Every finding on record at Maranatha Care Center

Based on observation, interview, and document review, the facility failed to ensure safety during transfer for 1 of 3 residents (R1) who used a standing mechanical lift (Liko [NAME] II Sit-to-stand lift). The failure resulted in actual harm when R1 fell from a standing mechanical lift causing a leg fracture and shoulder dislocation. The facility completed corrective measures by 8/14/26 and prior to the start of the survey so citation was issued at past non-compliance (PNC).Findings include:R1's face sheet dated 8/24/26, identified diagnoses of unspecified fracture of upper end of right tibia (large lower leg bone known as the shinbone), periprosthetic fracture around other internal prosthetic joint, unspecified dislocation of left shoulder joint, morbid obesity, aphasia (disorder which may impact speech and ability to write and understand language) and dysphagia (difficulty swallowing) following cerebral infarction (occurs when a blood clot or blocked artery cuts off blood and oxygen flow to an area of the brain), age-related osteoporosis (medical condition which weakens bones), muscle weakness, and polyosteoarthritis (condition where osteoarthritis affects multiple joints throughout the bodyR1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had intact cognition, adequate hearing and vision, clear speech, and ability to understand others. R1 had no behaviors or rejection of care. R1 had impairment to one lower extremity and required substantial and/or maximal assistance with transfers. R1's MDS identified she was 240 pounds.R1's care plan intervention dated 11/20/24, directed staff to transfer R1 with assistance from one staff and a standing mechanical lift with a large sized vest (Liko SafetyVest).During an interview on 8/20/26 at 8:35 a.m., nursing assistant (NA)-E stated R1 was alert and could tell you what she wanted. NA-E stated prior to 8/7/26, R1 transferred with a standing mechanical lift with one staff person. R1 stood well in the standing lift and did not lift her legs.R1's Nursing Home Incident Report dated 8/8/26, identified around 9:00 p.m. on 8/7/26, R1's right knee buckled while being transferred with a standing mechanical lift and was lowered to the floor. R1 was assessed, complained of pain to the right knee and left shoulder, and was transferred to the hospital.R1's hospital Discharge summary dated [DATE], identified R1 had diagnoses of mechanical fall fractured tibia and shoulder dislocation. R1 presented to the emergency department after a mechanical fall while getting out of shower and had left shoulder and right knee pain. R1's left shoulder dislocation was reduced in the emergency department. On 8/8/26 R1 had right knee spanning external fixator (temporary metal frame placed outside the leg with pins going into the thigh bone and shin bone to hold the knee joint still), and on 8/12/26 had right knee removal external fixator and open reduction internal fixation of right proximal tibia (a surgery used to line up and stabilize a broken shin bone near the right knee joint).During observation and interview on 8/19/26 at 3:24 p.m., R1 was in her bed with oxygen on via nasal cannula and left shoulder immobilizer. Family member (FM)-A was in the room. R1 indicated nursing assistant (NA)-A would do everything really good but NA-A would turn away and start something else in the middle of cares leaving R1 unattended. R1 explained prior to the fall she was standing on the lift near the corner of her bed when NA-A brushed against her arm, causing R1 to lose her balance. R1 also recalled the vest was hooked on loop one instead of loop two to four, which caused R1 to slip through the vest and onto the floor because the vest was loose. R1 indicated she jammed her left arm and dislocated her shoulder, and her legs twisted and stayed buckled in the lift for a while. FM-A indicated R1 recalled the events to her during hospitalization, and R1 reported NA-A went around a corner and was out of sight when R1 fell through the vest. FM-A indicated R1 was in bed more often and had more pain compared to prior to 8/7/26, and R1 now had oxygen via nasal cannula and a leg brace. During interview on 8/19/26 at 2:09 p.m., NA-A indicated she assisted R1 with a shower and dressed R1 in a gown and slippers in the evening on 8/7/26. NA-A used the vest that was in R1's room and each resident had their own vest. NA-A used the fourth loop to hook the vest up to the standing mechanical lift, raised R1 off the shower chair, dried R1, and placed incontinent product on R1. NA-A stated R1 was standing very good as she brought R1 in the standing mechanical lift from the shower chair to R1's bed. NA-A indicated one of R1's feet was on the standing platform of the lift and the other foot was raised up when they were near R1's bed. NA-A indicated she asked R1 if she was okay, and R1 did not reply. NA-A stopped moving the standing mechanical lift, went next to R1, grabbed the lift remote, and lowered R1 down as far as the lift would go. Then NA-A had her chest against R1 while loosening and unhooking the lift vest and lowered R1 the rest of the way to the floor and placed a pillow under R1's head. NA-A indicated R1 was lowered to the floor and did not fall to the floor.During follow-up interview on 8/20/26 at 1:31 p.m., NA-A indicated she used her walkie to ask for help when she noticed R1's leg was raised and no one answered. NA-A then lowered R1 to the floor and had to leave the room to get another staff to help. NA-A stated R1's arm did not hit anything when lowered to the floor.During interview on 8/19/26 at 4:04 p.m., licensed practical nurse (LPN)-A indicated he was R1's nurse on 8/7/26. LPN-A indicated he walked out of another resident's room when NA-A told him R1 fell. LPN-A entered R1's room, and R1 was on the floor on her back with her head on a pillow. R1's left leg extended out and right leg was bent up. R1's head was near the foot end of the bed, and the standing mechanical lift was near the head of bed. LPN-A indicated the vest was still hooked to the standing mechanical lift and was hanging without R1 in the vest. LPN-A took R1's vitals and indicated her vitals were stable. LPN-A stated NA-A had reported R1 was sliding down from the standing mechanical lift, and NA-A assisted R1 the rest of the way to the floor. R1 had reported she fell from the standing mechanical lift. LPN-A and NA-A placed the full mechanical lift sling underneath R1. R1 complained of right leg and left shoulder pain and indicated the areas hurt worse when touched or moved. LPN-A called other nurses to help assess R1, and then staff called 911, sent R1 to the hospital and called R1's family. During follow-up interview on 8/20/26 at 3:03 p.m., LPN-A stated he did not have a walkie on 8/7/26, because the battery was not working.During interview on 8/20/26 at 8:48 a.m., registered nurse (RN)-A indicated she was called around 9:30 p.m. on 8/7/26 and told R1 had a fall and difficulty with range of motion. When RN-A entered R1's room, R1 was laying on her back on the floor with the sling for the full mechanical lift underneath her. R1's right knee was more swollen than her left, and R1's right knee had a dent. RN-A indicated R1 reported she had screaming pain if leg was moved. RN-A indicated R1's right leg was more bent and shorter than the other. RN-A called another nurse, RN-B, for further assistance, and staff called the paramedics and primary provider. RN-A indicated the full mechanical lift and standing mechanical lift were in the room, and the standing lift vest was unhooked and laying on the standing mechanical lift. RN-A indicated the vest size matched the size indicated on R1's care plan. During follow-up interview on 8/20/26 at 2:16 p.m., RN-A indicated R1 used a large vest.During interview on 8/20/26 at 11:36 a.m., RN-B stated he was helping another resident when he heard there was an emergency for a resident who fell. RN-B responded and entered R1's room. RN-B stated R1 was on the floor with a full lift sling underneath her. R1 indicated she fell, and NA-A indicated R1's leg gave out and right knee buckled during transfer with standing mechanical lift from the shower chair to the bed. NA-A indicated R1's right knee hit the base of the standing lift, and NA-A unhooked the vest and leg strap to assist R1 to the floor and called a nurse. RN-B indicated he was unsure how NA-A could have supported R1 weight enough to unhook R1 from the standing lift while lowering her to the ground. R1 indicated she had pain in her right leg and left shoulder, and R1's pain worsened when touched. R1 was unable to perform range of motion, and the paramedics were called.During interview on 8/20/26 at 3:17 p.m., RN-E, who was a nurse manager, expected staff to stop the transfer if a resident appeared unsteady in a standing mechanical lift and lower the resident to a bed or other nearby surface. RN-E expected staff to pause when lifting resident from the beginning transfer surface and ensure resident was cooperative, steady, and in correct position.During interview on 8/20/26 at 4:49 p.m., the interim director of nursing (DON) indicated staff should lower residents to the safest place possible if a resident became unsteady in a standing mechanical lift. Staff should call a nurse while helping a resident to a safe transfer spot. The DON indicated a resident falling through a vest would result in a resident falling to the floor rather than another higher transfer surface.During interview on 8/24/26 at 10:17 a.m., a technical support lead coordinator for the standing lift company (TSLC) indicated a vest, which was properly applied and hooked to a standing mechanical lift, should hold the weight of a resident who was not hanging on. TSLC indicated there would be enough time to move an unsteady resident to sit on a piece of furniture rather than having to lower a resident to the floor.During interview on 8/24/26 at 12:19 p.m., the nurse practitioner (NP) of R1 stated having staff trained to use a standing mechanical lift, not leaving a resident in a mechanical lift, and properly hooking up a resident to a standing lift would prevent falls from lifts. A resident who fell from a standing lift could result in fracture, other injuries, or death if head strike occurred. [NAME] II Sit-to-Stand Lift Instruction guide included safety instructions which included but was not limited to: Never leave a patient unattended in [NAME] sit-to-stand lift!Before lifting, always make sure that: the lifting accessory is selected appropriately in terms of type, size, material and design with regard to the patient's needs the lifting accessory is correctly and safely applied to the patient in order to avoid bodily injury the lifting accessory is correctly applied to the sling bar the sling bar latches are intact. Missing or damaged latches must always be replaced with new ones; the sit-to-stand vest's/sling's straps are properly connected to the sling bar hooks when the straps have been fully extended but before the patient is lifted from the underlying surface. as a caregiver assure that the patient not are at risk of falling forward or to any side during liftingThe facility had completed the following prior to the start of the survey:- Nurses, nursing assistants, and therapy staff completed Skill Competency for standing mechanical lifts on 8/8/26:Determine which of the strap loops should be hooked to the lift by pulling straight forward on the outer vest straps and the loop straps at the same time.-Nurses, nursing assistants, and therapy staff completed Mechanical Lift Education on 8/12/26:Do not leave residents alone during transfer.If staff notice any problems with transfer vest, sling, or lift, stop the lifting process, lower the resident to the nearest surface, and notify the nurse immediately.Nurses and aids should always have their walkie with them.-Completed transfer assessments for residents who used the standing mechanical lift on 8/12/26, 8/13/26, and 8/14/26.-Placed NA-A on administrative leave on 8/8/26 and terminated NA-A on 8/19/26.

Based on observation, interview, and document review, the facility failed to ensure enhanced barrier precautions (EBP) were utilized for 1 of 2 residents (R2) who were observed during staff cares.Findings include: R2's face sheet dated 8/20/26, identified diagnoses of encounter for palliative care, chronic obstructive pulmonary disease, type two diabetes mellitus, acute on chronic diastolic (congestive) heart failure, stage four chronic kidney disease, and weakness.R2's care plan focus dated 9/10/24, identified R2 required enhanced barrier precautions due to a wound on her coccyx. An intervention dated 5/6/24, directed staff to wear gown and gloves during high-contact resident care activities.R2's quarterly minimum data set (MDS) dated [DATE], identified R2 had intact cognition and no rejection of cares or behaviors. R2 required substantial and/or maximal assistance with toilet and shower transfers and was dependent on staff for chair/bed-to-chair transfers, toileting hygiene, lower body dressing, wheelchair mobility, and bed mobility. R2 had one stage three pressure ulcer and application of nonsurgical dressings to an area other than to feet.During observation on 8/19/26 at 1:04 p.m., nursing assistant (NA)-B entered R2's room, washed her hands and applied gloves and no gown. NA-B placed a standing mechanical lift vest around R2 and hooked up to standing mechanical lift. NA-B transferred R2 to the toilet, removed gloves, and washed her hands. NA-B applied gloves and no gown, provided incontinence cares, removed gloves, washed hand, applied gloves and no gown, and transferred R2 from the bathroom to bed. NA-B unhooked R2 from the standing lift and assisted R2 from a sitting to laying position into bed while her uniform touched R2's bed and clothes.Upon exit of room from observation, a sign which read Enhanced Barrier Precautions was observed on the wall above R2's room number. The sign directed staff to wear gloves and a gown for the following high-contact resident care activities: Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use, and wound care.During interview on 8/19/26 at 1:23 p.m., nursing assistant (NA)-B indicated the nurses had to wear gloves and a gown when they assisted R2 with wound care, and staff wore gloves and no gown when they assisted R2 with other cares.During interview on 8/20/26 at 2:41 p.m., licensed practical nurse (LPN)-B indicated R2 had enhanced barrier precautions because she had wounds. LPN-B stated staff wore gown and gloves to assist R2 with wound care, and staff wore gloves and no gown to toilet and transfer R2.During interview on 8/20/26 at 4:49 p.m., the interim director of nursing (DON) expected staff to wear gloves and a gown to assist residents on enhanced barrier precautions with direct cares, which included transfers and toileting.The facility CC Enhanced Barrier Precautions Policy and Procedure dated April 2025, identified EBP as a preventative approach to the use of personal protective equipment (PPE) to reduce opportunities of multidrug-resistant organism (MDRO) transmission during high-contact resident care activities. The policy and procedure directed staff to perform hand hygiene, don gloves and a gown, complete high-contact activity, remove gloves and gown, and perform hand hygiene

Based on interview and document review, the facility failed to comprehensively assess and monitor vital sign parameters (blood pressure and pulse) prior to administering medications that had physician ordered parameters to hold, for 3 of 3 residents (R1, R2, R3) reviewed for quality of care.Findings include:Based on interview and document review, the facility failed to hold medications outside of parameters for 3 of 3 residents (R1, R2, R3) reviewed for physician parameters.Findings include:R1R1's face sheet dated 8/24/26, identified diagnoses of heart failure, chronic atrial fibrillation, morbid obesity, essential hypertension, chronic kidney disease, and aphasia (disorder which may impact speech and ability to write and understand language) and dysphagia (difficulty swallowing) following cerebral infarction (occurs when a blood clot or blocked artery cuts off blood and oxygen flow to an area of the brain), thrombocytopenia (low blood platelet count), and presence of cardiac implants and grafts.R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had intact cognition and no rejection of care or behaviors.R1's care plan focus dated 5/5/24, identified R1 had an alteration in cardiovascular status related to atrial fibrillation, hypertension, hyperlipidemia, chronic kidney disease, anemia, and [NAME] device (permanent, quarter-sized medical device used to reduce stroke risk in people with non-valvular atrial fibrillation).R1's physician order dated 8/14/26, directed staff to give R1 one and a half tablets of carvedilol (medication used to treat high blood pressure) oral tablet 25 mg (milligrams) by mouth two times daily for hypertension. The order identified to hold the medication if systolic blood pressure was less than 100 mmHg (millimeters of mercury) or pulse was less than 60 bpm (beats per minute).R1's Blood Pressure Summary and Pulse Summary, both dated 8/20/26, identified a blood pressure of 131/54 mmHg and pulse of 57 bpm on 8/19/26 at 4:26 p.m.R1's Medication Administration Record (MAR) dated 8/2026, identified the administration of carvedilol in the morning and evening medication pass times. The MAR indicated R1 received carvedilol during the PM medication pass time on 8/19/26.R1's medical record was reviewed and lacked evidence of further blood pressure and/or pulse reading on the evening of 8/19/26.During interview on 8/20/26 at 3:17 p.m., RN-E, who was a nurse manager, verified R1's blood pressure was within parameters, and pulse was outside of administering parameters during the evening medication pass time on 8/19/26. RN-E indicated whether to give the medication or not was tricky sometimes for staff when the blood pressure was within parameters and the pulse was not.During interview on 8/24/26 at 12:19 p.m., the nurse practitioner (NP) of R1 stated R1's order identified to hold carvedilol if blood pressure or pulse were outside parameters and expected staff to hold the medication when one or both measurements were out of range. The NP was not aware of R1's medication administration and pulse measurement on 8/19/26. The NP expected to be notified if medications were held multiple times in a row due to vitals outside of order parameters.R2R2's face sheet dated 8/20/26, identified diagnoses of chronic obstructive pulmonary disease, type two diabetes mellitus, chronic embolism and thrombosis of unspecified deep veins, acute on chronic diastolic (congestive) heart failure, stage four chronic kidney disease, obesity, and hypertension.R2's quarterly MDS dated [DATE], identified R2 had intact cognition and no rejection of cares or behaviors.R2's care plan focus dated 9/10/24, identified R2 had an alteration in cardiovascular status related to chronic heart failure and hypertensive heart and kidney disease with heart failure. An intervention dated 9/11/19, directed staff to give R2 medications per orders.R2's physician order dated 8/5/26, directed staff to give 12.5 mg of metoprolol tartrate (medication used to treat high blood pressure) by mouth two times a day for atrial fibrillation. The order identified to hold the medication if systolic blood pressure was less than 110 mmHg and pulse was less than 60 bpm.R2's medical record dated 8/6/26 to 8/23/26 was reviewed, such as Blood Pressure Summary dated 8/24/26, Pulse Summary dated 8/24/26, and MAR dated August 2026. R2's record identified consistent lack of correlating blood pressure and/or pulse readings at times of metoprolol administration during the morning and bedtime medication pass. Further, the record identified pulse readings outside of parameters of the provider's orders:8/6/26 - No blood pressure or pulse were recorded for the morning, and the morning medication was administered. Blood pressure was 138/57 mmHg and pulse was 46 bpm at 4:05 p.m., and medication was held at bedtime medication pass time.8/7/26 - No blood pressure or pulse were recorded with morning medication administration. No blood pressure was recorded, pulse was 53 bpm at 8:58 p.m., and medication was administered during bedtime medication pass.8/8/26 - No blood pressure or pulse were recorded for the morning medication administration. Blood pressure was 147/60 mmHg and pulse was 56 bpm 7:50 p.m., and medication was held during bedtime medication pass time.8/9/26 - No blood pressures were recorded. Pulse was 47 at 2:59 p.m. Medication was administered in the morning and bedtime medication pass time.8/10/26 - No blood pressures were recorded. Pulse was 43 bpm at 3:09 p.m. and 53 bpm at 6:52 p.m. Medication was administered in the morning and bedtime medication pass time.8/11/26 - Blood pressure was 122/66 mmHg and pulse was 60 bpm at 12:52 p.m., and medication was administered during the morning medication pass. Blood pressure was 127/56 mmHg and pulse was 47 bpm at 3:38 p.m., and medication was held at bedtime medication pass time.8/12/26 - No blood pressures were recorded. Pulse was 56 bpm at 4:43 p.m. Medication was administered in the morning and bedtime medication pass time.8/13/26 - No blood pressure was recorded for the morning. Blood pressure was 137/58 mmHg and pulse was 81 bpm at 3:48 p.m. Medication was administered in the morning and bedtime medication pass time.8/14/26 - No blood pressures were recorded. Pulse was 45 bpm at 3:32 p.m. Medication was administered in the morning and bedtime medication pass time.8/15/26 - No blood pressure or pulse were recorded with the morning medication administration. Blood pressure was 130/56 mmHg and pulse was 45 bpm at 3:56 p.m., and medication was held during bedtime medication pass time.8/16/26 - No blood pressure was recorded for the morning, and no pulse measurements measures were recorded for the day. Medication was administered in the morning and held at bedtime medication pass time.8/17/26 - No blood pressure or pulse measurements were recorded. Medication was administered in the morning and bedtime medication pass time.8/18/26 - Blood pressure was 130/59 mmHg and pulse was 70 bpm at 10:04 a.m., and morning medication dose was given. Blood pressure was 135/54 mmHg and pulse was 47 bpm at 3:47 p.m. Medication was held at bedtime medication pass time.8/19/26 - No blood pressure or pulse measurements were recorded. Medication was administered in the morning and bedtime medication pass time.8/20/26 - No blood pressure or pulse were recorded during the morning medication pass time. Blood pressure was 153/57 mmHg and pulse was 53 bpm at 4:09 p.m., and medication was held during the bedtime medication pass time.8/21/26 to 8/23/26 - No blood pressures or pulses were recorded. Medication was administered in the morning and bedtime medication pass time.During interview on 8/24/26 at 4:09 p.m., LPN-A indicated some residents had a trigger in the computer which prompted staff to enter blood pressure and pulse before marking medication administration, and R2's order with parameters did not. LPN-A verified R2's last recorded blood pressure and pulse was 8/20/26 and R2's medication with parameter was marked as administered 8/21/26 to 8/23/26. LPN-A stated I hope so when surveyor asked if staff documented vitals by exception and if no recorded blood pressure and pulse meant vitals were checked and within range to administer medication.R3R3's face sheet dated 8/24/26, identified R3 had diagnoses which included acute on chronic systolic (congestive) heart failure, chronic obstructive pulmonary disease, adult failure to thrive, rhabdomyolysis (rare muscle injury where muscle breaks down), stage three chronic kidney disease, long term use of anticoagulants, essential hypertension, repeated falls, presence of automatic (implantable) cardiac defibrillator, and weakness.R3's quarterly MDS dated [DATE], identified R3 had intact cognition and no behaviors or rejection of cares.R3's care plan care plan focus dated 4/17/26, identified R3 had an alteration in cardiovascular status related to congestive heart failure. An intervention dated 4/17/26, directed staff to give R3 his medications per orders and update physician/NP with changes in cardiovascular status as needed.R3's physician order dated 4/6/26, directed staff to give 1 tablet of sacubitril-valsartan (medication used to treat chronic heart failure) oral tablet 97-103 mg by mouth in the morning for heart failure. The order had parameters to hold medication if systolic blood pressure was less than 110 mmHg.R3's record was reviewed dated 8/1/26 to 8/23/26. The record lacked blood pressure measurements on multiple days of medication administration and identified blood pressure measurements outside of physician ordered parameters:-Blood pressures were recorded on 4 out of 23 days:On 8/4/26, blood pressure was 104/51 mmHg at 12:31 p.m.On 8/19/26, blood pressure was 105/63 mmHg at 5:38 p.m.-Medication was administered every day during the morning medication pass.During interview on 8/20/26 at 2:41 p.m., LPN-B stated she checked blood pressure and pulse before administering medications that included parameters, so she knew whether to give or hold the medication. LPN-B stated she documented blood pressure and pulse in residents' medical record and used a code to indicate when medication was held and/or documented a note. LPN-B indicated medication given outside of order parameters classified as a medication error.During interview on 8/24/26 at 4:33 p.m., the interim director of nursing (DON) expected staff to document blood pressure and/or pulse before medication administration in accordance with order parameters. The DON classified medication given outside of ordered parameters as a medication error. The DON indicated medications given outside of ordered parameters could cause adverse effects.During interview on 8/24/26 at 2:33 p.m., the consultant pharmacist (CP) indicated he reviewed R1, R2, and R3's medical record. CP confirmed medications were given outside of order parameters and expected staff to follow physician orders. CP indicated medications given outside of order parameters were more of an oversight than medication error.The facility Medication Administration Procedures dated 1/27/19, directed staff to administer oral medications in an organized and safe manner. Staff were directed to obtain any required vital signs prior to administration of medications with parameters.The facility Medication Administration Error Policy dated May 2021, identified a medication error was the observed preparation or administration of medications or biologicals which was not in accordance with prescriber's order; manufacturer's specifications regarding the preparation and administration of the medication or biological; and accepted professional standards and principles which apply to professionals providing services. Examples of medication errors included failure to follow prescribers' orders and failure to complete a medically related procedure as ordered by the prescriber (i.e. blood pressure or pulse to be taken before administration of a medication).

