Every finding on record at Madison Healthcare Services

Based on observation, interview and document review, the facility failed to ensure the call light was accessible for 1 of 1 residents (R30) who was reviewed for call light placement.Findings include:R30's face sheet dated 1/27/26, indicated R30 had low back pain, osteoarthritis, and a wedge compression fracture of R30s lumbar. R30's care plan dated, 1/8/26, directed staff to make sure R30's call light was within reach and to encourage R30 to use the call light. During an observation on 1/26/2026 at 10:02 a.m., R30 was sitting in the recliner covered with a blanket. R30's call light was attached to the bed rail across the room and not within reach of R30.During an observation on 1/26/2026 at 3:58 p.m., R30 was sitting in the recliner covered with a blanket. R30s call light was still attached to the bed rail across the room. R30 indicated if she needed anything she would use the call light to call the nurse for assistance. R30 stated R30 was able to use the call light but the call light was not within reach. R30 further stated she could not call for help because the call light was attached to the bed and no within her reach. R30 indicated she was unable to get to the call light across the room. During an observation/interview on 1/26/2026 at 4:16 p.m., trained medication aid (TMA) confirmed R30s call light was attached to R30s bed and R30 could not reach the call light. TMA moved R30s call light to her recliner and R30 stated oh I can call for help now.During an interview on 1/26/2026 at 4:52 p.m., director of nursing (DON) stated she expected all residents to have their call light by them at all times. DON further stated R30 could use her call light appropriately and R30's care plan stated R30 was to have her call light by here at all times. DON indicated it was important residents have their call lights so they could call for assistance if they needed it.Facility policy titled call light - answering of revised 6/25 when resident is in bed or confined to a chair, call light will be within easy reach of the resident.

Based on observation, interview, and document review, the facility failed to ensure residents were assessed for the ability to self-administer medications (SAM) for 1 of 1 resident (R41) reviewed for medication administration.Findings include: R41s facesheet indicated R41 had Alzheimer's disease, heart failure, and hypertension.R41s care plan dated 12/10/25, lacked documentation that R41 could self-administer medications. R41's electronic medical record (EMAR) lacked a [NAME] assessment. During an observation on 1/26/26 at 11:30 a.m., licensed practical nurse (LPN-A), placed R41s Xarelto 20mg medication in a medication cup in front of R41 at the dining room table. R41 indicated she wanted to eat a couple bites before she took her medications. LPN-A left medication cup with resident and walked away. LPN-A passed medications to two other residents. At 11:40 a.m., LPN-A talked to R41, R41 stated she took her medication and LPN -A stated thanks and walked away. In an email from director of nursing (DON) on 1/26/26 at 2:27 p.m., DON indicated a self-administration assessment was not completed for R41. During an interview on 1/26/2026 at 4:05 p.m., LPN-A confirmed the medication was set in front of R41 and LPN-A did not observe R41 take the medication. LPN -A stated R41 likes to have a few bites of food before R41 takes the medication. LPN indicated she did not know if R41 had a self-administration assessment. During an interview on 1/26/2026 at 4:48 p.m., DON stated her expectations were for staff to watch all residents take their medications. DON further stated R41 was on the list to have a self-administration assessment completed but that it had not been completed yet.Facility policy titled medication self-administration revised 9/25, residents may self-administrate drugs if a registered nurse (RN) has determined that it is safe.

Based on observation, interview and document review the facility failed to ensure resident status was accurately reflected in the Minimum Data Set (MDS) for 1 of 1 residents (R6) reviewed for pressure ulcers.Findings Include:The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual for Version 1.18.11 dated 10/23, was published by the Centers for Medicare & Medicaid Services (CMS). Section M of the RAI identified intent was to document the risk, presence, appearance, and change of pressure ulcers/injuries. The RAI identified if the resident had any pressure ulcer/injury (Stage 1, 2, 3, 4, or unstageable) in the 7-day look-back period, to proceed to M0300, Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage. The RAI identified a stage 3 pressure ulcer as full thickness tissue loss, in which subcutaneous fat may be visible and it may include undermining or tunneling. R6's admission Minimum Data Set (MDS) dated [DATE], identified R6 had moderate cognitive impairment and had diagnoses which included, hypertension, thyroid disorder and polyneuropathy (disease of nervous system). R6's MDS identified R6 had one stage 3 pressure ulcer. R6's care plan revised 11/6/25, identified R6 had potential for skin impairment due to impaired mobility, incontinence and Braden score of 18, indicating a mild risk for pressure injuries. Interventions included pressure-reducing devises: mattress on bed and cushion in wheelchair, and weekly treatment by wound care nurse. Review of R6's Wound Consult Nursing Note dated 11/6/25, identified wound located at the gluteal fold and was oblong. Wound cause appeared to be moisture associated skin damage (MASD) verses pressure. Wound 1.0 X 0.3 X 0.1 centimeter (cm). During observation on 1/26/26 at 9:46 a.m., nursing assistant (NA)-B and NA-C assisted R6 to stand up from toilet, using a sit to stand lift, performed perineal cares, then assisted R6 to recliner. R6 was noted to have a small black closed slit approximately 1/2 inch in length at the top of gluteal fold above coccyx. It appeared to have a white ointment covering the area. NA-B indicated the nurse had applied ointment to the area after R6 received morning cares. During interview on 1/26/26 at 12:48 p.m., NA-B indicated R6's wound appeared the same since R6's admission. During interview on 1/26/26 at 2:32 p.m., registered nurse/wound nurse (WN)-A stated had assessed R6's wound a few months ago. WN-A stated it was MASD. WN-A stated it was a small slit near R6's coccyx and it was not caused by pressure. WN-A confirmed R6 did not have a stage 3 pressure ulcer. During interview on 1/26/26 at 2:40 p.m., director of nursing (DON) confirmed that R6 did not have a stage 3 pressure ulcer and would expect the MDS to be accurately coded. DON indicated WN-A's wound assessment was completed during the MDS look back period so it should have been used for the MDS assessment. DON stated it was important for the MDS to be completed accurately to ensure it was properly documented and for financial reasons. DON indicated the facility would complete a correction of R6's admission assessment. The facility policy titled Assessments revised 12/25, identified purpose was to ensure all assessments were done according to federally mandated time frames. The policy identified all assessments were completed in Point Click Care (PCC) by the appropriate department, at minimum, within the mandated time frames, and dated within the MDS observation period, if applicable. The policy included various assessments to be completed on admission/readmission, quarterly, and with significant change.

Based on observation, interview and document review, the facility failed to recognize, evaluate and address the nutrition and hydration intake for 1 of 3 residents (R1) reviewed for nutrition. In addition, R1 was not administered physician ordered enteral feedings and water flushes due to missing equipment. This failure resulted in significant weight loss, malnutrition, and weakness.Findings include:R1's quarterly Minimum Data Set (MDS) assessment, dated 10/8/25, R1's cognition was intact without behaviors. R1 was frequently incontinent of bladder and always continent of bowel. R1's weight was 109 pounds and received tube feedings.R1's diagnoses included, anemia, adult failure to thrive, severe protein-calorie malnutrition, abnormal weight loss, muscle weakness, disorder of the intestines.R1's care plan dated 12/22/25, identified she had a feeding tube and directed staff to administer free water flushes, enteral feeds and site care per primary care provider orders. Registered dietician to evaluate quarterly and as needed (PRN). Monitor caloric intake and estimate needs. Make recommendations for changes PRN. Staff were directed to monitor food and fluid intake daily, provide and serve diet as ordered. Regular diet/texture and thin consistency. Record meals and fluid intake during each meal. Weigh weekly per facility policy (unless otherwise specified per provider orders and PRN).R1's provider orders included:-On 10/16/24, Regular diet- easy to chew texture, thin regular consistency as tolerated.-On 11/20/24, Daily weight one time a day every Tuesday, Thursday, Saturday related to unspecified severe protein-calorie malnutrition: abnormal weight loss. Update Provider with any notable changes.-On 11/20/25, Administer 1 container of [NAME] Farms 1.5 (calorically dense, plant based formula designed for enteral feeding) one time a day every Tuesday, Thursday, and Saturday. (goal weight 108 -112lbs). updated 1/8/26-see below.-On 12/4/25, free water flush 30 ml one time a day every Tuesday, Thursday, and Saturday for enteral tube feeding. updated 1/8/26-see below.R1's updated orders:-On 1/8/26, Daily weights one time a day for weight loss, start date 1/9/26.-On 1/8/26, administer 1 container of [NAME] Farms 1.5 one time a day every Tuesday, Thursday, Saturday, Sunday, (goal weight 108 to 112lbs).-On 1/8/26, 30 ml of free water flush one time a day every Tuesday, Thursday, and Saturday, Sunday.R1's December 2025 Electronic medication/treatment administration record (EMAR/TAR) from 12/1/25 through 12/31/25, identified:-There were 8 doses administered of [NAME] Farms and 30ml's of free water, 2 doses refused (12/2/25, 12/9/25) and 3 doses were not administered (12/25/25, 12/27/25, and 12/30/25).R1's January 2026 EMAR from 1/1/26 through 1/11/26 identified:- [NAME] Farms and 30ml of free water were documented as not administered on 1/2/26 and 1/3/26, 1/8/26 and R1 refused one dose on 1/6/26.R1's medical doctor (MD)-A (primary provider) visit dated 11/19/25, identified she was seen at care center for routine nursing home visit. R1's weight improved after last visit. She had since then received tube feedings three times a week and maintains 110lbs (weight today). R1 was happy about this and would like to continue current plan of care.R1's progress notes identified:-On 12/4/25 at 12:11 p.m. Interdisciplinary Team (IDT) Nutritional Risk: weight 112lb, R1's weight was currently within a healthy range and has been stable over the past 90 days, continues external feeds, registered dietician (RD) goal weight remained 112-117lbs, which she was currently meeting. Continue to monitor, enteral feeds, and promote oral intake.-On 12/25/25-1/8/26 R1's MIC-KEY tube extensions (used for daily continuous/pump feeding) were both thrown away and there were no replacements available to administer feeding.-On 1/4/26 at 3:56 p.m. R1 is freezing cold, weak, and stated she felt like she was dying. R1 requested to be seen by medical doctor (MD) today. Sent to emergency room (ER).-On 1/4/26 at 5:56 p.m. R1 returned from ER. No new orders to follow-up with MD in three days.-On 1/8/26 at 1:59 p.m. R1 to appointment for follow-up From ER visit.-On 1/8/26 at 2:59 p.m. Back from appointment. Orders to consult dietician due to recent weight loss. Change tube feedings to four times a week, Tuesday, Thursday, Saturday, Sunday, daily weights. Follow up in one week. Appointment made with provider 1/15/26 at 1:30 p.m.-On 1/8/26 at 11:38 p.m. Enteral feed order and free water flush. Extension not available and R1 will not drink supplement.-On 1/9/26 at 12:06 a.m. R1 had been tired since before supper. She sat slumped over sleeping in dining room for supper and caused concern from other residents. R1 was taken back to her room and placed into bed.-On 1/10/26 at 3:23 p.m. R1's sister arrived at care center and requested an update. R1 was very confused, did not seem like herself, tired, could barely keep her eyes open, and felt like crap. Asked if she wanted her evaluated in ER, wanted to speak to sister and let staff nurse know.-On 1/10/26 at 10:30 p.m. R1 was weak and had trouble holding water mug this shift.-On 1/11/26 at 8:00 a.m. Cefdinir antibiotic ordered for urinary tract infection (UTI) on 1/4/26.R1's weights from 12/13/25 through 1/13/26, identified:-12/13/25 at 10:25 a.m. 108.6-12/20/25 no weight documented-12/27/25 at 2:47 p.m. 109.6-12/28/25 through 1/7/26 no weight documented-1/8/26 at 2:56 p.m. 101-1/9/26 at 9:01 a.m. 99.3-1/10/26 at 12:22 p.m. 99.9-1/11/26 at 2:42 p.m. 99.4-1/12/26 no weight documented-1/13/26 at 11:49 a.m. 100. 5R1's Meal Intake Record from 12/24/25, through 12/31/25, identified: breakfast refused each day with lunch, and supper consumed 0-100% and documented a total of 1710 ml's of fluids intake. R1's Meal Intake Record from 1/1/26, through 1/9/26,identified: Breakfast - refused all 9 days. Lunch and supper consumed 0-75% and documented a total of 2350 of fluids took in.Communication with staff via point click care (PCC) (electronic medication records staff communication site) from 1/7/26 through 1/13/26, identified:R1's ER visit on 1/4/26 at 3:50 p.m. identified she presented with generalized weakness, recently diagnosed with shingles before Christmas, and does not feel well. R1's weight was 105 # and heart rate 108-111 per minute. Urinalysis results identified slightly cloudy urine, ketone +1 (body is used fat instead of glucose/sugar for energy and seen with eating disorders), blood trace, protein +1, leukocyte esterase (an enzyme produced by white blood cells (WBC)) and a marker for inflammation or infection particularly UTI, and white blood cells over 50 /high power field (normal range/none seen). Diagnosis: generalized weakness. Do not think UTI currently. Follow-up with primary provider in three days.R1's visit with nurse practitioner (NP)-B on 1/8/26, identified office visit for evaluation of shingles, urinary tract infection, weight loss, and constipation. R1 had lost weight since her ER. Notified after visit, R1 had not received tube feedings for 10 days due to missing connector. Education provided to nurses regarding notifying provider of weight changes or patient refuses weights/tube feedings. A dietician consult will be initiated to address the recent weight loss and adjust tube feedings to four times a week, starting today, Tuesday, Thursday, Saturday, Sunday. Daily weights will be monitored. Follow up in one week.During an interview on 1/12/26 at 4:15 p.m. family member (FM)-A stated on 1/9/26, she was informed by a staff nurse R1 had not received her tube feedings 10 days in September 2025, due to inability to locate a connection piece called MIC-KEY, and there had been a reoccurrence of the same situation. R1 had not received her tube feeding since 12/25/25, due to being unable to locate the connection piece for her tube feedings. R1's weight on 1/9/26, dropped down to 98 lbs. Her primary source of fluids/nutrition was the tube feeding and when she's feeling well, loved to drink coffee with French vanilla cream. R1 was unable to eat/drink enough to support her weight and nutritional needs by mouth and needed the tube feeding fluids to stay within the goal weight range.During an observation/interview on 1/13/26 at 11:49 a.m. nursing assistant (NA)-C had transferred R1 back into her recliner. NA-C stated R1 was just weighed and was 100.5lbs. R1 sat in her recliner with legs elevated covered with a large blanket. NA-C left room and then returned with covered mug with straw containing 450ml of water. NA-C did not offer R1 a drink, placed the mug on the bedside table next to her recliner and exited the room.During an observation/interview on 1/14/26 at 10:30 a.m. R1 sat in her recliner with lights off in the room. R1 stated she was unable to remember if she had received her tube feedings, refused them at times, and wanted to continue receiving them. R1 stated was aware she needed the tube feeding due to being unable to eat as much as she needed to and helped keep her weight up.During an interview on 1/14/26 at 10:59 a.m. dietician stated R1 was losing weight, oral intake was not adequate and therefore she needed to have the feeding tube to keep her nourished. R1's intake fluctuates and changes with her moods. The lowest weight R1 had was under 100lbs, unsure which date that was. R1 was currently on a regular diet and frequently refuses meals and tube feedings. When R1 was well nourished there was a noted improvement in mood and wanted to take part in things/activities, months ago. R1 does not eat breakfast and in November 2025, she ate approximately 75 to 100% of her meals, December 2025, started out well then had a stretch from 12/17/25 through 12/23/25, was hit and miss regarding her oral intake. For the past four months, R1's nutritional needs to maintain her weight were not met only with oral intake and she needed to have the tube feedings. When R1 dropped down to 100lbs outcomes were affected such as quality of life, longevity, loss of muscle mass, and quality of health. R1 was underweight and more likely to decline and she made it very clear she does not want that. Dietitian was unaware the staff were unable to locate the proper equipment to administer R1's tube feedings. When R1 was unable or refused to consume the solution orally a bolus could have been given slowly through the feeding tube and the water flushes would still be expected to be administered to keep the tubing patent (open). The staff would have been expected to notify the provider immediately when unable to administer her tube feedings due to lack of the connection piece. If the missing piece was ordered and would have arrived in a day or two, it would be ok to wait due to her ability to orally take in food and fluids. If more than two days, it would have been concerning and should have been brought to either myself or the providers' attention. Dietitian stated if staff would have made her aware of this situation she would have had a conversation with R1 and encouraged her to increase her oral intake, push to drink more supplements such as boost or ensure during the waiting time. Lack of tube feeding can contribute to weight loss.During an observation/interview on 1/14/26 at 12:03 p.m. R1 sat in dining room in a wheelchair with three other residents. Dietary aide (DA) stated she served R1 a small serving of mashed potatoes, a scoop of sausage/corn hotdish, lime Jello with whipped cream on top, small glass of water without ice and a large cup of coffee three creamers in it. R1 was able to feed herself one bite of Jello with whipped cream, entire scoop of potatoes, and a small bite of bread. The hotdish and water were left untouched and 1/8 of the coffee was drank. At 12:27 p.m. she was pushed in her wheelchair back to her room by staff.During an interview on 1/14/26 at 2:15 p.m. central supply purchasing (LPN-G) stated she had worked in purchasing since 2011. There was a tablet in the medication room the staff write down supplies they need and is filled once a week then the list is thrown out. When the staff needed supplies for R1, LPN-G was not working, they were expected to check in the storeroom downstairs and the hospital. A supply of MIC-KEY connection tubes was not kept in stock and staff nurses were expected to let LPN-G know they needed more ordered. Although the specific piece R1 was missing was a special order. LPN-G stated she did not work weekends. The staff did not make her aware they were out of the MIC-KEY connection and if she would have known she would have ordered more. The process for ordering supplies has not changed. LPN-G stated she ordered a box of 30 MIC-KEY connections and provided them to LPN-A, and added on the box a note, when down to 4 or 5 notify central supply. LPN-G said more can be ordered.During an interview on 1/14/26 at 3:00 p.m. LPN-C stated if unable to locate tube feeding supplies, staff are to go down to supply room, look for them and if unable to find call the supply/purchasing person, request it be ordered, follow up to see where it was and when it would arrive. The on-call provider should have been notified on 12/25/25, when the staff realized they did not have the proper supplies to administer R1's tube feeding and get an order on what to do next. The DON or ADON should have also been contacted and updated right away. R1 was ill with shingles and UTI, had a poor oral intake and would have been important to provide sufficient nutrition. R1 had a noticeable weight loss, poor oral intake and most likely needed the tube feeding nutrition to maintain her weight.During an interview on 1/15/26 at 11:47 a.m. MD-A stated R1's appetite varied and after discussion she agreed to try and keep her weight at least 110 and if it dropped below that she agreed to more frequent tube feedings. MD-A stated she was made aware R1 had lost weight and the staff were unable to administer the tube feedings due to a missing part. R1's weight was concerning when she dropped a pound a day and was below 100lbs. R1 remained a nutrition risk and monitored until stable in goal weight range. MD-A stated she would have expected nursing staff to notify a provider right away so that they are aware of what is happening and possibly give additional orders. The tube feeding solution could have been given orally but does not taste the best. R1 had maintained her weight four weeks prior to that so most likely the lack of tube feeding caused the weight loss. Additionally, R1 was aware she should be eating to maintain her weight and feel good, sometimes refused tube feedings. On 12/19/25, R1 became ill with shingles, 1/4/26 diagnosed with a UTI and affected her intake. R1 had a poor nutritional and fluid intake which placed her at a higher risk for a UTI.During an interview on 1/15/26 at 4:06 p.m. nurse practitioner (NP)-B stated she had last seen R1 on 1/8/26 for a follow up after the ER visit on 1/4/26. R1's weight was noted to be down and was concerning. When not feeling well a person tends to eat and drink less and would have been even more important to have received her tube feedings as ordered. The lack of receiving her tube feeding for many days could have played a part of her weight loss, being sick her weight fluctuates, a history of refused weights and tube feedings could also affect her weight loss. Staff would have been expected to notify a provider when she refused the tube feedings twice a week and/or unable to provide the tube feeding due to a missing piece of equipment so that her weight loss did not continue. Incontinence, dehydration, not cleaning well, anatomy and baths can all be causes of a UTI. R1 was able to drink fluids and could not say that lack of receiving the tube feeding and flushes could have caused the UTI directly but possibly could have. NP-B stated due to her concern about R1's weight changes, inability to provide tube feedings due to loss connection part or refusals, and lack of notification to provider she called the facility .Facility policy Change in Condition of Resident dated 5/2025, identified nursing judgement was an integral part of the skill care provided by the facility; therefore, such judgement must be applied in a case-by-case basis in keeping with acceptable nursing practice. The staff at the facility will contact the resident's physician, NP, or physician assistant, and (if known) notify the resident's family member(s) and/or legal representative under the following circumstances:A need to alter treatment significantly (i.e., a need to discontinue an exiting form of treatment due to adverse consequences, or to commence a new form of treatment). 1. Criteria: A need to alter significantly means: a need to commence a new form of treatment to deal with a problem (e.g. the use of any medical procedures or therapy that has not been used on the resident before). 2. Appropriate notification time may be immediate to 48 hours, depending on the nursing assessment. The medical record, which includes the nurse's notes, should reflect the care that is being provided to the resident should include: family notification and physician notification.Facility policy Tube Feeding and Management dated 11/2025, identified intermittent feeding: flush tube with 30 ml sterile water before and after each feeding.

