Every finding on record at Mapleton Community Home

Based on observation, interview, and document review, the facility failed to comprehensively assess new bruises and abrasions for 1 of 2 residents (R3) reviewed for non-pressure skin conditions.Findings include:R3's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated severely impaired cognition, no behaviors, diagnoses of arthritis, hip fracture, dementia, and use of anticoagulant (blood thinning medication).R3's care plan dated 11/23/24, indicated self-care performance deficit related to recent hip fracture and repair. Skin inspection: requires weekly skin inspection. Observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse.During observation on 6/29/26 at 10:39 a.m., R3 was walking in the hallway independently with wheeled walker. R3 stated she fell about a month ago and broke her hip.R3's nursing admission/readmission evaluation completed by registered nurse (RN)-B dated 5/26/26, indicated skin issues present, right antecubital bruising from hospitalization, left antecubital bruising from hospitalization, coccyx blanchable redness, left hip known surgical incision covered with dressing, bruising present. There was no further information about the bruise sizes, shapes, dimensions, or coloring. The assessment indicated a care plan goal focus area: anticoagulation with goal of free from discomfort related to anticoagulant use and intervention of labs as ordered. There was no intervention to monitor/document/report signs or symptoms of anticoagulant complications, such as bruising.R3's nursing weekly skin check completed by licensed practical nurse (LPN)-B dated 5/29/26, indicated bruising related to fall, abrasion left forearm, redness to right knee from recent fall. See readmission assessment for skin concerns related to hospitalization/falls. New abrasion to left forearm and redness to right knee from fall sustained yesterday. No further information was on the assessment form. There was no further descriptive information about the new abrasion or knee redness.R3's nursing weekly skin check completed by RN-A dated 6/21/26, indicated new skin condition, injury or skin change noted. New bruise of unknown origin measuring three centimeters by two centimeters located on left knee (rear). No further information was on the assessment form. There was no further descriptive information about the new bruise.R3'S incident report for skin tears and bruises completed by RN-A dated 6/21/26, indicated new bruise to back of left leg below knee. No redness/warmth/swelling, pain with walking, scheduled Tylenol helps. Measurement three centimeters by two centimeters. There was no further description of the bruise.During interview on 6/30/26 at 2:06 p.m., RN-A stated she did not recall anything specific about R3's bruise, but she documented it in Point Click Care (PCC- facility electronic health record) and filled out the incident report provided by the facility. RN-A stated she was unsure if she should have done a focused assessment when finding the new bruise, and that she was unsure how other nurses would be able to tell if the bruise was worsening or healing.During interview on 6/30/26 at 10:12 a.m., director of nursing (DON) stated she was unaware nurses were not completing comprehensive, descriptive assessments of new non-pressure skin conditions. DON stated she thought the incident form they used covered everything. DON stated without comprehensive assessment of the skin conditions, other nurses would not be able to compare when monitoring for worsening of the skin condition and this could lead to something being missed for the resident. DON stated she expected comprehensive skin assessments with more detailed descriptions of bruises.Facility Skin Integrity Management Program provided 6/30/26, indicated the following:For new bruises, measure and document a skin progress note in PCC. Enter an order to measure bruises weekly until resolved into the treatment administration record (TAR) in PCC. Notify the family and provider within 24 hours. Complete an incident report and place in filing location at each nurse's station. For pre-existing bruises, measure bruise weekly and document a skin progress note in PCC until resolved. Notify provider if bruise worsens.

Based on interview and document review, the facility failed to offer the recommended update for pneumococcal immunizations for 2 of 5 residents (R1, R9), reviewed for immunizations. Findings include: R1's face sheet printed on 6/30/26, included diagnoses of dementia, chronic kidney disease, congestive heart failure (when the heart does not pump as well as it should) and chronic obstructive pulmonary disease (lung condition that obstructs airflow and causes breathing difficulty).R1's admission Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood. R1 was dependent upon staff for activities of daily living (ADLs).R1's physician orders did not include vaccinations.R1's vaccine history indicated pneumococcal 23-valent vaccine was received in 2011.PneumoRecs VaxAdvisor application, a product created by the CDC (Centers for Disease Control and Prevention) for healthcare providers to determine which pneumococcal vaccines were needed, recommended to give one dose of PCV15, PCV20, PCV21 at least one year after the last dose of PPSV23.During an interview on 6/30/26 at 2:30 p.m., R1 had been sleeping in bed; family member FM-A stated she could not recall if the facility had talked to them about R1 receiving additional vaccinations, but stated if one were recommended, R1 would take it. FM-A stated she knew R1 had received pneumococcal, influenza and covid vaccines, but gave up trying to keep track.R9's face sheet received on 6/30/26, included primary and secondary diagnoses of hepatic encephalopathy (brain dysfunction caused by liver disease) and nonalcoholic steatohepatitis (aggressive form of fatty liver disease).R9's admission MDS assessment dated [DATE], indicated moderately impaired cognition, clear speech, could understand and be understood. R9 required substantial assistance or was dependent upon staff for ADLs.R9's physician orders did not include vaccines.R9's vaccine history indicated pneumococcal 23-valent vaccine in 2017, and PCV13 in 2020.PneumoRecs VaxAdvisor recommended to give one dose of PCV20 or PCV21 at least 5 years after the last pneumococcal vaccine dose.During an interview on 6/30/26 on 3:13 p.m., R9 stated if vaccines were recommended and offered, she would take them. R9 stated no vaccines had been offered or received since admission. During an interview on 6/30/26 at 12:44 p.m., the director of nursing (DON) who was also the infection preventionist, stated R1 had been admitted on [DATE], for short term rehabilitation, which was Medicare part A, so the facility would not automatically update any vaccines. Then on 4/17/26, R1 moved to long term care status, and missed the vaccine clinic held on 4/20/26. The next vaccine clinic would be held at the end of July. The DON stated the facility conducted quarterly vaccine clinics in conjunction with a pharmacy. Regarding R9, the DON stated vaccines would be recommended at end of her short-term stay. The DON stated the delay in R1 and R9 being offered to update their vaccine status while in short term stay, was due to billing. During an interview on 6/30/26 at 2:34 p.m., Doctor of Medicine (MD)-C had been informed some residents had not been offered pneumococcal vaccine updates on admission. MD-C stated pneumococcal would be important to have on admission and had been unaware of the process the facility utilized to determine which/when vaccines were offered.During an interview on 6/30/26 at 2:39 p.m., registered nurse (RN)-B who was also a nurse manager, stated her role in resident immunizations included looking up historical vaccinations, but did not assess vaccine status to determine if a resident was eligible for additional vaccines such as pneumococcal vaccines. RN-B stated that was handled by the DON and the pharmacy. RN-B stated immunization status was reviewed by pharmacy during vaccination clinics. Looking in the electronic medical record, RN-B stated both R1 and R9 had been eligible for PCV21 if a provider ordered it.Facility Standing Orders policy, undated, included per CDC guidelines, administer pneumococcal vaccines unless contraindicated.Facility Pneumococcal Vaccine Program policy dated 2024, indicated residents would be offered immunizations against pneumococcal disease in accordance with Advisory Committee on Immunization Practices (ACIP) recommendations. Pneumococcal disease was a serious illness that could cause sickness and even death. A physician order for all pneumococcal vaccines was required. Pneumococcal vaccination guidance for pneumococcal vaccination can be determined at CDC PneumoRecs VaxAdvisor.

Based on interviews and document review the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the resident's fall history for 2 of 3 residents (R2 and R10) reviewed for falls. Findings include: R2's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated impaired cognition, no behaviors or rejection of care, use of wheelchair, one fall with no injury, one fall with minor injury, and diagnoses of non-traumatic brain dysfunction, high blood pressure, and Alzheimer's disease. R2's care plan dated 11/2/23, indicated at risk for falls related to poor balance, assistive devices for mobility, psychotropic medication use, history of falls. Ensure non-slip footwear, follow facility fall protocol, if sitting on the edge of the bed to play cards, ensure that her bed is made or have her sit in the recliner. R2's facility progress notes reviewed on 6/29/26, indicated falls on 11/17/25, 1/7/26, 3/29/26, 3/30/26, 4/14/26, 4/18/26, 5/18/26, 5/23/26, and 6/15/26. R2's quarterly MDS assessment dated [DATE], indicated falls since the prior assessment that included one fall with no injury. Review of R2's falls during that assessment period indicated two falls had occurred. R2's significant change MDS dated [DATE], indicated falls since the prior assessment that included one fall with no injury and one fall with minor injury. Review of R2's falls during that assessment period indicated three falls had occurred. During interview on 6/30/26 at 10:20 a.m., assistant director of nursing (ADON) stated she was the MDS nurse for the facility and completed R2's MDS assessments. ADON stated she did not think the facility used point click care (PCC- facility electronic health record) to its full potential, still had a lot of paper charting, and it was likely falls could be missed when reviewing for assessments. ADON reviewed R2's falls and confirmed some falls were missed on her assessments. R10's quarterly MDS assessment dated [DATE] indicated R10 had no cognitive impairment, utilized a walker, was independent with walking, and had diagnoses that included non-Alzheimer's dementia, repeated falls, and chronic pain. Section J indicated R10 had experienced falls since admission or the prior assessment and was coded as having one fall with no injury and one fall with injury (except major). R10's care plan dated 4/29/26, identified R10 as being at risk for falls related to poor balance and a history of falls. Interventions included anticipating and meeting R10's needs, keeping the call light within reach and encouraging its use for assistance as needed, and following the facility's fall protocol. Review of R10's Accident Reports indicated R10 sustained falls on 2/14/26, 3/11/26, 3/24/26, and 4/30/26. On 6/30/26 at 8:47 a.m., the ADON, who also served as the facility's MDS nurse, stated they completed R10's MDS fall coding on 5/13/26. The ADON confirmed R10 experienced falls on 2/14/26, 3/11/26, 3/24/26, and 4/30/26, including two falls with injury (except major) and two falls with no injury during the applicable MDS look-back period. The ADON confirmed the MDS assessment was coded incorrectly and should have indicated two or more falls and two or more falls with injury (except major). On 6/30/26 at 11:18 a.m., the director of nursing (DON) stated they expected the MDS to accurately reflect residents' falls. Facility MDS Accuracy Policy, dated 3/2019, indicated the Resident Assessment Instrument (RAI) Manual would be followed to ensure accuracy in all coding areas.

Based on interview and document review the facility failed to ensure interventions developed following resident falls were implemented through a system that was available to staff to prevent further falls for 3 of 3 residents (R2, R3, R10) reviewed for accidents.Findings include:R10's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R10 had no cognitive impairment, utilized a walker, independent with walking, diagnoses included Non-Alzheimer's Dementia, repeated falls, chronic pain, had falls since admission or the prior assessment, one fall with no injury and one fall with injury (except major).R10's care plan dated 4/29/26, indicated R10 was at risk for falls r/t (related to) poor balance and history of falls and interventions included: anticipate and meet R10's needs, call light within reach and encourage her to use it for assistance as needed and follow facility fall protocol.R10's Accident Report documents which included interdisciplinary team review/investigation decision indicated:Review of R10's Accident Reports, including the interdisciplinary team (IDT) investigation and recommendations, identified the following falls and interventions:12/5/25: Unwitnessed fall after bending to pick up a box of crackers. Intervention: remind R10 to have staff retrieve items from the floor.2/14/26: Fell after attempting to sit on a walker without a seat. Intervention: use a chair when playing cards and move the walker aside before sitting.3/11/26: Found sitting on the floor beside the bed. Intervention: call staff for assistance with transfers and incontinent care.3/24/26: Found on the floor beside the bed with right hip and shoulder pain and transferred to the emergency department. Intervention: evaluate the need for a wider bed (determined not needed) and install a grab bar on the right side of the bed.4/30/26: Fell while bending to pick up cigarette butts outside without her walker, resulting in a skin tear and superficial abrasions. Interventions: develop a smoking contract or revoke smoking privileges and have staff move her chair after smoking if desired.6/8/26: Lost balance during dinner, fell backward, and struck the back of her head on another resident's chair before falling to the floor. Intervention: encourage R10 to slow down, stop and sit if feeling lightheaded, and provide smoking cessation education.Review of the interventions on 2/14/26, 3/24/26, 4/30/26, and 6/8/26, were not present on the care plan. On 6/29/26 at 10:33 a.m., R10 stated she had fallen approximately three weeks earlier after walking without her walker because she lost her balance. R10 stated staff reminded her to use her walker following the fall.On 6/29/26 at 2:41 p.m., licensed practical nurse (LPN)-B stated fall interventions are developed by the interdisciplinary team following falls, documented in the care plan, communicated to staff, and implemented. After review of the electronic medical record, LPN-B confirmed interventions developed following the resident's 6/8/26 fall were not added to the care plan and stated she was not aware of all interventions in place to prevent R10's falls.On 6/29/26 at 2:48 p.m., nursing assistant (NA)-A stated R10 was a known fall risk and staff relied on the care plan to identify the resident's current fall prevention interventions and prevent further falls.On 6/29/26 at 2:59 p.m., registered nurse (RN)-B, the nurse manager, stated immediate interventions are implemented following a fall and later reviewed by the interdisciplinary team. RN-B stated IDT-developed interventions are expected to be incorporated into the care plan so staff were aware of and able to implement measures to prevent further falls. RN-B stated if fall interventions were not added to the care plan, staff may not be aware of interventions intended to prevent R10's falls. RN-B further stated she was not aware of all specific interventions in place following R10's falls.On 6/29/26 at 3:09 p.m., the director of nursing (DON) reviewed the post-fall investigations for R10's falls occurring on 2/14/26, 3/11/26, 3/24/26, 4/30/26, and 6/8/26 and confirmed the interventions developed following those falls had not been incorporated into the resident's comprehensive care plan. The DON stated the interventions remained on paper fall investigation forms maintained in the DON's office and acknowledged staff would not have a readily available method to identify the resident's current fall interventions to further prevent falls.On 6/29/26 at 5:03 p.m., LPN-C stated staff rely on the resident's care plan to identify current fall prevention interventions and, if the care plan is not updated, staff would not be aware of the interventions to prevent further falls.On 6/30/26 at 7:58 a.m., nursing assistant (NA)-B stated new fall interventions were communicated during shift report but are also expected to be documented in the care plan so all staff know what interventions to implement to prevent falls.On 6/30/26 at 8:08 a.m., registered nurse (RN)-C stated resident care plans should be updated following a fall to include new interventions to prevent further falls.R2's significant change MDS assessment dated [DATE], indicated impaired cognition, no behaviors or rejection of care, use of wheelchair, one fall with no injury, one fall with minor injury, and diagnoses of non-traumatic brain dysfunction, high blood pressure, and Alzheimer's disease.R2's care plan dated 11/2/23, indicated at risk for falls related to poor balance, assistive devices for mobility, psychotropic medication use, history of falls. Ensure non-slip footwear, follow facility fall protocol, if sitting on the edge of the bed to play cards, ensure that her bed is made or have her sit in the recliner.R2's facility progress notes reviewed on 6/29/26, indicated falls on 11/17/25, 1/7/26, 3/29/26, 3/30/26, 4/14/26, 4/18/26, 5/18/26, 5/23/26, and 6/15/26.Review of R2's Accident Report documents which included interdisciplinary team review/investigation decision indicated the following interventions:11/17/25: Wide bed1/7/26: Clip call light to chest for easier access3/29/26: Fall mat at bedside3/30/26: Hospice referral4/14/26: Medication change5/18/26: Remove or flip out foot pedal if wheeling self5/23/26: Medication change6/15/26: Reviewed with hospice concern for adverse effect post administration of anxiety medication and discontinued medicationR3's significant change MDS assessment dated [DATE], indicated impaired cognition, no behaviors or rejection of care, independent with ambulation with wheeled walker, one fall with injury, and diagnoses of anemia, atrial fibrillation (irregular heartbeat), high blood pressure, and hip fracture.R3's care plan dated 11/23/24, indicated moderate risk for falls related to confusion, deconditioning, gait/balance problems. Be sure call light is within reach to encourage her to use it for assistance as needed. Ensure appropriate footwear. Fall mat at bedside and bed at knee height.R3's facility progress notes reviewed on 6/29/26, indicated falls on 11/7/25, 5/18/26, and 5/28/26.Review of R3's Accident Report documents which included interdisciplinary team review/investigation decision indicated the following interventions:11/7/25: decreased medication5/18/26: Remind to wear shoes in room and let staff get large items and carry for her5/28/26: Offer to move to room closer to nurses, discontinued medicationDuring interview on 6/29/26 at 3:45 p.m., NA-C stated she did not know specific interventions for R2 but knew they tried to keep her out in the main area to keep an eye on her. NA-C further stated she did not know where she would find interventions, but they were usually passed down in report. NA-C stated she did not work every day, so could have missed hearing some interventions. NA-C stated she was not sure if interventions were on R2's care plan.During interview on 6/29/26 at 4:02 p.m., NA-D stated she did not have a list of interventions on the care plan for R2 or R3 and did not know if interventions were documented anywhere. NA-D stated interventions were talked about in report.On 6/30/26 at 8:15 a.m., DON stated post-fall investigations had been completed and fall interventions had been decided for the above falls for R2 and R3. DON stated the interventions were passed on by word of mouth to the nurses in report. DON stated the interventions were not a part of the comprehensive care plan and were kept on paper in a binder in her office. DON further confirmed the interventions would not be available for staff if she were not there and it would be important for staff to know fall interventions to prevent future falls.Facility Falls Policy and Procedure dated 9/23, indicated; A plan of care will be developed to include measures to aid in prevention of falls.Post fall: an accident report is filled up by the charge nurse following a fall. The charge nurse of each wing brings this report to the daily interdisciplinary team meeting. The team reviews the fall and determines if the current plan is adequate or other interventions should be put in place. The reports given to the DON to log for QAPI.Reassessment and reevaluation: residents who are at risk for falls will have their plan of care reassessed with each MDS assessment and reviewed at their resident care conference.

