at 4:48 p.m., DON stated her expectation was staff would have performed hand hygiene prior to administering medications, after administering medication, and after any resident contact to prevent the spread of infection. Review of a facility policy dated April 2024, identified the facility would implement enhanced barrier precautions for prevention of transmission of multidrug-resistant organisms. The policy further identified EBP employed targeted gown and glove use during high contact resident care activities which included: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, wound care: any skin opening requiring a dressing. The policy also identified the facility would make gowns and gloves available near or outside of the resident's room; PPE for enhanced barrier precautions were necessary when performing high-contact care activities and EBP would have been used for the duration of the affected resident's stay in the facility or until the wound heals or indwelling medical device was removed. The facility policy titled Standard Precautions: Equipment, Nursing Unit Cleaning Of-Signature sheet, Use Of Form #BMH 689-91 Utensils (Nursing) And Personal Nursing Items, Washing And Sanitizing Of dated 12/2019, identified all shared equipment would be disinfected between residents. The policy also identified Tuesday night staff tasks included mechanical lifts and stands would have all hard surfaces disinfected using gloves and a Professional Disposables International Inc (PDI) Sani-cloth germicidal wipe after gross loose debris had been removed. A policy titled Hand Hygiene Policy dated 10/2020, indicated when to perform hand hygiene, before having direct contact with patients, after contact with a patient's intact skin, after contact with mucous membranes, after contact with inanimate objects (including medical equipment in the immediate vicinity of the patient, and after removing gloves.

Based on observation, interview and document review, the facility failed to ensure grievance forms and procedures were posted in prominent locations throughout the facility for residents and resident representatives to file grievances, and anonymously if desired for 4 of 4 residents (R40, R28,R8 and R19) reviewed for grievances. Findings include: On 9/19/23 at 2:00 p.m., a resident council meeting was held with four residents which included R40, R28, R8, and R19. During the resident council meeting, all four residents indicated they were not aware how to file a grievance. During an observation on 9/19/23 at 2:22 p.m., a walk through was conducted of the first floor, second floor and third floor of the facility. The walk through revealed there were no grievance forms or procedures posted for residents or resident representatives to refer to. During an interview on 9/19/23 at 2:22 p.m., registered nurse (RN)-A stated grievance forms were located at the front desk on first floor in a binder. RN-A indicated any staff member could complete the forms if a resident made a grievance. During an interview on 9/19/23 at 3:10 p.m., licensed social worker (LSW)-A identified a binder located on the front desk titled Room/Apartment Directory And Quality Improvement Request Form And Corporate Compliance Report Form And Envelopes. LSW-A opened the binder and indicated the grievance policy and forms were inside the binder in plastic sleeves near the back of the binder. The binder lacked identification it contained the grievance procedure and forms. LSW-A confirmed the binder at the front desk was the only place the grievance procedure and forms were stored. LSW-A indicated information was provided in the admission packet to each resident upon admission. During an interview on 9/19/23 at 3:32 p.m., DON-A stated she was the grievance officer. DON confirmed the facility had not posted the grievance procedure or forms in prominent locations within the facility. DON stated she felt it was important to inform residents at resident council how to file a grievance and to have forms available to complete anonymously when desired. The facility policy titled Complaint/Grievance Policy And Procedure dated 6/23, identified the purpose was to ensure all residents were informed of their ability to file a complaint and how to file a complaint. The policy identified each resident and/or resident representative received written notice of the facility's process for receiving and resolving complaints, which was located in the facility resident hand book. The policy lacked identification of further notification to residents individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing.

Based on interview and document review, the facility failed to ensure minimum required information was provided to a receiving healthcare facility for 1 of 1 residents (R48) who was transferred to the hospital and was subsequently admitted to the hospital. Findings include: R48's discharge Minimum Data Set (MDS) dated [DATE], indicated R48 was cognitively intact and had diagnoses which included cancer, anemia, diabetes mellitus. The MDS identified R48 required staff assistance with activities of daily living. Review of R48's progress notes from 8/17/23 to 8/24/23, revealed the following: - on 7/24/23 at 4:53 p.m. R48 had a temperature of 102.3, productive cough, lungs clear with low volume hum on expiration and COVID-19 test negative. R48's primary provider called and order a complete blood count and basic metabolic panel be drawn on 7/25/23, and would be seen on rounds. R48's daughter was updated. - at 7:21 p.m. R48 had a large liquid emesis, his stomach was upset, running a fever and coughing. - at 8:15 p.m. R48 had another large projectile emesis, temperature 102.9, oxygen levels 88 percent on room air with slightly labored breathing and fine crackles in his lungs. Family notified. - at 8:50 p.m. R48 sent to the emergency room for further evaluation. - at 10:42 p.m. R48 was admitted to hospital with pneumonia. R48's medical record lacked any documentation the required transfer information was sent to the receiving hospital. During an interview on 9/20/23 at 9:28 a.m., licensed social worker (LSW) stated R48 had been hospitalized and was not able to locate documentation in R48's medical record regarding his transfer to the hospital. The LSW indicated her expectation was for staff to complete the interagency referral form, the code status and the resident's medical condition and it should have been sent with the resident to the hospital. The LSW indicated staff should have made a copy of the transfer forms and placed them in the medical record. During an interview on 9/20/23 at 11:15, the director of nursing (DON) confirmed the above findings and indicated she would expect staff to follow the facility's policy and procedures for transfers and discharges. The DON indicated she would expect staff to make sure the necessary paper work including interagency form, face sheet, emergency contact information, medication sheets, treatment sheets and code status were sent to the receiving facility. Review of the facility policy titled, Transfer and Discharge revised on 7/98, indicated the interagency referral form would be completed and sent to the receiving hospital for all transfers. The policy indicated staff would make a copy of the completed form and attachments and place in the front of the resident's medical record.

Based on interview and document review, the facility failed to notify the Long Term Care (LTC) ombudsman of a facility initiated transfer for 1 of 1 residents (R48) who was transferred to an acute care facility on an emergency basis. In addition, the facility failed to provide written notifications for transfers to the resident and/or resident representative for 1 of 1 residents (R48) reviewed for hospitalization . Findings include: R48's discharge Minimum Data Set (MDS) dated [DATE], indicated R48 was cognitively intact and had diagnoses which included cancer, anemia, and diabetes mellitus. The MDS identified R48 required staff assistance with activities of daily living. Review of R48's progress notes from 8/17/23 to 8/24/23 revealed the following: - on 7/24/23 at 4:53 p.m. R48 had a temperature of 102.3, productive cough, lungs clear with low volume hum on expiration and COVID-19 test negative. R48's primary provider called and ordered a complete blood count and basic metabolic panel be drawn on 7/25/23, and would be seen on rounds. R48's daughter was updated. - at 7:21 p.m. R48 had a large liquid emesis, his stomach was upset, running a fever and coughing. - at 8:15 p.m. R48 had another large projectile emesis, temperature 102.9, oxygen levels 88 percent on room air with slightly labored breathing and fine crackles in his lungs. Family notified. - at 8:50 p.m. R48 sent to the emergency room for further evaluation. - at 10:42 p.m. R48 was admitted to hospital with pneumonia. R48's medical record lacked documentation the notification of the emergency transfer was sent to the LTC ombudsman and lacked documentation a written transfer notification was provided to the resident and/or resident's representative. During an interview on 9/20/23 at 9:28 a.m., licensed social worker (LSW) confirmed R48 had been hospitalized and was not able to locate in the medical record that a written notification had been provided to the family or the ombudsman. The LSW stated she would expect staff to provide the required written notices to the resident/family and the ombudsman. During an interview on 9/20/23 at 11:15 a.m., the director of nursing (DON) confirmed the above findings and indicated she would expect staff to follow the facility's policy and procedures for transfers and discharges. The DON stated she would expect staff would ensure the required notifications were completed for the resident, resident representative and the ombudsman. Review of the facility policy titled, Transfer and Discharge Notification revised on 3/94, indicated the resident and the resident representative would be provided proper ad timely notice of discharge as required by regulations and laws. The policy identified the facility would notify the LTC Ombudsman with 30 days of discharge from the facility.