Based on observation, interview and document review, the facility failed to notify the physician timely when enteral nutrition (tube feedings) was not administered as ordered for 1 of 3 residents (R1) reviewed for nutrition after staff identified the equipment used to deliver nutrition had missing parts.Findings include:R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R1 was cognitively intact without behaviors. R1's diagnoses included anemia (low red blood count), malnutrition, depression, Parkinson's (brain cells that make dopamine, a chemical that coordinates movement stop working or die), and chronic vascular disorders of intestines. R1's weight was 109 pounds (lbs.) and received tube feedings.R1's medical doctor (MD)-A visit note dated 11/19/25, included weight improved after increasing tube feeding, and maintains weight of 110 pounds. R1's care plan dated 12/22/25, identified R1 had a feeding tube and directed staff to administer free water flushes, enteral feeds and site care per primary care provider orders.R1's Electronic Medication/Treatment Administration Record (EMAR/TAR) reviewed from 12/25/25 through 1/8/26, identified: R1 was not administered seven scheduled tube feedings and free water 30 ml (milliliters) flushes as ordered.R1's provider orders at time of missed tube feeding included and not limited to:-On 10/16/24, Regular diet- easy to chew texture, thin regular consistency as tolerated.-On 11/20/24, Daily weight one time a day every Tuesday, Thursday, Saturday related to unspecified severe protein-calorie malnutrition: abnormal weight loss. Update Provider with any notable changes.-On 2/20/25, Change the extension tubing for MIC-KEY (used for tube feeding) port one time a day every month starting on the 20th. -On 11/20/25, administer 1 container of [NAME] Farms 1.5 (325 ml/455 calories per container) at 75ml per hour times four hours once a day every Tuesday, Thursday, and Saturday. (goal weight 108 -112lbs). -On 12/4/25, free water flush 30 ml one time a day every Tuesday, Thursday, and Saturday for enteral tube feeding.R1's progress notes identified:-On 12/4/25 at 12:11 p.m. Interdisciplinary Team (IDT) Nutritional Risk: weight 112 pounds. No refusals. Her weight was currently within a healthy range and has been stable over the past 90 days, continues external feeds, registered dietician (RD) goal weight remained 112-117 pounds. Continue to monitor, enteral feeds, and promote oral intake.-On 12/25/25 at 8:29 p.m. Enteral Feed: MIC-KEY tube extensions (used for daily continuous/pump feeding) were both thrown away and there were no replacements available to administer feeding.-On 12/25/25 at 10:11 p.m. Unable to get enteral feeding this shift due to MIC-KEY tube extensions not being in room and no new ones available.-On 12/27/25 at 7:19 p.m. No MIC-KEY extension tubing to give feeding, flushes, or check residuals.-On 12/30/25 at 4:09 p.m. Unable to do tube feeding, does not have supplies, supplies on order. At 4:11 p.m. feeding was not received related to supplies.-On 1/1/26 at 8:17 p.m. Enteral feed order and free water flush: No extension to administer feeding or flush.-On 1/2/26 at 10:26 p.m. Change syringe daily on evening shift. G-tube not utilized.-On 1/3/26 at 8:12 p.m. Enteral feed unable to administer. No equipment available, awaiting delivery.-On 1/4/26 at 3:56 p.m. R1 is freezing cold, weak, and stated she felt like she was dying. R1 requested to be seen by medical doctor (MD) today. Sent to emergency room (ER).-On 1/4/26 at 5:56 p.m. R1 returned from ER. No new orders, follow up with MD in three days.-On 1/8/26 at 1:59 p.m. R1 to appointment for follow-up from ER visit.-On 1/8/26 at 2:59 p.m. back from appointment. Orders to consult dietician due to recent weight loss. Change tube feedings to four times a week, Tuesday, Thursday, Saturday, Sunday, daily weights. Follow up in one week. Appointment made with provider for 1/15/26 at 1:30 p.m.-On 1/8/26 at 11:38 p.m. Enteral feed order and free water flush. Extension not available and R1 will not drink supplement.-On 1/9/26 at 4:00 p.m. Late Entry: per administrator, included; called R1's daughter on 1/9/26, to follow up on a voicemail she had left regarding a concern about her mom. She had been informed by licensed practical nurse (LPN)-A her mom had not been getting fed by the feeding tube due to a part being lost. Her mom had been seen by a provider in the clinic and weighed 101lbs. Conversation with LPN-A indicated, R1'daughter was informed at some point R1 weighed 101lbs and the daughter was concerned about weight loss. LPN-A informed R1's daughter the same issue with the missing tubing happened back in September for 10 days.-On 1/9/26 at 4:02 p.m.Extension tubing was delivered. R1's record lacked provider notification of missed tube feedings due to inability to locate a MIC-KEY tube connection, not following physician orders and R1's weight loss until 1/8/26.R1's visit with nurse practitioner (NP)-B on 1/8/26, identified R1 had lost weight since her ER visit even though she ate three meals a day, although occasionally skipped breakfast and receives tube feedings three times a week. R1's weight 101.5 lbs. Assessment Plan: her weight has decreased to 101lbs, below the goal weight of 110 set by MD-A. Notified after visit, R1 had not received tube feedings for 10 days due to missing connector, this has been ordered and will be restarted tomorrow.During an interview on 1/12/26 at 4:15 p.m. family member (FM)-A stated on 1/9/26, she was informed by a staff nurse R1 had not received her tube feedings since 12/25/25, due to missing connector piece for her tube feedings.During an observation and interview on 1/13/26 at 11:49 a.m. nursing assistant (NA)-C had just transferred R1 back into her recliner. NA-C stated R1 was weighed with results of 100.5 lbs.R1's care conference on 1/13/26 at 2:00 p.m. director of nursing (DON) indicated R1's MIC-KEY connection was missing on Christmas day, written on the order tablet located in the medication room, was missed due to her not working on that holiday, and should have been followed up by other staff nurses. The MIC-KEY connection had been thrown out and should not have been.During an interview on 1/13/26 at 4:50 p.m. licensed practical nurse (LPN)-A stated a feeding tube was placed to help R1 maintain her nutritional status. Provider ordered tube feedings to be given Tuesday, Thursday, and Saturday in December 2025, and 30 ml of water flushes before feeding and after. LPN-A indicated the facility received the tube feeding supplies on 1/9/26. Staff would have been expected to offer the [NAME] Farms solution by mouth and unsure if they did. Staff would have been expected to notify a provider when the MIC-KEY connection was unavailable and unable to administer tube feedings. LPN-A received a phone call from the clinic nurse who was calling to verify the receipt of new orders. During this same phone call LPN-A updated the clinic nurse of R1's missing tube feeding part and R1 had not received her feedings since 12/25/25.During an observation and interview on 1/14/26 at 10:30 a.m. R1 sat in her recliner with lights off in the room. R1 stated she was unable to remember if she had received her tube feeding, refused them at times, and wanted to continue receiving them. R1 stated an awareness she needed the tube feeding due to being unable to eat as much as she needed to and helped keep her weight up.During an interview on 1/14/26 at 10:59 a.m. dietician stated R1 was losing weight, oral intake was not adequate and therefore she needed to have the feeding tube to keep her nourished.During an interview on 1/14/26 at 2:15 p.m. central supply purchasing LPN-G stated there was a tablet in the medication room where the staff are to write down needed supplies. The supplies are filled once a week. R1's MIC-KEY connection tubes were not kept in stock and staff nurses were expected to let LPN-G know they were needed to be ordered as they are a special order and not kept in stock. During an interview on 1/15/26 at 11:47 a.m. MD-A stated they were later made aware staff were unable to administer tube feedings because a part was thrown out and did not have a replacement. R1 had lost weight. R1's weight was concerning when she dropped a pound a day and was below 100lbs. MD-A stated she would have expected nursing staff to notify a provider right away so they are aware of what is happening and possibly given additional orders. The tube feeding solution could have been given orally but does not taste the best. R1 had maintained her weight four weeks prior to that so most likely the lack of tube feeding caused the weight loss.Facility policy Change in Condition of Resident dated 5/2025, identified nursing judgement was an integral part of the skill care provided by the facility; therefore, such judgement must be applied on a case-by-case basis in keeping with acceptable nursing practice. The staff at the facility will contact the resident's physician, NP, or physician assistant, and (if known) notify the resident's family member(s) and/or legal representative under the following circumstances: A need to alter treatment significantly (i.e., a need to discontinue an exiting form of treatment due to adverse consequences, or to commence a new form of treatment). 1. Criteria: A need to alter significantly means: a need to commence a new form of treatment to deal with a problem (e.g. the use of any medical procedures or therapy that has not been used on the resident before). 2. Appropriate notification time may be immediate to 48 hours, depending on the nursing assessment. The medical record, which includes the nurse's notes, should reflect the care that is being provided to the residents and should include: family notification and physician notification.

