Every finding on record at Lyngblomsten Care Center

Based on observation, interview and record review, the facility failed to use the required personal protective equipment (PPE) for 1 of 2 residents (R15) who required Enhanced Barrier Precautions (EBP) and failed to ensure sanitization of mechanical lifts were completed between resident use 1 of 2 residents (R91) reviewed who required mechanical lifts for mobility. Furthermore, the facility failed to ensure hand hygiene was completed for 1 of 1 residents (R8) observed during wound and personal cares. Finding include: EBP R15's quarterly Minimum Data Set, dated [DATE], indicated R15 was cognitively intact and required set up for eating and oral hygiene. R15 was dependent on staff for toilet transfers and lower body dressing and substantial assist for upper body dressing. Diagnoses included aftercare following joint replacement surgery, and polyneuropathy (many nerves throughout the body malfunction at the same time). R15's care plan dated 7/2/26, indicated EBP had been initiated on 3/23/26 due to a wound. The care plan instructed staff to wear gowns and gloves during high-contact resident care activities, including dressing, transfers, providing hygiene care, and changing briefs. During an observation on 9/15/26 at 1:34 p.m., nursing assistant (NA)-A and trained medical assistant (TMA)-C entered R15's room. An EBP sign was on the outside of R15's door. The sign instructed staff to clean hands, wear gloves and gowns during direct cares; such as transfers, brief changes, dressing, and personal hygiene. Without sanitizing a mechanical lift, NA-A brought in mechanical lift into R15's room. NA-A and TMA-C then provided personal care to R15 without wearing the required gown as indicated on the EBP sign outside R15's door. During an interview on 9/16/26 at 9:36 a.m., NA-A confirmed he did not have the correct PPE on when providing direct cares to R15 and gown should have been worn. The EBP signage on the door instructed staff to clean hands, wear gloves and gowns during direct cares; such as transfers, brief changes, dressing, and personal hygiene. During an interview on 9/16/26 at 10:25 a.m., registered nurse (RN)-C stated for residents who required EBP staff needed to wear PPE as instructed for direct cares per signage and policy. Staff were expected to wear gown and gloves for all direct care, including dressing, bathing, transferring, and personal hygiene. EBP was important to follow for the safety and infection control for residents and the facility. During an interview on 9/16/26 at 11:54 a.m., TMA-C confirmed she did not have proper PPE when provided cares to R15 and a gown should have been worn. During an interview on 9/16/26 at 10:25 a.m., registered nurse (RN)-C stated residents on EBP the expectation was staff was to wear PPE as instructed for EBP when direct cares were provided. EBP was important to follow for the safety and infection control for residents and the facility. During an interview on 9/17/26 at 9:02 a.m., director of nursing (DON) expected staff to follow the directions on the signs outside the door and to wear the correct PPE. If a resident was on EBP, staff were to utilize PPE during direct contact with residents. It was important to follow orders and care plan to ensure the most appropriate care based on the individual needs of each resident. Sanitization of equipment R94's quarterly MDS dated [DATE], indicated R94 was cognitively intact, she was dependent on staff for all personal cares, transfers and bed mobility. Diagnoses of hemiplegia and hemiparesis (paralysis and weakness) following cerebral infarction (tissue death in the brain) affecting left non-dominant side. R94's care plan dated 7/22/26, indicated she required a mechanical lift and assist of 2 for transfers. R94's transfer assessment dated [DATE], indicated she required a mechanical lift and assist of 2 for transfers and bed mobility. R91's quarterly MDS dated [DATE], indicated R91 was cognitively intact and had diagnoses of chronic respiratory failure, diabetes and weakness. During an observation on 9/16/26 at 7:22 a.m., NA-B and NA-C entered R94's room with a mechanical lift. NA-B and NA-C repositioned R94. After repositioning R94, NA-B removed lift from room and without cleaning, was brought into R91's room. NA-B and NA-C then proceeded to reposition R91. After repositioning R91, NA-B removed the lift and placed it in the hallway and wiped down with Sani-wipes. During an interview on 9/16/26 at 7:38 a.m., NA-C confirmed the mechanical lift was not sanitized between resident use. The instructions were that mechanical lifts were to be sanitized with the purple top wipes between use. During an interview on 9/16/26 at 7:48 a.m., NA-B confirmed the mechanical lift was not sanitized between use of the residents. The instructions for cleaning the lift were to be sanitized before and after it was used with each resident. During an interview on 9/17/26 at 9:02 a.m., director of nursing (DON) expected staff to ensure mechanical lifts were sanitized the staff were to clean the machines with purple top wipes which were attached to the machines, they were to be sanitized before and after each use, between each and every resident. Hand Hygiene R8's Quarterly (MDS) dated [DATE], showed R8 was cognitively intact. R8 has diagnoses of left side hemiplegia and hemiparesis (loss of use of one side of body) following a stroke. Furthermore, R8 was fully dependent with all activities of daily living (ADLs). During observation on 09/15/2026 1:23 p.m., care manager (CM)-A entered R8's room and applied gown did hand hygiene and applied gloves. R8's dirty wound dressing was removed. CM-A removed gloves, completed hand hygiene and applied clean gloves. R8's pressure ulcer was cleaned with saline and patted dry. Without hand hygiene or glove change, CM-A applied a new dressing to R8's wound. Gloves removed. Clean gloves applied, no hand hygiene noted prior to clean gloves. Eye examined by CM-A, touched R8's face and right lower eye lid. Washcloth warmed up with water to apply to R8's right eye. No glove change or hand hygiene ws done prior to applying the washcloth. Gown removed and discarded, hand hygiene done at the sink. When interviewed on 09/15/2026 1:30 p.m., CM-A stated hand hygiene was expected between glove changes. CM-A stated gloves would be removed; hand hygiene be done and clean gloves after removing old dressing and before placing clean dressing. CM-A acknowledged she did not perform hand hygiene in between glove changes when moving from dirty to clean during wound cares and when assessing and providing washcloth to R8's eye. During observation on 09/16/2026 7:55 AM, NA-D and NA-E entered R8's room for cares, completed hand hygiene, donned gloves and gown. Warm water basin brought to bedside by NA-E, they washed and dried R8's face. Socks applied by NA-D then they washed R8's arms and chest. Without glove change or hand hygiene, NA-D and NA-E assisted with R8's clean clothing. Gloves removed by both NAs, hand hygiene done by NA-E prior to clean gloves however, NA-D applied new gloves without hand hygiene. NA-E did Suprapubic catheter (urine drainage system via the abdomen) bag changed from night bag to leg bag. NA-E removed soiled gloves and did hand hygiene, applied clean gloves, peri care done gloves removed, hand hygiene and clean gloves applied. NA-D removed soiled gloves and did hand hygiene prior to new gloves. R8 rolled to right side, back washed and cleaned up from bowel movement by NA-D. Without hand hygiene or glove change, NA-D applied cream to R8's back and placed clean brief without glove change and hand hygiene. NA-D applied new gloves without hand hygiene prior to pants being placed on R8. R8 was assisted to his chair with a full body lift. Without hand hygiene or glove exchange, NA-D took wet washcloth to dampen R8's hair and combed. Without glove exchange and hand hygiene NA-D grabbed toothbrush and toothpaste. Toothbrush given to R8 to perform task himself. NA-D rinsed toothbrush and put it away and without hand hygiene, exchanged gloves and assisted R8 with wiping face. When interviewed on 09/16/2026 8:32 a.m., NA-D stated washing hands between glove changes was required. NA-D also stated when moving from dirty areas to clean areas, hand hygiene and changing gloves were required. NA-D acknowledged they did not perform hand hygiene at all the required points. When interviewed on 09/16/2026 8:36 a.m., CM-A stated she expected staff to do hand hygiene between gloves changes and when they start doing a new task. Also, CM-A expected staff to wear gowns if indicated. When interviewed on 09/16/2026 2:43 p.m., DON expected staff to follow hand hygiene procedure (alcohol based or soap and water) prior to gloving and in between doffing and donning gloves, or any time hands were visibly soiled. This was important to minimize any risk of Infection control concerns. When interviewed on 09/17/2026 8:26 AM, Administrator expects hand hygiene upon entering a room, with gloves changing and dirty to clean tasks. A policy titled, Enhanced Barrier Precautions reviewed 9/2026, directed staff to use EBP in conjunction with standard precautions and expanded the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant organisms (MDRO's) to staff hands and clothing. A policy titled, Cleaning and Disinfection-Resident-Care and Equipment Items reviewed 3/2026, directed staff to assure all items that a resident may encounter are free for contaminants. To provide a safe and clean environment. Durable medical equipment (DME) must be cleaned and disinfected before being reused by another resident. A facility policy titled Hand Hygiene reviewed 9/2026, directed staff on indications for handwashing hand antisepsis, hand hygiene technique as well as other considerations.

Based on observation, interview, and document review the facility failed to ensure the behavioral health service provider was updated with symptoms and the need for a psychological visit for 1 of 1 resident (R151) reviewed for mood and behavior.Findings include:R151's quarterly minimum data set (MDS) dated [DATE], indicated R151 had impaired cognition, and was dependent on staff for most activities of daily living (ADL's). R151's diagnoses included major depressive disorder, dementia, multiple sclerosis, mood disturbance, and chronic pain.R151's care plan dated 8/25/26, indicated R151 had potential for mood concerns related to major depressive disorder, multiple sclerosis, chronic pain, and insomnia and had reported feeling down, depressed, and hopeless. Staff were directed to administer medications per orders, provide favorite snacks provided by family, offer bathroom or repositioning, and validate feelings.A mood and behavior assessment completed on 3/11/26 indicated R151 had mood of yelled/screamed and was short tempered/angry/annoyed. The assessment indicated R151 was followed by Associated Clinic of Psychology (ACP) psych services. A mood and behavior assessment completed on 9/9/26 indicated R151 had mood of frequent crying, yelled/screamed, believed something is true when it is not, and was short tempered/angry/annoyed. The assessment indicated R151 was followed by ACP psych services.A social service note documented on 3/18/26 at 10:48 a.m., indicated during a quarterly review R151 reported they felt depressed and stated they sometimes felt lonely or isolated. Progress note indicated R151 was followed by ACP.A behavior/mood note on 3/31/26 at 1:12 p.m., indicated R151 expressed delusional thoughts. A nurse's note on 8/31/26 at 6:52 a.m., indicated R151 had difficulty with sleep and wanted to talk with a priest and yelled out for help several times each time they had hallucinated about their dead husband. A social service note documented on 9/10/26 at 11:08 a.m., indicated during an annual review R151 reported they felt down, depressed, and/or hopeless, and indicated R151 was followed by ACP.R151's medical record indicated they were evaluated by ACP on 10/29/25 and the evaluation indicated R151 would be seen approximately 1-6 times in a 6-month period. The evaluation indicated R151's functional status was moderately impaired due to poorly managed symptoms of major depressive disorder, which included lack of motivation and lack of insight into condition.A review of R151's medical record indicated R151 had follow-up visits with ACP staff on 1/16/26 and 2/25/26. The ACP note from the 2/25/26 visit indicated continued services were needed, however no further visits were documented.During interview on 9/16/26 at 9:55a.m., R151 stated their mood was pretty okay. R151 stated they vaguely remembered someone came and talked about mood and things they could do to have better days. R151 stated they believed the visits had helped at the time and said they would like to have more visits since it had helped their mood before.During an interview on 9/16/26 at 2:39p.m., social services-A stated they met with ACP staff weekly and received and provided updates regarding residents on ACP's caseload. Social services-A stated R151 was last seen by ACP staff on 2/25/26. Social services-A stated they did not update ACP with the symptoms documented in the social services progress notes dated 3/18/26 and 9/10/26 and stated the documentation of R151 being followed by ACP was per the training they had received for documentation in medical records when a resident had established care with ACP.During an interview on 9/17/26 at 8:55 a.m., ACP staff-D stated they had not been updated regarding R151's symptoms until 9/15/26, when ACP received a phone request for R151 to be seen. ACP staff stated they would be notified by the facility either during a weekly onsite meeting with social services or phone call that a resident would need a visit. ACP staff-D stated they would expect the facility's social service or nursing department to update them if a resident was expressing tearfulness, sadness, difficulty sleeping, not going to activities they enjoy, or had hallucinations or delusions. The facility would rule out potential clinical reasons for the behavior as well. ACP staff-D indicated they did not think it would take more than a week to rule out a clinical reason for symptoms.During an interview on 9/17/26 at 9:39 a.m., registered nurse (RN)-D stated they would notify ACP of the need for a resident to be visited if reviewed progress notes indicated symptoms and they have ruled out potential clinical reasons for the symptoms. RN-D stated when they documented symptoms in mood and behavior assessments, they would not review the last time a resident was seen by ACP to determine the need for a visit. RN-D stated R151's family had reminded staff of the death anniversary of their spouse, which family attributed some their depressive and delusional symptoms to, which prompted family to request a visit from an ACP provider.During an interview on 9/17/26 at 10:45 a.m., director of nursing (DON) stated they would expect if a staff member had indicated through mood and behavior assessments or notes that a resident had depressive symptoms, there would be a follow-up or notification to ACP, and social services managed most of that with weekly meetings with ACP.A behavioral health service policy was requested but not received.