Based on observation, interview, and document review, the facility failed to ensure residents using a continuous positive airway pressure (CPAP) machine had appropriate orders for use to include equipment settings and failed to ensure supplemental oxygen order was clarified and administered as ordered for 1 of 2 residents (R1) reviewed for respiratory care.Findings include:R1's face sheet dated 8/24/26, identified diagnoses of heart failure, chronic atrial fibrillation, morbid obesity, obstructive sleep apnea, essential hypertension, chronic kidney disease, and aphasia (disorder which may impact speech and ability to write and understand language) and dysphagia (difficulty swallowing) following cerebral infarction (occurs when a blood clot or blocked artery cuts off blood and oxygen flow to an area of the brain).R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had intact cognition, a non-invasive mechanical ventilator, and no rejection of care or behaviors. R1 had one lower extremity impairment, did not walk, and required substantial and/or maximal assistance with most activities of daily living, such as dressing and transfers.R1's physician orders included orders for CPAP dated 4/16/26 that directed staff to complete the following:-Wipe Mask cushion with clean damp cloth to remove facial oils, empty the remaining water from the humidifier chamber, fill the chamber with soapy warm water and shake vigorously, rinse the chamber with clean water, and air dry every day shift.-Wash headgear, mask or nasal pillows and tubing in warm soapy water, rinse thoroughly, and air dry every Sunday day shift.-Replace white filters per guidelines which were evening shift every four weeks on Monday and Saturday. R1's care plan focus initiated 5/5/24, indicated R1 had an alteration in respiratory status related to sleep apnea. An intervention dated 5/7/24, directed staff to apply CPAP per MD/NP (doctor and/or nurse practitioner) orders. An intervention dated 5/8/26, directed staff to observe R1 for increased shortness of breath and update physician as needed.R1's hospital Discharge summary dated [DATE], identified R1 had diagnoses of mechanical fall fractured tibia and shoulder dislocation. The discharge summary directed for R1 to use a CPAP machine for obstructive sleep apnea syndrome at pressure 8, nasal mask x1/3 month with nasal cushion x2/mo. Directions included: Heat humidifier x 1/5 year, Humidifier chamber x 1/6mo, Heated tubing x 1/3mo, Headgear x 1/6mo, [NAME] strap x 1/6 months, Filters: Disposable x 2pk/1mo & Reusable x 1pk/6mo.Review of R1's care plan and/or physician orders were not revised to include the settings for the CPAP nor identify the routine replacement of accessories such as chin strap, humidification chamber, and heated tubing.R1's Provider On-Call Encounter dated 8/15/26 at 7:05 p.m., indicated a facility nurse called to request supplemental oxygen, and R1 had shortness of breath with oxygen saturation of 87 % (percent) on room air. An order was given to start oxygen 2 L/min [liters per minute] continuous to keep sats at or above 90%. Wean oxygen off as soon as possible.Review of the R1's transcribed physician orders dated 8/15/26 included but was not consistent with the order to provide 2 L supplemental oxygen to keep oxygen saturations above 90%, because it did not include the directive to wean oxygen off as soon as possible. R1's progress note dated 8/15/26 at 11:52 p.m., indicated R1 had shortness of breath and oxygen saturation of 87% on room air. A verbal order for oxygen at 2L received from on call NP to keep O2 sat [oxygen saturation] above 90% until provider seen on Monday [8/17/26].R1's progress note dated 8/16/26 at 9:41 p.m., indicated R1's oxygen saturation was 94% on 2 liters of supplemental oxygen.R1's provider progress note dated 8/17/26 at 5:03 p.m., indicated R1 had chronic CPAP use for obstructive sleep apnea and had supplemental oxygen at 2L per NC (nasal cannula). R1 denied shortness of breath. The provider note did not identify any changes or updates to the order that was written on 8/15/26. R1's O2 sats Summary dated 8/20/26, included the following oxygen saturation levels:-On 8/15/26 at 9:33 p.m., 94% with oxygen via nasal cannula-On 8/16/26, 90% at 9:04 a.m., 94% at 3:24 p.m., and 94% at 9:42 p.m. with oxygen via nasal cannula-On 8/17/26 at 5:08 a.m., 92% with CPAP use-On 8/17/26, 90% at 11:44 a.m. and 92% at 1:54 p.m. on room air-On 8/17/26 at 5:34 p.m., 95% with oxygen via mask-On 8/17/26 at 11:02 p.m., 92% with CPAP use-On 8/18/26, 98% at 9:44 a.m. and 5:31 p.m. with oxygen via nasal cannula-On 8/18/26, 99% at 9:28 p.m. on room air, and 92% at 11:31 p.m. with CPAP use-On 8/19/26 at 11:12 a.m., 94% with oxygen via nasal cannula Review of R1's record between 8/15/26 through 8/19/26 identified no indication if supplemental oxygen, CPAP, or both were to be worn overnight and what setting to use for CPAP. Further, the documentation did not consistently identify how much oxygen was delivered and/or if attempts of weaning were attempted and assessed. During observation and interview on 8/19/26 at 3:24 p.m., R1 was in her bed with oxygen on via nasal cannula and left shoulder immobilizer. Family member (FM)-A was in the room and indicated R1 had oxygen via nasal cannula and a leg brace since after hospitalization.During observation on 8/20/26 at 9:11 a.m., R1 was asleep in bed with her CPAP on and no supplemental oxygen.During follow-up interview on 8/20/26 at 4:16 p.m., R1 was in her wheelchair with supplemental oxygen via nasal cannula at 2 L. R1 stated she had tried to remove the oxygen and indicated the supplemental oxygen was needed to keep her oxygen saturation above 90%. R1 stated it was comfortable to keep the supplemental oxygen on.During interview on 8/24/26 at 4:06 p.m., licensed practical nurse (LPN)-A stated he cleaned and put new water in R1's CPAP, and the CPAP settings were pre-set and turned on automatically when R1 put the CPAP on. LPN-A stated he would look in R1's orders or medication and treatment administration record if he needed to verify R1's CPAP orders and settings.During interview on 8/20/26 at 8:58 a.m., registered nurse (RN)-C reviewed R1's oxygen and CPAP orders. RN-C stated R1 used supplemental oxygen during the day and CPAP at night. RN-C indicated R1 did not have supplemental oxygen prior to hospitalization. RN-C stated R1 was alert and able to let staff know if she felt short of breath.During interview on 8/20/26 at 3:17 p.m., RN-E, who was a nurse manager, reviewed R1's oxygen orders, CPAP orders, oxygen saturation summary, and provider progress note from 8/17/26. RN-E indicated the nurse practitioner (NP) saw R1 on Monday, 8/17/26, and the NP would have written new orders for R1's supplemental oxygen if the order needed to be changed. RN-E verified there were no CPAP setting directions or when to use CPAP with and/or instead of supplemental oxygen.During interview on 8/20/26 at 4:49 p.m., the interim director of nursing (DON) R1's medical record. The DON indicated staff should have followed up with the NP to clarify R1's supplemental oxygen and CPAP use. The DON expected staff to document trials to wean R1 from supplemental oxygen.During interview on 8/24/26 at 12:19 p.m., the nurse practitioner (NP) of R1 indicated the facility should have clarified respiratory related orders with her on Monday, 8/17/26, if that was what the order indicated. The NP indicated oxygen and CPAP orders were important to ensure R1 had enough respiratory support to avoid low oxygen saturation levels and avoid unnecessary supplemental oxygen use.The facility Oxygen Administration, Equipment Care and Maintenance Policy dated March 2022, directed staff to check physician's order for liter flow and method of administration.The facility CPAP and BiPAP Management Policy dated January 2023, directed staff to review care plan and/or verify physician's orders if required.

Based on interview and document review, the facility failed to ensure assessment, monitoring, and documentation surrounding PRN (as needed) psychotropic medication administration included resident-specific target behaviors and non-pharmacological interventions for 3 of 3 residents (R1, R2, and R3) reviewed for psychotropic medications.Findings include:R1R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had severe cognitive impairment, unclear speech, and impaired vision. R1 had disorganized thinking and no behaviors or rejection of care. R1's diagnoses included non-traumatic brain dysfunction, Alzheimer's, and non-Alzheimer's dementia. R1 received hospice services with a prognosis of less than six months of life.R1's care plan dated 5/27/26, indicated R1 had severe cognitive impairment related to neurocognitive disorder, Alzheimer's disease, and dementia and combative with cares. R1 received psychotropic medications. An intervention dated 6/21/24, directed staff to monitor occurrence for target behavior symptoms and document per facility protocol. A list of target behaviors was indicated, such as pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc.; however, the list target behaviors were not individualized to R1. The care plan indicated activities R1 enjoyed and other non-pharmacological interventions related to cognitive impairment, such as communication techniques and keeping a consistent routine; however, R1's care plan did not indicate if there were individualized, non-pharmacological interventions effective for R1's target behaviors.R1's Treatment Administration Record dated 4/1/26 to 5/29/26, indicated staff checked every shift for behavioral expression and referred to Behavior Expression progress note template for assessment and documentation requirements.R1's physician Order Summary Report, indicated: -On 4/16/26 to 4/30/26, lorazepam (part of a class of prescription central nervous system depressants used to treat anxiety, insomnia, seizures, and muscle spasms) oral tablet 0.5 mg (milligrams) by mouth every 6 hours as needed for anxiety/agitation/restlessness for 14 days.-On 5/7/26 to 5/21/26, lorazepam SoluTab (orally disintegrating tablet) 0.5 mg by mouth every 6 hours as needed for anxiety/restlessness for 14 days.-On 5/21/26 to 6/4/26, lorazepam SoluTab place and dissolve 0.5 mg buccally every six hours as needed for anxiety/restlessness for 14 days.-On 5/22/26, every two hour checks to assess for comfort/safety and if needing PRN medications, and call hospice if medications were not effective.-On 5/22/26 to 6/5/26, lorazepam SoluTab place and dissolve 0.5 mg buccally every two hours as needed for anxiety/restlessness for 14 days.-On 5/25/26 to 6/8/26, lorazepam SoluTab place and dissolve 1 mg buccally every two hours as needed for anxiety/restlessness for 14 days.R1's Medication Administration Record reviewed from 4/14/26 to 5/28/26, indicated R1 received PRN lorazepam on 18 occasions between this period. In review of R1's medical record dated 4/14/26 to 5/28/26, the record did not consistently identify individualized target behaviors to indicate reason for PRN psychotropic medication use and non-pharmacological interventions attempted or offered prior to the administration:-On 4/16/26, R1 self-transferred from bed, appeared restless, and brought into the common area for staff supervision. At 3:13 a.m., R1 received 0.5 mg of lorazepam as needed for anxiety/agitation/restlessness and noted R1 had restlessness and was unable to sleep. At 5:22 a.m., R1 was calm and sleeping. At 5:43 a.m., the PRN administration was identified as effective.-On 4/21/26 at 6:01 a.m., R1 received 0.5 mg of lorazepam as needed for anxiety/agitation/restlessness with note [R1] noted with anxiety. At 9:16 a.m., the PRN administration was identified as effective.-On 4/23/26 at 3:18 a.m., R1 received 0.5 mg of lorazepam as needed for anxiety/agitation/restlessness with note [R1] up and about. At 6:38 a.m., the PRN administration was noted as effective. At 1:03 p.m., a Hospice note identified R1 appeared comfortable with no signs/symptoms of pain or shortness of breath, and nursing staff did not have any new concerns besides R1 woke up at 2:00 a.m -On 4/25/26 at 9:55 a.m., R1 received 0.5 mg of lorazepam as needed for anxiety/agitation/restlessness. At 11:29 a.m., the PRN administration was noted as effective.-On 4/27/26 at 11:34 p.m., R1 received 0.5 mg of lorazepam as needed for anxiety/agitation/restlessness with note of non-pharmacological interventions attempted, which included snacks, repositioning, toileting, and music, and were not effective. R1 displayed restlessness and attempted to enter other residents' rooms. Redirection was somewhat effective. On 4/28/26 at 3:04 a.m., the PRN administration was ineffective. At 5:37 a.m., a note indicated R1 was awake most of the overnight shift and assisted to bed twice and had one-to-one observation.-On 5/14/26, R1 received 0.5 mg of lorazepam as needed for anxiety/restlessness at 7:29 p.m At 8:40 p.m., the PRN administration was noted as effective.-On 5/21/26 at 8:02 a.m., R1's left upper arm was swollen. The area was painful, and R1 was unable to move her arm. Vital signs were obtained, and the provider was notified. At 2:16 p.m., identified R1 received 0.5 mg of lorazepam as needed for anxiety/restlessness. At 4:27 p.m., the PRN administration was noted as effective. A note at 10:00 p.m., indicated R1 was observed in bed trying to get her legs outside the bed around 3:00 p.m., so staff changed R1 and transferred R1 into wheelchair using full lift and pillow to support her left hand.-On 5/22/26 at 9:38 a.m., R1 received 0.5 mg of lorazepam as needed for anxiety/restlessness. At 12:38 p.m., the PRN administration was noted as effective.-On 5/22/26 at 2:50 p.m., R1 received 0.5 mg of lorazepam as needed for anxiety/restlessness with note hospice nurse said ok to give, order being updated. At 7:42 p.m., the PRN administration was noted as effective. At 10:25 p.m., a hospice note identified R1 received comfort measures and had signs of pain with facial grimacing and yelling out. Agitation and restlessness noted in afternoon, and PRN medications were administered.-On 5/23/26 at 10:50 a.m., R1 received 0.5 mg of lorazepam as needed for anxiety/restlessness. At 1:18 p.m., the PRN administration was noted as effective.-On 5/24/26 at 10:05 a.m., R1 received 0.5 mg of lorazepam as needed for anxiety/restlessness. At 10:16 a.m., a hospice note indicated R1 was slightly clammy, had facial grimacing, and requested facility nurse to give as needed morphine. Calming music was utilized. At 11:01 a.m., identified R1's PRN administration of lorazepam was effective.-On 5/24/26 at 2:10 p.m., R1 received 0.5 mg of lorazepam as needed for anxiety/restlessness. At 3:51 p.m., the PRN administration was identified as effective. A progress note at 10:44 p.m., indicated R1 was comfortable and without signs of distress and comfort medications were administered as scheduled.-On 5/25/26 at 10:25 a.m., R1 received 0.5 mg of lorazepam SoluTab as needed for anxiety/restlessness. At 12:26 p.m., the PRN administration was identified as effective. At 2:29 p.m., a hospice note identified increased lorazepam scheduled and PRN.-On 5/25/26 at 7:23 p.m., R1 received 1 mg of lorazepam as needed for anxiety/restlessness. At 9:06 p.m., the PRN administration was indicated as effective.-On 5/27/26 at 10:34 a.m., R1 received 1 mg of lorazepam SoluTab as needed for anxiety/restlessness. At 2:28 p.m., a progress note indicated R1 appeared comfortable with shallow respirations.-On 5/28/26 at 7:42 p.m., R1 received 1 mg of lorazepam SoluTab as needed for anxiety/restlessness. At 9:58 p.m., the PRN administration was indicated at effective. A progress note at 10:55 p.m. indicated R1 had no signs of distress and appeared comfortable.-On 5/28/26 at 2:40 a.m., R1 received 1 mg of lorazepam SoluTab as needed for anxiety/restlessness. At 5:04 a.m., the PRN administration was noted as effective.-On 5/28/26 at 2:22 p.m., R1 received 1 mg of lorazepam SoluTab as needed for anxiety/restlessness. At 5:54 p.m., the PRN administration was noted as effective. At 9:57 p.m., a general note indicated R1 had no signs of distress.During interview on 6/2/26 at 3:20 p.m., nursing assistant (NA)-B stated R1 did not have anxiety or restlessness. NA-B stated R1 was busy and would not sit in one place and staff redirected her when needed.During interview on 6/2/26 at 3:38 p.m., registered nurse (RN)-B stated they knew which residents had anxiety by looking at their diagnoses. RN-B stated staff knew residents' behaviors and interventions from working with the residents and the care plan. RN-B stated they documented resident behaviors and non-pharmacologic interventions tried first before use of PRN psychotropic medication. RN-B stated R1 had anxiety and restlessness and wheeled herself around the building independently and would shout out hey one or two times and screamed when refused to eat or shower saying don't do it and I am not going. RN-B stated they spoke about R1's family to calm her down. Staff administered R1's as needed lorazepam when family stated R1 was anxious, and RN-B assessed R1's breathing pattern to identify if R1 was in distress and assessed relaxed breathing to know the as needed medication was effective.During interview on 6/2/26 at 4:53 p.m., the director of nursing (DON) reviewed R1's progress notes and care plan. The DON verified R1's PRN lorazepam medication administrations lacked consistent documentation of non-pharmacological interventions utilized prior to medication administration and nursing assessment to indicate reason for PRN lorazepam use. The DON stated the clinical coordinators updated care plans, resident monitoring, and Team sheets to indicate resident target behaviors and individualized non-pharmacological interventions.R2R2's admission MDS dated [DATE], indicated R2 had moderate cognitive impairment. R2 exhibited verbal behavioral symptoms directed toward others 1 to 3 days, which significantly disrupted care and living environments. R2's diagnoses included seizure disorder or epilepsy, traumatic brain injury, and anxiety disorder. R2 received antipsychotic, antianxiety, and antidepressant medication. The MDS indicated activity preferences as very important included books, newspaper, and magazines, music, animals, news, groups of people, favorite activities, fresh air, religious services.R2's care plan dated 5/27/26, identified R2 had an alteration in mood or behavioral expression and received psychotropic medications, such as antidepressant, antianxiety, and antipsychotic medications. R2's care plan directed staff to monitor occurrence for target behaviors and document per facility protocol; however, the care plan did not identify R2's individualized target behaviors. R2's care plan directed staff to encourage R2 to participate in activities of interest, explain all procedures to R2, intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, divert attention, and remove R2 from situation and take R2 to an alternate location as needed. The care plan did not specify individualized non-pharmacological interventions, such as music or television.R2's Order Summary Report, identified medications for anxiety with an order date of 5/19/26:-hydroxyzine HCl (hydrochloride) oral tablet 25 mg by mouth as needed three times a day for anxiety for 14 days.National Medical Association's Drug Information Database indicated hydroxyzine HCl is used for symptomatic relief of anxiety and tension associated with psychoneurosis (chronic emotional, mood, or anxiety disturbances) and as an adjunct in organic disease states in which anxiety is manifested. Hydroxyzine HCl is used as a sedative when used as a premedication and following general anesthesia. Hydroxyzine actions may be due to a suppression of activity in certain key regions of the subcortical area of the central nervous system.Review of R2's record dated 5/19/26 to 6/1/26, indicated POC (point of care) target behavior monitoring; however, the records did not indicate individualized target behavior for R2's anxiety or documentation of individualized non-pharmacological interventions.R2's progress and Medication Administration notes dated 5/19/26 to 6/1/26, indicated use of as needed medication for anxiety and lacked nursing assessment to indicate reason for PRN psychotropic medication and non-pharmacological interventions utilized first:-On 5/23/26 at 8:39 a.m., R2 received 25 mg of hydroxyzine as needed for anxiety and was identified as effective at 1:21 p.m -On 5/24/26 at 11:06 a.m., R2 received 25 mg of hydroxyzine as needed for anxiety and was identified as effective at 3:06 p.m -On 5/25/26 at 8:41 a.m., R2 received 25 mg of hydroxyzine as needed for anxiety and was identified as effective at 12:26 p.m -On 5/25/26 at 10:50 p.m., a progress note indicated R2 had an angry outburst, yelling loudly at dinner table, asking for double portions, and telling staff to wheel him around because he is paid to do it. The record did not indicate any further assessment or as needed medication use.R2's Psychotropic Medication assessment dated [DATE] at 11:24 a.m., identified R2 received 25 mg by mouth of hydroxyzine as needed for anxiety for 14 days three times a day and scheduled olanzapine 20 mg by mouth at bedtime for anxiety. R2's target behaviors/mood warranting the use of medication indicated anxiety and identified activities as non-pharmacological interventions currently used and effectiveness.During interview on 6/2/26 at 3:04 p.m., R2 stated they had been at the facility for two weeks. R2 stated he watched television or listened to music when anxious. R2 stated he had racing thoughts when he got anxiety but could not articulate what the specific thoughts were.During interview on 6/2/26 at 3:26 p.m., nursing assistant (NA)-A stated R2 yelled out and made loud sounds at times and could not articulate what he was saying. NA-A stated R2 had his music loud or on the phone often when she entered his room. NA-A stated they checked on R2 when they heard him, and R2 would sometimes say he would want his blinds closed and other times did not articulate why. NA-A stated they did not document resident behaviors, but they notified the nurse of resident behaviors. NA-A reviewed R3's Team sheet information dated 6/1/26, and the sheet indicated R3's ambulation and toileting status and other activity of daily living information. The sheet did not mention R3's behaviors or non-pharmacological interventions.During interview on 6/2/26 at 3:38 p.m., registered nurse (RN)-B stated they knew which residents had anxiety by looking at their diagnoses. RN-B stated staff knew residents' behaviors and interventions from working with the residents and the care plan. RN-B stated they documented resident behavior and non-pharmacologic interventions tried first before use of PRN psychotropic medication. RN-B stated R2 had anxiety and verified R2 had psychotropic medication use. RN-B stated R2 called out for assistance instead of using his call light and had not seen any other behaviors for R2.During interview on 6/2/26 at 4:53 p.m., the director of nursing (DON) reviewed R2's progress notes, assessment, and care plan. The DON expected staff to document how the resident shows anxiety, such as tearfulness or calling out for help, and what soothes the resident, such as music or a calm space. The DON verified R2's care plan lacked individualized target behaviors and non-pharmacological interventions for PRN medication use related to anxiety.R3R3's quarterly Minimum Data Set (MDS) dated [DATE], indicated R3 had moderate cognitive impairment and no hallucinations, delusions, behavioral symptoms, or rejection of care. R3's diagnoses included anxiety disorder and depression and received antipsychotic, antianxiety, and antidepressant medication.R3's Psychotropic Medication assessment dated [DATE], identified R3's target behaviors as agitation and non-pharmacological intervention currently used included social worker visits and watching television in the common area.R3's care plan dated 5/13/26, identified R3 received psychotropic medication and had an alteration in mood or behavioral expression related to anxiety and depression. The care plan directed staff to encourage R3 to participation in activities of interest, explain all procedures to R3, and intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, divert attention, and remove R3 from situation and take R3 to an alternate location as needed. The care plan did not indicate individualized target behaviors for R3. The care plan identified R3 enjoyed activities such as sorting poker chips, baking, crafts, sandbag toss, exercise class, devotionals.R3's Order Summary Report, indicated:-On 12/10/25, check and assess for agitation/restlessness and address accordingly every four hours.-On 12/19/25, behavioral expression: refer to behavior expression progress note template for assessment and documentation requirements every shift.In review of R3's PRN lorazepam administration documentation between 4/1/26 to 5/31/26, the record identified lack of individualized target behaviors to indicate reason for PRN psychotropic medication use and non-pharmacological interventions utilized first.-On 4/1/26 at 1:20 p.m. R3 received 0.5 mg of lorazepam as needed for anxiety/restlessness, and the PRN administration was identified as effective at 1:46 p.m -On 4/24/26 during 2:00 a.m. rounds, R2 was sitting at edge of bed looking for daughter who R2 thought was sleeping in the room next to her. The note indicated scheduled lorazepam was given, and R2 went back to bed.-On 4/29/26, R3 woke up around 1:00 a.m At 5:00 a.m., R3 received 0.5 mg of lorazepam as needed for anxiety/restlessness with a note indicating R3 had restlessness, and the PRN administration was identified as effective at 12:31 p.m -On 5/12/26, R3 was observed sitting on the floor at about 3:00 p.m. and stated she crawled out of bed to prepare the house for her child's birthday party. Physical assessment and vitals were completed. Full lift was used to transfer R3 to a chair.-On 5/13/26 at 12:00 a.m., R3 received 0.5 mg of lorazepam as needed for anxiety/restlessness, and the PRN administration was identified as effective at 7:08 a.m During interview on 6/2/26 at 3:20 p.m., nursing assistant (NA)-B stated R3 was anxious at times, such as suggesting going out the window to get to cars outside and not understanding the need to go through the building and out a door to get outside. NA-B stated they did not leave R3 alone in her room and encouraged R3 to read a book in the common area. NA-B stated they charted behaviors in POC (point of care) and told the nurse when they noticed R3 had anxiety or any behaviors. NA-B stated they knew about resident behaviors from their Team sheets. NA-B reviewed R3's sheet, and the sheet directed staff to not leave R3 in room alone, bring to common area, and talk to nurse if observed restlessness.During interview on 6/2/26 at 3:38 p.m., registered nurse (RN)-B stated they knew which residents had anxiety by looking at their diagnoses. RN-B stated staff knew residents' behaviors and interventions from working with the residents and the care plan. RN-B stated they documented resident behavior and non-pharmacologic interventions tried first before use of PRN psychotropic medication. RN-B verified R3 had as needed and scheduled psychotropic medication. RN-B stated R3's behaviors included crawling out of bed and thoughts of her children being young, such as needing to prepare a birthday party for a child, although her children were grown. RN-B stated R3 did not like to sit with people or noise, and RN-B would show R3 pictures on her wall of her grown children and grandkids.During interview on 6/2/26 at 4:53 p.m., the director of nursing (DON) reviewed R3's progress notes and care plan. The DON verified the record did not consistently indicate the reason for PRN psychotropic administration. The DON stated the care plan did not indicate how R3 displayed anxiety, and although the care plan indicated what activities R3 enjoyed, the DON expected a more robust care plan related to non-pharmacological interventions for R3's anxiety.The facility Psychotropic Medication Use Policy dated 3/2025, directed staff to monitor specific target behaviors for psychotropic medications. The policy indicated resident care plans were to include resident-specific target behaviors associated with psychotropic medication use and individual interventions. The policy indicated documentation would demonstrate resident subjective or objective improvements or maintenance of function while the resident received the medication.

