Every finding on record at Mala Strana Health Care, LLC

Based on observation, interview, and document review, the facility failed to ensure morning cares were provided in a dignified, courteous manner to prevent complication (i.e., frustration, misunderstanding) for 1 of 1 residents (R1) reviewed who expressed staff had been rough with her during provision of care. Findings include: R1's admission Minimum Data Set (MDS), dated [DATE], identified R1 had severe cognitive impairment but demonstrated no delusional thinking during the review period. A submitted Incident Report Summary (i.e., FRI), dated 8/4/25, identified an incident had happened on 8/3/25 where R1 had expressed nursing assistant (NA)-A and NA-B were rough when getting her out of bed in the morning. R1 was found to have a bruise on her left leg after this incident and the FRI outlined R1 had sustained potential mental anguish from it with dictation reading, Cried during interview. On 8/6/25 at 9:06 a.m., R1 was observed lying in bed while in her room. An interview was attempted with R1 at this time, and R1 nodded responses to verbal questions from the surveyor, however, responded aloud only in Spanish. Following, registered nurse manager (RN)-C was approached and expressed R1 knew only a few English words so staff often used a bedside AI [artificial intelligence] device or had facility' staff translate. RN-C recommended having the facility' staff translate as R1 could speak fast at times which made it hard for the device to translate. At 9:09 a.m., licensed practical nurse (LPN)-A joined R1 and the surveyor and acted as interpreter for the conversation in Spanish. R1 was unable to recall how long she had lived at the care center but expressed a desire to return home. R1 denied being abused while at the care center, but stated the staff who had helped her on Sunday [8/3] had been rough and fast-moving with morning cares adding, per LPN-A, the cares provided, They didn't get her up good. This was explained further as, She was laying down and they grabbed her. R1 expressed she didn't like talking about the incident and appeared to become more subdued while speaking to LPN-A at this point. LPN-A stated R1 had expressed, She wants to just forget about it, adding further that R1 was unsure if the staff who had helped her during this incident understood her (R1) or not due to a potential language barrier. Following, on 8/6/25 at 9:27 a.m., LPN-A was interviewed. LPN-A explained they had heard about the incident R1 had just described but expressed she (LPN-A) returned to work on Monday (8/4) afterward and R1 seemed really upset about it. LPN-A stated that is when they had found the bruising on R1's left leg and talked with trained medication aide (TMA)-B about the situation. TMA-B had told LPN-A they had overheard some of the interaction between R1 and NA-A, NA-B on 8/3/25 from outside the room as R1 had been cursing them [NA-A, NA-B] out in Spanish. LPN-A stated the director of nursing (DON) was informed about the incident on Monday (8/4), and added they were not sure what, if any, education for staff had been attempted or started yet as they hadn't seen any be assigned for themselves. When interviewed on 8/6/25 at 9:44 a.m., TMA-B verified they spoke Spanish, and explained staff whom were not able to speak Spanish were supposed to be using the AI device to communicate and explain cares to R1. However, TMA-B added they hadn't seen staff using it much at all. TMA-B recalled the incident with R1 on 8/3/25 and verified they were on shift working that day when it happened. TMA-B explained they were in the hallway outside R1's room at the medication cart and overheard R1 yelling to the aides to, Stop, slow down! TMA-B stated NA-A then was clearly heard saying, No commprendo, back to R1 in what TMA-B described as a kind of sarcastic manner while giggling aloud. TMA-B stated they then entered R1's room and saw R1 semi-sitting on the bedside and R1 expressed to her, They're not giving me time. TMA-B verified they never saw NA-A or NA-B be physically rough with R1. TMA-B stated she didn't approach NA-A about the comment made, however, reiterated they (TMA-B) had clearly heard it adding, Loud and clear. Further, TMA-B stated since the incident happened on 8/3/25 that management had told staff to give R1 more time to do cares, however, had nothing had been educated or sent to them about potentially inappropriate language (i.e., sarcastic comments to residents) use that they had seen yet adding aloud, No, not yet. R1's care plan, printed 8/6/25, identified R1's current or potential problems along with various goals and interventions to address them. The care plan identified a Focus, dated 6/16/25, which read, Alteration in communication speaks Spanish, along with interventions including, Speak clearly and distinctly to resident or use resident preferred communication method - use AI translator, and, Alternate communication method (AI translator and or picture binder in room). On 8/6/25 at 10:01 a.m., RN-C was interviewed, and verified they were the nurse manager for R1. RN-C explained they were also working on 8/3/25 and TMA-B approached them towards the end of the day to explain some staff had been moving too fast with [R1]. RN-C stated TMA-B had never mentioned NA-A making potentially sarcastic comments back to R1, and expressed if staff overheard that then it should have been reported immediately. RN-C stated there were multiple staff members working on 8/3/25 who could have communicated with R1 in Spanish if the staff were having issues explaining cares or communicating with her. Following this, on 8/6/25 at 10:20 a.m., TMA-B approached the surveyor and expressed they had forgot to say they had reported the sarcastic comment NA-A made to RN-C on 8/3/25 adding, I told [RN-C]. When interviewed on 8/6/25 at 11:28 a.m., via telephone, NA-A verified they had helped R1 with morning cares on 8/3/25. NA-A explained they entered R1's room and tapped R1's arm saying aloud in English it was time to get up for the day to which R1 nodded her head in response. NA-A stated though, I could tell she was tired. NA-A stated she started to get R1 up and R1 seemed very difficult to move on her own so, as a result, NA-A left to get more help. NA-A and NA-B then both physically attempted to get R1 up from the bed using a gait belt when R1 expressed aloud words in Spanish. NA-A stated both of them (NA-A, NA-B) couldn't understand R1 so then, at that time, they attempted to use the AI device to help translate her words, however, the device didn't work. NA-A stated they then did a 1-2-3 signal to R1 and attempted to sit her up again which is when TMA-B entered the room. NA-A stated she didn't feel R1 ever told her to stop cares or slow down, however, then added R1 spoke Spanish only so they (NA-A) weren't sure what had all been said. NA-A verified they made a comment aloud at one point of, No commprendo, however, denied making this in a sarcastic manner. NA-A stated they were trying to tell R1 they didn't understand her but then added, Maybe she [R1] took that tone as demeaning, I'm not sure. NA-A verified nobody had asked them or talked to them about the comment that day. NA-A expressed some frustration with the AI device and stated they'd never had training on it. NA-A stated the biggest thing about the incident on 8/3/25 was the language barrier adding if the device had worked like intended then maybe it would have gone differently. NA-A added, in hindsight, they knew TMA-B was working that day and they maybe should have gotten her earlier [to help translate or explain cares].On 8/6/25 at 12:43 p.m., a group interview was completed with the DON, administrator, regional director of operations (RDO)-A, and assistant director of nursing (ADON). DON verified they were first told of the incident which happened on 8/3/25 the following day, on 8/4/25, and explained R1 alleged two female staff members had pulled me out of bed. DON stated they visited with TMA-B who had explained to them they overheard R1 yelling at the two aides to slow down in Spanish which caused TMA-B to enter the room and tell the two aides to take your time with her. DON stated nobody had reported NA-A as potentially saying comments to R1 in a sarcastic manner, but acknowledged she didn't clarify that with anyone, either. DON stated if staff overhear that happening, they should immediately report it to, at minimum, their nurse manager so it can be reviewed or addressed. DON added such behavior was not acceptable here at [NAME] Strana. DON stated they had been investigating this incident since they were notified of it and expressed from their data collection thus far, the AI device had not been used or attempted until nearly after the cares were completed. DON verified staff should be knocking on the door and explaining what they're going to do to a resident prior to starting the care; and she reiterated there were staff members working in the building on the day of the incident whom could have helped interpret and provide communication between the NA(s) and R1 if there had been any confusion. The RDO stated they had started some education already about this incident, and the group all acknowledged the importance of maintaining the resident rights with the DON expressing aloud, That appears to be what was missed here. Further, the DON stated some education had been started and the administrator was going to send out an email with some resident' rights material to the staff that day. A facility policy on dignified care or treatment was requested, however, none was received.

Based on interview and document review, the facility failed to ensure an allegation of potential verbal abuse (i.e., mocking, demeaning) was reported to the administrator and, if needed, the state agency (SA) in a timely manner for 1 of 3 residents (R1) reviewed during the abbreviated survey. Findings include: R1's admission Minimum Data Set (MDS), dated [DATE], identified R1 had severe cognitive impairment but demonstrated no delusional thinking during the review period. A submitted Incident Report Summary (i.e., FRI), dated 8/4/25, identified an incident had happened on 8/3/25 where R1 had expressed nursing assistant (NA)-A and NA-B were rough when getting her out of bed in the morning. R1 was found to have a bruise on her left leg after this incident and the FRI outlined R1 had sustained potential mental anguish from it with dictation reading, Cried during interview. On 8/6/25 at 9:06 a.m., R1 was observed lying in bed while in her room. An interview was attempted with R1 at this time, and R1 nodded responses to verbal questions from the surveyor, however, responded aloud only in Spanish. Following, registered nurse manager (RN)-C was approached and expressed R1 knew only a few English words so staff often used a bedside AI [artificial intelligence] device or had facility' staff translate. RN-C recommended having the facility' staff translate as R1 could speak fast at times which made it hard for the device to translate. At 9:09 a.m., licensed practical nurse (LPN)-A joined R1 and the surveyor and acted as interpreter for the conversation in Spanish. R1 was unable to recall how long she had lived at the care center but expressed a desire to return home. R1 denied being abused while at the care center but stated the staff who had helped her on Sunday [8/3] had been rough and fast-moving with morning cares adding, per LPN-A, the cares provided, They didn't get her up good. This was explained further as, She was laying down and they grabbed her. R1 expressed she didn't like talking about the incident and appeared to become more subdued while speaking to LPN-A at this point. LPN-A stated R1 had expressed, She wants to just forget about it. Following, on 8/6/25 at 9:27 a.m., LPN-A was interviewed. LPN-A explained they had heard about the incident R1 had just described but expressed she (LPN-A) returned to work on Monday (8/4) afterward and R1 seemed really upset about it. LPN-A stated that is when they had found the bruising on R1's left leg and talked with trained medication aide (TMA)-B about the situation. TMA-B had told LPN-A they had overheard some of the interaction between R1 and NA-A and NA-B on 8/3/25 from outside the room as R1 had been cursing them [NA-A, NA-B] out in Spanish. When interviewed on 8/6/25 at 9:44 a.m., TMA-B verified they spoke Spanish and recalled the incident with R1 on 8/3/25, and verified they were on shift working that day when it happened. TMA-B explained they were in the hallway outside R1's room at the medication cart and overheard R1 yelling to the aides to, Stop, slow down! TMA-B stated NA-A then was clearly heard saying, No commprendo, back to R1 in what TMA-B described as a kind of sarcastic manner while giggling aloud. TMA-B stated they then entered R1's room and saw R1 semi-sitting on the bedside and R1 expressed to her, They're not giving me time. TMA-B verified they never saw NA-A or NA-B be physically rough with R1. TMA-B stated they had never seen NA-A or NA-B be rough or demeaning with someone prior, however, reiterated they heard NA-A make that comment to R1 adding, Loud and clear. TMA-B explained the comment was made with sarcasm and like [in a] giggly way, which TMA-B stated made them upset also. TMA-B stated they felt the manner in which they heard NA-A make the comment to R1 was said in a demeaning way. On 8/6/25 at 10:01 a.m., RN-C was interviewed, and verified they were the nurse manager for R1. RN-C explained they were also working on 8/3/25 and TMA-B approached them towards the end of the day to explain some staff had been moving too fast with [R1]. RN-C stated TMA-B had never mentioned NA-A making potentially sarcastic or demeaning comments back to R1, and expressed if staff overheard that then it should have been reported immediately. RN-C stated there were multiple staff members working on 8/3/25 who could have communicated with R1 in Spanish if the staff were having issues explaining cares or communicating with her. Following this, on 8/6/25 at 10:20 a.m., TMA-B approached the surveyor and expressed they had forgot to say they had reported the comment NA-A made to R1 to RN-C on 8/3/25 adding, I told [RN-C].The Centers for Medicare and Medicaid (CMS) iQEIS system was reviewed. This verified the allegation of R1 with rough care was not reported to the state agency (SA) until over 24 hours later on 8/4/25, despite TMA-B hearing staff make comments to R1 which were, in their view, potentially demeaning (i.e., verbally abusive) at the same time of the alleged rough care. When interviewed on 8/6/25 at 11:28 a.m., via telephone, NA-A verified they had helped R1 with morning cares on 8/3/25. NA-A explained they entered R1's room and tapped R1's arm saying aloud in English it was time to get up for the day to which R1 nodded her head in response. NA-A stated though, I could tell she was tired. NA-A stated she started to get R1 up and R1 seemed very difficult to move on her own so, as a result, NA-A left to get more help. NA-A and NA-B then both physically attempted to get R1 up from the bed using a gait belt when R1 expressed aloud words in Spanish. NA-A stated both of them (NA-A, NA-B) couldn't understand R1 so then, at that time, they attempted to use the AI device to help translate her words, however, the device didn't work. NA-A stated they then did a 1-2-3 signal to R1 and attempted to sit her up again which is when TMA-B entered the room. NA-A stated she didn't feel R1 ever told her to stop cares or slow down, however, then added R1 spoke Spanish only so they (NA-A) weren't sure what had all been said. NA-A verified they made a comment aloud at one point of, No commprendo, however, denied making this in a sarcastic manner. NA-A stated they were trying to tell R1 they didn't understand her but then added, Maybe she [R1] took that tone as demeaning, I'm not sure. NA-A verified nobody had asked them or talked to them about the comment that day, and they finished working their shift on that day. On 8/6/25 at 12:43 p.m., a group interview was completed with the DON, administrator, regional director of operations (RDO)-A, and assistant director of nursing (ADON). DON verified they were first told of the incident which happened on 8/3/25 the following day, on 8/4/25, and explained R1 alleged two female staff members had pulled me out of bed. DON stated they visited with TMA-B who had explained to them they overheard R1 yelling at the two aides to slow down in Spanish which caused TMA-B to enter the room and tell the two aides to take your time with her. DON stated nobody had reported NA-A as potentially saying comments to R1 in a sarcastic manner, but acknowledged she didn't clarify that with anyone, either. DON stated if staff overhear that happening, they should immediately report it to, at minimum, their nurse manager so it can be reviewed or addressed. DON added such behavior was not acceptable here at [NAME] Strana. The DON and administrator both acknowledged that demeaning comments could potentially be verbal abuse; but the RDO expressed people could perceive things differently and it was hard to immediately link an overheard comment to a willful intent of harm. The RDO stated the context of the situation along with how the comment was said mattered to help determine if it was reportable as an allegation of potential verbal abuse or more a customer service concern. However, all of the group acknowledged the staff who heard that comment, including with their concerns about it, should have reported it to them right away so it could be acted upon. The facility Abuse Prohibition/Vulnerable Adult Policy, dated 4/2025, identified all staff were responsible for reporting, . any situation that is considered abuse or neglect . The policy directed a supervisor would be notified whom would then assess the situation to determine if any emergency treatment of action was required. The policy outlined, Notification to the facility Administrator will occur immediately for any incidents of resident abuse, alleged or suspected abuse, injury of unknown origin, neglect, financial exploitation, or involuntary seclusion. The policy listed a definition of abuse which included, . It includes verbal abuse, sexual abuse, physical abuse, and mental abuse . Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. However, the policy lacked a specific definition of what did or could constitute 'verbal abuse' under their review. The policy directed any suspected abuse would be reported to the SA via the online reporting system not later than 2 hours after the forming of suspicion of potential abuse.