Based on interview, observation, and document review, the facility failed to revise and update the comprehensive care to include new fall interventions implemented for 3 of 3 residents (R2, R3, and R10) reviewed for falls. Findings include: R10's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R10 had no cognitive impairment, utilized a walker, independent with walking, diagnoses included Non-Alzheimer's Dementia, repeated falls, chronic pain, had falls since admission or the prior assessment, one fall with no injury and one fall with injury (except major). R10's care plan dated 4/29/26, indicated R10 was at risk for falls r/t (related to) poor balance and history of falls and interventions included: anticipate and meet R10's needs, call light within reach and encourage her to use it for assistance as needed and follow facility fall protocol. R10's Accident Report documents which included interdisciplinary team review/investigation decision indicated: Review of R10's Accident Reports, including the interdisciplinary team (IDT) investigation and recommendations, identified the following falls and interventions: 12/5/25: Unwitnessed fall after bending to pick up a box of crackers. Intervention: remind R10 to have staff retrieve items from the floor. 2/14/26: Fell after attempting to sit on a walker without a seat. Intervention: use a chair when playing cards and move the walker aside before sitting. 3/11/26: Found sitting on the floor beside the bed. Intervention: call staff for assistance with transfers and incontinent care. 3/24/26: Found on the floor beside the bed with right hip and shoulder pain and transferred to the emergency department. Intervention: evaluate the need for a wider bed (determined not needed) and install a grab bar on the right side of the bed. 4/30/26: Fell while bending to pick up cigarette butts outside without her walker, resulting in a skin tear and superficial abrasions. Interventions: develop a smoking contract or revoke smoking privileges and have staff move her chair after smoking if desired. 6/8/26: Lost balance during dinner, fell backward, and struck the back of her head on another resident's chair before falling to the floor. Intervention: encourage R10 to slow down, stop and sit if feeling lightheaded, and provide smoking cessation education. Review of the comprehensive care plan failed to identify the interventions developed following the falls on 2/14/26, 3/11/26, 3/24/26, 4/30/26, and 6/8/26. On 6/29/26 at 10:33 a.m., R10 stated she had fallen approximately three weeks earlier because she lost her balance while walking without her walker. R10 stated staff reminded her to use her walker following the fall. On 6/29/26 at 2:41 p.m., licensed practical nurse (LPN)-B stated fall interventions were developed by the interdisciplinary team following falls, documented in the care plan, communicated to staff, and implemented. LPN-A was observed to review R10's electronic medical record (EMR) and confirmed interventions form R10's most recent fall on 6/8/26, were not added to the care plan. On 6/29/26 at 2:48 p.m., nursing assistant (NA)-A stated R10 was a fall risk and relied on the care plan to identify current fall interventions. On 6/29/26 at 2:59 p.m., registered nurse (RN)-B, known as the nurse manager, stated following a resident fall the nurse completes a fall report on paper and puts an immediate intervention in place and emails the nursing staff of the new interventions or writes a progress note. RN-B stated the the interdisciplinary team (IDT) meets and reviews the fall, and discusses interventions and the implemented interventions would be expected to appear in the resident's care plan. RN-B stated the IDT team consists of themselves, director of nursing (DON), assistant director of nursing (ADON), social worker, dietary, activities, business office, therapy and nursing floor staff. RN-B confirmed no new care plan interventions were documented following the 6/8/26, fall. RN-B stated DON or ADON updated resident care plans. On 6/29/26 at 3:09 p.m., the DON stated the IDT reviews each fall and attempts to implement a new intervention unless all appropriate interventions are already in place. The DON reviewed R10's fall investigation forms for the falls occurring on 2/14/26, 3/11/26, 3/24/26, 4/30/26, and 6/8/26 and confirmed the interventions developed following those falls had not been incorporated into the comprehensive care plan. The DON stated the paper fall investigation forms containing the interventions were maintained in the DON's office and acknowledged staff would not be able to readily identify the interventions from the care plan. The DON confirmed the DON and ADON were responsible for updating resident care plans. On 6/29/26 at 5:03 p.m., an LPN-C stated fall interventions are communicated during report or by email but should also be included in the care plan because staff rely on the care plan to identify resident-specific interventions. 6/29/26 at 5:57 p.m., R10 was observed ambulating independently in the hallway using a two-wheeled walker. On 6/29/26 at 6:06 p.m., R10 was seated on a bench outside the facility smoking a cigarette. On 6/30/26 at 7:58 a.m., a NA-B stated new fall interventions were communicated during shift report and would also be expected to be documented in the care plan. On 6/30/26 at 8:08 a.m., a RN-C stated following a fall, interventions should be updated in the resident's care plan and confirmed the DON and ADON were responsible for revising and upateing the care plan. R2's significant change MDS assessment dated [DATE], indicated impaired cognition, no behaviors or rejection of care, use of wheelchair, one fall with no injury, one fall with minor injury, and diagnoses of non-traumatic brain dysfunction, high blood pressure, and Alzheimer's disease. R2's care plan dated 11/2/23, indicated at risk for falls related to poor balance, assistive devices for mobility, psychotropic medication use, history of falls. Ensure non-slip footwear, follow facility fall protocol, if sitting on the edge of the bed to play cards, ensure that her bed is made or have her sit in the recliner. R2's facility progress notes reviewed on 6/29/26, indicated falls on 11/17/25, 1/7/26, 3/29/26, 3/30/26, 4/14/26, 4/18/26, 5/18/26, 5/23/26, and 6/15/26. Review of R2's Accident Report documents which included interdisciplinary team review/investigation decision indicated the following interventions: 11/17/25: Wide bed 1/7/26: Clip call light to chest for easier access 3/29/26: Fall mat at bedside 3/30/26: Hospice referral 4/14/26: Medication change 5/18/26: Remove or flip out foot pedal if wheeling self 5/23/26: Medication change 6/15/26: Reviewed with hospice concern for adverse effect post administration of anxiety medication and discontinued medication R3's significant change MDS assessment dated [DATE], indicated impaired cognition, no behaviors or rejection of care, independent with ambulation with wheeled walker, one fall with injury, and diagnoses of anemia, atrial fibrillation (irregular heartbeat), high blood pressure, and hip fracture. R3's care plan dated 11/23/24, indicated moderate risk for falls related to confusion, deconditioning, gait/balance problems. Be sure call light is within reach to encourage her to use it for assistance as needed. Ensure appropriate footwear. Fall mat at bedside and bed at knee height. R3's facility progress notes reviewed on 6/29/26, indicated falls on 11/7/25, 5/18/26, and 5/28/26. Review of R3's Accident Report documents which included interdisciplinary team review/investigation decision indicated the following interventions: 11/7/25: decreased medication 5/18/26: Remind to wear shoes in room and let staff get large items and carry for her 5/28/26: Offer to move to room closer to nurses, discontinued medication During interview on 6/29/26 at 3:45 p.m., NA-C stated she did not know specific interventions for R2 but knew they tried to keep her out in the main area to keep an eye on her. NA-C further stated she did not know where she would find interventions, but they were usually passed down in report. NA-C stated she did not work every day, so could have missed hearing some interventions. NA-C stated she was not sure if interventions were on R2's care plan. During interview on 6/29/26 at 4:02 p.m., NA-D stated she did not have a list of interventions on the care plan for R2 or R3 and did not know if interventions were documented anywhere. NA-D stated interventions were talked about in report. During interview on 6/30/26 at 10:20 a.m., DON stated she reviewed all fall investigations for R2 and R3 and confirmed those interventions were not added to the comprehensive care plan. DON stated interventions were shared in verbal report with staff. DON further stated the investigation forms were kept in her office and not always available to staff, and it would be important for all staff working with R2 and R3 to be aware of their fall interventions to prevent falls. The facility Care Planning and Care Conference policy dated 8/28/17, indicated; The care plan will be reviewed quarterly with the IDT, resident and/or resident representative and staff. Corrections will be made to the plan of care as needed. Care plans are an on-going process and will have updates made on PRN basis with any changes. Auding will be done weekly on two random care plan by the Director of Nursing to endsure that care plans are up to date. The facility Falls Policy and Procedure dated 9/23, indicated A plan of care will be developed to include measures to aid in prevention of falls. Post fall: an accident report is filled up by the charge nurse following a fall. The charge nurse of each wing brings this report to the daily interdisciplinary team meeting. The team reviews the fall and determines if the current plan is adequate or other interventions should be put in place. The reports given to the DON to log for QAPI. Reassessment and reevaluation: residents who are at risk for falls will have their plan of care reassessed with each MDS assessment and reviewed at their resident care conference

Based on observation, interview and document review the facility failed to implement appropriate infection prevention and control practices by ensuring Enhanced Barrier Precautions (EBP), including gown and glove use during wound care, were implemented for 2 of 2 residents (R5 and R11) reviewed for skin conditions and by ensuring transmission-based contact precautions, including gown and glove use during direct personal care, were implemented for 1 of 1 resident (R58) reviewed for infection prevention. Findings include: R5's face sheet printed 6/30/26, indicated diagnoses of blister of left and right lower leg. R5's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, no rejection of care, use of wheelchair, dependent for dressing and hygiene, and application of ointments/medications and nonsurgical dressings. R5's care plan dated 9/28/23, indicated potential for pressure ulcer development, goal of skin remaining intact through review dates, and interventions of administering treatments as ordered and checking skin when assisting with toileting and dressing daily and also weekly in the bath. R5's physician's order dated 6/6/26, indicated left lower extremity (LLE) wound care: Cleanse leg, foot, toes, and between toes with normal saline or wound cleanser. Pat dry and dry well between toes. Moisturize intact skin, avoiding wounds and between toes. Right lower extremity (RLE) wound care: Cleanse leg, foot, toes, and between toes with normal saline or wound cleanser. Pat dry and dry well between toes. Moisturize intact skin, avoiding wounds and between toes. Apply skin prep to periwound skin and allow to dry. Apply a single layer cut-to-fit piece of foam over blisters. Cover with small pad, secure with wrap and tape from base of toes to just below the knee. R5's provider visit note dated 6/19/26 indicated RLE blister measuring 0.4 centimeters by 1.1 centimeters. Prep: cleansed with saline. Noted serosanguineous (thin fluid that is a mixture of water and blood) drainage. Surrounding skin noted to have tenderness. Patient tolerated procedure well. Moisturized and applied foam dressing. R5's progress note dated 6/29/26, indicated R5 had a hospice bath this shift. Wound continue to right lower extremity. Review of R5's treatment administration record (TAR) indicated licensed practical nurse (LPN)-A completed R5's RLE wound treatment on 6/29/26 and 6/30/26. During observation on 6/29/26 at 1:34 p.m., no enhanced barrier precaution (EBP) signs were noted on R5's room door. No personal protective equipment (PPE) for EBP was observed at his room entrance. During interview on 6/0/26 at 1:13 p.m., LPN-A state she completed R5's wound care for his RLE wound. LPN-A stated she did wear gloves but did not wear a gown. LPN-A stated she was not aware she needed to wear EBP PPE while taking care of R5's wound and he had not been placed on EBP as far as she knew. During interview on 6/30/26 at 11:20 a.m., director of nursing (DON) also known as the infection preventionist, stated EBP should be used for R5 during cares and wound treatments due to his RLE wound with drainage. R11's significant change in status MDS assessment dated [DATE], indicated no cognitive impairment, independent with personal cares and transfers, and diagnoses included non-Alzheimer's dementia and cellulitis (bacterial infection of the skin) of left lower limb. R11's care plan dated 5/19/26, indicated impairment to skin integrity r/t (related to) cellulitis and monitor/document location, size and treatment of skin injury. R11's wound care provider note dated 6/19/26, identified two open ulcers to the left lower extremity requiring daily wound care, including cleansing, application of topical treatments, Xeroform (sterile, non-adherent medical dressing) dressing, ABD (absorbent medical dressing) pad, and Kerlix (gauze bandage) wrap. On 6/29/26 at 2:39 p.m., R11 was seated in a recliner in their room with a dressing to the left lower leg. R11 stated nursing staff performed daily dressing changes and wore gloves during wound care but did not wear gowns. R11's room identified no EBP signage or PPE cart outside or outside the room. On 6/30/26 at 10:00 a.m., RN-C performed R11's wound care, including removal of the dressing, cleansing the wound, application of prescribed treatments, and placement of a new dressing. RN-C performed hand hygiene and wore gloves throughout the dressing change; however, a gown was not worn. RN-C stated R11 would be expected to be on enhanced barrier precautions because of the wound requiring dressing changes. RN-C stated the director of nursing (DON) determined which residents were placed on EBP and was responsible for EBP signage and PPE carts. On 6/30/26 at 11:18 a.m., the DON stated residents with wounds requiring dressing changes would be expected to be on enhanced barrier precautions with gown and glove use during wound care. The DON stated she believed R11 only had a scratch and was unaware the resident had active wound care orders. The DON confirmed R11 should have been on EBP and stated any nurse could initiate EBP by posting signage and placing a PPE cart outside the resident's room. R58's entry MDS assessment dated [DATE], indicated reentry from short term hospital on 6/22/26. R58's treatment administration record (TAR) dated 6/1/26-6/30/26, indicated start date 6/22/26, contact precautions used as directed per CMS guidelines every shift for VRE in urine (Vancomycin-Resistant Enterococci- bacteria primarily spread through direct contact with contaminated hands or surfaces). R58's After Visit Summary dated 6/22/26, indicated skin care/pressure management instructions wound care: buttocks; pressure injury. R58's care plan dated revised on 6/22/26, indicated at risk of transmitting an infection, contact isolation: wear gowns and gloves when entering room. On 6/29/26 at 12:23 p.m., observation identified a PPE cart containing gowns and gloves and contact precaution signage posted outside R58's room. On 6/29/26 at 12:26 p.m. trained medication aide (TMA)-A was observed providing toileting assistance to R58 while wearing gloves but no gown. TMA-A exited the resident's bathroom without having a gown. TMA-A confirmed R11 was on contact precautions for VRE in the urine, and confirmed a gown and gloves were required during care, and stated they forgot to put on the gown. On 6/29/26 at 4:51 p.m., the DON confirmed R58 was on contact precautions for VRE in urine and stated staff should know to use gown and gloves when providing toileting assistance, due to the signage posted and the PPE cart outside of R58's room. Facility Infection Prevention and Control Manual Policy dated 2024, indicated; Enhanced Barrier Precautions: refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following: Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; or Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.