Based on observation, interview, and document review, the facility failed to implement interventions to prevent further falls for 1 of 3 resident (R 41) reviewed for falls. Findings include: R41's quarterly Minimum Data Set (MDS) dated [DATE], identified R41 had severely impaired cognition and had diagnosis which included non traumatic brain dysfunction and cancer Indicated R41 required extensive assistance with activities of daily living (ADL's) which included, bed mobility, transfers, toileting, and locomotion. Identified R41 required physical assistance to maintain balance during transitions and toileting. Revealed R41 has two falls with no injury since the last required assessment. R41's significant change Care Area Assessment (CAA), dated 10/3/22, identified R41 had impaired cognition and had diagnosis which included dementia, cancer and diabetics mellitus (DM). Indicated R41 required extensive assistance with activities of daily living (ADL's). Identified R41 was a high fall risk related to dementia and not communicating her needs for assistance with transfers. Review of R41's current care plan revised 10/18/22, revealed R41 was incontinent of bowel and bladder. Care plan revealed R41 was at high risk for falls related to de-conditioning , cognitive deficits and history of falls prior to admission. R41's care plan listed various fall interventions which included bed in low position, bed and wheelchair alarms, ensure resident wore gripper socks or shoes when out of bed, remind resident to use call light and to move wheelchair and walker out into hallway when resident was in bed. Review of R41's most recent fall risk assessment dated [DATE], identified R41 was at high risk for falls related to impaired mobility, impaired cognition and urinary incontinence. Review of R41's undated nursing assistant (NA) worksheet revealed R41 required a bed alarm and directed staff to place wheelchair and walker in the hallway when not using. Review of R41's adverse event reports from 3/16/23 to 7/8/23, revealed the following: - 3/16/23, R41 had an unwitnessed fall at 4:40 p.m R41 was found sitting on the floor hanging onto the grab bar on the bed. R41 attempted to transfer from the bed to the wheelchair. R41 had not received any injuries and an intervention was added to ensure R41 was wearing non slip socks or shoes. -7/8/23, R41 had an unwitnessed fall at 2:45 p.m. R41 was found on the floor with her head on her right arm toward the foot of the bed and her feet toward the head of the bed. R41 had not received any injuries and an intervention was added to implement a raised edge mattress. During an observation on 9/18/23 at 11:34 a.m., R41 was lying in bed and R41's wheelchair was noted to be five feet from the bed against the wall within sight of R41. During an observation on 9/19/23 at 3:38 p.m., nursing assistant (NA)-A exited R41's room and placed a pal lift in the hallway. R41 was lying in bed and R41's wheelchair was noted to be five feet from the bed against the wall within sight of R41. During an observation on 9/19/23 at 4:17 p.m., R41 continued to be lying in bed with the wheelchair noted to be five feet from the bed against the wall within sight of R41. During an interview on 9/19/23 at 4:19 p.m., NA-A stated she had placed the wheelchair five feet from the bed against the wall when she laid R41 down in bed. NA-A stated R41's care plan identified staff were to move R41's wheelchair into the hallway when not in use. NA-A stated she was not aware R41's wheelchair was to be placed in the hallway when not in use. During an interview on 9/19/23 at 4:24 p.m., licensed practical nurse (LPN)-A verified R41's wheelchair was placed five feet from R41's bed against the wall and was visible to R41. LPN-A stated staff were expected to place R41's wheelchair in the hallway and out of R41's sight when not in use as a fall intervention. LPN-A stated R41 was a high fall risk and had fallen out of bed when she was able to see her wheelchair in the room. LPN-A indicated he expected staff would place R41's wheelchair in the hallway when not in use. LPN-A proceeded to place R41's wheelchair in the hallway at that time. During an interview on 9/19/23 at 4:29 p.m., registered nurse (RN)-B verified R41's wheelchair had been in her room near the bed before LPN-A moved it into the hallway. RN-B stated R41 was at high risk for falls and had fallen in the facility however, she was not aware R41's wheelchair was to be placed in the hallway when not in use. During an observation on 9/20/23 at 7:15 a.m., R41 was lying in bed and the wheelchair was noted to be five feet from the bed against the wall within R41's sight. During an observation on 9/20/23 at 7:49 a.m., R41 was lying in bed and the wheelchair continued to be five feet from the bed against the wall within R41's sight. During an interview on 9/20/23 at 7:51 a.m., RN-B verified R41's wheelchair was five feet from the bed against the wall and within sight of R41. RN-B moved R41's wheelchair into the hallway and stated her expectation was R41's care plan would have been followed. During an interview on 9/20/23 at 9:05 a.m., director of nursing (DON) verified R41 was a high risk for falls and has had falls in the facility. DON stated she was not aware R41's wheelchair was to be placed in the hallway when not in use however verified R41's care plan stated to ensure R41's wheelchair was in the hallway when not in use. DON indicated she expected staff to follow R41's care plan and ensure falls interventions were in place. Review of a facility policy titled Fall Prevention Program revised 6/2013, revealed the facility assessed residents upon admission and at least quarterly for falls and promptly began a falls prevention plan. Policy indicated a post - fall analysis was done after each fall and appropriate care planned interventions were to be follow. .

Based on observation, interview and document review, the facility failed to ensure the required nurse staffing information was posted daily. This deficient practice had the potential to affect all 42 residents who resided in the facility and/or any visitors who may have wished to view the information. Findings include: During an observation on 9/18/23 at 9:32 a.m., a sign was posted in the main lobby of the nursing home to the right of the entrance which revealed the following: The sign identified the nurse staffing information was located on the second floor north in the day room near the nurses' station. Hanging on the wall approximately three feet form the ground was a square wooden box. On the outside of the wooden box a sign indicated the posting of nursing staff levels were inside the box. Inside the box was a clipboard with a posting indicating Posted Nurse Staffing Information. The posting was dated 9/18/23, and identified a census of 42. - at 10:37 a.m., the staff posting remained the same. - at 3:09 p.m., the staff posting remained the same. - at 7:37 p.m., the staff posting remained the same. The posting lacked the actual and total number of hours worked per shift by registered nurses (RN), licensed practical nurses (LPN) and nursing assistant (NA). During an observation on 9/20/23 at 8:31 a.m., the staff posting located on the second floor north by the nurses station in the wooden box revealed the posting was dated 9/19/23, and identified the census of 42. - at 12:09 p.m., the staff posting remained the same. - at 1:41 p.m., the staff posting remained the same. The posting lacked the actual and total number of hours worked per shift by RN's, LPN's and NA's. During an interview on 9/19/23 at 1:43 p.m., the director of nursing (DON) confirmed the above findings and indicated the staff scheduler (SS) was responsible for the daily staff postings. The DON indicated her expectation for staff would be for the staff posting to be completed daily and to reflect the current staffing patterns and census. The DON stated she would expect the staff posting to be visible for everyone to see and to be completed. During an interview on 9/19/23 at 1:53 p.m., the SS confirmed the above findings and indicated she was responsible to ensure the staff posting was updated on a daily basis. The SS stated she was not aware the staff posting needed to be posted for the public to see. The SS indicated she would expect the staff posting to be completed and updated to reflect the current staffing and census. Review of the facility policy titled, Posted Nurse Staffing Information dated 4/2022, indicated the total number and the actual hours worked by licensed and unlicensed nursing staff (RN, LPN, NA/R) directly responsible for resident care would be posted daily per shift to allow the public access to posted nurse staffing data.