Based on observation, interview and document review, the facility failed to ensure a transfer belt was used to assist with a safe transfer for 1 of 2 residents (R30) reviewed for falls. This resulted in actual harm for R1 who fell when being transferred without a transfer belt, which resulted in a fall with a pelvic fracture. This deficient practice is being cited at past non-compliance related to corrective action taken prior to survey to ensure proper use of transfer belt prior to the survey. Findings include: R30's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had intact cognition, no rejection of care, dependent on staff with toileting hygiene, toilet transfer, sit to stand, chair/bed-to-chair transfer, required substantial/maximal assistance with shower/bath and lower body dressing, required partial/maximal assistance with personal hygiene, utilized a wheelchair, with diagnoses including fracture of superior rim of right pubis (break in the pelvis), displaced intertrochanteric fracture of left femur (hip fracture), and one fall with major injury since admission. R30's care plan dated 2/21/25, indicated alteration in mobility d/t (due to) bilateral leg pain and interventions included follow PT (physical therapy) instructions, assist with transfers A1 (assist of one). R30's care plan dated 5/21/25, indicated alteration in mobility d/t bilateral leg pain and dementia,3/12/25: acute nondisplaced fracture of the right pubic rami that is nonoperative, weight bearing as tolerated and pain control as needed per ED physician and interventions included PT per MD order, follow PT instructions, assist with movement in bed and in/out of bed, assist with transfers, A1 EZ stand (mechanical transfer equipment); fall risk related to diagnosis of cognitive impairment, heart failure, alcoholism, assistance with transfers toileting needs, assistance with ADL's (activity of daily living), gets tired and weak during ambulation r/t to heart failure, 3/12/25: fall from chair, interventions included PT to eval, resident given reacher devices, in PT for ambulation program. R30's fall review evaluation dated 8/3/24, indicated history of one-two falls within last six months, unable to independently come to a standing position, risk factors include impaired mobility r/t weakness and recent fall with hip fracture, fall history, forgetfulness, and daily use of medications that may contribute to fall risk, alert, able to make needs known, 1A (one assist), EZ transfer, staff will follow therapy recommendations and update as needed, current fall interventions: appropriate footwear with transfers, room to be kept clear of clutter and debris, personal items and call light within reach. Facility document title Incident Review and Analysis dated 3/13/25, indicated on 3/12/25 at 2:10 p.m., R30 was ambulating in the hallway, felt weak tired, and was trying to sit down, NA (nursing assistant) was following behind with wheelchair, R30 missed the wheelchair when she was trying to sit down. IDT (interdisciplinary team) met to review current plan of care and fall care plan and further indicated staff was assisting R30 with walking program, R30 was to complete walking program per PT -BID (two times daily walk 15-20 feet (from room to nursing station) with right platform FWW (front wheel walker, A1, follow with w/c (wheelchair). Staff and R30 reported R30 had walked about 20 feet when R30 because tired and asked to sit down, R30 stated that as she was sitting down, she lost her balance and tipped over to her right side and feel, root cause: R30 appeared to be tired and weak during ambulation and after review walking program discontinue, PT to reassess and treat, son aware, and prefers R30 not to ambulate anymore. R30's document ED (emergency department) encounter summary dated 3/12/25, indicated R30 fell as she was leaning backwards to sit in her wheelchair and lost her balance resulting in a fall, resulting in right hemipelvis pain. R30 ED visit confirmed an acute nondisplaced fracture of the right pubic rami (pelvis fracture), and orthopedics was consulted and confirmed this was a nonoperative weight bearing as tolerated and pain control as needed, will require ongoing pain management and additional assistance at her care facility, and increased support and nonemergent outpatient physical therapy that maybe benefit to help her with the discomfort and pain. R30's progress note dated 3/12/25 at 3:49 p.m., licensed practical nurse (LPN)-A indicated R30 had a witnessed fall in the hallway on [NAME] Wing at 3:30 p.m. R30 was walking in the hallway with staff and fell, new injuries to left temp, skin tear, hematoma, left shoulder shin tear, lower back of head-lump-hematoma, nursing checked R30 for bleeding and applied pressure to her left temp and her left shoulder, bandages applied vital signs taken Neuro ok, range of motion per normal with pain 3/10 in right hip that was new, assisted off the floor with a mechanical lift and two staff to her wheelchair then to bed, provider and family notified by RN (registered nurse) manager, sent to hospital due to being on blood thinners and a head strike. R30's progress note dated 3/12/25 at 11:28 p.m., registered nurse (RN)-A indicated phone call from ED nurse identified R30 would be returning to the facility via family, and R30 had a pubic rami fracture that was inoperable. Facility document titled Internal 4 Point Plan of Correction dated 3/19/25, indicated the NA (nursing assistant) was not following the residents (R30) plan of care/not using a transfer belt during ambulation, R30 was sent to ER for evaluation on 3/12/25, complete room audit for transfer belt availability, education was initiated for appropriate staff for the use of the transfer belts for ambulation, spoke with NA who was ambulating R30 and the incident, statement was given, resident interviews initiated for transfer belt use and safe ambulation, observation audits initiated related to staff following the residents plan of care r/t ambulation and use of gait (provide support and stability during transfers and ambulation), provider update, like residents interviewed and audited for the use of transfer belts for safe ambulation, interviews initiated with staff on resident gait belt use an safe ambulation process, care plans updated and reviewed for ambulation safety, continued audits related to staff following the residents plan of care r/t use of gait belts and ambulation, education on use of transfer belts with ambulation, the incident review further indicated on 3/19/25, NA-A indicated in an email to the director of nursing, NA-A indicated R30 told me that she was trying to sit down and lost her balance, went into room [ROOM NUMBER] to asked if she (R30) wanted to walk she said yes I made sure she had good shoes on and forgot a gait belt, had the wheelchair behind her the whole time and we took a little break to rest, she started moving her feet and I thought she was going to start walking again but she lost her balance and fell. On 5/19/25 at 12:56 p.m., R30 was observed seated in a wheelchair in her room. R30 stated about a month ago while staff were helping her walk in the hallway she fell and broke her pelvis. R30 stated she lost her balance and fell, R30 confirmed staff were not using the gait belt when she fell. R30 stated since the fall staff used a mechanical lift for toilet transfers, and stated when staff transferred her now staff always use the gait belt. On 5/20/25 at 10:00 a.m., the director of nursing (DON) stated on 3/12/25 R30 experienced a fall on resulting in a fractured pelvis. The DON reported that during the initial fall review, the facility was unaware that a gait belt had not been used. However, upon completion of a comprehensive fall investigation, it was concluded that nursing assistant (NA)-A did not use the gait belt during the transfer and while assisting R30 to ambulate in the hallway with her walker. The DON confirmed that NA-A acknowledged the gait belt was not applied as expected during the ambulation on 3/12/25. The DON stated that the facility's policy and expectation was that a gait belt be used when transferring and walking residents. The DON further confirmed that following the incident, the facility initiated education for staff regarding the importance of transfer belt use, and ensured all staff received training on proper use of gait belts and safe transfer techniques On 5/20/25 at 10:16 a.m., NA-C stated a transfer belt should always be used for any resident who required assist with transfers or ambulation, and confirmed the facility provided recent education on resident transfers. On 5/20/25 at 10:21 a.m., RN-C stated that all facility nursing staff had received training and education on the use of gait belts. RN-C confirmed that it was the facility's policy and expectation that staff use a gait belt during all resident transfers and ambulation to ensure resident safety. On 5/20/25 at 1:01 p.m., NA-B stated a gait belt was expected for any resident transfer and confirmed the facility provided training on resident transfers and use of gait belt when transfer or ambulating residents. On 05/20/25 at 2:43 p.m., RN-B stated when someone required assistance with transfers staff were expected to always use a transfer belt. A transfer belt was used for stability and safety in case the resident got weak. On 5/20/25 at 2:46 p.m., NA-D stated a transfer belt should always be used when a resident required assistance with transfers. NA-D stated the facility provided recent education on the use of transfer belts with all residents to help prevent falls. On 5/21/25 at 7:36 a.m., during a telephone interview nursing assistant NA-A stated that on 3/12/25, she assisted R30 to ambulate out of her room. R30 used a walker, and NA-A followed behind the resident with a wheelchair while holding the back of R30's pants. NA-A confirmed that a gait belt was not applied to R30's waist during ambulation as required. She stated she completely forgot to use the gait belt and stated a gait belt was expected when walking with residents. NA-A stated that while assisting R30 in the hallway, approximately 100 feet from her room, R30 attempted to sit in the wheelchair without verbalizing the intent to do so. As a result, R30 lost her balance and fell. NA-A stated that following the fall, R30 immediately complained of pain to her leg and head, and she observed visible skin tears. NA-A stated she had been trained by the facility to use a gait belt when transferring or ambulating residents. She acknowledged this was the first time she failed to use the gait belt, stating it was an oversight. NA-A confirmed that gait belts are designated and readily available in all resident rooms, including R30's. NA-A stated that a nurse, whose name she could not recall, responded to the incident, assessed the R30, obtained vital signs, and staff used a mechanical lift to transfer R30 to a wheelchair. NA-A stated R30 was transferred to the hospital. NA-A stated that after the fall, she experienced a panic attack and left the scene. NA-A stated she accepted full accountability for the incident and, following R30's fall she provided a statement to the facility, received re-education on gait belt use, transfer safety, corrective action, and completed a competency evaluation, including a return demonstration on proper ambulation techniques. On 5/21/25 at 8:28 a.m., NA-E stated that in March 2025, the facility provided staff education on the proper use of gait belts. NA-E reported that gait belts were available in each resident room and confirmed that, per the facility, two staff members were required to assist when ambulating a resident. She further stated that the use of a gait belt during ambulation was expected On 5/21/25 at 8:29 a.m., during an interview NA-F stated that when ambulating a resident, two staff members are expected to assist. One staff member was to walk alongside the resident, holding the gait belt, while the second staff member walks behind the resident pushing a wheelchair for safety. NA-F stated the facility had provided education and training to staff regarding the use of gait belts at all times during transfers and ambulation to ensure resident safety. During the survey resident observations, resident and staff interviews, and review of staff education records identified the facility was using transfer belts during all non-mechanical transfers that required staff assistance, and the facility had corrected the non-compliance of not transferring residents without a transfer belt who required the use of a transfer belt prior to entrance on 5/19/25, prior to survey entrance. Facility Fall Prevention and Management policy dated 2/24, indicated: The purpose of this protocol is to identify residents at risk for fall implement fall prevention interventions, provide guidelines for assessing a resident after a fall and to assist staff in identifying causes off the fall. Avoidable Accident- means that an accident occurred because the facility failed to : -Identify environmental hazards and/or assess individual resident risk of an accident, including the the need for supervision and/or assitive devices and/or -Implement interventions including adequate supervision and assistive devices consistent with a resident's needs, goals, care plan and current professional standard of practice in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident.

Based on observation, interview, and document review the facility failed to notify the provider, family/resident representative, and hospice of bruising for 1 of 1 resident (R2) reviewed for skin. Findings include: R2's significant change in status Minimum Data Set (MDS) assessment dated [DATE], indicated R2 had severe cognitive impairment, dependent on staff for toileting, dressing, personal hygiene, and transfers, utilized a wheelchair, and diagnoses included arthritis, abnormalities of gait and mobility, and hospice care. R2's care plan dated 3/21/25, indicated risk for alteration in skin integrity r/t (related to) impaired mobility and interventions included monitor skin integrity daily during cares, weekly skin inspection by nurse, monitor for skin breakdown for signs/symptoms of infection, report signs/symptoms to provider, and document on skin condition and keep provider informed of changes. R2's progress note dated 5/12/25 at 11:49 p.m., registered nurse (RN)-B indicated new bruises: writer informed by nursing staff of client's skin bruise, two thin fading bruises were noted on clients midback section, writer unable to ascertain the clear cause but suspects could be a result of lift sling straps, on call nurse and DON (director of nursing) notified, monitoring orders placed to monitor bruises. R2's record review lacked documentation the provider, family or hospice had been notified of R2's bruising. On 5/19/25 at 2:57 p.m., during a phone interview family member (FM)-D stated she would expect notification from the facility if R2 was found with new skin concerns including bruising. On 5/20/25 at 10:22 a.m., during observation with RN-C and NA-B, R2's back was examined, revealing a faint discoloration (greenish/darker brown) approximately 2 centimeter by 1 centimeter below the right scapula. RN-C stated she had become aware of R2's bruising the day before (5/19/25) upon reviewing progress notes. On 5/20/25 at 10:29 a.m., RN-C, known as the nurse manger, stated she was not aware of R2's bruising until yesterday (5/19/25), when she reviewed R2's progress notes. RN-C stated she did not recall receiving notification from RN-B or discussion from the DON. RN-C stated the family and provider were expected notification of R2's bruise. On 5/20/25 at 10:36 a.m., the DON stated she was notified on 5/12/25, by phone from RN-B of new back bruising. The DON stated the bruising was assessed and consistent with the transfer sling straps. The DON stated education to staff regarding proper use was provided. The DON confirmed that notification of the family and provider was expected. On 5/20/25 at 1:37 p.m., RN-D, known R2's hospice case manager, stated the facility was expected to notify hospice of new skin conditions including bruising and confirmed the facility had not made hospice aware of R2's bruising. On 5/20/25 at 2:43 p.m., RN-B stated he was informed on 5/12/25, by NA-D of bruising on R2's back. RN-B stated R2's skin was assessed and the bruises were consistent with the transfer sling straps. RN-B stated he contacted by phone the DON and RN-C. RN-B stated did not notify the family or provider, due to the time of day and expected the next shift nurse to follow up with family and the provider. On 5/20/25 at 2:46 p.m., NA-D stated on 5/12/25, when repositioning R2 she observed bruising on R2's back and notified RN-B. NA-D stated the bruising was consistent with the straps of the sling used for transfers. On 5/21/25 at 12:09 p.m., during a telephone interview nurse practitioner (NP)-E stated any new skin condition, including bruising, should be reported to the provider. Facility Skin Assessment and Wound Management policy dated 2/25, indicated When a significant alteration in skin integrity is noted, the following actions will be taken Notify provider/treatment ordered Notify resident representative Review and update care plan