Based on observation, interview and document review, the facility failed to ensure required and accurate nursing staffing information was posted for residents and visitors. This had the potential to affect all 47 residents residing in the facility and their visitors.Findings include:During an observation on 6/29/26 at 2:17 p.m., observed the daily nursing staffing posting for 6/29/26, in an acrylic holder on the countertop at the nurses station inside the main entrance. The posting included all of the required information, including the number of staff on duty: RN (registered nurse), LPN (licensed practical nurse), TMA (trained medication aide), and CNA (certified nursing assistant). Postings for April through June were requested for review.For April, from 4/1/26 through 4/30/26, 16 shifts had been left blank (all night shifts). Further, a registered nurse had not been identified as having been scheduled/working five of the dates: 4/1/26, 4/10/26, 4/15/26, 4/24/26, and 4/29/26. For May, from 5/1/26 through 5/31/26, 12 shifts had been left blank (16 night shifts and one evening shift). Further, on 5/27/26, one shift identified an RN in training, but no other RN had been identified.For June, from 6/1/26 through 6/28/26, 16 shifts had been left blank (12 night shifts, three evening shifts and one day shift). Further, a registered nurse had not been identified as having been scheduled/working on four of the dates: 6/6/26, 6/7/26, 6/10/26, and 6/24/26.During an interview on 6/29/26, at 3:37 p.m., the director of nursing (DON) stated it was the responsibility of charge nurses to complete the staffing posting sheet at the start of their shift. The DON stated a minimum of one registered nurse was scheduled for eight consecutive hours every day. In addition, a nurse leader was scheduled to work the day shift, Monday through Friday, either the DON, assistant DON or nurse manager. According to the DON, the shifts where an RN had not been identified as scheduled/working, were primarily shifts worked by agency nurses who likely did not know they needed to complete the form. In addition, for nine of the 10 dates, an RN nurse leader had worked 8 consecutive hours too, except for Saturday 6/6/26, when the RN was an agency nurse. The agency nurses time card had been reviewed for verification. The DON stated she did not monitor the process to ensure nurses completed the form each shift/each day.During an interview on 6/29/26 at 6:08 p.m., registered nurse (RN)-A who was the charge nurse stated she had never filled out a staffing posting for a shift she worked, adding it was usually already filled out. During an interview on 6/30/26 at 8:39 a.m., licensed practical nurse (LPN-A) stated the charge nurse completed the daily staffing posting for that shift. LPN-A stated she looked at the online electronic scheduling system to determine who was scheduled to work, added it to the sheet and made changes to it if someone called in (not able to work). LPN-A stated there was at least one RN scheduled to work every day.Facility Posting Nursing Staffing Hours policy, undated, indicated early in the shift, the charge nurse would obtain a staffing hours form from the bottom file drawer located in the nurses station. The form would be completed with date, census, the type of nursing staff scheduled to work, and their scheduled hours. This would be done by the charge nurse on each shift.

Based on observation and interview, the facility failed to ensure safe and appropriate water temperatures were maintained below 120 degrees Fahrenheit (F) to prevent potential scalding for 2 of 2 residents (R37, R28) observed for accidents and hazards. Findings include:R37's facesheet received on 8/20/25, included diagnosis of Parkinson's disease. R37's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, was understood and could understand. R37 was independent with personal hygiene, toileting and toileting hygiene. R37 used a wheelchair and walker for mobility. R37's care plan with revised date of 12/23/23, indicated R37 needed extensive assist with toileting. R37's care plan with revised date 10/27/23, indicated R37 needed extensive assist of one for personal hygiene.During an observation and interview on 8/18/25 at 2:07 p.m., in R37's room, noted water at the bathroom faucet seemed excessively hot to the touch. R37 agreed and stated he didn't want to tell anyone because others (residents) complained it wasn't hot enough. R37 stated he used the bathroom independently. R28's facesheet received on 8/20/25, included chronic kidney disease.R28's annual MDS dated [DATE], indicated intact cognition, clear speech, was understood and could understand. R28's used a walker and wheelchair for mobility and was independent with personal hygiene, toileting and toileting hygiene. R28's care plan with revised date of 11/15/23, indicated independence with personal hygiene and care plan with revised date of 10/3/23, indicated independence with toileting.During an observation and interview on 8/18/25 at 3:30 p.m., in R28's room, noted water at the bathroom faucet seemed excessively hot to the touch. R28 stated the water got pretty hot but she had not burned herself. During an observation and interview on 8/19/25 at 8:29 a.m., with director of environmental services (DES)-A, he measured the water temperature at R37's bathroom faucet with a mug and a digital thermometer with probe. The temperature reached 121.8 degrees Fahrenheit (F). DES-A stated he tried to keep the temperature between 115 and 118-degrees F and was aware the water temperature in resident bathrooms should not exceed 120 degrees F due to potential for scalding a resident. DES-A stated all bathroom faucet water temperatures in this hallway would be the same, as the water was coming from the same location. DES-A stated he did not regularly check water temperatures - only when he noticed water seemed too hot or staff reported the water was hot and did not document water temperatures. DES-A stated most residents complained about water being too cold. DES-A stated he would turn the water temperature down. During an observation and interview on 8/19/25 at 9:16 a.m., DES-A measured the water temperature at R28's bathroom faucet at 121.3 degrees F. R28 stated she used her bathroom independently. During an interview on 8/20/25 at 7:44 a.m., trained medication aide (TMA)-A stated both R37 and R28 used their bathrooms independently. During an interview on 8/20/25 at 7:45 a.m., DES-A stated now the water temperature in R37 and R28's hallways was 115 degrees F. and stated he had started working on a process to monitor and record the temperatures going forward. Facility policy on monitoring water temperatures in resident bathrooms was requested and not received.

Based on observation, interview and document review the facility failed to ensure personal protective equipment (PPE) was utilized for 1 of 3 residents (R21) reviewed for pressure ulcers.Findings include:R21's admission Minimum Data Set (MDS) dated [DATE], indicated sever cognitive impairment, one stage two pressure ulcer present on admission, four stage two pressure ulcers present on admission, and diagnoses included open wound left food, open wound left lower leg, open wound left buttock.R21's care plan revised 6/12/25, indicated actual impairment to skin integrity r/t (related to) decreased mobility, poor nutrition, current wounds; complete wound care as ordered.On 8/19/25 at 11:05 a.m., no signage was posted to indicate R21 was on enhanced barrier precautions (EBP), and registered nurse (RN)-A and nursing assistant (NA)-A were present in R21's room. RN-A and NA-A were observed with gloves on hands, however, were not wearing gowns. RN-A and NA-A were observed to roll R21 from side to side while in bed, and RN-A was observed to complete wound care on R21. R21 was observed with open wound on buttocks area, RN-A was observed and completed wound care and applied a dressing to R21's buttocks. NA-A completed R21's brief change. RN-A and NA-A removed gloves and disinfected hands prior to exiting R21's room.On 8/19/25 at 11:44 a.m., NA-A stated she had asked the director of nursing (DON) if gowns were required and was educated by the DON R21's wound did not meet requirements that required gown or additional PPE beyond gloves.On 8/19/25 at 11:47 a.m., RN-B stated R21 had chronic wounds that were opened and would expect R21 was placed on EBP with the wounds.On 8/19/25 at 11:50 a.m., RN-A stated R21 was not on EBP that required a gown to be worn during the dressing change.On 8/19/25 at 11:53 a.m., the director of nursing (DON), who also served as the facility's infection preventionist, stated the facility's EBP policy applies to residents with catheters, central lines, wound vacuums, or wounds with depth/tunneling. DON acknowledged misinterpreting EBP guidelines, and confirmed R21 had chronic pressure wounds and should have been on EBP. DON stated she would immediately place PPE and signage outside R21's room.Facility policy titled Infection Prevention and Control Manual Transmission-Based Precautions dated 2024, indicated:Enhanced Barrier Precautions (EBP) Policy.It is the policy of this facility that Enhanced barrier precautions in addition to standard and contact precautions will be implemented during high risk care activities from caring for residents that have increased risk for acquiring a multi-drug resistant organism (MDRO), such as a resident with wounds and dwelling medical devices or residents with infection or colonization's with an MDROEnhanced barrier precautions refer to an infection control intervention designed to reduce transmission of multi drug resistant organisms that employs targeted gown and gloves used during high contact resident care activitiesProtective equipment is required for all staff providing high contact resident activities to include: gown and gloves: with transferring, providing hygiene , changing liens, changing briefs, wound care: any skin opening requiring a dressing.

Based on observation, interview, and document review, the facility failed to provide timely repositioning and toileting for 1 of 3 residents (R5) reviewed for pressure ulcer care and who was dependent on staff for repositioning, toileting, and who had a PU on her sacrum. Findings include:R5's face sheet received on 8/20/25, included diagnoses of a stage 4 pressure ulcer (PU) to sacral region, and obesity.R5's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated severe cognitive impairment. R5 had clear speech, was usually understood and could usually understand. R5 was dependent upon staff for all activities of daily living (ADLs) and had no rejection of care. R5 was always incontinent of bowel and bladder. R5 was at risk for pressure ulcers and had one stage 4 PU present on admission in May 2022. R5's significant change MDS care area assessment (CAA) dated 9/23/24, indicated R5 was at risk for skin breakdown related to decreased mobility, inability to change or shift positions, urinary and bowel incontinence, previous pressure ulcer, and poor nutrition. R5 was repositioned every one-two hours. Resident had a pressure relieving mattress on her bed and pressure reducing cushion in her chair. R5's physician orders included: --3/18/24: Lay down between 12:30 p.m. and 1:00 p.m., and be up by 2:00 p.m., for activity. Husband upset R5 not out of bed and going to activities. -- 7/22/25: Encourage R5 to lay down for at least one hour between meals to help offload (relieve or redistribute pressure from at-risk areas of the body - typically a wound) after meals related to pressure ulcer of sacral region, stage 4. -- 8/8/25: Continue with Broda type wheelchair with built in memory cushions. Encourage R5 to lay down for at least one hour between meals to help offload every shift. -- 8/8/25: T & R (turn and reposition)/offload at least every two hours or more frequently as indicated.R5's care plan with revision date of 8/21/23, indicated R5 had actual impairment to skin integrity related to healing stage 4 pressure injury on her coccyx. Care plan dated 7/29/24, indicated R5 was to lie down in bed for two to three hours per day. When in wheelchair, reposition every two hours - standing in place for one minute. While in bed, turn on side. R5's care plan with revision date of 9/19/24, indicated total assist of two staff to use toilet with mechanical lift. R5's care plan with revision dated of 8/20/25, indicated extensive assist of one staff to reposition and turn in bed. Wound provider notes indicated: --5/16/25: sacral ulceration measure 0.4 cm (centimeters) x 0.6 cm x 0.3 cm. Wound has decreased in size. No odor or drainage. Tissue is friable (delicate and prone to easy tearing or bleeding when touched or manipulated) and 100% granular new connected tissue which forms on the surface of a would during healing). Margins intact and irregular. --6/20/25: sacral ulceration measured 1.4 cm x 1 cm x 0.2 cm. Wound has increased in size. No odor or drainage. Tissue is friable and 100% granular. Margins intact.--8/8/25: Sacral ulceration measured 1.3 cm x 2.3 cm x 0.4 cm. Wound has increased in size. No odor or drainage. Tissue is friable and 100% granular. Margins intact.Wound nurse note dated 8/20/25, indicated: sacrum: 1.0 cm x 1.5 cm x 0.3 cm. Granular base. Pink healthy skin. No pain or discomfort. Drainage noted. During continuous observation on 8/19/25 from 8:20 a.m., to 1:00 p.m., R5 was not checked or changed, nor repositioned: At 8:20 a.m., R5 was observed in her wheelchair in the dining room for breakfast. At 9:10 a.m., R5 was in her room in her wheelchair. The small plastic will return clock on the outside of R5's door indicated 10:30 a.m., the time when R5 should be checked, changed and/or repositioned.At 9:55 a.m., R5 was taken via wheelchair to bible study in the chapel.At 10:36 a.m., R5 was still in the chapel, sitting in her wheelchair in a row with other residents. At 11:23 a.m., R5 was moved from the chapel to the activity room for an activity and to await lunch. R5 remained in her wheelchair. At 11:56 a.m., R5 was moved to the dining room via wheelchair for lunch. At 12:36 p.m., R5 was transported from the dining room to her room via wheelchair. At 12:49 p.m., R5 remained in her wheelchair in her room. During an observation and interview on 8/19/25 at 1:00 p.m., nursing assistant (NA)-B and NA-C entered R5's and assisted R5 to lay down in bed via mechanical lift. Once R5's adult diaper was removed, NA-B stated it was pretty wet. The absorbent part of the adult diaper was significantly expanded. R5 was turned onto her right side. R5 had a large and fleshy buttock, and the lower half was pinkish/red in color with many skin creases. A new adult diaper was applied and R5 was repositioned onto her left side with a bolster pillow behind her back. NA-B stated R5's buttock was red from sitting so long, adding R5 also had a lot of wrinkles in her skin from sitting. NA-B stated the last time R5's adult diaper had been changed, or she had been repositioned was about 8:00 a.m. that morning. NA-B stated R5 needed special care because of the wound on her bottom and stated she R5 should be offloaded every two hours. NA-B stated it was hard to do every two hours because of the activities R5 attended. During an interview on 8/20/25 at 11:31 a.m., the director of nursing (DON) stated she went through camera footage and observed staff had not changed or repositioned R5 for more than four hours on 8/19/25. DON had interviewed licensed practical nurse (LPN)-A who had been on duty to determine if NAs reported any behaviors indicating R5 refused to lay down. There were no behaviors or refusals. DON stated R5's family wanted her at activities, but R5 should still be checked and changed and offloaded every two hours. DON stated on 8/19/25, staff had an opportunity to take R5 back to her room after chapel to change her, or before or during music-in-motion activity and offload before lunch. DON stated she had been working hard with staff to ensure R5 was offloaded and had implemented the will return clock outside of R5's room as a tactic to help remind staff to reposition and/or change R5's adult diaper. During an observation on 8/20/25 at 12:40 p.m., with DON, looked at R5's PU. DON pulled back the border adhesive dressing. DON described PU was circular shaped and the approximate diameter of a D-size battery. No drainage observed. Tissue around PU was skin colored. DON stated the PU waxed and waned in size. DON stated a wound provider assessed the wound monthly and an employed wound nurse assessed it weekly. This was verified with document review. Facility Pressure Ulcer Prevention Program policy, undated, indicated a resident admitted with a pressure ulcer would receive treatment and services to promote healing, pretention infection and prevent new pressure ulcers from developing. Facility Pressure Ulcer Management Program, undated, indicated if a resident had an order for a specific repositioning schedule, the resident would receive a will return clock, placed on the resident's door. Upon completion of repositioning, the nursing staff would turn the clock to the next time that repositioning is due so that all parties working with the resident would be aware of the turning schedule.