Based on interview and document review, the facility failed to adequately monitor possible side ffects for 1 of 5 residents (R15) reviewed for unnecessary medications.Findings Include:R15's quarterly Minimum Data set (MDS) dated [DATE], identified R15 was cognitively intact, with diagnoses which included anxiety, depression and bi-polar (manic and depressive episodes) disease. R15's MDS also identified R15 received antipsychotic, antianxiety, and antidepressant medications.R15's care plan revised 7/29/26, identified R15 had depressive disorder, insomnia, anxiety, post-traumatic stress disorder (PTST), and bipolar. Interventions included to monitor R15 for onset/worsening of Tardive Dyskinesia (TD) (abnormal, recurrent, involuntary movements that may be irreversible and typically present as lateral movements of the tongue or jaw, tongue thrusting, chewing, frequent blinking, brow arching, grimacing, and lip smacking, although the trunk or other parts of the body may also be affected.)R15's Order Summary Report signed 9/8/26, identified the following: Vraylar oral capsule (carlprazine HCI) (antipsychotic) give 3 milligrams (mg) by mouth at bedtime related to major depressive disorder, recurrent, severe psychotic symptoms.R15's Abnormal Involuntary Movement Scale (AIMS) dated 7/6/26, was dated, but no areas of the assessment were completed or signed. R15's health record lacked any other AIMS assessments completed.During phone interview on 9/15/26 at 1:43 p.m., consulting pharmacist (CP)-A indicated it was important to complete an AIMS assessment to monitor for possible abnormal movements if a person took an antipsychotic medication. CP-A stated an AIMS assessment should be completed on admission and every six months.During interview on 9/15/26 at 3:45 p.m., registered nurse unit manager (RN)-A confirmed R15's AIMS assessment had been opened but had not been completed. RN-A indicated AIMS were important to observe for possible side effects and if present to notify R15's primary care provider.During interview on 9/16/26 at 7:18 a.m., director of nursing (DON) stated AIMs assessments were important for antipsychotic monitoring, to ensure no changes and if warranted other follow up and communications would be completed with primary provider. Any time an AIMS indicated side effects, the medication may be adjusted or other medications added. DON indicated the managers were responsible on each unit to assure the assigned nurse had completed the assessment. DON verified R15's AIMS had not been completed, so they were reviewing others to assure no others were opened and not finished. DON stated CP-A was also responsible to assure AIMS assessments were completed as well.The facility policy titled Psychotropic Medication-Monitoring Of Adverse Effects reviewed 9/26, identified purpose to assure psychotropic medications were monitored for adverse effects. All antipsychotic and medications known to cause TD would have an AIMS assessment tool completed. An AIMS assessment tool would be completed within 30 days of all newly admitted with or new order for a TD causing medication, a change in dosage, or medication, and when the medication was discontinued. While receiving a TD causing medication, an AIMS would be completed every three months. Any resident having a high score would have their primary physician contacted.

Based on interview and document review, the facility failed to obtain and document informed consent, including an explanation of risks and benefits, for 2 of 5 residents (R15, R135 ) reviewed for unnecessary medications. Findings Include: R15's quarterly Minimum Data set (MDS) dated [DATE], identified R15 was cognitively intact, with diagnoses which included anxiety, depression and bi-polar (manic and depressive episodes) disease. R15's MDS also identified R15 received antipsychotic, antianxiety, antidepressant and opioid medications. R15's care plan revised 7/29/26, identified R15 had alterations in behavior, mood concerns, and history of psychiatric hospitalizations. R15 had aftercare following joint replacement surgery. Interventions included: to identify and monitor for changes in behaviors related to medications. Refer to psychologist/psychiatrist as needed for treatment recommendations, and/or medication dose adjustments. Administer pain medication as ordered and evaluate for effectiveness, observe for side effects. Review of R15's Order Summary Report signed 9/8/26, identified the following orders: -lorazepam (antianxiety medication) oral tablet 0.5 milligram (MG). Give 1 tablet by mouth as needed for sleep every hour of sleep (QHS). start date 4/9/26 -oxycodone HCI (opioid pain medication) oral tablet 10 MG, give 10 mg by mouth every 4 hours as needed for pain related to aftercare following joint replacement surgery, dislocation of internal left hip prosthesis, subsequent encounter. And give 10 MG by mouth three times a day for pain, start date 7/21/26 -buspirone HCI (antianxiety) tablet 5 mg, give 10 mg by mouth two times a day for anxiety, start date 6/6/26 -zolpidem tartrate (sedative-hypnotic medication) oral tablet 5 MG, give 5 mg by mouth at bedtime related to insomnia, start date 7/10/26 R15's electronic health record and paper chart lacked evidence that a consent form was completed with risks verses benefit education provided for the above medications. R135's quarterly MDS dated [DATE], showed moderately impaired cognition, had diagnoses of chronic pain and was admitted due to neurological disorder. Furthermore, R135 was prescribed opioids. R135's provider orders identified the following orders: -On 8/14/26, R135 was prescribed oxycodone HCL (opioid pain medication) give 2.5mg one time a day in the morning related to chronic pain syndrome, give 5mg by mouth at bedtime related to chronic pain syndrome and 5mg by mouth twice daily as needed for pain related to chronic pain syndrome twice a day. R135's medical record lacked evidence of a signed risk versus benefits education and consent for Oxycodone. During interview on 9/15/26 at 3:45 p.m., registered nurse unit manager (RN)-A reviewed R15's electronic health record and paper chart and confirmed R15 was missing consent forms with risk verses benefit education for the medications identified. RN-A indicated that was important to discuss, and to let the resident or resident representative know what the medication was being administered for and possible risks. RN-A stated their usual process did not include doing risk verses benefit education and consents for opioid medications. During a phone interview on 9/15/26 at 1:43 p.m., consultant pharmacist (CP)-A stated any resident who received a psychotropic medication should have a consent form on file. CP-A stated the consent forms were important to make sure the resident, or representative was aware of the possible risks associated with taking those medications. CP-A stated the facility's usual process did not include doing the risk verses benefit education and consent forms with opioid medications. CP-A stated she would discuss the use of the facility consent forms for opioid medications with director of nursing (DON). During interview on 9/16/26 at 7:18 a.m., DON indicated his expectation would be that all residents would have a consent form completed for all residents receiving psychotropic medications. DON stated they walk through the possible side effects and benefits of those medications and get consent. DON verified R15 had some consent forms missing and was not sure why they were not completed. DON stated he would inform the nurses how to review all new psychotropic medication orders in their computer program to assure not missed. DON stated consent forms were important to complete to assure no harm and so the residents or representatives knew what medications they were taking and what the risks were. At 7:49 a.m., during a follow up interview, DON stated was unaware opioid medications also required consent forms with the discussion of risks verses benefits. The facility policy titled Psychotropic Medications reviewed 9/26, identified when selecting medications and non-pharmacological approaches, members of the interdisciplinary team (IDT) and the resident and resident representative, if applicable, will participate int eh care plan process to identify, assess, advocate for, and communicate the resident's needs for changes of condition. If considering the initiation of a medication, staff would discuss with the physician/provider the type of medication(s), including dose and duration, considering the resident's age, condition and the individualized goals and preferences. The facility and/or provider would review with the resident and/or representative information on the medication, indication, dose, side effects, potential adverse consequences and goal of treatment. The facility would obtain informed consent from the resident and/or representative and document in the medical record.

Based on observation, interview and document review, the facility failed to ensure medications were administered safely for 1 of 2 residents (R139) who had medications left at the bedside and had been assessed as not safe to self administer those medications.Findings Include:R139's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R139 had moderate cognitive impairment with diagnoses which included arthritis, adjustment disorder with depressed mood and chronic pain. R139 required partial assistance with dressing, and supervision or touching assistance with personal hygiene.R139's Self Administration of Medication (SAM) assessment dated [DATE], identified R139 did not wish to self administer medications and did not self administer medications before R139 came to the facility.During observation on 9/14/26 at 1:15 p.m., R139 was lying in bed with eyes closed. On R139's bedside table was a container of Vicks vapor rub (mentholated topical ointment) and a Vicks vapor rub stick. At 4:13 p.m., R139 was sitting on edge of bed. R139 indicated her nose got congested, and she put the Vicks in her nose to help her breath. R139 was unable to indicate how often she used it, but stated less than once a day.Review of R139's Order Summary Report signed 9/3/26, identified R139 lacked an order for Vicks Vapor rub or to self administer medications.During a follow up interview on 9/15/26 at 9:23 a.m., R139 stated her family had brought in the Vicks vapor rub. During a phone interview on 9/15/26 at 1:47 a.m., consultant pharmacist (CP)-A verified R139 did not have orders to self-administer Vicks vapor rub. CP-A stated normal process was to have an order for the medication and an assessment indicating safe to keep at bedside. CP-A indicated it was important to assure the residents knew how to administer the medication.During interview on 9/15/26 at 2:13 a.m., trained medication assistant (TMA)-A verified the two containers of Vicks were on R139's bedside table. TMA-A then removed the items and placed them in R139's drawer in room. TMA-A stated family must of brought the Vicks in. TMA-A stated R139 did not have orders to self administer medications and she would notify registered nurse unit manger (RN)-A who would then contact R139's family.During interview on 9/15/26 at 3:49 p.m., RN-A confirmed R139 should not have the Vicks medication in her room, and R139 was not able to self-administer medications. RN-A stated R139's family member brought in the medication, and she would contact them to inform them to give medications first to her, and she would contact the primary care provider to get an order. RN-A opened both containers, and verified the medication had been used, though she had not been aware R139 had used the medication.During interview on 9/16/26 at 7:13 a.m., director of nursing (DON) indicated he had been made aware of R139 having Vicks vapor rub in room and R139 was not to self-administer medications. DON stated their usual process was to complete a SAM assessment if a resident wanted to self-administer medications to determine if they had the cognitive and physical ability to do so safely. It would then be care-planned and put in the residents' orders. DON stated this was important so other residents would not have access to the medications and to assure the residents administered them appropriately.The facility policy titled Self-Administration Of Medications reviewed 7/25, identified purpose was to allow a person-centered approach to the management and administration of medications. To allow residents to self-administer medications and/or treatments if the resident wished and was assessed to be capable of safely self-administering medications.

Based on observation, interview, and document review the facility failed to ensure the care plan was updated timely and accurately and failed to monitor effectiveness of interventions and modify the care plan as needed for 1 of 1 resident (R151) reviewed for falls.Findings include:R151's significant change in status minimum data set (MDS) dated [DATE], indicated R151 had impaired cognitive status, required assist from staff for transfers, and had a history of multiple falls. R151's diagnoses included osteoarthritis, weakness, history of falling with fractures, generalized anxiety disorder, major depressive disorder, and age-related physical debility.R151's care plan dated 8/25/26, indicated R151 was at risk for and had a history of falling. R151's care plan directed staff to keep the wheelchair next to their bed when they were in bed, to not leave R151 unattended in the dining room, provided assist with all transfers, and used auto lock brakes on a regular wheelchair.R151's care sheet used by nursing assistants indicated fall interventions including; non-skid slippers or shoes on at all times, do not leave unattended in dining room, bed in low position at all times, Broda wheelchair when family was not here, and regular wheelchair when family requested it (do not leave her alone in this chair).R151's progress notes included the following fall reports:6/3/26 at 3:30p.m., R151 was found in hallway 1 step from their room door.Immediate intervention put in place was low bed and keep mobility device at bedside.6/26/26 at 7:10p.m., R151 was found on the floor in their room by the bed.Immediate intervention put in place was non-skid shoes or socks, low bed, keep mobility device at bedside.9/12/26 at 3:10p.m., R151 was found on the floor in their room.Immediate intervention put in place was non-skid socks/shoes, low bed.During observation on 9/16/26 at 7:27a.m., R151 was lying in their bed and their wheelchair was not next to the bed it was in the middle of room facing away from bed.During interview on 9/16/26 at 8:37a.m., TMA-B verified wheelchair was in middle of room and not placed next to bed. TMA-B stated wheelchair was usually in bathroom at night so R151 could not reach it or see it. TMA-B stated they were not aware of the intervention on the care plan that indicated the wheelchair was to be placed at the bedside. TMA-B verified they would look at R151's care sheet for fall interventions and verified there was no fall intervention regarding placement of the wheelchair in the room when R151 was in bed.During observation on 9/16/26 at 2:27p.m., R151 was observed lying in bed sleeping with Broda wheelchair facing bed and pushed up against it.During interview on 9/16/26 at 2:30p.m., RN-B stated nurses would come up with an immediate intervention after a resident would fall as part of the fall assessment. RN-B stated the facility had a fall committee that would meet monthly to review falls and ensure the appropriate interventions were on the care plan and care sheets. RN-B stated R151's interventions were a low bed, frequent checks, and low Broda wheelchair. RN-B stated they would look in the resident's care plan for their fall interventions, and nursing assistants would refer to the care sheets as the same interventions would be on both documents.During interview on 9/17/26 at 9:59a.m., registered nurse (RN)-D stated they would expect staff to follow the interventions on the care plan and care sheet specific to each resident. RN-D stated they did try the intervention of leaving the wheelchair next to the bed for R151 however R151 would bypass or go around the wheelchair, and this was the intervention when R151 was using a regular wheelchair, R151 is now using a Broda wheelchair. RN-D stated the intervention of leaving the wheelchair at the bedside was never really removed as a fall intervention, however the staff would be going back and forth on which interventions to use to prevent R151 from falling from bed. RN-D stated the fall interventions on care sheets are updated first, then the care plan is updated, however they would both have the same interventions after several days, so the nurses and nursing assistants would have the same information.During interview on 9/17/26 at 10:45a.m., director of nursing (DON) stated they would expect staff to follow fall interventions that were on the care plan and care sheets. DON stated the care plan and care sheets would have the same fall interventions or at least not contradict each other.A facility policy fall investigation and assessment dated 4/2026, indicated the plan of care is updated immediately to reflect follow-up measures (interventions) taken to prevent reoccurrence. The policy also stated the nursing assistant assignment sheets (care sheets) are updated immediately to reflect interventions.A facility policy fall risk assessment and accident management dated 4/2026, defined an avoidable accident as one that occurred due to failure to monitor effectiveness of interventions and modify as needed. The policy also stated if falling recurs staff will implement additional or different interventions or indicate why current interventions remain relevant.