Based on observation, interview and document review, the facility failed to ensure the acting culinary services director (CS)-D was certified and credentialed to oversee food preparation and service(s) in 1 of 1 main production kitchen. This had potential to affect all residents who consumed food from the kitchen. Findings include: During interview on 5/19/25 at 11:40 a.m., CS-D stated she had worked at the facility for 30 years and was had not completed a qualifying course for her position. CS-D further stated she was not interested in further schooling. CS-D stated cook (C)-A was enrolled in a certified dietary manager (CDM) course through North Dakota University but had not completed the course yet. CS-D was not aware of the facility ever having a qualified by certification dietary manager and further stated she was unsure when C-A wound complete the course. CS-D stated she consulted with the registered dietician (RD), but the registered dietician was not at the facility full time. During interview on 5/21/25 at 10:36 a.m., RD stated CS-D had worked at the facility for many years and based on experience was qualified for the position, but did not want to complete classes to become certified in dietary management. RD further stated C-A was enrolled in the CDM class in February 2023, and had one year to complete the course through University of North Dakota. RD stated C-A did not complete the course on time and was reenrolled for an additional year in March of 2025. RD stated C-A has submitted two modules and is making progress. RD stated it would be beneficial for residents to have a CDM at the facility. During interview on 5/20/25 at 2:41 p.m., administrator stated CS-D had worked at the facility for 30 years but was not interested in CDM classes. Administrator further stated C-A was taking classes through University of North Dakota but had not completed them in the allowed year. Administrator stated C-A was enrolled in the class again on 3/2025, and her preceptor was RD. Administrator stated she was aware the facility did not have a qualified certified dietary manager according to current regulation. Review of facility provided email titled Welcome to the Nutrition and Foodservice Professional Training from UND Courses addressed to RD dated 1/19/23, indicated C-A had been enrolled in a Nutrition and Foodservice Professional training course and RD would be her preceptor. Review of facility provided email titled Welcome to the Nutrition and Foodservice Professional Training from UND Courses addressed to RD dated 2/10/24, indicated a different cook (C)-B had been enrolled in a Nutrition and Foodservice Profession training course and RD would be her preceptor. Review of a facility provided email dated 3/18/25, indicated C-A had again been enrolled in a course titled Nutrition and Foodservice Professional Training Program through University of North Dakota. In addition, the email stated the following regarding C-B: We regret to inform you that your enrollment in the Nutrition and Foodservice Professional Training Program has been canceled due to not completing your course in the timeframe that was provided to you. Your course end date was: 2/23/25. During review of email provided by administrator on 5/21/25, administrator indicated C-A had started CDM classes on 1/2023, and did not complete the classes in the required year. Administrator further indicated C-B had started courses in 2/2024, after C-A failed to complete her classes. C-B also did not complete her classes in the required year and her enrollment was canceled by the university. Administrator indicated C-A was then reenrolled in the class again in 3/2025. Administrator confirmed the facility did not have a qualified CDM on staff. A facility policy on requiring a CDM was requested but not received.

Based on observation, interview, and record review, the facility failed to ensure dignity was maintained for 1 of 1 residents (R44) who was transported through the hallway to the tub room. Findings include: R44's quarterly Minimum Data Set, dated dated dated [DATE], indicated R44 was severely cognitively impaired, had a diagnosis of dementia, and was dependent for bathing, tub transfers, and lower body dressing. R44's care plan reviewed 1/31/24, included R44 received hospice services due to end stage dementia, and directed staff to provide assist on one staff for bathing. During observation on 3/13/24 at 7:18 a.m., R44 was seated sideways on the shower chair as they were being pushed through the hallway from their room to the tub room by nursing assistant (NA)-A. R44 wore a shirt, nothing below the waist, and had a hospital gown over their arms and covering the front side of their body and top of their legs. The sides of their hips and back of their buttocks were visible, as well as approximately four inches of buttocks which were protruding from the hole on the bottom of the shower chair. R44 passed by 10 resident rooms, included two containing residents who were facing the hallway with their doors open. One nurse and one other NA were also present in the hallway. When asked about R44's state of undress, NA-A confirmed R44 was exposed, apologized, and stated usually the gown covered any exposed parts. During observation on 3/13/24 at 7:35 a.m., NA-A transported R44 from the tub room down the hallways past the 10 rooms, including the two residents facing their doors, covered in blankets and towels. A small portion of R44's buttocks were exposed through the bottom of the shower chair during transport. During interview on 3/13/24 at 1:15 p.m., NA-B stated staff made sure resident were covered when going to the tub or shower and would often use a hospital gown. During interview on 3/13/24 at 1:24 p.m., 03/13/24 NA-C stated there was usually one NA who completed residents' showers during the morning and another in the evening, and NA-A was doing them that day. During interview on 3/13/24 at 1:28 p.m., NA-A stated they usually brought residents to the shower room clothed, however it was sometimes easier to prepare R44 for a bath in their room due to behavioral concerns. They stated they usually had a towel underneath residents' covering the hole while being transported in the shower chair, however R44 had a bowel movement so NA_A removed the towel. The stated R44 started to become combative so they wanted to get them to the tub since it helps calm them down. NA-A apologized and confirmed they should have looked more closely at R44's state of undress before transporting through the hallway to avoid exposure. During interview on 3/13/24 at 3:10 p.m., registered nurse (RN)-C stated resident should always be covered for their own privacy, and they wouldn't want their family member or themselves to have body part exposed in the hallways. During interview 3/14/24 at 8:50 a.m., RN-D stated the facility used a tub transport chair to take residents to the shower or tub room, and they had bath blankets with holes in them for their heads like a poncho and they covered everything to protect residents' dignity. They stated residents loved them because they were warm, and the facility had plenty of them. If they were out on the unit, they could ask laundry to bring more. During interview on 3/14/24 at 10:57 a.m., director of nursing stated they expected all residents to be adequately covered in public areas and to be treated with dignity and respect. The Resident choices/Dignity Procedure dated 3/24, included resident dignity will be respected during cares and treatments including bathing.

Based on observation, interview, and document review, the facility failed to ensure a resident had an appropriately sized wheelchair for 1 of 1 residents (R23) reviewed for wheelchair fit, and failed to ensure call lights were accessible for two of three residents (R37, R36) reviewed for call light accessibility. Findings include: Wheelchair R23's significant change Minimum Data Set (MDS) dated [DATE], indicated they were cognitively intact, had diagnoses of cancer, fracture, and arthritis, impairment of one lower extremity, used a wheelchair for mobility, could independently use a manual wheelchair to move 150 feet with two turns, and was receiving hospice services. R23's care plan dated 3/2/24, indicated R24 had history of falls, was able to self-propel in a wheelchair, and frequently self-transferred. A hospice progress note dated 2/20/24, indicated R23 was able to self-propel very short distances/in room in a standard wheelchair but pedal [hospice] chair was ordered within the last few weeks. Due to patient's height, they are unable to self-propel and R23 was switched back to a standard wheelchair. A hospice progress note dated 2/27/24, indicated the facility was still trying to find R23 a standard wheelchair as R23 did not like their pedal [hospice] chair. R23's MHM Incident Review and Analysis dated 3/6/24, included R23 was found on the floor after falling from their wheelchair, had two wheelchairs in their room, and indicated hospice nurse would continue to monitor the need for both wheelchairs. During observation and interview on 3/11/24 at 1:59 p.m., R23 stated their wheelchair clocks, and they could only go around in two-foot circles, and when they stood up from the chair it got caught on their hips and lifted six inches off the ground when they rose. The arm rest were too short, they couldn't rest their wrists, and it wasn't deep enough. R23 stated they were going to land on [their] nose again, and darn tootin', it's too small!. R23's lower body filled the wheelchair seat and the seat depth stopped mid-thigh. The end of the arms of the wheelchair stopped in the middle of R23's forearms. During interview on 3/14/24 at 8:22 a.m., nursing assistant (NA)-C stated R23 had a different chair but did not like it as it restricted movement, so hospice obtained a different one for R23. NA-C stated R23's current chair did not roll well on one side when R23 was seated in it, and it appeared to be too small. They stated R23 completely fills it out and would probably be more comfortable in a larger chair. During interview on 3/14/24 at 8:28 a.m., registered nurse (RN)-D stated R23 was switched back from a hospice-provided wheelchair to a regular wheelchair at R23's request as R23 had a hard time moving around their room in the hospice chair. They stated R23 had fell out of their wheelchair in the past, and hospice managed R23's wheelchair needs, measured for fit, and provide a new one if needed. RN-D stated the placed a maintenance request for any chairs needed to be fixed and was unaware of R23's difficulty moving in their chair or the small size. During interview on 3/14/24 at 8:56 a.m., physical therapist (PT) stated the facility therapy department did not follow residents, including R23, if they were on hospice, and hospice had their own therapists. During interview on 3/14/24 at 9:29 a.m., hospice nurse (HRN) stated R23 tried a different chair but did not like it, so they sent an email to the director of nursing (DON) to see if they could find a regular standard wheelchair for R23. HRN was not sure, but thought it was the same one as before as it looked similar. They stated the facility assessed residents for wheelchair size, and hospice only assessed if it was a specialty chair for hospice purposes. During interview on 3/14/24 at 10:13 a.m., maintenance director (M) stated R23 receive the current wheelchair a month or two prior, and it was 20 inches wide with a standard depth. During interview on 3/14/24 at 10:15 a.m., RN-D stated therapy or the hospice nurse made the wheelchair size determination, but the therapy department was good about completing a quick assessment. They stated if the hospice nurse had noticed R23's wheelchair was too small they would have let the staff know. During interview on 3/14/24 at 10:57 a.m., DON stated R23 had a history of falls and was on hospice. He was switched to a hospice chair but did not like it and requested to move back to a regular wheelchair so he could move independently more easily. DON stated they were not sure how R23 ended up with the small wheelchair, but they needed one that fit, and someone must have grabbed the wrong one. Call lights R37's quarterly Minimum Data Set (MDS) dated [DATE], included R37 was moderately cognitively impaired, had diagnoses of heart failure, respiratory failure, dementia, seizure disorder, depression, and manic depression. R37 was dependent for toileting and transfers and required assistance with bed mobility. R37's care plan dated 8/9/23, included keep call light within reach of resident at all times. During observation and interview on 3/11/24 at 3:45 p.m., R7 was lying in bed with their call light hanging on the bed frame down to the floor out of reach on the right side of the bed. R37 stated it was lost, and staff told her to use the call light when she needed something, but sometimes she had to holler to get the attention of staff. During observation and interview on 3/11/24 at 6:47 p.m., R37's call light was wrapped around the right side of the bed frame behind R37 and hanging down to the floor out of reach. R37 called out for staff assistance and registered nurse (RN)-D entered R37 room and left without providing them with the call light. R37 stated they were very uncomfortable and waiting for some pain cream. During observation on 3/11/24 at 6:47 p.m., RN-C entered R37's room with a topical cream and left the room at 6:55 p.m. The call light was still in the same position out of reach. During observation on 3/11/24 at 7:04 p.m., R37 called out hello from her room. Nursing assistant (NA)-F peeked into the room from the doorway, stated they were checking on R37, and left while the call light was still on the floor attached to the bed frame behind R37. During interview on 3/11/24 at 7:05 p.m., NA-F stated staff made sure residents had call lights before leaving the room. NA-F looked around R37's room and was unable to locate the call light, and once they found it, stated, oh, there it is, picked it up off the floor and gave it to R37 who asked NA-F to turn off the room lights. During interview on 3/11/24 at 7:07 p.m., RN-C stated R37 was capable of using the call light, and they did not look at the call light to see where it was when they entered R37's room earlier to apply R37's cream. During interview on 3/11/24 at 7:19 p.m., RN-D stated all call lights should be reachable by the resident to ensure staff responds to resident needs and did not notice the call light location when in R37's room earlier. During interview on 3/14/24 at 10:57 a.m., director of nursing stated they expected call lights to be placed within reach of residents so they could call if they needed assistance with something. 48299 R36's admission Minimum Data Set (MDS) dated [DATE], indicated R36 was cognitively intact and required substantial/maximal to dependent assistance with bed mobility and transfers. R36 had diagnoses of heart failure, cancer, renal insufficiency, renal failure, or end-stage renal disease. The MDS indicated R36 had hospice services. R36's Function Abilities Care Area Assessment Worksheet undated, indicated R36 needed assistance with most activities of daily living tasks, such as hygiene, dressing, and eating. R36's mood and behavior care plan dated 3/14/24, directed staff to keep R36's call light within reach and answer promptly to help reassure resident. During interview and observation on 3/11/24 at 2:04 p.m., R36's call light was on the floor. R36 stated he pressed the round button when he needed help from staff and normally the call light was on the bed or the bedside table. During interview on 3/11/24 at 2:17 p.m., nursing assistant (NA)-E stated call lights were placed where residents could reach them. NA-E confirmed R36's call light was on the floor and clipped the call light to R36's blanket where he could reach it. NA-E stated R36 cannot do much for himself so needed the call light within reach to call for assistance. The Call Light Policy dated 4/24/23, indicated call cords, buttons, or other communication devices must be placed where they are within reach of each resident.