Based on observation, interview, and record review the facility failed to use appropriate infection prevention and control practices for 1 of 2 residents (R28) who was dependent on staff for pressure ulcer wound care. In addition, the facility to ensure a mechanical transfer lift was cleaned after resident use for 2 of 2 residents (R7 and R14) observed for infection control practices and proper infection prevention practices was observed when sorting soiled laundry. Findings include: R28's facesheet printed on 7/10/24, included diagnoses of pressure ulcer of the sacral region and urinary incontinence. R28's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R28 is cognitively intact, could understand and be understood. R28 required substantial assistance with most activities of daily living (ADL), including wound care. R28 was at risk for developing pressure injuries, had a pressure ulcer over a bony prominence, had one or more unhealed pressure injuries, indicated pressure ulcer care, and had no rejection of care. R28's Pressure Injury Care Area Assessment (CAA) dated 4/30/24, indicated R28 was at risk for skin breakdown related to immobility and urinary incontinence. R28 had a stage four pressure ulcer to coccyx, currently healing. R28 required assistance from staff for managing wound care. R28's Mobility CAA dated 4/30/24, indicated R28 required substantial/maximum assistance for all ADLs except eating. R28 was dependent on staff for toileting, dressing, and managing hygiene. R28's care plan with revised date of 8/21/23, indicated actual impairment to skin integrity related to healing stage four pressure injury on coccyx. R28's physician orders included the following: 1. 7/5/24: Cleanse wound with normal saline or wound cleanser, pat dry. Apply skin prep to peri wound skin and allow to dry. Sprinkle collagen powder (supports granulation tissue formation and debridement of wounds) into open wound or use collagen dressing packed gently into wound bed, apply thin layer of Triad Paste (helps promote skin healing) to help hold in powder and protect peri wound skin from maceration, cover with bordered foam adhesive dressing. Change every other day and as needed for healing stage 4 pressure ulcer. 2. 7/6/24: Triad Hydrophilic Wound Dress External Paste Wound Dressings, (helps maintain optimal wound healing), apply to coccyx/sacrum topically one time a day every other day for wound care and apply to coccyx/sacrum topically every 12 hours as needed for wound care. During observation on 7/10/24 at 7:16 a.m., licensed practical nurse (LPN)-A used R28's overbed table as a work surface as she opened dressing change supplies, setting the supplies on top of the packages they came in. LPN-A did not clean or disinfect, nor use a barrier between the table and the supplies. Further, LPN-A did not remove R28's personal items, including muffins in a Ziploc bag and water bottle off the overbed table before using it at a work surface for dressing change supplies. During observation on 7/10/24 at 7:40 a.m., the overbed table was not cleaned or disinfected prior to setting R28's breakfast tray on it after it being used as a work surface for a dressing change as evidenced by multiple water rings on the surface. During interview on 7/10/24 at 9:51 a.m., LPN-A stated the supplies she set out were placed on top of the opened packages, not directly on the overbed table. After further thought, LPN-A stated the table should have been cleaned before and after wound care. During interview on 7/10/24 at 10:13 a.m., the DON stated she expected staff to move everything off the overbed table prior to starting wound care and expected the overbed bedside table to be cleaned before and after wound care. Facility Dressing Changes policy updated on 6/13/11, indicated, all dressings must be handled in a safe and sanitary manner. 50764 Mechanical Lift Disinfecting R7's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R7 was cognitively intact, dependent on staff for toileting, required substantial/maximal assistance with transfers, used a wheelchair for mobility, and had diagnoses of hemiplegia (muscle weakness or paralysis on one side of the body) and reduced mobility. R7's care plan updated 4/19/24, indicated R7 was to transfer with a mechanical lift with toileting sling in and out of bed and a mechanical standing lift with two staff members for all other transfers. R14's face sheet printed on 7/10/24, indicated R14 had diagnoses of unspecified dementia (loss of cognitive functioning) and the need for assistance with personal cares. R14's quarterly MDS assessment dated [DATE], indicated R14 had severely impaired cognition, was dependent on staff for all transfers, and had diagnoses of dementia and Parkinson's disease (a disorder that affects movement). R14's care plan updated 4/15/24, indicated R14 required the assist of two staff with a full body mechanical lift for all transfers. On 7/9/24 at 8:58 a.m., nursing assistant (NA)-A removed a mechanical standing lift from R7's room and placed the mechanical lift near a wall in the hallway. NA-A was observed to walk down the hallway and no cleaning of the mechanical lift was observed. NA-A confirmed he should have disinfected the mechanical lift immediately after use and verified he did not disinfect the mechanical lift after use with R7. On 7/9/24 at 9:09 a.m., NA-B removed a mechanical lift from R14's room and placed it in room [ROOM NUMBER]. NA-B was observed to walk to a different hallway and no cleaning of the mechanical lift was observed. NA-B confirmed she did not clean the mechanical lift after use or while it was in room [ROOM NUMBER] for storage. On 7/9/24 at 10:20 a.m., licensed practical nurse (LPN)-A verified mechanical lifts should be cleaned immediately after each use with disinfectant wipes to prevent spread of infection. LPN-A further confirmed education was provided to staff regarding disinfecting mechanical lifts after each use at the time of hire and at staff meetings. On 7/9/24 at 2:07 p.m., with director of nursing (DON), also known as the infection preventionist, the DON stated it was the expectation staff were to clean mechanical lifts immediately after each use and between uses to prevent spread of infection. The DON stated mechanical lifts are shared among multiple residents. Facility policy titled Mechanical Lift Cleaning Procedure dated 7/10/24, indicated after use of a lift with a resident the handles and prongs will be wiped down following a two-minute contact time for disinfection. Laundry During observation and interview on 7/10/24 at 8:15 a.m., housekeeping (H)-A was observed in the laundry room where dirty and soiled laundry requiring laundering and clean laundry were both present. H-A stated soiled laundry comes into the laundry room through a central door and passes directly in front of the washing machines. H-A further stated soiled laundry was sorted in the same room near the washing machines and soaking of soiled laundry was completed in a double sink in the same room. H-A was observed dumping soiled laundry from a clear plastic bag with gloves on but without a gown. H-A stated she does not wear a gown while sorting soiled laundry. H-A verified this could cause contamination to clean laundry when removing from washing machines, dryers, and when folding. H-A stated she was not trained to wear a gown and was not facility practice to wear a gown when sorting dirty linens. On 7/10/24 at 8:22 a.m., environmental services (EVS)-A director confirmed soiled laundry and clean laundry were processed in the same room and verified laundry staff do not wear gowns to sort soiled laundry. EVS-A stated this could cause contamination to clean laundry. On 7/10/24 at 8:45 a.m., the DON, also known as the infection preventionist, confirmed laundry staff should be wearing a gown when sorting dirty laundry and soiled laundry should be sorted in a separate room to prevent the spread of infection. Facility Infection Prevention and Control Manual section titled Handling Soiled Linen dated 2019, directed staff to wear gown/apron if gross soiling of uniform is likely.

Based on observation, interview, and document review, the facility failed to ensure dietary staff followed appropriate infection control practices when handling cups during food service in the dining room. This had potential to affect all 47 residents who resided in the facility. Findings include: During an observation on 7/9/24 at 12:00 p.m., when filling cups with juice for residents seated at tables, dietary aide (DA)-A was observed holding the small, clear plastic tumblers by the rim of the cup with bare hands, and when setting the cup on the table. During an observation on 7/9/24 at 12:05 p.m., when filling beverages for residents, observed DA-B pour milk and orange juice into two small, clear plastic tumblers. With bare hands, DA-B set the cups on the table by holding the rim. During an observation on 7/9/24, at 12:07 p.m., when filling beverages for residents, observed DA-B pour coffee into a navy-blue thermal coffee mug and set it on a residents table by holding the rim of the mug. During an observation on 7/9/24 at 12:11 p.m., observed DA-A pour juice for a resident and set the cup on the table by holding the rim. During an interview on 7/9/24 at 12:26 p.m., dietary manager (DM)-C stated dietary staff received training at orientation on the proper way to hold cups when filling and serving. DM-C was informed of observations and stated staff should not hold cups by the rim due to potential contamination by their hands. During an interview on 7/9/24 at 12:27 p.m., both DA-A and DA-B stated they had training on the proper way to hold a resident's drinking cup when filling and serving. When informed of observations, both acknowledged they held cups by the rim and were aware they should not be due to potential infection control concerns. An orientation packet for DA-A indicated he signed an undated policy titled Dish & Utensil Handling on 10/12/23, which indicated: fingers would not be placed in or at the lip of contact surfaces of cups, glasses, and/or flatware. The same policy was signed by DA-B on 6/19/23. 50761

Based on interview and document review, the facility failed to offer/provide a summary of the baseline care plan to the resident and/or resident representative for 1 of 1 resident (R26) reviewed who were newly admitted . Findings include: R26's Admission Record printed on 7/10/24, identified an admitted [DATE], with diagnoses of sepsis (infection of the blood stream), cerebral infarction (stroke when a cluster of brain cells die when they don't get enough blood), and type 2 diabetes mellitus. R26's admission Minimum Data Set (MDS) assessment dated [DATE], identified R26 as having a brief interview for mental status (BIMS) score of 15 indicating the resident was cognitively intact. R26's required substantial to maximum assistance with activities of daily living, did not walk and used a wheelchair. R26 received insulin, antidepressant, antibiotic and antiplatelet agent 5 days. R26's baseline care plan dated 6/17/24, indicated R26 required staff assist of two and mechanical aid for transfers, and was able to eat independently after set up by staff. When interviewed on 7/8/24 at 2:15 p.m., R26 stated she never received a copy of her baseline plan of care and would like to have one so she could share it with her family. During interview on 7/9/24 at 9:11 a.m., R26 indicated she did have a care conference and some things about her care were discussed but was not offered or received a copy of her plan of care and would like to have a copy of it. When interviewed on 7/9/24 at 10:23 a.m., social worker (SW)-A indicated they did have a care conference where the care plan was discussed, but typically residents aren't given a copy unless they request it. SW-S was unsure who is responsible to ensure a copy of the plan of care is given to the resident. When interviewed 4/10/24 at 10:36 a.m., the director of nursing (DON) confirmed a copy of the baseline care plan was not being offered to the resident or a family member unless it was requested. When interviewed on 7/9/24 at 1:57 p.m., registered nurse (RN)-B, also identified as assistant director of nursing (ADON) and MDS coordinator, indicated she attended R26's care conference and confirmed the baseline care plan was not offered to R26 at that time. Facility Care Planning and Care Conference policy dated 8/28/17, included: -The facility will work with each individual resident and their families/designees to develop a plan of care that all are in agreement with. -An initial care conference, the resident and their party will work with nursing, dietary, social service and therapeutic recreation staff on their individual plan of care. Each of these staff will bring the initial care plan that was developed from interviews conducted to the initial care conference for a final review and acceptance from the resident and/or family/designee. -The resident has the right to review the plan of care and request/participate in changes to the plan of care.

Based on interview and document review, the facility failed to ensure a pre-admission screening and resident review (PASARR) II referral was completed upon a significant change in condition for 1 of 1 resident (R16) reviewed for PASARR. Findings include: R16's, face sheet identified she had an admitted [DATE], with a diagnosis of Parkinson's, dementia, and depression. R16's, 3/3/23, pre-admission screening and resident review (PASRR) identified R16 had Parkinson's and was not considered by the state to have a serious mental illness or intellectual disability or related condition. R16's, undated, current Diagnosis Report identified R16 received a new diagnosis of anxiety disorder on 6/06/23 and psychotic disorder with hallucinations on 6/06/23. R16's, 4/09/24, quarterly Minimum Data Set (MDS) assessment identified R16 had a severe cognitive impairment and no behaviors. R16 felt down, was depressed or hopeless 2 to 6 days and had taken antidepressants on a routine basis. R16's, 4/26/24, significant change (MDS) identified R16 had hallucinations, felt down, was depressed or hopeless 7 to 11 days, trouble falling or staying asleep or sleeping too much 12 to 14 days, feeling tired or having little energy 7 to 11 days, and trouble concentrating on things 12 to 14 days. Section A 1510 identified R16 had not been evaluated for Level II PASRR and did not have a serious mental illness or intellectual disability or related condition. R16's medical record lacked any indication that the State Mental Health Agency (SMHA) had been notified since the new onset of R23's mental illnesses for further evaluation and determination of need for specialized services. Interview on 7/10/24 at 9:38 a.m., with social services designee (SSD) stated the facility process was to discuss new admissions and verify completion of Level I screen but was unsure of the process for Level II screening. She agreed a Level II should have been completed for R16. Interview on 7/10/24 at 9:51 a.m., with director of nursing (DON) stated the facility had no process in place to ensure residents with a new qualifying mental illness diagnosis would receive a Level II screening. Interview on 7/10/24 at 10:10 a.m., with administrator stated the facility had no knowledge of when to determine a Level II screening would be required and have not had to complete one before. Review of undated, Mapleton Community Home Preadmission Screening policy identified required preadmission screening for all admissions admitted to a Medical-Assistance certified nursing facility. There was no mention of how the policy would refer any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition to the state mental health or intellectual disability authority for a Level II resident review.