Based on interview and document review, the facility failed to report an injury of unknown origin within the two-hours for 1 of 1 resident (R1) who had an injury of unknown origin of the left humerus (the long bone located in the upper arm, from the shoulder to the elbow).Findings include R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had severe cognitive impairment, unclear speech, and impaired vision. R1 had disorganized thinking and no behaviors or rejection of care. The MDS identified R1's diagnoses included non-traumatic brain dysfunction, peripheral vascular disease, renal failure, Alzheimer's, and non-Alzheimer's dementia. R1 had hospice services with prognosis of less than six months of life. R1 was independent with wheelchair use, required partial and/or moderate assistance with eating and substantial/maximum to dependent on staff for other activities of daily living, such as transfers, dressing, toileting, and bed mobility.R1's abuse and/or neglect care plan focus dated 6/3/24, directed staff to follow the facility Vulnerable Adult Policy and keep R1 safe at all times.R1's progress note dated 5/21/26 at 8:02 a.m., identified R1's left upper arm was swollen. The area was painful, and R1 was unable to move her arm. Vitals were 126/93 mmHg (millimeters of mercury; standard unit of measurement for blood pressure), 99.7 degrees F (Fahrenheit), 18 RR (respiratory rate; number of breaths a person takes per minute), and 68 pulse. The provider was updated.R1's progress note dated 5/21/26 at 3:25 p.m., identified a 2-view x-ray of the left humerus was ordered.R1's Radiology Report dated 5/21/26, identified R1 had an acute mid humeral shaft fracture.R1's progress note dated 5/22/26 at 5:50 a.m., identified the DON was contacted about the results of the x-ray. R1 received scheduled pain medication for pain in her left arm, and R1's left arm was warm to touch, red in color, and swollen.The facility reported incident (FRI), submitted to the state agency on 5/22/26 at 9:30 a.m., identified R1 had an acute fracture deformity of the mid humerus shaft with mild displacement of the left arm. The report identified a nursing assistant noticed R1 grimacing and holding left arm while getting R1 up for the day. The nursing assistant noticed R1's left arm was swollen, and a nurse assessed R1 around 8 a.m. and notified R1's hospice team. An x-ray was ordered STAT (immediately, without delay), obtained in the afternoon of 5/21/26, and results were confirmed on 5/21/26 at 11:42 p.m Alleged perpetrator 1 information indicated unknown.During interview on 6/2/26 at 9:02 a.m., registered nurse (RN)-A stated they received report from the evening shift on 5/21/26 about waiting for the results of R1's x-ray. RN-A did not remember what time the x-ray result was received and stated they reported the results to the director of nursing (DON) and the triage provider line.During interview on 6/2/26 at 12:42 p.m., the DON stated the overnight nurse notified them of the x-ray results at 11:47 p.m. on 5/21/26, and verified the facility submitted their initial report to the State Agency on 5/22/26 at 9:30 a.m During follow-up interview on 6/2/26 at 4:53 p.m., the DON stated they started to interview staff about R1 Thursday morning on 5/21/26. The DON stated at the time of R1's x-ray result they had interviewed staff, reviewed camera footage, and continued to interview staff. The DON stated they could not determine someone had harmed R1 at the time of the x-ray results. By the end of Friday, 5/22/26, they were concluding R1's fracture was not a result of abuse or harm and continued to interview staff.On 6/2/26 at 6:28 p.m., the administrator stated abuse had not been ruled out at the time of the fracture report.The facility Vulnerable Adult Abuse Prevention Plan dated 10/2025, indicated allegations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, will be reported immediately within the state and federal guidelines. The policy directed the administrator or designee to report no later than two hours after the allegation is made if the event that caused the allegation involved abuse or resulted in serious bodily injury.

Based on observation, interview and document review, the facility failed to ensure food safety practices including proper food storage such as labeling and dating foods stored in the kitchen as well as monitoring the temperature of the dishwashers and refrigeration/freezer units and maintaining a sanitary work environment in the main kitchen and kitchenettes on the resident floors. This had the potential to affect ,d+[DATE] residents. Findings include: Food storage During the initial kitchen tour on [DATE], at 7:17 a.m., the following items were discovered in the walk-in refrigerator without proper label/date; 12 Quart clear plastic square storage container with a blue lid ,d+[DATE] full of unknown cream colored liquid, a small, metal pan of pork cutlets- covered with plastic wrap, breaded meat in an uncovered, flat, metal pan, diced onions in clear plastic, square, covered container with plastic wrap, four separate small, metal pans - contained rice, mashed potatoes, chicken breast, and sliced zucchini as well as a sealed, plastic storage bag of raw hot dogs in in a small, metal pan, frozen shrimp in a large, metal pan covered with plastic wrap, cottage cheese in original container ,d+[DATE] full, and a large clear, plastic, covered container with mixed melons/grapes/pineapple. During an interview on [DATE], at 7:37 a.m., culinary director (CD)-A stated she expected staff to label cooked food items and containers when opened, before they were put in the walk-in refrigerator. Items needed to be used within five days of being cooked or opened. CD-A stated this was important, so expired food was not served to vulnerable residents. During an observation on [DATE], at 03:05 p.m., in the second-floor kitchenette, the reach in refrigerator had whipped topping in a partially used disposable, plastic tube with no cover on the open tip and no date label. A small amount of dried whipped topping was noted on outside of tube and the dispensing tip. During an interview on [DATE], at 10:06 a.m., corporate certified dietary manager (CDM)-B stated she expected items were labeled and dated when opened. Facility policy titled Labeling and Dating Policy (Ready to Eat and/or Potentially Hazardous Food) dated ,d+[DATE], indicated ready to eat and potentially hazardous food items should be labeled and dated when opened. Kitchen Sanitation- During interview on [DATE], at 7:54 a.m., CD-A stated they have tried to point out cleaning tasks to dietary staff with the intention tasks were completed when noticed. Facility implemented more cleaning recently; however, no check list/log had been developed for cleaning. During observation on [DATE], at 2:45 p.m., in the second-floor kitchenette the following items were noted; counter shelf above microwave had red syrup-like substance spilled on it, steam table had all pan lids soiled (both sides) with unknown dark brown substance as well as on removable stainless-steel divider bars. During observations on [DATE], at 3:11 p.m., the third-floor kitchenette ice and water machine had cloudy clear plastic ice dispenser chute and water tube had an unknown brownish colored substance inside. During observations [DATE], at 3:11 p.m. and [DATE], at 10:21 a.m. the third-floor steam table had all pan lids soiled (both sides) with unknown dark brown substance and unknown dark, brown substance on each divider bar. During observations on [DATE], at 10:26 a.m., the second-floor steam table had all pan lids soiled (both sides) with unknown dark brown substance and removable stainless-steel divider bars had unknown dark brown substance on each. bar Additionally, the swinging doors contained built up fingerprints and general soiled appearance, sticky to touch. During interview and observation with CDM- B, on [DATE], at 09:56 a.m., the third-floor floor steam table had all pan lids soiled (both sides) with unknown dark brown substance and removable stainless-steel divider bars had unknown dark, brown substance on each bar. Additionally, the ice and water machine had a cloudy clear plastic ice dispenser chute and water tube had an unknown brownish colored substance inside. CDM-B confirmed presence of brown substance. CDM-B stated she expected kitchen staff would oversee cleaning the beverage station. The beverage station, in the current state, did not meet CDM-B's expectations. Facility document titled Infection Prevention and Control Manual, Dietary Department, page ,d+[DATE] Dated 2020 from Pathway Health Services section H. Cleaning Procedures: a.) Dietary department is cleaned on a regular schedule and logs are maintained. Temperature Logs: During an interview on [DATE], at 1:29 p.m., the kitchen supervisor (KS)-C stated CD-A, himself and the day supervisor were responsible for ensuring the logs were completed. KS-C also stated it was important to make sure the logs are completed because they bring food to different areas upstairs where residents are served. Review of the ,d+[DATE], Temperature Logbooks from the kitchenettes on the second and the third floor which were stored under counters had missing several entries for month of March, dishwasher temp and fridge freezer temp logs each missing several entries. Record review of [DATE] temperature logs noted the following information: Main kitchen - - Dish machine temperature log was missing ,d+[DATE] entries with an additional 7 entries that were below the required temperature. - Walk-in refrigerator log was missing ,d+[DATE] entries - Walk-in freezer log was missing ,d+[DATE] entries. [NAME] one kitchenette- - Reach-in refrigerator was missing ,d+[DATE] entries for the morning shift and ,d+[DATE] entries for evening shift. - Dish machine included eight missing entries for wash temperature for breakfast shift and 8 missing entries for rinse temperature for breakfast shift. - Dish machine over the noon hour was missing nine entries for wash and nine entries for rinse temperatures. - Dish machine for the evening meal wash included 15 missing entries and one reading below required temperature, and 11 missing entries for rinse temperatures. Facility policy Infection Prevention and Control Manual, Dietary Department page ,d+[DATE] Section E 2 f. indicates High temperature dish machine water temperature should be at least 150 degrees F or according to manufacturer's specifications. Rinse temperature will reach at least 180 degrees or manufacturer's instructions. Hair Nets: During initial kitchen observation and interview on [DATE], at 7:40 a.m., a volunteer, with blonde/gray hair was noted to have no hair covering, was walking throughout the kitchen including cooks' area where the cook was preparing food, dish room, storage area CD-A stated she expected hairnets worn in the kitchen by everyone in the kitchen regardless of their reason for being in the kitchen. CD-A stated it was very important everything must be sanitized. She expected everyone to wear one and expected the whole head of hair to be covered. Observation made on [DATE], at 09:45 a.m., in the main kitchen, an unidentified cook was observed wearing a hairnet on top of hair, back of hair down past shoulders, was not contained within the hairnet. Observation and interview on [DATE], at 09:58 a.m., an unidentified nursing assistant (NA) entered the kitchenette on third floor without wearing a hair net. NA was observed preparing toast for a resident behind the kitchenette counter. When NA was asked by CDM-B if there were hairnets available, the NA was not aware of hairnet rules or location. CDM-B stated it was expectation that all staff be wearing hairnets that cover all hair in any food prep areas, and stated the facility has had challenges with nursing staff coming in and out of kitchenettes without hair covering. Review of facility policy, Nutrition & Culinary Uniform Policy revised [DATE], stated that all staff must wear hair restraints while preparing food in prep areas to prevent hair from contacting/contaminating food. Additionally, the policy identified areas behind the cook line, kitchenettes where staff are serving food, and special events where staff would be preparing food.

Based on interview and document review, the facility failed to ensure the Physician Orders for Life Sustaining Treatment (POLST) was reviewed and/or revised following a change in condition comprehensive assessment for 1 of 1 residents (R1) reviewed. Findings include: R1's significant change Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses of chronic kidney disease, dementia, and malignant neoplasm of sigmoid colon. Further, R1's cognition was noted to be moderately impaired. R1's POLST dated 9/13/24, which was signed by R1's health care agent and family member (FM)-A, indicated R1's wishes were to be do not attempt resuscitation (DNR), allow natural death, in the event R1 had no pulse and was not breathing, as well as comfort-focused treatment (allow natural death) to relieve pain and suffering through the use of any medications by any route, positioning, wound care, and other measures. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. Patient prefers no transfer to hospital for life-sustaining treatments. Transfer if comfort needs cannot be met in current location. R1's care conference summary printed 12/5/24, indicated a care conference was held on 11/21/24, with FM-A present. Further, the document revealed information shared included code status of DNR and comfort-focused treatment and to see R1's POLST for details. In addition, the questions: advanced directives reviewed with the resident/resident representative and does the POLST match the code status order were left blank and not completed by staff. The summary lacked evidence the POLST was reviewed with resident/resident representative. However, on 12/6/24, summary revealed revisions had been made by social services (SS)-A indicating advanced directives were reviewed with the resident/resident representative. On 12/5/24 at 12:03 p.m., FM-A indicated when R1 was admitted to the facility with hospice services and a POLST was completed for R1 by FM-A, which indicated R1 wished to be DNR and comfort focused treatment. FM-A stated R1's health improved and no longer qualified for hospice services. FM-A stated the facility initiated a care conference following R1 discharging from hospice services, however the facility staff did not review R1's POLST with FM-A at the meeting and R1 remained DNR and comfort focused treatment. FM-A stated had she been given the option to review the POLST at that time, she would have revised the POLST to not include comfort focused treatment due to R1 wanting to live and hospice was no longer involved in R1's care. FM-A stated she was R1's power of attorney and health care agent. On 12/6/24 at 12:17 p.m., registered nurse (RN)-A stated during each resident's care conference the POLST was expected to be reviewed. RN-A stated social services (SS) would review the POLST with the resident and the resident representative. Further, RN-A stated on the day of R1's care conference, RN-A was not present when the POLST would have been reviewed so she was unsure if SS-A reviewed the POLST. RN-A was not aware of any revisions to R1's POLST either. On 12/10/24 at 11:58 a.m., SS-A stated on 11/21/24, R1 had a significant change care conference related to ending hospice services. SS-A stated she checked R1's POLST order in the computer and offered the option to make changes, which no changes were requested. SS-A stated the discussion could be confirmed by RN-A. SS-A stated she did not lock the care conference summary following the meeting as expected, no revisions were made but confirmed she did not check the boxes related to code status prior. On 12/10/24 at 12:45 p.m., director of nursing (DON) stated staff were expected to review the resident's POLST during care conferences and change in condition or when a family requested. Review of facility policy titled Code Status: Physician's Order for Life Sustaining Treatment Policy dated 6/11, indicated advanced directors/other treatment options may be discussed in a care conference and at any time the form can be updated to reflect any changes requested and with any significant change in status.