Based on observation, interview, and document review, the facility failed to develop and implement medical device interventions for a ventriculoperitoneal (VP) shunt (implanted tube that drains excess cerebrospinal fluid from ventricles within the brain to the abdomen) in accordance with professional standards of practice for 1 of 1 resident (R21) reviewed for medical devices. Findings include: St. [NAME] Hospital VP Shunt information page dated 9/2022, identified a VP shunt traveled inside the body from the ventricles in the brain down the neck and chest and into the abdominal cavity. Some shunts were programmable and some were not, and warning signs should be monitored that may identify the shunt was not working or infected such as swollen skin along the path of the VP shunt. The name and contact information of the neurosurgeon responsible for shunt malfunctions or infections, the name and kind of shunt, and computed tomography (CT) or magnetic resonance imaging (MRI) images of brain ventricles when the shunt was working, should be available at all times. R21's Pre-Admission Medical Screening dated 1/22/24, identified diagnosis of hydrocephalus (buildup of fluid in cavities called ventricles deep within the brain) and VP shunt placed in 2018. R21's associated Temporary Care Plan lacked interventions related to the VP shunt. R21's admission Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment according to staff assessment. Extensive assistance from two staff was required for bed mobility, transfers, and toileting. R21 had a diagnosis of Parkinson's disease and encephalopathy (a group of conditions that cause brain dysfunction, such as confusion, memory loss or coma). R21's diagnosis information dated 3/14/24, also identified diagnoses of encephalopathy and Parkinson's disease but lacked mention of his VP shunt. R21's active orders dated 1/23/24 through 3/12/24, lacked nursing interventions for his VP shunt. R21's care plan dated 3/12/24, lacked nursing interventions for his VP shunt. During an observation and interview on 3/13/24 at 8:46 a.m., registered nurse (RN)-A assessed R21's skin and stated there was linear swelling above the right collarbone area about three inches in length and about one inch out from the chest wall. RN-A pressed on the area and asked if the area hurt, R21 did not show signs of symptoms of pain and said no. Licensed practical nurse (LPN)-A was also in the room, observed the area and agreed with the abnormal swelling finding. LPN-A stated she worked with R21 routinely and had not noticed this before. LPN-A stated they would update the nurse manager later. During a follow up interview together on 3/13/24 at 9:24 a.m., RN-A and LPN-A stated they were not aware R21 had a VP shunt. They reviewed the St. [NAME] VP Shunt information page and R21's medical record together, and stated the VP shunt was not on R21's diagnosis list, orders or care plan interventions. RN-A and LPN-A stated they were not familiar with VP shunts and would not know what interventions were pertinent, but stated it would be important to know in a nurse-to-nurse report if R21 needed to get transported to the emergency room . RN-A left to notify the director of nursing (DON) on these findings. During an observation and interview on 3/13/24 at 9:28 a.m., the DON assessed R21 and stated he was sweaty. RN-B entered the room and assessed R21's vital signs: temperature was 97.1, pulse was 81, and blood pressure was 165/98 (normal blood pressure should be around 130/80 in the elderly). RN-A stated he would look in the orders to see what medical devices a resident had or the care plan for monitoring of a shunt. RN-A stated he could not find any nursing interventions related to the VP shunt in R21's orders or care plan. During a follow up interview on 3/13/24 at 9:45 a.m., the DON stated she expected VP shunt interventions would include monitoring for changes in cognition from baseline and to assess the site for swelling. During an interview on 3/13/24 at 12:10 p.m., NP-A stated R21 had the VP shunt placed in 2018. NP-A stated nurses should be made aware R21 had a VP shunt and follow appropriate facility policies and procedures related to shunts. NP-A stated, like a pacemaker, nurses caring for patients with medical devices should be aware of the devices and relevant interventions, especially in the case of a change in condition. During an interview on 3/13/24 at 1:06 p.m., the neurosurgical clinical registered nurse specialist (CRNS) stated R21's symptoms sounded like localized inflammation from the VP shunt and nursing could apply heat, but not to worry unless it swelled like a water balloon. If swelling was similar to a water balloon, fluid may have disconnected from the shunt. R21 had normal pressure hydrocephalus (excess fluid in the brain ventricles which can lead to brain damage and symptoms such as walking difficulties, memory loss, and bladder problems) and if the shunt became disconnected he may not become acutely ill, but if issues occurred, nursing could call for advice. Neurological assessments were important also, however, changes in cognition would be difficult to assess in R21 because of his dementia diagnosis. The CRNS stated while there was no specific protocol in place for VP shunts, it was important for nursing staff to be aware if a patient had a VP shunt. For example, since the tubing was superficial and ran over the collarbone (where R21's swelling was noticed), positioning may need to be modified. Additionally, anything that could interfere with programmable devices such as very strong magnets (MRI's, recording studios, some areas of the Minnesota Science Museum) should be avoided. During an interview on 3/13/24 at 1:40 p.m., the facility's regional nurse consultant (RNC), stated R21's care plan was now updated with nursing interventions for the shunt. A policy for medical devices was requested, however the RNC stated a policy was not established.

Based on interview and record review the facility failed to ensure incidents of potential abuse were immediately reported to the State Agency (SA) no later than 2 hours after the knowledge of the allegation of abuse, for 1 of 2 residents (R1) reviewed for allegations of abuse. Findings include: Facility reported incident (FRI) submitted on 9/18/23, at 11:44 a.m. identified that on 9/17/23, at 9:00 p.m. nursing assistant (NA)-A first became aware of an allegation of abuse that occurred when R1 reported a black male aide who wore a hat and no name tag later identified as nursing assistant (NA)-C on 9/14/23, at 10:00 p.m. had assisted R1 with evening cares. R1 indicated NA-C did not wash her up, would not let R1 wear her own gown and made her wear a hospital gown, R1 also stated, was thrown onto the toilet, and that R1 is too picky. R1's quarterly, Minimum Data Set (MDS) dated [DATE], indicated R1's cognition was intact, was independent with eating, unable to walk, required extensive assist of 2 with bed mobility and extensive assist of 1 with all other activities of daily living (ADL)'s. Further indicated diagnoses of schizophrenia, anxiety disorder, dementia, and depression. During a phone interview on 10/3/23, at 12:18 p.m. NA-A indicated on 9/17/23, R1 was assisted to bed and reported that a male dark aide wearing a hat and no name tag had helped her with evening cares. R1 indicated this staff member did not wash her up, would not let R1 wear her own gown, was made to wear a facility gown, the staff member threw her onto the toilet and told R1 she was too picky. NA-B called the DON and directed us to write down on a piece of paper what happened and put it under her door. NA-A was unable to articulate when or who allegations of abuse should be reported to. NA-B indicated on 9/17/23, at 8:45 p.m. R1 told her three nights ago when a male dark aide wearing a hat and no name tag helped her with evening cares. The staff member did not wash her up, would not let R1 wear her own gown, and the staff member threw her onto to the toilet. The staff member also told R1 she was too picky. NA-B immediately called the DON and reported the allegation of abuse. The DON directed us to write down the concerns and put it under her door. Three attempts to contact NA-C via phone were unsuccessful with no call backs. During an interview on 10/3/23, at 2:48 p.m. DON indicated NA-A and NA-B called her at home and reported the above allegations of abuse. NA-B indicated that R1 was in bed and felt safe. DON stated, I reported it late, it should have been no later than two hours. I didn't get to it until the next morning on 9/18/23. Abuse Prohibition/Vulnerable adult policy, revised 8/2023, indicated a Purpose: 1. To protect residents against abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends or other individuals, or self-abuse. 2. To promptly report, document and investigate all incidents of alleged or suspected abuse/neglect. 3. To promptly investigate, report and determine probable cause of unknown origin injuries. 4. To identify and remedy any potentially abusive situations. 1. Suspected Abuse shall be reported to OHFC online reporting process not later than 2 hours after forming the suspicion of abuse. Notify the Minnesota Department of Health (MDH) on the notification website immediately after discovery of incident.

Based on observations, interviews, and records review, the facility failed to assess and monitor the skin condition for timely implementation of appropriate wound treatment for 1 of 1 resident (R2) who incurred a skin injury after a fall. Findings include: R2's admission minimum data set (MDS) dated [DATE], indicated an entry date of 6/1/23, and on hospice care. The MDS listed R2's active diagnoses including debility, respiratory condition, and depression. The MDS also indicated R2 did not have a skin tear, wound, or any skin problems. R2's care plan identified potential for alteration in skin integrity related to age, decreased mobility, and adult failure to thrive. The care plan also indicated that on 6/17/23, R2 had abrasion to the right lateral lower extremity. The care plan's goal noted R2 will remain free from skin breakdown, and the planned interventions directed staff to monitor skin integrity daily during cares, and nurse to do weekly skin inspections. The care plan also indicated R2 is at risk for falls related to age, decreased mobility, chronic pain, weakness, and self-transferring. The document titled, MHM Incident Review and Analysis, dated 6/17/23, showed report regarding R2's fall in the bathroom while self-transferring. The report did not indicate any skin tear or wound sustained from the fall. The progress notes showed that R2's wound was not identified during fall on 6/17/23, until 2 days later or on 6/19/23, as follows: -On 6/17/23 at 4:20 a.m., R2 had a fall in the bathroom. R2 did not incur any injury such as skin tear. -On 6/19/23 at 9:00 a.m. (late entry note dated 6/21/23), licensed practical nurse (LPN)-B's documentation indicated notifying the nurse practitioner about the skin tear on R2's right lower leg on this date and time. The progress notes also showed the subsequent actions (in chronological order) for R2's right lower leg wound, as follows: -On 6/19/23 at 12:09 p.m., registered nurse (RN)-A documented that R2 had a wound on right lower leg, described as weeping old bloody drainage from previous skin tear and the leg had 2+ (bad) pitting edema. RN-A cleansed the wound with wound cleaner, applied Bacitracin, and covered with Tegaderm. -On 6/19/23 at 3:44 p.m., RN-A obtained and documented Hospice wound treatment orders for the right lower leg wound as follows: 1) Cleanse with wound cleanser, pat dry, apply alginate to wound bed and cover with foam dressing in the morning every other day and as needed, and 2) Apply tubi grips, on in the morning, and off at night. -On 6/20/23 at 9:25 p.m., RN-A documented new treatment orders from the wound nurse practitioner to clean the wound, pat dry, apply Xerofoam 2 layers to wound bed, cover with foam dressing, change every 3rd day. R2's treatment administration record (TAR) for the month of 6/23, showed Hospice's wound treatment order to right lower leg started and then discontinued on 6/20/23, noted in part as Cleanse with wound cleanser, pat dry, apply alginate to wound bed and cover with foam dressing. The TAR also showed the wound nurse's treatment order that also started on 6/20/23, noted partly as, clean the wound, pat dry, apply Xerofoam 2 layers to wound bed, cover with foam dressing and indicated to be changed every 3rd day. During interview on 7/20/23 at 10:57 a.m., LPN-B stated she worked on 6/17/23, following the night shift when R2 fell . LPN-B said, I saw [R2's] leg wrapped in kerlix, and I asked her what happened, she said she fell on the night and was why her leg was wrapped. LPN-B added, I didn't do anything after that because I was not her [R2's] nurse. At 11:46 a.m., LPN-B verified she made a late entry note dated 6/21/23 about notifying the nurse practitioner on . LPN-B stated that on 6/19/23 or 2 days after she first saw R2's right lower leg wrapped with kerlix, she followed up with the other nurse to make sure the the nurse practitioner was notified about the wound. On 7/20/23 at 11:41 a.m., surveyor attempted to contact registered nurse (RN)-C, who was the nurse when R2 fell on [DATE] at about 4:02 a.m., but she did not call as instructed. During interview on 7/20/23 at 12:45 p.m., LPN-A stated she worked the 2nd shift (from 2:00 p.m. to 10:00 p.m.) on 6/17/23 and remembered R2 as one of the residents under her care that time. LPN-A also stated she received report from agency nurse that R2 had a fall but nothing was said about a wound. LPN-A further stated, If there was wound and treatment, it should have been in the TAR but there was none that I recall. During interview on 7/20/23 at 4:15 p.m., RN-A stated she is an agency nurse and had worked the morning shift on 6/17/23, and received a report from the night shift nurse that R2 had a fall. RN-A said, There was a lot going on that day and I don't remember report of a skin tear when [R2] had the fall. RN-A also stated she remembers time when she was called into R2's room where R2's daughter showed the soaked dressing on R2's right lower leg, and that when she removed the dressing, the wound was macerated. RN-A stated she was unsure if R2 came from assisted living with the wound. RN-A stated she checked the TAR and there was nothing about a wound. RN-A added, [R2] had edema in the leg and weeping in that wound. RN-A stated she decided to do something before calling the doctor and so she cleansed the weeping wound with wound cleanser, applied Bacitracin, and put a transparent dressing (Tegaderm) over the wound. RN-A stated after her assessment and intervention, she notified the doctor and Hospice and asked for a wound treatment order. RN-A verified her documentation that these actions happened on 6/19/23 or 2 days after R2 fell . On 7/20/23 at 1:28 p.m., the director of nursing (DON) verified there was lack of evidence to show assessment and monitoring of R2's skin tear/wound that was incurred from the fall on 6/17/23. The DON also verified documentation that indicated the wound (weeping) was only identified, assessed, and treated starting on 6/19/23 (2 days after the fall). The policy titled, Skin Assessment and Wound Management dated 2/23, provides the guidelines include implementation of appropriate preventative skin measures, staff to perform routine skin inspections (with daily care), and nurses are to be notified if skin changes are identified. The policy indicates if a new non-pressure wound is noted, notify the doctor and obtain treatment orders.