Based on interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect discharge status for 1 of 1 resident (R200) reviewed for hospitalization. Findings include: R200's discharge Minimum Data Set (MDS) dated [DATE], indicated R200 admitted to facility on 2/10/25, from a Short-Term General Hospital, and discharged from facility on 3/6/25, discharging to Short-Term General Hospital. R200's progress note dated 3/5/25 at 10:00 a.m., indicted R200 discharge home back to [name of assisted living] signed onto hospice so no home services. R200's nursing progress note dated 3/6/25 at 11:04 a.m., indicated R200 discharged to [name of assisted living]. On 6/4/25 at 10:05 a.m., registered nurse (RN)-F, know as a MDS coordinator reviewed R200's MDS dated [DATE], and confirmed the MDS was inaccurately coded and R200 discharged home and not to the hospital. RN-F stated the MDS was expected coded correctly and correction would need to be completed. On 6/4/25 at 2:49 p.m., the director of nursing (DON) stated the MDS was expected to be accurate and the MDS coordinators follow the MDS RAI (Resident Assessment Instrument) manual. Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual dated 10/24, indicated In addition, an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident ' s medical record, physician, and family, guardian and/or other legally authorized representative, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy (what the resident ' s actual status was during that observation period) by the IDT completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment.

Based on observation, interview and document review, the facility failed to ensure freedom of movement was not restricted for 1 of 1 resident (R143) who was reviewed for physical restraints. Findings include: R143's quarterly Minimum Data Set (MDS) assessment, dated 4/16/25, identified severely impaired cognition. R143's diagnoses included; Parkinson's disease (a chronic progressive neurological disorder), dementia, and progressive neurological conditions accompanied by a psychotic disorder. R143 required maximum assistance to ambulate ten feet and was fully dependent on others when using the wheelchair. They also needed maximal assistance for transfers, including rolling from side to side, seating, and positioning in bed. A bed alarm was used daily. R143's care plan reviewed on 4/10/25, identified interventions for self care deficits, fall risk, and mood enhancement. The interventions included placing the resident in the common area recliner to engage in activities-such as watching the news-and for staff to observe and intervene when R143 attempted to self transfer. Staff were encouraged to keep R143 in public areas whenever not eating or napping. Furthermore, the care plan recognized impaired mobility secondary to impaired balance and unsteady gait. R143 required assistance from two staff members with a walker; one to two staff for bed mobility, repositioning, sitting up, and rolling side to side; and that a mechanical lift was used when R143 became stiff. R143 was able to propel self short distances but needed assistance for longer distances or when off the unit. R143's active providers orders last reviewed 5/6/25, identified a pressure alarm and pads but lacked an order for restraints. R143's quarterly Interdisciplinary Care Conference report dated 4/28/25, identified family member (FM)-A attended the conference and requested the television on when R143 was in the lounge area and recommended which channels were preferred and suggested R143 held a book for comfort. R143's progress notes dated 5/10/25 at 1:55 p.m., indicated R143 had more than one fall in the past three months, had balance and decreased muscular coordination and used medications that placed R143 at moderate risk for falls. R143's progress notes dated 5/16/25 at 6:33 p.m., indicated R143 was screened by occupational therapy (OT) post fall, was not a candidate for OT due to the lack of following directions and declined in basic activities of daily living (BADL) and needed extensive assist since admission despite therapy intervention. R143's progress notes dated 5/31/25 at 6:12 p.m., indicated R143 self-transferred and was seen walking around his room unassisted and indicated R143 was not stable walking on his own and brought out to the nurse's station for one-on-one cares. R143's electronic medical record (EMR) lacked documentation for a medical diagnosis treated by use of the electric recliner. Furthermore, the medical record failed to show an assessment or R143's ability to rise independently out of the chair/recliner. During an interview on 6/2/25 at 12:30 p.m., FM-A stated staff placed R143 in the common area in the chair, reclined, with his feet up because the bed alarm can no longer be used. The recliner was the only place staff could keep him because of the recent falls. During an observation on 6/3/25 at 3:52 p.m., R143 was in the common area, in a recliner with both feet up. The recliner remote was hung over the back of the chair. R143's personal paid companion was seated to the right and two other residents were in their wheelchairs. No staff were present. During an interview on 6/4/25 at 8:54 a.m., registered nurse (RN)-C stated R143 can't activate the chair, and the wife requested the use of the recliner. RN-C further stated any assessment would be done by OT and was not aware of any completed assessment. During an observation on 6/4/25 at 9:54 a.m., R143 was in the recliner in the common area, both feet were up. R143 was awake and looking around the room. The remote was placed arms reach away on the heat register. During an interview 6/4/25 at 11:42 a.m., FM-A stated no consent, or waiver was signed that approved the use of the recliner. During an interview on 6/4/25 at 11:46 a.m., director of therapy (DOT) stated R143 had been assessed for transfers, but never assessed for a recliner. During an interview on 6/4/25 at 11:46 a.m., the director of therapy (DOT) stated R143 was assessed for transfers only and never assessed for safety with the use of an electric recliner. The DOT was not aware of any assessments ever completed for a lift chair or recliner. During an Interview on 6/5/25 at 7:09 a.m., the director of nursing (DON) stated he confirmed with the nurse manager on the unit that R143 cannot get up from the recliner, but felt the recliner was a safe intervention and now staff could observe and intervene as he is in the lobby and not in his room. During an interview on 6/5/25 at 8:29 a.m., occupational therapy (OT)-A confirmed no referral was received to assess the safety and use of the electric recliner for R143 furthermore, an assessment would be requested for a recliner only if a pressure injury occurred that required a cushion or if a resident had fallen out of a recliner. OT-A was aware of assessments for recliners and completed those at other facilities, then confirmed R143 had not been assessed to use the recliner. Restraint Use policy revised 5/21, identified the use of physical restraint was prohibited for discipline or convenience, unnecessarily inhibit a resident's freedom of movement or activity. Convenience was defined as the result of any action that has the effect of altering a resident's behavior such that the resident requires a lesser amount of effort or care and is not in the resident's best interest. Freedom of movement means any change in place or position for the body or any part of the body that the person is physically able to control. Physical Restraint is defined as any manual method, physical or mechanical device, equipment, or material that meets all the following criteria: is attached or adjacent to the resident's body, cannot be removed easily by the resident, restricts the resident's freedom of movement or normal access to his/her body. Physical Device Evaluations policy revised 6/22, identified evaluations for any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. The guidelines identified an atypical method, or device is considered any intervention or equipment that is nonroutine or would not be considered standard or required in the normal delivery of care. Some examples of atypical methods or devices are Geri-chairs, wedge cushion in wheelchairs, bed placed against a wall for purposes other than room décor/style, anti-roll back wheelchairs.

Based on observation, interview, and document review, the facility failed to consistently utilize a communication device or provide an interpreter for 1 of 1 resident (176) reviewed who was deaf and used ASL to communicate care needs. Findings Include: R176's significant change Minimum Data Set (MDS) assessment dated [DATE], identified no cognitive impairment, primary language was American sign language (ASL), and an interpreter was needed to communicate with doctors and health care staff. R176's care plan revised on 12/3/24, identified impaired communication. R176's care plan identified methods for communicating such as short, direct simple phrases, visual aids, and indicated please provide me with an ASL interpreter for all significant meetings/interactions such as care conferences, cognitive/mood assessments, etc. R176's active provider orders last reviewed 5/5/25, indicated weekly pain and skin assessments, daily ambulation program and a fluid restriction order which could have required staff to communicate with R176. During an initial interview on 6/2/25 at 1:11 p.m., R176 wrote on a notebook, some of the staff do not know how to use the iPad to contact the ASL interpreter and wrote on a notebook to communicate. R176 wrote my preference was the ASL interpreter be used with all cares because writing in ASL structure confuses staff that are non-English speaking. An ASL Interpreter was used for the remainder of the interview and through the interpreter R176 expressed concerns that aids and nurses do not understand me and it has always been my preference to use the ASL interpreter. During an interview on 6/3/25 at 4:00 p.m., R176 typed on a word document that staff did not use the iPad interpreter with any interactions or cares today and that only the social worker used the iPad interpreter. R176 indicated a concern that registered nurse (RN-D) completed a skin assessment and did not use the interpreter to communicate. R176 was upset and wheeled out to the nurse's station and pointed at RN-D. During an interview on 6/4/25 at 9:23 a.m., R176 was asked via typed communication on a computer whether the iPad interpreter in the social worker ' s office had been used for care. R176 responded by shaking their head to indicate no. They continued to communicate through written messages, stating that few staff members knew how to use the iPad interpreter but were unable to specify which staff members. During an interview on 6/4/25 at 9:30 a.m., nursing assistant (NA)-E confirmed not having ever used the iPad but was familiar with how it worked and where it was kept. During an interview on 6/4/25 at 9:40 a.m., trained medical aid (TMA)-B stated does not use the iPad to administer medications or with cares because R176 was able to answer yes or no. TMA-B stated R176 called staff and wrote down messages in a notebook. TMA-B was unaware of R176's preference, and confirmed this was the only way staff communicated with her. TMA-B confirmed not using the iPad, knowing ASL, and R176 was on her assignment sheet for the day. During an interview on 6/4/25 at 3:18 p.m., registered nurse (RN)-D stated an iPad would normally be used, but R176's skin was checked with no major concerns, the interaction wasn't a big deal. RN-D confirmed a notebook and pen was used. During an interview on 6/5/25 at 7:06 a.m., the director of nursing (DON) stated that the care plan dictated how to communicate with the resident. The DON explained that alternative communication methods were sometimes used, and that the facility had a comprehensive policy in place for serving the deaf community. The expectation was to use the ASL interpreter for all major interactions. The DON agreed that if the resident preferred the interpreter, staff were expected to use the iPad interpreter. The DON noted that a skin assessment might not typically require use of the iPad interpreter, but given R176 ' s stated preference, it should be used. During an interview on 6/5/25 at 8:57 a.m., R176 was asked, do you prefer staff to use the iPad with all communication with you? To which R176 replied, yes, they need education, they do not know how to use it, the social worker knows how to use it he is the only one. They think I write they have hard time reading my writing so it best to use iPad ASL it best I have to do it. Facility Access for Communication-Impaired Residents/Patients policy reviewed 8/2023, identified an interpreter be used upon request of patient/resident, explaining medication and possible side effects, and obtaining permission for treatment.

Based on observation, interview and document review, the facility failed to ensure a self-administration of medication (SAM) assessment was completed and a provider order obtained to self-administer medications for 1 of 3 residents (R13) reviewed for medication administration. Findings include: R13's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated severely impaired cognition and diagnoses of Alzheimer's disease (a progressive neurological disorder affecting a person's memory, thinking, and behavior), heart failure and anxiety. The MDS indicated R13 required partial to moderate assistance for oral hygiene and substantial to maximum assistance for personal hygiene cares. R13's self-administration of medication assessment dated [DATE] indicated R13 did not wish to self-administer her medications. R13's undated order summary report included the following orders: - Resident is not capable of safely self-administering medications, dated 10/31/23. - Albuterol Sulfate Inhalation Nebulization Solution (Albuterol Sulfate) 3 milliliters (mL) inhale orally via nebulizer three times a day for cough or difficulty breathing, dated 3/13/25. R13's care plan was reviewed on 6/2/25, and revealed a lack of documentation of an assessment she was okay to self-administer medications. During a continuous observation on 6/2/25 starting at 1:23 p.m., a buzzing noise was heard from outside R13's room. At 1:24 p.m., trained medication aide (TMA)-A walked out of R13's room and back to a medication cart, leaving R13's door open. Inside R13's room, a nebulizer treatment machine was observed to be running and causing the buzzing noise heard. There was tubing going from the nebulizer treatment machine to a mask that covered R13's nose and mouth, and connected below the mask was a medicine cup with liquid condensation inside. R13 sat in her wheelchair inside her room facing the nebulizer treatment machine that was plugged into the wall. TMA-A was observed going from the medication cart into other resident rooms and back to the medication cart during this time. At 1:32 p.m., TMA-A returned R13's room and announced, time is up. R13 had removed the mask from her face and was holding it in her lap. R13 stated to TMA-A, I don't want it on. I have had worse colds than this. TMA-A responded, you took it off, and told R13 would need to update the doctor if she did not want the treatment any longer. TMA-A offered a drink of water and attempted to complete the medication pass, however R13 began to cry, spit out her medications and stated she wanted to leave. During interview on 6/2/25 at 1:37 p.m., TMA-A stated R13 had been having a cough and was taking a scheduled nebulizer treatment before breakfast and after lunch for the cough. TMA-A stated R13 did not like the afternoon nebulizer treatment but took the morning treatment well. TMA-A confirmed she administered the nebulizer treatment and left R13 in her room unsupervised while she finished her treatment. TMA-A stated she normally kept the mask on but today was not normal for her. TMA-A stated R13 should have an order in her medication administration record (MAR) stating it was okay for her to be left alone (or unsupervised) to finish her nebulizer treatment. TMA-A was unsure about the self-administration assessment but indicated the nursing manager would know. TMA-A expected there to be an order in place indicating R13 could complete her nebulizer treatment on her own. TMA-A reviewed MAR and identified for R13; Albuterol Sulfate Inhalation Nebulization order and opened the administration instructions and stated, it doesn't have all the details in there. TMA-A was unable to locate a provider order indicating R13 was okay to self-administer her nebulizer treatment, however stated the MAR banner or administration instructions was where it should be. During interview on 6/2/25 at 1:47 p.m. with registered nurse (RN)-A, indicated a resident who wished to self-administer medications, including complete their nebulizer treatment after set-up unsupervised, would need a provider's order and an assessment. RN-A reviewed R13's orders and identified an order dated 10/31/23, that indicated R13 was not able to self-administer medications. RN-A confirmed this order would include nebulizer treatments. RN-A reviewed R13's electronic health record (EHR), including her MAR, and confirmed staff should stay with R13 for the duration of the nebulizer treatment to ensure she kept the mask on. RN-A explained if a resident wished to self-administer medications, staff were expected to obtain an order and perform an assessment to determine if they could safely do so. During interview on 6/5/25 at 8:45 a.m. with RN-B, indicated if a resident had an order to self-administer their medications, it should be in the MAR and/or in the administration instructions for staff to see. During interview on 6/5/25 at 9:56 a.m., the director of nursing (DON) expected staff to follow the facility's self-administration policy and procedure. Facility Self-Administration of Medications policy revised 5/22, indicated the facility would allow residents to self-administer medications and/or treatments if the resident wished AND if the resident was assessed to be capable of safely self-administering medications. The policy directed staff to complete a self-administration of medication assessment and if the resident wished to self-administer and was determined to be safe to do so, to obtain a physician's order to self-administer. Further, the policy guided staff on the specificity of the self-administration order, including any modifications (if any) determined during the assessment.