Based on interview and document review, the facility failed to monitor and evaluate response to interventions for 1 of 1 resident (R1) identified to have been taking antibiotics for a urinary tract infection (UTI). Findings include: R1's significant change Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses of chronic kidney disease, dementia, and malignant neoplasm of sigmoid colon. Further, R1's cognition was noted to be moderately impaired. R1's medication administration record (MAR) and treatment administration record (TAR) for the month of November 2024, indicated Keflex 500 milligram (mg) twice daily for UTI until 11/15/24, ordered on 11/13/24 and Macrobid 100 mg twice daily for retention of urine for 5 days begin on 11/8/24 discontinued on 11/12/24. Further on 11/8/24, refer to infection progress note template for assessment and documentation requirements. Document at least with the start and the end of an antibiotic regimen and during the course of treatment with clinical change or vital signs/assessment that was not within normal limits one time a day for clinical monitoring for seven days. Review of R1's progress notes revealed the following: -On 11/8/24, resident had a new foley catheter inserted, urine sample was collected to rule out infection. Resident was started on Macrobid, and first dose had been given at the hospital. -On 11/8/24, R1 returned at 1:00 p.m. with a new catheter inserted and a five-day prescription for Nitrofurantoin 100 mg, twice a day with breakfast and dinner. -On 11/10/24, Infection Note included type of infection was urine retention, vital signs were obtained, treatment was Macrobid 100 mg twice a day for 3 days, response to treatment was ongoing, no notification to provider was needed, date resolved was ongoing. -On 11/14/24, Infection Note included type of infection urinary tract, vitals obtained, treatment included Keflex 500 mg by mouth twice daily until 11/15/24, response to treatment was ongoing, and date resolved was ongoing. R1's progress notes lacked consistent monitoring and evaluation for effectiveness of treatment through the antibiotic course. On 12/5/24 at 4:38 p.m., licensed practical nurse (LPN)-A stated if a resident was ordered antibiotics staff were expected to implement infection monitoring which would include obtaining vital signs every shift as well as documenting the medication and the reasoning for the medication. On 12/5/24 at 4:54 p.m., registered nurse (RN)-C stated she recalled R1 being prescribed an antibiotic for urinary infection. RN-C stated staff were expected to monitor a resident on antibiotics for at least seven days to ensure the treatment was effective and there were no adverse reactions, and the monitoring included obtaining vitals signs every shift. On 12/6/24 at 9:37 a.m., LPN-B stated staff were expected to monitor the resident for symptoms of the infection, obtain vital signs, and effectiveness of treatment for the duration of the antibiotic. The treatment for monitoring was typically added as a treatment order in the resident's record and would be expected to be completed every shift. On 12/6/24 at 12:17 p.m., RN-A stated at the start of the resident's antibiotic staff were expected to document a progress note related to the resident's status and condition as well as at the end of the antibiotic course. Further, RN-A stated staff would be expected to obtain vital signs with each administration of the antibiotic, or at least once a shift, due to resident having a change in condition requiring an antibiotic. RN-A stated monitoring a resident would be important during the antibiotic course to ensure the treatment was effective and no adverse reactions. RN-A stated R1 was started on an antibiotic for a urinary tract infection (UTI) and completed the antibiotic on 11/15/24. RN-A stated nurses were expected to be monitoring R1's urine for any signs or symptoms of a UTI and monitoring vital signs every shift because R1 was on treatment and staff should have been keeping a close eye on him for anything abnormal. Further, RN-A confirmed staff were not consistent with obtaining vital signs and there were very poor notes related to monitoring R1 during his antibiotic course. On 12/10/24 at 10:35 a.m., nurse practitioner (NP) stated the facility's goal was good stewardship of antibiotic use and would expect staff to obtain vital signs every shift for at minimum three days to ensure the resident was stable because the antibiotic should have kicked in and be effective. NP would also expect staff to update her with the effectiveness of the antibiotic. On 12/10/24 at 12:45 a.m., director of nursing (DON) stated there was a standard practice for monitoring infections that staff were expected to implement right away which included staff documenting a progress note in the resident's record with type of infection, symptoms, all vital signs, change in condition, isolation precautions, response to treatment, and notifications to the provider (if needed). Further, DON stated he would expect the clinical coordinator on the unit to initiate the monitoring and would expect the monitoring to be completed every shift as once daily would not reveal accurate information due to over a few hours the resident could have a change in condition. Further, DON confirmed R1 was on antibiotic treatment from 11/8 through 11/15/24 and there was only monitoring on 11/10/24 and 11/14/24. DON stated there was a problem with documentation and it was a learning opportunity. In addition, DON stated monitoring an antibiotic was important to ensure the treatment was effective and no further infection concerns were noted. Review of facility policy titled Infection Control-Antibiotic Stewardship Procedure dated 8/17, directed the nursing to complete progress note and documentation at the start and end of an antibiotic regimen, with any change in condition, and monitor/review response to antibiotics, and laboratory results when available, to determine if the antibiotics was still indicated or adjustments should be made. However, the policy lacked identification how often staff were required to monitor or evaluate the response to antibiotics or obtain vitals.

Based on observation, interview, and document review, the facility failed to ensure proper glove use and hand hygiene was performed during assistance with toileting and incontinence care for 2 of 4 residents (R5, R4) reviewed for toileting needs. Findings include: R5's significant change Minimum Data Set (MDS) dated [DATE] indicated R5 needed extensive assistance with personal hygiene. On 7/11/24 at 9:30 a.m., nursing assistant-A (NA-A) entered R5's room to assist him to the bathroom. NA-A assisted R5 to the bathroom and placed gloves on without performing hand hygiene. NA-A assisted R5 to stand after he was done urinating and wiped his peri area and buttocks with toilet paper. Urine was in the toilet. NA-A took off the soiled gloves, and without performing hand hygiene, assisted R5 to pull up his pants and sit in his wheelchair. NA-A assisted R5 back to his bedside in his wheelchair, and placed the TV on for him to watch. NA-A washed her hands prior to exiting the room. R4's annual MDS dated [DATE] indicated R4 needed extensive assistance with personal hygiene. On 7/11/24 at 10:42 a.m., NA-A entered R4's room to provide peri cares. NA-A closed the blinds and donned gloves without performing hand hygiene. NA-A wiped R4's peri area and buttocks, removed R4's soiled incontinent brief and placed a clean incontinence brief under R4. NA-A removed the soiled gloves, and without performing hand hygiene, donned clean gloves. NA-A assisted with getting R4 back in her wheelchair, placed oxygen back on R4, and sanitized the mechanical lift. NA-A doffed her gloves and washed her hands. On 7/11/24 at 11:02 a.m., NA-A stated normally she would use hand sanitizer before putting gloves on and after taking them off, but there was no sanitizer within reach, so she didn't hand sanitize when caring for R4 and R5. On 7/12/24 at 8:41 a.m., the director of nursing (DON) stated staff should do hand hygiene before and after taking off gloves. On 7/12/24 at 8:56 a.m., the administrator stated staff should wash their hands before and after applying gloves. The facility policy Infection Control Standard Precautions dated 2020 directed hand hygiene should be performed before donning and doffing personal protective equipment.

Based on interview and document review, the facility failed to ensure injuries of unknown origin were reported to the State Agency (SA) immediately (within two hours) for 1 of 2 residents (R1) reviewed for injuries of unknown source. Findings include: On 3/25/24 at 3:10 p.m., a facility reported incident (FRI) submitted to the SA indicated R1 had bruises of unknown origin. These included bruising on her left upper inner arm measuring 30 centimeters (cm) x 5cm, the left palm of her hand measuring 4 cm x 1 cm, her left shoulder measuring 5 cm x 4 cm, and a skin tear to her left knee measuring 5 cm x 4 cm. R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1 had severe cognitive impairment, and had a diagnosis of dementia. The MDS indicated R1 required substantial to maximum assistance of staff for all personal care and transfers. The MDS also indicated R1 was non-ambulatory, required a manual wheelchair for all locomotion, and she had a history of falls. On 3/23/24 at 2:15 a.m. a progress note indicated R1 had an open area and bruise. The documentation lacked location, description and measurements of the open area and the bruise. On 3/23/24 at 10:44 a.m. a progress note indicated R1 had pain in her left leg, and a skin tear below her left knee. The progress note lacked a description or measurements of the skin tear. On 3/24/24 at 2:18 p.m. a progress note indicated R1 had a bruise to her left hip area. The progress note lacked a description or measurements of the bruise. On 3/24/24 at 5:00 p.m., a facility Resident Occurrence Report indicated R1 had a bruise to her left inner arm measuring 4 cm x 2 cm and a bruise to her left shoulder. The report indicated the DON was notified of the injuries on 3/24/24. On 3/24/24 at 5:16 p.m. a progress note indicated R1 had a bruise to her left upper inner arm of unknown origin. The progress note lacked a description and measurement of the bruise. On 3/24/24 at 6:55 p.m. a progress note indicated R1 had a bruise to her left upper inner arm measuring 4 cm x 2 cm. On 3/25/24 at 3:17 p.m. a progress note indicated a adult report was made regarding the bruising. A facility document Resident Occurrence Report dated 3/23/24 at 2:15 a.m., indicated R1 had an open area on left leg below the knee. A facility document Resident Occurrence Report dated 3/24/24 at 8:00 a.m., indicated R1 had a bruise to her left hip measuring 3 cm x 3cm. The report indicated the director of nursing (DON) was notified of the injury on 3/24/24 at 2:13 p.m. On 3/29/24 at 10:10 a.m., licensed practical nurse (LPN)-A stated R1 had a skin tear and pain to her left leg on the morning of 3/23/24. LPN-A stated he notified the DON of the injury right away. On 3/29/24 at 11:39 a.m., registered nurse (RN)-A stated on 3/24/24 nursing assistant (NA)-A notified her of R1 bruise to R1's left upper arm. She stated the bruise measured 4 cm x 2 cm, and R1 was unable to identify how she sustained the bruise. RN-A stated she notified the DON of the bruise at 4:00 p.m. on 3/24/24. On 3/29/24 at 11:57 a.m. NA-A stated she first saw the bruise to R1's left upper arm on 3/24/24 after lunch, when she was assisting R1 to put a sweater on. She stated she informed RN-A immediately of the bruise. On 3/29/24 at 12:57 p.m., the DON stated LPN-A called him on 3/23/24 around 2:00 p.m., to report left hip bruise and pain. LPN-A was not aware of an origin for the bruise and pain. RN-A called him on 3/24/24 at 4:00 p.m., to report R1's left upper inner arm bruise measuring 4 cm x 2 cm. The DON stated RN-A was not aware of an origin for the bruise. On the morning of 3/25/24 he observed the bruises to R1's left hip, inner arm, palm of hand and shoulder. He made the report to the SA on 3/25/24 at 3:00 p.m. He stated he did not report the bruises of unknown injury because R1 likely had an unwitnessed fall. On 3/29/24 at 1:14 p.m., the administrator stated the facility should investigate injuries of unknown origin, and report to the SA right away. The facility policy Vulnerable Adult Abuse Prevention Plan dated 1/23 directed each resident has the right to be free from abuse including but not limited to verbal, sexual, physical, and mental abuse, injuries of unknown origin, corporal punishment, misappropriation of property, mistreatment, neglect or involuntary seclusion. The policy directed allegations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property will be reported immediately within the state and federal guidelines.

Based on observation, interview and records review, the facility failed to correctly transcribe and administer an ordered medication for 1 of 1 residents (R11) reviewed for quality of care. Findings include: R11's quarterly Minimum Data Set (MDS) dated [DATE], indicated that R11 had intact cognition and was diagnosed with heart failure, kidney failure, respiratory failure, and chronic obstructive pulmonary disease (COPD- incurable lung disease causing breathlessness, frequent coughing, and chest tightness). The MDS indicated R11 was receiving oxygen therapy and hospice care but indicated R11 did not demonstrate shortness of breath during the look-back period. The MDS indicated R11 required moderate assistance with dressing, supervision with transferring, and was independent with eating. R11's care plan dated 9/11/23, indicated R11 received hospice care related to her diagnosis of COPD. The care plan indicated R11 had an alteration in respiratory status related to COPD, heart failure, and dyspnea (shortness of breath) with exertion. The care plan goal was limiting respiratory distress that impacted R11's activities of daily living and listed the following interventions: administering medications and monitoring respiratory status per the physician's orders, providing oxygen therapy, and encouraging rest periods. R11's written provider report dated 10/24/23, indicated an order for oxycodone 5 mg by mouth every one hour as needed for pain/dyspnea. The report indicated that two staff members had signed off on the order, one of them being licensed practical nurse (LPN)-D. R11's Order Summary Report dated 10/24/23, included an order for five milligrams (mg) of oxycodone every one hour as needed for pain. The order did not include an administration indication of dyspnea but indicated the order was prescriber-written. The report also included an order for three milliliters (mL) of .63 mg/3mL albuterol sulfate nebulization solution every six hours as needed for COPD. R11's medication administration record (MAR) dated 1/1/24-1/31/24, indicated R11 did not receive any doses of oxycodone during this period. R11's MAR dated 2/1/24-2/14/24, indicated R11 received three doses of oxycodone for pain ranging from six to 10/10 during this period. R11's provider note dated 1/9/24, indicated R11 was diagnosed with end-stage COPD and had ongoing dyspnea. During an interview on 2/12/24 at 2:09 p.m., R11 stated she often felt short of breath and sometimes felt like she was suffocating, but she had concluded that the nursing staff did not know how to help her with this symptom. R11 stated nursing staff would sometimes try to give her nebulizer breathing treatments but they usually did not help. R11 stated she now tried to manage her shortness of breath on her own because she felt that the nursing staff did not implement helpful interventions for her shortness of breath, and it often left her in distress. During an interview on 2/13/24 at 11:59 a.m., LPN-D stated that she noticed that R11 had occasional dyspnea so she would assess R11's oxygen level, titrate her oxygen level as needed, and give her nebulizer breathing treatments when necessary. LPN-D stated that oxycodone was only used to treat pain and not dyspnea. During an interview on 2/13/24 at 1:27 p.m., Medical Doctor (MD)-A stated that to minimize R11's dyspnea, the only real treatment is morphine because of R11's diagnoses of end-stage COPD and heart failure. MD-A then stated that the ordered oxycodone would work similarly to morphine to address R11's dyspnea. MD-A stated that titrating R11's oxygen would not have been a helpful strategy related to her COPD diagnosis. During an interview and observation on 2/14/24 at 11:08 a.m., the third-floor clinical coordinator (RN)-H stated that if R11 was reporting or demonstrating symptoms of dyspnea he expected the nurse on duty to check oxygen levels and titrate her oxygen therapy, test for COVID-19, and administer a nebulizer as needed. RN-H stated that if the nebulizer did not work he expected the nurse to contact the hospice team for further orders. RN-H was observed reviewing the written order dated 10/24/23 which indicated the oxycodone was written for pain and dyspnea. RN-H stated that he did not think that oxycodone was an appropriate treatment for dyspnea and would need to call the provider to verify that the written order was correct but did not think that had been completed previously. RN-H verified that the health unit coordinator (HUC) and a nurse had signed off on the order as was their protocol. During an interview on 2/15/24 at 10:15 a.m., the director of nursing (DON) stated that when a written order was received from a prescriber, the HUC queued the order and the nurse on duty would then confirm that the order in the queue was accurate before the order became active. The DON stated that if the nurse was unsure about an order, the nurse should then contact the ordering prescriber to obtain clarification. The DON stated that ensuring that the written orders were correctly transcribed into the electronic medical record was very important, especially as the oxycodone would likely have been helpful in treating R11's shortness of breath. A policy/procedure regarding transcribing physician orders was requested and not received.

During observation, interview and document review, the facility failed to ensure resident call lights were accessible for 3 of 3 residents (R8, R67, R195) reviewed for call lights. Findings include: R8 R8's quarterly Minimum Data Set (MDS) dated [DATE] indicated R8 had severe cognitive impairment and required assistance for all hygiene, dressing, and mobility. In addition, R8 had diagnoses including dementia, coronary artery disease (impaired blood flow to the heart), and renal disease. R8's care plan (CP) dated 8/7/22 indicated, Place call light within reach and answer promptly. During observation on 2/12/24 at 3:12 p.m., R8 was sleeping in bed with the call light looped through a plastic tube attached to bed frame aligned with R8's left shoulder. However, the controller for the call light was laying on the floor out of reach of R8. During observation on 2/14/24 at 7:36 a.m., R8 was sleeping in bed with the call light looped through a plastic tube attached to bed frame aligned with R8's left shoulder. However, the controller for the call light was laying on the floor out of reach of R8. During interview with licensed practical nurse (LPN)-C on 2/14/24 at 7:36 a.m., LPN-C stated regarding the call light, not in reach for her and it should be because [sic] very very important that it is in reach. R67 R67's quarterly MDS dated [DATE] indicated R67 had severe cognitive impairment, and required substantial assistance for toileting and dressing. Also, R67 with had diagnoses of Alzheimer's disease, dementia, depression, and psychosis. R67's CP dated 5/10/21 indicated, Be sure my call light is within reach and encourage me to use it for assistance as needed. During observation on 2/12/24 at 3:06 p.m., and 5:40 p.m., R67 was laying on bed uncovered with a blanket on the floor. R67's call light was coiled up on the floor under the head of bed and out of reach. During observation on 2/13/24 at 7:45 a.m., R67 was laying in bed covered with blanket up to the chin with the call light coiled up on the floor under head of bed out of reach. During observation on 2/13/24 at 10:56 a.m., R67 was laying in bed covered with blanket up to the chin with the call light coiled up on the floor under head of bed out of reach. During observation on 2/14/24 at 7:36 a.m., R67 was laying in bed with call light coiled up on the floor under the head of the bed and out of reach. Surveyor requested licensed practical nurse (LPN)-C to R67 bedroom. LPN-C stated regarding the call light, it is not in reach [of R67] and pinned it to R67's pillow case in reach of R67. R195 R195's admission MDS dated [DATE] indicated R195 had moderate cognitive impairment and required substantial/maximal assistance with toileting and mobility. Also, R195 had diagnoses of heart failure, anxiety, arthritis, dementia and macular degeneration (age related vision loss). R195's CP dated 2/2/24, indicated, Place call light within reach and answer promptly. During observation on 2/13/24 at 8:02 a.m., R195 was sitting in a recliner with the call light attached to the floor lamp behind her right shoulder with the controller on the floor out of sight and reach of R195. R195 stated, I can't reach it. I guess I would have to just wait here until someone comes in here to see if I am okay or just yell out. During observation and interview on 2/13/24 at 1:11 p.m., R195 was sitting in a recliner with the call light attached to the floor lamp behind her right shoulder with controller on the floor out of sight and reach of R195. LPN-A stated, Call light is not in reach and it should be. During interview with R195's family member (FM)-B on 2/14/24 at 8:30 a.m., FM-B stated, yes, I think it is important that she [R195] has the call light by her hand so she knows that she can use it if she needs it. How else is she [R915] going to get help if she doesn't have a means to ask for it? During interview with nursing assistant (NA)-A, on 2/13/24 at 10:49 a.m., NA-A stated, call lights should be in reach of everybody to help them. During interview with registered nurse (RN)-B, on 2/13/24 at 1:02 p.m., RN-B stated, call light [need to be] close to patient so they can ask for help. During interview with NA- C on 2/14/24 at 7:46 a.m., NA-C stated call lights, need to be close so they can reach in case they need [something]. It should be up where she [R195] can reach it. During interview with registered nurse (RN)-D on 2/14/24 at 10:20 a.m., RN-D stated regarding call lights, within reach so they can have access to help if they need it. During interview with social services designee (SS)-D on 2/14/24 at 10:37 a.m., SS-D stated, [call lights] must be next to person within reach so they can access it if they need help. During interview with director of nursing on 2/14/24 at 12:59 p.m., DON stated, call lights should be within reach at all times. Facility policy titled Call Light Policy modified November 2022 state, Position the call light conveniently for the resident to use. Tell the resident where the call light is and show him/her how to use the call light when needed.

Based on interview and document review, the facility failed to notify the emergency contact (FM-A) in a timely manner for 1 of 1 residents (R71) reviewed for notification of change when R71 required an emergency hospital procedure. Findings include: R71's quarterly Minimum Data Set (MDS) dated [DATE] indicated R71 had severe impairment of cognition, did not speak and was nonresponsive. In addition, R71 had diagnoses of traumatic brain dysfunction, seizure disorder, oxygen dependency, dysphagia (with gastrostomy tube), and cognitive communication deficit. Also, R71 was dependent on staff for all activities of daily living (ADL's) for all cares including bathing, dressing, and hygiene. R71's facesheet printed 2/15/24 at 4:50 p.m., indicated R71's Emergency Contact #1, Responsible Party, and Guardian was FM-A. R71's progress note (PN) documented with Effective date of 1/29/24 at 8:49 p.m., indicated R71, pulled the G-tube. The resident [sic] called the NP, instructed to put on a folly [sic] and send the resident ER. The resident was sent NMH ER at 1030. PN did not document communication with FM-A regarding a hospital intervention. R72's PN with effective date of 1/29/24 at 11:56 p.m., indicated, The resident returned from North memorial hospital at 1445 [2:45 p.m.], . PN did not document communication with FM-A regarding a hospital intervention. During interview with FM-A on 2/12/24 at 4:57 p.m., FM-A stated R71's feeding tube, got dislodged and FM-A stated she was never told about it by the facility. FM-A stated she found out about R71's emergency room visit when the, hospital called me. FM-A stated she expected to be notified by facility and would like to know theses things. FM-A stated she called the facility to ask why FM-A was not notified and, that was a big concern for me. FM-A stated the staff member was, going to check into it and [FM-A] never heard back. FM-A stated the experience was, pretty scary to hear from the hospital rather than the facility. During interview with registered nurse (RN)-C on 2/13/24 at 2:03 p.m., RN-C stated the facility procedure for sending a resident to the hospital was to inform the provider immediately and obtain an order, then notify family. Then resident facesheet and paperwork must be prepared for the transfer. RN-C stated the expectation for a nurse is to, notify the family and write a progress note. RN-C stated he was R71's nurse on 1/29/24, I remember very well. RN-C stated, I forgot to call family when we sent [R71] to the hospital. RN-C stated FM-A had, called the clinical coordinator to complain that they [FM-A] was not informed by me that R71 went to the hospital. During interview with director of nursing (DON) on 2/15/24 at 11:07 a.m., DON stated, we are supposed to [be] notifying responsible party for hospitalization s and, should be written in the progress note in the EMR [electronic medical record]. Facility policy titled Communication and Notification-Staff, Practitioners, and Resident Representatives modified November 2022 state, Staff will notify the resident representative any time there is a: Change in condition. Also, From 8:00 a.m. to 10:00 p.m. notification of any change in the resident's condition will be done in a timely manner. Notification is to be done within 1/2 to 1 hour of incident or change. In addition, Document, in the resident's medical record, the time called, the person spoke with, what was reported and their response, if any.