Based on observation, interview and document review, the facility failed to perform ongoing monitoring and wound care for 1 of 1 residents (R1) reviewed for wound care. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact and had diagnoses that included heart failure and a hip fracture. Identified R1 required maximum assistance with bed mobility, transfers and toileting. R1's care plan dated 3/26/25, lacked documentation about R1's wound care. R1's signed physicians orders dated 5/21/25, identified Mepilex dressing to left hip change every two to three days, ok to shower with on one time a day. R1's signed physician's note dated 5/21/25, identified R1 had a surgical incision of the left hip that was open and had a small amount of drainage. Further identified nursing staff had been placing a Mepilex dressing over that area. Review of R1's electronic health record (EHR) skin observation tool from 3/26/25 to 6/1/25, revealed the following: 3/26/25, left thigh front surgical incision. 4/16/25, incision to left hip, staples intact. 4/23/25, left trochanter (hip), surgical incision 11 centimeters (cm) X 0.1 cm. 5/1/25, continues with incision to left hip. 5/7/25, continues to have incision on left hip. 5/14/25, nothing about hip. 5/21/25, surgical would to left hip healed at this time. 6/1/25, no skin concerns noted. R1's Electronic Treatment Administration Record (ETAR) dated 4/1/25 to 6/5/25, identified R1 received dressing changes every three days. During an interview on 6/4/25 at 4:35 p.m., registered nurse (RN)-A indicated R1 saw the provider on 5/21/25, and the provider stated the dressing could be left off because the surgical incision only had a small pink mark. RN-A further indicated three days later R1 was sent to the hospital due to an abscess that was actively draining from the left hip and R1 needed antibiotics. RN-A stated RN-B looked at the wound on 5/30/25, when R1 returned from the hospital. R1's EMR lacked documentation the would had been assessed since R1 came back from the hospital. During an observation on 6/4/25 at 8:38 a.m., nursing assistant (NA)-A and NA-B were done giving R1 a bath. Licensed practical nurse (LPN)-A entered R1's bathroom to assess R1's wound. LPN-A put on a pair of gloves and removed the undated Mepilex dressing from R1's left thigh. LPN-A inspected the surgical wound and noted the wound was intact with only a small pin point opening at the top of the wound. LPN-A removed her gloves, left the room and returned with a new Mepilex dressing. LPN-A put on a new pair of gloves and applied the Mepilex dressing over the surgical would. LPN-A removed gloves and stated she was going to chart the wound later. During a follow-up in interview on 6/4/25 at 9:30 a.m., RN-A stated the orders for the Mepilex dressing were received from Prairie Lakes clinic in South Dakota. RN-A stated when R1 had the wound vacuum removed, the facility received orders to apply a Mepilex dressing over the surgical wound from the clinic. During an interview on 6/4/25 10:20 a.m., family member (FM)-A stated the dressing had not been changed since R1 returned from the hospital on 5/30/25. A call was placed to R1's medical provider, however no return call was received. During an interview on 6/4/25 at 2:08 p.m., director of nursing (DON) stated she was unaware staff had not changed the Mepilex dressing since returning from the hospital. DON indicated she would expect nursing staff to properly assess the surgical wound and follow providers orders regarding dressing changes. DON further stated it was important to change the dressing following providers orders to prevent a further infection. The facility policy wound assessment and care revised 12/2023, identified all residents would have a head-to-toe skin assessment completed upon admission and readmission which will be performed by the Clinical Care Coordinator (CCC) or admitting RN. Skin assessments would be at least weekly thereafter. Date and time first assessed. Document if present on admission. Wound classification (ulcer, surgical wound , etc.). Descriptive location. Measurement: measure all wounds in centimeters using a paper ruler and cotton-tipped applicator as needed. Measure in this order: Length x Width x Depth.

Based on observation, interview, and document review, the facility failed to have a process in place to ensure resident provider recommendations were followed up on in a timely manner for 1 of 1 residents (R1). Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact and had diagnoses that included heart failure and a hip fracture. Identified R1 required maximum assistance with bed mobility, transfers and toileting. R1's Care Area Assessment (CAA) for nutritional status dated 4/8/25, identified contractures, functional limitation in range of motion, partial or total loss of arm movement that could affect her nutritional status. R1's care plan dated 3/26/25, indicated R1 would maintain adequate nutritional status. Review of R1's progress notes dated 4/17/25 to 6/3/25, identified R1's mouth was very dry and that it may contribute to the decay and discomfort. Please help with brushing her teeth two x/day- eliminating the plague in her mouth was very important. Have medical doctor (MD) look into options to help resident within her xerostomia (commonly known as dry mouth, the sensation of not having enough saliva). R1's signed physicians orders dated 5/21/25, lacked documentation R1 received any medication for xerostomia. During an interview on 6/3/25 at 5:20 p.m., R1 stated her mouth was very dry and indicated it was difficult to swallow at times due to her dry mouth. During an interview on 6/3/25 at 6:00 p.m., family member (FM)-A and FM-B revealed R1 had a dry mouth frequently and R1 had not received any medication to help with her dry mouth. FM-A stated R1 had seen the dentist and it was recommended R1 receive something from her primary provider for her dry mouth. During an interview on 6/4/25 at 4:35 p.m., registered nurse (RN)-A stated the facility had not talked to R1's provider about ordering something for R1's dry mouth per the dentist recommendations on 5/24/25 at 10:21 a.m. During an interview on 6/4/25 at 2:08 p.m., director of nursing (DON) was unaware R1 had received recommendations from the dentist. DON stated nursing staff should have contacted R1's provider to get something ordered. DON further stated it was her expectation that staff would be in contact with the provider when recommendations were made. A facility policy notifying the provider was requested but facility stated they did not have a specific policy on notifying the provider.

Based on observation, interview and document review, the facility failed to ensure the call light was accessible for 1 of 1 residents (R1) who was reviewed for call light placement. R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact and had diagnoses that included heart failure and a hip fracture. Identified R1 required maximum assistance with bed mobility, transfers and toileting. R1's care plan dated, 3/26/25, directed staff to make sure R1's call light was within reach and to encourage R1 to use the call light. During an continuous observation on 6/4/25 at 7:10 a.m. to 8:21 a.m., R1 was sitting in her wheelchair eating breakfast. R1 received her breakfast tray at 7:20 a.m., nursing assistant (NA)-A cut up R1's french toast and applied syrup. NA-A provided R1 half of a banana on her tray also. R1 began to eat her meal. R1 completed eating her meal at 7:54 a.m. R1 began looking for her call light. R1 stated she was unable to find her call light. R1 further stated staff did not always provide her with her call light when she was sitting in her wheelchair. R1 indicated she would just have to wait for staff to come back in her room to help her. R1's call light was attached to her bedside railing and R1 was unable to reach her call light. R1 continued to wait for staff to come to her room to assist her. During an observation on 6/4/25 at 8:20 a.m., NA-A and NA-B entered R1's room to assist her. NA-A grabbed a washcloth and ran it under warm water and handed the wash cloth to R1. R1 washed her face and hands and gave the washcloth back to NA-A. NA-A and NA-B assisted R1 to the restroom. During an interview on 6/3/25 at 5:20 p.m., R1 stated staff often forgot to give her the call light when she was sitting in her wheelchair. R1 indicated she did not have good eye sight and was not able to find the call light if it was not placed on her wheelchair handle. R1 stated at times she would need to yell out for help because she did not have her call light. During an interview on 6/3/25 at 6:00 p.m., family member (FM)-A and FM-B revealed they have had to provide R1 with her call light on several occasions because staff did not provide the call light to R1. FM-A indicated R1's call light was to be placed across R1's chest when laying in bed and attached to the right handle of R1's wheelchair when R1 was sitting in her wheelchair. FM-A further indicated there were several occasions where R1 did not have her call light for extended periods of time. During a follow-up interview on 6/4/25 at 11:28 a.m., R1 was laying in her bed and her call light was across her chest. FM-A indicated FM-A placed R1's call light on R1's chest after staff assisted R1 to bed. FM-A revealed staff did not provide R1 with her call light after R1 was in bed. During an interview on 6/4/25 at 11:52 a.m., NA-A and NA-B stated they were not aware they did not provide R1 with her call light during breakfast. NA-A and NA-B stated they thought they had provided R1 with her call light after getting her up in her wheelchair for breakfast. During an interview on 6/4/25 at 2:08 p.m., director of nursing (DON) was unaware R1 did not have her call light for one hour and 11 minutes. DON stated it would be her expectation to have a call light within reach for residents. Facility policy titled call light - answering of revised 6/2025, when resident was in bed or confined to a chair call light would be within easy reach of resident.

Based on interview and document review the facility failed to ensure 5 of 8 staff (administrator, director of nursing (DON), registered nurse (RN)-A, RN-C, and trained medication aide (TMA)-A ) received annual training and 1 of 1 newly hired staff nursing assistant (NA-B) received initial training on Alzheimer's disease or related disorders, assistance with activities of daily living (ADL), problem solving with challenging behaviors, and communication skills. This had the potential to affect all the residents in the facility. Findings include: Review of the administrators personnel file identified a hire date of 9/28/12. Review of his Alzheimer's training records identified he had completed training on ADL care, communication needs, and behaviors and obtained a certificate on 9/30/22. The administrator training record lacked identification that he had completed training on Alzheimer's disease and related disorders annually. Review of the DON's personnel file identified a hire date of 11/01/21. Review of her Alzheimer's training records identified she had completed training on ADL care, communication needs, and behaviors and obtained a certificate on 9/28/22. The DON training record lacked identification that she had completed training on Alzheimer's disease and related disorders annually. Review of the personnel file for RN-A identified a hire date of 8/04/20. Review of her Alzheimer's training records identified she had completed training on ADL care, communication needs, and behaviors and obtained a certificate on 10/25/22. RN-A's training record lacked identification that she had completed training on Alzheimer's disease and related disorders annually. Review of the personnel file for RN-C identified a hire date of 2/16/23. Review of her Alzheimer's training records identified she had completed training on ADL care, communication needs, and behaviors and obtained a certificate on 2/16/23. RN-C's training record lacked identification that she had completed training on Alzheimer's disease and related disorders annually. Review of the personnel file for TMA-A identified a hire date of 8/16/18. Review of her Alzheimer's training records identified she had completed training on ADL care, communication needs, and behaviors and obtained a certificate on 11/28/22. TMA-A's training record lacked identification that she had completed training on Alzheimer's disease and related disorders annually. Review of the personnel file for NA-B identified a hire date of 10/15/24. Review of his training record lacked identification that he had not completed training on Alzheimer's disease and related disorders upon hire. Review of July 2024 Facility Assessment identified the facility would provide staff training, education, and competencies necessary to provide support and care needed for the resident population and to ensure knowledge competency for all staff. The facility would provide education and training in person, online, and other various formats. Lastly, staff competencies would be verified upon orientation, annually, and as needed. Interview on 11/06/24 at 9:57 a.m. with DON identified she was aware that staff had not all completed Alzheimer/Dementia training. She stated the facility was awarded a grant to help facilitate the training for all staff, previously. In addition, the facility had opted not to purchase the course on an annual basis and was in the process of purchasing new education software for 2025 and would plan for staff to complete the training for new hires and on an annual basis. Request a copy of In-service Training policy and none was provided.

Based on observation, interview, and record review, the facility failed to ensure a portable oxygen (O2) tank (E-cylinder) was safely secured for 1 of 4 residents (R21). Findings include: Observation and interview on 11/04/24 at 12:52 p.m. with R21 identified he was alert and oriented and was seated on the edge of his bed with oxygen on at 2 liters (L) per minute (M) via a nasal cannula (NC) connected to an oxygen concentrator. Two oxygen tanks were observed, one of which was in a portable stand with a regulator attached and one sitting unsecured on the floor in addition to a small black portable oxygen carrier were noted to be at the end of the dresser visible upon entry to the room. R21 reported he used oxygen when he was in his room, and used the portable tanks if he went to an appointment or left the building. R21 reported the oxygen tanks were left in his room for his use when he needed them and had been left there since he had been admitted . R21 was admitted to the facility in August 2024 with diagnoses of pulmonary fibrosis, cerebral infarction, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), PTSD, major depressive disorder, and generalized anxiety disorder. R21's current physician orders identified but the current electronic physician orders identified staff were to check oxygen saturation (O2 sat) every shift, and apply O2 via NC 1-3 LPM as needed (PRN) as needed when O2 sat less than 90%. Observation of R21 on 11/04/24 at 7:03 p.m. noted R21 seated in his recliner watching TV in a darkened room with O2 on via NC. The O2 tanks remained in the same location with the one tank resting on the floor in an upright position unsecured. He reported he was not aware the unsecured tank was a problem and identified his O2 tanks were routinely left sitting in his room in that location since he had been admitted . Interview on 11/04/24 at 7:05 p.m. with licensed practical nurse (LPN)-A identified when O2 tanks were not in use they should be stored in the oxygen supply closet, and if they were in a resident space they needed to be positioned either in an oxygen cart or in a holder located on the resident's wheelchair. She reported oxygen tanks were not supposed to be left unsecured sitting in a resident room and she was not aware of the unsecured tank in R21's room. Interview on 11/4/24 at 7:10 p.m., with the director of nursing (DON) who accompanied this surveyor to R21's room confirmed one of the two O2 cylinders was standing unsecured on the floor of R21's room and it should not have been left there. O2 tanks were to be kept in a stand or wheelchair holder and it was not acceptable to leave a tank unsecured. A policy on O2 use and monitoring was requested, but the DON reported they did not have a current policy for Oxygen use in the long term care (LTC) setting.