Based on observation, interview, and document review, the facility failed to comprehensively assess transfers with a mechanical lift or develop and implement policies to ensure the safety and supervision for 1 of 4 residents (R20) reviewed for accidents. Findings include: R20's annual Minimum Data Set (MDS) assessment dated [DATE], identified severely impaired cognition and had limited function to the right arm and hand, used a wheelchair, required maximal assistance for mobility and was on hospice. R20's diagnoses included cerebral palsy, seizure and psychotic disorders, and post-polio syndrome. R20's care plan (CP) created on 6/2/23, identified mobility as an area of concern and indicated one staff assisted with bed mobility, repositioning, and sitting up. Furthermore, the CP identified R20 had a history of compression fractures to the spine and spasticity/hemiparesis of the right hand since birth, was not ambulatory and needed one to two staff for transfers with the mechanical lift (EZ Stand). R20's electronic medical record (EMR) contained a completed annual physical device evaluation dated 3/3/25 but failed to reassess R20's transfer needs when a mechanical lift was used. During an observation and interview on 6/2/25 at 4:51?p.m., R20 was found in bed with the upper body against the wall, the head resting against the wall at an angle, and the left foot hanging off the bed while calling out for help. Licensed practical nurse (LPN) B entered the room and repositioned R20. R20 was moved into a seated position, a belt was placed around the resident and attached to the mechanical standing lift; both feet were lifted onto the foot plate by the nurse. R20's left hand was placed on the handle and held securely by a nursing assistant (NA)-C. R20's right arm was flaccid and hung down at the side of the body. R20 was observed hanging from the stand, unable to bear weight while being lowered onto the wheelchair. LPN B stated that R20's mode of transfer was by the mechanical standing lift and the criteria to use the lift was to bare weight and at least one hand on the handle, then stated R20 met criteria for a standing lift. During an interview on 6/3/25 at 9:15 a.m., NA-A stated I am not comfortable with R20's transfers and called for a second aid. NA-A stated the standing lift was appropriate for R20 because he stood up good and held on to the handle with one hand. During an observation and interview on 6/3/25 at 9:25 a.m., NA-A and NA-C assisted R20 transfer using the mechanical standing lift. R20's left hand was secured to the handle, but R20 did not stand up independently, could not bear weight and hung from the lift. NA-A stated R20 supported himself during other transfers and would often stand without hanging on and needed reminders to hang on before the aids would start the transfer. During an interview on 6/3/25 at 1:35 p.m., director of therapy (DOT) stated therapy assessed residents for transfers upon admission, status change, or if a referral was received. The DOT stated R20 was not currently in therapy and was unfamiliar with the transfers. The qualifications to use the EZ Stand (mechanical standing lift) would be to bear weight, moderate to maximal assistant, tolerated standing at least thirty seconds, and to hold on with one hand decently. The DOT stated patients with hemiparesis, for example a stroke patient would not be a candidate for the EZ Stand. The DOT stated resident needed to assist with the stand to use the EZ Stand and confirmed therapy has not received a referral to assess transfers for R20 but would observe a transfer later today. During an interview on 6/3/25 at 1:50 p.m., licensed practical nurse (LPN)-A explained the process on how residents are assessed for transfers. It starts with new admissions, physical and occupational therapy (PT, OT) provided guidance, the resident and family's goals and fears are discussed and overall allowed the residents to function at their highest level but remained safe. LPN-A stated if there was a change in transfer abilities a referral was placed to PT for an evaluation and the criteria used for the EZ Stand was to bear weight. If a resident had a stroke, two assistants were required. LPN-A stated the nursing assistants kept the nurse updated on transfers, but ultimately it was the nurse's decision and if there was a concern after the evaluation the resident would use the next level for transfers. LPN-A stated staff were aware of the process. During an observation and interview on 6/3/25 at 3:33 p.m., NA-B and NA-C entered R20's room and began to transfer R20 with the standing lift. The DOT observed the transfer. NA-B and NA-C indicated they were familiar with R20 and abilities to transfer. R20's legs were dependent upon staff to lift them on to the foot plate, the belt was attached to R20's waist, left hand placed on the handle, and right arm hung to the side in a flaccid position. The DOT asked how long R20 could stand and then R20's left hand fell from the handle. NA-C asked the DOT if this meant R20 could not safely transfer with the EZ Stand and the DOT nodded yes. The DOT stated EZ Stand transfers needed 20 some seconds of tolerance, but usually 45-60 seconds was needed to transfer to the wheelchair or toilet and then confirmed R20 should no longer use the EZ Stand. During an interview on 6/4/25 at 3:52 p.m., the director of nursing (DON) stated the process for transfers was continuous monitoring of care needs and adjusted transfer abilities based on the front-line staff recommendations. Any changes are discussed, care planned, and it was a collaborate effort based on a formal assessment from therapy. The DON stated the staff knew how to transfer resident safely and are saying the correct things but had learned that staff didn't identify unsafe transfers. Facility Transfer Procedures policy revised 5/24, identified residents are not suited for standing transfers are unpredictably able to bear weight, unable to hold onto handles/lift frame. Facility Physical Device Evaluations policy revised 6/22, identified evaluations for any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. The guidelines identified an atypical method, or device is considered any intervention or equipment that is nonroutine or would not be considered standard or required in the normal delivery of care. Some examples of atypical methods or devices are geri-chairs, wedge cushion in wheelchairs, bed placed against a wall for purposes other than room décor/style, anti-roll back wheelchairs.

Based on observation, interview, and document review, the facility failed to ensure residents were free of significant medication errors for 1 of 6 residents (R115) reviewed for medication administration. Findings include: R115's face sheet printed 6/5/25, indicated diagnoses of reduced mobility, cardiac pacemaker, personal history of sudden cardiac arrest, Alzheimer's disease, and heart failure. R115's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated moderately impaired cognition, use of wheelchair, substantial/maximal assistance with personal hygiene, lower body dressing, and bathing. R115's care plan printed revised 8/14/24, indicated self-care deficit related to congestive heart failure, pacemaker in left chest, and dementia. Staff crush my pills, mix together in applesauce to aide in swallowing. R115's physician's orders printed 6/5/25, indicated an order for metoprolol succinate extended release 50mg tablet (blood pressure medication) daily for high blood pressure. An additional order stated medications may be crushed or given in liquid form unless contraindicated or otherwise. During observation on 6/4/25 at 8:30 a.m., trained medication aide (TMA)-C prepared medications for administration to R115. TMA-C crushed acetaminophen 1000mg, metoprolol 50mg extended release, potassium 20meq, torsemide 30mg, and sertraline 100mg for ease of swallowing for R115. During interview on 6/4/25 at 8:35 a.m., prior to administration of medication to R115, TMA-C verified she had been crushing R115's metoprolol succinate extended-release tablet for quite some time due to R115's difficulty swallowing multiple pills and intended to administer metoprolol succinate tablet crushed. TMA-C further stated R115 had an order to crush medications so she assumed metoprolol succinate extended release could be crushed. TMA-C stated she did not see the green sticker on the metoprolol succinate extended-release medication card that read: do not crush or chew. During interview on 6/4/25 at 8:45 a.m., registered nurse (RN)-E stated R115 had an order to crush medications. RN-E further stated she was unsure if the metoprolol succinate extended-release could be crushed and she would need to call the provider to check. RN-E stated she did not know the metoprolol succinate extended-release medication card included a sticker indicating not to crush or chew the medication. During interview on 6/4/25 at 9:15 a.m., RN-E stated she had called nurse practitioner (NP)-D and NP-D stated the metoprolol succinate extended-release could not be crushed. NP-D changed the order to metoprolol tartrate 25mg tablet two times per day. During interview on 6/5/25 at 8:39 a.m. director of nursing (DON) stated he had heard about this medication error yesterday and had informed RN-E that extended-release medications could not be crushed unless specifically ordered by a provider due to them needing to be released in the body over time. DON further stated it was the facility's responsibility to make sure the provider was notified if a medication needed to be changed to a different form to be crushed and he would expect the nurses to do that. R115's blood pressure readings were reviewed for one month and ranged from 117/75 to 157/86. A facility policy on crushing of medications was requested but not received.

Based on observation, interview and document review, the facility failed to ensure individualized activities were provided for 2 of 4 residents (R88 and R143) reviewed for activities. Findings include: R88's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R88 was admitted to the facility 2/1/25, severe cognitive impairment, sometimes feel lonely or isolated from those around, no rejection of care, wandering occurred four to six days, but less than daily, utilized a walker and wheelchair, required substantial/maximal assistance with dressing, supervision with personal hygiene, sit to lying, sit to stand, and walking, and diagnoses included hip fracture and non-Alzheimer's dementia. R88's care plan printed 6/3/25, indicated R88's leisure interests include going to church, listening to music, talking with others and watching TV and interventions included document attendance/refusals, encourage to tell staff of leisure needs, encourage short durations of activities as able, monitor activity setting for safety, place near outside edge of group, place near sound stage, provider current activity calendar. R88's Activity/Recreation assessment dated [DATE], therapeutic recreation (TR)-D director indicated activity preferences: discussion/education, food programs (baking/cooking), gardening/plants, music, reading, religious/spiritual programs, socialization, likes to talk about her family and genealogy, likes dogs and cats, family; preference for program style: small groups, 1:1, summary indicated R88 needs interaction and encouragement, visual learner, enjoy being reassured and people interaction with me in a kind way, feel best when doing something, like to laugh and enjoy funny story or joke, love to read and garden, cook, listening to music and love dogs and cats. R88's Documentation Report dated 3/1/25-3/31/25, and 4/1/25-4/30/25, indicated no documentation of R88's activities. R88's Documentation Report dated 5/1/25-5/31/25, indicated on 5/22/25 at 2:59 p.m., R88 music observed. No other documentation of activities. R88's Documentation Report dated 6/1/25-6/30/25, indicated on 6/2/25, the documentation report added 1:1 visits, independent leisure, and spiritual. On 6/2/25 at 6:38 p.m., during a telephone interview family member (FM)-E stated concern regarding the lack of available activities in the TCU (transitional care unit). FM-E stated frequent afternoon visits and had not observed R88 participate in activities. FM-E stated the TCU unit did not have activities going on for the residents. FM-E stated R88 enjoyed interaction with others and would likely participate if activities were offered. On 6/3/25 at 8:45 a.m., R88 was observed sleeping in bed. On 6/3/25 at 12:43 p.m., R88 was seated in a wheelchair by the first-floor nursing station and stated she wanted to go home, and further stated she like to be kept busy, specifically mentioning she enjoyed cleaning and having her fingernails painted. On 6/3/25 at 1:33 p.m., R88 was seated in a wheelchair in the day room watching television. On 6/3/25 at 1:10 p.m., trained medication aide (TMA)-D stated that each resident had an activity calendar in their room. TMA-D stated activities staff were responsible for offering activities to the residents. TMA-D stated occasionally R88 would go to chapel. On 6/3/25 at 1:13 p.m., R88's room was observed and both April 2025 and June 2025 activity calendars were found posted, April's near the door and June's behind the bedside table. Nursing Assistant (NA)-D stated that activity staff were responsible for offering activities to residents, including R88, but could not recall if R88 had participated. On 6/3/25 at 1:20 p.m., registered nurse (RN)- G stated activities staff were responsible for offering and including R88 in activities. On 6/3/25 at 1:39 p.m., TR-D stated she was responsible for first floor resident activities including R88, and stated any staff can offer and include R88 in activities. TR-D confirmed there was no documentation of R88 participating in activities prior to 6/3/25. TR-D acknowledged R88's activities were not consistently offered or documented as expected. TR-D stated she completed R88's activity interest and assessment but could not confirm those preferences were being consistently implemented On 6/4/25 at 8:18 a.m., R88 was observed in a wheelchair and self-propelled through the dining room and R88 stated she did not know what she was going to do today. On 6/4/25 at 12:58 p.m., during a follow up interview TR-D confirmed R88 was not consistently offered or included in activities and was unsure if other staff had included R88 in activities. TR-D confirmed that she was responsible for the TCU residents' activity planning and should have ensured offers were made based on R88's assessment. On 6/4/25 at 2:57 p.m., the administrator stated residents were expected to be offered activities based of interests and specific to each resident and confirmed activities staff were expected to offer and document on R88's activities. The administrator confirmed that activity offerings were expected based on the preferences and activity assessment. R143s admission MDS dated [DATE], identified activity preferences were books, pets, news, engaged in favorite activities, attended religious activities and going outdoors. R143's quarterly MDS dated [DATE], identified cognitive impairment, diagnoses of Parkinson's disease, dementia with progressive neurological conditions. R143 had clear speech, wore hearing aids, had no impairment to vision, had the ability to understand others, used a walker/wheelchair and was dependent on staff for mobility/transfers. R143's care plan initiated 4/10/25, identified a care area of activities and had interventions to attend group activities and wanted encouragement to attend group programs for short periods and if unable to stay would be assisted out of the group. R143 would like his activity level monitored and assessed for changes, preferred to pursue independent activities such as having someone read devotions, bring pets to visit, walking, listening to music. The care plan identified R143 would notify activities if he needed independent leisure supplies and for staff to anticipate independent needs and to be reminded and assisted to group activities of interest. R143's paper chart that included an activities tab was reviewed but had no activities recorded. R143's electronic medical record (EMR) was reviewed but had no attendance to activities recorded. An activities assessment dated [DATE], identified R143's family was very involved and visited daily. He had attended some music events and was willing to stay for concerts if family attended. He enjoyed going for walks around the facility and activities of interest were animals, table games, music, singing, concerts, special events, news, devotions and worship services. R143 was a gardener and had an interest in nature groups. R143's quarterly therapeutic recreation note dated 1/16/25 and 4/28/25, were reviewed and contained the same note, R143 continued to pursue independent leisure interests daily with assistance setting up as needed and participated or observed group programs as desired/able. R143's family was very involved and often visited daily. Family typically walked R143 around the neighborhood halls on 3rd floor and would at times encourage him to join activities. He had attended some music events- not a fan of polka music but more willing to stay for concerts if family attended with him. R143 used a walker for mobility and required staff/family assistance/supervision. Activities of interest include animals (had dogs), table games (risk, monopoly), music/singing/concerts (Elvis, 50's), special events, keeping up with the news, devotions and worship services (Lutheran). R143 was previously a gardener and has observed flower arrangements/nature groups when walking through the activity room with family. Independent leisure interests consist of watching tv/movies (CNN news, Netflix), visited with family, devotions, music, walking, pets, resting in my room or neighborhood lounge, and snacking as able. He often rests in the neighborhood lounge with peers where they watch tv together/ observe those passing in hallway. R143 responded to conversation and hears with loud tone and used hearing aids. His care plan has been reviewed and remained appropriate. During an interview on 6/2/25 at 12:30 p.m., family member (FM)-A stated a calendar of activities was posted in R143's room every month, but the facility doesn't invite him to attend. Most of the activities are over by the time family arrives and felt if family doesn't take him to an activity or to church, R143 sat in his room and FM-A would appreciate if staff would invite him to activities. FM-A stated the few staff that came which was a long time ago, they would ask, but if he didn't respond or shook his head no, they would just leave. FM-A stated the facility had a shortage of staff and felt she needed to visit every day to take R143 out of his room. During an observation on 6/3/25 at 9:43 a.m., R143 was in the lounge area, laying in the recliner watching the news. During an observation and interview on 6/3/25 at 3:52 p.m., R143 was in the lounge area in a recliner. A privately paid companion (FM)-B stated I arrived today at 1:00 p.m., have been with R143 since he lived at home and came every Tuesday since R143 moved to the facility. FM-B stated no one from activities came today to invite R143 but the facility used to invite him to activities when he first came and confirmed no one has invited R143 to activities recently. Activity calendar for 6/3/25 read at 10:15 a.m. included devotions, 11:00 a.m. [NAME] music class, 2:00 p.m., bingo, 6:45 p.m. cloudberry choir concert. During an interview on 6/4/25 at 11:45 p.m., activities personnel (A)A stated R143 preferred to watch tv in the lounge with a small group, doesn't like large groups and therefore would not be invited to an activity such as bingo. A-A was aware R143 preferred music events but was unable to sit for long periods, so if staff brought him to an activity, he would come last. A-A acknowledged R143's wife brought him to most activities but stayed to the side. The facility didn't invite R143 as much as they should, confirmed he did not attend the music event yesterday, and that he has not attended any activity by invitation recently. All activities have been with his family the past several months. During an interview on 6/4/25 at 1:18 p.m., TR-D stated the facility offered individualized activities such as an art and roving library cart, puzzles, cross words and for residents that are unable to attend large group activities we ask the nursing assistants to turn on the lounge television to view the scheduled program in a smaller group setting. Residents that need more one on one interaction could request a special friend visit or have a book read by volunteer services. Activities are tracked using point click care (computer software), but residents that decline activities were not tracked. The TR-D reviewed all R143's 2025 activity tasks reports in his EMR and confirmed no activities had been recorded. Facility Therapeutic Recreation Assessments and Documentation policy dated 5/17, indicated: Policy: To provide for official, comprehensive written records of all Resident's interests and involvement in Therapeutic Recreation programs. The Therapeutic Recreation staff are assigned the residents to which they must complete all documentation with in specified time frames. 1. admission Assessment a. Upon admission sections Band F of the MDS will be completed and serve as the initial assessment for the resident/patient. b. A progress note which includes details of the assessment will be done c. Any corresponding raps will be completed for appropriate sections 2. Resident Care Plans a. The care plan is developed from information that is collected in the initial assessment, observations from the resident and information obtained from their representative. b. A care plan will be developed for each resident/patient within 21 days c. Care Plan will be reviewed and updated as needed every 90 days, if a significant change occurs and as needed. 3. Daily Attendance Records a. Daily attendance will be recorded in POC b. Review records every 90 days, if a significant change occurs and as needed to ensure any emerging needs for resident / patient reassessments or care plan reviews. c. File attendance records for a minimum of 5 years d. Make use of attendance records as data for summary within resident /patient progress notes 4. Quarterly/Annual/ Significant Change Progress Notes a. Summarize information from activities, care plan and MDS assessments to complete quarterly progress note. b. Do a Therapeutic Recreation Progress note.