Based on observation and interview, facility failed to ensure dignity was maintained for 1 of 1 (R71) reviewed for dignity. Findings include: R71's quarterly Minimum Data Set (MDS) dated [DATE], indicated R71 had severe impairment of cognition, did not speak and was nonresponsive. In addition, R71 had diagnoses of traumatic brain dysfunction, seizure disorder, dysphagia (with gastrostomy tube), and cognitive communication deficit. In addition, R71 was dependent on staff for all activities of daily living (ADL's) for all cares including bathing, dressing, and hygiene. R71's care plan (CP) with revision date of 8/29/23 indicated, Dressing, Grooming, Hygiene: I require assist of 2. During interview with family member (FM)-A and emergency contact on 2/12/24 at 5:00 p.m., FM-A stated, she'd [R71] be very uncomfortable with her pants left down while in bed. FM-A stated she had observed R71 with pants down below the knees while R71 was in bed. FM-A stated she had, talked with [designated social services (SS-D)] about this concern and was told by SS-D that he, will talk to them [staff] with no follow up or anything discussed following it. During observation and interview on 2/13/24 at 10:27 a.m., R71 was laying in bed on her back with head of bed elevated and a thin sheet covering her. R71's sweat pants were rolled down to above ankles and below knees with an adult brief in place. Licensed practical nurse (LPN)-B stated, I don't know when asked if her pants were supposed to be placed below R71's knees. During interview with nursing assistant (NA)-A on 2/13/24 at 10:42 a.m., NA-A stated, we leave her [R71] pants down below her knees after we change her so when the nurse feeds her in the tube [gastrostomy tube], then she pees [urinates] and we can come back and change her diaper again. During interview with registered nurse (RN)-B on 2/13/24 at 1:02 p.m., RN-B stated, I believe it is a dignity issue because I would not like to walk in on a loved one with their pants below their knees while lying in bed. It makes me wonder why the staff put the pants on at all. Also, RN-B stated, if R71 or family preference is to have pants left below the knees, then it should be care planned. During interview with SS-D on 2/14/24 at 10:48 a.m., SS-D stated, the pants being left below knees was a concern that was brought up by sister [FM-A] a month after admission. I spoke to staff. I want to say I filled out a grievance form but I do not know. SS-D stated he, brought up the issue [pants being left below knees while in bed] in unit meeting (QI). I talked specifically with floor staff. In addition, SS-D stated, QI meetings are weekly in-services where we gather with staff to provide updates and information every week. SS-D stated he was responsible for the QI meeting minutes and was unable to provide requested meeting minutes. SS-D stated he recalled speaking specifically to NA-A about this concern when it was brought up by FM-A. During interview with NA-A on 2/14/24 at 12:35 p.m., NA-A stated, she had worked full time for facility for four years and was familiar with R71's cares. NA-A stated education from SS-D regarding R71's pants being left below her knees was never provided to her or staff until 2/14/24. NA-A stated, important for them [pants] to not be below her [R71] knees while in bed. Dignity is why. During interview with director of nursing (DON) on 2/14/24 at 12:59 p.m., DON stated SS-D, should have filed a grievance [on behalf of R71 when notified by FM-A] then we could have made a plan to prevent reoccurrence. DON stated concern for R71 is dignity. During interview with care center administrator on 2/14/24 at 1:58 p.m., administrator stated no Quality Concern/Grievance Process form was filled out on R71's behalf regarding pants being found below knees. Administrator stated the form should have been filled out and pants being found below knees is a concern for dignity. Facility policy titled Resident Rights Policy modified November 2022 state, PHS (Presbyterian Homes and Services) uses person centered care to give personalized attention to the well-being of each resident while enhancing their independence and dignity.

Based on observation, interview and records review, the facility failed to ensure controlled medications were properly recorded, stored and secured to prevent and minimize the risk of diversion for 1 of 1 residents (R243) reviewed for medication storage. Findings include: R243's admission Minimum Data Set (MDS) was in progress, no information available. R243's admission record dated 2/15/24 indicated R243 was admitted to facility on 2/9/24, with diagnoses of amyotrophic lateral sclerosis (a disease that weakens muscles and impacts physical function), insomnia, quadriplegia (paralysis of all four limbs), sleep apnea, shortness of breath, generalized muscle weakness. R243's progress notes written by nurse practitioner (NP), dated 2/14/24, also indicated diagnoses of chronic lower back pain and glaucoma (eye condition that causes blindness). R243's admission orders dated 2/9/24 included orders for 1-2 tablets of tramadol (a controlled medication) 50-100 milligrams (mg) by mouth twice a day as needed for eszopiclone (medication used for inability to sleep and a controlled medication) 2 mg tablet by mouth at bedtime (HS) for insomnia. During observation and interview on 2/12/24 at 2:48 p.m., R243 was alert, oriented, soft spoken, and able to communicate his needs. R243 stated he arrived at the facility on Friday 2/9/24 at 2:20 pm with orders for tramadol and Lunesta (eszopiclone). R243 stated he took tramadol twice a day for back pain, buttocks, and legs. Lunesta at bedtime for insomnia. R243 stated he was not sure what the facility's difficulty was to get these medications from their pharmacy. R243 added on Sunday [2/11/24] my family brought both medications [tramadol and eszopiclone] from home and gave them to the nurse on duty. R243 stated, I received his first dose of Lunesta on Sunday [2/11/24], and the first Tramadol dose on Monday [2/12/24]. During observation and interview on 2/14/24 at 1:59 p.m., licensed practical nurse (LPN)-B was unable to locate the tramadol or the eszopiclone logged in the narcotic book. The tramadol and eszopiclone were subsequently found stored in the medication cart with other resident's non-controlled bottles of medications. LPN-B removed two bottles of tramadol one containing 5 tablets and a second bottle of tramadol secured with paper tape and 90 tablets written on the tape. The bottle of eszopiclone had an unknown number of tablets. LPN-B stated the staff made sure the bottles had a pharmacy label with the resident's name, name of the medication, right dose, and had an expiration date. LPN-B stated she did not use a web site, a medication reference book or called the pharmacist to verify the tablets in the bottles were in fact the right medication. LPN-B confirmed either medication was not logged in the narcotic book and had not been counted between shifts. LPN-B stated I know better, and the MAR clearly has a C under the medication's name. [C identifies a controlled medication] I don't know what to say. LPN-B stated she would immediately count the medications, log them in the narcotic book, lock them, and report to her supervisor. During interview on 2/15/24 at 10:39 a.m., registered nurse (RN)-B stated she had worked at facility for two years and she had never admitted a resident bringing medication from home. RN-B said the supervisor will need to authorize it and, at the very least, the medication labels will need to include the resident's name, match the order, and have an expiration date. RN-B stated the facility probably had a policy and procedure. During interview on 2/15/24 at 9:44 a.m. with clinical coordinator RN-H and director of nursing (DON), the DON stated the only time they accepted medications brought from outside was when a resident had Medicaid or was private pay. DON stated Medicaid will not dispense the medication twice, including narcotics. R243 had Medicaid therefore they had to accept his medications. RN-H stated at the very least the nurse should make sure the label matches the order, have an expiration date and then refer to the description provided about the medication such as the color of the tablet, shape, or number to make sure it matches what is inside the bottles. RN-H and DON verified there was no documentation when these medications were brought up by the family or if they were properly identified before they were administered by the nurses. DON stated it was important to assure the residents receive the right medications and controlled medications needed to be double locked and counted every shift per facility's policy and procedure. During interview on 2/15/24 at 12:03 p.m. pharmacist (PH) stated the nurses needed to follow their policy and procedure. PH stated the nurses needed to check the orders and compared to the medications' labels. PH stated the nurses can call the pharmacist or they can also use a website such as Drugs.com. The nurse inputs the name and dose of the medication, and the website will display the shape, color, and characteristics of the medication. This must be done before the medication is administered to assure residents' safety. PH stated the facility did not send the prescriptions and did not contact them during the weekend. PH stated on 2/14/24 the facility sent the prescriptions for tramadol and eszoplicone and the prescriptions were filled and delivered. The undated Facility's policy Medication Monitoring and Management, III B3: Narcotic Reconciliation indicated Federal regulation F755 requires that skilled nursing facilities have a system for recording the receipt and disposition of all controlled medications and maintain and routinely reconcile an accounting of all controlled medication. The undated facility's policy titled Medication Ordering and Receiving from Pharmacy, IC12: Medications Brought to the Facility by a Resident or Responsible Party indicated Use of medications brought to the facility by a resident or responsible party is allowed only when the following conditions are met: The medication name, dosage form, and strength have been verified by consulting a tablet identification reference (e.g., Physician's Desk Reference), or calling the dispensing pharmacy for a physical description of the medication. The policy also indicated a licensed nurse receives and documents the delivery of the medication on the appropriate form.

Based on interview and document review, the facility failed to ensure a Level I pre-admission screening (PAS) was clarified or acted upon in a timely manner to determine what, if any, additional evaluation or screenings (i.e., Level II) were needed for 1 of 2 residents (R75) reviewed for pre-admission screening and resident review (PASARR). Findings include: R75's significant change Minimum Data Set (MDS), dated [DATE], identified R75 had intact cognition along with several medical conditions including Bipolar Disorder; however, R75 did not have a current dementia or Alzheimer's Disease diagnosis. In addition, R75's Medical Diagnosis, contained in their electronic medical record (EMR), listed all of R75's current medical conditions with a corresponding effective date. This listing included, Bipolar Disorder, Unspecified, with an effective date of 10/2022. R75's initial Minnesota Senior Linkage Line Preadmission Screening (PAS) Results, dated 10/2022, identified R75 was admitting to the care center from an acute care hospital located in another county. R75 was listed as having mental illness, however, had not had inpatient hospitalization for the disease, nor suicidal ideation or a past civil commitment for such. The PAS outlined R75's physical assistance needs and listed at the top, OBRA: It appears this person does not need an OBRA Level II assessment. However, attached to this PAS was a cover letter, also dated 10/2022, from the Minnesota Senior Linkage Line which outlined the included PAS but also, The Senior LinkAge Line forwarded the PAS to the county/managed care organization for processing [bolded]. The PAS is not final until the lead agency sends documentation to the nursing facility. If you have questions about this PAS or referral, contact the lead agency below [contact information listed]. R75's progress notes, dated 11/19/23 to 12/30/23, identified R75 was sent to the hospital on 11/19/23 for an acute change in condition with shortness of breath. R75 was admitted to the hospital. R75 readmitted to the care center on 12/8/23, with dictation present, . used to be here before, but after hospital went to another facility before coming back. R75's corresponding Minnesota Senior Linkage Line PAS Results, dated 12/2023, identified R75 was admitting to the care center from a local acute care hospital. However, R75 was now listed as not having a mental illness (despite having Bipolar Disorder diagnosed previously). The PAS, again, outlined R75's physical assistance needs and listed at the top, OBRA: It appears this person does not need an OBRA Level II assessment. However, again, attached to this PAS was a cover letter, also dated 12/2023, from the Minnesota Senior Linkage Line which outlined the included PAS but also, The Senior LinkAge Line forwarded the PAS to the county/managed care organization for processing [bolded]. The PAS is not final until the lead agency sends documentation to the nursing facility. If you have questions about this PAS or referral, contact the lead agency below [contact information listed]. R75's medical record was reviewed and lacked evidence either of the completed PAS' were clarified or acted upon (in collaboration with any applicable managed care program or the county, as directed) prior to the recertification survey to determine what, if any, additional screenings or actions were needed to ensure R75's mental health needs were adequately addressed (i.e., a Level II PASARR, if needed). On 2/14/24 at 2:50 p.m., household coordinator (HC)-A was interviewed and verified they were the social services designee (SSD) for R75's unit. HC-A verified they had reviewed R75's medical record and were unable to locate documentation to demonstrate any of the PAS were clarified or acted upon as directed by the Senior Linkage Line instructions adding, We didn't [find any]. As a result, they had just contacted the Senior LinkAge Line who would initiate further screening, if needed. HC-A stated R75 was hospitalized in December 2023, and then admitted from there to another transitional care unit (TCU) before returning to the care center. When that happened, HC-A stated the care center understood a new PAS was not needed, however, completed one due to we didn't have one on file. HC-A verified the medical record lacked evidence the PAS' had been addressed or had the instructed follow-up completed and stated they were unaware of anyone doing so prior to the recertification survey adding, Not that I know of. HC-A stated PAS' were received by the care center medical records personnel who then uploaded them to the records and such was all I know of the process adding they had never been asked or directed to review PAS results to ensure they're clarified or acted upon, if needed. However, HC-A stated it was important to ensure PAS were, if needed, clarified or acted upon with appropriate follow-up to help make sure the resident with mental illness is getting the services they need. When interviewed on 2/14/24 at 8:28 a.m., the care center administrator stated they had worked at the campus for several months. The administrator explained the admissions department was responsible to complete the PAS' process; however, they were unaware of the cover letters attached to R75's PAS(s) which directed further action was needed. The administrator stated the care center was looking at their current chart audit process and trying to make it a little bit more thorough to help catch issues like un-addressed PAS(s). Further, the administrator stated it was important to ensure PAS were completed and appropriate services, if needed, we in place to help the resident be successful. A provided Pre-Admission Screening and Resident Review (PASRR) Policy, dated 11/2016, identified all applicants (i.e., residents) to the care center would be evaluated for mental disorder or intellectual disability prior to admission and received corresponding services, if needed. The policy outlined a negative Level I screen permitted admission and ended the pre-screening process. The policy listed a section labeled, Procedure, which directed the admission personnel or social services department would complete any needed intake forms, and the information would be saved in the medical record. However, the policy lacked direction or guidance on how or whom would obtain further information, if needed, from the Senior LinkAge Line (i.e., state authority); nor dictation or guidance on any audit process of this to ensure all PAS were reviewed and acted upon, if needed.

Based on interview and document review, the facility failed to ensure a potential allegation of mental or emotional abuse was recognized and reported to the State agency (SA) in a timely manner for 1 of 1 resident (R77) reviewed who reported being bothered and potentially harassed by another resident. Findings include: R77's quarterly Minimum Data Set (MDS), dated [DATE], identified R77 had intact cognition but did not speak English as their primary language with use of an interpreter to communicate with healthcare staff preferred. R77's care plan, last reviewed 1/17/24, identified R77 had impaired mobility and used a wheelchair to reach all destinations. The care plan outlined, [R77] have impaired cognitive function. BIMS [brief interview for mental status] score varies 11/15 to 14/15 [moderate impairment to cognitively intact], and directed to use R77's family member (FM) to help interpret as needed. The care plan indicated R77 had a communication-barrier but added, Knows some English. Further, the care plan outlined, I [R77] am at risk for abuse and/or neglect d/t [due to] language barrier and functional limitations, with multiple interventions including following the care center abuse preventions policy and, Keep me safe at all times. On 2/12/24 at 3:08 p.m., R77's family member (FM)-C was interviewed and explained R77 understood some English but was likely not conversant with it. FM-C stated they had been told about an incident which involved R77 and a male resident on the same unit. FM-C explained the male resident and R77 both spoke the same language and, as a result, started to hang out together. However, the male resident then started to make inappropriate comments to R77 which included comments about sexual intercourse and, from what R77 reported to FM-C, had made her very uncomfortable. FM-C stated they were told of this by the care center a month or two ago when they reached out after R77 reported the comments to an interpreter. FM-C stated they felt the care center had since developed a good plan to keep the two residents more separated since the incidents. R77's Associated Clinic of Psychology (ACP) Progress Note, dated 1/16/24, identified the therapist met with R77 in her room with an interpreter present. The note recorded, . [R77] presented as anxious with exaggerated behavior . reported to be irritated with another resident who she feels is bothering her. A section labeled, Treatment Recommendations/Plan, outlined several actions R77 and care center staff could implement for R77 which outlined, [R77] has been experiencing difficulty while interacting [with] another resident who she feels acts aggressively towards her, and, If possible, it may be beneficial to move her to a different floor to minimize negative interactions. R77's subsequent ACP Progress Note, dated 1/30/24, identified R77 was met in her room and presented with a flat, depressed affect. R77 reported pain from her medical conditions negatively affected her mood along with dictation, . Clinician inquired about any ongoing issues with residents which she reported were no longer a problem. The section labeled, Treatment Recommendations/Plan, outlined, Previous issues regarding difficulties with other resident no longer effecting her mood or thoughts. On 2/13/24 at 11:59 a.m., household coordinator (HC)-A was interviewed. HC-A explained they were aware of the incident and verified it involved R77 and another male resident who, previously, had been sitting at R77's table in the dining room. HC-A stated they were made aware of it first when R77 reported the male resident had been getting kind of rude and she didn't like the way he talked to her. HC-A stated they visited with R77 about it and did not feel R77 was too concerned with it, however, voiced to let staff or her family know. However, a few weeks later R77 then asked to move tables and not be seated with the male resident any longer, so R77 was moved to a different table in the dining room. HC-A stated ACP had had met with her on it with concerns being voiced to them, too. HC-A stated it was hard to determine how much, if at all, the incident had affected R77 adding since they moved her table, there had been no further issues with the male resident. HC-A explained they were unsure exactly what comments the male resident had been making to R77 to cause her becoming upset but expressed they were sexual in nature from what they knew but added R77 would not say specifically what was said. HC-A verified the administrator was aware of the incident and expressed, to their knowledge, it had not been reported to the SA adding, We didn't report it. HC-A stated the management team had decided it was not reportable as R77 seemed to be not very concerned about it adding, in their opinion, it seemed like it more bothered her [R77] but wasn't worried about it. The Minnesota Department of Health (MDH) Aspen Complaint and Incident Tracking System (ACTS) was reviewed and lacked evidence the allegation of repeated offensive comments made to R77 by the male resident were reported to the SA as an allegation of potential mental or emotional abuse despite R77 reporting being bothered by them, having potential behavioral changes due to them (as outlined in the ACP notes), and wanting to physically move dining room tables due to these interactions. On 2/14/24 at 12:09 p.m., the care center administrator was interviewed. They verified they were aware of the incident, and had a chance to follow-up and review it prior to interview. The administrator explained HC-A had brought the incident to them and wanted to make me aware of it as they were going to change R77's dining room table. The administrator stated they couldn't recall the exact words used to describe the situation but recalled R77 having emotional distress but which was more annoying than abusive in nature. The issue was then discussed a few weeks later while at R77's care conference, where R77 had no further concerns with the male resident but did express wanting to move dining room tables. The administrator stated they were unsure of the rationale for R77 wanting to move tables. The administrator verified the incident was not reported to the SA as they believed the behavior was just annoying to R77 and not she didn't seem emotionally distressed about it. Further, the administrator stated they had not, to their knowledge, re-visited it with R77 since moving tables but expressed they felt R77 would have reported it again if the issue persisted. The administrator reiterated they felt the situation was not reportable adding, Being annoyed and being offended is different. A provided Vulnerable Adult Abuse Prevention Plan policy, dated 1/2023, identified each resident had the right to remain free of abuse including verbal, sexual, physical and mental abuse adding, Any form of resident abuse will not be tolerated. The policy listed several definitions of each abuse type which included, Emotional or Psychological Abuse, and this included the verbal or non-verbal infliction of anguish, pain, or distress which resulted in mental or emotional suffering including, . Demeaning statements, harassment, threats, insults, humiliation, intimidation. The policy included, 13. Resident to Resident - Willful Intent . altercations that must be reported include any willful action that results in physical injury, mental anguish, or pain, adding, It is the staff/facility to judge on determining willful intent, best to err on the side of caution. The policy included several steps for reporting, to both internal and external contacts, which outlined, Immediately make a report to the State Agency [MDH].

Based on interview and document review, the facility failed to ensure resident mail was delivered on Saturdays for 3 of 3 residents (R17, R20, R29) who voiced concerns with mail delivery. This deficient practice had the potential to affect all 94 residents residing in the facility. Findings include: R17's significant change Minimum Data Set (MDS) dated [DATE], indicated R17 had resided at the facility for over one year and had no cognitive impairment. R20's quarterly MDS dated [DATE], indicated R20 had resided at the facility for over one year and had no cognitive impairment. R29's quarterly MDS dated [DATE], indicated R29 had resided at the facility for over one year and had no cognitive impairment. During an interview on 2/14/23 at 10:43 a.m., R20 stated he never got his mail on Saturdays and sometimes it would take until Tuesday to get his mail. R20 then stated that it bothered him that this kept happening. During the same interview, R29 stated that she had also not been receiving her mail on Saturdays and was wondering why this was not occurring. During the same interview, R17 stated she agreed with them, stating she also not been receiving any mail on Saturdays. During an interview on 2/14/24 at 12:28 p.m., health unit coordinator (HUC)-A stated that the HUCs only worked Monday through Friday and on those days, they distribute the mail. The HUC stated she was unsure who distributed the mail on the weekends. During an interview on 2/14/24 at 1:35 p.m., the care center administrator stated she was unsure who distributed the mail on the weekends. During an interview on 2/14/24 at 1:52 p.m., registered nurse (RN)-E stated she worked every other weekend, and she previously would receive a call from the receptionist to pick the mail. RN-E stated that she had not been receiving a call for a while so she did not think the mail was being distributed to the residents on the weekends. During an interview on 2/15/24 at 7:40 a.m., the campus administrator stated that mail delivery on Saturdays is something the facility needed to revisit and was unsure if the mail was delivered to residents on Saturdays. During an interview on 2/15/24 10:12 a.m., the campus administrator stated that she had attempted to call the weekend receptionist but the number that had on file was no longer in service, and they did not have another way to contact her. A policy/procedure regarding mail delivery was requested at this time. A policy regarding mail delivery was not received from the facility.