Based on observation, interview and document review, the facility failed to ensure resident status was accurately identified in the Minimum Data Set (MDS) assessment for 1 of 1 resident (R40) reviewed for hospice. Findings include: R40's, undated medical diagnoses face sheet identified she had malignant neoplasm of the colon, malignant neoplasm of the tail of the pancreas, and mild intellectual disability. R40's, 6/11/24, . (name of local hospice agency) Hospice Open Orders identified she was on hospice services. R40's, 6/13/24, significant change Minimum Data Set (MDS) assessment identified R40 was moderately impaired section J, Prognosis: conditions or chronic diseases that may result in a life expectancy of less than 6 months was marked as yes. There was no mention of hospice services under section O. Interview on 7/10/24 at 9:42 a.m., with registered nurse (RN)-B who is the facility MDS coordinator, identified R40 was on hospice. Upon review of the significant change MDS on the PCC (Point Click Care) system online, RN-B confirmed section O was not coded accurately and would ensure to complete a modification of the data assessment. Interview on 7/10/24 at 10:03 a.m., with director of nursing (DON) and administrator both agreed the MDS should have been coded accurately. Review of 3/2019 MDS Accuracy Policy identified the facility would ensure to utilize the RAI Manual for accurate coding. In addition, the facility would investigate and modify coding errors found and submit them to the QIES (Quality Improvement and Evaluation) system.

Based on observation, interview, and document review, the facility failed to provide timely repositioning for 1 of 1 resident (R28) who was dependent on staff for repositioning and who had a pressure ulcer (PU) on her coccyx. Findings include: R28's facesheet printed on 7/10/24, included diagnoses of pressure ulcer of sacral region and urinary incontinence. R28's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R28 was cognitively intact, was dependent or required substantial assistance with most activities of daily living (ADL), including repositioning and toileting. R28 was unable to walk. R28 was at risk for the development of pressure ulcers and had one or more unhealed pressure ulcers. R28 did not have a turning/repositioning program and had no rejection of cares. R28's Care Area Assessment (CAA) for pressure ulcer dated 4/30/24, indicated R28 was at risk for skin breakdown related to immobility and urinary incontinence. R28 required substantial assistance with repositioning. R28 had a stage four pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) to coccyx, which was healing at the time of the assessment. R28 was receiving supplements to assist with wound healing/promotion along with utilizing a pressure relieving cushion in the wheelchair and pressure reducing mattress on bed. R28's Mobility CAA dated 4/30/24, indicated R28 required substantial/maximum assistance for all ADLs except eating. R28 was wheelchair bound and required two staff for transfers with use of a mechanical standing lift (also known as an EZ stand - an assist device that moves residents from one surface to another surface). R28 was dependent on staff for toileting, dressing, and managing hygiene. R28's pressure ulcer risk assessment (Braden Score) dated 6/24/24, identified R28 at low risk for the development of a pressure ulcer. R28's care plan with revised date of 8/21/23, indicated a healing stage four pressure ulcer on the coccyx. There were no interventions listed for repositioning or offloading. In addition, the care plan indicated R28 was frequently incontinent of bladder, would be free from skin breakdown, used disposable briefs and was to be checked for incontinence (no time frame was specified). Care plan with revised date of 10/27/23, indicated R28 required total assistance of two staff to use the toilet, using the EZ stand. R28's physician orders dated 5/5/23, indicated R28 was to lie down in bed for two to three hours per day. When R28 is in the wheelchair, reposition every two hours (stand in place for one minute was ok). During a continuous observation on 7/9/24 from 9:40 a.m. to 12:30 p.m., (2 hours 50 minutes) R28 was not repositioned in the wheelchair, offloaded, or toileted. During the observation period from 9:40 a.m. to 11:24 a.m., R28 was seating in her wheelchair in her room, watching TV. At 11:34 a.m., R28 was taken via wheelchair to the dining room for lunch. At 12:30 p.m., R28 remained in her wheelchair at the dining room table. During interview on 7/9/24 at 1:24 p.m., nursing assistant (NA)-B stated she was assigned to care for R28 that day and was aware R28 had a pressure ulcer on the coccyx. NA-B stated R28 should be off her bottom every couple hours and stated she had repositioned R28 that morning, however, was not able to say what time she had repositioned R28. During interview on 7/9/24 at 1:45 p.m., licensed practical nurse (LPN)-A stated she didn't think R28 had been laid down that morning and stated R28 should be repositioned or offloaded every two hours. During an observation on 7/10/23 at 7:20 a.m., observed LPN-A complete a dressing change to the PU on R28's coccyx. The wound was approximately the size of a nickel, pink and no drainage. LPN-A stated it was much improved and healing well. During interview on 7/10/24 at 10:09 a.m., the director of nursing (DON) stated R28 was to be repositioned every two to three hours and offloaded every two hours. The DON stated staff would offer toileting or use the EZ stand to offload pressure. The DON was informed of the continuous observation on 7/9/24, from 9:40 a.m. to 12:30 p.m., (2 hours 50 minutes) where R28 had not been repositioned or offloaded. The DON looked in the EHR (electronic health record) and stated when R28 was in the wheelchair she should be repositioned every two hours or could stand in place for one minute to offload. The DON was not aware R28 had not been repositioned and stated she expected staff to follow the physician orders for repositioning and offloading. Facility Pressure Ulcer Prevention Program policy revised date 5/24/11, indicated residents admitted with pressure ulcers would receive necessary treatment and services to promote healing. Pressure ulcer (stage 2-4 and unstageable): follow wound nurse recommendations.

Based on observation and interview, the facility failed to follow Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control (CDC) guidelines to prevent the spread of Covid-19, when during a Covid-19 outbreak, residents and visitors were observed not wearing appropriate personal protective equipment (PPE), specifically masks, for 9 of 41 resident (R2, R5, R8, R10, R14, R22, R24, R25, R35) not in transmission based precautions (TBP). In addition, the facility failed to offer hand-hygiene prior to meals for 4 of 4 residents (R2, R6, R8, R37). Lastly, the facility failed to ensure staff wore wear proper PPE specifically eye protection, when entering the room for 1 of 6 residents (R29) on TPB. This had the potential to affect all 47 residents who resided in the facility. Findings include: Upon survey entrance, on 9/18/23 at 11:30 a.m., observed signs to front doorway entrance indicating masks recommended due to positive Covid-19 as of 9/15/23. Staff noted wearing face masks at front desk, several unknown residents across from front desk in day room without face masks During an observation and interview on 9/18/23 at 4:02 p.m., noted hand sanitizer had not been immediately available outside resident rooms who were in TBP for Covid-19. The director of nursing (DON) stated the facility had made a conscious decision about that and staff were to use the hand sanitizer dispensers on the walls. The DON stated this was to prevent visitors from taking the bottles of hand sanitizer and was a safety measure for residents with dementia. In a hallway of 13 resident rooms, on OW (Old Wing), only 5 hand sanitizer dispensers were mounted on the wall and available to staff. There were no hand sanitizer dispensers in resident room. During an observation and interview on 9/18/23 at 5:19 p.m., observed a male visitor enter the facility without a mask. Nursing assistant (NA)-E stated visitors did not need to wear a mask. The visitor got further into the building and the DON informed him he needed a mask. The visitor returned to the vestibule of the main entrance and donned a mask. R10's facesheet printed on 9/21/23, included diagnoses of end stage renal disease, diabetes, and dementia. R10's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R10 was cognitively intact; could be understood and could understand others. R10's current care plan with last care plan review date of 8/16/23, did not include precautions for Covid-19, nor if R10 had been assessed for the ability to wear a mask. During an observation on 9/19/23 at 8:55 a.m., R10 was observed with no mask, waiting in a wheelchair next to the nurses station for transportation to dialysis. During an interview on 9/19/23 at 9:02 a.m., R10 had been outside waiting for transportation. R10 stated he had been aware there were residents in the facility who had Covid-19 but no one had informed him he should wear a mask. R10 stated he would wear a mask if asked to. During an observation and interview on 9/19/23 at 9:35 a.m., (NA)-F stated she had not been cleaning her hands immediately when exiting the rooms of residents in TBP for Covid-19. NA-F admitted there had been no hand sanitizer directly outside the room for staff to utilize. NA-F stated staff had to walk to the hand sanitizer dispensers mounted intermittently on the corridor walls, which were approximately 10-12 feet from resident rooms. R24's facesheet printed on 9/21/23, included diagnoses of dementia, asthma, and chronic kidney disease. R24's significant change MDS assessment dated [DATE], indicated moderately impaired cognition; could be understood and could understand others. R24's current care plan with last care plan review date of 8/16/23, did not include precautions for Covid-19, nor if R24 had been assessed for the ability to wear a mask. During an observation and interview on 9/19/23 at 11:00 a.m., activity aide (AA)-A escorted unmasked R24 from his room on the old wing through the facility to the activity room on the new wing. AA-A was aware the facility was in Covid-19 outbreak, adding I was told it was their decision if they wanted to wear them [mask]. AA-A stated she did not ask or encourage R24 to wear a mask and thought he could make a decision to wear a mask if asked. R2's facesheet printed on 9/21/23, included diagnosis of Parkinson's disease. R2's significant change MDS assessment dated [DATE], indicated R2 had moderately impaired cognition; could be understood and could understand others. R2's current care plan with last care plan review date of 5/17/23, did not include precautions for Covid-19, nor if R2 had been assessed for the ability to wear a mask. During an observation and interview on 9/19/23 at 11:30 a.m., trained medication aide (TMA)-A was observed escorting R2 via wheelchair from his room to the dining room without a mask. TMA-A stated she was aware of the Covid-19 outbreak, and stated residents did not need to wear masks outside of their room; they could if they wanted to. On 9/20/23 at 11:20 a.m., NA-D entered R2's room and assisted R2 from his recliner to stand. R2 used a walker and NA-D walked behind R2 in the hallway to the dining room R2 entered the dining room and was assisted by NA-D and seated in his wheelchair at the dining table. R2 was not offered a mask or offered to wash hands prior to exiting his room. On 9/20/23 at 11:25 a.m., NA-D confirmed the facility was in outbreak status and stated residents were not required to wear masks, but should wear a mask. NA-D confirmed R2 was not offered a mask. On 9/20/23 at 11:33 a.m., R2 was seated in a wheelchair in the dining room. R2 stated he was not offered to wash his hands prior to the meal and stated he would wash his hands when offered. R2 stated was not offered a mask would not wear a mask if not required. On 9/20/23 at 12:57 p.m., NA-D confirmed R2 was not offered to wash hand prior to dining and residents were expected to have hand hygiene prior to meals. R5's facesheet printed on 9/21/23, included diagnosis of cerebral vascular disease (a condition that affects blood flow to the brain). R5's annual MDS assessment dated [DATE], indicated moderately impaired cognition, could be understood, and could understand others. R5's current care plan with last care plan review date of 4/12/23, did not include precautions for Covid-19, nor if R5 had been assessed for the ability to wear a mask. During an observation and interview on 9/19/23 at 12:12 p.m., R5 was observed self-propelling in her wheelchair from the dining room to her room without a mask. In her room, R5 stated she was unaware anyone in the facility had Covid-19, and stated staff had not asked or encouraged her to wear a mask. R5 stated if they would have, she would wear a mask. 44630 R29's quarterly MDS assessment dated [DATE], indicated R29 was severely cognitively impaired, no rejection of care, required one person physical assist with dressing and personal hygiene, diagnoses included heart failure, Non-Alzheimer's Dementia, and localized edema (swelling). R29's progress note dated 9/16/23 at 9:30 a.m., indicated R29 was moved to room [ROOM NUMBER] r/t (related to) cold symptoms and direct exposure to someone that tested positive for COVID 19. On 9/19/23 at 7:47 a.m., NA-B donned a gown, gloves, and N-95 mask and entered R29's room, without eye protection. The wall outside of R29's room two signs were posted one sign indicated contact precautions and the other sign indicated droplet precautions. The signs indicated details for PPE and included eye protection. On 9/19/23 at 8:15 a.m., NA-B stated she assumed R29 was on contact precautions and would not need to wear eye protection. No garbage was observed outside R29's room to discard dirty PPE. On 9/19/23 at 8:22 a.m., the DON confirmed R29 was on droplet precautions and confirmed staff had not worn proper PPE when protective eye wear was not worn. R14's quarterly MDS assessment dated [DATE], indicated no rejection of care, independent with bed mobility, transfer, locomotion and required one person physical assist with dressing and personal hygiene; diagnoses included hypertension (high blood pressure) and Alzheimer's disease. On 9/19/23 at 11:30 a.m., R14 was observed in the hallway and walked to the dining room, R14 stated he had not been asked or educated by staff to wear a mask. R14 stated would wear a mask if offered a mask. R6's quarterly MDS assessment dated [DATE], indicated two person physical assist with bed mobility, toilet use, and one person physical assist with personal hygiene; diagnoses included non-Alzheimer's dementia, and hemiplegia (paralysis of one side of body). On 9/20/23 at 11:34 a.m., R6 was in the dining room and was eating her meal, and stated she was not offered to wash hands and would if offered. On 9/19/23 at at 8:42 a.m., during an interview with the DON and administrator stated the residents in the facility who were in TBP precautions at the facility were in droplet precautions, and expected staff to wear proper PPE that included gown, glove, N95 mask, face shield and/or goggles. The administrator and DON stated staff were expected to discard the N95 mask when the room was exited and change into a new clean mask. The administrator and DON confirmed a garbage was not outside of residents' room who were on droplet precautions to discard the mask. 45417 R22's face sheet printed on 9/19/23, included diagnoses of hemiplegia/hemiparesis (paralysis of one side of body), tobacco use, heart failure (HF), oxygen dependence, cerebral infarction (stroke), and type 2 diabetes mellitus (DM)- abnormal blood sugars). R22's annual MDS assessment dated [DATE], indicated R22 had intact cognition, could be understood, and could understand others. R22's current care plan, printed on 9/19/23, did not include precautions for Covid-19, nor if R22 had been assessed for the ability to wear a mask. During an observation and interview on 9/18/23 at 12:32 p.m., R22 indicated he came out of room for meals, occasionally to participate in activities, and to go outside to smoke cigarettes. R22 stated he was not exhibiting any signs or symptoms (s/s) of Covid-19 at time, was aware of other residents on unit positive for Covid-19. R22 indicated had not been offered face mask when out of room in common areas, would wear face mask if had to, but preferred not to, but had not been offered face mask per staff. R25's face sheet, printed on 9/20/23 included diagnoses of heart failure (HF), kidney disease, chronic obstructive pulmonary disease (COPD)-lung disease), and history of Covid-19 10/20. R25's quarterly MDS assessment, dated 8/31/23, indicated R25 was cognitively intact, could be understood and could understand others. R25's current care plan, printed on 9/20/23, did not include precautions for Covid-19, nor if R25 had been assessed for the ability to wear a mask. During observation and interview on 9/18/23 at 1:02 p.m., R25 indicated she came out of room for meals and to participate in activities, stated she was not exhibiting any s/s of Covid-19 at time, was aware of other residents on unit positive for Covid-19, indicated had not been offered face mask when out of room in common areas, would wear face mask if offered. Later in survey, on 9/19/23, R25 tested positive for Covid-19 and was isolated to room. R37's admission MDS assessment, dated 6/27/23, indicated R37 had intact cognition, could be understood and understands others, and required extensive assist of 1 staff for personal hygiene cares. MDS assessment included diagnoses of HF, renal insufficiency, arthritis (joint inflammation), and anxiety. During an observation and interview on 9/20/23 at 7:34 a.m., R37 was observed sitting at a dining table, no hand sanitizer/wipes present to any dining tables in dining room. R37 indicated dining staff do not offer hand sanitizer/wipes before meals, nursing staff occasionally encouraged residents to wash hands prior to meals, typically only after toileting cares would nursing staff encourage/assist with handwashing. R37 stated would hand sanitize if offered per staff. R8's quarterly MDS assessment, dated 8/8/23, indicated R8 had moderately impaired cognition, could be understood and understands others, and was dependent upon staff for personal hygiene cares. MDS assessment included diagnoses of dementia, seizures, anxiety, bipolar disorder (mental disorder), and schizophrenia (mental disorder). While observed and interviewed on 9/20/23 at 11:25 a.m., NA-F was noted to push R8 in wheelchair from 200-unit activity room to dining room. NA-F set R8 at dining table, NA-F placed a clothing protector on R8, NA-F walked away from R8 at table. The table R8 was sitting at had no hand sanitizer/wipes available, R8 stated would hand sanitize if offered per staff. During an interview on 9/20/23 at 11:27 a.m., NA-F indicated had brought R8 directly from 200-unit activity room to dining table. NA-F confirmed did not offer R8 hand hygiene prior to meal, stated typically only offers/assists residents with hand hygiene after toileting cares. NA-F indicated dining tables used to have hand sanitizer/wipes available for resident hand hygiene prior to meals, no longer available and unsure why, stated hand sanitizer/wipes should be reimplemented. While interviewed, on 9/20/23 at 12:01 p.m., the DON indicated it was her expectation for staff to offer/assist residents with hand hygiene needs, especially after toileting and prior to meals. The DON indicated hand hygiene in dining rooms was one of current performance improvement project (PIP) and quality assurance performance improvement (QUAPI) plans, stated trying to find safest product to use for resident hand hygiene prior to implementing, was continuing to work on plan. When interviewed on 9/21/23 at 10:10 a.m., the DON confirmed providing education and masking of residents during an outbreak was expected of staff. The facility Infection Prevention and Control Manual- Interim policy for Suspected or Confirmed Coronavirus (Covid-19) undated, indicated policy of this facility to minimize exposures to respiratory pathogens, promptly identify residents or healthcare personnel with signs or symptoms of Covid-19 and implement interventions based upon Federal/State/Local recommendations to prevent and/or mitigate the spread of Covid-19; consisted of hand hygiene using alcohol based hand sanitizer before and after all patient contact, contact with infectious material and before and after removal of PPE including gloves- ensure ABHR is accessible in all resident-care areas including inside and outside resident rooms. The facility Infection Prevention and Control Manual- Standard Precautions- Hand Hygiene policy dated 2019, indicated appropriate hand hygiene is essential in preventing transmission of infectious agents. Purpose: to cleanse hands to prevent the spread of potentially deadly infections, to provide a clean and healthy environment for residents/staff/visitors, to reduce the risk to the healthcare provider of colonization or infections acquired from a resident. Hand hygiene (HH) (e.g., hand washing and/or alcohol based hand rub (ABHR)) should be completed when hands are visibly soiled, after caring for a resident with known or suspected infections during an outbreak, before eating, and after using the restroom. The facility educational sign per CDC recommendations, Use of Personal Protective Equipment (PPE) when Caring for Patients with Confirmed or Suspected Covid-19 dated 6/3/20, indicated before caring for patients with confirmed or suspected Covid-19, healthcare personnel (HCP) must: receive comprehensive training on when and what PPE is necessary, how to don and doff PPE, limitations of PPE, proper care, maintenance, and disposal of PPE; must demonstrate competency in performing appropriate infection control practices and procedures; doffing method: Remove gloves, remove gown and dispose in trash receptacle; HCP may now exit patient room, perform hand hygiene, remove face shield or goggles, remove and discard respirator- do not touch the front of respirator, perform hand hygiene, put on new mask.