Based on interview and document review, the facility failed to immediately report, no later than 2 hours, an allegation of abuse to the State Agency (SA) for 1 of 3 residents (R2) reviewed for abuse. Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 had moderate cognitive impairments and had diagnosis which included hypertension (elevated blood pressure), depression and bipolar. Indicated R2 required extensive assistance with activities of daily living (ADL's) which included bed mobility, transfers and toileting. R2's care plan dated 5/10/21, revealed R2 was vulnerable related to placement in a nursing home. Care plan stated any employee who observed an interaction that placed any resident at risk for abuse would record it in the resident's progress notes under a behavior note and staff would also notify a charge nurse to follow up. The facility State Agency (SA) report dated 8/22/23, identified a lady or man came into her room and slapped her on the arm, lip, or eye. The report indicated the incident occurred at 11:50 p.m. on 8/21/23. During an interview on 9/5/23 at 10:13 a.m., nursing assistant (NA)-A stated shortly before midnight on 8/22/23, NA-A entered R2's room to change her incontinent product. NA-A stated while she was in the room, R2 said you hit me. NA-A indicated she immediately left R2's room and informed the trained medication aide (TMA) what R2 had stated. During an interview on 9/5/23 at 12:49 p.m., TMA indicated on 8/22/23 around midnight NA-A answered R2's call light and exited R2's room about five minutes later. When NA-A exited R2's room NA-A stated R2 said NA-A had hit her. TMA-A stated a few minutes later R2 placed her call light on again and TMA-A answered the call light and R2 reported to TMA-A that NA-A had slapped her on the face a few minutes ago. TMA-A stated she immediately exited the room and informed the charge nurse about the allegation of abuse. During an interview on 9/5/23 at 12:58 p.m., registered nurse (RN)-A stated around midnight on 8/22/23, TMA-A informed her R2 stated NA-A had hit her. RN-A stated she did not believe the allegation of abuse needed to be reported to the SA since R2 had a history of making accusations against staff who were a different race from her. During an interview on 9/5/23 at 1:33 p.m., RN-B stated on 8/22/23 at 10:45 a.m., R2 informed her NA-A had slapped her on the eye, lip, and her arm. RN-B indicated she immediately reported the allegation of abuse to the administrator. During an interview on 9/5/23 at 2:03 p.m., director of nursing (DON) stated she worked the night shift on 8/22/23. DON indicated she had not been informed of the allegation of abuse that night and stated she became aware of the allegation later that day. DON was unsure why the allegation of abuse had not been reported to her or to the SA within two hours. DON stated her expectation was all allegations of abuse would have been reported immediately but no more than two hours to the SA. During an interview of 9/6/23 at 10:40 a.m., administrator stated RN-B had notified her of the allegation of abuse on 8/22/23 at 10:50 a.m. Administrator stated she reported the allegation of abuse to the SA as soon as she became aware of it. Administrator verified the allegation of abuse had not been reported within two hours to the SA and stated her expectation was any allegation of abuse would have been reported immediately but no more than two hours to the SA. A facility policy titled Vulnerable Adult Act (VA): Reporting, Internal and External-1065-95 Notification to Internal Concerning External Reporting of Suspected Maltreatment dated 10/2019, revealed all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property, were to be reported immediately, but no more than two hours after the allegation was made to the State Survey Agency. /

Based on interview and document review, the facility failed to ensure a thorough investigation of an allegation of potential abuse was completed for 1 of 3 residents (R1) reviewed for abuse. In addition, the facility failed to protect residents after an allegation of abuse occurred by allowing the alleged perpetrator (AP) to continue to have access to other vulnerable adults for 1 of 3 residents (R2) reviewed for abuse. Findings include: R1 R1's annual Minimum Data set (MDS) dated [DATE], indicated R1 had moderately impaired cognition and had diagnoses which included heart failure, renal insufficiency and non Alzheimers dementia. Indicated R1 required staff supervision with activities of daily living which included bed mobility and transfers and required extensive staff assistance with toileting. R1's care plan revised 8/18/23, revealed R1 was vulnerable related to placement in a nursing home with a goal that R1 would not experience any abuse. The facility report to the State Agency (SA) dated 8/27/23 at 6:49 p.m., indicated R1 reported he had increased back pain when placed in a certain position by nursing assistant (NA)-B. The facility five day SA report dated 8/31/23 at 5:21 p.m., lacked evidence the facility interviewed other residents regarding potential abuse from NA-B. During an interview on 9/5/23 at 2:03 p.m., director of nursing DON indicated she had assisted in completing the facility's internal investigation for the abuse allegation for R1. DON stated she had not interviewed any other residents to determine if there had been other potential abuse concerns with NA-B. DON indicated she did not feel it was necessary since she had just spoke with several residents the prior week regarding a separate allegation for another resident. DON stated interviewing other residents who resided in the facility would have been important to ensure there were no further concerns of potential abuse from NA-B. During an interview on 9/5/23 at 2:07 p.m., administrator indicated she had assisted in completing the facility's internal investigation for the abuse allegation for R1. Administrator verified no other residents had been interviewed regarding R1's allegation of abuse. Administrator stated it would have been important to interview other residents to ensure there were no further concerns of potential abuse from NA-B. R2 R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 had moderate cognitive impairment and had diagnosis which included hypertension (elevated blood pressure), depression and bipolar. MDS indicated R2 required extensive assistance with activities of daily living (ADL's) which included bed mobility, transfers and toileting. R2's care plan dated 5/10/21, revealed R2 was vulnerable related to placement in a nursing home. Care plan stated any employee who observed an interaction that placed any resident at risk for abuse would record it in the resident's progress notes under a behavior note and staff would also notify a charge nurse to follow up. The facility State Agency (SA) report dated 8/22/23, identified a lady or man entered her room and slapped her on the arm, lip, or eye. The report identified the incident occurred at 11:50 p.m. on 8/21/23. The facility five day SA report dated 8/24/23 at 1:00 p.m., identified through investigation the incident was unsubstantiated and nursing assistant (NA)-A had been removed from the schedule until the investigation was completed. During an interview on 9/5/23 at 10:13 a.m., nursing assistant (NA)-A stated shortly before midnight on 8/22/23, NA-A entered R2's room to change her incontinent product. NA-A stated while she was in the room, R2 said you hit me. NA-A indicated she immediately left R2's room and informed the trained medication aide (TMA) what R2 had stated. NA-A stated she was asked not to work with R2 anymore that night however,she was allowed to continue working with other residents until 7:00 a.m. the next morning when her shift ended. During an interview on 9/5/23 at 12:58 p.m., registered nurse (RN)-A stated around midnight on 8/22/23, TMA-A informed her R2 reported NA-A had hit her. RN-A stated she had asked NA-A to stay out of R2's room the rest of the night. RN-A verified NA-A was allowed to independently continue working with other residents for about seven more hours after the allegation of abuse had been made. During an interview on 9/5/23 at 2:03 p.m., director of nursing DON verified on 8/22/23, NA-A had been allowed to continue to work and had access to other residents for approximately seven hours after the allegation of abuse had been reported. DON stated her expectation would have been NA-A would have been removed from the schedule immediately following the allegation of abuse. During an interview on 9/5/23 at 2:07 p.m. administrator verified NA-A had been allowed to continue to work and had access to other residents for approximately seven hours after the allegation of abuse had been reported. Administrator stated her expectation was NA-A would have been removed from the schedule immediately following the allegation of abuse while the investigation was being completed. A facility policy titled Vulnerable Adult Act (VA): Reporting, Internal and External-1065-95 Notification to Internal Concerning External Reporting of Suspected Maltreatment dated 10/2019, revealed the facility would thoroughly investigate all alleged violations and prevent further potential abuse while the investigation was in progress.