Based on observation, interview and document review, the facility failed to ensure complaint investigation survey results were readily accessible and available for review within the campus. This had potential to affect all 207 residents, visitors, and their families who could wish to review the information. Findings Include: During the recertification survey on 6/2/25 at 12:21 p.m., a binder labeled survey results hung on the wall to the left of the information board located in a hallway on the 1st floor, adjacent to the front desk and contained the following results: Recertification survey dated 3/14/24 Abbreviated complaint survey results dated 5/21/24. The facility binder lacked documentation in the form of a CMS 2567 (Formal investigation documentation required by the Centers for Medicare and Medicaid Services-CMS) for investigations or standard surveys completed during the following dates: 6/27/24, abbreviated complaint survey results, 7/29/24, abbreviated complaint survey results, 8/29/24, abbreviated complaint survey results with F578- cited at J. 1/17/25, standard abbreviated survey results During interview on 6/2/25 at 6:17 p.m., the administrator stated the director of nursing was responsible for maintaining the binder. The director of nursing (DON) entered the office and stated the past survey results will be printed and placed in the binder. During an interview on 6/4/25 at 11:00 a.m., R63 stated survey results are not available for residents to review. Policies related to survey results were requested, but no policies were received.

Based on interview and document review, the facility failed to ensure the Physician Order for Life Sustaining Treatment (POLST) accurately reflected current resuscitation wishes for 2 of 4 residents (R1, R4) reviewed for advance directives. This deficient practice resulted in an immediate jeopardy (IJ) for R1 and R4 who would have received cardiopulmonary resuscitation (CPR), contrary to their wishes, in the absence of a pulse or respirations. The IJ began on [DATE] when R1's POLST dated [DATE] indicated full code status with comfort cares contrary to R1's wishes for do not resuscitate (DNR) status with comfort cares. The administrator and director of nursing (DON) were notified of the IJ on [DATE] at 1:25 p.m. The IJ was removed on [DATE] at 4:33 p.m. when the facility had implemented corrective action, however; non-compliance remained at the lower scope and severity level of D, isolated with no actual harm but potential to cause more than minimal harm. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had moderately impaired cognition with a diagnosis of stroke R1's POLST signed [DATE] identified R1 desired full code status (initiate cardio-pulmonary resuscitation [CPR]). R1's Provider Order dated [DATE] instructed DNR comfort care. On [DATE] at 11:19 a.m., R1 stated he wished to be Do Not Resuscitate (DNR) status. R4's admission MDS dated [DATE] indicated moderately impaired cognition with a diagnosis of femur fracture. R4's POLST signed [DATE] identified R4 desired full code status. R4's Provider Order dated [DATE] directed R4's POLST be changed to a DNR status. R4's medical record lacked the new POLST reflecting his wishes for change in code status. On [DATE] at 4:07 p.m., R4 stated he wished to be DNR status. On [DATE] at 2:28 p.m., registered nurse (RN)-B stated she assisted R1 with filling out the POLST form. R1 had requested DNR status with comfort cares. She had checked the wrong box on the POLST form. Staff are required to view the paper POLST form when a resident has no pulse and was not breathing. If R1 had no pulse and was not breathing, staff would perform CPR against his wishes because the POLST form instructed them to do so. On [DATE] at 2:50 p.m., licensed practical nurse (LPN)-A stated she would look at the paper POLST form to determine a resident's code status. LPN-A confirmed R1's POLST instructed staff to perform CPR. On [DATE] at 3:29 p.m.,the director of nursing (DON) stated staff should look at the paper POLST form to determine a resident's code status. On [DATE] at 4:26 p.m., RN-D confirmed R4's wishes were to be DNR status, and the paper POLST in his chart was inaccurate and instructed staff to perform CPR on R4. On [DATE], at 10:37 LPN-C stated any nurse can assist a resident with changing their POLST after confirming the resident was able to make their own decisions. On [DATE] at 11:17 a.m., medical director (MD)-A stated nurses and social workers can assist residents with changing code status with the POLST form. The facility policy Advance Directive dated ,d+[DATE], directed changes to the resident choices for advance directives will be documented, including the resident medical record, the POLST will be updated as necessary, physician orders will be obtained to reflect new choices as applicable, and all items will be communicated to those staff responsible for resident care. The IJ that began on [DATE] was removed on [DATE] at 4:33 p.m., when the facility completed an audit of all resident POLST forms to be reflective of resident wishes and consistent with provider orders, facility policy was reviewed with no changes deemed necessary, new procedures for processing POLST forms and code status orders were developed, and all licensed nursing staff were educated on the new procedures. This was verified though observation, interview and document review.