Based on observation, interview, and document review, the facility failed to ensure the required nurse staffing information was posted daily and retained for 18 months. This had the potential to affect all 94 residents residing in the facility and/or visitors who may wish to view the information. Findings include: During an observation, document review, and interview on 2/12/24 at 12:11 p.m., the nursing staff posting was observed in the main lobby near the entrance and was dated 2/9/24 with a resident population of 96. During interview, administrator stated the staffing coordinator (SC) was in charge of updating the staff posting but it had not been completed yet today. During an interview on 2/13/24 at 2:44 p.m., the director of nursing (DON) stated that he and the SC worked jointly to address staffing needs and required posting information. The DON stated that he was unaware of the requirement to retain previous staff postings and therefore could not produce these. The DON stated he had attempted to print off the previous staff postings from the computer program the facility used, but the postings were not accurate to what was previously posted or the staffing levels of that day. During an interview on 2/15/24 at 9:25 a.m., The SC stated she was unsure why the daily staff posting had not been updated on 2/10/24 and 2/11/24. The SC stated she would print out the staff postings on Friday and put them behind the plastic staff posting display before she left for the weekend. The SC stated the weekend staff would dispose of the previous day's staff posting to show the current day's posting that she had previously placed behind it. The SC was unsure who updated the number of staff, actual hours worked, or current census number over the weekends as these numbers changed and thought this was likely not occurring. The facility Nurse Hours Staff Posting Policy dated 10/22, indicated the nursing staff data should have been posted on a daily basis the beginning of each shift. The policy indicated nursing staff posted data forms should have been kept by the facility for eighteen months and made available upon request.

Based on interview and document review, the facility failed to ensure comprehensive assessments were completed and interventions implemented for 1 of 1 resident (R68) who was reviewed for elopement. This resulted in an immediate jeopardy (IJ) when R68 left the facility without supervision and without staff awareness for at least 30 minutes. The facility implemented immediate corrective action and was issued as past non-compliance. In addition, the facility failed to provide proper positioning before eating or supervision while showering for 2 of 3 residents (R70, R37) reviewed for accidents. The IJ began on 8/23/22, at 9:20 p.m. when R68 left the facility the facility without supervision and without staff awareness. The director of nursing (DON) was notified of the IJ on 12/8/22, at 3:41 p.m. The facility implemented immediate corrective action on 8/24/22, prior to the start of the survey and was issued as past non-compliance. Although the immediacy was removed on 8/24/22, the facility remained out of compliance at the scope of isolated and severity of no actual harm with potential for more than minimal harm (D) that was not immediate jeopardy. Findings included: ELOPEMENT During review of the facility's investigation file, it was discovered R68 eloped from the facility on 8/23/22, at 9:21 p.m. when she exited through the emergency exit door; however, when the alarm sounded staff silenced their pagers and did not check the exit door or searched for any missing residents. R68 walked to the independent living facility and was observed standing outside the independent living facility's door seven minutes later (at 9:28 p.m.). The independent living residents opened the door and brought R68 inside. The staff at the long-term care facility were not aware R68 was missing until the independent living staff paged the long-term staff and informed registered nurse (RN)-G that R68 was at the independent living facility. RN-G then called the first floor to have the staff look to see if any residents were missing. RN-G went downstairs to the first floor and observed two of the independent living staff at 9:50 p.m. ambulating with R68. R68's quarterly Minimum Data Set (MDS) dated [DATE], indicated R68 was severely cognitively impaired with diagnoses of closed right femoral neck fracture with routine healing, dementia, and anxiety disorder. R68 was independent with walking in room, walking in corridor, locomotion on unit, and locomotion off unit. The MDS indicated R68 had not exhibited any wandering behaviors. R68's admission MDS dated [DATE], indicated R68 was severely cognitively impaired with a diagnosis of closed right femoral neck fracture with routine healing, dementia, and anxiety disorder. R68 required limited assistance of one staff with walking in room, walking in corridor, locomotion on unit, and locomotion off unit. The MDS indicated R68 had not exhibited any wandering behaviors. R68's discharge summary from Allina Health hospital dated 7/5/22, indicated R68 had a past medical history was significant for advanced dementia and presented to the hospital from a memory care unit. R68's Elopement Risk assessment dated [DATE], indicated R68 had short term memory loss, intermittent confusion, was disoriented to person, place, and time, and had impaired decision-making skills. R68 had wandering behaviors, restlessness, seeking behaviors, desire to go home, and verbalized seeking of things like home, car, people, etc. The Elopement Risk Assessment also indicated R68's care plan was reviewed and updated. R68's care plan dated 7/5/22, indicated R68 was at risk for elopement; however, no interventions were identified to prevent an elopement. R68's Progress Note (PN) dated 7/5/22, at 10:42 p.m. indicated R68's family member (FM)-A informed the facility staff R68 was an elopement risk. R68's PN dated 7/6/22, at 4:33 p.m. indicated FM-A and the social services household coordinator were unable to locate R68 in the gathering room, resident room, or therapy suites. R68 was located in another resident's room laying in bed. FM-A had previously noted R68 was an elopement risk. Further, indicated R68 remained extremely confused. R68's PN dated 7/7/22, at 8:06 p.m. indicated R68 continued to ask to go home and needed frequent orientation. R68's PN dated 7/27/22, at 1:38 p.m. indicated R68 had been wandering into another resident's room and need to be monitored and redirected to not go into the room. R68's PN dated 7/27/22, at 2:52 p.m. indicated R68 continued to wander into another room several times throughout the day and needed to be redirected to her own room. R68's Elopement Risk assessment dated [DATE], indicated R68 did not wander and had not demonstrated any exit seeking behaviors. Further, indicated R68 was low risk for elopement, even though R68 had progress notes that identified wandering behaviors. R68's PN dated 8/2/22, at 5:58 a.m. indicated R68 was observed wandering while well dressed around midnight. R68's PN dated 8/4/22, at 6:13 a.m. indicated R68 got up regularly throughout the night and wandered around. R68's PN dated 8/4/22, at 11:54 p.m. indicated R68 was wandering around, talking irrationally, and attempting to exit the building. R68's PN dated 8/6/22, at 6:23 a.m. indicated R68 was on 30 minute checks; however, the medical record lacked any evidence of the 30 minute checks were completed. R68's medical record lacked any evidence of a new elopement risk assessment being completed after several progress notes indicating R68 was wandering and exit seeking. The care plan lacked any evidence of interventions to prevent R68 from elopement. When interviewed on 12/8/22, at 12:19 p.m. the interim director of nursing (DON) stated the risk for elopement should have been communicated by the admission coordinator when the admission paperwork was screened so the IDT could have put interventions in place to prevent elopement. The interim DON further stated, the expectation was to initiate a care plan with interventions when a resident was identified as an elopement risk. The interim DON verified the care plan had a focus of R68 was an elopement risk, however no interventions were placed to keep R68 safe with her wandering behavior and elopement risk. The Wandering and Elopement policy modified December 2022, indicated information would be obtained from admission assessment, family/resident representative interviews, staff observations and social history. Further, indicated a care plan identifying wandering and elopement risk would be implemented on admission, on quarterly review, and as needed. The past noncompliance immediate jeopardy began on 8/23/22. The immediate jeopardy was removed, and the deficient practice corrected by 8/24/22, after the facility implemented a systemic plan that included the following actions: On 8/23/22, a body audit of R68 was completed which indicated no injuries. This was verified by record review on 12/8/22. On 8/24/22, a new elopement risk assessment was completed which indicated R68 was at risk for elopement. This was verified by record review on 12/8/22. On 8/24/22, R68 was transferred to the secure memory care unit. This was verified by observation on 12/5/22 through 12/8/22 and by record review on 12/8/22. On 8/24/22 through 8/28/22, audits were completed to ensure appropriate staff response to the door alarms. This was verified by record review on 12/8/22. On 8/24/22, the facility reviewed the elopement policy, and no changes were needed. This was verified by record review on 12/8/22. On 8/24/22, the nursing staff were educated on the elopement policy and how to respond to the door alarms. This was verified by staff interviews and record review on 12/8/22. On 8/24/22, the facility requested a quote for a delayed egress system (a system designed to prevent a door from opening immediately when someone attempts to exit) and received the quote on 9/9/22. This was verified by record review on 12/8/22. On 11/23/22, the delayed egress system with an alarm on the emergency exit door was installed. This was verified by observation and record review on 12/8/22. POSITIONING R70's quarterly MDS dated [DATE], indicated R70 was cognitively intact and required extensive assistance of two staff for bed mobility. Further, the MDS indicated no rejection of care or any other behaviors. R70's care plan dated 12/6/22, indicated R70 had an activities of daily living (ADL) deficit related to impaired balance and weakness with an intervention to assist R70 to an upright position for eating and set up the meal on the bedside table. The nursing assistant (NA) team sheets dated 12/5/22, indicated R70 required assist of one staff for repositioning; however, lacked any evidence of how to assist R70 with meal set up or positioning for meals. The NA team sheets updated 12/6/22, indicated R70 continued to require assist of one staff for repositioning and was updated to direct the staff to assist with meal set-up on bedside table and assist resident into an upright position while eating. The Resident Occurrence Report dated 12/5/22, at 12:20 p.m. indicated R70 spilled soup on right neck and right shoulder. Further, indicated the analysis as to cause of occurrence was R70 was in bed eating. The action to minimize reoccurrence was to encourage R70 to get out of bed for meals. The report lacked any evidence of the position R70 was in bed when the soup spilled. R70's progress note on 12/5/22, at 12:22 pm indicated R70 spilled soup on her right side of neck and right upper back. The intervention was to boost R70 up in the bed to finish her meal and applied a cool towel to the area. R70's progress note on 12/5/22, at 9:52 p.m. indicated writer received shift report of resident having redness on right shoulder due to soup spilled. The progress note lacked any evidence of an assessment of the area. During observation and interview on 12/5/22, at 6:00 p.m. R70 informed the surveyor soup was spilled on her right shoulder and pulled her hospital gown over to show the area. The area was red with a serous fluid-filled blister 3 cm in diameter. When the surveyor entered the room R70 was laying flat on her back in bed with her supper plate laying on her stomach. When asked if R70 always ate her meals laying flat [R70] stated, I can't find my bed controller. R70 verified the staff placed her plate on her stomach and did not assist with repositioning. R70's bed controller was found under her right thigh and the call light was on the floor. When interviewed on 12/5/22, at 6:02 p.m. RN-A stated they were aware of R70's incident and the burn, however, wasn't aware of a blister to the right shoulder area. R70's late entry progress note on 12/6/22, at 8:15 a.m. indicated the interim director of nursing (DON) assessed R70's right shoulder and noted a 1.1 cm x 1.1 cm serous fluid-filled blister on the top of the right shoulder and R70 reported tenderness to the area. When interviewed on 12/6/22, at 2:04 p.m. licensed practical nurse (LPN)-D stated when R70 spilled the soup the NA had taken the meal tray into the room and R70 was not positioned in an upright position. Further, stated after R70 spilled the soup when staff boosted R70 up in bed so she was in an upright position. When interviewed on 12/6/22, at 2:26 p.m. the interim DON stated when an incident happens a root cause analysis should be completed, interventions documented on the care plan and team sheets, and each shift nurse monitor the area and update the doctor with any changes as needed. When interviewed on 12/6/22, at 3:09 p.m. the nurse practitioner (NP) stated they were informed of the burn however, wasn't aware of any blisters forming. When interviewed on 12/7/22, at 7:22 a.m. NA-D verified R70's bed was not in an upright position when the soup was given to R70 on 12/5/22. The care plan policy and procedure modified November 2022, indicated the care plan should reflect what the resident desires for himself/herself and include unique interventions which meet the need of the resident. Further, indicated the care plan was to be changed and updated as the care changes for the resident and should be current at all times. SUPERVISION R37's annual MDS dated [DATE], indicated R37 was cognitively intact and required extensive assist of one staff for dressing and personal hygiene. R37's care plan dated 2/17/22, indicated R37 had an activities of daily living (ADL) self-care performance deficit and required one staff participation for bathing and to stay in the shower room with the resident. R37 had limited physical mobility and required one staff assistance until 12/9/22 for ambulation and transfers. The NA team sheets updated on 12/6/22, indicated R37 required assist of one staff for ADL's and the staff were to stay with R37 during the shower. When interviewed on 12/5/22, at 3:34 p.m. R37 stated, my care plan says I'm not supposed to be left unattended in the shower because I'm a fall risk, but they leave me unattended. Last Wednesday the staff left me in the shower alone with my wheelchair sitting right outside the shower with a towel on the arm of the chair. I had to transfer myself being wet and the floor wet to my wheelchair alone. R37 was afraid they would fall. During observation and interview on 12/7/22, at 7:33 a.m. R37 was in the shower room alone with the water off. R37 was wet from the shower and seated in her wheelchair, with no staff in the shower room. R37 stated she was left alone again and had to transfer to her wheelchair alone again. At 7:36 a.m. NA-E entered the shower room and stated, Oh I'm with her, here to help her dry off and get dressed. When interviewed on 12/7/22, at 9:38 a.m. LPN-D stated the NA's should stay with R37 throughout the whole shower according to the care plan. LPN-D verified the NA should assist R37 with washing, drying, and getting back into the wheelchair. When interviewed on 12/7/22, at 9:47 a.m. NA-E stated they were aware R37 required staff to stay throughout the whole shower. NA-E verified leaving R37 alone in the shower stated they had left the room due the need to speak with the nurse. When interviewed on 12/7/22, at 10:12 a.m. LPN clinical coordinator stated when the care plan and team sheets indicate staff should stay in the shower with R37, then the staff should bring all supplies needed and stay throughout the entire shower. When interviewed on 12/8/22, at 3:57 p.m. the interim DON stated the staff should follow the care plan and team sheets and stay with R37 throughout the entire shower. A policy for supervision was requested but not provided.