Based on observation, interview, and document review, the facility failed to ensure oxygen tubing was changed according to physician orders and professional standards for 2 of 2 residents (R33, R41) reviewed for oxygen therapy. In addition, the facility failed to ensure oxygen was provided for 1 of 2 residents (R33) whose portable oxygen tank was empty. Findings include: R33's quarterly Minimum Data Set (MDS) dated [DATE], indicated R33 had intact cognition, was independent with eating and required extensive assistance with all other activities of daily living (ADLs). R33's diagnoses included congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD resulting in difficulty breathing), and obstructive sleep apnea (periods of not breathing during sleep). R33's care plan dated 2/6/23, indicated R33 had an alteration in respiratory status related to COPD. Interventions included R33 preferring to sleep in a recliner and requesting his bed be removed from his room, monitoring R33's oxygen level as ordered and as needed, monitoring for shortness of breath with a goal to keep oxygen levels above 90%. R33's physician orders dated 5/22/23, indicated R33 was on oxygen at 1-3 liters per minute (lpm) to keep oxygen levels above 90%. During an observation on 5/21/23 at 12:03 p.m., R33 was sitting in his room with a nasal cannula (tubing that delivers oxygen through two prongs inserted into the nostrils) that was delivering humidified oxygen. The nasal cannula tubing had a piece of tape labeled 5/8 and the humidified water bottle (bubbler) was dated 3/27/23. During an observation and interview on 5/22/23 at 5:33 p.m., R33 was sitting in his wheelchair in his room. R33's nasal cannula tubing was dated 5/22 but the bubbler remained dated 3/27/23. R33's nasal cannula was attached to a portable oxygen tank that was hanging from the back of his wheelchair. The portable oxygen tank was set to deliver oxygen at 1.5 lpm however, the oxygen tank gage needle was in the red, indicating it was empty. Upon notifying R33, he removed the cannula from his nostrils and verified he could not feel any oxygen coming out. R33 then checked his oxygen saturation level with a personal pulse oximeter which read 90% and denied increased shortness of breath but.stated he was on oxygen continuously and requested staff assistance to switch his oxygen tubing to the large main tank in his room as they should have when he returned from activities over an hour prior. At 5:41 p.m. licensed practical nurse (LPN)-A entered R33's room, verified his portable oxygen tank was empty, and attached R33's nasal cannula to the large tank. LPN-A stated R33 needed to be on oxygen continuously and should have been switched to the main tank by staff when he was brought back to his room after his activities. LPN-A also verified R33's bubbler was dated 3/27/23, but stated she did not know how often the bubbler or tubing were supposed to be changed because it was done on the night shift. During an observation on 5/23/23 at 7:27 a.m. R33's bubbler was dated 3/27/23. During an interview on 5/23/23 at 7:47 a.m. LPN-B verified the date on R33's bubbler was 3/27/23. LPN-B further stated the date on the oxygen tubing indicated the last time it was changed. LPN-B also stated she was unsure how often the bubbler was to be changed but thought it was every 30 days. R41's quarterly MDS dated [DATE], indicated R41 had moderate to severe cognitive deficits, required supervision with eating and bed mobility, limited assistance with transfers, personal hygiene and dressing, and extensive assistance with toileting. R41's diagnoses included dementia, anxiety, diabetes, chronic respiratory failure with low oxygen, a pacemaker,and heart failure. R41's care plan dated 5/23/23, lacked indication R41 was on oxygen or interventions regarding R41's oxygen use. R41's physician orders dated 5/22/23, indicated the following: -Change oxygen tubing weekly every night shift on Sunday. -Oxygen at 1-2 lpm by nasal cannula to keep oxygen level above 90%. During an observation and interview on 5/21/23 at 10:14 a.m., R41 was in her wheelchair getting ready to leave with her family for the day. R41 had a nasal cannula on that was dated 4/3 and a bubbler attached to her large main oxygen tank dated 1/30/23. R41 stated she had her oxygen with her all the time just in case. Trained medical aid (TMA)-A entered R41's room to assist her to get ready and stated oxygen tubing was changed on Sundays but was unsure if it was done every Sunday. TMA-A also stated she thought the tubing and bubbler would be changed at the same time. During an observation on 5/22/23 at 5:11 p.m., R41's nasal cannula tubing was dated 5/22 and her bubbler was dated 1/30/23. During an observation on 5/23/23 at 7:30 a.m., R41 was sitting in her room in a recliner with a nasal cannula delivering humidified oxygen from the main tank. The bubbler was dated 1/30/23. During an interview on 5/23/23 at 7:34 a.m., in R41's room, registered nurse (RN)-A stated she believed the oxygen tubing was changed every Sunday and verified the tubing dated 4/3 indicated that was the last time the tubing had been changed. During an interview on 5/23/23 at 12:58 p.m., the director of nursing (DON) stated nasal cannula oxygen tubing was to be changed weekly and the bubblers were to be changed at least monthly and both should be dated each time they were changed. The DON stated a resident on continuous oxygen should be switched from their portable tank to the main tank whenever they were in their room to avoid the portable tank from running out of oxygen and the resident becoming hypoxic (low oxygen). The DON also stated any staff could switch the resident from their portable tank to the main tank if the settings remained the same. The facility uses the Northwest Respiratory Services (NRS) customer handbook as their policy and procedure for oxygen use. The NRS handbook dated 3/2007, indicated to replace nasal cannulas each week and the humidifier bottle (bubbler) once every month. No other policy or procedure regarding oxygen use or delivery was provided.

Based on observation, interview, and document review, the facility failed to ensure food was served at a palatable temperature for 3 of 3 residents (R11, R19, R31) reviewed for dining services. Findings include: R11's annual Minimum Data Set (MDS) dated [DATE], indicated R11 had intact cognition, was independent with eating. R19's quarterly MDS dated [DATE], indicated R19 had severe cognitive deficits, was independent with eating. R31's quarterly MDS dated [DATE], indicated R31 had intact cognition, was independent with eating. Review of Resident Council Meeting notes from January 2023 to May 2023 indicated the following: -1/18/23, Cold meals-especially B-fast [breakfast] -Response from the culinary director (CD): Residents can eat in the main dining room where food would be served a lot warmer. Food is already covered to help it stay warm and microwaves are available. -5/18/23, Meal trays sitting in hallway too long. Some still getting cold food; mainly breakfast. -Response from CD: If come down to main dining room for meals-we can fix issues more quickly. Are using covered tops and bottoms. During an interview on 5/22/23 at 5:16 p.m., R11 stated she ate in her room and breakfast was often cold. R11 stated she had complained about it before, and it would get better for a day or two, but then go back to being cold. During an observation and interview on 5/23/23 at 8:00 a.m., the last resident meal tray was delivered to a resident's room on the northeast wing of the facility. During observation on 5/23/23 at 8:01 a.m., the CD removed the insulated cover from the test tray and recorded the scrambled eggs to be 122 degrees Fahrenheit. During an observation on 5/23/23 at 8:03 a.m., consumption of the test tray indicated the scrambled eggs were room temperature and not warm, decreasing their palatability. During an interview on 5/23/23 at 8:13 a.m., R19 was in his room and had finished eating breakfast. R19 stated the breakfast was good but his scrambled eggs were cold and would have liked them better if they were warmer. During an interview on 5/23/23 at 8:15 a.m., R11 stated the eggs could have been warmer because they tasted better when they were really warm. 22580 Interview on 5/23/23 at 2:59 p.m., R31 indicated he eats all his meals in his room. He indicated he really prefers to have eggs for breakfast when they are on the menu, but they always come cold, so he eats hot cereal. During an interview on 5/23/23 at 8:23 a.m., the registered dietician (RD) stated scrambled eggs should have been served at a minimum holding temperature of 135 degrees Fahrenheit. The RD further stated eggs served below 135 degrees Fahrenheit could be less appealing to the residents. No further policies regarding food service or food palatability were provided.

Based on interview and document review, the facility failed to ensure an allegation of misappropriation of property was reported to the state agency (SA) within 24 hours, in accordance with established policies and procedures, for 1 of 1 residents (R1) reviewed for potential diversion of a narcotic medication. Findings include: R1's facesheet printed on 2/24/23, included diagnoses of chronic pain syndrome, osteoporosis and dorsalgia (back pain). R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R1 was cognitively intact and required extensive assistance of one or two staff for most activities of daily living (ADL's). R1 received scheduled pain medications for infrequent pain. R1's care plan initiated on 7/29/21, indicated R1 was at risk for discomfort due to advanced age, decreased mobility, arthritis, back pain and chronic pain syndrome. R1 would have adequate relief from pain as evidenced by freedom from verbal and non-verbal symptoms of pain. R1's physician order dated 2/8/23, included fentanyl (a controlled substance used to treat severe pain) transdermally (application of medicine through the skin) patch 72 hour 12 mcg/hr (microgram per hour). Apply one patch transdermally one time a day every three days for pain and remove per schedule. An order dated 9/17/20, indicated staff were to check the fentanyl patch placement every shift. Progress notes in R1's electronic medical record (EMR) indicated missing fentanyl patches on the following dates: --1/5/23, at 9:18 a.m., registered nurse (RN)-A documented staff were unable to locate R1's fentanyl patch this morning. A new patch [was] to be applied 1/6/23. Family member (FM)-D was contacted who stated she preferred to have the fentanyl patch replaced today. Orders were updated and a new patch was applied to R1's LUB (left upper back). --1/27/23, at 3:45 p.m., licensed practical nurse (LPN)-A documented the TMA had been unable to locate R1's fentanyl patch; the provider was notified and orders were updated to restart the patch; a new patch was applied. --1/31/23, at 2:44 p.m., RN-B documented TMA reported she had not been able to find R1's fentanyl patch that was supposed to be on R1's RUB (right upper back). R1 had a bath that morning and the bath aide did not recall seeing the patch. RN-B looked through R1's pajama's and bedding and was not able to find the patch. The DON had been informed of the situation. Nurse practitioner (NP) visit note dated 2/7/23, indicated there had been a meeting between social services, nursing, family. R1 had three incidences this month of fentanyl patch holding [sic]. During an interview and observation on 2/24/23, at 9:46 a.m., R1 was in her room in a wheelchair watching TV and reading a newspaper. R1 stated her pain was controlled pretty good. When asked where her medication patch was located, R1 used her right hand to indicate her upper back, behind her left shoulder. With permission, viewed patch which was very small, approximately 1.5 inches x 1.5 inches, thin and clear. Printing on the patch indicated Fentanyl 12.5 mcg per/hr. The patch was covered with a clear, occlusive dressing with white tab with handwritten date of 2/23/23. During an interview on 2/24/23, at 9:54 a.m., LPN-A stated only licensed nurses could apply fentanyl patches to residents. Location of fentanyl patches were to be rotated, and tegaderm (a clear occlusive dressing) was to be applied over the top of the patch to secure it. LPN-A stated it was not policy to apply the tegaderm, but was what nurses liked to do. LPN-A stated once applied, either the fentanyl patch or the occlusive dressing was dated and initialed by the nurse. When the fentanyl patch was removed by a nurse, it was folded in half and disposed of in the sewer. The nurse who removed the patch along with another nurse, witnessed and signed off on the process on a paper fentanyl destruction log. During an interview and observation on 2/24/23, at 9:58 a.m., together with LPN-A, went to R1's room and looked at the fentanyl patch. LPN-A confirmed it was dated 2/23/23, and was without nurse initials. LPN-A stated the patch was replaced every three days. Further, LPN-A stated in the past, nurses rotated the patch between the front and back of R1's chest, but then noticed it stuck to her clothing sometimes, so now the patch was applied only to her upper back. During an interview on 2/24/23, at 10:10 a.m., trained medication aide (TMA)-A stated she had observed nurses dispose of R1's fentanyl patch about a month ago when they flushed it down the toilet in the bathroom at the nurses station. TMA-A was not aware of R1's patch ever coming off or getting stuck on her clothing or bedding. During an interview on 2/24/23, at 10:20 a.m., LPN-B stated when a fentanyl patch was removed from R1, the patch along with the tegaderm was removed, folded over and the whole thing flushed down the sewer, adding that another nurse witnessed the disposal and both nurses signed off on the process. The presence of R1's fentanyl patch was assessed every shift to make sure it was still in place and documented on the treatment administration record (TAR). LPN-B had been aware of times when R1's patch was not in place during one of the checks. After this occurred, there had been re-education of staff regarding the process of applying and removing medicated patches. During an interview on 2/24/23, at 10:26 a.m. the director of nursing (DON) stated that on 2/3/23, FM-D talked to her about R1's missing fentanyl patches. During the conversation, FM-D told the DON she had been informed of the missing patches by RN-B on 1/31/23. After speaking to FM-D, the DON informed the nurse practitioner (NP) of the missing patches, and scheduled a care conference with R1's family for 2/7/23. A progress note dated 2/7/23, written by the social worker (SW) indicated a family meeting had been held for 30 minutes with FM-D and FM-E in attendance, along with the NP, LPN-A, and the DON. The progress note further indicated R1's pain medications, pain management and options for change to help R1 be more comfortable were discussed. The DON stated it was the expectation that nurses always placed a tegaderm dressing over the fentanyl patch. Following the incidents, a nursing order to apply a tegaderm over the patch had been added to R1's TAR to ensure nursing staff applied it. The DON stated it did not cross her mind that a visitor could have removed the patch. The DON stated, I thought about reporting, but my gut told me it wasn't a diversion incident. The DON admitted she did not consider this to be misappropriation of resident property for possible narcotic diversion which was reportable to the SA. During a telephone interview on 2/24/23, at 12:23 p.m., FM-D stated the following: -- On 1/5/23, FM-D stated RN-A told her they couldn't find the fentanyl patch on R1's back. FM-D stated about five years ago, when R1 lived in another facility, a patch went missing and was found on R1's sweater, adding, That's why we asked them to put tegaderm over the patch. --On 1/31/23, when at the facility visiting R1, RN-B asked FM-D for permission to apply another fentanyl patch on R1, as R1's patch was missing. That was the first FM-D had heard about it, and told RN-B that the facility was to notify R1's family when this occurred because it had happened before. FM-D stated she assumed RN-B was referring to the incident that occurred on 1/5/23, to which RN-B replied she was not aware of an incident on 1/5, and had been referring to an incident on 1/27. FM-D stated she was not aware of an incident on 1/27. FM-D stated she had looked for the DON that day to discuss the missing patches with her, but the DON was not there, so she briefly talked to the SW about it. FM-D stated she also left a voicemail message for the DON on 1/31/23, and the DON returned her call on 2/4/23. FM-D stated when she talked to the DON about the three incidents where R1's fentanyl patch was missing, instead of listening, the DON said the patch probably fell off in the laundry, then in the bathtub, then when sleeping . FM-D stated she felt the DON was dismissive of her concerns. At the end of that conversation, FM-D told the DON she wanted to see documentation in R1's chart going back three months, and that she wanted to meet with the DON by the end of the week. FM-D stated that's when the SW called and set up a meeting. On 2/7/23, FM-D, FM-E, LPN-A, the SW, DON and NP met. The NP did most of the talking, mainly about pain control for R1. The DON informed FM-D and FM-E she had made a report of her investigation and could not determine what happened to the patches. During a telephone interview on 2/24/23, at 1:25 p.m., RN-B stated she wasn't surprised the patch was missing on 1/31/23, as there was no tegaderm over the top of it; the nurse who had applied it told her she couldn't find any tegaderm. When the patch went missing, RN-B stated they looked everywhere - all clothing, bedding and drawers. R1 had a bath that day and the patch could have come off .it's so small and clear. RN-B stated she had no problem finding tegaderm .she went and found it the same day. RN-B informed the DON of the missing patch. During a telephone interview on 2/24/23, at 1:39 p.m., RN-A stated on 1/5/23, she recalled looking for R1's fentanyl patch to document it was present, but couldn't find it. RN-A stated she informed LPN-A and the NP about the missing patch. RN-A stated staff checked for the patch three times a day; every shift. RN-A stated tegaderm was usually placed over the top, but stated there had been a period of time this year when they were waiting to get tegaderm restocked. During an interview on 2/24/23, at 3:07 p.m., the DON and administrator were informed of findings of failure to report misappropriation of resident property for possible diversion of a narcotic. The DON again stated she did not think it was diversion and therefore had not reported it. Facility policy titled Fentanyl Removal, Application, and Destruction dated 10/13, indicated the purpose was to address safe and secure medication handling of controlled substances, delivery and disposal of fentanyl patches. Remove the fentanyl patch and fold the adhesive sides together so there is no exposed medication. Take the used patch to the locked medication room, complete fentanyl destruction log with two licensed nurses wrapping the used fentanyl patch in toilet paper and flushing down the sewer. Two licensed nurses must verify destruction and sign the paper form for proof of destruction. The policy indicated placing tegaderm over the fentanyl patch was optional. Facility policy titled Discrepancies, Loss and/or Diversion of Medications, dated April 2018, indicated all discrepancies, suspected loss and/or diversion of medications, irrespective of drug type or class, are immediately investigated and a report filed. Facility policy titled Abuse Prohibition/Vulnerable Adult Plan, dated 2/2/23, indicated all staff were responsible for reporting misappropriation of resident property. Suspicion of misappropriation of resident property must be reported to OHFC (Office of Health Facility Complaints) online reporting process not later than two hours if the incident resulted in serious bodily injury. If the suspected misappropriation of resident property did not result in serious bodily injury, the reports must be made within 24 hours. The investigative team including the administrator, DON, nurse manager and social worker would review all incident reports regarding residents including those that indicate misappropriation of resident property no later than the next working day following the incident.