Based on observation, interview, and record review the facility failed to complete a safe transfer assessment for the use of sit-to-stand mechanical lift and follow manufacturer instructions and maintenance of the lift for 1 of 1 resident (R1) which resulted in a fall from the lift with a fracture. This resulted in an Immediate Jeopardy (IJ) for R1. The IJ began on [DATE], when R1 became tired and weak from standing in the lift while staff changed out two batteries and were unaware of the emergency lowering features which resulted in R1 letting go sustaining left arm fracture and left wrist tendon tear. The Administrator and director of nursing (DON) were notified of the IJ on [DATE] at 5:24 p.m. The IJ was removed on [DATE] after it could be verified that the facility had implemented an acceptable removal plan, however, non-compliance remained at D isolated severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's Diagnoses Report dated [DATE], Alzheimer's, dementia with behavioral disturbance, primary osteoarthritis (condition that affects the joints causing pain, stiffness, and reduced movement) of the right shoulder, anxiety, and was on hospice beginning ,d+[DATE]. R1's Minimum Data Set, dated dated dated [DATE], identified admitted ,d+[DATE]. R1 had moderately impaired cognition with inattentive and disorganized thinking, adequate hearing and vision, no behaviors, and required substantial staff assistance with all activities of daily living. R1's care plan dated [DATE], identified R1 had impaired physical mobility related to osteoarthritis in right shoulder, Alzheimer's, dementia with increased confusion, agitation, and history of delusions. Interventions included assist of one to transfer with the [WeStand]. Brand name of a sit-to-stand mechanical lift. R1's care plan dated revised [DATE], identified R1 had alteration in behavior related to Alzheimer's disease, dementia with behavioral disturbance, generalized anxiety disorder. R1's Behaviors included yelling, hitting, swearing, scratching, kicking, pushing, grabbing, threatening and calling staff names, and refusal with cares and medications. Interventions did not include what staff should do when R1 demonstrated those behaviors. R1's record did not include a comprehensive safe transfer assessment that identified the size and type of back belt/sling used for R1 when a mechanical lift was implemented. There was no mention of R1 had behaviors or mannerisms related to her diagnoses that could arise during sit-to-stand transfers using a mechanical lift. During an interview on [DATE] at 10:08 a.m., physical therapist (PT)-A stated they did not make recommendations for harness/sling size to use on residents. If a resident was not holding onto the stand or has their elbows in the air that would be a reason for nursing to get an evaluation to review the residents change. PT-A stated R1 discharged from therapy on [DATE] and was discharged using a WeStand for transfers. During an interview on [DATE] at 8:26 a.m., trained medication assistant (TMA)-C stated the care sheets (abbreviated care plan for direct care staff) only acknowledged a resident was a mechanical sit-to-stand or full body lift to transfer. TMA-C stated the slings are colored to identify the sizes, there was no height/weight guide on the slings or the lifts. TMA-C explained she knew which sling to use because she had been at the facility for many years and there everyday. During an interview on [DATE] at 9:04 a.m., nursing assistant (NA)-F stated the sling size was not on the care sheets. If a resident had elbows out and was not holding on to the stand properly or complaining of pain under the arms she would get a nurse to assess. NA-F indicated she had not worked with R1 and was not aware of sling size she used and/or R1's transfer ability. During an interview on [DATE] at 9:12 a.m., NA-G stated for standing lift transfers were not included on the care sheets. The sling/harness size was dependent on the size of the resident, sizes came in small, medium, and large. NA-G was aware what size slings resident required because she had worked with the residents before but would ask a nurse if she had to work with different set of residents. During an interview on [DATE] at 8:45 a.m., NA-E explained the sling sizes on the size of the resident, there was small, medium, and large. NA-E knew which sling size to use because it would already be in the resident's room. NA-E stated for the last six weeks when R1 was being raised in the lift, she would say enough, enough or No, staff would just wait a few minutes and try again. She [R1] never stands, she is always on the chair so you can imagine how her knees feel, so you would tell her a little bit more and she would go up a little bit more to get in the position to go to the toilet. NA-E did not articulate if the nurse had been notified or was aware of the difficulty R1 was having with these transfers. During an interview on [DATE] at 2:15 p.m., registered nurse (RN)-B stated sometimes R1 would have issues with transfers and would be quite behavioral; RN-B did not define or elaborate on what issues or behaviors R1 had. RN-B stated it was discussed with R1's family about using the full body mechanical lift, she could not remember how long ago the discussion. R1's family wanted R1 to continue to use the commode for toileting. RN-B explained, if R1 was a full body mechanical lift she would not be able to use the commode. Most of the time the floor staff would make her aware if someone was having difficulty with the WeStand lift, no one had reported to her any concerns with R1. RN-B did not know what she would do if a resident was stuck in the raised position mid-transfer; RN-B would probably have one person stay with the resident and the other one get a new battery. During an interview on [DATE] at 9:26 a.m., RN-C stated staff should be prepared and have all the equipment in position to make the transfer as quick as possible to minimize R1's time in the lift and to prevent and/or minimize R1's behaviors. If a resident was not weight bearing and hanging in the WeStand they would not be able to use the lift. The facility did not have an official assessment for the slings and staff go by the size of the person so it is not too tight or too big so staff can place the sling around them and adjust the seatbelt. During an interview on [DATE] at 3:17 p.m., director of nursing (DON) stated R1 had entered hospice care ,d+[DATE]. The facility did not have a comprehensive safe transfer assessment for mechanical lifts, but nursing staff completed a significant change MDS and all assessments would have been completed during that time frame. DON was unsure if a transfer assessment had been completed since [DATE], even though R1 was on hospice and had been gradually declining and losing weight. During an interview on [DATE] at 3:32 p.m., family member (FM)-A stated R1 hated the WeStand, she always asked to get down. R1 would fight the staff and clench her arms. R1 always had her elbows up and extended outside the stand and never had the strength to hold on to the bars due to her osteoarthritis. FM-A stated about a month ago on R1's video camera they witnessed R1 hanging in the WeStand while staff cleaned the floor. FM-A provided the video to the facility but was not aware of who received it. FM-A reported when she was at the facility on [DATE], the lift stopped working during the transfer, staff left R1 in the lift while they got another battery. Then on [DATE], the same thing happened but R1 fell out of the lift and sustained injuries. FM-A stated since that incident occurred R1 had not been eating or drinking, however, some of that was happening before but after the injury she seemed to decline quicker. R1's progress notes dated [DATE], indicated after R1's shower staff were transferring R1 from the shower chair to the wheelchair with an EZ-stand. The EZ-stand got stuck in the standing position. In the middle of changing the battery, R1 pulled her left hand out of the sling and staff helped her down to the wheelchair. R1 complained of pain with the left arm with touch or activity, unable to grab, move, or even lift the hand. Updated house supervisor, family, and hospice. Got order for an x-ray of left arm. X-ray of two view of the left shoulder, hand and wrist completed at 1:30 p.m. R1's radiology result report dated [DATE] at 8:44 p.m., identified R1 had a minimally displaced fracture at the surgical neck of the left humerus (break in the bone of the upper arm). There is severe degenerative joint disease (deterioration of cartilage and bone) in the glenohumeral joint. The three-view x-ray of the left wrist shows widening of the scapholunate joint space consistent with ligamentous tear or laxity. R1's medical note from the physician dated [DATE], identified R1 has overall significant decline since injury and has been mostly sleeping, less interactive with staff and poor intake. R1's progress note dated [DATE], indicated R1 passed away at 12:30 p.m. on [DATE]. During a phone interview on [DATE] at 1:50 p.m., NA-A stated he had been working on [DATE] and was involved in the incident with R1. NA-A stated he had just completed R1's shower and called trained medication aide TMA-A for assistance with transferring R1 with the lift. NA-A explained he did not feel comfortable transferring R1 alone because R1 was weak. NA-A thought R1 had been weaker for awhile. NA-A was unsure if nurses had been notified of the decline in R1's ability to transfer. NA-A explained when he and TMA-A were raising R1 in the mechanical lift the battery died . NA-A and TMA-A left R1 standing suspended in the lift by the back strap/sling while NA-A left the room to exchange the battery. The new battery did not work either so NA-A left R1's room again to get another battery; R1 continued to be suspended in the lift. NA-A indicated R1 then slipped out of the back strap/sling and landed in her wheelchair. They notified the nurse of the incident. NA-A stated there was something wrong with it [the lift] it had been having issues for a long time but was unaware if anyone had reported the issue or if the lift had been inspected. NA-A was not sure if the lift had been inspected after the incident on [DATE]. NA-A stated they did not use the emergency lowering mechanism on the lift to lower R1 once the lift stopped working. NA-A stated prior to the incident he had not been provided training on the WeStands and had been unaware of how to use the emergency stop or lowering mechanism. NA-A stated recently a similar incident with the battery not working during a transfer happened when R1's family was present and was not aware if a nurse was notified. During a phone interview on [DATE] at 3:54 p.m., TMA-A stated she had been working on [DATE] and was involved in the incident with R1. TMA-A explained R1 was raised in the WeStand and it would not go down. TMA-A tried to physically push the arms of the stand down and they would not move so NA-A changed the battery. TMA-A stated they needed to get two batteries from the charger. TMA-A stated R1 just let go; she slipped her right arm out of the sling which caused her to continue to slide out of the sling and falling into her wheelchair. TMA-A stated RN-A provided education to staff after the incident on how to lower the WeStand - I never seen that before. I have been trained but I did not remember. I usually work as a TMA. During an interview on [DATE] at 2:06 p.m., RN-A stated stated he had been working on [DATE] at the time of the incident. RN-A explained NA-A and TMA-A brought R1 to the nurse's station. They reported when they had transferred R1 from the shower chair to the wheelchair. R1 was stuck on the WeStand in the raised position and when they were tried to lower her the machine stopped. They tried to get a replacement battery but R1 was trying to get out of the sling, they managed to lower R1 to her wheelchair. RN-A had asked if NA-A and TMA-A if they used the manual release to lower R1 when the machine stopped and both staff reported they had pressed the emergency button but it did not work. RN-A stated the two staff were showed the emergency stop button that they pressed, not the emergency release button. After the incident RN-A stated R1 was unable to grab RN-A's hand and unable to raise her arm. RN-A notified hospice, family, and supervisor. RN-A mobilized R1's arm and gave R1 pain medications for comfort and ordered an x-ray. RN-A took the WeStand and placed it behind the nurses station. RN-A used the same WeStand to demonstrate to staff who were working on R1's unit on how to use the lifts emergency functions and had them do return demonstrations. RN-A stated he put on his report sheet for the following shift the WeStand needed to be checked by maintenance. RN-A was unaware of any specific numbers used to identify the machine or batteries that had been used and did not work. She was unsure if the lift he had removed or inspected by maintenance before it was used again. During an interview on [DATE] at 2:00 p.m., NA-D stated prior to the incident she had not been trained on the emergency features on the WeStand. After the incident with R1, RN-A provided education with return demonstration. During an interview on [DATE] at 9:17 a.m., NA-B stated she was unaware of that there was battery indicator light on the WeStand machines. NA-B stated if the battery stopped working while a resident was standing on the lift, she would leave the resident standing and have another staff watch the resident while she got a new battery. During an interview on [DATE] at 1:20 p.m., assistant director of nursing (ADON)-A reviewed that the WeStand distributor (WE)-A had been at the facility for about a week beginning [DATE] providing training on the new lifts. Staff would need education yearly on the lifts during their annual reviews and ADON-B kept track of those. ADON-A stated RN-A educated the four staff working on R1's unit after the incident. Then the house nurses educated staff on the manual release but neither of those education opportunities were documented. During a phone interview on [DATE] at 12:39 p.m., WeStand representative (WE)-A stated he was not notified of R1's incident with the lift until [DATE]. WE-A stated the batteries need to charged for eight hours to have a full charge but that a person could use the battery after an hour of charging, however it wouldn't last very long. WE-A recommended to switch the batteries out at the end of each day to ensure proper charge time. The batteries do not have any memory so the more you charge them the better they are. WE-A stated he was at the facility a few days ago to go over how to fix the issue with the remotes being pulled from the machines. During a subsequent interview on on [DATE] at 4:47 p.m. WE-A reviewed emergency procedures. The emergency red handle on the actuator (arm) of the stand is what a person would lift up to lower a resident. The secondary emergency lowering button would require a pen/pencil tip to poke it and cause the motor to lower the person. Only one emergency lowering mechanism is needed to lower the person, both are not needed to be activated together. There is a battery indicator on the back of the control box that shows how many bars are left in the battery and when the plug shows that means it needs to be put on the charger. WE-A stated if a resident is not using upper body strength and/or has behaviors they should not be using the sit-to-stand machine, staff should not rely on the back belt/sling to hold a resident. During an interview on [DATE] at 10:33 a.m., maintenance director (MAD)-A stated he had just heard about the incident with R1 that occurred on [DATE] just this morning ([DATE]). MAD-A stated the maintenance department was trained to service the lifts. They have had two lifts serviced recently for repairs and could only assume one of the lifts was the one from the incident, as the nursing staff always moved the lifts around the units. The two lifts that were serviced needed to have the remote zip tied because the cord for the remote was being pulled out and losing power to the machine. MAD-A stated there were serial numbers on each lift for them to be tracked, however, this was not completed. MAD-A did not have a system in place to monitor the batteries for the lifts but there was one extra battery for each lift on each neighborhood. MAD-A stated the WeStand representative gave all the in-services for the staff on the equipment he sells and distributes. During an interview on [DATE] at 11:06 a.m., director of nursing (DON), ADON-A, and ADON-B the DON stated prior to getting the WeCare lifts [DATE], the old lifts had battery issues. Staff were used to running and grabbing a battery during a transfer. DON stated at some point NA-A and TMA-A should have used the lowering mechanism to lower R1 to the wheelchair. DON stated NA-A and TMA-A were not able to problem solve of what action to perform first and were trying to do the quickest and most safe thing in their minds. DON stated the harness and sling size were pretty standard and come in different sizes. When the WeStand representative provided initial training last June, he said 90% of residents would use an adult size large. The slings were adjustable by colored loops based on the size of the individual. R1 used adult size large sling. After R1's incident on [DATE], the staff did not make comments about the sling being in disrepair or frayed so it was not examined. DON was unsure which WeCare lift was used for the transfer but thought MAD-A would have known. The facilities Safe Assisted Resident Transfers policy revised ,d+[DATE], identified that stand assist lift (EZ-stand): one staff use assistive device to provide moderate to maximum assist in lifting resident. Resident must be able to bear some weight, participates by following direction and holding onto hand grips. May need two staff if resident needs high level of cueing or has behaviors. The WeStand operating lift manual dated ,d+[DATE], identified that before using the WeStand to transfer patients, all staff must be trained and authorized to use the WeStand. A DVD demonstrating transfer techniques and WeStandTM care was sent to the facility with the lift. This DVD can be used, along with hands on training led by a nurse or professional rehabilitation staff member who has been designated as your facility's mechanical lift trainer, as part of your facility's mechanical lift education program. Only staff members who have been trained according to the procedures in this manual, by a manufacturer's representative, or by a nurse or professional rehabilitation staff member designated as your facility's mechanical lift trainer, be allowed to use the WeStandTM. Watching the DVD without hands on training DOES NOT QUALIFY AS TRAINING. Staff members who have seen the DVD but who have not had hands on training described above may not use the WeStandTM. Before using the WeStandTM, patients must be assessed by the facility's professional nursing or professional rehabilitation staff to determine which patients are suitable for transfer with the WeStandTM, which WeStandTM transfer technique to use, which size belt/sling is appropriate, and the number of staff members necessary to transfer each patient. Although one person can perform patient transfers, certain patients or situations may require the help of one or more additional staff members. For example, patients with unpredictable behavior due to dementia may require additional help if their behavior poses risk of injury to themselves or to staff members. Patients Not Suited For WeStandTM Standing Transfers 1) Patients whose unpredictable behavior during transfers poses risk of injury to patients or staff. Examples are patients who: a) Attempt to pick one or both feet off of the floor during gait belt transfers or off of the WeStandTM foot pad during WeStandTM standing transfers b) Attempt to climb the knee pad c) Attempt to step backward off of the WeStandTM foot pad d) Are unpredictably able to bear weight e) Frequently exhibit combative behavior during transfers f) Are unable to follow simple directions The IJ was removed on [DATE] when the facility inspected all lifts, belts, and slings for function and safety and removed from service any that were out of compliance. The facility reassessed all residents who utilized mechanical lifts with a comprehensive assessment and updated care plans and care sheets for staff. A routine maintenance program was developed and implemented following manufacturer guidelines with monthly and annual lift inspections. The facility reviewed and/or developed policies for stand assist and full lift transfers. The facility developed policies that define procedures for the assessment/re-assessment of resident transfers. Facility staff were trained on all procedures.

Based on interview and document review, the facility failed to have a water management program consistent with nationally accepted standards, e.g., ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) or CDC (Centers for Disease Control and Prevention). This had the potential to effect all 212 residents who resided in the facility. Findings include: During an interview on 3/14/24 at 8:07 a.m., the director of physical plant (DPP)-A, stated he was responsible for the water management program, however was unfamiliar with regulations for a water management program which would prevent growth of Legionella and other waterborne pathogens. DDP-A explained the actions he took related to a water management program which included measuring water temperatures at various sites within the facility and annual testing for Legionella. DDP-A was not aware of additional requirements including completion of a Legionella risk assessment, creating a detailed diagram of the facility water system and following nationally accepted standards for a water management program. During an interview on 3/14/24 at 9:38 a.m., the director of nursing (DON) and registered nurse (RN)-A who was also the infection preventionist were informed of findings related to the water management program. Neither were aware of regulations pertaining to an effective water management program, but would begin to address it. The facility Legionnaire Policy dated 4/2018 indicated: It was the policy to prevent the occurrence of Legionnaire's disease by maintaining a water management program to reduce Legionella growth and spread. The water management program was managed by physical plant. Testing for Legionnaire's disease would be considered if there had been positive environmental tests for Legionella or current changes in water quality that may lead to Legionella growth (such as low chlorine levels). Growth of Legionella could be promoted by biofilm, scale, and sediment, fluctuations in water temperature and pH, inadequate levels of disinfectant, changes in water pressure, and water stagnation. Regular testing of chlorine free levels and regular flushing and cleaning of systems would help prevent the growth of Legionella.