Based on observation, interview, and document review, the facility failed to follow their policy and complete an Abnormal Involuntary Movement (AIMS) assessment for 1 of 5 residents (R31) who had been administered an antipsychotic. Findings include: R31's 8/16/24, quarterly Minimum Data Set (MDS) assessment identified he had diagnosis of non- traumatic brain dysfunction, Alzheimer's disease, and depression. R31's cognition was severely impaired, he required supervision with walking and extensive assistance with toileting and personal hygiene. R31's current diagnosis list identified on 8/6/24, he received a new diagnosis of severe episode of recurrent major depressive disorder, with psychotic features. R31's 8/29/24, physician order form identified R31 started taking olanzapine (anti-psychotic medication) 5 milligrams (mg) by mouth daily at bedtime on 8/29/24. R31's 10/31/24 outpatient detail report identified the physician increased R31's olanzapine to 10 mg every morning. R31's 9/13/24, care plan identified he takes an antipsychotic with interventions to complete an AIMS assessment per facility policy and as needed. R31's September 2024, medication administration record (MAR), identified he was administered olanzapine 10 mg daily. Review of R31's assessments completed since admission identified no AIMS assessment had been completed. Interview on 11/6/24 at 8:22 a.m., with the MDS coordinator identified an AIMS assessment was to be completed upon the start of an antipsychotic medication. The nurse who transcribed the order was to complete the initial AIMS assessment and schedule the next AIMS assessment in 30 days. The assessment should be completed with any changes in dose, and 30 days after the new medication started. She reviewed R31's chart and agreed he had not had an AIMS assessment completed. Interview on 11/6/24, at 8:17 a.m., with the pharmacist consultant identified he would expect the facility to complete an AIMS assessment when starting an antipsychotic. He identified the assessment is used to determine if the resident is having side effects of extrapyramidal movement (involuntary movements), in this case the medication may need to be changed or discontinued before worsening. Review of the July 2024, Psychotropic Drug Monitoring policy identified nursing staff were to complete an assessment for Tardive Dyskinesia which is the AIMS assessment for: 1) Baseline target behavior before an antipsychotic had begun or upon admission. 2) When a new antipsychotic medication was added or the dose had been changed. 3) At 6 months for re-evaluation.

Based on observation, interview, and document review, the facility failed to ensure the resident safety from accident and hazards for 1 of 1 resident (R149) who smoked unsupervised while using oxygen via nasal cannula that was connected to a compressed oxygen (O2) canister. This resulted in an immediate risk of serious harm, injury, or death, from thermal burns to R149. In addition, the facility failed to follow facility policy and secure smoking materials (cigarettes and lighter) away from R149. The IJ began on 2/19/24 when R149 was admitted to the facility (a non-smoking facility) and with facility knowledge, smoked unsupervised while wearing oxygen upon her admission. On 2/26/24 at 3:32 p.m., R149 was observed to be smoking a cigarette unsupervised, while receiving oxygen from a portable oxygen tank. It was determined the facility failed to ensure the safety of R149 from this highly flammable and potentially deadly situation and had her sign a waiver to hold the facility harmless if she were to become injured because of her choice to continue smoking while she required oxygen. The administrator and director of nursing (DON) were informed of the IJ on 2/26/24 at 6:03 p.m. The IJ was removed on 2/27/24 at 12:37 p.m., when the facility took steps to remove the immediate situation, however non-compliance remained at the lower scope and severity level of a D, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy: Findings include: Observation on 2/26/24 at 3:32 p.m., of R149 and an unknown person smoking within a couple feet of R149 in front of the HUD apartment entrance connected to the facility. R149 was smoking while wearing an oxygen nasal cannula tubing in her nose that was connected to a portable oxygen tank that was sitting on her electric scooter between her legs unsecured. The oxygen flow rate was on and flowing at 7 liters per nasal cannula. Interview on 2/26/24 at 3:33 p.m., R149 confirmed her oxygen was on and identified that she comes out to smoke several times a day. She identified she often forgets to turn her oxygen off before lighting her cigarette. The administrator was immediately notified by surveyor. Interview on 2/26/24 at 3:36 p.m., with administrator identified they are aware R149 smoked with her oxygen on and noted We had her sign an 'Assumption of Risk' because she sometimes forgets to remove her oxygen. Interview on 2/26/24 at 3:42 p.m., with the DON identified she educated R149 of the risks related to smoking with her oxygen on and they were aware that she sometimes forgot to take it off, but they do not supervise R149 while smoking. Facility staff do not ensure her oxygen is removed before she leaves the building to smoke. The DON stated the facility did not have the staff to go out with R149 to ensure she was not using oxygen while she smoked. R149's 2/26/24, admission Minimum Data Set (MDS) assessment identified a brief interview of mental status (BIMS) score of 12 out of 15 indicating her cognition was moderately impaired, she used a wheelchair for mobility, and she had diagnosis of chronic obstructive pulmonary disease (COPD), and tobacco use. R149's 2/19/24, admission orders identified R149 received continuous oxygen via nasal cannula administered at 6 liters (L) per minute via nasal cannula. R149's progress notes identified on: 1) 2/19/24, the social worker (SW) reviewed the facility's smoking policy with the resident and advised the resident if she was going to smoke while she was a resident at the facility, the nurse had to perform a smoking assessment. R149 was notified she would have to go across the street and asked about [senior living facility where she lived prior to her admission], which was located next door to the facility. The SW advised R149 she did not think she could smoke there unless visiting a friend. 2) 2/20/24, the SW noted they met with R149 about smoking in the parking lot. The SW told R149 she needed to make sure she is across the street before lighting up. R149 apologized and told the SW It wont happen again. She told the SW she was sitting in her brothers truck (an enclosed space) so she did not think it was a big deal. The SW noted she again told R149 smoking was prohobited at the facility. R149 apologized and said it wont happen again. 3) 2/20/24, a note was made that Resident is aware she is to exit from [NAME] door due to allowing herself to self-exit to smoke. R149 had requested a water based lubricant to be applied to both her nostrils. Provider [physician] to be notified that due to nasal dryness and congestion, request for saline sinus spray to reduce difficulty breahing. 4) 4) 4) 2/21/24, a nurse noted that they, along with R149's physician met with R149 and her family present to discuss R149's smoking status. R149 was noted to have verbalized understanding of appropriate, designated smoking areas. R149 was agreeable to have occupational therapy assess her to determine safety of operating scooter [electric wheelchair device used for mobility] off grounds. R149 signed Assumption of Risk for if she forgets/chooses not to remove oxygen while smoking, despite extensive education. Will place sign on scooter to remind resident. Resident also verbalized understanding of signing in/out of the facility so staff are aware of resident's whereabouts. 4) 2/23/24, staff made a late entry noting a sign placed on resident's scooter to remind her to remove oxygen prior to smoking. 6) 2/26/24, staff noted the licensed nurse (LPN) went to a registered nurse (RN) with concerns of R149's hypoximia (low oxygen levels) and non-compliance with oxygen. Both staff met with R149 and discussed the reasoning for her being on hosppice statting to turn O2 [oxygen] down to 3 L/min, not monitoring O2 sats. R149 verbalized understanding. Also educated resident on smoking cessation and encouraged resident to find alternative activities, resident laughed. The RN then reminded R149 to sign out when leaving the facility and remove O2 prior to smoking to which R149 stated well i know all that. R149's 2/20/24, Smoking Assessment identified her cognition was intact. She smoked 2-5 times each day. She could light her own cigarettes, and required no supervision or other safety measures. The assessment identified the facility did not lock up or store R149's smoking materials to secure them. The Smoking assessment identified Her care plan was to be used to assure R149 was safe while smoking. The assessment made no mention of R149's use of oxygen or that staff were aware of the fire or potential explosion hazard that may incur from smoking to R149 or others around her. Review of the 2/21/24, Assumption of Risk Agreement Policy and Procedure signed by R149 identified R149 was at risk for injury because she chose to smoke cigarettes and sometimes forgets to or chooses not to remove oxygen prior to smoking. The facility noted they had offered smoking cessation and identified the Assumption of Risk Agreement was added to R149's care plan. R149's current, undated care plan related to smoking only identified she had signed an Assumption of Risk waiver stating she chose to smoke and had not always removed her oxygen. The goal was for R149 was to remain free from complications or harm. Staff were to monitor her safety and intervene when necessary. Observation and interview on 2/27/24 at 5:00 p.m., R149 was on her scooter, she identified that staff had placed a sign in her basket to remind her to take off her oxygen before she smoked, she looked for the sign but it had been burried in her basket and was no longer visible. R149 moved several items and the sign was laying at the bottom of her basket. Review of the [NAME] R. Hall, Jr., The Smoking Material Fire Problem, NFPA [National Fire Protection Association] Fire Analysis and Research Division, July 2013 article indicated: 7% of fatal victims of smoking-material fires who were themselves the smokers whose smoking materials started the fires were under treatment with medical oxygen. The combination of smoking and use of medical oxygen is so dangerous that it became the subject of one of the seven recommended educational messages from the project. The article states In an NFPA analysis of fires and burns involving home medical oxygen, smoking materials were involved in 73% of 2003-2006 thermal burns reported to hospital emergency room s and involving home medical oxygen. Interview on 2/28/24 at 2:34 p.m., with the medical director identified he was unaware R149 was smoking with her oxygen on, and unaware the facility had her sign an Assumption of Risk waiver. He confirmed the facility was responsible for her safety. He agreed R149 was not able to sign away her right to be safe. If the facility had knowledge that R149 forgot to remove her oxygen or chose not to remove her oxygen prior to smoking, the facility should be supervising her while she smoked. Review of the facility November 2023, Smoking policy identified the facility would determine resident smoking status upon admission. If a resident smokes, they would educate them on the facility policy of no smoking on the property and they would keep all smoking material locked in the medication room. The effectiveness of the individualized care plan would be reviewed and/or revised quarterly and as needed. The immediate jeopardy that began on 2/26/24 at 3:32 p.m. was removed on 2/27/24, at 12:37 p.m., when the facility took steps to ensure R149's safety including requiring staff to provide 1:1 supervision while smoking to ensure oxygen was removed and placed at least 15 feet away, and the oxygen was allowed to dissipate off clothing for a minimum of 5 minutes before lighting her cigarette. The facility also acquired an physician order to allow R149 to have her oxygen removed while smoking. R149's smoking materials were locked up to ensure she would have to ask staff prior to leaving the facility to smoke. A care conference was scheduled for 2/27/24 to inform family of the changes made to R149's care plan related to smoking and to present smoking cessation options. The smoking policy had been reviewed and revised to include all residents who smoke were to be supervised. Facility staff were educated on the updated smoking policy to include having a safety plan for R149 and all other residents who smoke to ensure safety to R149 and others within her vicinity from fire, injury, or explosion. All staff were educated prior to their next shift.

Based on interview and document review, the facility failed to offer and/or administer the most recent Centers for Disease Control (CDC) pneumococcal vaccine for 4 of 5 residents (R21, R28, R29, R40) reviewed for immunizations. Furthermore, the facility failed to have a method or system to ensure the facility offer or provided any initial or updated vaccine to residents per Centers for Disease Control (CDC) vaccination recommendations. Findings include: Review of the current CDC pneumococcal vaccine guidelines located at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/pneumo-vaccine-timing.html, identified for: Adults [AGE] years of age or older, staff were to offer and/or provide based off previous vaccination status as shown below: a) If NO history of vaccination, offer and/or provide: aa) the PCV-20 OR bb) PCV-15 followed by PPSV-23 at least 1 year later. b) For PPSV-23 vaccine ONLY (at any age): aa) PCV-20 at least 1 year after prior PPSV-23 OR bb) PCV-15 at least 1 year after prior PPSV-23 c) For PCV-13 vaccine ONLY (at any age): aa) PCV-20 at least 1 year after prior PCV13 OR bb) PPSV-23 at least 1 year after prior PCV13 d) For PCV-13 vaccine (at any age) AND PPSV-23 BEFORE [AGE] years: aa) PCV-20 at least 5 years after last pneumococcal vaccine dose OR bb) PPSV-23 at least 5 years after last pneumococcal vaccine dose e) Received PCV-13 at any age AND PPSV-23 AFTER Age [AGE] years: aa) Use shared clinical decision-making to decide whether to administer PCV20. If so, the dose of PCV-20 should be administered at least 5 years after the last pneumococcal vaccine. R21's Medical Diagnosis list printed 2/28/24, identified R21 was [AGE] years old and had diagnoses of arthritis, gout, polyneuropathy, dysthymic disorder, hypokalemia, and atrial fibrillation. R21's Immunization record printed 2/28/24, identified R21 had received the pneumococcal conjugated vaccine (PCV-13) on 3/26/15, the pneumococcal polysaccharide vaccine (PPSV-23) initially on 10/4/10 and again on 11/11/11. R21's medical record did not include evidence R21 or R21's representative received education regarding pneumococcal vaccine booster, the physician had been consulted, or indication R21 was offered the PCV-20 at least 5 years after prior pneumococcal vaccine per CDC guidance. R28's Medical Diagnosis list printed 2/28/24, identified R28 was [AGE] years old and had diagnoses of Alzheimer's disease, Parkinsonism, insomnia, and anxiety disorder. R28's Immunization record printed 2/28/24, identified R28 had received the PPSV-23 on 11/27/98, and the PCV-13 on 2/9/16. R28's medical record did not include evidence R28 or R28's representative received education regarding pneumococcal vaccine booster, the physician had been consulted, or indication R28 was offered the PCV-20 at least 5 years after prior pneumococcal vaccine per CDC guidance. R29's Medical Diagnosis list printed 2/28/24, identified R29 was [AGE] years old and had diagnoses of hypothyroidism, and gastro-esophageal reflux disease (GERD), and vitamin D deficiency. R29's Immunization record printed 2/28/24, identified R29 had received the PVC-13 on 10/6/15, and the PPSV-23 on 11/29/16. R29's medical record did not include evidence R29 or R29's representative received education regarding pneumococcal vaccine booster, the physician had been consulted, or indication R29 was offered the PCV-20 at least 5 years after prior pneumococcal vaccine per CDC guidance. R40's Medical Diagnosis list printed 2/28/24, identified R40 was [AGE] years old and had diagnoses of dementia, insomnia, and anxiety. R40's Immunization record printed 2/28/24, identified R40 had received the PPSV-23 on 1/7/99, and the PCV-13 on 5/4/17. R40's medical record did not include evidence R40 or R40's representative received education regarding pneumococcal vaccine booster, the physician had been consulted, or indication R40 was offered the PCV-20 at least 5 years after prior pneumococcal vaccine per CDC guidance. Interview on 2/28/24 at 10:59 a.m., with registered nurse (RN)-A who revealed she was responsible for resident vaccinations at the facility. The facility had been referencing the Epic Systems Corporation (EPIC) a software system that hospitals use for medical records and the Minnesota Immunization Information Connection (MIIC) a system that stores immunization records to determine if a resident was up to date and current with their vaccinations. She reported neither system showed to offer the PCV-20. She further identified she reached out to the clinic, and they had reported that they had only received the PCV-20 vaccinations within the last 6 months. RN-A confirmed the facility had not been offering the PCV-20 to residents who were eligible as they had not been following the CDC guidance at the facility. She reported she would be creating a spreadsheet to monitor and offer recommended CDC vaccinations going forward. Review of October 2023, Vaccination-Pneumococcal, Influenza, and COVID-19 policy identified the facility would offer the pneumococcal vaccine as available and according to current CDC recommendations. Residents would be assessed for eligibility and offered and/or administered pneumococcal vaccinations according to CDC recommendations.