Based on interview and document review, the facility failed thoroughly investigate and take corrective action to prevent recurrence of a significant medication for 2 of 2 residents (R1, R2) reviewed for medication administration. Findings include: R1's Diagnoses Report dated 5/31/23, identified diagnoses pyogenic arthritis (painful infection in a joint). R1's Order Summary Report dated 6/6/23, identified: -5/31/23, Vancomycin intravenous (IV) solution 750 milligrams (mg)/150 milliliters (ml) use 1 vial IV every 18 hours for left should septic arthritis until 6/23/23, at 11:59 p.m. Flush using SASH method Saline, antibiotic, saline, heparin. -6/5/23, Vancomycin IV solution 1250 mg IV one time a day for septic arthritis until 6/23/23 at 11:59 p.m. Review of Incident Report submitted to the Minnesota Department of Health (MDH) on 6/5/23 at 4:31 p.m., identified an incident occurred on 6/1/23 at 3:30 a.m. The report indicated from 6/1/23 to 6/4/23, an order for Vancomycin 750 mg every 18 hours on electronic medical record (EMAR), label on Vancomycin read 1.25 mg every 24 hours. R1 had been receiving 1.25 mg every 18 hours. Review of Incident Investigation form dated 6/9/23 at 10:59 a.m., included the following information: IV orders were received on 5/30/23, resident was admitted on [DATE]. Medication arrived from outside pharmacy on 5/31/23. Order on EMAR was for Vancomycin 750 mg every 18 hours. Order on medication label was 1.25 gm every 24 hours. 6/1/23 through 6/4/23, resident received 1.25 mg every 18 ours. On 6/5/23, upon discovery of the order discrepancy pharmacy was contacted. On 5/31/23 orders had been received by pharmacy from hospital to change the order to 1.25 mg every 24 hours. This was not communicated to nursing home. As part of correction, on 6/5/23 facility received fax orders reflecting change from pharmacy and order was corrected on EMAR. Review of an Incident Investigation form dated 6/9/23, action taken to prevent reoccurrence to other residents will now have IV medication double checked by two licensed staff prior to administration. Similar incidents that have occurred in the past six months: had an incident about one month ago where a resident was receiving IV Vancomycin and IV Cefepime twice a day (bid) and the resident received two doses of Vancomycin in one day instead of the Cefepime. Facility lacked evidence corrective action identified indicated in investigation form dated 6/9/23 was implemented. Additionally, no nursing staff were re-educated to identify discrepancies during medication administration to prevent re-occurrence. R2's Order Summary Report dated 6/6/23, identified: methicillin resistant staphylococcus aureus infection (MRSA) (staph infection difficult to treat due to resistance against some antibiotics) and infection of implanted electronic neurostimulator of the spinal cord. . R2's Order Summary Reported dated 5/11/23, identified: -4/18/23, Cefepime IV solution 2 grams (gm) two times a day for sepsis (every 12 hours). -4/24/23, Cefepime IV solution 2 gm two times a day for sepsis until 4/26/23 at 10:59 a.m., Flush using SASH method with each use. -Vancomycin IV use 1000 mg one time a day IV for sepsis (every 24 hours). -Vancomycin IV solution use 1000 mg IV one time a day for sepsis until 4/25/23 at 11:59 p.m. (every 24 hours). Review of an Incident Report submitted to the Minnesota Department of Health (MDH) on 4/24/23 at 11:26 a.m., identified an incident occurred on 4/23/23 at 12:00 a.m. The report indicated resident received two doses of IV Vancomycin in one day. Order was for Vancomycin daily and Cefepime twice a day. Review of Incident Investigation form dated 4/28/23 at 11:09 a.m., indicated action taken to prevent reoccurrence to other residents was to have all registered nurses who administered the IV medication to complete an audit for administration of oral medications, since there were no residents in facility at this time receiving IV medication, with particular attention being paid to checking the medication label against the medicine list on the EMAR. During an interview on 6/13/23 at 2:30 p.m., registered nurse (RN)-A stated the facility medication administration policy was reviewed and a change was to be made to include two staff required to double check the rights of medication administration prior to the IV medication to be given. RN-A verified medication administration education, audits, and competencies had not been completed. During an interview on 6/13/23 at 3:30 p.m., RN-B stated unaware of any changes made or education provided staff in the past three months to avoid further IV medication errors. During an interview on 6/13/23 at 4:20 p.m., RN-C stated Educare was required to be completed throughout the year on the computer, but IV medications are not included. RN-C also stated had not heard anything about or completed IV medication administration education, audits, or a competency to be completed with another staff. During an interview on 6/14/23 at 10:54 a.m., assistant director of nursing (ADON) stated she had planned on making a change and update to the medication policy to read two staff needed to verify the IV medication prior to administration. ADON verified this had not been implemented yet. ADON indicated she had a medication administration checklist available, planned on completing audits with the nurses involved in both incidents but never got that completed. ADON also stated a refresher on rights of medication administration with those licensed nursing staff involved would have been important to assure things were completed, so no resident was harmed. ADON indicated a one-to-one competency regarding medication administration was planned to be completed among licensed staff to observe each other but had also not been implemented yet. During an interview on 6/14/23 at 3:30 p.m., director of nursing (DON) verified medication administration education had not been given to staff yet after R1 or R2's incident. Review of a facility policy titled Medication Administration and Disposal dated 1/2023, identified to ensure safe, accurate medication administration to residents authorized personnel are expected to follow appropriate standards and protocols including the seven rights of medication administration: right patient, medication, dose, time, route, documentation, and refusal. Requested IV medication administration policy and was not received.

Based on observation, interview and document review, the facility failed to implement a system to ensure destruction of medications were promptly and properly witnessed to prevent potential loss or diversion for 1 of 2 residents (R5) reviewed for medication diversion. Findings include: R5's Order Summary report dated 6/13/23, identified Loratadine tablet 10 milligrams (mg) give 1 tablet by mouth one time a day for allergies. On 6/13/23 at 9:30 a.m. trained medication aide (TMA)-A administered 12 oral pill medications to R5 on the second floor south dining room. TMA-A placed a small medication cup on the table in front of R5. R5 picked one pill up at a time with her fingers, placed each pill into her mouth, and drank water. R5 attempted to place the last pill into her mouth, dropped the pill onto her chest, and then pill fell on to the floor. TMA-A picked up the pill off the floor with her hands and informed R5 she would get a new pill. TMA-A exited the dining room, walked to the medication cart, and placed the pill in a medication cup. TMA-A identified the white oblong pill as Loratadine tablet 10 mg for allergies, dispensed a new pill, and administered it to R5. TMA-A stated she would need to consult with staff nurse regarding the disposal of the medication, re-entered the dining room, and talked to licensed practical nurse (LPN)-A. TMA-A entered the locked medication room with the pill and completed the Medication Destruction Record (MDR): R5's MDR identified: Prescription number - 1498238 Drug name - Loratadine Strength - 10 mg Quantity - one Date - 6/13/23 Nurse: [Signed by TMA-A] RN (registered nurse) /Pharm (Pharmacy) witness: [signed by LPN-A] Method of Destruction: HWC TMA-A picked up pill cup with Loratadine pill in it and MDR, exited the medication room, locked the door, re-entered the dining room, and approached LPN-A. TMA-A requested LPN-A sign MDR document as a witness. LPN-A glanced into medication cup, in the column labeled RN/[NAME] Witness and signed document. TMA-A exited dining room re-entered the medication room and placed the Loratadine pill from the pill cup into the large zip lock bag located on the counter. The large zip lock bag already contained approximately over 30 unidentified lose pills, and five small bottles of eye drop medications. TMA-A stated the medications in the zip lock bag had been on the counter for a while now and would eventually be placed into the big destruction box for disposal. TMA-A also stated she was unaware of where the medication destruction box was located, used the zip lock bag because other staff were doing the same, and the medication room was always locked. During an interview on 6/13/23 at 1:35 p.m., LPN-B stated medications to be destroyed are entered onto the MDR for each resident in a logbook located in the medication room. LPN-B indicated a new system had been installed, a big blue disposal/destruction machine, where destroyed medications should be placed, located on two south in locked medication room. LPN-B also stated TMA- A dropped a pill this morning and she had co-signed the medication destruction record as a witness. LPN-B verified she did not visually witness TMA-A's disposal of the allergy medication pill and should have gone with her to see where she placed the pill but was too busy. During a follow up interview on 6/14/23 at 1:08 p.m., LPN-B stated a plastic bag of medication should not have been left in the medication room on the counter and those medications should have been destroyed right away. LPN-B verified the bag of lose medication pills to be destroyed had been on the counter in the medication room since last week or longer. LPN-B verified there were over 20 medication pills different sizes and numerous other pills the same color and size, along with bottles of eye drops, but unsure as to what they were. LPN-B indicated she had signed the MDR as a witness with other staff also and never went with them to visually witness the destruction of the medication. LPN-B indicated the importance to visually witness the destruction of each medication was to safe guard from drug diversion. LPN-B also stated staff were not clear on the disposal of medications process