Based on observation, interview, and document review, the facility failed to ensure activities of daily living (ADLs) were provided, including shaving for 1 of 4 residents (R4) reviewed, who needed staff assistance to maintain good personal hygiene. Findings include: R4's quarterly Minimum Data Set (MDS) assessment, dated 7/5/23, indicated R4 had severely impaired cognition and was visually impaired, required extensive assistance from 1 staff for personal hygiene needs. R4's care plan, printed on 9/21/23; indicated R4 had ADL self care performance deficit related to dementia (brain disorder causing impaired memory/thought process) and required 1 staff to assist with personal hygiene needs. During an observation, on 9/18/23 at 1:45 p.m., R4 was observed to have short, white, stiff facial hairs, approximately 0.5 centimeters (cm) in length; present to chin and surrounding sides of upper lip. While interviewed, on 9/18/23 at 1:53 p.m., R4's family member (FM)-C indicated R4 always liked to appear neat and well-groomed, did not like longer facial hairs present. FM-C noticed occasionally when visiting R4 presence of facial hairs to chin and lips, FM-C would assist R4 with shaving cares to remove unwanted facial hairs. During an observation and interview, on 9/19/23 at 11:37 a.m., trained medical assistant (TMA)-B, also known as nursing assistant (NA), noted presence of facial hair to R4's chin and lips. TMA indicated awareness R4 did not like facial hair present and required staff assistance with shaving to maintain good personal hygiene. TMA-B stated R4 had a bath earlier in morning, and indicated staff should have noticed longer facial hair to R4's chin and lips, and removed facial hair. While interviewed, on 9/19/23 at 12:39 p.m., the director of nursing (DON) indicated R4 needed staff assistance for personal hygiene needs, including shaving. The DON stated residents could be provided shaving cares anytime, and indicated it was her expectation for staff to be removing resident's facial hair anytime noted or per resident request when providing daily routine cares. The facility ADL Performance Policy undated, indicated ADLs will be completed by nursing staff as directed by the individual care plan. ADLs will be completed in the AM and PM and as needed throughout the day, dependent on resident needs.

Based on observation, interview, and document review, the facility failed to monitor ongoing safe smoking practices, and failed to provide an environment and assistive smoking devices to prevent accidents for 1 of 1 resident (R22) reviewed for smoking. Findings include: R22's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R22 had intact cognition, displayed no behaviors, required extensive assist of 2 staff with transfers, extensive assist of 1 staff for locomotion on/off unit, had impairment of both lower extremities and left upper extremity, used a wheelchair for mobility, and was a tobacco user. R22's face sheet printed on 9/19/23, indicated diagnoses including hemiplegia/hemiparesis (paralysis of one side of body), tobacco use, heart failure (HF), nuclear cataracts (cloudy vision), anxiety, oxygen dependence, morbid obesity, reduced mobility, major depressive disorder (mood disorder), cerebral infarction (stroke), and type 2 diabetes mellitus ((DM)- abnormal blood sugars). R22's order summary report printed on 9/19/23, indicated orders for no smoking until off oxygen- if resident refuses, remove oxygen 15 minutes before going outside and document refusal. R22's care plan printed on 9/19/23, indicated R22 was a vulnerable adult, would not be able to remove self from harm, was a current smoker, had impaired vision, used supplemental oxygen, was not able to walk- could move wheelchair independently using right leg. Interventions for R22 included for staff to ensure removal of oxygen 15 minutes prior to R22 smoking for safety, ensure R22 wore a smoking apron when outside smoking, and complete smoking safety evaluation yearly and as needed (PRN). R22's smoking assessment completed on 8/9/23, indicated R22 did not have a visual deficit or dexterity problem, smoked 10+ cigarettes per day during morning/afternoon/evening hours, could light own cigarette, needed adaptive equipment- smoking apron while smoking, and plan of care used to assure resident safe while smoking. During an interview on 9/18/23 at 12:32 p.m., R22 indicated he was a smoker, needed to go to nursing station to get cigarettes and lighter when wanting to smoke as nursing staff kept cigarettes and lighter in a locked area, stated he is independent of smoking, and had not had any smoking accidents since facility admission. R22 indicated for smoking safety, he takes off supplemental oxygen 30 minutes before smoking and wears an apron during smoking activity. While observed and interviewed on 9/19/23 at 9:08 a.m., R22 was sitting in his wheelchair at a table outside near facility's front entrance smoking a cigarette, smoking apron observed to be in place at time. While smoking, R22 was visualized flicking ashes from cigarette onto cement ground, as no ashtray was present at table, smoking receptacle was across from R22, approximately 25 ft away. A piece of Kleenex tissue was lying on cement ground next to right back wheel of R22's wheelchair, small amount of cigarette ashes covering top of Kleenex tissue. When R22 was finished smoking cigarette, he rolled cigarette, just under burning tip of cigarette, with first and second fingers of right hand back and forth until the burned tip of ash dropped onto cement, extinguishing cigarette. R22 then folded cigarette butt with right hand and laid on top of plastic table sitting at. R22 observed to sit in wheelchair at table for a few minutes, picked up cigarette butt lying on top of plastic table, and propelled self in wheelchair using right foot over to smoking receptacle, placed cigarette butt into receptacle container, then propelled self into facility entrance door. Cigarette ashes and Kleenex tissue left remaining on cement ground. During an interview on 9/19/23 at 9:34 a.m., trained medical assistant (TMA)-B, also known as nursing assistant (NA), indicated awareness R22 was independent of smoking, had to take oxygen off prior to smoking, needed to wear a smoking apron during smoking activity. TMA-B indicated awareness of smoking receptacle outside near front of facility entrance, was unaware of any smoking assistive devices at table outside of front facility entrance door. TMA-B stated was unaware of R22 extinguishing burning cigarettes with his fingers due to no ash tray available at table, indicated residents' safety to smoke independently and smoking assistive device needs was managed by social services (SS) or the director of nursing (DON). While interviewed on 9/19/23 at 9:37 a.m., SS-A indicated residents' safety to smoke independently was determined based on smoking safety assessments completed by charge nurse on each unit, any changes in residents' smoking safety assessment should be brought to the DON's attention, as SS-A stated she does not assist in management of smoking safety process. During an interview on 9/19/23 at 9:42 a.m., the DON indicated residents' smoking assessments could be completed by charge nurse on resident unit, activities coordinator, and SS. The DON indicated R22 was safe with smoking independently, just recently had a smoking assessment completed, no changes to his ability to smoke safely and independently. The DON stated unawareness if ash trays were available at table outside of facility's front entrance for residents to smoke at, stated there was a smoking receptacle within area. The DON initially indicated if residents were smoking at table outside of facility's front entrance, it was acceptable for residents to flick cigarette ashes on cement ground if ash tray was not available, later DON confirmed during interview debris lying on cement ground could potentially cause an accidental fire if cigarette ashes encountered, and stated residents should be using an ash tray or smoking receptacle when smoking. The DON indicated unawareness no ash tray available at table outside front building entrance,and R22 was extinguishing burning cigarettes with his fingers. The DON confirmed R22's extinguishing a burning cigarette with his fingers posed a risk for injury. The DON stated a smoking safety reassessment would be completed with R22 to determine his ability to smoke safely unsupervised, and would discuss with administrator implementation of covered ash trays to be placed at table outside front facility entrance to allow residents to smoke at and prevent accidents from occurring. The facility Mapleton Community Home Smoking Policy dated 5/23, indicated designated smoking area is located outside the building by the main entrance, smoking evaluation must be completed by the charge nurse prior to resident smoking, smoking privileges may be revoked for resident safety at the discretion of Mapleton Community Home. Facility policy for accidents/hazards was requested, not received.