Based on interview and document review, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) CMS-10055 for 2 of 3 residents (R11 and R30). Findings include: Review of R11's medical record identified she had received skilled Medicare covered services from 12/7/23 through 1/31/24. The facility identified they had initiated the discharge from Medicare Part A Services when benefit days were not exhausted and R11 remained at the facility. An Advanced Beneficiary Notice was never issued. Review of R30's medical record identified she had received skilled Medicare covered services from 8/13/23, through 9/19/24. The facility identified they had initiated the discharge from Medicare Part A Services when benefit days were not exhausted and R30 remained at the facility. An Advanced Beneficiary Notice was never issued. Interview on 2/28/24, with director of nursing (DON) identified her social service designee was responsible for the medicare notices. She agreed with the above and identified she was not trained regarding what notice was required to be given when ending Medicare Skilled Services. She called the Social Service director into her office. Interview on 2/28/24, with social servied director (SS) identified she always gives a NOMNC and was not aware when to give an Advanced Beneficiary Notice (ABN) notice vs a Notice of Medicare Non-Coverage (NOMNC) and that she had been giving everyone a NOMNC. Interview on 2/28/24 at 12:50 p.m., administrator identified it was his expectation the correct notices would be given with the correct time frame. He would ensure the DON and social service designee received training to ensure understanding of the process. Review of the facility admission agreement identified the facility would notify residents and/or their representative of changes within the time frame specified by law. A policy was requested but none was provided prior to the end of survey.

Based on record review and interview, the facility failed to complete a comprehensive assessment related to post traumatic stress disorder (PTSD) for 1 of 1 (R6) resident. Findings include: R6's 1/03/24, quarterly Minimum Data Set (MDS) identified she had moderate cognitive impairment and had symptoms of feeling down, depressed, or hopeless 2 to 6 days. R6 had a diagnosis of cancer and took antipsychotics and opioids. The MDS did not identify R6 has PTSD. R6's undated, medical diagnosis sheet identified she had anxiety, depression, PTSD, vascular dementia, and Malignant melanoma metastatic to brain. R6's undated, current care plan identified that R6 had potential vulnerability related to her vascular dementia, anxiety disorder and malignant melanoma. The goal for R6 would be to receive needed cares that provide safety and dignity to her needs. Interventions were for staff to see interventions of R6 care plan for noted areas of vulnerability. There was no mention of interventions for R6's PTSD, what caused R6's PTSD, or how to decrease or eliminate stressors related to PTSD. Interview on 2/25/24 at 7:30 p.m., with R6 stated she had a history of trauma and had PTSD but declined to offer more information. Interview on 2/27/24 at 4:18 p.m., with registered nurse (RN-A) confirmed R6 had a diagnosis of PTSD since admission. She stated the facility had implemented behavior monitoring for all residents, but had not care planned or placed interventions for R6's symptoms of PTSD. Interview on 2/27/24 at 4:38 p.m., with RN-B stated she was not aware that R6 had PTSD and would not know what PTSD symptoms to identify for R6. Interview on 2/28/24 at 9:32 a.m., with R6 stated she had visited a mental health provider in Sioux Falls in the past. She stated her PTSD comes and goes and would prefer her husband to be around more to support her during those moments. R6 stated she did not remember the names of the medications she took at the facility but would want to get back to normalcy. Interview on 2/28/24 at 1:02 p.m., with director of nursing (DON) confirmed R6 did not have PTSD care planned and interventions in place. She stated social services (SW) completes the assessments of residents in the facility, including trauma assessment. DON stated R6 had no trauma assessment completed since her admission. Interview on 2/28/24 at 1:13 p.m., with SW stated R6 had a diagnosis of PTSD and no triggers to evaluate her for PTSD when she admitted to the facility. She agreed that R6 had no trauma assessment completed since admission to the facility and did not have PTSD care planned. Review of May 2023 Trauma policy identified the facility would promote development and availability of trauma services for residents. The facility would complete screening for trauma and trauma related exposure as well as trauma assessments for residents in the facility.

Based on observation, interview, and document review interview the facility failed to follow the care plan for a fall intervention to mitigate the risk for falls or falls with serious injury for 1 of 6 residents (R1) who had history of falls with injury. Findings include R1's annual Minimal Data Set (MDS) dated [DATE], identified R1 had diagnosis of Alzheimer's disease. R1 required limited assist of one staff with two wheeled walker for ambulation and required supervision with two wheeled walker for transfers. R1 had no falls. R1's Fall Analysis Risk assessment dated [DATE], indicated R1 had an unwitnessed fall when she self-transferred out of bed, got dizzy, and fell to the floor. The fall analysis identified R1 was dizzy, did not always use her walker, and was not wearing shoes or gripper socks. New fall interventions included adding a bed alarm. Review of R1's fall care plan dated 9/22/21, indicated R1 was at risk for falls due to impairment of mobility and poor safety awareness. The care plan included the intervention for bed alarm dated 10/9/23. R1's fall incident report dated 10/11/23, identified R1 had an unwitnessed fall when she self-transferred out of bed. The report indicated the bed alarm had sounded. R1's fall incident report dated 11/9/23, identified R1 had an unwitnessed fall after a self-transfer. The report did not identify if the bed alarm had been functioning or was in place at the time of R1's fall. During an observation on 11/17/23 at 8:25 a.m., R1 was lying in bed with eyes closed when hairdresser entered R1's room and told R1 it was time to get her hair done. R1 stood up from her bed; no alarm sounded and the call light was not activated. R1 exited her room and followed the hairdresser down the hallway, passing licensed practical nurse (LPN-A), who then followed R1 to the beauty shop. During an interview on 10/17/23 at 9:06 a.m., nursing assistant (NA)-M, indicated bed alarms were activated when a resident got off the bed and call light goes off with a special flash and sound at the nurses stations. Staff were to respond to that room right away to prevent the fall. During an interview on 10/17/23 at 9:41 a.m., NA-A stated that the bed alarms were connected to the call light system that would alert staff by a special light. Staff were supposed to respond right away to those lights to prevent falls. During an interview on 11/17/23 at 10:00 a.m., LPN-A reviewed R1's care plan and verified R1 required a bed alarm. LPN-A did not know why the bed alarm had not sounded nor activate the call light at 8:25 a.m. when R1 got out of bed. During an interview on 11/17/23 at 10:08 a.m., registered nurse (RN)-A reviewed R1's care plan and went to R1's room. RN-A was unable to locate the bed alarm device anywhere on or around R1's bed. RN-A stated she was not aware of how long the alarm had not been on the bed. During an interview on 11/17/23 at 10:46 a.m. director of nursing (DON) stated bed alarms alert staff when residents were moving or getting out of bed. DON reviewed R1's care plan and verified R1 was supposed to have an alarm, DON's stated expectation staff were to follow care plans for all residents. DON was not aware if an alarm had been in place on 11/9/23 when R1 last fell . Review of the facility's policy entitled Care Plan-Care Center dated 03/2023, indicated all resident would have an individualized plan of care addressing problems and needs identified in the comprehensive assessment. The plan would include problems, goals and interventions to meet the individualized needs of each resident.

Based on observation and interview the facility failed to ensure hair nets were accessible in 1 of 1 kitchenette located in the Harvest dining area and had the potential to effect 17 of 44 residents who were served food out of the kitchenette. The facility further failed to ensure 7 of 7 buttermilk containers had been discarded after expiration and failed to ensure 1 of 1 homemaker (HM)-B had appropriately secured her hair into her hairnet while serving food. Finding include: Observation on [DATE] at 11:37 a.m., of Homemaker (HM)-B prior and during the noon service identified they were standing behind a counter and would be dishing up and serving food in the Harvest Kitchenette. HM-B's hair net only covered her hair held in palace by a ponytail in the back. HM-B's hairnet did not secure the hair around her face which hung loose and downward over HM-B's cheeks and neck area during the entire meal service which could potentially contaminate resident's food. Further observation and interview on [DATE] at 11:00 a.m., in the kitchen with cook-(A), identified the walk-in refrigerator had 7 quart sized cardboard containers of buttermilk that were expired with a date of [DATE]. Staff were to check expiration dates weekly and must have missed them. Cook-A agreed the buttermilk should have been discarded on the expiration date but it had not been used for meal prep after it had expired. Interview on [DATE] at 12:37 p.m., with dietary manager (DM) immediately after the noon meal service identified her expectation was hair nets were to be worn at all times with hair properly secured and not hanging down around the face uncovered. Staff were to discard any perishable items that were expired during their weekly cleaning process. Review of the February, 2023, Daily Cleaning Schedule for Cooks identified on Monday mornings, the cook was to clean the walk-in cooler and throw away any old or items that may have not been labeled appropriately. The cleaning schedule identified staff last cleaned the walk-in cooler on [DATE]. There was no policy related to hair net use or labeling or discarding food after expiration provided by the end of the survey.

Based on observation and interview the facility failed to ensure transmission based precautions (TBP) were followed by 1 of 1 dietary aide (DA)-A prior to entering R34's room. In addition, the facility failed to ensure appropriate whirlpool cleaning and disinfecting of 1 of 2 whirlpool tubs used for bathing which had the potential to affect 5 of 44 residents, R25, R18, R35, R5, R1, R37, and R34 who used the whirlpool tub. Findings include: TBP Observation on 2/27/23 at 6:28 p.m., with R34's room had a white personal protective equipment (PPE) holder on the door. A sign indicated Contact Precautions hung outside the door prior to entrance. PPE required for any persons entering the room included a gown, gloves, and a mask. Observation on 2/27/23 at 6:30 p.m., of dietary aid (DA)-A identified DA-A was passing food trays and stopped at R34's door, looked at the sign, paused, and entered R34's room without donning a gown or gloves. Interview on 2/27/23 at 6:30 p.m., with DA-A indicated she had understood the sign to donn proper PPE, but disregarded the sign because she was only passing food trays. DA-A stated she typically would have nurses give the food to residents on TBP, but failed to do on 2/27/23. DA-A received training on infection control and appropriate TBP with PPE, but had not worn PPE when entering R34's room due to her short height stating the gowns were too big and she would trip and fall, as this had happened in previous months. Interview 2/27/23 at 6:40 p.m., with director of nursing (DON), identified her expectations of residents on transmission-based precautions (TBP) and use of appropriate PPE were to follow the instructions on the sign. DON also relayed that CNAs were to follow the manufacturing directions to disinfect the whirlpool tub. DON informed, if the staff didn't follow the instructions, she would first speak with them, and if it continued, she would reeducate them but said that nursing was the only ones with privileges to enter these rooms. Upon learning it was DA-A regarding proper PPE, DON indicated she would email her supervisor for re-education of DA-A. Review of the July, 2010, Standard and Isolation Transmission Based Precautions policy identified the use of PPE for Contact Precautions included wearing a gown, gloves, and mask protection prior to entering a resident' room. WHIRLPOOL TUB CLEANING Observation and interview on 3/1/23, at 11:02 a.m. with nursing assistant (NA)-A identified she began cleaning and disinfecting the whirlpool tub. NA-A applied gloves and demonstrated the process of how to clean and disinfect the tub following completion of a resident bath. NA-A noted she used [NAME] Classic Whirlpool disinfectant cleanser to disinfect the tub, bath chair, cushion and straps attached to the bath chair and poured in a splash of the solution into the tub. NA-A took a scrub brush and brushed over the interior surfaces of the tub, jets, chair with straps and cushion. NA-A continued the process for cleansing and disinfecting the tub, by scrubbing then pushed the Rinse Jets-button to allow the [NAME] Patient Care whirlpool disinfectant cleanser, to flow from the jets into the tub. NA-A, then left tub room to make R1's bed. All surfaces dried in approximately 1 minute. After 13 minutes NA-A returned, the drain was opened. NA-A then used the hand sprayer to rinse the tub and chair surfaces. NA-A had no instructions for cleaning and disinfecting the tub. NA-A was unaware of the appropriate amount of solution required, or the need to ensure the surfaces of the tub, chair, and straps remained wet with the disinfection solution for 10 minutes as directed to ensure disinfection was completed. Interview on 3/1/23, at 1:23 p.m., with NA-B, identified she also gave residents tub baths and was unaware of how much solution and wet contact time were required to appropriately disinfect the tub. Review of the 9/20/20, Tub Cleaning policy identified staff were to let the disinfectant remain on surface for 10 minutes. There was no mention the solution was to have a wet contact time of 10 minutes, nor did it identify to follow manufacturer's instructions for use of the disinfecting solution.