and need clarification. During an interview on 6/14/23 at 10:54 a.m., assistant director of nursing (ADON) stated staff are expected to fill out the MDR along with a witness. ADON also stated two staff are to witness the destruction of the medications and go together to the two south medication room and visually witness the medications being destroyed. ADON verified two witnessed was required to ensure there would be no drug diversion. ADON indicated staff should have not been allowed to have placed a plastic bag in the mediation room on the counter with lose mediation pills in it. ADON stated staff who signed off the destruction sheets should have destroyed the medications however they were not destroyed. ADON stated TMAs are allowed to co-sign to witness the destruction of medications but not allowed to have completed the disposal of medications, adding the licensed nursing staff have more authority and education as to what the medications are and should complete the destruction of the medications versus the TMA. During an interview on 6/14/23 at 12:04 p.m., TMA-B stated staff were expected to bring the medications to be destroyed down to two north medication room destruction bin rather than place them into a plastic bag. TMA-B indicated once staff had signed the MDR, placed medications in the plastic bag located on the counter in the two north medication room, they acknowledged they destroyed the medications and really had not. TMA-B stated once staff dump pills in the plastic bag without a bottle was unknown as to what there were. TMA-B verified an understanding a TMA had been able to destroy medications with a witness to help avoid removal of medications. TMA-B indicated she had entered the two north medication room, located on the counter was a large plastic bag with many pills, and unsure as to how many or what they were. TMA-B stated the plastic bag of pills had been there for more than two days. TMA-B carried the plastic bag with medications down to the two north medication room, disposed of the bag in the medication destruction bin without a witness and documentation. During an interview on 6/14/23 at 12:45 p.m., LPN-A verified she did not have another staff with her when she disposed of the medications in the medication safe located on two north. LPN-A stated another staff probably should have gone with to witness the destruction of the medications so that there is visual verification they were destroyed. LPN-A indicated she had placed 12 senokot (treats constipation) loose pills in a large zip lock bag in the past and left it on the counter in the medication room to add more pills to it to save on bags. LPN-A verified she had placed 42 lose multi vitamin pills in a large zip lock bag on 4/6/23 and was destroyed (7 days later) by TMA-B on 6/13/23. During an interview on 6/14/23 at 3:30 p.m., director of nursing (DON) stated they expected staff to complete the MDR in the logbook located in the medication rooms prior to the destruction of medications. DON also stated two staff were required to physically be present to witness the destruction of the medications, to ensure it had been completed correctly, the proper medication had been destroyed, and help avoid diversion of medications. DON indicated witnesses could include TMA, LPN, RN, or pharmacy consultant, however a licensed staff was required to destroy the medications. During a telephone interview on 6/15/23 at 12:15 p.m., pharmacy consultant (PC) stated the facility had a Med Safe provided by the pharmacy located in locked room in a central area. PC also stated a nurse and a witness are required to fill out the destruction form. PC indicated it was not standard practice or appropriate for staff to place lose pills unidentified in a plastic zip lock bag and leave it on the counter to be destroyed later. PC stated any staff witness signed on the MDR record was expected to visualize the disposal of medications to verify the disposal of it and required two staff to be physically present. Review of facility policy titled Medication Administration and Disposal dated 1/2023, indicated medications will be disposed of according to regulations and will be placed in the MedSafe when applicable to ensure safe, accurate medication disposal.

Based on interview and document review, the facility failed to ensure the appropriate diet was served for 1 of 3 residents (R1) and failed to adequately supervise R1 who was at risk for choking. This resulted in immediate jeopardy (IJ) for R1 who was served the incorrect diet and left unsupervised during a meal resulting in R1 choking and requiring the [MEDICATION(S)] maneuver. The facility had implemented corrective action prior to the start of the survey, therefore the deficient practice is being issued at past non-compliance. The IJ began on 8/31/22, at 12:39 p.m. when facility staff observed R1 choking in a common area of the facility while eating unsupervised. The administrator and director of nursing were notified of the IJ on 8/7/22, at 3:00 p.m. The facility had implemented immediate corrective action on 9/5/22, prior to the start to the survey so the deficiency was issued at past non-compliance. R1's Speech Therapist- Therapy Progress and Discharge Summary dated 10/7/22, indicted R1 was tolerating regular diet with chopped meats and identified an aspiration risk. The summary directed staff to assist and supervise and indicated R1 was to remain on a regular diet with chopped meats, up to chair for meals, supervision, and eat only when awake and alert. R1's quarterly Minimum Data Set, dated dated dated [DATE], indicated he was severely cognitively impaired and required staff supervision while eating. R1's care plan dated 6/2/22, identified a self care deficit and indicated R1 was able to feed himself independently, after set up assistance and required supervision & prompting from staff to continue eating. A report to the state agency (SA) dated 8/31/22, indicated R1 was eating in the dayroom due to periodic agitation in dining room and was left was unattended. The report indicated R1 had a history of a choking episode in the past year. R1 was observed by an activities staff member to be choking. First abdominal thrusts were unsuccessful, a second Nursing Assistant (NA) attempted and resident coughed up food. It was noted that his turkey was not chopped as directed on the meal ticket. During interview on 9/7/22, at 11:12 a.m. dietary aide (DA)-A stated he served R1 the meal on 8/31/22. DA-A stated he gave R1 a piece of regular turkey and R1 choked on it. DA-A stated he felt the dietary slip was clear enough but said he had not looked at the slip before serving and gave R1 the wrong diet texture. On 9/7/22, at 11:21 a.m. NA-A stated she was working on 8/31/22, when R1 choked on his food but did not witness it because she was in the dining room and R1 was in the day room. NA-A stated she did not know who served R1 his food but stated they should have known his diet was not correct. NA-A indicated retraining had been completed on diets and supervision. On 9/7/22, at 11:34 a.m. licensed practical nurse (LPN)-A stated she had been on her lunch break when R1 choked on his food. LPN-A stated R1 required monitoring during meals and said someone should have had eyes on him the whole time he was eating. LPN-A stated staff should have known R1 needed to be monitored. On 9/7/22, at 11:45 a.m. NA-B stated she was in the dining room assisting another resident when R1 choked on his meal. NA-B stated activity aide (AA)-A came to the dining room and requested help because R1 was choking. NA-B stated she went to the day room and asked R1 if he was choking and he was unable to answer so she performed the [MEDICATION(S)] maneuver. NA-B stated R1 required supervision at all times during meals due to a previous choking incident and said that was when R1's diet had been changed. On 9/7/22, at 12:01 p.m. AA-A stated the day R1 was choking on his meal, she had walked by and noticed he was not making any noise and was trying to catch his breath. AA-A stated she attempted the [MEDICATION(S)] maneuver but was not successful so she went to the dining room and got NA-B to assist. AA-A stated at that time she had not been aware R1 needed supervision during dining but had since been retrained. On 9/7/22, at 12:44 p.m. the DON stated R1 had been given the incorrect diet on 8/31/22, which resulted in him choking. The DON stated R1 ate in the day room and not the dining room due to agitation and behaviors. The DON stated there was no one in the day room monitoring R1 and said there should have been someone in there. The DON stated prior to the incident the NA worksheets did not address monitoring during meals. The past noncompliance immediate jeopardy began on 8/31/22. The immediate jeopardy was removed, and the deficient practice corrected by 9/5/22, after the facility implemented a systemic plan that included the following actions, which were all verified by interview and record review on 9/7/22. -R1's care plan was updated 8/31/22, to include risk for choking related to dementia and directed staff to monitor for choking with all meals. R1's dietary order was clarified to specify meat to be minced and moist. Treatment administration Record was updated to include nurse sign off each meal that R1 received supervision. -Education provided to DA-A and all dietary staff to make sure consistency of food is correct when served. Dining room seating chart and adaptive equipment charts updated to include who needed monitoring and/or assistance and dietary staff educated not to serve food to those residents unless nursing staff was present. Food service and dining audits were implemented. All resident received a Risk for Eating and Drinking Assessment that will be conducted quarterly to reassess need for monitoring. For new admissions, assessments to be conducted on admission and quarterly. -Nursing assistant worksheets were updated to include if residents required supervision to eat. -Education provided to nursing staff to monitor R1 during all meals and to ensure meat is moist and minced. Other education for nursing department included training videos related to diets. Audits and competencies were implemented. Competency checklist was updated to include: staff can verify correct meal delivered to residents, identify where to locate if a resident can eat unsupervised, needs cuing, monitoring or close supervision. Facility policy titled Nursing Department Resident Care Communication System dated July 2022, indicated all nursing department staff are responsible for completing cares per the care plan.