Based on observation, interview and document review the facility failed to implement interventions developed to reduce elopements risks for 1 of 3 residents (R1) reviewed for elopements Findings include: R1's undated admission record Face Sheet indicated R1 was admitted to the facility on [DATE], with diagnoses of dementia, Alzheimer's disease, [CONDITION(S)] disease, and urinary tract infection ([CONDITION(S)]). R1's Base Line Care Plan completed 7/29/21, by licensed practical nurse (LPN)-A, identified R1's Cognition Assessment as confused and was identified as an elopement risk. Behavior Concerns included confusion, wandering and elopement risk; documented Alarms and Restraints were identified as WanderGuard (device placed on person or persons' mobility device which alarms when person passes through exit threshold to alert staff of potential safety concern) ; and Physician Orders indicated to see current treatment administration record (TAR). R1's Safety Risk Evaluation dated 7/29/21, identified LPN-A documented R1 tried to elope from the facility twice since admission to the facility, R1 was noted to appear confused and looking for his truck and tractor and wandering into other resident rooms. R1's Elopement Risk Assessment Form completed on 7/29/21, by registered nurse (RN)-A, identified the summary of the assessment question(s), is the resident at risk for elopement and is the care plan updated were not completed. The facility Admission Checklist dated 7/29/21, identified the Elopement Risk Assessment Form as completed. R1's Progress Note(s) identified the following: - 7/29/21, at 7:35 p.m. identified R1 as very confused and wandering into other resident rooms; made multiple comments about needing to leave to find his pickup and tractor; and attempted unsuccessfully to exit the facility twice through emergency exit doors. - 7/31/21, at 3:56 p.m. R1 sustained a fall from his wheelchair and stated he was just looking for his truck. - 7/31/21, at 10:00 p.m. indicated R1 was impulsive and forgetful during the shift. R1 had the capability to propel himself down the halls and entered a resident room with two female residents. R1 was described as confused and the female residents went to find a nurse for assistance. The responding nurse indicated R1 displayed confusion, asking what time he had to be at the funeral and what his wife should wear. - 8/1/21, at 1:12 p.m. indicated R1 was wandering the halls most of the shift, propelling himself in his wheelchair. R1 made attempts to enter other resident rooms but was easily redirected. R1 stated he should be working here and is looking for his wife. - 8/3/21, at 6:15 p.m. (late entry) identified an unidentified nurse in the office adjacent to north exit heard the door release being depressed and witnessed R1 push open the door and begin to wheel himself into the vestibule. R1 was assisted back into the building. The nurse informed the unidentified charge nurse and unidentified nursing assistant registered (NA) R1 was exit seeking. The maintenance director (MD) was contacted by the nurse and asked if the north door could be locked. MD replied R1 needed a WanderGuard. The nurse obtained a WanderGuard device but could not locate R1. The nurse announced over the walkie for staff to cease current tasks and assist in locating R1. As staff proceeded to look for R1, it was reported there were people at the main front door. The people at the front door reported there was a gentleman outside and wondered if he is a resident. Staff proceeded to the north exit door where neighbors, from across the street, were assisting R1 in his wheelchair back to the north door. The neighbors stated they witnessed R1 wheel to the end of the sidewalk of the north entrance, over the curb, and tipped out of the wheelchair. R1 was brought inside the facility and a WanderGuard was applied. R1's medical record lacked evidence R1's WanderGuard was placed prior to eloping from the facility on 8/3/21. During an interview on 8/10/21, at 11:23 a.m. the director of nursing (DON) stated the facility utilized WanderGuard's to prevent residents from eloping. The Base Line Care Plan and Elopement Risk Assessment were required to be completed upon resident admission. The elopement risk was determined by the Base Line Care Plan which indicated R1 required a WanderGuard, but it was not placed. The elopement risk was screened on admission and should have been placed on R1 at that time; however,the facility did not place it until yesterday 8/9/21. R1 was in the hospital for [CONDITION(S)] issues and was not sure what happened as they thought they had a good process in place for admissions. During interview on 8/10/21, at 11:57 a.m. RN-A stated R1 was an elopement risk and she must have forgotten to answer the questions on the elopement risk questionnaire of, is the resident at risk for elopement and is the care plan updated. RN-A stated she only completed the Elopement Risk Assessment Form on 7/29/21, and did not look at the Base Line Care Plan. During interview on 8/10/21, at 12:45 p.m. LPN-B stated LPN's could complete the Baseline Care Plan, but a registered nurse had to complete all the rest of the assessments. Once the Base Line Care plan was completed it was placed in a 3-ring binder at the nurse's station. The 3-ring binder was available for all staff so they know what cares should be completed for the resident. Once the Comprehensive Care Plan was completed, the Base Line Care Plan was placed in the resident's paper chart, and staff access the Comprehensive Care Plan in PCC. During interview on 8/10/21, at 1:04 p.m. R1 stated if he wanted to go outside, he can just go. He does not need anyone to go with him. R1 could not recall that he went outside and fell out of his wheelchair. During interview on 8/10/21, at 1:38 p.m. LPN-A started the beginning of the admission process but had to hand it off due to short staffing. LPN-A indicated reading the hospital summary for R1 it described R1 was confused and indicted he was at risk for elopement. The completed Base Line Care Plan was put in a binder in the nurse's station for everyone to see. Further, R1 should have had a WanderGuard placed on admission, but the evening shift was busy and short staffed, and no upper management was in the facility to obtain a WanderGuard, so it was passed off to the unidentified night nurse. During observation on 8/11/21, 10:02 a.m. seven WanderGuard bracelets with numerous attachment bands were in a small plastic box, just inside the assistant director of nursing (ADON) office. During an interview on 8/11/21, at 11:16 a.m. ADON stated WanderGuard bracelets are always available in her office and during off hours, the key to her office was in the Medication Storage Room. Further, all staff were previously educated on obtaining the key because of other medical supplies kept in her office. Facility provided staff records lacked evidence of staff education regarding baseline care plans upon admission, elopement protocols, WanderGuard device locations/access, or re-education on assessment completion. The facility indicated they did not have an elopement policy.