Based on observation, interview and document review the facility failed to implement care plans for 2 of 2 residents ( R25 and R30). Findings include: R25's 2/15/23, quarterly Minimum Data Set (MDS) assessment identified R25 had moderate cognitive impairment. R25 needed extensive assistance from 2 staff for bed mobility, transfers, and toileting. R25 was unable to balance on his own and needed staff assistance. R25 had no behaviors noted during the assessment period. R25 was identified to take a daily antidepressant. R25 was identified to have Manic Depression (bipolar disease) and depression. The MDS lacked identification of the antipsychotic medication Invega Sustenna Suspension injection that R25 received each month. R25's 3/1/23, printed Order Summary Report identified Invega Sustenna Suspension Prefilled Syringe 39 mg/0.25 milliliters (ml) inject 39 mg intramuscularly the 21st of every month,an antipsychotic for bipolar, and Sertraline HCI 50 mg by mouth at bedtime, an antidepressant for bipolar. The orders lacked target behaviors for the medication or monitoring if the medications were effective. R25's 10/13/22, care plan identified R25 had a grab bar on his bed to aid in mobility. R25 required 1 staff assistance to transfer with an easy (EZ) stand. R25 was at risk for falls related to hypotension and psychoactive medication use. Staff were to ensure R25's call light was within reach and to provide prompt response to all R25's requests. The care plan identified that R25 may need reminding to use the call light. Staff were to assist R25 after eating to the bathroom and into his recliner as he often attempted self transfers. Observation and interview on 2/28/23 at 4:20 p.m., R25 was laying sideways on his bed, hand on his grab bar, feet hanging off the side of bed with call light laying at end of bed across the foot board. R25 was asked if he could reach his call light and he stated no but that would be a good idea at that time one surveyor stayed with R25 for safety and the other surveyor obtained facility staff to assist R25. Licensed practical nurse (LPN)-A entered R25's room to assist R25 and confirmed that the call light was not within reach and should have been. R30 2/7/23, significant change Minimum Data Set (MDS) assessment identified R30 had severe cognitive deficit. R30 required extensive assistance with transfers and toileting. R30 took a daily antipsychotic, antidepressant, and antianxiety medication. R30 had behavior 1-3 days during assessment period that was not directed at other. R30 had 2 falls with no injury, 1 fall with minor injury, and 1 fall with major injury identified on the assessment. R30's 1/24/23, care plan identified R30 was at risk for falls and staff were to complete 30 minute checks, anticipate and meet needs, and staff were not to leave R30 in her room unattended unless she was in her recliner or bed. Observation on 2/27/23 at 12:52 p.m., R30 was sitting in her wheelchair in her room, yelling out help. A facility staff member was obtained to assist R30 in her room. Interview on 2/28/23 at 5:59 p.m., with director of nursing (DON) identified her expectation was that all staff follow the residents care plans as written. The direct care staff were to review the resident care plans for changes at beginning of their shift. The DON revealed she had explained to staff that if the care plan was not followed and something happened to a resident from not following the care plan that there could be ramifications such as being reported to the nurse aide registry or board of nursing. Review of November 2023, Care Plans policy identified residents would have individualized care plans that addressed deficits that had been identified during the comprehensive assessment. Care plans will be reviewed and revised quarterly and as needed. There was no mention of how direct care staff would be informed of the care plan and/or any revisions to the care plan.

Based on interview and document review the facility failed to review the Initial Pre-Admission Screening (PAS) for accuracy for 1 of 1 residents (R25) to ensure a level II screening was completed to identify if services were needed. Finding include: R25's 3/1/23, printed Admission Record identified R25 admitted on [DATE], that included admitting diagnoses of bipolar disorder with secondary diagnoses of depression, alcohol dependence, muscle weakness, and hypotension. R25's 11/22/21, admission Minimum Data Set (MDS) assessment identified in section A 1500 Pre-Admission Screening and Resident Review (PASRR) had the resident been evaluated for a level II screening and been determined to have a serious mental illness or related condition with the answer check as no. Section I 5900 of the MDS identified R25 had active diagnoses of Manic Depression (bipolar disease). Additionally, the following MDS's significant change 3/25/223, quarterly 5/18/22, and quarterly 8/17/22 had in section I active diagnoses of Manic Depression (bipolar) and Schizophrenia checked. Then the quarterly MDS's 11/16/22 and 2/15/23 under section I no longer had an active diagnoses of Schizophrenia but continued to have active bipolar disease. Review of the 11/15/21, PAS results identified R25 had no major mental disorder. Based on the information provided for the nursing home stay it appeared that R25 did not meet the criteria for mental illness (MI). Please note the final determination of the need for further evaluation will be made by Senior LinkAge Line. Senior LinkAge Line had forwarded the PAS to the county/managed care organization U-care for processing. Interview on 2/28/23 at 11:00 a.m., with director of nursing (DON) and social services designee (SSD) who both confirmed that the facility had no process for reviewing the PAS for accuracy compared to the residents admitting diagnoses. The DON revealed that the facility needed a process's to review the PAS for accuracy and bring that forward to the QAPI committee. The DON further revealed the facility needed a better process for maintaining PASRR results. The DON agreed by not ensuring the PAS was accurate and a level II screening was completed the facility may have missed pertinent services that the resident may have needed. A PASRR policy was requested, however the DON identified that the facility did not have one.

Based on observation, interview and document review, the facility failed to provide appropriate supervision and comprehensively assess exit seeking behaviors for 1 of 1 resident (R1). This resulted in an immediate jeopardy (IJ) when R1 was able to repeatedly exit the East door to the facility on to an unsafe walkway with stairs to one side and a sloped sidewalk to the other. The IJ began on 3/25/22, when R1 exited the building and was observed outside by a visitor. Staff were notified and R1 was returned to the building. R1 was not comprehensively re-assessed at that time to determine causative factors, needed interventions, or was provided appropriate supervision when exhibiting those behaviors to prevent R1 from further attempts to exit the building to return home. On 4/1/22, at 1:45 p.m., R1 exited the building again to the same unsafe area on campus after exhibiting exit-seeking behavior. The administrator and director of nursing (DON) were notified of the IJ on 4/13/22, at 2:58 p.m. The IJ was removed on 4/14/22, at 12:46 p.m., however, non-compliance remained at D-ISOLATED, no actual harm with potential for more than minimal harm. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had severe cognitive impairment, and required supervision walking in R1's room, the corridor, and off the unit. R1 utilized a walker and was unsteady walking. R1 had not wandered during the assessment period however, she was identified to have a wander/elopement alarm and bed alarm placed. R1's diagnoses included non-traumatic [CONDITION(S)], Alzheimer's disease and dementia. R1's 9/23/21, Wandering Assessment indicated R1 was at high risk for elopement following an incident on 9/23/21. R1 was discovered across the parking lot and in front of the clinic portion of the hospital, (approximately 1/2 to 1 block form the entrance door). Interventions implemented at that time were to add a WanderGuard monitor on her right ankle. No further interventions were identified. No current or updated Wandering Assessments were noted in the medical record. R1's current, undated care plan, identified R1 was an elopement risk and had a history of attempts to leave the facility unattended with a history of impaired safety awareness. R1 had a Wander Guard monitor to her right ankle implemented on 9/23/21. On 3/25/22, staff updated her care plan to include 30-minute safety checks. There was no intervention related to the need for increased supervision when R1 continued her attempts to open the egress exit doors on the East and West end of the unit. R1's progress note dated 3/19/22, at 12:30 p.m. identified R1 attempted to exit through the West door by holding the egress release bar until the door released. She was intercepted by an unidentified staff before she could exit the second door to a dirt area, which extended between a fence bordering the new construction and the building that extended to the street. Review of the 3/25/22, report submitted to the State Agency (SA) identified R1 was last seen sitting in the dining room at 9:40 a.m. At 9:45 a.m., staff were alerted R1 was outdoors by a visitor. The visitor reported the observation to an unidentified staff member. The door alarm system was sounding. R1 was seen outdoors by staff. Staff then retrieved R1 and she was brought back into the facility at approximately 9:50 a.m. The facility identified the alarms had sounded and staff were doing appropriate 1 hr checks at that time. Review of the 3/30/22, 5-day report to the SA identified staff were interviewed. 1 nurse aide (NA)-A stated they were down a hall, toileting another resident. NA-B reported they were on break at the time of the incident. Licensed practical nurse (LPN)-C reported she was returning from break at 9:45 a.m Registered nurse (RN)-A stated she was toileting a resident. NA-C reported she saw R1 in the East hallway at 9:45 a.m and verbally redirected R1 to turn around. NA-C did not ensure R1's safety and ensure she did not exit seek prior to entering another residents room to toilet a resident. NA-F stated she was in a resident's room and unable to hear the alarm. NA-E reported she heard the alarms and shut off the alarm. She had not seen any residents immediately in eyesight inside. The facility implemented staff to increase her safety checks from every hour to every 30 minutes, and review policies for elopement and alarm systems. Maintenance was to work on obtaining a method to increase the loudness of the alarms so they could be heard in resident rooms. There was no indication the facility identified staff failed to provide appropriate supervision upon seeing R1 wandering with potential exit-seeking behaviors, nor was it identified staff were re-educated to immediately check all doors and ensure all residents were accounted for, prior to turning off any alarm. There was also no indication the facility identified the need for increased supervision when R1 would exhibit potential exit seeking behaviors to prevent future occurrences. Review of the 3/25/22, video footage of the incident identified at the recorded time of 9:47 a.m., R1 was seen walking quickly with no staff in attendance towards the East exit door. At 9:48 a.m., R1 was observed to have pushed buttons on the keypad and pressed the door release bar repeatedly, and finally held the egress door push button bar until the egress door released and R1 was able to open the door. R1 then held the door open, pulled her walker through the door and exited the hallway into the entry way between the inner and outer doors. NA-A responded to the alarm at 9:49 a.m. and looked around the inside area of the door. NA-A did not open the outer door to look outside. At 9:54 a.m. registered nurse (RN)-A responded, opened the door, looked into the entry way between the 2 doors, and returned to hallway by the nurses station. RN-A failed to check outside the outer door to see if a resident had actually exited the building. At 9:53 a.m. NA-A and NA-B were seen rushing out the outer door and returned with R1. Review of an additional incident report submitted to the SA on 4/1/22, identified R1 had once again exited the facility out of the East door at 4:45 p.m She was last checked at 4:39 p.m. and was noted to be in the dining room by LPN-A. NA-C and NA-J heard the alarm but were assisting another resident in their room. After finishing assisting that resident, both NAs went outside and located R1. R1 was then escorted back inside the facility. R1 commented to staff, I will get out again and you won't catch me next time. R1 was to have 1:1 supervision until further notice. Review of the 4/1/22, video footage identified at 4:46 p.m., R1 was noted to be walking rapidly with her walker in the hallway towards the East door. No staff were visible in the hallway. R1 repeated the same actions as she attempted to open the door on the 3/25/22, incident and exited through the door at 4:47 p.m. NA-C and NA-F responded to the alarm for the East door and exited the building to find R1. At 4:50 p.m. NA-C and NA-F returned through the East door with R1. R1 pulled her walker away from the two NAs and walked rapidly toward the nursing station. R1's progress notes from 4/1/22 through 4/9/22 made no mention R1 was on a 1:1 with staff or how staff were tracking and ensuring a 1:1 actually occurred. Review of the 4/5/22, 5 day report submitted to the SA identified 7 staff were interviewed. 6 staff were in other residents' rooms and not able to monitor R1's whereabouts, and 1 staff was on break. The report identified the care plan was to be revised to show 1:1 supervision was to occur until the alarm volume annunciator was to be installed. The facility noted R1 had exited the facility 1 week prior at a different time. There was no mention staff analyzed R1's exit seeking behaviors to look for patterns or trends to help identify when those behaviors were likely to occur. Review of R1's care plan identified staff had not updated R1's care plan on 4/1/22, to show she required 1:1 continuous supervision. On 4/4/22, a revision was made noting a care conference was to be set up with family and R1's MD to discuss different placement options. There was no indication staff were educated R1 was to have continuous 1:1, the care plan was updated with that plan, or how the facility was ensuring continuous 1:1 actually occurred. There was no mention a comprehensive assessment or root cause analysis was completed to determine if 1:1 supervision was attainable, or if the facility looked for patterns of exit seeking behaviors to identify when those behaviors were likely to occur or when R1 would need increased supervision. R1's progress note dated 4/7/22, at 1:36 p.m. identified a care conference was held with R1's spouse and children, the assistant director of nursing (ADON), and MD to discuss possible options of different placement and potential safety measures for R1. The family members were resistant to transferring R1 to a different facility, as R1's spouse was tentatively able to visit daily wanted to keep her in the facility. There was no mention staff had analyzed R1's behaviors to identify when she was most likely to have exit seeking behaviors, or what they would do if all staff were busy and unable to respond to behaviors to prevent R1 from exiting in the future. Observations on 4/12/22 at 10:15 a.m. of R1 identified she was in her room lying in bed. Later at 12:00 p.m., R1 was observed eating her noon meal in the dining room. Interview on 4/12/22, at 10:51 a.m. LPN-A stated she was working on 4/1/22, and was at the nursing station when R1 was standing by the East doorway. LPN-A left the nursing station to assist a different resident who was standing up from his wheelchair and assisted that resident to their room. LPN-A heard the door alarm sound at the East door. LPN-A observed 2 staff members running toward the door, and upon their return to the area, LPN-A was informed R1 had gone out the East door. LPN-A interviewed staff on duty who reported to her they did not hear the alarm as they were in other residents' rooms. The DON requested 1:1 monitoring of R1 until the new annunciator bells were installed on 4/8/22. Education was provided to staff following the 4/1/22, incident which included when R1 was in the hall, staff were to monitor her location, offer snacks, coffee, and possibly sit with her until she was ready to return to her room. R1's family was to be notified so they could come visit and assist staff with monitoring R1's location. LPN-A agreed she had not correctly identified R1 as exit seeking that day when R1 was staying by the East door just prior to the incident. LPN agreed she should not have left R1 alone or should have called for assistance so another staff could have supervised R1 preventing her from leaving the facility into an unsafe area outside the East door. Interview on 4/12/22, at 11:28 a.m., with NA-B stated she was working on 3/25/22 and 4/1/22. NA-B identified on 3/25/22 and 4/1/22, R1 pushed the bar on the door until it released, and she went out both inner and outer East doors. On: 1) 3/25/22, staff received education on WanderGuard door alarms in addition to the outside door alarms, how to reset the alarms, and the procedure for retrieving a resident and immediately reporting the incident to nursing staff. 2) 4/1/22, NA-B and NA-H were in another resident's room with the door closed when they heard the East door alarm. NA-B remembered commenting to NA-H she thought it was R1 who had caused the alarm to sound. As soon as they were able to ensure the current resident's safety, they went to investigate the alarm. Another resident was standing in the hall and pointed to the exit door. NA-B and NA-H went outside the East outer door. NA-B recalled it was very windy that day. R1 was at the end of the ramp hunched forward over her walker with her shirt pulled over her head from the wind. Both NA's assisted R1 to pivot and turn around and go back up the ramp and into the building. NA-B noted R1 had difficulty with her balance in the wind and NA-B and NA-H walked on either side of her to assist as she walked back up the ramp into the building to prevent her from potentially falling over. R1 was upset at being brought back into the facility and when they were back in the building made the statement I will get out again, and you won't catch me next time. R1 was to be placed on 1:1 supervision upon return to the building where it was to have continued until 4/8/22, when the new annunciators were installed as the facility felt louder alarms would alert staff to R1's exiting. R1 was reported to staff to be a high risk for elopement and staff were directed to monitor R1's location if she wasn't in the dining room. NA-B was unaware if staff were to be in the dining room at all times while R1 was there. NA-B was unsure if staff were to provide increased supervision at times when R1's behaviors escalated to prevent R1 from exiting the building. Interview on 4/12/22, at 12:01 p.m. with NA-G stated he was working on 4/1/22, when R1 exited the building, and the alarms sounded. NA-G did not check on the alarm, as he thought it was from another resident standing near the door. R1 was able to walk very quickly with her walker and her gait was steady. NA-G received education following the incident related to monitoring residents, how doors activated with release, and sounds that would indicate if the door was opened and a resident was outside the building. NA-G was unsure if staff were to provide increased supervision at times when R1's behaviors escalated to prevent R1 from exiting the building. Interview on 4/12/22, at 12:14 p.m. family member (FM)-A stated R1 was initially admitted to the facility due to being up at night and wandering. FM-A received notification of the elopement incidents and was told a new alarm system was being installed. FM-A was unaware of any increased supervision required to prevent R1 from exiting the building. Interview on 4/12/22, at 1:02 p.m. with NA-I identified staff were to provide 1:1 monitoring of R1 after the 4/1/22 incident. R1 repeatedly stated she wanted to go home and would often walk back and forth in the hall and then to her room. All staff were aware of the need to monitor R1's location. They were aware she frequently wandered in the halls and had exit seeking behaviors. NA-I was unaware if staff were to provide 1:1 supervision at times when R1's behaviors escalated showing exit seeking. NA-I indicated the louder alarms were to alert staff if R1 exited. There was no indication NA-I was trained to provide increased supervision at times when R1's behaviors escalated to prevent R1 from exiting the building. During interview on 4/12/22, at 2:56 p.m. licensed social worker (LSW) stated a care conference was held on 4/7/22, with herself, R1's spouse, two daughters, ADON, and physician to discuss options for R1's safety. They discussed the possibility of the need to look for other placement if the facility was unable to keep R1 safe and in the building. LSW was not aware all staff were busy and not monitoring R1 when she exhibited exit seeking behaviors. Discussion of a transfer to a locked unit was suggested, but R1's spouse was not accepting of this option and stated if staff were able to hear the alarms there should not be a problem. Interview on 4/12/22, at 3:50 p.m. with MD-A (who was also R1's medical doctor) identified he was aware of R1's elopements out of the facility. He agreed there was a safety concern. MD-A discussed the care conference with family on 4/7/22, but family preferred R1 remain at the facility. MD-A stated the louder alarm system would be effective in allowing staff to hear the alarms better, and possibly intervene, but it would not prevent R1 from exiting if she were unattended and could open the door. MD-A was not aware of comprehensive assessment having been completed to identify potential causative factors to determine the level of supervision R1 required when exit-seeking behaviors were occurring to prevent future elopements. During follow-up interview on 4/12/22 at 5:08 p.m., the DON identified she detailed the events of R1's elopement in the follow up reports to the SA, but did not complete additional comprehensive assessment or analysis of R1's exit-seeking behaviors to identify when R1 would require increased supervision to prevent future elopements from occurring. R1 seemed to be aware of times when staff were busy. That was when she felt R1 was likely to attempt to leave the building. R1's statement about attempting to leave again was concerning. Measures to keep R1 safe included redirection by offering food and drink, use of a WanderGuard device, and 30-minute safety checks. After 4/1/22, when R1 was restless and wandering, R1's spouse was to be contacted to come and sit with her. There was no documentation provided to support current 30-minute safety checks were being completed or if staff identified the need to provide 1:1 supervision at times when R1's behaviors would increase. The DON felt R1 was not an appropriate placement at the facility due to safety concerns and her repeated attempts to exit. The DON elaborated a locked unit might be more appropriate placement, but the family did not want R1 transferred out of town. The DON agreed the facility had no method to monitor 30-minute checks were occurring, effective, or had directed staff when they would need to provide 1:1 direct supervision when R1's behaviors escalated to prevent future elopements. During interview on 4/13/22 at 10:11 a.m., NA-C identified R1 was very mobile, able to self-transfer, and was able to ambulate quickly using her walker. NA-C observed R1 attempting to exit by going to the exit doors, and pushing on the locking bar, but she was able to intervene before R1 actually got the door open. R1 asked NA-C how to leave, stating she wanted to go home. NA-C stated redirection was successful short term, but R1 continued to repeat the behavior. NA-C was unaware if staff needed to provide increased supervision between 30-minute checks when R1 was exhibiting increased exit-seeking behavior. During interview on 4/13/22 at 10:48 a.m., NA-A stated she was aware R1 made repeated attempts to leave the building and following the recent elopements. NA-A did not feel comfortable R1 was not going to try and exit the building again. R1 had repeatedly voiced to NA-A of her intent to leave the facility and go home. NA-A reported she had since observed R1 attempt to open the exit door by pushing the release bar at different times, but the alarm had sounded, and staff were able to intervene before she was able to open the door. NA-A was unaware of any needed increased supervision to prevent exiting from occurring. Observation on 4/13/22 at 11:00 a.m., of R1 identified she was seated at the table in the dining room having tea. At 11:30 a.m., R1 ambulated independently back to her room, and was observed to undress in front of her window with opened curtains. Staff were notified by this surveyor to provide assistance to R1 and provide for her privacy. Observation on 4/13/22, at 2:00 p.m. with the DON of the East door exit identified a ramp was on one side, and several steep steps to the other. The ramp extended from the East door with a partial railing on the hill side of the ramp that extended only halfway along the hill. Review of the October 2021, Elopement Policy directed the admitting nurse to complete the Safety Risk Assessment and identify potential elopement and/or wandering behaviors and develop a specific plan of care for each resident. A Root Cause Analysis/Comprehensive assessment was to be completed following an elopement to identify what measures needed to be implemented. The IJ which began on 3/25/22, was removed on 4/14/22, at 12:46 p.m., when it could be verified through observation, interview and record review, the facility had educated all staff to recognize R1's triggers and behaviors of agitation, such as when she was observed pacing the hallways. Staff were to provide immediate supervision and contact R1's spouse to visit. If he was not available, activity staff were to be contacted to provide an activity for R1. If neither spouse of activity staff were available, staff were to provide increased supervision up to and including 1:1 supervision until R1's agitation passes or her exit seeking behaviors subsided. The care plan was updated to reflect those changes and R1 was comprehensively re-assessed.