Based on interview and document review, the facility failed to conducted a thorough investigation for possible drug diversion after becoming aware of missing narcotic patches for 1 of 1 residents (R1) reviewed for misappropriation of property. Findings include: R1's facesheet printed on 2/24/23, included diagnoses of chronic pain syndrome, osteoporosis and dorsalgia (back pain). R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R1 was cognitively intact and required extensive assistance of one or two staff for most activities of daily living (ADL's). R1 received scheduled pain medications for infrequent pain. R1's care plan initiated on 7/29/21, indicated R1 was at risk for discomfort due to advanced age, decreased mobility, arthritis, back pain and chronic pain syndrome. R1 would have adequate relief from pain as evidenced by freedom from verbal and non-verbal symptoms of pain. R1's physician order dated 2/8/23, included fentanyl (a controlled substance used to treat severe pain) transdermally (application of medicine through the skin) patch 72 hour 12 mcg/hr (microgram per hour). Apply one patch transdermally one time a day every three days for pain and remove per schedule. An order dated 9/17/20, indicated staff were to check the fentanyl patch placement every shift. Progress notes in R1's electronic medical record (EMR) indicated missing fentanyl patches on the following dates: --1/5/23, at 9:18 a.m., registered nurse (RN)-A documented staff were unable to locate R1's fentanyl patch this morning. A new patch [was] to be applied 1/6/23. Family member (FM)-D was contacted who stated she preferred to have the fentanyl patch replaced today. Orders were updated and a new patch was applied to R1's LUB (left upper back). --1/27/23, at 3:45 p.m., licensed practical nurse (LPN)-A documented the TMA had been unable to locate R1's fentanyl patch; the provider was notified and orders were updated to restart the patch; a new patch was applied. --1/31/23, at 2:44 p.m., (RN)-B documented TMA reported she had not been able to find R1's fentanyl patch that was supposed to be on R1's RUB (right upper back). R1 had a bath that morning and the bath aide did not recall seeing the patch. RN-B looked through R1's pajama's and bedding and was not able to find the patch. The DON had been informed of the situation. Nurse practitioner (NP) visit note dated 2/7/23, indicated there had been a meeting between social services, nursing, family. R1 had three incidences this month of fentanyl patch holding [sic]. During an interview and observation on 2/24/23, at 9:46 a.m., R1 was in her room in a wheelchair watching TV and reading a newspaper. R1 stated her pain was controlled pretty good. When asked where her medication patch was located, R1 used her right hand to indicate her upper back, behind her left shoulder. With permission, viewed patch which was very small, approximately 1.5 inches x 1.5 inches, thin and clear. Printing on the patch indicated Fentanyl 12.5 mcg per/hr. The patch was covered with a clear, occlusive dressing with white tab with handwritten date of 2/23/23. During an interview on 2/24/23, at 10:26 a.m. the director of nursing (DON) stated it wasn't until after the third incident of R1's missing fentanyl patch on 1/31/23, that it had been brought to her attention by RN-B. Once informed, the DON stated she launched an investigation. During the investigation, the DON stated staff had reported there had been no tegaderm to cover the fentanyl patch which the DON stated could have allowed the fentanyl patch to rub off. However, the DON admitted she did not confirm for herself if the facility was in fact out of tegaderm patches. The DON stated after being notified of the incidents, she audited nursing staff schedules, medication administration records (MARs), TARs, and the narcotic book and found no inconsistencies or patterns indicative of narcotic diversion. The DON stated she talked to some nursing staff but did not conduct formal interviews of staff who were involved in applying the fentanyl patches, staff who identified the patches as missing and staff who subsequently replaced the patches. The DON stated she spoke to FM-D but did not conduct a formal interview. The DON admitted she did not take notes of conversations with staff or R1's family members during her investigation or ask for written statements. The DON had not considered the possibility of visitors removing the patch and did not check the visitor log for patterns. The only notes documented for the investigation of R1's missing fentanyl patches where documented on a paper form titled Investigation Documentation and included: --Under a heading titled investigation dated 2/3/23, the DON wrote: DON investigated situation. Audited electronic MAR and TAR, audited schedules from days [patch] reported missing for any discrepancies. Audited narcotic book. --Under a heading titled plan of correction/resolution dated 2/9/23, the DON wrote: completed education during all staff meetings on 2/9/23 on medicated patches. --Under a heading titled follow up comments, reviewed with concerned party undated, the DON wrote that she spoke with FM-D via phone on 2/3/23, and informed her the facility was investigating. Held family meeting with SW, LPN-A, NP, DON, FM-D and FM-E. During an interview on 2/24/23, at 3:07 p.m., the DON and administrator were informed of the findings of failure to conduct a thorough investigation following the identification of R1's missing fentanyl patches. A thorough investigation would include interviews with all staff who had involvement in applying, removing, and observing R1's fentanyl patches, and family members who expressed concerns, and then thoroughly documenting the interviews. The DON acknowledged this had not been done. Facility policy titled Discrepancies, Loss and/or Diversion of Medications, dated April 2018, indicated immediately upon the discovery or suspicion of a discrepancy, suspected loss or diversion, the administrator, DON and consultant pharmacist were to be notified and an investigation conducted. The DON lead the investigation. Facility policy titled Abuse Prohibition/Vulnerable Adult Plan, dated 2/2/23, indicated the investigation team including the administrator, DON, nurse manager and social worker would review all incident reports regarding misappropriation of resident property. The investigation may include interviewing staff, residents or other witnesses to the incident. Corrective action would be based on the investigation would be completed.

Based on observations, interviews, and policy review, the facility failed to ensure that two of four medication carts were kept locked and under direct observation of authorized staff in areas where residents and visitors could access the medications. This deficient practice had the potential to affect all residents who resided at the facility. Findings include: Review of the facility policy Medication Storage in the Facility, revised January 2018 and initialed as revised 12/27/21 by the DON, revealed that the policy did not specifically state that the medication carts should be locked; however, under the controlled substance section the policy stated that medications . are subject to special handling, storage, disposal, and recordkeeping . in accordance with federal, state, and other applicable laws and regulations. Review of the facility map revealed that the facility had two nurses' stations, the north/west wing and the east wing, with four medication carts serving the residents of the facility. Observation on 12/26/21 at 4:52 PM at the north/west nurses' station revealed that one of two medication carts was unlocked and no staff in the area. Ambulatory residents, visitors, and dietary staff delivering trays were observed in the hallways. The surveyor waited with the cart and Registered Nurse (RN) B came out of a resident room at 4:54 P.M. with a glucometer in her hand. When asked if the medication cart should be unlocked RN B said that she had gone to re-check a blood sugar, and when asked again if the medication cart should be unlocked RN B verified the cart should have been locked. When asked about the facility policy for locking medication carts RN B did not respond. Observation on 12/27/21 at 9:20 AM at the east wing nurses' station revealed one of the two medication carts was unlocked. There were no staff observed in the area. The surveyor stayed with the cart and Certified Nurse Assistant (CNA) A came out of a room behind the nurses' station. CNA A stated that she was a trained medication assistant. When asked if the medication cart should be unlocked, CNA A verified that the cart should not be unlocked and locked the cart before leaving the area. During an interview on 12/27/21 at 4:20 PM, the Director of Nursing (DON) stated that it was her expectation that the medication carts be locked per policy.

Based on observation, record review, and staff and resident interviews, the facility failed to develop a comprehensive plan of care directing measurable goals and interventions for indwelling urinary catheters (a tube inserted into the bladder to drain urine) for one resident (R8) of six residents having indwelling urinary catheters out of a total sample of 27 residents. This failure placed the residents at risk for unmet care needs. Findings include: Review of the Face Sheet located in the Profile tab of the electronic medical record (EMR), revealed R8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/01/21 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R8 was cognitively intact for decision-making. This MDS assessment further indicated R8 had an indwelling urinary catheter. Review of R8's comprehensive care plan did not show a focus, measurable goals, or interventions for the use of an indwelling urinary catheter. In an interview on 12/29/21 at 8:10 AM, the Director of Nursing (DON) was asked if R8 had a care plan developed for the use of an indwelling urinary catheter. She stated, I will get back to you on that. On 12/29/21 at 10:58 AM, the DON was again asked if a care plan had been developed for the indwelling urinary catheter. The DON stated, I think he does have a care plan for the catheter, but I am not sure, but was told that he had a care plan.

Based on interview, and document review, the facility failed to ensure a peripherally inserted central catheter (PICC) was appropriately managed for 1 of 1 resident (R29) who received intravenous (IV) medications. Findings include: R29's Admission Record dated 12/29/21, indicated R29 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R29's 5-Day Prospective Payment System Minimum Data Set (MDS) dated [DATE], indicated R29 had a moderate cognitive impairment and received IV medications at the facility. A Hospital Discharge Summary dated 12/14/21, indicated R29 had a PICC line. R29's Order Summary Report dated 12/21/21, directed staff to administer [MEDICATION(S)] (antibiotic) two grams IV every 12 hours through 1/17/22. The order further directed staff to monitor R29's PICC line for patency and to notify the provider of resistance. R29's December 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] R29's care plan dated 12/29/21, lacked indication R29 had a PICC line or related interventions. Review of R29's progress notes revealed: - On 12/24/21, at 12:24 p.m. R29 was found still connected to the antibiotic during the morning. Licensed practical nurse (LPN)-C attempted to flush R29's PICC line with normal saline, however, it was met with resistance. - On 12/24/21, at 2:51 p.m. the on-call provided was notified and recommenced to send R29 to the emergency room for evaluation related to an increased creatinine, CRP, and SED rate (labs). - On 12/24/21, at 5:40 p.m. R29 was sent to the hospital around 4:00 p.m. and emergency medical technicians (EMTs) were notified R29's PICC line had resistance. - On 12/28/21, at 1:28 p.m. LPN-A was requested to disconnect the IV medication from R29's PICC line at 6:00 a.m. The progress note further revealed the IV medication was from 12/27/21, at 7:00 p.m. LPN-A disconnected the IV medication and flushed the PICC line with 10 cubic centimeters (cc) of normal saline. The IV site was patent and flushed without resistance. During an interview on 12/28/21, at 7:00 a.m. LPN-A stated she had just removed the IV medication from R29 (from 12/27/21). At 7:45 a.m. LPN-A stated the night nurse (from 12/27/2) left the IV antibiotic connected to R29 and did not remove it once completed. LPN-A stated she was informed by R29's nursing assistant (NA) the antibiotic was still connected to R29's PICC line. LPN-A stated if IV medication was left and not removed after administration it could cause the PICC line to clot off. During an interview on 12/28/21, at 1:00 p.m. pharmacist (P)-A stated R29 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Her recommendation for nursing staff would be to administer the medication per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The antibiotic should be removed immediately after infusion and infusions last for 30 to 45 minutes. The complication from not disconnecting the antibiotic and flushing the PICC line would be a line occlusion. During an interview on 12/28/21, at 2:06 p.m. the director of nursing (DON) stated her expectation would be to administer medications as ordered and flush the PICC line. The DON stated she was made aware R28's IV medication was still attached from the previous evenings dosing. An untitled letter indicated registered nurse (RN)-B left an antibiotic medication connected to R29's PICC line on 12/24/21, at 3:30 a.m. and 12/27/21, at 6:09 p.m. The letter further indicated RN-B was provided competency training which included the proper administration of IV medication. A Teachable Moment Form dated 12/28/21, indicated on 12/27/21, LPN-D documented she hooked up an antibiotic to R29's PICC line, but lacked documentation the antibiotic was removed. A Teachable Moment Form dated 12/28/21, indicated on 12/27/21, RN-B documented she hooked up an antibiotic to R29's PICC line, but lacked documentation the antibiotic was removed. Facility policy titled Infusion Therapy dated 4/17, indicated staff would be knowledgeable regarding the use of elastomeric infusion devices. The policy directed staff to disconnect and dispose of sphere when infusion is finished. Staff are further directed to document the following in the resident's medical record.

Based on interview and document review, the facility failed to ensure pneumococcal vaccinations were offered and/or provided the series as recommended by the Centers for Disease Control (CDC) for 3 of 5 residents (R1, R4, and R5) reviewed for immunizations. Findings include: R1's quarterly minimum data set (MDS), dated [DATE] indicated R1 was [AGE] years old and admitted to the facility on [DATE]. R1's immunization record, printed 12/15/2020, indicated R1 received the one dose of [MEDICATION NAME] (pneumococcal [MEDICATION NAME] vaccine (PPSV23)) on 12/17/07, prior to admission to the facility. There was no evidence the pneumococcal conjugate (PCV13) vaccine was offered or administered. R4's quarterly MDS, dated [DATE], indicated R4 was [AGE] years old and admitted to the facility on [DATE]. R4's immunization record, printed 12/15/20, indicated R4 received the PCV-13 pneumococcal vaccine on 3/31/15, prior to admission to the facility. There was no evidence the PPSV23 vaccine offered or administered. R4's [DIAGNOSES REDACTED]. R5's quarterly MDS, dated [DATE], indicated R5 was [AGE] years old and admitted on [DATE]. R5's [DIAGNOSES REDACTED]. R5's immunization record, printed 12/15/20, indicated R5 received the one dose of PPSV23 on 12/19/14, prior to admission to the facility. There was no evidence the PCV13 was offered or administered. During an interview on 12/15/20, at 11:13 a.m., the director of nursing/infection preventionist (DON) stated she began working in March of 2020, and was focused on the COVID pandemic and reducing risk of COVID transmission in the facility. The DON also stated updating vaccinations were on a list of things that needed to be updated. The DON verified R1, R4, and R5 were overdue for their second pneumococcal vaccines. The facility's Vaccination of Residents policy, dated August 2016, indicated the facility recognized only one type of pneumococcal vaccine. The CDC guideline, Pneumococcal Vaccine Timing for Adults, dated 6/25/20, indicated persons ages 19-[AGE] years old with certain medical conditions, including diabetes mellitus, chronic renal (kidney) failure, [MEDICAL CONDITION], and chronic [MEDICAL CONDITION], should receive a dose of PPSV23 followed by a dose of PCV13 at least one year later with a final dose of PPSV23 at [AGE] years or older. The CDC guideline indicated persons 65 or older should receive a dose of PCV13 if not previously received, followed by a dose of PPSV23 at least one year later.