Based on observation, interview and document review, the facility failed to maintain clean and sanitary ceiling fans to prevent contamination of foods and dishware in the main kitchen of the facility. This deficient practice had the potential to affect all 52 residents who currently resided in the facility. Findings include: During the initial kitchen tour on 2/28/22, at 11:48 a.m. with the dietary manager (DM) the ceiling fan located to the left of the main entrance door of the kitchen had a moderate to heavy amount of dark gray to black fuzzy substance present on it. The ceiling fan blew air down from the ceiling towards the main kitchen cooking area, prepping area, entries of the refrigerator and freezer and over the clean dishes that were drying and stored. The ceiling fan located on the corner of the dirty/clean dish area had a moderate to heavy amount of dark gray to black fuzzy substance present on it. The ceiling fan blew air down from the ceiling towards the dirty dish area and over clean dishes coming out of the dishwasher. -at 3:12 p.m. the ceiling fans in the main kitchen area continued to blow air towards the main kitchen cooking area, prepping area, entries of the refrigerator/freezer, over the clean dishes that were drying/stored and towards the dirty dish area and over clean dishes coming out of the dishwasher. -at 5:18 p.m. the ceiling fans remained the same. During observations on 3/1/22, at 1:03 p.m. the ceiling fans remained the same and were blowing air towards the main kitchen cooking area, prepping area, entries of the refrigerator/freezer, over the clean dishes that were drying/stored and towards the dirty dish area and over clean dishes coming out of the dishwasher. During the kitchen tour on 3/1/22, at 2:09 p.m. with the DM the ceiling fan located to the left of the main entrance door of the kitchen had a moderate to heavy amount of dark gray to black fuzzy substance on it. The ceiling fan blew air down from the ceiling towards the main kitchen cooking area, prepping area, entries of the refrigerator and freezer and over the clean dishes that were drying and stored. The ceiling fan located on the corner of the dirty/clean dish area had a moderate to heavy amount of dark gray to black fuzzy substance on it. The ceiling fan blew air down from the ceiling towards the dirty dish area and over clean dishes coming out of the dishwasher. The DM confirmed the fans were dirty and had a build up of debris on them. The DM indicated she did not know the last time the fans had been cleaned and indicated maintenance staff cleaned the fans. The DM stated she had filled out a maintenance ticket for the fans to be cleaned on 1/1/22, and verified maintenance staff had not completed the request yet. On 3/1/22, at 2:25 p.m. the DM indicated she would expect staff to make sure the ceiling fans were cleaned routinely. On 3/1/22, at 3:00 p.m. the maintenance manager (MM) confirmed the above findings and indicated the ceiling fans in the kitchen had only been cleaned every 6 months. The MM indicated the fans were due to be cleaned again in May of 2022 according to his schedule. In a follow up interview on 3/2/22, at 11:18 a.m. the MM indicated he would expect staff to clean the fans when they were dusty and dirty and stated staff were supposed to be cleaning the fans monthly after he checked his logs and indicated some how the regular maintenance order had been deleted out of the system. The MM verified the last time the ceiling fans in the kitchen had been cleaned was 9/21. Review of the facility policy titled, General Sanitation of Kitchen dated 2019, indicated food and nutrition service staff would maintain the sanitation of the kitchen through compliance with written and comprehensive cleaning schedules. Review of the facility policy titled, Cleaning Instructions Commercial Fans undated, indicated commercial fans in the food service department would be cleaned regularly per maintenance schedule.

Based on interview and document review, the facility failed to provide timely wound care referrals, conduct an accurate pressure ulcer re-assessment, and implement appropriate interventions for 1 or 1 discharged residents (R140) reviewed for pressure ulcers. This deficient practice resulted in actual harm for R140 when a stage 1 pressure ulcer worsened to stage 3. Findings include: R140's admission Minimum Data Set ((MDS) dated [DATE], identified R140 had [DIAGNOSES REDACTED]. The MDS further identified R140 had moderate cognitive impairment, was at risk for developing pressure ulcers, needed extensive assist with all activities of daily living (ADL'S) and had a stage one (intact skin with non-blanchable redness of a localized area over a bony prominence) pressure ulcer to the coccyx (medial aspect of the buttocks towards crease). R140's Pressure Ulcer Care Area Assessment (CAA) dated [DATE], identified R140 had risk factors for development of pressure ulcers which included requiring extensive assist with ADL's, currently had a stage one (an observable pressure related alteration of intact skin whose indicators as compared to another area of skin on the body may include changes in one or more of the following parameters: skin temperature, tissue consistency, sensation and/or area of persistent redness in lightly pigmented skin) pressure ulcer on the coccyx, was newly admitted , and had medical [DIAGNOSES REDACTED]. R140's CAA directed to care plan R140's pressure ulcers and risk factors for developing further pressure ulcers, and the goal was to prevent further skin breakdown and to have the present pressure ulcer heal. R140's acute care plan (short term), titled Stage 1 Pressure Sore dated [DATE], identified R140 had a stage one pressure ulcer to the coccyx which measured 0.8 centimeters (cm) by 0.5 cm. R140's acute care plan directed staff to initiate a wound record (dated [DATE]), initiate pressure tolerance test lying and sitting, review and update checklist for skin risk factors and interventions, use a duoderm (thin [MEDICATION NAME] dressing), reposition R140 off the pressure ulcer as able, observe and monitor pressure area site each day shift, report to physician evidence of increased severity, and to assess the stage one pressure ulcer to R140's coccyx every Tuesday. R140's ADL care plan dated [DATE], directed staff to reposition the resident every two hours related to a self care deficit and need for extensive assist with ADL's. R140's pressure ulcer care plan dated [DATE], indicated R140 had a stage three pressure ulcer (despite stage three not identified until ,[DATE]), potential for further pressure ulcers related to history of pressure ulcers, immobility, diabetes mellitus, diabetic [MEDICAL CONDITION] and pain. R140's care plan interventions directed staff to inspect skin daily with cares, complete a pressure tolerance testing upon admission and with significant change in functional or cognitive status, a Braden scale and checklist of skin risk factors and interventions upon admission, weekly for four weeks, quarterly and with significant change in cognitive or functional status, and to report improvements and declines to the pressure ulcer to the physician. The care plan had a print date of [DATE], and there were also handwritten revisions to the care plan, however, no changes had been made to R140's pressure ulcer interventions from [DATE], to [DATE], when R140 expired. Review of R140's Admission Nursing assessment dated [DATE], indicated R140 had a stage one pressure ulcer to the coccyx (medial aspect of inner buttocks) which measured 0.8 cm by 0.5 cm, had multiple bruises, and [MEDICAL CONDITION]. Review of R140's Quarterly Summary and Analysis of Skin Conditions/Risk Narrative dated [DATE], indicated R140 had a "small stage one" to coccyx area with a large, blanchable area of redness area surrounding the stage one pressure ulcer; this area had a foam dressing in place. The Quarterly Summary and Analysis of Skin Conditions/Risk indicated R140 was receiving physical, occupational, and speech therapy to gain strength, mobility, and increase tolerance for activity and cognitive status. R140's Pressure Tolerance Test (a tool to identify appropriate repositioning schedules and risk for developing pressure ulcers) dated [DATE], indicated R140 was not able to reposition herself, and was to be repositioned every two hours. However, the form was not complete and there was no summary or explanation of how the turning and repositioning schedule was determined for R140. Review of R140 Pressure Sore Risk Assessment (a tool to identify risk for developing pressure ulcers) revealed the following: - [DATE], and [DATE], R140 was identified at moderate risk for pressure ulcer development - [DATE], [DATE], and [DATE], R140 was identified at low risk for pressure ulcer development. R140's Wound/Skin record initiated on [DATE], indicated the following assessments of R140's coccyx pressure ulcer: -[DATE]: Stage one ulcer on coccyx, measured 0.8 cm by 0.5 cm, no depth, surrounding skin color was a blanchable redness, surrounding skin/wound edges were WNL (within normal limits) and R140 had no pain related to the wound. -[DATE]: Stage one ulcer on coccyx, measured 1 cm by 1 cm, wound bed was red, surrounding skin was pink and surrounding tissue was WNL, R140 had no pain related to wound. . -[DATE]: Stage three (full thickness tissue loss, subcutaneous fat may be visible, slough may be present but does not obscure the depth of tissue loss, may include undermining or tunneling) pressure ulcer to right coccyx, measurement of 1.7 cm by 1.4 cm, no depth measured, wound bed had slough (sticky whitish tissue which sticks to the wound bed and is an indicator of ineffective healing) present, surrounding skin color was pink, and surrounding tissue/wound edges were WNL, response to treatment: deteriorated. However, according to the Long Term Care Facility Resident Assessment Instrument User's Manual version 3.0 dated [DATE], R140's pressure ulcer met the definition for an unstagable ulcer (an ulcer that has eschar or slough tissue present such