Based on observation, interview and document review, the facility failed to ensure mechanical lift transfers were conducted in a safe manner, resulting in an immediate jeopardy (IJ) with risk for serious injury to 2 of 7 residents (R33, R70) reviewed for accidents. The IJ began on 3/14/18, when staff were observed to transfer R33 and R70 with standing mechanical lifts in a manner inconsistent with the residents' assessed needs for safe implementation. The administrator and regional registered nurse (RN) consultant were informed of the IJ at 12:42 p.m. on 3/15/18. The immediate jeopardy was removed on 3/15/18, at 7:47 p.m. but non-compliance remained at the lower scope and severity of D-isolated scope and severity level, which indicated no actual harm with the potential for more than minimal harm that is not an immediate jeopardy. Findings include: R33 was observed to be transferred utilizing a standing lift when she was unable to hold on, and the lift vest was observed to slide out of place. R33 was unable to actively participate in the stand lift resulting in an unsafe transfer. The improper transfers placed R33 at risk for significant injury from falls during the transfer. R33 was at additional risk for significant injury due to [DIAGNOSES REDACTED]. R33's Admission Record indicated the resident had [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE], indicated R33 required extensive physical assistance of one staff with transfers, and also indicated R33 had no behaviors, including refusal of cares. R33's activities of daily living care area assessment (CAA) dated 4/25/17, indicated R33 had a self-care deficit and impaired functional mobility related to muscle weakness and dementia. In addition, the CAA indicated R33 required physical assistance from staff with transfers, personal hygiene, toilet use and getting dressed. R33's care plan revised 3/15/18, indicated R33 had impaired physical mobility as evidenced by the need for physical staff assistance for mobility related to muscle weakness, dementia, [MEDICAL CONDITION] and [MEDICAL CONDITION]. The care plan indicated R33 required use of a mechanical lift, with two staff assistance, for all transfers using a medium vest. On 3/14/18, at 9:28 a.m. NA-A entered R33's room with an Sabina II EZ stand mechanical lift and stated she was waiting for another NA to assist because R33 needed two staff to assist with transfers. At 9:31 a.m. NA-A and NA-B approached R33 and stated they were going to take her to the bathroom. NA-A went to the closet and got a green sling vest. At 9:33 a.m. NA-A approached R33 from the front and asked R33 to lean forward and NA-A was observed to put the vest behind R33's lower back. NA-A then leaned R33 back and reached to the front took the braided loop strap over the cloth loop across R33's abdomen and put it through the right silver D ring. NA-A was not observed to check the tension. Both NA's hooked the outer vest strap, inner vest strap and used the third braided loop strap to the Sabina II EZ stand lift to both side hooks and cued R33 to hold on to the handles on the sides. The NA's were observed to stabilize R33's feet, reached behind R33's knees and applied the leg strap. NA-A used the remote to lift R33 up to a standing position. As R33 began to stand with lift assist, she was observed to hold onto the handles with her elbows above her shoulders, hips bent in v-shape with buttocks thrust out. The right leg was observed to hang off the base as the NA's wheeled R33 from where the wheelchair was parked in the room, into the bathroom, a distance of approximately 10 feet. During the observation the vest migrated up under the resident's chin, and the resident's right leg hung off the base of the lift. Once R33 had been transferred onto the toilet, with the straps and the EZ stand lift still attached, the vest was observed resting above breast level as R33's hands rested on the handles. Leaving R33 attached to the lift, the NAs both stepped out of the bathroom to afford the resident privacy. When the NAs attempted to transfer R33 off the toilet with the lift, R33 became agitated and attempted to remove a slipper from her right foot. NA-A removed both slippers as NA-B went through the closet to find another pair. At 9:43 a.m. NA-A and NA-B applied another pair of slippers, then NA-B was observed to stand in front of the lift and use the remote to stand R33 up without any adjustment of the vest. The vest was observed to be under R33's chin, R33's right leg was observed hanging in the air off the base, and her buttocks were thrust out. NA-B continued to stand R33. NA-B stated she was going to have R33 sit back down on the toilet. During the observation the NA's never acknowledged the vest placement or R33's posture. At 9:45 a.m. the NAs were observed to begin helping R33 stand again with the lift. At that time, the surveyor intervened and requested the NAs get the nurse manager or physical therapist to observe the transfer. At 9:47 a.m., NA-A stated she was a float nursing assistant. When asked about the vest positioned under R33's chin, NA-A stated because R33 had a hunched posture, She always folds herself and this is how she always stands during transfers. At 9:52 a.m., LPN-A arrived to observe the transfer. The vest was not adjusted before NA-A lifted R33 up off the toilet to stand. The vest remained up under R33's chin, and R33's buttocks were thrust out, elbows above the shoulders, hands resting on the handles of the lift. LPN-A held onto R33's pants as NA-A wheeled R33 back to the wheelchair which was approximately 10 feet. During the observation, R33's right leg was hanging up off the base of the lift. LPN-A stated she had noticed R33 was not standing like she was supposed to when using the EZ stand lift and acknowledged the vest was supposed to stay below the breast, not up under R33's chin. LPN-A stated she was going to get an order for [REDACTED]. At 10:03 a.m., NA-A stated she didn't remember if she had previously reported R33's poor posture with transfers to the nurse, because she was a float. NA-A confirmed the lift vest was supposed to be positioned below the breast when R33 stood up and should not have moved up under her chin. She also acknowledged she had not snugged the vest after applying it originally, nor when R33 was being stood from the toilet. NA-A stated neither of them (NA-A or NA-B) had checked the vest to ensure it was properly positioned before transferring R33. NA-A also acknowledged she and NA-B had left R33 attached to the lift when they stepped outside the bathroom and R33 was not within their eye sight. On 3/14/18, at 10:05 a.m. the PT was interviewed and stated a resident had to be able to stand to use the Sabina II EZ stand lift, and that an appropriately applied vest was not supposed to be ride up. On 3/14/18, at 11:40 a.m. NA-B stated she had not worked with R33 before. She verified the vest was not supposed to ride up under a resident's chin, and stated she thought R33 might have been tired which was why R33 was not able to hold on to the lift handles appropriately. NA-B further stated a resident had to be able to stand up to use the EZ stand lift. During review of R33's Resident Transfer assessment dated [DATE], it was revealed R33 was unable to stand for even 8 seconds holding onto an assistive device, was partial weight bearing, was cooperative, but needed prompting, and was able to follow simple commands. Based on the assessment, a decision had been made for one person to transfer R33 with the stand assist lift using the medium Sabina vest size. On 3/14/18, at 3:28 p.m., the lift manufacturer's representative was interviewed by phone. The representative stated the correct position of the sling was such that it would rest on the resident's lower back, depending on the size of resident, and the front should go above the waist. When asked whether the vest should be able to ride up under the chin level during a transfer, the representative stated staff should stop and re-assess the resident using the assessment tool if this happened. On 3/15/18, at 2:56 p.m. the director of clinical services (DCS), and RN-A clinical coordinator, were interviewed about R33's observed transfers. When asked if the vest was supposed to ride up under a resident's chin during transfer, they both acknowledged it should not. The DCS also added that she did not think the NA's were supposed to snug the vest after application. When asked if R33 was supposed to be able to bear weight with both feet during the transfers, the DCS stated R33 did not have to have both feet on the base of the lift. Following notification of the facility about the concerns with R33's posture and vest placement during observed transfers, a PT (physical therapy) evaluation was conducted 3/15/18. The evaluation indicated R33 required a full body mechanical lift related to R33's inconsistent ability to stand and bear weight. During interview with the regional director of clinical services (RDCS) on 3/16/18 at 10:55 a.m., R33's transfer was described again. The RDCS stated the NA should have stopped the transfer if it was unsafe, and stated he was unsure whether resident's could be left alone while hooked up to the lift, but would look into it. The RDCS further stated the NA's should have ensured proper vest placement as directed by the manufacturer. On 3/16/18, at 11:06 a.m. RN-A stated the vest should not have moved up to under the chin when R33 was being transferred. RN-A said when staff noticed the vest move up, they should have checked the placement, and if after doing so the problem still existed, they should have gotten the nurse. RN-A stated the NA's should have had some visual of the resident when attached to the machine. On 3/16/18 at 1:29 p.m., the RDCS reported a resident was not supposed to be left alone while attached to the mechanical lift and stated residents hooked to the lift should be observed. R70 was observed to be transferred utilizing a standing lift when she was unable to hold on, and the lift vest was observed to slide out of place. R70 was unable to actively participate in the stand lift resulting in an unsafe transfer. When it had been determined R70 should be transfered using a full lift, R70 was again observed to be transfered with the standing lift rather than the full mechanical lift directed by revision to the plan of care. The improper transfers placed R70 at risk for significant injury or death from falls during the transfer. Additionally, R70 was at risk for significant injury to her upper extremities during transfer due to R70's impaired ROM and the improper fit and placement of the lift belt. R70's Mobility care plan initiated 6/12/15, indicated R70 had impaired mobility due to a history of a stroke, impaired cognition and abnormal posture. Care plan interventions dated 6/12/15, indicated R70 transferred with assist of two using a standing lift. The resident's care plan was revised on 3/14/18, to indicate R70 required a full mechanical lift transfer with a medium sling, and that therapy would evaluate the transfer plan. R70's quarterly minimum Data Set ((MDS) dated [DATE], indicated R70 was severely cognitively impaired, required extensive assistance with transfers, and had [DIAGNOSES REDACTED]. A previous annual MDS from 5/17/17, indicated R70 had impaired range of motion (ROM) to the upper extremity on one side. On 3/13/18, at 9:49 a.m. R70 was observed sitting in a low wheel chair when nursing assistants (NA)-F and NA-G approached her for a transfer. As preperation for the transfer to a standing position, NA-F and NA-G applied the yellow tagged lift vest. NA-F put the leg strap behind R70's legs. NA-G stated the strap could be tight or loose based on resident preference. NA-G stated for a resident to use the standing lift, they must be able to stand, not pull their legs up, and be able to hold on to the handles. A Sabina II standing lift was used to help stand R70. R70 was unable to hold onto the handles of the lift. The nursing assistants were observed to guide R70's hands to the handles. R70 held on to the bar with two fingers momentarily before letting go. The mechanical lift vest slid up into R70's arm pits, with the straps in front riding up and above R70's breasts. The bottom of the strap in the back rose up to the base of R70's shoulder blades. NA-G and NA-F verified the lift vest was in the correct position. NA-F stated R70 had trouble staying awake, so they used two staff to transfer her. NA-G stated it was hard for R70 to hold on to the lift handles because R70 had contractures in both hands. On 3/14/18 at 8:45 a.m. physical therapist (PT)-A stated he assessed residents for lift use, but did not provide training to nursing staff for this function. PT-A explained that the lift belt should remain at the waist and not ride up under the resident's arms. He also stated a resident using the mechanical standing lift should have the strength to stand, bear weight, and hold on to the handles of the lift. On 3/14/18, at 10:56 a.m. NA-G used the Sabina II standing lift to transfer R70. During the observation, NA-G put R70's wheelchair in an upright position and applied the lift vest behind R70's back at waist level. As NA-G stood R70 from the wheelchair to a standing position, R70 did not hold onto the handles of the mechanical lift bars. R70 reached her hands up in the air with her elbows at the level of her shoulders. As a result, the lift vest was observed to slide up R70's body. R70 was transferred from where her wheelchair had been parked in the resident's room to the bathroom in the standing lift, which was approximately 10 feet. Once at the toilet, NA-G told R70 she was going to pull her pants down and place her on the toilet. R70 raised her arms up even higher, resulting in her elbows above her shoulders. The lift vest slid higher up R70's body, rising above R70's breasts in front, and the bottom of the lift belt was at R70's mid shoulder blade in back. NA-G stated the vest slipped so high up on R70 due to the shape of her body. NA-G, who stayed with R70 while on the toilet, stated because R70 did not have a large bust, the lift vest would slide up R70's chest. A Progress Note dated 3/13/18, at 12:20 p.m. indicated a resident transfer assessment had been conducted by registered nurse (RN)-B however, lacked details regarding what had been assessed, why the transfer assessment had been conducted, or how the determination for appropriate transfer had been made. There was no rationale for the type of transfer selected. The Team 1 nursing assistant assignment sheet with hand written date updated 3/12/18, received on 3/13/18, at 2:30 p.m. indicated R70 was A-2 (assist of two people), Stand Lift med (yellow) vest. The 1 had a line through it and a 2 had been written above it. During interview on 3/14/18, at 11:26 a.m. RN-D stated residents were assessed quarterly and as needed for use of the standing lift. RN-D stated residents had to have some control of their trunk and upper extremities, be able to stand, and hold on to the lift bar to use the standing lift. RN-D stated that due to weight, or some behaviors, a second staff member might be required for safety during transfers with the standing lift. RN-D stated the type of lift, number of staff required, and sling size would be documented on the individual resident's care plan. RN-D further stated the standing lift belt should be above the umbilical area, but not high enough to compress the breast or shoulders. RN-D further stated when the lift belt was applied correctly it should not be too tight or too loose. RN-D stated R70 had been changed to a two person assist with the standing lift earlier this week because R70 could not follow directions, and had contractures in both hands making it difficult for R70 to hold on to the lift handles. During interview on 3/15/18, at 11:40 a.m. licensed practical nurse (LPN)-B stated R70 had been admitted with contractures in both hands but they'd have worsened over time. LPN-B stated R70 had a little more use of her left hand than her right. Upon observation, R70's right hand, fingers 3, 4 and 5 curled into the palm with R70's index finger partially bent, and the thumb over the index finger. R70 was able to lift her right thumb on her own. The last three fingers of R70's left hand also curled into the palm. R70 was able to open the fingers slightly herself, but indicated pain when doing so. LPN-B stated R70 could use both hands to hold a cup without handles if it was not too heavy, and could pick up some finger foods independently. During interview on 3/15/18, at 12:05 p.m. RN-B stated he had received training on how to complete resident transfer assessments as part of new employee orientation. RN-B stated the floor nurses are to complete a resident transfer assessment quarterly and when the resident experiences an acute change of condition. RN-B verified completing a resident transfer assessment for R70 on 3/13/18, and 3/14/18. RN-B reviewed R70's Resident Transfer assessment dated [DATE], at 12:20 p.m., which indicated R70 was able to stand for 8 seconds holding onto an assistive device, was partial weight bearing, with unpredictable behavior and indicated R70 should be a Two person transfer with standing lift (If behavior is unpredictable or resident is not able to sit on the edge of bed without support). RN-B stated he'd had made a mistake on R70's 3/13/18, assessment and had intended to identify R70 as a full lift with two person assist, until the physical therapist could assess R70. RN-B reviewed R70's Resident Transfer assessment dated [DATE], which indicated R70 was able to stand for 8 seconds holding onto an assistive device, was full weight bearing, with unpredictable behavior and indicated R70 should be a Two person transfer with full lift (If resident unable to bear weight). RN-B stated he made that decision because of R70's hand contractures, and had wanted to have Physical therapy evaluate R70 for safety. RN-B reviewed R70's Resident Transfer assessment dated [DATE], completed by another nurse which indicated R70 was unable to stand for 8 seconds holding onto an assistive device, was non-weight bearing, with unpredictable behavior, but still indicated R70 should be a One person transfer with standing lift (If behavior is predictable and resident can sit on the edge of bed for at least 8 seconds). RN-B stated that based on the assessment data from 1/30/18, R70 had been correctly coded as a one person assist with a standing lift for transfers. When asked what had prompted the new assessment completed on 3/13/18 at 12:20 p.m., RN-B initially stated R70 had experienced an acute change of condition but was unable to explain what the change of condition was. RN-B then added staff had notified him of the surveyor's questions about R70's transfer the morning of 3/13/18. RN-B clarified that based on the assessment and care plan, R70 should have been transferred with two staff members on 3/14/18, and staff should have encouraged R70 to put her arms down. R70 was changed to a full lift on the evening of 3/14/18. R70's Physical Therapy (PT) Plan of Care (Evaluation only) dated 3/15/18, at 3:50 p.m., indicated: patient observed to be unable to appropriately participate in transfers using a sit to stand lift, compromising her safety while using this device. It further indicated R70 had limited range of motion in shoulder, weakness in legs, and was only able to grasp with two fingers on each hand. The PT document included: Patient with severely arthritic hands, able to only use her index and middle fingers functionally on each hand. On 3/15/18, at 3:22 p.m. the regional director of clinical services (RDCS) stated transfer assessments were to be conducted upon admission, annually, quarterly and if there was a change in a resident's transfer status. The RDCS stated the results of the assessment would be documented on the care plan and communicated to the nursing assistants on their assignment sheets. RDCS further stated staff was to transfer residents in accordance with the resident's assessment and care plan, and stated if the nursing assistants had any questions they were to notify their nurse. During interview on 3/16/18, at 11:31 a.m the learning and development specialist supervisor (LDSS), stated nursing assistants and nurses were trained during orientation on how to use the mechanical lifts and how to apply the safety vest (lift belt) for the standing lift. Nursing assistants were checked off annually during competency class on how to use the mechanical lifts. The LDSS stated staff were instructed to put on the safety vest by applying it around the resident's waist according to the legal directions, and that staff were supposed to pull the straps so the belt was snug but not too tight, which staff were to verify by ensuring they were able to put their fingers between the belt and the resident's back. The LDSS stated staff were supposed to raise the resident up in the lift until the resident's bottom had just left the transfer surface and then pause for the cause, indicating the pause was a safety check to ensure all straps were fully attached with the safety latches on, and to ensure the resident was comfortable.The LDSS stated the safety vest should not be creating discomfort and should not be pinching the resident's breast area before staff lifted the resident up the rest of the way. The LDSS stated staff should encourage the resident to lean back, and stated it would not be acceptable for a residents elbows to be above their shoulders, for the lift belt to ride up under the chin or on or above the breasts, or for staff to leave the resident unattended while attached to the standing lift. The LDSS stated staff were trained to report to the nurse any concerns, questions or change in ability to transfer, to get advise on how to proceed. During interview on 3/16/18, at 11:48 a.m. the director of clinical services (DCS) stated nurses were trained on how to perform Resident Transfers with assessment during orientation. The facility's Mechanical Lift Transfer Policy modified (MONTH) 2012, Essential point for use of standing lift or total lift: Always follow manufacturer's recommendations for the proper use of the equipment and slings Standing Lift: b) Attach the appropriate sling so the label faces OUTSIDE away from the resident. Standing Sling- Position the bottom of the sling at the lower back, resident's arms outside of the sling. c) Adjust the tightness of the sling by buckling the belt and adjusting it until it is snug but comfortable. d) Position Lift and lock wheels. Open legs oft (sic) the mechanical standing lift to the widest position by moving the handle to the right most position. e) Standing outside the assist the resident's to position his/her knees into knee pads and feet onto foot plate. the footplate can be adjusted up or down. f) The loops on the sling accommodate the resident's girth. Bring them from the outside when attaching the loop. g) Have the resident lace his/her hands on the hand grips or the bar of the lift, and his/her arms should be located on the outside of the sling. h) Have resident lean back into the sling and press his/her knees into the kneepad. i) Assistance with a standing lift 1. One person assist-use the controls to raise the lift so the resident is suspended slightly is over the equipment that they are moving from-STOP and verify everything is hooked appropriately and then continue raising the lift following the directions for the specific type of lift used at the facility . Gently move the resident to the chair or other equipment. 2. Two person assist- one staff member is to use the controls to raise the lift so the resident is suspended slightly over the equipment they are moving from_STOP and verify everything is hooked appropriately and then continue raising the lift following the directions for the specific type of lift used at the facility . Gently move the resident to the chair or other equipment. The second staff member present may guide and support the resident if needed. 11. Lower the lift and position the resident in the chair or other equipment. 12. When the resident is securely seated, release the attachments. Remove sling from under the resident and roll the lift out of the way. Review of staff training for use of the lifts for nursing assistant (NA)-I, identified training had not been completed. The employee action sheet dated 12/28/16 indicated NA-I was training to be a NA. NA-I was hired on 12/28/16 as a nursing assistant, and completed the competency evaluation in orientation on 12/21/16 including a skills cheklist for lifts. There was no annual competency for NA-I since 12/21/16. NA-I had been on leave from 7/24/17 to 12/1/17, and had been working since that time. The compentency training for NA-A had not been completed annually. NA-A had been hired 1/18/17 and completed a competency on lifts on 2/13/17. She did not have a competency completed on her anniversary date of 1/18. During an interview with the human resources director on 3/16/18 at 12:30 p.m. she stated that annual competency would be done on the anniversary date of employment, and verified it had not been completed for NA-I or NA-A. The facility policy Presbyterian Home and services Standardized Training Program date 11/21/17 indicated RA/HHA competency class including use of mechanical lifts are done on hire and annually. The immediate jeopardy that began on 3/13/18, was removed on 3/15/18, when R33, R70 and all other residents who required mechanical lift transfer assistance had been reassessed for their transfer ability, and use of appropriate transfer equipment by nursing and/or physical therapy; resident plans of care were updated; nursing staff education on how to appropriately use mechanical lifts, what concerns to watch for, and what/when to report to the nurse was also initiated. In addition, the facility began re-educating clincial coordinators and other nursing staff who conduct assessment of mechanical standing lift use, regarding how to determine the proper lift equipment for individual residents, and the importance of re-evaluating residents for appropriate lift use when they experience a change of condition. These interventions were verified by interviews with staff, review of resident records, and review of training documentation. The provider had also made arrangements for representatives from the lift manufacturer to provide onsite training for staff. Noncompliance remained at the lower scope and severity level of D due to ongoing educational needs of staff.

Based on interview and document review the facility failed to ensure 2 of 3 residents (R1, R2) reviewed were free of significant medication errors when R1's antibiotic was transcribed and administered incorrectly. Harm occurred when R1 needed treatment at the hospital for an antibiotic overdose. Additionally, R2's antibiotic orders were transcribed incorrectly and R2 missed two months of the prescribed antibiotic. Findings include: R1's medical record included R1 was admitted to the facility with [DIAGNOSES REDACTED]. R1 was cognitively intact and admitted with physician's orders [REDACTED]. After completion of these antibiotics, R1's physician changed her antibiotic order on 4/26/17 to [MEDICATION NAME] 750 mg every day, one time per day by mouth for 6 months. Review of R1's physician's orders [REDACTED]. R1's May 2017 Medication Administration Record (MAR) indicated R1's [MEDICATION NAME] 750 mg was transcribed as [MEDICATION NAME] 750 mg one tablet every other day however was scheduled for six times per day. R1's May 2017 MAR indicated R1 recieved the [MEDICATION NAME] 750mg six times per day every other day for three days for a total of 18 doses over a six day period from 5/26/17-5/31/17. Review of R1's progress note dated 5/29/17 at 12:04 p.m. indicated R1 verbalied she had shaking on her upper extremities last night and mentioned to staff she thought she was having a stroke. Facility staff documented R1's vital signs, which were within normal limits. No shaking was observed by staff. Staff observed R1 had equal hand grasps, no shortness of breath, was alert and had no changes in mentation and R1's blood sugar was within normal limits. An on-call nurse practitioner was updated who directed staff to continue to monitor R1's condition. A progress note dated 5/29/17 at 10:15 p.m. indicated R1 had an emesis after dinner at 5:00 p.m. R1 indicated to staff she felt better after the emesis and staff noted they would continue to monitor R1. A progress note dated 5/30/17 at 9:25 p.m. indicated R1's appetite and fluid intake was low due to complaints of nausea. The note further indicated R1 had a small emesis in the evening and R1's blood pressure was low, however other vital signs were within normal range. R1 requested to speak with the nurse practitioner the following morning. A progress note dated 5/31/17 at 5:51 a.m. indicated R1 was needy with cares and observed to be anxious and staff indicated they would continue to monitor R1. On 5/31/17 R1's Nurse Practitioner (NP) reviewed R1's medical record and discovered R1's [MEDICATION NAME] 750mg was transcribed and administered incorrectly over the last six days from 5/26/17-5/31/17. R1's MAR indicated R1 recieved the medication six times per day every other day for three days instead of the order of [MEDICATION NAME] 750 mg one time per day every other day. The NP consulted with the pharmacist and physician. The NP then called poison control and had R1 sent to the emergency room for an evaluation. R1's progress note dated 5/31/17 at 9:13 p.m. indicated a call was placed to the hospital to check the status of R1. The hospital nurse indicated R1 would discharge back to the facility later that night and [MEDICATION NAME] was flushed out of R1's system at the hospital and new orders would include to hold the [MEDICATION NAME] for 48 hours. Hospital records dated 5/31/17 indicated R1 was treated for [REDACTED]. R1 returned to the facility the same evening with physician's orders [REDACTED]. A progress noted dated 6/1/17 at 1:27 a.m. indicated R1 returned from the hospital before midnight. A facility Medication Variance Report dated 6/8/17 indicated a transcription error occurred on 5/26/17 and was noted on 6/1/17 regarding R1's [MEDICATION NAME] mg physician's orders [REDACTED]. The order was entered by the Health Unit Coordinator (HUC) and double checked by a nurse, per facility policy, however the error was not caught and the medication was administered incorrectly over a period of six days. The report included that the medication error was significant. On 7/27/2017, R1's May 2017 MAR was reviewed and indicated [MEDICATION NAME] 750 mg was administered six times per day on 5/26/17, 5/28/17, and 5/30/17 to R1 for a total of 18 doses and administered by 5 different staff members. Interview with the Health Unit Coordinator (HUC)-A on 7/27/17 at 10:40 a.m. indicated she had entered R1's physician order [REDACTED]. HUC-A stated she must have read the order wrong. HUC-A indicated this error should have also been caught on the second check of the medication by the nurse prior to the order being changed on R1's MAR and medical record. Interview the Registered Nurse (RN)-B on 7/27/17 at 12:20 p.m. indicated he was the nurse manager on R1's unit. RN-B confirmed his name was indicated on R1's electronic orders indicated he had second checked the orders in the computer prior to the orders being changed on the MAR and in R1's electronic medical record. RN-B stated he had observed the orders were not signed off in the computer, however were signed off as double checked in R1's paper chart and he then signed off on the orders in the computer. RN-B admitted he did not check to see the frequency of the time of administration of the medication under the physician's orders [REDACTED]. Interview with the Director of Nursing (DON) on 7/27/17 at 1:45 p.m. confirmed the R1's medication was transcribed incorrectly and administered incorrectly by staff. The DON confirmed she identifed the medication error as a significant error due to the medication being an antibiotic and R1 having to be treated at the hospital for an antibiotic overdose. The DON stated the HUC and RN-B who transcribed R1's Levoquin order had been re-educated and retrained. The DON stated LPN-A no longer worked at the facility when the medication error was discovered. The DON could not indicate why the medication error report was filled out on 6/8/17 and not on 5/31/17 when the medication error was discovered. The DON futher stated she expected all staff who enter physician's orders [REDACTED]. Interview with R1 on 8/2/17 at 11:02 a.m. confirmed she recalled the medication error. R1 stated it was awful and now questions every medication that is given to her. R1 could not recall the details of the medication error, but knew she was given too much of the medication and could not recall if she was treated in the hospital. Interview with the licensed practical nurse (LPN)-A on 8/3/17 at 11:14 a.m. who had signed off on the second check of R1's paper physician orders [REDACTED]. Interview with the Nurse Practitioner (NP) on 8/4/17 at 1:41 p.m. confirmed she found the medication error after being informed of R1's complaints of shaking and quivering mouth movements. The NP was doing a medication review of R1's prescribed medication when she discovered the error. The NP stated she discussed the medication error with the pharmacist who directed her to call poison control and have R1 sent to the emergency room (ER) for an evaluation. The NP stated she was told by the facility it was a transcription error, however felt that staff administering the medication should have questioned the amount and frequency of the medication being given. R2 Review of R2's medical record included R2 was admitted to the facility with [DIAGNOSES REDACTED]. R2 admitted to the facility with physician orders [REDACTED]. R2 had further physician's orders [REDACTED]. The physician orders [REDACTED]. R2's MAR for March 2017 and April 2017 indicated R2 did not recieve the prescribed [MEDICATION NAME] for March 2017 or the prescribed Sulfamethoxazone/[MEDICATION NAME] for April 2017, for a total of 20 missed doses of profalactic antibiotics. A Medication Variance Report dated 5/4/17 indicated R2 did not recieve the prescribed [MEDICATION NAME] for March 2017 or the prescribed Sulfamethoxazone/[MEDICATION NAME] for April 2017. The report indicated staff did not input the antibiotic correctly in the specific months leading to the missing doses for March and April. The report indicated this was a significant medication error. R2's medical record indicated R2 did not have noted side effects from missing the March 2017 and April 2017 prescribed antibiotic doses. R2 passed away on 5/27/2017 from end stage [MEDICAL CONDITION]. Interview with the DON on 7/27/17 at 1:45 p.m. confirmed she had found R2's medication errors when reviewing monthly antibiotics for an infection control log. The DON further stated she discussed the error with the staff who entered the error and held an all staff meeting on input of physician orders [REDACTED]. The DON further confirmed she expected staff to enter orders correctly per facility policy and if the order was difficult to ask another staff member or herself about the order prior to entering it in the computer. A facility policy provided entitled Medication Administration Error Policy dated August 2015 indicated medications not prepared or administered in accordance with prescribers orders, manufacturer's specifications, or accepted professional standard and practice regulations is defined as a medication error. The policy further indicated a significant medication error means one which causes the resident discomfort or jeapordizes his/her health and safety. The policy included criteria for determining significance of medication error included resident condition, drug category and frequency of the error.