Based on interview, observation and document review, the facility failed to have ongoing communication and collaboration with dialysis facility for 1 of 2 residents (R54) reviewed for dialysis care. Findings include: R54's facesheet printed on 3/14/24, included diagnoses of dependence on renal dialysis (a treatment for failing kidneys to remove fluid and waste from the blood), diabetes mellitus type two, acquired absence of right and left leg below the knee, and dementia. R54's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R54 was cognitively intact, had clear speech, was understood and able to understand. R54 did not walk, uses a wheelchair and has bilateral prosthesis. R54 required partial to moderate assist with activities of daily living, and was totally dependent for transfers. R54 was receiving dialysis. R54's care plan dated 12/7/23, indicated R54 has an alteration in renal function. Interventions included: administer medications as ordered; check access site for bruit (whooshing sound of turbulent blood flow) or thrill (vibratory movement heard through a stethoscope) every shift, if indicated; have ready for pick up on Tuesday, Thursday and Saturday between 6-6:30 a.m.; if bleeding occurs at access site, apply direct pressure, notify doctor and if bleeding does not cease call 911. Notify dialysis if unable to go; monitor for signs and symptoms of bleeding or any significant drop in blood pressure (BP); monitor intake and output; monitor weight and lab data as ordered; observe for changes in mental status such as lethargy, somnolence, fatigue, tremors and or seizures; see current orders for dialysis location with ride times and dates. The care plan did not include instructions on post dialysis fistula site dressings. Physician orders dated 2/14/24 included: check dialysis shunt for thrill and bruit every shift, no BP in left arm and dialysis Tuesday, Thursday and Saturday. During observation and interview on 3/11/24 at 6:03 p.m., R54 indicated the staff never remove her dressing after dialysis from her fistula (connection of vein and artery used for hemodialysis) (a machine that filter out toxins from the blood) because she had problems with bleeding once. R54 stated she will take it off herself the next day sometimes or they remove it when she goes back to dialysis. R54's pointed to left upper arm above elbow and stated fistula site. Site was uncovered with bruising present. During observation on 3/12/24 at 8:45 a.m., R54 was not in room and staff stated R54 was at dialysis. During observation on 3/12/24 at 3:07 p.m., R54 was in her wheelchair in her room asleep. R54 had two, 2x2 gauze dressings taped on left upper arm fistula that are dry and intact. During observation and interview on 3/13/24 at 8:33 a.m., R54 was in her wheelchair. Two, 2x2 gauze dressings remain on her left upper arm fistula site and dry and intact. R54 stated staff are afraid to take it off. R54 stated the dressing should be removed the morning after dialysis. During interview 3/13/24 at 9:07 a.m., registered nurse (RN)-C indicated they send an appointment folder with R54 to dialysis including medication list, face sheet and appointment referral, which the dialysis center should document on and return. RN-C indicated sometimes they get the dialysis run sheet back and sometimes they don't and then will get them in a batch with multiple sheets at a later date. R54's dialysis packet for 3/14/24 was present at the nurses station and included an Appointment Referral form with resident name, physician, transport company, date and time. The bottom portion included blank space for documentation under Resident Condition, Physician Progress Note, and Orders. During observation on 3/13/24 at 9:53 a.m., licensed practical nurse (LPN)-A entered R54's room and changed left hand wound dressing. LPN-A did not remove R54's fistula dressing. During observation and interview on 3/13/24 at 1:35 p.m., R54 was sitting in her wheelchair in her room with two, 2x2 gauze dressings still in place on left arm fistula. R54 indicated the dressing should come off the morning after dialysis and stated I'm going to just take it off myself and proceeded to remove the dressing. Fistula site with bruising present and no bleeding or drainage. During interview on 3/13/24 at 1:37 p.m., LPN-A indicated VS and weights are done prior to R54 going to dialysis and a packet of information is sent with her. When she returns we check fistula site for bleeding and infection. LPN-A stated the dialysis dressing should not come off and sometimes R54 will remove it herself and they have to redress it. LPN-A indicated dialysis is responsible for removal and changing of the dressing and care of the fistula site. During interview on 3/13/24 at 1:40 p.m., RN-C stated we can take the fistula dressing off here but it should be left on for at least 12 hours. RN-C indicated they have never received instructions from dialysis on what to do with the fistula dressing post dialysis. RN-C indicated they send a referral sheet with R54 but that never gets returned and sometimes R54 comes back with no information. RN-C indicated she has never called and requested further information for dressing/fistula site care or to ensure communication is sent back with the resident. RN-C indicated she has had to call the dialysis center when the resident didn't return and found out the resident was hospitalized . During interview 3/13/24 at 2:06 p.m., dialysis center registered nurse RN-D indicated the fistula site dressing should be left on for 4 hours post dialysis. RN-D indicated there can be issues with clotting or infection if left on longer. RN-D added they do not want the dressing left on overnight. RN-D indicated patients are given education on fistula site care and dressing removal and any pertinent labs or weight changes. RN-D indicated for residents at long term care facilities, if a communication or referral form comes with the resident, it should be filled out for their care givers regarding post treatment and cares, changes to orders, complications experienced during dialysis and if any bleeding from the fistula site. During interview on 3/13/24 at 2:29 p.m., the director of nursing (DON) confirmed facility has a dialysis policy and procedure but it doesn't address fistula site dressing. The DON stated he would expect the dialysis facility to instruct the facility on the fistula dressing. The DON confirmed the physician orders don't address the fistula dressings either, nor does the plan of care. The DON stated he would expect communication to be documented on the referral form that is being sent from the facility and if not being done someone should have followed up on this. The facility Practice Guideline and Procedure: Care of a Resident with End Stage Renal Disease receiving Dialysis policy and procedure, last reviewed 9/2023 included: A. Residents on dialysis will have a care plan in place to ensure adequate communication between the dialysis center and the facility, prevention of avoidable complications, appropriate response in case of emergency or acute change in condition. B. The facility will establish communication process between the facility and the dialysis facility to be used 24 hours a day. The care of the resident receiving dialysis services must reflect ongoing communication, coordination and collaboration between the facility and the dialysis staff. The communication process should include how the communication will occur, who is responsible for communicating, and where the communication and responses will be documented in the medical record including but not limited to: - Timely medication administration by nursing home and/or dialysis facility -Physician/treatment orders, laboratory values and vital signs - Advance directives and code status; specific directives about treatment choice; and any changes or need for further discussion with the resident/representative and practitioner. -Nutritional/fluid management including documentation of weights, resident compliance with food/fluid restrictions or the provision of of meals before, during and/or after dialysis and monitoring intake and output measurements as ordered -Dialysis treatment provided and resident's response, including declines in functional status, falls, the identification of symptoms such as anxiety, depression, confusion and/or behavioral symptoms that interfere with treatments -Dialysis adverse reactions/complication and/or recommendations for follow up observations and monitoring, and/or concerns related to the vascular access site. -Changes and or decline in condition unrelated to dialysis. This would include communication related to care concerns such as a resident who is at risk for or who has a pressure ulcer, receiving appropriate interventions; and -The occurrence or risk of falls and any concerns related to transportation to and from the dialysis facility. C. Nursing staff will maintain an awareness of the care and precautions surrounding grafts, fistulas, and other access devices. D, Routine methods for communicating information to/from the facility and dialysis center will be utilized to document pertinent information (e.g. dialysis Post Treatment form). E. Care of Arterio-venous fistulas: -Care involves the primary goals of preventing infection and maintaining patency of the catheter (preventing clots)

Based on interview and document review, the facility failed to make a follow-up appointment for 1 of 2 residents(R54) reviewed for vision. Findings include: R54's face sheet printed 3/14/24, indicated admitted [DATE] and included diagnoses of diabetes mellitus type 2, end stage kidney disease, bilateral below the knee amputations, and cataract (clouding of lens of the eye that affects vision) extraction bilateral. R54's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R54 had intact cognition, was dependent on staff for toileting, and required partial to moderate assist with personal hygiene, and transfers and rolling required substantial to maximum assistance. The MDS also indicated adequate vision, and no corrective lenses. R54's care plan printed 3/14/24, did not include a visual impairment. During interview on 3/11/24 at 6:11 p.m., R54 indicated she has asked more than once to see an eye doctor over the past year. R54 stated she feels like she is losing her vision and it is blurry especially in the mornings when she gets up. R54 added she used to get shots in her eye and she isn't sure why she doesn't get them anymore. During observation on 3/12/24 at 8:45 a.m., R54 was at dialysis. During interview and observation on 3/13/24 at 8:33 a.m., R54 indicated she has not seen an eye doctor for over a year. R54 stated she used to go every month and the last time she went, the eye doctor told her they would see her in a month but she hasn't seen them since. R54 stated she had cataract surgery 4-5 years ago and continued to get the injections in her eye after that so she isn't sure why she doesn't go anymore. R54 stated she has blurred vision especially in the morning and just can't see like she used to. R54 was sitting in her wheelchair 6 feet from the television and indicated she can see that far most of the time but not always. R54 stated she has asked them multiple times about seeing an eye doctor and they still haven't scheduled one for her. R54's progress note dated 12/22/23 at 2:41 p.m., by registered nurse (RN)-B, also identified as nurse manager) indicated a care conference was completed. Comments included R54 would like to be scheduled for vision appointment. A Retina Consultants of Minnesota visit dated 6/14/21, indicated R54 has diabetic macular edema (swelling in the eye causing blurred vision) in her right eye and severe nonproliferative diabetic retinopathy (large number of bulging and leaking blood vessels in the retina) in her left eye. R54 has posterior vitreous detachment (condition of the eye where the gel that fills the eye separates from the retina) in both eyes. R54 had Eylea injection (drug used to treat wet age-related macular degeneration (eye disease that affects central vision resulting in blurred or no vision) to help slow vision loss) today and was well tolerated. R54 was to follow-up in 12 weeks. A Retina Consultants of Minnesota discharge instruction dated 1/18/23 indicated R54 had an intraocular injection of VEGF inhibitor (slows the abnormal growth of blood vessels and used in age related macular degeneration) was given. A follow up appointment is scheduled for Tuesday 4/11/23 at 1:30 a.m. The electronic medical record (EMR) did not include any further follow-up visits. Requested further information on follow-up visits. During interview at 10:39 a.m., the director of nursing (DON) indicated the nurse manager (who is currently on vacation) sent a message last week asking that R54 be scheduled to see the eye doctor and she is scheduled for 4/9/24. During interview on 3/12/24 at 11:03 a.m., DON indicated the 6/14/21 visit was prior to R54's arrival to facility and he did not find any further follow-up. Upon further review of the medical record, the DON did confirm there was discharge instructions from a visit on 1/18/23 which included a follow-up appointment was scheduled for either 4/11/23 or 6/11/23 (this was hand written and difficult to read) at 1:30 a.m., which the DON indicated was likely 1:30 p.m. The DON indicated he will investigate this further. During interview on 3/13/24 at 2:44 p.m., the DON stated he contacted Retina Consultants of Minnesota and R54 never attended her 4/11/23 appointment. The DON indicated the health unit coordinator was responsible for appointments and was no longer at the facility to investigate why and there was no order in the EMR to indicate this appointment was scheduled. The DON confirmed the appointment was missed and made an appointment for R54 on Friday 3/15/24. A policy or protocol for assisting residents with making appointments was requested however, the DON indicated the facility had none.

Based on observation, interview and document review, the facility failed to provide routine shaving for 1 of 1 resident (R36) reviewed for activities of daily living (ADL) who was dependent on staff for cares. Findings include: R36's face sheet printed 3/14/23, indicated R36 had diagnoses including heart failure (progressive disease that affects pumping action of heart muscle), morbid obesity, arthritis, and respiratory failure (serious condition that affects breathing and oxygen levels). R36's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R36 had intact cognition, no care refusal behaviors, and requires partial to moderate assist with personal hygiene. R36's care plan dated 6/28/23, indicated R36 had a self care deficit and will be clean and well groomed through the review period. The care plan indicated R36 required assist of one as needed with dressing, grooming and bathing. The care plan did not include shaving. R36's resident care sheet indicated shaving as needed. R36's task list included shaving. Review of this list for was the resident shaved, for the past 30 days indicated no data was found. During observation and interview on 3/11/24 at 4:30 p.m., R36 was observed seated in a wheelchair with white whiskers present on lower face approximately, 1/4 inches in length. During interview, R36 indicated she would prefer not to have whiskers but staff do not perform that care. R36 indicated her daughter generally does her hair weekly and shaves her whiskers then, but has been out of town and now is ill. During observation and interview on 3/12/24 at 1:29 p.m., R36 was observed sitting in her wheelchair with chin hairs still present. R36 indicated she doesn't like having whiskers but since her daughter is not available and she will have to wait until she returns. R36 indicated she does not have a razor to shave and staff here don't do that. During observation on 3/13/24 at 8:38 a.m., R36 was wheeled to the shower by nursing assistant (NA)-A and returned to her room at 9:01 a.m. During observation and interview on 3/13/24 at 11:28 a.m., R36 was seated in her wheelchair with chin hairs present. R36 was pulling on her whiskers and indicated the whiskers bug her and she wishes they were gone. During interview on 3/13/24 at 11:32 a.m., trained medication assistant (TMA)-A indicated staff keep shavers in a cart on each unit. TMA-A indicated all residents should be shaved on the day they receive a shower or more often if whiskers are visible. During interview on 3/13/24 at 11:36 a.m., NA-A indicated she wasn't aware she was supposed to shave R36 or that R36 wanted to be shaved. During interview 3/13/24 at 12:07 p.m., registered nurse (RN)-A, also the unit manager, indicated if whiskers are visual they should be shaved off. During interview on 3/13/24 at 2:46 p.m., the director of nursing (DON) confirmed if whiskers are present, the resident should be shaved. Requested a policy and procedure on resident shaving or activities of daily living and the DON indicated there was none. A Nurse Aide Clinical Skill Competency checklist for new hires was shared which included: shaving for all genders unless specified on care sheet/plan.