that the anatomic depth of soft tissue cannot be visualized in the wound bed should be classified as unstagable). There was no evidence the treatment was changed to the pressure ulcer when there was a significant decline in the condition. -[DATE]: Stage three pressure ulcer to coccyx, measurement of 3 cm by 3 cm, no depth as wound bed was yellow and black, surrounding skin color was red, surrounding tissue/wound edges were rolled, response to treatment was deteriorated, plan of care to continue treatment, and no pain. R140 was seen by the CNP at the facility on [DATE], however, there were no changes to the treatment, and the NP instructed staff to contact the wound clinic for further management of the residents worsening pressure ulcer. -[DATE]: Stage three pressure ulcer to coccyx, measurement of 2.5 cm by 2.7 cm, no depth as wound bed had black with yellow edges, surrounding skin color was red, surrounding tissue/wound edges were rolled, resident did not express pain, and plan of care was to continue with the duoderm dressing. There was no evidence the physician was contacted regarding the pressure ulcer, and R140 had still not been seen by the wound clinic for further management of the pressure ulcer per the NP orders written on [DATE]. -[DATE]: Stage four (full thickness tissue loss with exposed bone, tendon or muscle, slough or eschar may be present on some parts of the wound bed, may include undermining and tunneling) to buttocks (coccyx), measurement of 4.5 cm by 4 cm, no depth as wound bed had black eschar (collection of dead tissue within a wound, causes damage to the tissue and surrounding tissue) tissue with odor. Surrounding skin was red, surrounding tissue/wound edges were yellow. Response to treatment was not indicated, and the care plan had been updated with a comment that R140 had been seen by a wound nurse at the hospital on [DATE], as R140 had been hospitalized from [DATE], to [DATE]. The hospital wound nurse indicated R140's coccyx pressure ulcer was to have the dressing changed three times a week and as needed using [MEDICATION NAME] foam dressing. -[DATE]: Stage four pressure ulcer to buttocks measuring 7 cm by 6 cm, no depth as wound bed had black (eschar tissue), strong foul odor, had been noted as tunneling, The wound record lacked any tunneling or undermining measurements, response to treatment was marked as deteriorated, and R140 had pain related to wound. R140's February 2015, Medication Administration Record [REDACTED]. R140's [DATE], MAR indicated [REDACTED]. On [DATE], another treatment was administered of packing the sacral pressure ulcer with Nugauze, cover with foam dressing-remove and unpack daily; change dressing daily. Review of R140's nurses pogress notes from [DATE], to [DATE], indicated the following: -[DATE], R140's open area on coccyx with duoderm intact and later in day a note indicating R140 had an open area on coccyx-bone that was quarter size of blackened area. R140 was reminded that staff, "Really had to repo (reposition) off butt." -[DATE], R140's open area to coccyx after bath, stage 3 and had been prior a stage 1, covered with duoderm. Area was measured (see wound record for ulcer characteristics,) and the Certified Nurse Practitioner (CNP) would be updated on rounds. -[DATE], R140 was seen on routine rounds by the CNP who instructed the facility to have R140 be seen at the wound clinic for the sacral pressure ulcer, however, there was no indication the wound clinic referal had been made by the facility. -[DATE], R140's pressure ulcer dressing was changed as the other had fallen off and a, "Very bad odor," was coming from the site and a new dressing was applied. There was no indication the physician or CNP had been updated in the change in R140's pressure ulcer developing an odor. -[DATE], R140's bottom/ coccyx pressure ulcer looked black and raw. -[DATE], R140 was noted to have [MEDICAL CONDITION] (swelling) to the sacral area. -[DATE], R140 had complained of pain in, "Butt." There was no indication the physician or CNP had been updated in the change in R140's pressure ulcer pain. -[DATE], R140 complained of "lots of pain in her bottom," when being assisted with repositioning in early morning and in mid morning. The pressure ulcer was black and very "foul smelling." An evening note indicated R140 complained of severe pain to the coccyx area. Another note later that evening indicated R140 had been having increased pain to the coccyx and had a foul odor from the pressure ulcer. Family had requested R140 be sent to the hospital and assessed. R140 was sent to the emergency room via ambulance for evaluation and was admitted . A Discharge Summary Note from R140's hospital stay dated [DATE], indicated R140's hospital stay from [DATE] to [DATE], primary [DIAGNOSES REDACTED]. R140's secondary [DIAGNOSES REDACTED]. R140 had imaging studies (CT scans, ultrasound and x-rays,) revealed the following: CT scan of R140's abdomen and pelvis with IV (intravenous) contrast done on [DATE]th, 2015, revealed a sacral (end of the tailbone area of the buttocks, adjacent to coccyx)decubitus ulcer extending to the sacral periosteum (a dense layer of vascular connective tissue enveloping the bones except at the surfaces of the joints.) ( E.g. The resident ' wound was open from the skin down to the periosteum (tissue which directly envelopes the bone.) Review of R140's Full Body Skin assessment dated [DATE], (return from hospital,) indicated R140 had a pressure ulcer on the sacrum which measured 4.5 cm by 4 cm with black eschar (hard dead tissue,) and a wound nurse at the hospital had assessed and made treatment changes. R140's Nursing Progress Notes upon the residents return from the hospital indicated the following: -[DATE], R140 returned from the hospital. R140's Skin Assessment note dated [DATE], indicated R140 had an [MEDICATION NAME] foam dressing over the pressure ulcer (see wound record for measurements and characteristics.) A Nurses Note written later that evening indicated R140's pressure ulcer was black with white outlining the black circle, and was odorous. -[DATE], R140 complained of severe pain to the pressure ulcer on the coccyx in late afternoon. -[DATE], R140's pressure ulcer on her sacrum was noted to be necrotic and, "Very foul smelling like rotting flesh." A note later in the day indicated R140 had been seen by a practitioner. The pressure ulcer dressing order was changed to: "Pack sacral ulcer with Nugauze, remove and repack daily, cover with foam dressing, and change dressing daily." -[DATE], R140's pressure ulcer dressing was changed and was noted to have a large amount of brown, extremely foul liquid which had come out of the pressure ulcer. The note indicated the pressure ulcer was repacked and the dressing was applied. On [DATE], at 3:20 p.m. R140 expired. R140's provider progress notes were reviewed for visits of [DATE], [DATE], [DATE], [DATE] and [DATE]. Upon review of the progress notes the following was revealed regarding R140's pressure ulcer for three out of the five visits: -[DATE], R140's pressure area on the coccyx was black and had yellowish slough. The residents physical exam indicated a sacral decubitus ulcer, measuring 3 cm by 3 cm with black necrotic base and white-yellow slough, with surrounding [DIAGNOSES REDACTED] (redness.) The physican had instructed the staff to make a referral to a wound clinic for further management of R140's pressure ulcer. There was no documentation in R140's record a wound clinic referal had been made for R140. -[DATE], review of systems indicated a large odorous skin ulcer of the sacrum, and the facility should consider wound clinic consult when R140 was stronger and able to tolerate being up in a chair. -[DATE], review of systems indicated a large sacral pressure ulcer, the dressing was saturated and changed daily, and had a foul odor. R140's pressure ulcer dressing orders were changed to the following: "Pack sacral ulcer with Nugauze and cover with foam dressing for now." R140's physician orders [REDACTED]. -[DATE]: Skin assessment every day, which was discontinued on [DATE]. - [DATE]: Cover sacral ulcer with [MEDICATION NAME] foam dressing one time a day every Tuesday and Friday and as needed. -[DATE]: Pack sacral ulcer with Nugauze, cover with foam dressing; remove and unpack one time a day for pressure ulcer, change dressing daily During interview on [DATE], at 4:07 p.m. Registered Nurse (RN) D stated R140's pressure ulcer treatment did not change until R140 was hospitalized on [DATE], and was seen by a wound nurse at the hosptial. RN-D was unaware of why R140 had not been seen by a wound clinic when R140 had been referred by CNP on [DATE]. During interview on [DATE], at 4:18 p.m. the director of nursing (DON) stated she needed to review R140's medical record before commenting on the resident pressure ulcer. No additional information was provided during survey. The facility policy titled Broen Home Skin Care Program dated [DATE], indicated based on a comprehensive assessment the facility would ensure that under the direction of a physician a resident who had pressure sores received the treatment necessary to promote healing, prevent infection and prevent new sore from developing. The policy revealed the facility would utilize "standardized prevention and treatment protocols" and position changing for those residents unable to position self would be based on assessment and care plan. The policy also revealed a brief definition of stage 1 through stage 4 ulcers, though lacked any definition, identification or treatment of [REDACTED]. The facility policy directed nursing staff to contact the physician if orders for additional treatment were necessary based upon an RN assessment, and staff was directed to individualize approaches specific to the resident condition and treatment protocols which were implemented based on assessed data, acute care plan, skin and specific physician orders. The facility policy directed the nursing staff to, "Try a treatment for 2 weeks then re-evaluate, if not improving obtain orders for a treatment change."