Based on observation, interview and document review, the facility failed to properly implement fall prevention interventions to prevent reoccurring falls for 2 of 3 residents (R5, R3) reviewed for accidents. This deficient practice resulted in actual harm for R5, who sustained thoracic spine comprehension fractures. Findings include: R5's Face Sheet dated 7/11/19, indicated R5 was admitted to the facility on [DATE], with initial diagnoses of weakness and repeated falls. R5's Diagnosis Report updated 12/13/21, added the diagnosis of wedge compression fracture of thoracic vertebra. R5's Quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R5 scored 9 of 15 on the brief interview for mental status (BIMS) which signifies moderate impaired cognition, and functional status identifying R5 needing extensive assistance with bed mobility, transferring, locomotion, dressing, toileting, personal hygiene, and walking did not occur. R5's Care Plan falls focus area last revised 11/18/20, identified R5 as moderate risk for falls. Fall prevention interventions included: 7/29/19, anticipate and meet R5's needs; 7/29/19, be sure call light is within reach and encourage to use; 7/29/19, ensure R5 is wearing appropriate footwear; 7/29/19, follow facility fall protocol; 7/29/19, physical therapy to evaluate and treat as ordered/as needed; and 11/18/20, requires assist of one for all transfers and has a history of self-transferring. A Fall Risk assessment dated [DATE], indicated R5 scored 17, meaning at high risk for falls. Document review indicated R5 had the following falls: On 09/19/21, at 6:10 p.m. staff were notified by another resident that R5 was yelling and concerned he may have fallen. Staff responded and found R5 sitting on the floor next to his bed and wheelchair. R5 stated he was trying to go to the bathroom. R5 sustained a skin tear on his left elbow. The incident report noted and fall assessement was completed and fall prevention interventions of ensure call light, cell phone, and wheelchair are within reach. However, R5's care plan was reviewed and lacked evidence the fall interventions were added and implemented post fall. The incident report further documented that R5 has had seven falls since his admission on 7/11/19. On 12/04/21, at 9:00 p.m. resident activated his call light to summon help because he had fallen while trying to go to the bathroom. Staff found R5 sitting on the floor between his bed and wheelchair. R5 did not sustain an injury. The incident report documented fall assessment was completed and fall prevention interventions of ensure call light is within reach, wear appropriate footwear, and to add offer toilet every two hours at night if awake. R5's care plan was reviewed and lacked evidence the new fall intervention was added and implemented post fall. The incident report further documented that R5 has had eight falls since his admission on 7/11/19. On 12/05/21, at 5:00 p.m. staff performing bed checks found R5 lying on the floor in the corner of the room. R5 stated he did not know what he was doing but maybe going to the bathroom. R5 complained of left rib pain. The incident report documented a fall assessment was completed but lacked evidence fall interventions were developed or implemented to reduce the likelihood of future falls for R5 post fall. On 12/10/21, at 11:45 a.m. staff passing by R5's room heard him yelling for help. R5 was found sitting on the floor next to his bed. R5 stated no one pays attention to him and ignores his cries for help. The incident report documented no injuries. The Post Fall assessment dated [DATE], documented the fall resulted in a fracture and that the care plan was reviewed. Hospital discharge summary dated 12/10/21, diagnosed R5 with T8-T9 thoracic compression fractures. The hospital summary also documented that R5 had fallen out of bed on three occasions. The incident report documented a fall assessment was completed lacked evidence fall intervention were developed or implemented to reduce the likelihood of future falls for R5 post fall. On 12/14/21, at 4:50 p.m. R5 was found sitting on the floor holding onto the mobile table. The incident report documented R5 did not have any injuries. The 24-Hour Post Fall Assessment documented that R5 is at risk for further falls due to restless behavior and inability to make his needs known. The incident report lacked evidence fall intervention were developed or implemented to reduce the likelihood of future falls for R5 post fall. On 12/16/21, at 10:09 a.m. R5 was observed being wheeled to his room from the dining room. R5 was unable to hold his feet up and staff were observed frequently stopping to let the resident rest. R5 was leaning over to his left side with the arm rest holding him up. During an interview on 12/16/21, at 10:01 a.m. R5 stated he is not doing very well. He stated he was in constant pain from the fall and could not get comfortable. During the interview R5 was observed to hold his left side and was continually rolling from side to side and attempting to sit up. R5 stated he just could not find a comfortable position. R5 stated he received pain medication, but it barely helped alleviate the pain. R5 further stated he is so weak that he could not walk and was only able to pivot transfer. R5 stated he knows he should not transfer by himself, but it takes too long for staff to respond to his call light. During a family interview on 12/13/21, at 9:00 a.m. the family stated they had safety concerns with R5 being discharged from the hospital to the nursing home because of the multiple falls R5 had sustained. Two members of the family FM-(A) and FM-(B) met with assistant director of nursing (ADON) and registered nurse (RN)-B. FM-A and FM-B questioned what the facility was going to do for safety and how to prevent another fall. ADON and RN-B stated they will put the bed in the lowest position, placed a fall mat next to the bed, and will start performing 30-minute safety checks. FM-A and FM-B stated R5 sustained a fall at the facility approximately a year ago and now R5 had another back injury. FM-A and FM-B also stated that R5 is now on hospice care due to his thoracic compression fractures. During an interview on 12/16/21, at 10:16 a.m. NA-B stated NAs do not fill out incident reports or have access to view them; only nursing staff complete the forms and have access to them. NA-B stated that R5's safety interventions are in POC and have not changed. NA-B further stated, when a fall prevention intervention is added in the care plan, it is linked to their Kardex (Point of Care) and they receive a notification that a new responsibility or intervention has been added. NA-B stated she was not unsure what R5's fall interventions were previous to his hospital stay. During an interview on 12/16/21, 12:10 p.m. licensed practical nurse (LPN)-A stated floor nursing staff enter new fall prevention interventions on the Falls Assessment and the CCC enters them into the care plan. LPN-A stated she was unsure if there were any changes in the care plan for R5 and she was not aware of fall interventions for him previous to his return from the hospital. R3's Face Sheet dated 7/24/17, indicated R3 was admitted to the facility on [DATE]. R3's Diagnosis Report dated 7/24/17, indicated R3 diagnosis included Alzheimer's disease, dementia, anxiety, restless and agitation, and history of falling. R3's Quarterly MDS assessment dated [DATE], indicated R3 scored 3 of 15 on the BIMS assessment, signifying R3 as severely impaired cognition; physical behaviors symptoms towards others, such as hitting, kicking, or pushing; uses a walker for mobility; and requires extensive assistance with dressing, toileting, and personal hygiene. R3's Care Plan, falls focus area was last revised 4/10/18. Fall prevention interventions included: R3 requires supervision with ambulation, keep room and pathway free of clutter, may walk around in bare feet, and WanderGuard placed. A Fall Risk assessment dated [DATE], indicated R3 scored 14, meaning at moderate risk for falls. Record review revealed R3's discharged to another nursing facility on 11/29/21. Document review indicated R3 had the following falls: On 9/21/21, at 7:45 a.m. R3 was found on the floor next to her bed. The walker was in the bathroom and there was water on the floor as well as clothes all over her room. R3 did not sustain an injury. Documentation indicated R3 has had sixteen falls since her admission on 7/24/17. The incident report documented fall prevention interventions of anticipate R3's needs, be sure call light is within reach, provide a safe environment with floors free from spills and clutter, and ensure walker is always within reach. R5's care plan was reviewed and lacked evidence the new fall interventions were added and implemented post fall. On 11/01/21, at 5:30 a.m. staff heard a thud from R3's room and upon investigation, R3 was found lying on the floor by her bed. During an assessment for injuries, it was found that R3 sustained a 0.25 cm x 7.0 cm laceration to the back of her head. R3 was taken to the nurse's station and a cold pack was applied to the wound. The incident report lacked evidence of new fall interventions but noted interventions from fall on 9/21/21 were not care planned post fall of anticipate R3's needs, be sure call light is within reach, provide a safe environment with floors free from spills and clutter, and ensure walker is always within reach. R3's care plan was reviewed and lacked evidence the fall interventions were added and implemented post fall for 11/1/21 fall as well. During an interview on 12/16/21, 10:27 a.m. ADON stated the new interventions that were placed for R5 include keeping the bed in lowest position, fall mat next to the bed, and 30-minute safety checks. ADON indicated that the clinical care coordinator (CCC) is responsible to enter care interventions in the Treatment Administration Record (TAR) and to update the care plan adding, if there are not any fall prevention interventions in the care plan for the five recent falls then no interventions were created. ADON further agreed that no root cause analysis was completed for the falls. ADON stated it was her expectation that the care plan be updated after every fall for R3 and R5 and this was not getting done. During an interview on 12/16/21, 11:01 a.m. CCC-A stated she is just becoming aware there is a system issue of who enters fall prevention interventions in the care plan. CCC-A stated it was the floor nurse's responsibility to enter interventions. CCC-A stated the inter disciplinary team (IDT) only briefly discusses falls during the morning stand-up meeting and new interventions are not discussed. CCC-A further stated the facility does not have a falls prevention committee and QAPI is not tracking if current fall prevention interventions are working or should be updated/revised. During an interview on 12/16/21, at 9:46 a.m. nursing assistant (NA)-A stated fall prevention interventions are in the Point of Care (POC) section of PointClickCare (PCC) electronic medical record. When a fall prevention intervention is added in the care plan, it is linked to their Kardex (Point of Care) and NA's receive a notification that a new intervention has been added. NA-A explained there have been no new fall prevention interventions because NA's would have been notified that one has been added. NA-A further stated that NAs do not fill out fall incident reports or have access to look at them. This prohibit NA's from viewing fall prevention interventions and being able to implement them. NA state she was unware of R3's fall interventions were previous to her demission or what R5's interventions were previous to his hospital stay. The facility's policy entitled Falls, last revised 10/21, directed the charge nurse, CCC, or the DON/ADON complete the Fall Root Cause Analysis, investigation, provide intervention from the root cause analysis, and CCC or DON/ADON to update the care plan with the intervention. It was found that the facility is not following the Falls policy.