Based on observation, interview and document review, the facility failed to comprehensively re-evaluate and supervise residents who experienced reoccurring falls for 3 of 7 residents (R40, R50 & R15), reviewed for accidents. R40 sustained actual harm, a right femur fracture as the result of a fall on 4/3/18. Findings include: The most current [DIAGNOSES REDACTED]. R40's Brief Interview for Mental Status (BIMS, a cognitive assessment), indicated flucating cognition. On 12/11/17, R40's BIMS score was identified as 11/15 (moderate impairment). A BIMS score was identified as 15/15 on 3/6/18 (fully intact cognition). The most recent quarterly Minnimum Data Set (MDS) assessment dated [DATE], indicated a BIMS score of 9/15 (moderate cognitive impairment). According to a comprehensive Care Area Assessment (CAA), completed 1/2/18, R40 was identified as at risk for falls, requiring interventions. R40's care plan identified a focus area including: R40 had an actual fall with serious injury, poor balance, unsteady gait. The goal was identified to include: will resolve without complication by review date. Interventions for falls included: 1.) Encourage/remind R40 to call for assistance before she transfers. 2.) Keep call light within reach. 3.) Sign placed to remind to call for assistance before getting up; 4.) Physical therapy (PT) consult for strength and mobility. Additional care plan focus areas included: Activities of Daily Living (ADL) self care performance deficit related to (r/t) confusion, does not remember to use wheelchair brakes; short of breath and becomes entangled in the tubing when transferring self with the oxygen on; Often forgets to call for assistance with transfers. Interventions included: 1.) Physical Therapy(PT)/Occupational Therapy (OT) evaluation and treatment as per MD (medical doctor) orders; 2.) Encourage to use the call light for assistance with all transfers; 3.) EZ stand lift (mechanical lift device) and 2 staff assist with transfers. Review of R40's incident reports and progress notes since (MONTH) (YEAR), indicated R40 had a history of [REDACTED]. The facility failed to comprehensively assess the falls in order to identify predisposing/causative factors so individualized preventative interventions could be developed. Falls included: 12/11/17, 3:30 p.m. R40 was in the bathroom and fell to the floor and was lying on her right side. Abrasions/skin tears to right (Rt) arm, and Rt lower extremity, c/o of rt hip pain. The nursing progress note from 12/11/17 included: Resident in the bathroom changing her jeans; slippers off, jeans off and pushed the door open and fell . Skin tears down the right arm, a bruise on her right forearm and write wrist skin tear with a bruise. Range of motion to all extremities with moderate to severe pain in righ thip. A the same time, (physician) called in regards to her recent left back and left abdomen pain. orders received to send to (local hospital) for eval (evaluation) and treat (treatment) of both issues. A follow up nursing progress note indicated, Called (local hospital) at 2040 (8:40 p.m.) for update on resident. Resident had a CT (computed X-ray Tomography) scan from head to toe and impression was normall. All blood work was fine. Resident was up walking, felt dizzy then retried and felt fine. She will be returning to the facility via ambulance. Incident Report follow up included: Measures/Interventions to Prevent Further Accidents: Continue current plan of care. 12/12/17, 2:50 p.m. R40 found lying on the floor of her room. Resident was complaining of right hip pain rated at 10/10 (10 being most severe pain). R40 was transferred to the emergency room (ER) where X-ray revealed a right [MEDICAL CONDITION] and the need for surgical repair. The corresponding nursing progress note from 12/12/17 at 3:22 p.m. included: Notified taht resident had self transferred and was hoyered from floor. Resident c/o (complained) tailbone, butt and right hip and leg hurting. Resident has hand holding her lower back and abdomen while laying in bed. C/o pain 10/10. Rec'd (received) orders to send to (local emergency room ) for eval/treatment via ambulance. An additional progress note indicated the local hospital had been contacted for an update, and staff were informed the reisdent had a right [MEDICAL CONDITION] with surgery requqired. Subsequent notes indicated R40 returned to the facility on [DATE], and care plan interventions were updated to include reminding R40 to use her call light and to ask for assistance. No additional monitoring and/or interventions were indicated. 1/2/18, 6:30 p.m. R40 was heard yelling for help and found sitting on the floor in front of her recliner. The resident indicated she was self transferring and didn't know what had happened. The call light was in reach, but had not been activated. No injury was noted. An interdisciplinary (IDT) meeting was held on 1/3/18, with an intervention identified to increase frequency of visual checks to every hour. However, there was no documentation initiated to confirm the hourly visual checks were conducted. 1/7/18, 5:20 a.m. A nursing progress note indicated R40 was seated on the floor and indicated she was going to her closet for clothes, and slid out of her wheelchair. R40 had further stated she had decided to attempt to get to the door after she realized she could not get back up. The incident report indicated an IDT meeting was conducted 1/8/18, and indicated the team had spoken with the resident to remind her about asking for assistance before walking out of room. In addition, the IDT recommended a new intervention to conduct every 15 minute visual checks. Documentation was provided of visual checks from 1/8/18 at 2:00 p.m. until 1/10/18, at 2:15 p.m. The resident's record indicated the resident was hospitalized for [REDACTED]. Upon return to the facility on [DATE], the frequent visual checks were no longer in place, and no additional monitoring for falls was instituted. In addition, no fall assessment was completed after the hospitalization . 2/2/18, 5:15 p.m. R40 was observed sitting on the floor next to her recliner and stated, she was just getting up and her legs didn't hold. The nursing progress note indicated the residetn was complaining of pain in her right hip rated as 5/10 (10 greatest pain). The notes indicated R40 was transfered from the floor to a recliner by a hoyer lift. A call was placed to the on-call physician who ordered a transfer to the local hospital for evaluation. The progress notes indicated the resident was returned to teh facility that same evening, and that no fracture or injury was identified in the emergency room . A post fall IDT meeting 2/5/18 indicated Measures/Interventions to prevent Further Accidents: Continue current plan of care. A nursing progress note, dated 2/5/18 indicated R40's niece called expressing concerns about repeated falls, and a sign was placed in R40's room to remind R40 to ask for help before trying to transfer herself. 2/12/18, at 10:10 p.m. staff heard a loud noise, after which R40 was heard yelling and was found sitting on her bottom on the floor in front of her recliner. R40 stated she wsa trying to get a Kleenex from her nightstand. Documentation on the report with rspect to contributing factors for the fall indicated: Unaware of safety, transfers self and does not use call light, she was given a touch pad call light (one that is more easily activated). A subsequent IDT meeting was held on 2/13/18, team discussion notes indicated: impulsive, forgetful about recent fracture and repair, PT/OT completed. Interventions: Continue frequent visual checks-offer assistance if looking restless. 2/16/18, at 8:15 p.m. R40 was heard yelling, help, I fell , and was found lying on her back on the floor. The call light had not been activated. R40 was not able to recall what she was doing that resulted in the fall and was not able to recall if she had hit her head. The subsequent IDT meeting, held on 2/19/18 team discussion notes indicated: cares being met; impulsive. Measures/Interventions put into place included: hourly checks. Documentation in R40's medical record indicated hourly visual checks were completed from 2/16/18 at 11:15 p.m. - 2/20/18, at 8:20 a.m., then discontinued. 3/1/18, at 8:45 p.m. R40 was heard yelling, help me, and was found sitting on the floor but did not know what she needed or why she had fallen. Immediate actions indicated to prevent falls on the accident report indicated: ever hour safety checks started. Review of R40's medical record indicated the hourly checks were documented as starting 3/1/18, at 9:00 p.m. - 3/3/18, at 7:00 p.m., then discontinued. An IDT meeting related to this fall dated 3/2/18 indicated under team discussion notes: history of falls, working with PT/OT; forgetful. Interventions to prevent further accidents included: Continue current plan of care. 3/9/18, at 10:30 a.m. R40 was witnessed attempting to stand from recliner. R40 stated her oxygen tubing caught on the foot rest and she fell to a sitting position on the floor. R40's call light had not been activated and R40 was unaware of why she had stood or where she was attempting to go. The subsequent IDT meeting on 3/12/18 indicated measures/interventions to prevent falls indicated: Continue current plan of care. 3/13/18, at 8:00 p.m. R40 was witnessed by a nurse (unidentified) standing up from recliner and attempting to transfer to her wheelchair, her breaks on the wheelchair were not locked resulting in the chair rolling away from R40, and fell to the floor. A subsequent IDT meeting held on 3/14/18 indicated interventions to prevent further accidents included: Moving to room closer to desk and anti-rollback breaks on w/c. 4/3/18, at 3:50 p.m. R40 was heard yelling, help me, and was found sitting on the floor. R40's call light was indicating second request (indicating it was the second time the light had been activated for assistance) when NA (unknown) entered the room. R40 was not sure why she had stood up or where she was attempting to go. R40 was complaining of right arm and elbow pain in addition to right hip pain rated at 10/10. A nursing progress note, dated 4/3/18 indicated R40 was transported to ER for evaluation at 6:51 p.m., and on 4/6/18, nursing progress notes indicated she returned to the facility at 3:32 p.m. The note further indicated, Resident is to be toe touch weight bearing as fracture could not be fixed; non-displaced [MEDICAL CONDITION] acetabular fracture. Documentation of an IDT meeting on 4/4/18 indicated: call light on-assistance provided between first and second request. Interventions to prevent further accidents included: Continue to toilet frequently and work with therapy. Visually monitor resident for restlessness. 4/7/18, at 2:05 p.m. R40 heard yelling and was found lying on her left hip on the floor. R40 stated she was trying to reach for her tranfer belt which was on her bed and way out of reach. R40's call light had not been activated. New bruising was noted on the underside of her left wrist. Documentation of an IDT meeting held on 4/9/18 indicated: frequent fall history; recent hospital stay, was recently viewed in chair by nurse. Interventions to prevent further accidents included: Discuss with family potential referral to a memory care unit, and the possibility of use of a recliner in the hallway instead of in R40's room to keep less secluded. During observation on 4/16/18, at 3:14 p.m., R40 was seated in her recliner with the foot rest elevated and was c/o feeling tired. R40 was located beside the window and the privacy curtain was pulled between her bed and the resident in the bed closest to the door. Therefore R40 was not visible from the hallway. During observation on 4/17/18, at 8:39 a.m. R40 was observed seated in her wheelchair being transported from the dining room to her room, where two staff utilized an EZ stand lift to transfer R40 from her w/c into the recliner located in her room. At 10:15 a.m., R40 remained in her recliner, wrapped in a blanket sleeping. During an observation 4/17/18, at 12:30 p.m. R40 was in her room and was speaking with a visitor. The visitor was overheard telling R40 she had to wait and have help with transfers. The privacy curtain between R40, on the window side of the room, and her roommate was pulled so that only R40's lower legs were visible from the door. On 4/18/18 at 11:30 a.m., R40 was transferred from the recliner to w/c with the assist of two and the EZ stand lift and transported to the dining room for the noon meal. During observation on 4/19/18 at 7:30 a.m., R40 was sleeping in her recliner in her room, with both feet resting on the floor. At 8:30 a.m. two staff transferred R40 from the recliner to her wheelchair and transported her to the dining room for breakfast. At 9:00 a.m., R40 was back in her room seated in the recliner sleeping. During observation from 9:00 a.m. - 10:15 a.m., R40 remained in her recliner in the room with feet elevated and the room curtain partially pulled. R40's feet were visible from the door of the room however, the privacy curtain blocked any view of the resident's chair from the hall. During interview on 4/18/18 at 1:32 p.m., the director of nursing (DON) verified the only Safety Risk Assessment (facility assessment used to determine falls risk and appropriate strategies to manage falls) completed for R40 was dated 1/2/17. The DON verified this assessment was only completed at the time of initial admission to the facility. At the time of R40's original admission when the 1/2/17 assessment was completed, R40 did not have a history of falls. During an interview on 4/18/18 at 3:02 p.m., registered nurse (RN)-A and RN-B stated R40 was transferred with the use of an EZ stand and her call light was kept within reach. However, they said R40 frequently called out for assistance rather than using the call light. Both RN-A and RN-B stated staff frequently walked by R40's room, but there was no specific time frequency for safety checks. They also verified R40 was able to be heard from the nursing station when she called out and staff looked in on her when they were passing by in the hall. RN-A indicated R40 would yell help, help and not know what she wanted, or even realize she had been yelling out. RN-A stated R40 had been transferred to her current room on 3/15/18, and confirmed R40 had become increasingly confused since the move. RN-A indicated that since R40 had fallen and obtained the most recent fracture on 4/3/18, R40 had not been observed attempting to self transfer. NA-A was interviewed on 4/18/18 at 3:34 p.m., and indicated R40 required use of an EZ stand lift for transfers and required staff assist with transportation from one location to another. NA-A stated R40 would call out at times and other times would use her call light. NA-A indicated R40 was on an every two-hour toileting schedule, but there was no specified time period for visual checks, and the time varied depending on what was happening with other residents. NA-A further confirmed she was unaware of any process to document visual checks when they were completed. During an interview on 4/19/18, at 7:33 a.m. NA- B also stated she was unaware of any scheduled frequency for visual checks of R40, only that staff checked in as they walked by her room. NA-B stated sometimes R40 would yell out for help. NA-B said when staff responded, R40 didn't know what she was yelling for or if she needed assistance. NA-B indicated that since R40 had fallen on 4/3/18, she no longer attempted to self transfer. During a follow up interview on 4/19/18 at 10:05 a.m., RN-A verifed if there was a program for safety checks, there should be a form with documentation of when the checks were completed. RN-A also she was not aware of any ongoing monitoring or if/when routine checks, either 15 minute or hourly, were implemented. RN-A stated the safety checks would have been short term, and she was unaware of any specific time frame used when monitoring occurred. During interview on 4/19/18, at 10:16 a.m. both the director of nursing (DON) and assistant director of nursing (ADON) confirmed no specific monitoring was in place for R40 because she was already in a room close to the desk and staff frequently went by her room. The certified occupational therapy assistant (COTA)-A was interviewed on 4/19/18, at 1:51 p.m. and confirmed R40 had experienced multiple falls due to self transfer attempts. COTA-A further indicated R40 didn't use her call light-at all, and would call out for help. COTA-A indicated R40 had been moved closer to the nursing station, which helped. During an interview on 4/19/18 at 2:01 p.m., NA-B and NA-C stated they felt R40 was confused most of the time. They also stated they would give R40 her call light, but frequently had to explain how to use it. They said she didn't use the call light most of the time. The NAs stated if a staff person was in the hall, R40 was able to be heard, but if they were in assisting another resident's room, R40 could not be heard. The director of health information was interviewed on 4/19/18, at 2:30 p.m She stated the facility's Safety Committee Meetings were held monthly, but falls were addressed at the Quality Assurance (QA) meetings and those were held quarterly. The assistant director of nursing (ADON) was interviewed on 4/19/18, at 2:38 p.m., and stated a daily report meeting in addition to the Interdisciplinary Team meeting was held Monday - Friday with each wing's nurse bringing incident reports for discussion. The ADON stated a log of incidents was completed for each wing and brought to the QA meetings. During a group interview on 4/20/18, at 9:47 a.m. including the administrator, DON, ADON, and MDS coordinator, the staff present confirmed IDT meetings were the facility's primary method of discussing interventions to prevent falls and incidents, and confirmed the IDT meeting notes would be reflective of any documented analysis and investigation of R40's incidents. R50 R50's diagnoses, according to the [DIAGNOSES REDACTED]. R50's admission Minimum Data Set ((MDS) dated [DATE], identified R50's cognition as moderately impaired. R50 required extensive assistance for mobility, toileting, transfers, and most activities of daily living (ADLs) and identified as occasionally incontinent of urine with no toileting program. R50 was identified as having fallen within one month prior to admission and 2 or more falls since admission, one with injury (except major), and no falls with major injury since admission. R50's balance was unsteady and required assistance for stability. R50's Care Area Assessment (CAA) dated 12/27/17, indicated physical therapy (PT) was initiated 12/27/17, with a goal to improve strength, balance, and independence, and decrease the risk of falls. The CAA also indicated to increase visual checks on R50 to ensure safety. The quarterly MDS dated [DATE], identified no changes in residents mobility or functional care areas. Review of R50's safety risk evaluation, dated 12/19/17, indicated R50 had a history of [REDACTED]. Internal risk factors for falls (underlying health problem) included: pacemaker, decline in functional impairment, [MEDICAL CONDITIONS], dizziness, [MEDICAL CONDITION], high blood pressure (antihypertensive prescribed) and a history of [MEDICAL CONDITION]. It indicated these factors were to be care planned. R50's care plan dated 12/26/17, indicated R50 was a high risk for falls related to confusion, gait and balance problems, poor communication and comprehension, and unawareness of safety needs. The goal listed identified: will not sustain serious injury. Interventions included: (1) ensure call light is within reach, (2) prompt response to all requests for assistance (3) educate, family and care givers about safety reminders and what to do if a fall occurs, (4) R50 needs a safe environment with even floors, free from spills, and or clutter, a working reachable call light, and to have personal items within reach, (5) physical therapy (PT) to evaluate and treat as ordered or as needed, and (6) utilize activities that minimize the potential for falls while providing diversion and distraction. R50's care plan was revised on 4/16/18 with the following interventions: (1) resident requires assistance with all toileting tasks to use toilet, (2) to encourage to use call light for assistance, (3) resident is able to turn and reposition self independently, (4) resident requires stand by assist of 1 to ensure safety in and out of bed, (5) requires one staff participation to dress upper and lower body, and (6) requires contact guard, stand by assistance with transferring. Review of R50's accident reports dated since admission 12/19/17, were as noted: (1) dated 12/20/17, at 8:15 a.m.- found in bathroom on the floor; no injuries noted and no pain. Interdisciplinary team (IDT) post-fall review dated 12/21/17, Interdisciplinary team (IDT) fall review identified that staff were to stay with R50 when on the toilet, and to anticipate needs, and assist as necessary. (2) dated 12/22/17, at 7:45 a.m.- fall witnessed by roommate reported it to staff. Found lying on the floor at the entrance to room [ROOM NUMBER]. Injuries included a left elbow skin tear, bruise, and left hip pain. No signs of fracture. An IDT fall review indicated R50 was a new admission who lived at home and had frequent falls. Staff encouraged to keep close eye on resident, continue current plan of care, obtain and order for physical (PT) and occupational therapy (OT). (3) dated 12/27/17, at 4:55 a.m. - found lying on floor on back next to bed. No injuries indicated. An IDT fall review on 12/27/17, indicated R50 is a new admit, with dementia. Immediate interventions indicated to monitor resident every 15 minutes. No documentation provided to indicate completion of 15 minute checks. No measures to prevent further falls indicated. (4) dated 12/29/17, at 4:00 p.m. - found lying on floor. Resident assessed for injury, no injury noted. IDT fall review not indicated on accident report, and no measures to prevent further falls indicated. (5) dated 1/20/18, at 11:30 a.m. - found on the floor in the bathroom in room [ROOM NUMBER]. Injuries were an abrasion to the left thigh and pain on R50's tailbone. An IDT review indicated R50 was impulsive, forgetful, had a history of [REDACTED]. Resident was receiving physical therapy (PT). R50 obtained an x-ray to rule out fracture. No measures to prevent further falls indicated. (6) dated 3/16/18, at 8:10 a.m. R50 fell , landed on stomach. Fall resulted in a small abrasion to R50's head. IDT fall review indicated R50 was received therapy, and had a recent hospital stay. No measures to prevent further falls indicated. (7) dated 4/10/18, at 5:00 p.m. -fell in the activity room, which resulted in a skin tear on left pinky finger, a scratch by left eye, and a new bruise on left elbow. An IDT fall review indicated OT/PT recently completed, resident was impulsive, forgetful, and free to move in w/c from room to activity room. No measures indicated to prevent further falls. R50's physical therapy (PT) notes indicated R50 was referred to PT/OT for history of falls. PT started on 12/27/17, and ended 1/24/18. PT identified R50 had deficits in strength and balance. R50 was treated three times per week for six weeks for history of falls. R50's PT discharge summary dated 1/24/18, indicated resident had fair progress in therapy mostly limited by cognitive deficits, required a lot of redirection to stay on task, and required one assist for transfers and ambulation. According to the PT discharge summary, R50 was placed on nursing walk program, however, R50's current care plan indicated no walking program was in place. R50 was treated again by PT from 3/2/18, to 4/10/18, following hospitalization for pneumonia, for decreased strength and balance, and low endurance. R50's PT discharge summary on 4/10/18 indicated R50 did not progress as anticipated, maximized level of improvement was reached, and placed R50 on a walk program. OT treated R50 from 3/3/18, to 4/12/18. R50's OT discharge summary, dated 4/12/18 indicated Resident plateaued and required stand by assist with ambulating, ADLs and transfers to remain safe due to limited cognition and impulsiveness. During observation on 04/18/18, at 8:30 a.m., R50 was in room [ROOM NUMBER] sitting in a wheelchair after breakfast. R50 was asking for help to use the bathroom, and the call light was on/activated. R50 stated it was ok, he could do it alone and wheeled himself towards the bathroom. The surveyor again encouraged R50 to wait, and R50 stated he would wait, but not for much longer. The surveyor approached unit assistant (UA) O-F and asked for assistance for R50. O-F, replied It's not my job, and continued walking towards dining room. Surveyor reapproached O-F and asked if it was possible to call for help with the walkie talkie clipped to O-F's uniform. O-F sighed, radioed for assistance, and continued to the dining room. On 04/18/18, at 8:35 a.m., trained medication aide (TMA)-A was observed to walk past room [ROOM NUMBER] from the direction of the dining area to the nurse station holding a med cup and white plastic spoon. A few minutes later, TMA-A walked past room [ROOM NUMBER] from the direction of the nurse station, towards the dining room. R50 resident called out Nurse, from the doorway as TMA-A briskly walked past room [ROOM NUMBER], stated she was busy, and continued walking towards the dining room. At 8:40 a.m., R50 stated he could not wait any longer, and pedaled towards the bathroom. R50 entered the bathroom to transfer self onto toilet. The surveyor got assistance from RN-A at the nurses station by room [ROOM NUMBER], who finished assisting R50 onto the toilet. During interview on 04/18/18, at 8:40 a.m. RN-A indicated R50 required one person assist to transfer on and off the toilet. RN-A stated R50 had a history of [REDACTED]. RN-A described R50 as impatient, not safety aware, and attempts transfers self to toilet frequently. Staff are frequently reminded to assist resident and to remind resident no to try transfer without help. During interview on 04/18/18, 8:42 a.m. with TMA-A indicated the resident needs assistance to the toilet and had fallen recently, but was not sure when. R15 R15's currrent [DIAGNOSES REDACTED]. Review of R19's Quarterly MDS dated [DATE], indicated resident had severely impaired memory, and a depression score of two. R19 required extensive assist of two for bed mobility, transfers, toileting, and dressing, and requires supervision of one for eating. R19 is frequently incontinent of bladder and bowel, short of breath, and has had two or more falls since the last MDS assessment without major injury. Review of R19's care plan, dated 1/22/18, indicated R19 was a fall risk. Interventions included: (1) to ensure oxygen tubing is above feet, (2) educate R19 about safe transferring, (3) scoop mattress on bed, (4) maintain bed in low position with a fall mat and motion sensor while in bed, (5) uses a Broda chair maintained in lowest position with a seat alarm, (7) R19 required assist of one with toileting tasks, (8) two assistance when tired /weak with EZ stand (9) able to move and repo self in bed, (10) sit up independently when alert, and (11) staff assist required when fatigued. Review of R19's accident reports indicated the following: (1) On 10/14/17, at 3:22 p.m. resident found on floor in room fall was unwitnessed. No injury. An IDT fall review on 10/16/17, indicated R19 was on hospice, had frequent falls, had alarms and fall mat, continue current plan of care. No measures to prevent further falls were indicated. (2) On 10/20/17, at 21:20 p.m. R19 found on floor with no injury noted. An IDT fall review dated 10/21/18, indicated R19 had a history of [REDACTED]. No measures to prevent further falls were listed. (3) On 11/6/17, at 7:55 am R19 observed crawling on hands and knees on floor in room. No injury. An IDT fall review dated 11/17/17, indicated resident has history of falls, had alarms and fall mat in place. Measures to prevent falls included to attempt to toilet more frequently. (4) On 11/16/17 at 4:40 p.m. R19 was found on the floor in their room, and resulted in a bruise to fifth finger knuckle and skin tear to left top hand. An IDT fall review on 11/17/17, indicated the fall alarm did not sound, the facility was working to become an alarm free community, and R19 had frequent falls, R19 had frequent staff checks. Fall alarm replaced. Frequency of checks not indicated, no documentation provided to indicate frequent checks. No measures to prevent further falls were noted. Frequent checks not indicated in plan of care. (5) On 11/25/17, at 6:45 a.m. - found sitting on floor without injury. IDT fall review on 11/27/17, indicated R19 had a history of [REDACTED]. Measures to prevent further falls indicated to increase visual checks and toileting. Continue current plan of care, and no new interventions. No revised goal or interventions for frequency of visual checks or toileting indicated in plan of care. (6) On 1/14/18, at 8:37a.m. -found on floor resident stated hit head on oxygen but unable to recall why he stood up. Injury included a 0.5 cm round open area to back of right side of head with minimal bloody drainage. An IDT fall review on 1/15/18, indicated med review and [DIAGNOSES REDACTED]. Review indicated to continue current plan of care. No measures to prevent further falls indicated, no frequent checks or frequency indicated on plan of care. No documentation of frequent checks available. (7) On 3/4/18, at 9:15 p.m. R19 yelling for help, found on floor, and stated, hit head on the wheels of bedside table. Injuries included a 3.2 x 2.3 centimeter (cm) bruise on top of a goose egg on right side of the forehead, and a 5.5 x 3 cm bruise and abrasion to the right shoulder. An IDT fall review on 3/5/18, indicated resident on hospice, had oxygen deprivation, and to continue current plan of care. No measures to prevent further falls indicated. During interview on 04/18/18, at 1:46 p.m. RN-A indicated R19 no longer used call light, and used to call out for help when needed the bathroom. R19 had a history of [REDACTED]. Staff monitored R19 by looking into the room when passing in hallw (TRUNCATED)