Based on observation, interview and document review, the facility failed to comprehensively assess and implement interventions to prevent additional pressure ulcers from developing for 1 of 1 residents (R173) who had two unstageable pressure ulcers (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar). This resulted in actual harm for R173. Findings include: R173 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R173's admission minimum data set (MDS) dated [DATE], identified R 173 as having a baseline interview for mental status (BIMS) of 15 (cognitively intact). R173 required extensive assistance with activities of daily living (ADL's) that included mobility. The MDS identified R173 as being at risk for pressure ulcers and identified 1 venous/arterial ulcer (back of left calf) with interventions of a dressing change. No other interventions were noted. The MDS did not include a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care area assessment (CAA), included PU as a care area of concern. The CAA referred to the care plan. Review of the admission (temporary) care plan dated 8/11/21, identified R173 as having physical impairment in mobility, related to being non-ambulatory. R173 was also identified as having impairment in skin integrity, secondary to [CONDITION(S)] in left lower leg. Interventions included: turn and reposition every 2 hours, encourage to shift weight when in bed and wheelchair, check skin weekly on bath day, avoid massage on bony prominence's, document skin condition and report any changes to the provider, float heels, pressure reduction mattress on bed and pressure reduction cushion on chair. Review of the weekly skin checks from 8/11/21 to 9/9/21, did not identify any skin breakdown on R173's heels. R173's progress note dated 9/10/21, at 4:55 p.m. indicated R173 has a intact blister on the right heel. The blister measured 3.0 centimeters (cm) by 3.0 cm. and foot boots were placed in R173's room to wear at night. The note did not identify if this was a PU and what stage, along with description of the wound characteristics, pain, or treatment. There was no indication an assessment was completed to determine how the PU developed or implemented interventions to prevent additional PU from occurring. R173's progress note dated 9/14/21, at 4:53 a.m. indicated R173 had pressure injuries to both heels, 4 days after a blister was noticed on the right heel. R173's wound assessment tool dated 9/14/21, identified R173 as having a unstageable pressure ulcer to the left heel that measures 1.5 cm by 2.4 cm. The ulcer was described as having a moderate amount of serosanguineous drainage and the surrounding skin to be macerated (softening and breakdown of skin). [MEDICATION(S)] (a antimicrobial foam that absorbs exudate) dressing applied. The assessment identified a right heel ulcer that measured 3.5 cm by 5.0 cm, with a large amount of serosanguineous drainage. The ulcer is black/purplish in color with blistered areas. [MEDICATION(S)] applied. Interventions listed: offload heels in bed with pillows or heel boot. R173's nurse practitioner (NP)-A progress notes dated 9/14/21, identified R173 with bilateral [CONDITION(S)] and wounds. Right and left heel wound had been debrided in the a.m. The right heel wound was identified as having a blister last week and is now draining. Lower extremities exhibit vascular skin changes with chronic [CONDITION(S)], due to diabetes mellitus and PVD (reduced blood flow to the limbs). (PVD was not included in the admission or current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The calf wound was present on admission. During observation and interview on 9/14/21, at 10:00 a.m. R173 was sitting in a recliner, with legs slightly elevated on the foot rest of the recliner. Both feet were wrapped with ace bandages. R173 stated she had 2 PU's on both heels and a wound on the back of her calf. Both heels were resting directly on the foot rest of her recliner. R173 further stated she did not recall having PU's prior to admission to the facility. During observation on 9/15/21, at 2:00 p.m. R173 was observed to be sleeping in her recliner with both legs elevated. Both heels were resting on the foot rest of the recliner. No interventions were implemented to keep pressure off of the heels. During observation and interview on 9/16/21, at 10:30 a.m. R173's ulcers of the heels were measured by licensed practical nurse (LPN)-A. The right heel ulcer measured 3.8 cm by 5.2 cm., the skin was reddened around the ulcer with slough tissue in the center. The left heel ulcer measured 2.0 cm by 2.6 cm with 100 percent eschar (dead tissue). The skin was reddened and macerated (when skin is too moist) around the ulcer. LPN-A cleansed both ulcers and applied a calcium alginate dressing. R173's lower legs were slightly bluish in color. R173 stated she had [CONDITION(S)] in both of her legs. LPN-A stated R173 did not have the heel ulcers upon admission, but was unsure when the heels started to break down. LPN-A further indicated R173 did not have any interventions in place, other than to wear heel protectors in bed at night. R173 stated she does not lay in her bed during the day, but rather rested in her recliner. During observation on 9/16/21, at 12:00 p.m. R173 was sitting in her wheelchair with both heels resting on the foot pedals. R173 did not have any interventions implemented to prevent pressure on her heels. The heel protectors were laying on her bed. R173 indicated she was not sure when she was suppose to wear the heel protectors, and that the staff put them on. During observation on 9/16/21, at 3:00 p.m. R173 was sitting in her wheel chair. Both heels were resting on the foot rest. No interventions were in place to keep pressure off of her heels while she was in her wheelchair. During observation on 9/17/21, at 10:00 a.m. R173 was sitting in her wheelchair with both of her heels resting on the foot rest. R173's heel protectors were on the bed. Interview with registered nurse (RN)-A at this time, stated she was unsure when R173 is to wear heel protectors, but would look up the order. After RN-A looked up the order, she stated R173 was to have heel protectors on in the am and throughout the day. RN-A further indicated she was unsure who was responsible for applying R173's heel protectors. R173's current physicians orders dated 9/16/21, included to off load /float heels every shift. R173's nursing assistant (NA) care sheet dated 9/17/21, identifies R173 as having [CONDITION(S)] in the lower extremity. The NA care sheet did not include R173's heel wounds nor did it include interventions to prevent skin breakdown . R173's current plan of care dated 9/17/21, identified R173 as having impaired mobility and non-ambulatory. R173 requires assistance of 1-2 staff with positioning. R173 utilizes a wheelchair. R173 was identified as having impairment with skin integrity related to a pressure injury of the right and left heels, and a vascular wound to the left calf. Interventions included: check skin weekly and monitor, pressure redistribution mattress and chair cushion, encourage position changes and float heels. Interview on 9/16/21, at 2:00 p.m. NA-B indicated she was not aware of R173's ulcers on the heels. NA-A indicated she follows the NA care sheet when providing care for the residents. NA-A confirmed R173's heel protectors and heel ulcers were not included on the NA care sheet. Interview on 9/17/21, at 9:30 a.m. NA-B indicated he was not aware of R173s heel wounds. NA-B confirmed he was assigned to provide cares for R173 that day, but was not aware of any interventions related to offloading heels. Interview on 9/17/21, at 10:30 a.m. assistant director of nursing (ADON)-B, indicated all staff are trained on prevention of pressure ulcers. ADON-B further indicated staff should have monitored R173's pressure ulcers more closely and assure interventions were implemented to keep pressure off of the heels. Review of the facility policy The prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment analysis identifies and implements interventions consistent with residents risk factor, goals and standards of practice. Effects of the interventions are monitored and revised as the residents condition changes.

Based on observation, interview and document review, the facility failed to assess, monitor and implement pressure relieving interventions for 1 of 3 residents (R85) reviewed who were at risk for pressure ulcer development/deterioration. The facility's failure resulted in R85 sustaining harm when the resident developed 2 unstageable pressure ulcers on the right heel. Findings include: Pressure ulcer stages from the National Pressure Ulcer Advisory Panel (NPUAP) defines Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. R85 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During interview and observation on 7/8/19, at 3:38 p.m. R85 indicated she had a sore on her right heel that staff were treating with a treatment cream. R85 was observed sitting in a wheelchair wearing gripper socks, the resident wore no shoes, and had both feet resting flat on the foot pedals. The right heel was resting on the back of the pedal. R85 further indicated she often would bump her right heel against the pedal causing her pain, and that both her feet/heels were always resting on the foot pedals when she is sitting up in her wheelchair for the day. During observation and interview on 7/10/19, from 9:51 a.m. to 1:00 p.m. R85 was observed sitting in her wheelchair with both feet resting on the foot pedals. The residents right heel was resting flat on the back of the foot pedal. The resident had gripper socks on with no shoes. R85 indicated her feet hurt at times and that her right heel sore hurts when she bumps it throughout the day. R85 indicated she is up in her chair most of the day and that she does not elevate her legs or wears heel protectors or heel lift boots. R85 indicated she is unable to move her legs/feet independently to keep the pressure off of her heels for very long. Review of R85's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R85 as having a baseline interview for mental status (BIMS) score of 15 (no cognition impairment).The MDS further indicated R85 required extensive assistance with activities of daily living (ADL's) that included repositioning. R85 is at risk for pressure ulcers and has an unstageable pressure ulcer that was not present on admission (right heel) and a suspected deep tissue injury that was present on admission. Interventions included: pressure reducing device on the bed/wheelchair and is on a repositioning program as well as receiving a nutritional intervention. Review of R85's Braden Scale for Predicting Pressure Sore Risk dated 5/10/19, identified R85 as being at moderate risk for developing pressure ulcers. Review of the current plan of care dated 9/17/18, identified R85 as requiring extensive assistance with all ADL's that included repositioning. R85 is identified as having impairment in skin integrity and having a current pressure ulcer to the right heel. Interventions: check skin weekly, assist with repositioning, dietary supplement, evaluate skin and tissue tolerance, follow skin care policy, air mattress to bed, reposition every 2 hrs and as needed (PRN), wheelchair cushion, wound treatment and float heels when in bed. During observation and interview on 7/10/19, from 1:41 p.m. to 3:00 p.m. R85's right heel pressure ulcer was measured by registered nurse (RN)-B at 4:41 p.m. The right heel ulcer measured 2.0 centimeters (cm) by 2 1/2 cm. The area was dark bluish in color, spongy and non-blanchable with a slightly whitish center. There was a newly identified pressure ulcer (unstageable) located to the left of the original ulcer that measured 1.0 cm by 2.0 cm that was also dark bluish in color, non-blanchable and spongy. R85 complained of pain when the right heel was touched and indicated she often bumps the sore on the foot pedals when her feet fall off the pedal. During this time, R85 continued to have both feet/heels resting on the foot pedals without any protection to relieve pressure from the heels/ulcer. Interview with RN-B at this time, indicated the right heel pressure ulcer was identified sometime in 10/18, after admission. RN-B further indicated there were interventions to off-load the right heel in bed with a pillow, but there were no interventions to relieve pressure from the heels when the resident was sitting up in the wheelchair. RN-B revealed the newly identified pressure ulcer to the heel was identified on 7/7/19, but the staff had failed to assess, document in the medical record, notify the physician or implement new interventions. The physician had not been notified and no treatment changes were made with the change in the pressure ulcer. After RN-B measured the residents right heel ulcer and left the room, R85 continued to have her feet/heels resting on the foot pedals with no intervention implemented to off-load the pressure on her heels. With continuous observation up until 3:00 p.m. R85's heels remained placed on the foot pedals Review of a wound data tool dated 10/18/18, identified R85 with an acquired unstageable pressure ulcer to the right heel that measured 1.0 cm by 1.8 cm. The ulcer was described as being purple in color and skin barrier was applied. Review of the weekly wound data tool for the right heel pressure ulcer after it had been identified on 10/18/19, was reviewed. There were no weekly wound assessments done from 10/31/19 to 12/28/19, to assess the progress of the right heel ulcer after identified. See below measurements and progress of the right heel ulcer: Dates: (right heel) 10/24/18-10/31/19- 1.0 cm by 1.8 cm (100% eschar) 12/28/19- 1.0 cm by 1.8 cm (no changes in description) 1/10/19-1/25/19- 0.5 cm by 1.5 cm (100% eschar). 2/1/19-2/22/19- 0.5 cm by 1.0 cm (100% eschar) 3/1/19-3/29/19- 0.5 cm by 1.0 cm (100% eschar) 4/5/19-4/26/19- 0.4 cm by 1.0 cm (100% eschar) 5/3/19-5/31/19- 0.5 cm by 0.5 cm (100% eschar) 6/7/19-6/29/19- 1.0 cm by 2.0 cm with 20% granulation and slough. No notification of physician or change in treatment. 7/5/19-7/10/19- 1.0 cm by 2.0 cm 50% granulation and 50% slough. No notification of physician or change in treatment. Review of the current physicians orders for R85 included an order for [REDACTED]. There had been no changes in the treatment order to R85's right heel since the pressure ulcer was identified. Review of the physician progress notes [REDACTED]. Review of a wound nurse visit and note dated 11/28/19, identified R85's right heel as an unstageable pressure ulcer that measured 1.5 cm by 2.5 cm with a crusty loose flaky edge and a deep maroon colored center. Interventions: suspend heels with a pillow. No further visits or communication with the wound nurse was found in the medical record after that time. During observation and interview on 7/11/19, from 9:43 a.m. to 1:30 p.m. R85 was observed sitting up in her wheelchair in the dining room eating breakfast. The residents feet/heels were resting on the foot pedals. The resident had only socks on. R85 indicated she tries to keep her right heel off of the foot pedal but it is difficult for her to do independently. R85 further included that when she attempts to move her right foot she bumps the heel ulcer causing her pain. During interview on 7/10/19, at 2:00 p.m. trained medication assistant (TMA)-D and TMA-C both confirmed R85 did not have interventions in place to off-load the heels when in the wheelchair. TMA-D and TMA-C indicated R85 would not be able to elevate her feet/heels independently and verified the resident rests her heels on the foot pedals when up in her chair. TMA-D and TMA-C both indicated R85's heels are off-loaded only during the night when in bed with a pillow under legs and that the resident rarely rests in bed during the day. TMA-D and TMA-C confirmed R85 always wears gripper socks when up for the day. During interview on 7/11/19, at 12:05 p.m. RN-D confirmed R85's pressure ulcer had not been routinely monitored for healing or re-assessed when the pressure ulcer worsened or when a new pressure ulcer was identified. RN-C further verified interventions to promote healing and prevent pressure on the residents heels had not been implemented. Interview with the director of nursing (DON) on 7/11/19, at 12:12 p.m. stated he expected staff to follow the facility's policy on wound/pressure ulcer care and this had not been done. The facility's 11/16 Prevention and treatment of [REDACTED].