Based on observation, interview and document review, the facility failed to develop elopement prevention interventions upon R1's admission even though R1 was at moderate risk for elopement, and staff were aware R1's had exit seeking attempts before R1 successfully eloped from the facility. The immediate jeopardy (IJ) began on 9/23/21 at 1:03 p.m., when it was determined the facility failed to provide elopement prevention interventions and R1 eloped. The chief executive officer and interim director of nursing (DON) was informed of the IJ on 10/6/21, at 6:29 p.m. The IJ was removed on 10/7/21, at 2:38 p.m. however, non-compliance remained at an isolated scope and severity which indicated no actual harm with potential for more than minimal harm (Level D). Findings include: R1's admission record document dated 9/22/21, identified dementia with behavioral disturbance as the primary admitting diagnosis. R1's admission Minimum Data Set (MDS) assessment dated [DATE], identified R1 had a brief interview of mental status score of nine, indicating moderately impaired cognition. R1's care area assessment (CAA) summary dated 9/29/21 documented R1 had cognitive loss - dementia, communication - impaired ability to make self-understood, activities of daily living (ADL) - extensive assistance with dressing, toileting and personal hygiene, behavioral symptoms - wandering, falls - one fall since admission, and [CONDITION(S)] drug use - received hypnotic medication administered since admission. On 9/24/21, facility submitted a vulnerable adult report to state agency identifying that R1 was found by herself outside the care center and walking on the street. R1 had eloped and the facility was unaware of the elopement. The facility risk management (incident report) document #2393 dated 9/23/21, at 1:49 p.m. indicated R1 was confused, impaired memory, and was an active exit seeker. During an interview on 10/5/21, at 11:18 a.m., RN-A stated there was no root cause analysis of the incident, only completion the vulnerable adult (VA) report. RN-A was unable to provide any details of how R1 eloped, only that video footage showed R1 exited the west door of the unit. RN-A was unable to describe any staff re-education on how to prevent R1 or any other VA from eloping. During an interview on 10/6/21, at 9:01 a.m. NA-A stated they observed R1 twice trying to exit out the west door during the morning (unknown times) on 9/23/21. NA-A was unaware if R1 was an elopement risk. NA-A stated R1's exit seeking was not reported to the unit charge nurse that day. RN-A and DON were unavailable that day. R1's Admission/Readmission Evaluation Assessment, completed by RN-A on 9/22/21, at 4:49 p.m. included the following question, #2. Risk Alerts: may attempt exit. RN-A did not select may attempt exit, even though the wandering risk assessment indicated R1 was at moderate risk for elopement. R1's Safety Risk Assessment Elopement, completed by RN-A on 9/22/21, at 4:51 p.m. indicated R1 required a bed alarm due to decreased cognition related to progression of dementia, decline in decision making skills, orientated to only herself, and the risk of getting up by herself and falling. RN-A did not identify R1 was at moderate risk for elopement after identifying the concern during the admission wandering risk assessment. R1's Admission Wandering Risk Assessment, completed by RN-A on 9/22/21, at 4:51 p.m identified the following: orientation (disorientated x 2 spheres), behavior-mood (does not understand surroundings), recent experiences (admission within the last month), mobility (ambulates with one assist), diagnosis (dementia with [CONDITION(S)]), medication (taking antipsychotic's). R1's calculated wandering risk assessment score was 6 (out of 31) indicating moderate risk, however the facility did not implement elopement prevention interventions even though they assessed him at moderate risk level. R1's admission baseline care plan dated 9/22/21, completed by RN-A did not include elopement prevention interventions. R1's falls risk assessment note dated 9/22/21, 4:51 p.m. identified R1 as being at moderate risk for falls and used a 4-wheel walker for mobility. An admission summary progress note dated 9/22/21, at 5:01 p.m. indicated R1 was oriented to her room and call light but the family does not think R1 will use call light appropriately and asked that a pressure pad alarm be placed on bed to alert staff that R1 is self-transferring. The note further indicated R1 needed assistance of one staff person for ADL's, toileting and mobility with her 4-wheel walker. An electronic progress note written by social worker (SW).dated 9/22/21, at 2:40 p.m. described R1 as being admitted from her home and laid on her bed as writer visited with her family and did not participate in the admission discussion. A health status note dated 9/23/21, at 2:40 a.m. documented R1 is alert, very confused and needs constant supervision while awake. R1 appears unable to sit in one place very long and takes off wandering without her 4-wheel walker and needs frequent monitoring by staff. During an interview on 10/06/21, at 8:41 a.m. R1 was asked why she left the facility and R1 stated, it was a nice day, and she went for a walk around the block. R1 stated she goes for walks all the time. During an interview on 10/06/21, at 3:43 p.m. DON stated her expectations if a resident is exit seeking, NA's are required to immediately notify the charge nurse so a WanderGuard could be placed. DON stated she was not informed that R1 had attempted twice to elope from the facility. The DON stated NA-A could have reported the elopement attempts to any nurse in the units and they could have placed a WanderGuard (mechanical device to alert staff when someone leaves the building). During an interview on 10/06/21, at 10:07 a.m. licensed practical (charge) nurse (LPN)-A and LPN-B stated that LPN's do not complete admission assessments but the RN-A completes them. LPN-A and LPN-B stated not knowing what a moderate elopement risk is or what a level six moderate risk means, as this is not included on the elopement risk form LPN-A and LPN-B stated RN-A completes interventions and they would refer to the treatment administration record (TAR) for direction. LPN-A and LPN-B further stated interventions or new interventions are not shared during end of shift report and that staff must look at the TAR for direction. During an interview on 10/06/21, at 10:21 a.m. DON stated R1 had a wandering risk assessment on day of admission, and scored a six on the assessment. DON stated, that means she is at moderate risk for wandering but DON was not clear what that means. DON indicated a definition of low, medium, or high wandering risk was not defined in electronic medical record system nor was she aware of definition. DON described a conversation with RN-A in which she described R1 as laying in her bed with her eyes closed all through admission, stayed in bed throughout the rest of the day/evening, and would not eat supper. DON stated, based on RN-A admission assessments, no wandering or elopement interventions were required at that time. DON stated RN-A received a call on 9/23/21, at approximately 1:00 p.m. from the medical clinic informing her that R1 was outside in front of the clinic. During an interview on 10/06/21, 10:32 a.m. medical clinical receptionist (CR)-A stated she is a neighbor of R1. CR-A stated she was just coming to work at the medical clinic and saw R1 walking alone with her walker, in front of the clinic. CR-A stated R1's family never lets her walk alone. CR-A requested a co-worker call RN-A from facility and inform her that R1 is out front of the facility. CR-A caught up to R1, close to the intersection of 8th Street and 2nd Avenue as R1 was walking further away from the facility campus. CR-A asked R1 what she was doing and R1 replied, going for a walk. CR-A was able to get R1 turned around and walk her back to the facility. They were met in the driveway of the facility by RN-A. During an interview on 10/06/21, at 10:40 a.m. RN-A stated during the admission to the facility, R1's husband and daughter were in the room and answered almost all of the intake questions. R1 was laying on the bed with her eyes closed and appeared at times to be sleeping. R1's first day was spent in bed sleeping and she would not leave her room or eat supper. On the second day, R1 was up and on the move. She was completely different from the first day. RN-A stated R1 scored a six on the wandering risk assessment, but due to R1's first day, wandering/elopement interventions were not needed. RN-A stated she is unclear what a moderate risk for wandering means from the wandering/elopement assessment. (add what your were referring to- assessment). RN-A further states, she does not develop wandering/elopement prevention interventions for low and moderate risk, only high risk. RN-A stated she does not know what the scale means and if a score of six is high or not. RN-A shared that the facility administrator reviewed the security video footage of R1's elopement and discovered R1 exited the west door of the unit on 9/23/21, at 1:03 p.m. She further shared that on 9/23/21, at 1:13 p.m. CR-B called and informed her that CR-A was outside of the facility with R1. RN-A stated upon R1 returning to the unit a WanderGuard was immediately placed, and one-hour safety checks were initiated. RN-A stated she feels R1 was walking home. R1 lives close to the facility, and her sister is also in the facility. R1 would walk back and forth from her home to visit her sister. RN-A stated what is different during R1's admission, is R1 is confused and has mentally declined over the last few months. The facility failed to develop elopement prevention interventions upon R1's admission to the facility, even though the wandering risk score indicated R1 had a moderate risk of eloping. The facility NA also failed to report exit seeking attempts, which enabled R1 to elope. The facility policy Elopement last revised 09/2020, directed the admitting nurse to complete the Safety Risk Assessment and identify potential elopement and/or wandering and develop a specific plan of care for each resident The IJ which began on 9/23/21 at 1:03 p.m., and was removed on 10/7/21, at 2:38 p.m. after the facility successfully implemented a removal plan which included the following: R1 was reassessed for elopement and R1's care plan was updated to include: identifying R1 as an elopement risk, placement of WanderGuard, and implementing one-hour safety checks. Updated elopement intervention included: the Elopement policy was updated to include residents at the low to moderate risk for wandering will have thirty minute safety checks for the first seventy-two hours of admission and high risk for wandering will have a WanderGuard placed on admission. On 10/07/21, eight of eight on-duty staff were interviewed and found that reeducated started on 10/07/21, and all staff were knowledgeable of the changes in the Elopement policy and new documentation requirements. The staff were all educated to communicate residents exit seeking behavior to the nurse on duty immediately so intervention could be implemented.

Based on interview and document review, the facility failed to provide the correct mechanical lift to prevent accident hazards for 1 of 1 residents who fell from the mechanical lift and sustained a fractured femur (upper leg), resulting in actual harm. Findings include: R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified moderate cognitive impairment, and needed extensive staff assistance for bed mobility, transfers, locomotion on/off unit, dressing, toileting and personal hygiene. Both verbal and physical behavior was identified 1-3 days during the assessment period, and no falls identified. The MDS identify [DIAGNOSES REDACTED]. R1's care plan with a initiation date of 6/13/14 and revision date of 8/23/19, listed a Focus of at risk for falls related to unaware of safety needs, need for total assist with mechanical lift for all transfers. Physically unable to bear own weight independently or walk. Interventions included: Transfer: Requires two staff and hoyer lift for all transfers in and out of bed. The EZ stand may be used for transfers to and from wheelchair to commode only. The nursing assistant care sheet (undated), Transfer: The resident requires 2-3 staff and hoyer lift for all transfers. R1 had a documented history of becoming agitated and both verbally and physically aggressive during the provision of cares. In order to promote safety for R1 and the staff providing the care, 2-3 staff persons were care planned to assist with the provision of care and transfers with the use of both the EZ stand (allows for transfer of a patient in a standing position) and hoyer lifts (full body lift). Review of the facility investigation of the incident dated 8/13/19, at 11:40 a.m. indicated R1 was being transferred by staff, nursing assistant (NA)-A from her wheelchair to the bed utilizing the EZ stand lift. R1 became agitated, let go of the EZ stand hand holds and began swinging at NA-[NAME] R1 slid from the EZ stand, onto the bed and from the bed to the floor. R1 had no obvious injuries, but complained of her left shoulder and hip hurting. R1 was transferred to the Emergency Department for evaluation where she was found to have a non displaced left femur subcapital fracture. RN-A whom investigated the incident indicated the original care plan listed: Toilet Use: The resident requires one-two staff and the EZ Stand, Use commode for all toileting. Transfer: The resident requires two staff and hoyer lift for all transfers in and out of bed. The EZ Stand may be used for transfers to and from wheelchair to commode only. The investigation revealed NA-B had failed to place a lift sheet underneath R1 when she was gotten up that morning. During the subsequent interview with NA-B it was verified the EZ Stand lift had been utilized to get R1 out of bed on 8/13/19 and transfer her to the wheelchair, instead of the hoyer lift as indicated in the care plan. Both NA-A and NA-B were interviewed by RN-A and verified they had failed to follow the directions identified in the care plan for R1. The interim director of nursing (DON) was interviewed on 8/22/19, at 3:14 p.m. and verified as a result of the facility investigation it was determined NA-A and NA-B had failed to provide care according to the care plan for R1. As a result R1 fell and sustained a serious injury. The incident was reviewed by the licensed social worker and a report filed with the state agency. DON stated both employees received written disciplinary warnings. In addition documentation was provided and an in-service provided by the EZ Way Representative on 7/15/19 (before R1's fall out of the lift) which included the appropriate use of both the EZ Stand and EZ sling lifts. NA-A was verified to have been in attendance at the in-service, NA-B was not in attendance. During a subsequent interview on 8/23/19, at 11:30 a.m. the DON verified her expectation that staff followed the individualized resident plan of care and followed the facility policies. RN-A was interviewed on 8/23/19, at 11:30 a.m. and verified all residents using the EZ stand and EZ sling lift are being reviewed by therapies for safety and use of the appropriate device and the care plan is being updated appropriately. Review of the facility policy Safe Patient Handling dated 6/16: Preferred Methods for Lifting and Transferring Clients: The key to your successful lift program is the correct assessment of the patients for the four point lift and the stand assist lift; clear and consistent communications regarding the need for assistive devices for individual patients; and the skillful use and familiarity of the lift by your associates. Based on the patient's classification from the Plan of Care, specific methods of transferring and lifting will be designated for each patient. Review of the the facility policy: EZ Stand dated 4/06: Policy this mechanical aid will be used, as necessary, to assist in moving a resident. Purpose: To help reduce manual lifting of dependent or obese residents with safety and minimal effort. The EZ Stand was designed specifically for toileting and changing briefs of residents. (Used twice for chair to bed transfer) Residents should be able to bear some weight. (Care plan: Physically unable to bear own weight or walk). General Safety Requirements: When using the EZ Stand two people will be in attendance beside the resident. (Care Plan indicated 1-2 persons for EZ Stand use).