Based on observation, interview and document review, the facility failed to provide services related to the prevention of pressure ulcer development for 1 of 3 residents (R36) in the sample reviewed for pressure ulcers. This practice resulted in actual harm for R36. Findings include: R36 did not receive the necessary care and services to prevent development of pressures ulcers. As a result, R36 had developed six pressure ulcer areas while residing at the facility since his admitted . R36's admission Minimum Data Set ((MDS) dated [DATE], indicated a brief interview of mental status (BIMS) score of 08, indicating moderately impaired cognition. R36 required extensive assist for transfers, bed mobility, toileting, and ADLs (activities of daily living). R36's [DIAGNOSES REDACTED]. The corresponding Care Area Assessment (CAA) indicated an actual problem of existing pressure ulcers and identified a right foot Stage 2 (Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough.) area and a left outer ankle Stage 2 area. The CAA indicated to provide a special mattress and "regular schedule of turning." The CAA identified R36 as immobile, incontinent, altered mental status, and poor nutrition. R36 was admitted to the facility from an assisted living facility on 5/15/12. Progress notes dated 5/15/12, indicated a skin assessment was completed and indicated "pretty good skin" with no mention of pressure related areas. However, R36 was identified at high risk for pressure ulcers and a comprehensive skin assessment was not noted in the medical record. A Tissue Tolerance Test (a test to determine the skin's ability to tolerate pressure) dated 5/15/12, indicated R36 was not able to position himself and indicated no red areas noted after lying in bed or sitting in his wheelchair for 2 hours; as a result, R36 was placed on a 2 hour repositioning schedule. A Tissue Tolerance Test dated 7/26/12, indicated no redness after 3 hours of lying in bed and sitting in his wheelchair. R36 remained on a 2 hour repositioning schedule. R36's plan of care dated 6/6/12, included comfort cares, assist with dressing, grooming, bathing, and assist resident with repositioning every 2 hours. Also, the plan of care identified a problem of pressures ulcers and interventions included daily inspection of skin with cares, a pressure reducing mattress to his bed and a cushion to his wheelchair (not specific to pressure reducing). A Stage II Acute Care Plan was initiated 5/22/12, which identified one pressure ulcer to R36's right outer great toe, which measured 1.0 x 1.0 cm (centimeters) and one pressure ulcer to R36's left outer ankle, which measured .4 x .5 cm. An additional Stage II Acute Care Plan was initiated 7/26/12 which identified a Stage 2 area to R36's left buttock which measured .5 x .5 cm. Also identified were three Stage 2 areas to R36's right buttock: one 1.5 x .75 cm, one .5 x .5 cm, and a pinpoint area. A nursing progress note dated 5/22/12, indicated R36 had seen a Podiatrist the previous day and wrote orders for a multi-vitamin with zinc, apply Silversorb to ulcers and cover with sterile gauze, and [MEDICATION NAME] 300 mg (milligrams) every 8 hours for 10 days. physician progress notes [REDACTED]. Debridement was done at this visit. A nursing progress note dated 6/12/12, indicated R36 had seen the podiatrist in the morning that day for ankle and foot cares. physician progress notes [REDACTED]. As a result, the podiatrist called the nursing home and spoke to a nurse to clarify treatment. Debridement was done at this visit. physician progress notes [REDACTED]. physician progress notes [REDACTED]. A nursing progress note dated 7/31/12, indicated R36 had been to see the podiatrist for his left ankle ulcer, returned with no new order, and was scheduled to return to the clinic again on August 21. Dictation for visit dated 7/3/12, was not yet available in the medical record. A nursing progress note dated 7/26/12, indicated onset of a Stage 2 pressure area was noted to R36's left buttock measuring .5 x .5 cm, and three Stage 2 pressure areas were noted to his right buttock, measuring 1.5 x .75 cm, .5 x .5 cm, and third area was noted as "pin point." The note also indicated an order was received from R36's provider to use [MEDICATION NAME] (ointment used to heal skin irritations from bowel and bladder incontinence) with incontinent cares. A nursing progress note dated 8/8/12, indicated the area to R36's buttocks remained the same, no change. At no time in the medical record was a Tissue Tolerance Test completed for R36's recliner, which is where he stated he spent most of his day sitting. A checklist of skin risk factors and interventions dated 5/29/12, 6/5/12, and 6/12/12, included the following: a Braden (a tool used for predicting pressure ulcer risk) score of 14 (14 or less indicates serious risk for pressure ulcer development) on 6/5/12, scored lower than 2 in mobility, terminal [MEDICAL CONDITION], comfort cares, inspect skin daily, weekly skin assessment by nurse, risk assessment per protocol, monitor pain and administer pain meds. A treatment record indicated a daily nutritional supplement was ordered on [DATE]. However, R36's medical record did not reveal completion of a comprehensive assessment to further identify risk factors and additional interventions. Observation of R36 on the morning of 8/8/12, revealed he was up in his wheelchair for breakfast at 7:40 a.m. At 9:35 a.m., he was assisted to the bathroom and positioned in his recliner to watch television. Rooke boots were on both lower legs. Later at 11:40 a.m., an interview was conducted with R36 when he stated it is his preference to spend most of his days in his recliner, as that is where he feels most comfortable. He stated there is not a special cushion in his recliner. At 11:52 a.m. on 8/8/12, an interview was conducted with clinical manager (CM)-C. She confirmed the area on R36's right outer great toe was healed and she stated he was continuing to see the podiatrist for the ulcer on his left ankle. In review of R36's medical record, CM-C verified the left outer ankle ulcer was pressure related and she indicated staff were applying treatment dressing as ordered. She also stated they report to the the physician and family regarding worsening of the areas. CM-C confirmed the areas to R36's buttocks were related to pressure and she described treatment as being [MEDICATION NAME] three times daily with cares. CM-C explained the facility process related to onset of skin issues: the nursing assistants inform the charge nurse who then initiate an acute care plan depending on what stage of the ulcer and she stated the acute care plan explains what to do, who to notify, how to measure and directs staff to initiate a pressure ulcer record and complete a tissue tolerance lying and sitting. CM-C verified R36 spends most of the time in his recliner chair. She confirmed a tissue tolerance for the recliner chair had not been completed and she agreed one should have been done. CM-C also confirmed that after discovery of the areas on R36's buttocks, his repositioning schedule had not been changed. She stated, "Everyone who is admitted to the facility is placed on two hour repositioning unless you see a reason to change it." She further explained R36 was "less mobile now than when he came in" and that he doesn't like to be repositioned; she further verified no risk benefits were explained to him or documented in the medical record. CM-C stated upon admit, R36 had a pressure-relieving mattress, a wheelchair cushion, 2 hour repositioning, and Rooke boots to both lower legs. R36 had the boots prior to admission per the podiatrist, due to history of previous foot ulcers. CM-C verified the wheelchair cushion was not a specialized pressure-relieving cushion and stated, "I don't like it." CM-C also confirmed R36 was admitted to the facility with no pressure ulcers and he had developed 6 open areas since his admitted , with no comprehensive skin assessment completed upon onset. A facility policy entitled Skin Care Program dated April 2012, indicated a comprehensive is to be completed to ensure a resident who enters the facility without pressure sores does not develop pressure sores unless the individuals clinical condition demonstrates that they were unavoidable; and under the direction of a physician, a resident who has pressure sores receives the treatment necessary to promote healing, prevent infection and prevent new sores from developing. The policy also indicates that residents will be assisted with repositioning based on the comprehensive assessment and care plan.