Based on observation, interview and document review, the facility failed to implement care planned interventions to reduce the risk of falls for 1 of 3 residents (R1) reviewed for falls. This resulted in actual harm when R1 fell from bed resulting in hematoma to the forehead, bruising to face, arms, knees and feet causing R1's increase in scheduled [MEDICATION(S)] (strong narcotic pain medication) dose to be doubled. Findings include: R1's significant change Minimum Data Set (MDS) dated [DATE], indicated R1 was severely cognitively impaired, unable to speak, required total assistance from two staff for bed mobility, transfers, toileting and total assistance of one staff for locomotion and eating. The MDS indicated R1 had no falls since the previous assessment. R1's Pressure Ulcer Care Area Assessment (CAA) dated 11/17/20, indicated R1 had decreased mobility after a stroke and had inability to communicate discomfort. The CAA also identified R1 was incontinent of bowel and bladder and required staff to reposition, check and change incontinence product every two to three hours. R1's care plan dated 10/13/20, identified R1 had a self-care deficit and directed staff R1 was dependent on two staff for bed mobility, check and changing of incontinent pad every two to three hours. R1's fall care plan initiated 11/17/20, identified a fall risk due to history of stroke with left sided [CONDITION(S)] and dependency on staff for transfers and positioning. The care plan further instructed staff to anticipate R1's needs and monitor position in chair. On 12/9/20, at 4:13 p.m. R1 was observed lying in bed on her left side, covered with blankets. R1's left side of the bed was up against the wall. R1 had her eyes closed and did not open them when the light was turned on or when spoken to. Bruising was observed on R1's right cheek up to just above her eyebrows, on the left side of her face from lower cheek up to the top of the forehead and the bruises were fading with yellow undertones. R1's Incident Review and Analysis report dated 12/2/20, indicated that at approximately 6:10 p.m. registered nurse (RN)-A heard nursing assistant (NA)-A call for help from R1's room. RN-A observed R1 laying on the floor face down, next to her bed. NA-A was at R1's side. NA-A told RN-A that R1 rolled off the bed when NA-A was trying to change R1 and her sheets. After the incident the new interventions for fall prevention were added, staff to provide assistance of two staff for bed mobility and changing bed linens. In addition, a beriatric bed was obtained from hospice. Although these interventions were added to the resident Info Sheet, R1's care plan had previously identified R1 was an assist of two staff for bed mobility and toileting. R1's progress note (PN) dated 12/1/20, indicated upon observing R1 on the floor RN-A turned off the tube feeding pump. RN-A went and obtained the mechanical lift and returned to R1's room. The PN further indicated RN-A and NA-A rolled R1 onto her back and using the mechanical lift placed her in bed. After R1 was cleaned up and in bed, RN-A assessed her for injury. The note also indicated R1 had a bloody nose from her right nostril, a hematoma (a solid swelling of clotted blood beneath the surface of the skin) on her forehead, swelling between eyes, redness, swelling both checks, swelling and abrasions to both knees, bruises both shoulders, forearms, knuckles on right hand, top of left foot and she was bleeding from her mouth. R1's progress note dated 12/2/20, indicated R1 was wincing with cares specifically repositioning and washing her face and the nurse had requested pain medication to be re-evaluated due to discomfort. R1's hospice nurse's progress note dated 12/2/20, indicated R1 was not tolerating touch or repositioning and was grimacing, moaning and guarding when staff were doing cares. The note indicated a new pain medication order was obtained to increase scheduled [MEDICATION(S)] from 5 milligrams (mg) every six hours to 10 milligrams every six hours. scheduled, after R1's fall out of bed. During interview on 12/9/20, at 3:42 p.m., RN-A stated prior to R1 being transferred to the Covid-19 unit, R1 was an assist of two people for turning and repositioning. RN-A stated that when R1 moved to the Covid unit, staff were completing R1's cares with one person because they did not always have two people. RN-A stated R1 was dependent on staff for all of her cares due to a stroke years ago. RN-A reviewed R1's care plan and stated the care plan required R1 to have assist of two staff with bed mobility and toileting. RN-A said, It was a really horrible accident, it is not like (NA-A) pushed (R1) off the bed or was negligent, it was just that when (NA-A) rolled her, (R1) went too far for (NA-A) tried to stop, (R1's) weight took (R1) over the edge of the bed. RN-A stated when she entered R1's room, the bed was at about waist height, with the head of the bed flat. During interview on 12/9/20, at 8:06 p.m., NA-A stated R1 had a bowel movement so she was sliding the sheet under R1 when R1's left arm and left leg went forward and R1 just rolled off the bed. NA-A stated R1 had been lying on her right side and she was holding on to R1 with her left hand at her waist and was unable to pull R1 back to prevent the fall. NA-A stated she always thought R1 was a one person assist for cares except for when she got out of bed. During interview on 12/10/20, at 9:11 a.m. NA-B stated she had worked with R1 before she was on the Covid unit and they needed two people to reposition, change and transfer R1. During interview on 12/10/20, at 9:45 a.m. NA-C stated she had worked with R1 for a long time. NA-C stated R1 was two people total care for rolling side to side in bed, changing brief, washing up and transferring to the wheelchair. NA-C stated R1 only required one person to get dressed because of the adaptive clothing. NA-C stated she used the care sheets to figure out what to do for residents. During interview on 12/10/20, at 9:50 a.m. hospice NA-D stated prior to R1 being on the Covid unit she always requested staff assistance with repositioning R1 and changing sheets if necessary for comfort and safety. During interview on 12/10/20, at 10:50 a.m. the nurse practitioner (NP) stated she had concerns regarding possible injury for R1. The NP stated R1 was not examined at the hospital because she was on hospice with comfort focus however R1's family was allowed choice to send R1 to the hospital. The NP stated she was concerned regarding pain but hospice had increased R1's pain medications so R1 was comfortable. During interview on 12/10/20, at 11:10 a.m. RN-B reviewed R1's Incident Review and Analysis report and care plan. RN-B stated that when she reviewed the fall, she looked at the fall care plan but did not look at the ADL care plan. RN-B verified that R1 had been an assist of two for bed mobility and toileting since 4/22/20. RN-B stated she would expect staff to follow the care plan or if there had been a change in patient condition to let the nurse know so a re-assessment could be completed. During interview on 12/10/20, at 12:16 p.m. the director of nurses (DON) stated R1's care plan was not followed at the time of her fall because the care plan indicated R1 was dependent of two people for bed mobility and toileting. The DON stated staff need to be following the care plan and if they did not agree with care plan, they needed to talk to their floor nurse and nurse managers. During interview on 12/10/20, at 2:31 p.m. the administrator stated the facility did not have a policy for following the care plan. The administrator stated staff were expected to follow the care plan.

Based on interview and document review the facility failed to report allegations of neglect of care to the state agency for 1 of 3 residents (R1) reviewed for accidents. Findings include: R1's significant change Minimum Data Set (MDS) dated [DATE], indicated she was severely cognitively impaired, unable to speak, required total assistance from two staff for bed mobility, transfers and toileting. R1's care plan dated 10/13/20, indicated a self care deficit and directed staff R1 was dependent on two staff members for bed mobility and checking and changing incontinent pad every two to three hours. R1's Incident Review and Analysis report dated 12/2/20, indicated that at approximately 6:10 p.m. registered nurse (RN)-A heard nursing assistant (NA)-A call for help from R1's room. RN-A observed R1 laying on the floor face down, next to her bed. NA-A was at R1's side. NA-A told RN-A that R1 rolled off the bed when NA-A was trying to change R1 and her sheets. R1's progress note (PN) dated 12/1/20, indicated R1 had a bloody nose from her right nostril, a hematoma (a solid swelling of clotted blood beneath the surface of the skin) on her forehead, swelling between eyes, redness, swelling both checks, swelling and abrasions to both knees, bruises both shoulders, forearms, knuckles on right hand , top of left foot and she was bleeding from her mouth. R1's progress note dated 12/2/20, indicated R1 was wincing with cares specifically repositioning and washing her face. Nurse requested pain medication be reevaluated due to discomfort. PN dated 12/2/10, indicated a new order was received to increase [MEDICATION(S)] from 5 milligrams (mg) every six hours to 10 mg every six hours. During interview on 12/9/20 3:05 p.m. the director of nurses (DON) and float administrator stated we did not do a report because we were following plan of care.We did an internal review and felt it was an accident and based on our abuse policy we did not see any violations, we saw this as an opportunity for education of the staff. During interview on 12/10/20, at 12:16 p.m. the DON acknowledged R1's care plan was not followed at the time of her fall, because the care plan indicated R1 was dependent of two people for bed mobility and toileting. During interview on 12/10/20, at 1:07 p.m., the administrator stated she did not report the fall because she was told the care plan was being followed. The administrator stated when we spoke with the nursing assistant it was not willful and the resident did not sustain any significant bodily injury. The administrator stated R1 had some bruising but that can be typical with the elderly. The administrator stated she was unaware the care plan had not been followed and that R1's pain medications had been doubled. The administrator stated if she had known she would have consulted with her nurse consultant regarding reporting. Abuse Prohibition/Vulnerable Adult Plan policy dated 7/5/19 instructed staff, Suspicion of Neglect, Exploitation or Misappropriation of resident property must be Reported to OHFC [Office of Health Facility Complaints] online reporting process not latter than 2 hours if the incident resulted in serious bodily injury. The policy also indicated if the suspected Neglect, Exploitation or Misappropriation of resident property did not result in serious bodily injury, the report must be made within 24 hours. The policy defined neglect as the failure of the facility or its employees to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish or emotional distress.

Based on observation, interview and document review the facility failed to provide quality care by not implementing interventions to prevent new and worsening skin conditions from occurring for 1 of 3 residents (R1) and failed to assess open areas for 1 of 3 residents (R3). This resulted in actual harm for R1 who had new and worsening skin ulcers throughout her stay at the facility. Findings include: R1's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R1 was cognitively intact, required extensive assistance from two staff for bed mobility, toileting and transfers, was occasionally incontinent of bladder and was frequently incontinent of bowel. The MDS further identified R1 had a stage I pressure ulcer (An observable, pressure related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include a defined area of persistent redness). R1's care plan dated 5/15/19, indicated an alteration in mobility related to left ankle fracture and an alteration in skin integrity exhibited by a sacral pressure ulcer. On 7/22/19, the care plan identified current ulcers on the sacrum, and inside of left heel. Care planned interventions dated 6/10/19, included: R1 to be followed by wound care nurse, pressure redistribution mattress on bed and cushion in wheel chair. On 7/24/19, the care plan was updated to include shoes only when transferring or ambulating. Review of Integrated Wound Care Visit Notes dated (MONTH) 2019 to (MONTH) 2019, identified the following: 5/9/19: Wound 3) Sacral stage II pressure ulcer 2.5 cm x 1.5 cm, 50-75% slough. 5/28/19: Wound 3) Stage III, 3 cm x 1.5 cm 26-50% slough, non -viable tissue in wound base. 6/3/19: Wound 3) 3 cm x 1.5 cm with undermining noted at 12:00, maximum distance of 3 cm. Wound bed has 1-25% slough. 6/10/19: Wound 3) 3 cm x 1.5 cm, undermining 4 cm. Wound bed 1-25% slough. Wound 7) Left heel suspected deep tissue injury (SSDTI), (A pressure-related injury to subcutaneous tissues under intact skin). 3.5 cm x 4 cm. Wound 8) Left lateral foot SSDTI measuring 2 cm x 1.5 cm. 6/25/19: Wound 3) 3 cm x 2 cm x 0.7 cm. 1-25% slough, Wound improving. Undermining at 12:00, 2 cm and 3:00 1.5 cm. Wound 7) 0.6 cm x 0.6 cm, wound improving. Wound 9) Left plantar foot unstageable pressure injury 2 cm x 2 cm. 7/1/19: Wound 3) 2.5 cm x 1.5 cm x .7 cm, undermining 3.5 cm. Wound bed 1-25% slough. Wound 7) 0.8 cm x 0.6 cm, scab and bruising on heel. Wound 12) Right lateral ankle blister measuring 1 cm x 0.5 cm. 7/8/19: Wound 3) 3 cm x 1 cm wound bed 25-50% slough. Wound 7) resolved. 7/15/19: Wound 3) 3 cm x 1 cm, 26-50% slough. Wound 12) partial thickness blister, 1 cm x 1.6 cm, 76-100% slough. 7/22/19: Wound 3) 3 cm x 1 cm with undermining noted at 12:00 with a distance of 3.5 cm 1-25% slough in wound bed. Wound 12) 0.8 cm x 1.5 cm , wound bed 76-100% slough. Wound 14) Left heel SSDTI. 2.5 cm x 4 cm. An Integrated Wound Care Follow-up Progress note dated 7/29/19, identified the following wounds: Wound 5) Sacral pressure ulcer unstageable 2.5 cm x 1 cm. 50% slough, 50% granulation. Wound 6) Left heel deep tissue injury 2 cm x 2 cm. No further description of wounds provided on this assessment. A facility assessment titled Weekly Skin Inspection dated 7/30/19, indicated no new skin issues noted. A Weekly Skin Inspection dated 8/6/19, indicated no new concerns. R1's discharge MDS dated [DATE], indicated she had one unstageable pressure ulcer, one unstageable due to SSDTI. Review of a report dated 8/9/19, identified R1 was admitted to the hospital due [MEDICAL CONDITION]. On the morning of admission to the hospital the patient complained of significant pain in lower extremities, back, and coccyx. Upon assessment with doctor many wounds were noted on coccyx area and lower extremities. Patient had significant pain with touch and movement. Wounds included: Coccyx wound 3 cm x 2 cm x 6 cm necrotic foul smelling unstageable pressure ulcer with 2 cm undermining at 1200. Stage II pressure injury (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed) left gluteal cleft/buttocks, proximal. Stage II pressure injury, left gluteal cleft/buttocks distal. Stage II right gluteal cleft/buttocks. Right lower extremity, Stage II pressure injury right lateral ankle, Deep tissue injury right ankle. Deep tissue injury left heel. Left posterior ankle deep tissue injuries. Left unstageable medial pressure ulcer. Severity and number of wounds, added to the type of wounds appeared that patient had been left in one position for an extended period of time. The deep tissue injuries on the back of her legs would mirror where a wheelchair leg rest would put pressure on her. When ask if the patient was left in her wheelchair for periods of time, she acknowledged that she indeed was. There are deep tissue injuries on the bottoms of her feet and the back of her ankles, these would also indicate pressure from being in one spot for too lo R3's admission MDS dated [DATE], indicated he was cognitively intact and required assistance for bed mobility, transfers and toileting. The MDS indicated R3 was continent of bowel and bladder and had no skin concerns identified. R3's care plan dated 8/8/19, indicated a potential alteration in nutrition and identified a chronic ulcer to left foot, heal, mid foot and right buttock. The care plan further identified an alteration in skin integrity related to wounds to left foot, ankle and heel. An Admission/Initial Data Collection dated 8/6/19, indicated R1 had a 1 cm x 1.5 cm open area on his right buttock. Review of R3's facility Progress Notes indicated on 8/14/19, hospice RN wrote, R3 had a wound on his coccyx that was being covered by a foam dressing. R3's medical record lacked evidence of assessment of his right buttocks open area. Review of Integrated Wound Care assessments dated 8/15/19 and 8/19/19, identified wounds to R3's left foot, heel and ankle. The assessments did not address R3's buttocks. During interview at 12:25 p.m. the interim DON stated R3 had diabetic ulcers and that Integrated Wound Care come in weekly to assess. In regard to R3's buttocks, the interim DON stated she was not aware of anything. She further stated all wounds were followed by Integrated Wound Care and they should be doing a full skin check every week. The DON stated she was going to look at R3's buttocks and surveyor requested to go with for the assessment, however at 1:15 p.m. R3 was leaving the facility with a visitor. Interview with the interim DON at 1:37 p.m. the interim DON stated she had seen R3's skin and stated I forgot we were going to see it together. The DON stated, he does have something open now, looks like hospice has been following.