Based on observation, interview and document review, the facility failed to adequately assess to identify and implement appropriate interventions for pain for 1 of 3 resident (R39) reviewed for pain. This caused actual harm for R39 who experienced pain during care. Findings include: R39 was observed on 3/9/16, at 8:17 a.m. sitting in a reclining wheel chair. His left leg was extended out with the foot slightly inverted. A pillow was in place under his knees and calves. During an observation on 3/10/16, at 8:19 a.m., nursing assistant (NA)-B and NA-C were observed performing morning cares for R39. The NAs provided R39 a pillow to hold during cares. When staff lifted R39's left arm to wash underneath, R39 yelled out loudly OW and pulled away from the NAs as they provided upper extremity cares. The resident displayed facial grimacing as he yelled. The resident again yelled out Ow, Ow, Ow! while NA-B and NA-C applied compression hose to his lower extremities. The licensed practical (LPN)-A was in the room at the time of the observation and did not intervene or ask the NAs to stop cares so pain relief could be provided. The NAs did not suggest to the nurse that R39 needed pain relief. LPN-A left the room before the resident was transferred into the wheelchair. When the NAs initiated transferring R39 to the wheelchair, they had R39 hold a pillow to prevent the resident from striking out during the care. The surveyor stepped out of the room during the transfer at 8:37 a.m. R39 could be heard screaming out loudly across the hall and through two closed doors during the transfer to the wheelchair. Another surveyor who was in the dining room when R39 screamed out. That surveyor said R39's screaming was heard all the way to the dining room. R39's room was approximately the third room from the dining room. An admission Pain Evaluation dated 1/5/16, indicated R39 had a history of [REDACTED]. Behavioral indicators of pain included aggressive behaviors, striking out and protecting area. The summary on the Pain Evaluation indicated Resident is on scheduled [MEDICATION NAME] (narcotic). Noted striking, protecting areas and aggressive at time (of) care. R39's admission Minimum Data Set ((MDS) dated [DATE], indicated he was severely cognitively impaired, required extensive assistance with all ADLs, and had limited mobility in all extremities. In addition, the MDS did denote R39 had behaviors of hitting and kicking out during cares one to three times a week, but no refusals of care were noted. Another pain assessment dated [DATE], indicated R39 was noted to strike, protect areas and display aggression at time of care. The assessment identified these behaviors as non-verbal indicators of pain. R39's care plan dated 1/22/16, identified a potential for pain related to decreased mobility, contractures, and neuralgia. A review of the March 2016 Medication Administration Record [REDACTED].m There was no evidence medications were administered prior to morning cares, even though R39 had been assessed to have pain with cares. An undated and untitled Nursing Assistant Assignment sheet, indicated [REDACTED]. The Assignment sheet identified direction to provide R39 with a pillow to hold to prevent hitting and striking out at staff during cares. During an interview on 3/10/16, at 11:53 a.m. NA-C stated it was normal for R39 to yell out during care, especially in the morning. He stated in the evening, not as much. He stated it happens at least a couple of times a week. During an interview on 3/10/16, at 11:53 a.m., licensed practical nurse (LPN)-A stated the NA's had not reported pain during transfers but stated, screaming out during transfer is typical for R39. LPN-A stated R39 had expressed pain with transfers when he was admitted but he was not sure whether R39 continued to have pain. LPN-A further stated R39 had scheduled pain medication, but verified R39 did not receive pain medication prior to morning cares. During an interview on 3/10/16 at 12:00 p.m., registered nurse (RN)-D stated she had not observed R39 having any pain, but stated he did have behaviors during cares. RN-D stated she was aware he was resistive with care but was not aware whether the behaviors were related to pain. During an interview on 3/10/16, at 12:42 p.m., the physical therapist (PT)-E stated R39 had been evaluated for transfers but was combative with treatment. During an interview on 3/10/16, at 12:44 occupational therapist (OT)-E stated a range of motion program had been trialed for R39 but was not initiated due to R39's inability to tolerate it. OT-E said R39 was combative and would grimace during range of motion. During an interview on 3/10/16, at 1:34 p.m., the director of nursing (DON) stated the facility tries to monitor pain. He stated the nursing assistants chart when pain was noted would alert the nurse in the electronic record to assess. The DON stated R39 was not currently having any specific daily or every shift pain monitoring conducted by a licensed nurse. During an interview on 3/10/16, at 3:14 p.m., NA-D verified R39 displays behaviors. She stated, He fights in the evening at bedtime and calls out ouch, ouch. NA-D stated she was unsure whether R39 was having pain but stated, All the time he makes the noise. NA-D stated she charted R39's calling out and resistance to cares as behaviors and not pain. During a subsequent interview on 3/10/16, at 2:36 p.m., RN-D stated, we got orders to provide pain medication prior to morning cares now that you brought it to our attention. Review of the 3/10/16 orders for pain management included, scheduled pain medication prior to morning cares and pain monitoring five times daily. A facility policy titled Pain Assessment and Management Policy, dated March 2015, indicated: It is the right that all residents have the appropriate pain assessment and pain management, and to aid residents in maintaining a comfortable level of function in activities of daily living. The policy directed staff to assess the resident that cannot consistently verbalize pain by interviewing staff regarding nonverbal indicators as pain, symptoms of pain, specific times and activities that appear to cause the resident pain. The policy further directed staff to update the physician in order to start or change a pain management program. While R39's pain assessment indicated he displayed nonverbal indicators of pain during cares and staff had reported pain with range of motion and activities of daily living, there was no indication of pain management interventions utilized to reduce discomfort with morning cares. In addition, there had been no assessment to determine whether the behaviors R39 displayed were related to pain. In addition, although R39 was receiving scheduled pain medication, the medications were not being administered until after R39's morning cares were completed.

Based on observation, interview and document review, the facility failed to ensure interventions were implemented to promote healing and prevent further skin breakdown for 1 of 2 residents (R15) in the sample reviewed for pressure ulcers. This resulted in actual harm, as R15 had a recurrent pressure ulcer. Findings include: On 9/10/14, at 7:18 a.m. R15 was observed lying in bed awake. Nursing assistant (NA)-C and licensed practical nurse (LPN)-A was in R15's room to help R15 get up from bed. With R15's permission, the surveyor observed a pressure ulcer on R15's coccyx with LPN-A. LPN-A stated she had "just changed" the dressing to R15's coccyx. The wound dressing was dated 9/10 and was intact. LPN-A carefully opened the adhesive dressing to be checked. The wound was observed to have no drainage however, a yellow discoloration was observed on the dressing which LPN-A identified as being from [MEDICATION NAME], a gel wound treatment. During observations of R15 on 9/11/14, from 7:10 a.m. to 7:25 a.m., R15 was observed in her room seated on a cushion in the wheelchair. -At 7:26 a.m. registered nurse (RN)-D, entered R15's room and was observed to give R15 some medications, then left when R15 took all the medications. -From 7:27 a.m. to 8:00 a.m. R15 remained in her room alone, seated in front of a mirror grooming herself. -At 8:01 a.m. NA-B and NA-M were observed to enter R15's room, NA-B approached R15 and put her dentures in and changed her shirt. NA-M then pushed R15 out to the hallway at 8:05 a.m., and to the Northern Lights Lane (NLL) unit television (TV) area/lounge. During that observation, R15 was not off-loaded from her wheelchair, nor was she repositioned. -From 8:06 a.m. to 8:35 a.m. R15 remained seated in wheelchair in the same spot in the TV lounge. R15 remained in the same position in her wheelchair and did not receive assistance, nor reposition herself. -At 8:35 a.m. RN-E approached where R15's wheelchair was parked in the NLL TV lounge. RN-E was observed to speak briefly to R15, and then to push R15 to the dining room area towards R15's table. R15 was not off-loaded or repositioned and did not reposition herself. -From 8:49 a.m. to 9:20 a.m. R15 remained seated in wheelchair at the dining room, slowly working on breakfast with the use of right hand. -At 9:25 a.m. NA-B wheeled R15 away from the dining table towards the NLL TV area. NA-B left R15 in front of TV at the NLL TV area. -At 9:32 a.m. NA-B returned to push R15's wheelchair away from NLL TV area towards hallway going past the first floor nurses' station and to the elevators. NA-B stated she was to take R15 to the 3rd floor for an activity. -At 9:34 a.m. R15 was observed in the 3rd floor activity room with other residents where a female staff member was reading the newspaper. R15 was not off-loaded nor repositioned and did not reposition herself. -At 9:43 a.m. R15 was still seated in wheelchair, was calm and appeared to be listening to the reader at the news reading activity. -At 10:02 a.m. RN-D was notified by the surveyor that R15 had been seated in the wheelchair since 7:25 a.m., and requested that R15 be assessed for skin condition. -At 10:03 a.m. R15 was pushed to the common area in room [ROOM NUMBER] by NA-M and RN-E. The two staff members left R15 seated in the wheelchair in the common area/hallway. -At 10:05 a.m. RN-D, RN-E and NA-D, were observed to enter R15's room with her permission. R15 also gave permission for the staff to check the skin on her buttocks. R15 was transferred from her wheelchair to her bed with the use of a gait belt by RN-D, RN-E and NA-D. RN-D confirmed the dressing on R15's wound was from 9/10/14. RN-E assessed the pressure wound on R15's buttocks and described the open area on R15's as having 90% slough and slight redness on the surrounding skin up to the open area. The skin over the rest of the buttocks was clear, dry, intact, and the skin was blanchable. Although the resident had been observed from 7:10 a.m.-10:05 a.m. on 9/11/14, a period of 2 hours and 55 minutes, she was not offered, or encouraged, to be repositioned during that time. R15's electronic admission record dated 3/18/13, indicated R15 had [DIAGNOSES REDACTED]. The admission care plan dated 3/18/13, revealed R15 had been admitted with a pressure ulcer to the coccyx. A review of the Nurses' Progress Notes from the facility's last recertification survey exited in June 2013 forward, indicated R15 had a pressure ulcer on her coccyx as of 6/19/13. The Nurses' Progress Notes revealed R15's pressure ulcer on coccyx persisted through assessment dates beginning 6/19/13 until 7/25/14. The pressure ulcer had fluctuated in its stages of healing as evidenced by varied measurements pulled from the interdisciplinary/wound team progress notes as follows: -On 6/19/13, R15's coccyx pressure wound measured 1.5 centimeters (cm) X 0.5 cm X 0.3 cm. -On 12/5/13, R15's coccyx pressure wound measured 2.7 cm X 0.9 cm X 0.4 cm. -On 6/3/14, R15's coccyx pressure wound measured 0.3 cm X 0.3 cm X 0.2 cm. -On 7/8/14, R15's coccyx pressure wound measured 0.7 cm X 0.3 cm X 0.2 cm. -On 7/25/14, the documentation indicated the wound team had determined R15's coccyx pressure wound was resolved. The notes indicated continued interventions were to include: a wheelchair cushion, repositioning, air mattress and routine observations of the area. - On 7/29/14, a Nurses' Progress Note written by the interim clinical administrator (ICA) indicated R15 had a pressure ulcer on the coccyx described as, "unstageable" (full-tissue thickness loss in which the base of the ulcer is covered by slough or an eschar and, therefore, the true depth of the damage cannot be estimated until these are removed) area present on coccyx that measured 1 cm in length and 0.6 cm, bed of wound covered in slough, surrounding skin with scar tissue and presence of redness between wound and rectum. The facility had conducted an assessment 7/5/13 on a form entitled, Tissue Tolerance (Bed) (a tool used to determine repositioning schedule). The assessment documentation indicated the resident was not independent in mobility/positioning. The form was also checked for "No discoloration is present after resident has been in the same position for three hours on skin. Consider to care plan to reposition every three hours." However, the analysis included, "Resident on repositioning every 2 hrs (hours) in bed." The facility had also completed a Tissue Tolerance (Chair), which was undated. The documentation on that form indicated the resident was not independent in mobility/positioning. But was also checked for "No discoloration is present after resident has been in the same position for three hours on skin. Consider to care plan to reposition every three hours." However, the analysis included, "Resident is on every 2 hrs Repo. (repositioning) when up in w/c (wheelchair) & when in bed." The medical record lacked evidence of any other Tissue Tolerance documents having been completed. Directions on the Tissue Tolerance document indicated it was "To be completed upon, admission, annually and with significant change in status, upon emergence of pressure ulcer and changes with pressure surfaces." The surveyor requested to review any further assessments following recurrence of R15's pressure ulcer on 7/29/14, and no further documents were provided. An occupational therapy flow sheet, Rehabilitation Daily Flow Sheet dated 12/13/13, indicated R15 had trial use of a Broda chair (a tilt and recline positioning chair) for improved resident repositioning and protection of skin integrity. According to record documentation, the chair had been formally assigned to R15 on 12/16/13, after R15 had demonstrated improved repositioning with the chair. A Comprehensive Skin Risk Data Collection (CSRDC) had been completed for R15 on 3/7/14, and indicated R15 had a Braden Risk score of 13 (indicated moderate risk for pressure ulcer development). The CSRDC also indicated R15 had a history of [REDACTED]. The surveyor requested to review any further assessments following recurrence of R15's pressure ulcer on 7/29/14, and no further documents were provided. A Care Area Assessment (CAA) dated 3/13/14, indicated R15 had a stage II pressure ulcer (partial thickness skin loss involving epidermis, dermis, or both. The ulcer could be superficial and presents clinically as an abrasion, blister, or shallow crater) on the coccyx, and that the resident was at risk for further skin breakdown due to bowel incontinence, use of Foley catheter and decreased mobility. The CAA indicated R15 needed the assistance of two staff for mobility in bed; staff would check skin on shower days and as scheduled; and care plan to address pressure ulcer to avoid complications and minimize risks. A Wound Assessment Flow Sheet was completed 7/25/14, which indicated R15's pressure ulcer had healed. However, there was no Wound Assessment Flow Sheet completed for the wound that subsequently re-developed on 7/29/14. R15's quarterly Minimum Data Set ((MDS) dated [DATE], identified R15 as having a Stage 2 pressure ulcer with granulation tissue, which needed extensive assistance of one staff for repositioning, transfers, toileting, and personal hygiene. The progress notes from the physician and geriatric nurse practitioner (GNP) entitled, Geriatric Services of Minnesota Progress Notes were reviewed from 7/7/14 through 9/11/14. The notes included: - On 7/7/14, "Res. (resident) has coccyx wound seen by wound nurse & reported as stable. Size of wound has decreased (arrow downward image) in size 1.1 cm x 0.8 cm, currently 0.4 cm x 0.2 cm." - On 8/8/14, "Nsg (nursing) request to assess wound of 7/29/14, 1 cm x 0.6 cm. Wound RN (registered nurse) involved." Also noted was "Coccyx wound: red, blanchable, no drainage (circle with a line drawn through it to depict no), no [MEDICAL CONDITION], shallow ulcer, no bruising." The GNP wrote a plan for the staff to follow: "keep skin clean & dry, keep HOB (head of bed) < (less than) 30 degrees, change position q (every) 2 (hours), continue with current wound care orders." - On 9/5/14, the physician notes indicated the wound was "shallow coccyx wound per GNP note 8/8/14." Documentation from a Wound Consultation dated 7/8/14, indicated the coccyx ulcer was a Stage 3 (full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue). The facility documented, "chronic ST II (stage 2) but had slough." According to this documentation, the granulation was at 90% and the slough was at 10%, and the wound measured 0.7 cm x 0.3 cm x 0.2 cm. A Wound Consultation note dated 7/29/14, indicated the resident had an unstageable coccyx ulcer with 100% slough. The measurement was 1.0 cm x 0.6 cm x 0.1 cm and the edges were described as rolled. The note indicated, "slough has resurfaced." The recommendations revealed the goal was to "protect as goal may not be (sic) to heal but maintain current status." A physician's orders [REDACTED]. skin irritations) to peri-wound to protect, cover with [MEDICATION NAME] Sacrum (an all-in-one foam dressing that effectively absorbs and retains wound fluid (exudate) but keeps the wound sufficiently moist), seal dressing with Skin-Prep (a liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction during removal of tapes and films) around edges of dressing." On 8/12/14, the doctor ordered the application of [MEDICATION NAME] (used to help wounds that have stalled under first-line treatment to progress towards healing) to R15's coccyx wound instead of the silver [MEDICATION NAME] ointment, which had been unavailable since ordered on [DATE]. Until then the product became available, staff was directed to use the previous wound treatment orders. R15's care plan revised on 7/31/14, indicated R15 had a chronic pressure ulcer to coccyx. The care plan interventions directed facility staff to: complete treatments as ordered and monitor for effectiveness; follow facility policies and doctor's orders for skin care regime; provide information to R15 about the importance of frequent repositioning; and finally, reposition R15 every two hours during the day and two times at night. The care plan lacked evidence that R15 could off load/reposition self in the wheelchair and lacked evidence of any new interventions implemented to minimize/prevent an increase in size for the recurrent unstageable pressure ulcer to the coccyx. A Wound Consultation sheet dated 8/12/14, indicated R15's coccyx pressure ulcer was 2.6 x 0.5 cm and was superficial. The stage was identified as "MA" (the key for MA was not available on the form). The wound base was at 100% slough with scant drainage. The edges were macerated and scarred. The Wound Consultation sheet dated 8/26/14, indicated R15's coccyx pressure ulcer was "non-stage (unstageable)" and at 100% slough, loosening with slight drainage. The measurement was 1.3 x 0.5 cm. The consult documentation indicated R15 was to be turned and repositioned every two hours. The MDS dated [DATE], revealed R15 had one Stage 2 pressure ulcer and that the pressure ulcer was there upon admission. The MDS did identify R15 as being at risk for development of pressure ulcers. The MDS did not identify that R15 had a Stage 3 pressure ulcer that was identified by the facility on 7/8/14. The MDS also lacked evidence of the unstageable pressure that was identified by the facility on 7/29/14, when the new pressure ulcer developed, and again on 8/26/14, as identified on the Wound Consultation sheet. In addition, the MDS lacked evidence R15 was on a turning and repositioning program as that section was left blank. The MDS also lacked evidence that there was a previous healed pressure ulcer identified on 7/25/14, as per the progress note which indicated the coccyx pressure ulcer had been resolved. The facility's undated Nursing Assistant Care Sheet for Team 2, Northern Lights Lane, described R15 as non-ambulatory and requiring assistance of two staff for transfers, toileting and repositioning. The Nursing Assistant Care Sheet directed staff to reposition R15 every two hours. When interviewed on 9/10/14, at 7:48 a.m. LPN-A verified R15's pressure wound had been there for a "long time." LPN-A stated interdisciplinary team (IDT) do wound rounds every Tuesdays where wound measurements were done. LPN-A stated she did not measure the wound but stated the wound was at Stage 2. On 9/11/14, at 10:10 a.m. NA-D checked her nursing assistant care sheet and stated R15 was supposed to be repositioned every two hours. On 9/11/14, at 10:20 a.m. RN-E stated he would expect a resident with pressure ulcer to be repositioned according to care plan and further stated R15 should have been repositioned every two hours per R15's care plan. On 9/11/14, at 10:29 a.m. RN-D was interviewed and acknowledged R15 had chronic pressure ulcer to coccyx, and that different treatments had been tried and the pressure ulcer would "get better" but open up again. RN-D verified R15's care plan interventions indicated the resident would be repositioned every two hours, but that R15 was not repositioned accordingly given the time R15 was brought out from her room until that time today. On 9/11/14, at 3:22 p.m. the ICA acknowledged that facility staff should follow the intervention to reposition R15 every two hours according to R15's care plan. The facility's Skin Risk Policy modified on 8/13, directed the facility staff to complete a new Braden Scale, a new Comprehensive Data Collection Tool, and a new tissue Tolerance algorithm with the onset of a new pressure ulcer, and care plan interventions according to the resident and/or individual risk factors. The policy was not followed for R15 when a new pressure ulcer was developed on 7/29/14. The policy further directed staff to establish individualized repositioning schedule if a resident was unable to move. R15's newly re-opened Stage 2 pressure area was not properly re-assessed by the facility as the facility did not follow the policy "to properly identify, assess and monitor residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for ulcers according industry standards of care" nor did R15 receive repositioning in a timely manner.