Based on observation, interview and document review, the facility failed to ensure timely identification, evaluation, treatment and notification of the medical provider regarding a right lower extremity assessed to be cold to the touch and mottled (discoloration of the skin from constricting of the blood vessels) for 1 out of 3 residents (R1) reviewed for quality of care. This resulted in an immediate jeopardy (IJ) for R1 who developed non-viable tissue (not capable of living) resulting in progressive gangrene to her right lower leg. The IJ began on 5/29/19, when a facility licensed nurse identified the cold, mottled right lower leg but failed to further assess and notify R1's medical provider of the acute change. The IJ was identified on 6/7/19, and the administrator, director of nursing (DON) and nurse consultant (NC) were notified of the IJ at 2:20 p.m. on 6/7/19. The immediate jeopardy was removed on 6/7/19 however, noncompliance remained at the lower scope and severity level of G- isolated, with actual harm that is not immediate jeopardy. Findings include: R1's face sheet indicated an initial admission to the facility date of 2/12/16, with [MEDICAL CONDITION] and [MEDICAL CONDITION] following cerebral infarction affecting left side. R1's other [DIAGNOSES REDACTED]. R1's quarterly Minimum Data Sheet (MDS) assessment dated [DATE], indicated a moderate impairment in cognition and R1 required extensive assistance of two for bed mobility, transfers and toilet use and extensive assistance of one for personal hygiene and eating. R1's skin assessment identified a deep tissue injury, moisture associated [MEDICAL CONDITION] (inflammation of the skin) and a significant weight loss over the past 30 days. R1's current plan of care printed 6//7/19, identified altered cardiovascular status related to arrhythmia, hypertension, [MEDICAL CONDITION], and history of cerebral infarction. Interventions identified included: assess fingers and toes for warmth and color as needed. On 12/26/18, the plan of care was updated to include hospice cares. Interventions and tasks were updated to include: contact hospice with change of condition 24/7 (24 hours a day/7 days a week), maintain communication with hospice care, contact person keeping them informed of resident's condition as needed and keep hospice care informed of any changes in resident's condition. On 6/7/19, the plan of care was updated to include ischemic (inadequate blood flow) right lower extremity, with 5 digits on right lower extremity (RLE) having necrotic (the death of cells) tissue from underneath all the way to the nail bed. New interventions included: monitor necrotic toes on RLE. Ensure there is no pressure or rubbing. (MONTH) wrap with dressing as needed. Monitor RLE for signs and symptoms of pain and darkened area expanding past marked area. Per hospice, please use as needed [MEDICATION NAME]. Resident will need to be assessed via pain scale for pain as resident does not verbalize pain. Measure RLE discolored areas daily and document in progress note. If area worsens, update provider, family and hospice. Avoid weight bearing to the RLE. Use Lift to transfer. When in bed elevate right leg and use a cradle. During interview on 6/6/19 at 1:33 p.m., the certified nurse practitioner (CNP) stated on 5/30/19, she'd been conducting rounds with the medical doctor (MD) at the facility when they were approached by registered nurse (RN)-A requesting evaluation of R1's right lower leg. The CNP stated the leg was pulseless, cold and purple. The CNP stated R1 had denied pain with movement and there were no nonverbal signs of pain. The CNP stated she'd asked RN-A whether hospice had been notified and was told they had not been notified. The CNP stated she then contacted hospice who indicated if R1 wanted treatment, they should transfer her to an emergency department (ED). The CNP stated the facility then contacted the family who had requested transfer to the ED for evaluation. The CNP stated upon her review of the electronic medical record (EMR), she could determine issues with the leg had been identified on 5/29/19 at 10:20 p.m., with nursing documentation indicating the leg was cold and mottled. The CNP expressed concern that an acute situation had not been reported to hospice, the family or the medical provider. The CNP further indicated the RLE may have been re-vascularized if the change in status had been reported sooner. An interdisciplinary nursing progress note dated 5/29/19 at 10:20 p.m., written by licensed practical nurse (LPN)-A included: The right lower leg is cold to touch and appears to have modelling (sic), no [MEDICAL CONDITION]. Resident denies pain, discomfort. A progress note dated 5/30/19, at 11:25 a.m., written by RN-A included: TMA (trained medication aide) called writer into room this A.M. to assess RLE. RLE cold to the touch below the knee but warm to the touch above the knee. LLE warm to the touch both above and below the knee. Writer asked resident if she was having any pain in that leg and she stated no. Possible occlusion suspected. (CNP) notified and assessed and agreed that possible occlusion is the most probable. The documentation further indicated the physician had also been in the facility conducting rounds and had called to find appropriate placement. RN-A's note also included: Writer also called family and informed family what was going on and asked them if they wanted resident to be sent out to ED (emergency department) or if they wanted to let it run its course. Writer informed them of what could happen if it remains untreated. The note indicated the family had ultimately requested to send R1 for treatment to try to save the limb. A progress note dated 5/30/19, by the medical doctor (MD) included: The cold right leg likely represents an arterial thrombus. I discussed the case with (a physician's name), [MEDICATION NAME] radiology. He said that typically this is treated with catheter directed lytic medications. This is followed by treatment of [REDACTED]. The CNP will discuss options with hospice and the family. An interdisciplinary progress note dated 5/31/19 at 6:15 a.m., written by LPN-B, included: Nurse assessed resident on Wednesday (5/29/19) and applied skin prep to heels when nurse noticed that resident's right leg was colder and more pale than her left leg. Nurse took off her compression sock and warmed it up with a blanket thinking the circulation might have been getting cut off. Nurse notified the next nurse since it was close to shift change. An ED to hospital admission discharge summary note dated 6/3/19, indicated patient's leg was cool to the touch the night prior and was discolored on the morning of admission. The note indicated another hospital's ED confirmed R1 to have a cold, mottled, pulseless RLE and R1 was transferred to this facility where an angiogram of RLE showed occlusion of the right distal common femoral artery, superficial femoral artery, and popliteal artery .Her right foot was clearly non-viable and it was felt that her lower leg was also likely nonviable. Vascular surgery noted R1 would require an above-the-knee amputation if surgical options were pursued. Options were discussed with the family who opted to transition R1 to comfort cares and not pursue surgery. During observation on 6/6/19, at 2:13 p.m., R1 was lying in a low positioned bed. She had a vascular boot on her right lower extremity and a towel was wrapped around her right foot and ankle. R1 denied pain. The toes on RLE from posterior base of toes to the toenails were black. Her RLE from ½ inch below the knee to the ankle was purple. The rest of the foot was covered with a towel. An outline drawn with pen was present at the top of the purple discoloration. During interview on 6/6/19, at 2:50 p.m., family member (FM)-C indicated he was notified by the CNP on 5/30/19, that R1's leg was cold and likely had a blood clot and the family had an hour to decide what to do. He spoke with other family members and decided to send R1 to the ED. FM-C stated when she got to the ED, they were notified they could not treat the leg at that facility and would require transfer to a vascular surgeon, which was then completed. FM-C indicated he had received a phone call the previous night related to a burn to R1's arm, but he was not informed of the RLE being cold and mottled. During observation on 6/7/19, at 8:31 a.m., R1 was in bed with cradle at bottom elevating blankets from both lower legs. R1 denied any pain. RLE was in a vascular boot and remained purple from below the knee into the foot. The toes on the RLE remained black on posterior toes to the nail beds. A 1x1 centimeter blister was present on was present on 2nd toe. During interview on 6/7/19, at 8:33 a.m., LPN-B stated on 5/29/19, at approximately 2:00 p.m., she was putting skin cream on R1's legs and had noticed the RLE was cool to the touch, but had good capillary refill. LPN-B stated she had not assessed pulses. LPN-B described her assessment was identifying decreased circulation from the [MEDICAL CONDITION]-embolic deterrent hose (TED), so she had removed the TED stocking and notified the next nurse caring for R1. The LPN-B further stated the charge RN was not notified. During interview on 6/7/19, at 8:50 a.m., RN-A confirmed she had been asked to assess R1's lower right leg on 5/30/19, by the TMA shortly after starting her shift at 6:00 a.m RN-A said she'd assessed R1's lower extremities and determined that the LLE was warm to the touch and normal in color and the RLE was cold to the touch and had no discoloration. RN-A indicated the hospice nurse was scheduled to see R1 that morning so RN-A's plan was to have hospice RN assess when she arrived. RN-A indicated approximately 9:00 a.m., she became aware the CNP and MD were at the facility and requested they evaluate the RLE. After the CNP and MD assessed the RLE, RN-A said she was requested to notify hospice regarding possible arterial occlusion. RN-A then notified hospice who requested family be notified and determine if they wanted transfer to ED and further evaluation and treatment. RN-A stated she spoke with the FM-C, who after consulting other family members requested further care and treatment. R1 was then transferred to the ED. During interview on 6/7/19 at 9:12 a.m., LPN-A stated a nursing assistant had notified her R1's leg was cold on 5/29/19, at approximately 9:30 or 10:00 p.m LPN-A stated she assessed the leg to be cold and mottled and consulted with a hospice nurse onsite from a different organization than R'1s. LPN-A stated she did not check for pedal pulses. LPN-A stated the hospice nurse had told her, that is what happens at the end of life. LPN-A also stated she had consulted with other staff members including RN-B who did not go assess R1's RLE. LPN-A stated because she'd been concerned about R1's RLE, she had passed on her concern to the next shift. LPN-A stated after her shift, while she was at home, she discovered R1's [MEDICATION NAME] had been discontinued and she became more concerned but stated with her being on hospice, we weren't thinking about it being abnormal. LPN-A stated, With any change in condition, if a resident is on hospice, you notify them first then the provider and family. I didn't really think it was a change in condition or I would have notified them. I know now I should have called hospice. During interview on 6/7/19 at 9:53 a.m., the CNP stated the [MEDICATION NAME] had been discontinued for R1 after long term use for [MEDICAL CONDITION] due to a decline in health. The CNP indicated R1 was refusing her medications and meals at times and the international normalized ratio (INR) (a laboratory test used for monitoring the effects of anticoagulation treatment) was extremely variable. The CNP stated it became unsafe to continue dosing the [MEDICATION NAME] therefore, she'd discussed the risks and benefits with the family who had agreed to discontinue the [MEDICATION NAME]. During interview on 6/7/19 at 10:04 a.m., RN-B stated she was informed R1's RLE was cold to the touch and mottled, but LPN-A had consulted a hospice nurse who'd said it was a normal process for dying and was expected. RN-B further stated, At the time, I was not aware it was not (R1's) hospice agency nurse. RN-B verified LPN-A was concerned about R1's RLE. RN-B stated her interpretation of the conversation was LPN-A was mentioning it to her, but not reporting it to her as the charge nurse. RN-B confirmed she did not assess or examine R1's RLE and trusted LPN-A's judgement. During interview on 6/7/19 at 10:34 a.m., the DON stated R1 had been declining so her foot being cold could have been another step in the dying process however, the DON stated, You would expect bilateral coldness and mottling versus just one side. During interview on 6/7/19, at 11:50 a.m., the administrator stated a Correction, Direction or Re-education form had been completed on 6/6/19 with LPN-A. The form indicated corrective action included: Employee noted change in condition and failed to update provider, hospice, and/or family as evidenced by nursing note dated 5/29/19. A policy titled Procedure of Notification of Provider/MD: included: 1. The floor nurse, nursing assistants, and nurse manager will monitor all residents for a change or decline in resident condition. If a change in condition or decline is noted, the floor nurse and/or nurse manager will complete a comprehensive assessment of the resident . 2. The unit nurse/nurse supervisor will notify resident's attending physician/NP or on call physician when there has been: -A significant change in the resident's physical/emotional/mental condition -A need to alter the resident's medical treatment significantly -A need to transfer the resident to a hospital/treatment center 3. A significant change of condition is a decline or improvement in the resident's status that: -Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions. The IJ that began on 5/29/19 was removed on 6/7/19, when the facility provided an appropriate removal plan including: Implementation of training for all licensed staff on change of condition, clinical monitoring, hospice protocols, and procedures for notification of provider and family;.Assessment of residents currently residing in the facility assessed for change in condition, and any residents with signs or symptoms of circulatory change to lower extremities were placed on clinical monitoring every shift. and it could be verified as having been implemented. Implementation of the removal plan was verified by document review and interview. While the immediacy was able to be removed, non-compliance remained at the lower scope and severity of G, because R1's right lower extremity continued to deteriorate.