Every finding on record at Meeker Manor Rehablitation Center, LLC

Based on interview and record review, the facility failed to ensure residents receiving psychotropic medications were adequately assessed and monitored. Further the facility failed to initiate target behavior monitoring for 1 of 5 residents (R3) reviewed for unnecessary psychotropic medications.Findings include:R3's admission Minimum Data Set (MDS) dated [DATE], identified R3 had severe cognitive impairment and required assistance with activities of daily living (ADL's). R3's diagnoses included non-traumatic brain dysfunction (impaired brain function not caused by injury), unspecified dementia without behavioral, psychological, mood, or anxiety disturbances (decline in memory and thinking abilities), non-Alzheimer's dementia (cognitive decline not caused by Alzheimer's disease), anxiety disorder (a condition involving excessive worry or fear), and mood affective disorder (a mental health condition affecting mood and emotional state). The MDS further identified R3 received antipsychotic, antidepressant, anticonvulsant, and anticoagulant medications.R3's signed physician orders dated 4/29/26, identified an order dated 04/14/2026 at 12:30 p.m. for Risperidone 0.25 mg (milligram), two tablets by mouth every four hours as needed (PRN) for agitation and paranoia, with a maximum of three PRN doses in 24 hours. Review further identified an order dated 4/14/26 at 2:00 p.m. for Risperidone 0.5 mg, one tablet by mouth three times a day for paranoia/agitation.R3's electronic medical record (EMR) on 5/18/26, failed to identify documentation an AIMS (Abnormal Involuntary Movement Scale) assessment had been completed upon admission despite R3 being admitted on [DATE] and received antipsychotic medications.R3's EMR lacked evidence target behavior monitoring had been initiated for the antipsychotic medications. The EMR failed to identify measurable target behaviors, including documentation of frequency, duration, severity, precipitating factors, or response to interventions for R3's agitation and paranoia. The facility was unable to demonstrate ongoing monitoring of the effectiveness of Risperidone therapy or the continued need for the medications.R3's EMR further identified an AIMS assessment was completed on 5/18/26 after surveyor request; however, the assessment was not completed upon admission or initiated timely in relation to the start of R3's antipsychotic medications on 4/14/26. The delayed completion did not ensure timely monitoring for potential adverse effects associated with antipsychotic medication use.During interview on 5/20/26 at 9:57 a.m., registered nurse case manager (RN)-A stated residents receiving antipsychotic medications required an AIMS assessment completed, orthostatic blood pressures obtained as ordered, target behavior monitoring initiated, and side effects monitored. RN-A reviewed R3's EMR and stated she had completed the AIMS assessment the other day. RN-A stated the AIMS assessment should have been completed within the first week of admission because it was important to establish the resident's baseline status prior to ongoing antipsychotic use. RN-A further confirmed behavior and side effect monitoring had not been initiated until recently and should have been implemented earlier. RN-A stated monitoring was important, particularly because the facility utilized agency staff, so all staff would be aware of the resident's behaviors, response to medication, and ongoing needs.During interview on 5/20/26 at 10:46 a.m. director of nursing (DON) stated residents receiving antipsychotic medications required ongoing monitoring to identify changes in condition and determine effectiveness of the medication regimen. The DON stated behavioral monitoring and an AIMS assessment were completed upon admission or initiation of antipsychotic medications. The DON reviewed R3's EMR and confirmed the AIMS assessment was completed on 5/18/26; however, it should have been completed upon admission. The DON further confirmed target behavior monitoring should have been in place for R3 and acknowledged monitoring had not been initiated. The DON stated target behavior monitoring was important to ensure staff understood what behaviors were occurring and to evaluate whether the medications were effective.Review of the facility policy titled Psychotropic Medication Use Policy, revised 5/2025, identified psychotropic medications were to be used only when clinically indicated and supported by documented target symptoms and behavioral monitoring. The policy further identified residents receiving antipsychotic medications would receive ongoing monitoring for effectiveness and adverse consequences, including documentation of identified target behaviors and individualized interventions. The policy required target behaviors to be monitored and supported in the clinical record. In addition, the policy identified residents initiated on antipsychotic medications would receive DISCUS or AIMS assessments at baseline, with ongoing monitoring completed thereafter. The policy further identified monitoring for behavioral symptoms and re-evaluation of residents receiving new psychotropic medications or dose changes to assess medication effectiveness and continued need.

Based on interview and record review, the facility failed to ensure appropriate care and services were provided for the management of an external urinary catheter system, including failure to obtain physician orders and implement care instructions for cleaning, disinfecting, and changing the condom catheter drainage bag for 1 of 1 resident (R1) reviewed for urinary catheter care.Findings include:R1's comprehensive Minimum Data Set (MDS) dated [DATE], identified R1 had intact cognition and required assistance with activities of daily living (ADL's). R1's diagnoses included atrial fibrillation (an irregular and often rapid heart rhythm), heart failure (a condition in which the heart cannot pump blood effectively), benign prostatic hyperplasia (BPH; enlargement of the prostate gland that can affect urination), stroke (damage to the brain caused by interrupted blood flow), malnutrition (lack of proper nutrition due to inadequate intake or absorption), anxiety disorder (a condition involving excessive worry or fear), and depression (a mood disorder causing persistent sadness or loss of interest).R1's signed physician orders dated 4/29/26, indicated use of a condom catheter at bedtime. Review of the electronic medical record (EMR) failed to identify physician orders or documented instructions related to cleaning, disinfecting, monitoring, or routine changing of the catheter drainage bag associated with the condom catheter system.During observation on 5/19/26 at 11:57 a.m. R1's catheter drainage bag was observed hanging on the side rail in R1's bathroom. Observation and record review failed to identify documentation the drainage bag was routinely cleaned, disinfected, monitored, or replaced in accordance with accepted standards of practice.During interview on 5/20/26 at 9:44 a.m. licensed practical nurse (LPN)-A stated R1 used a condom catheter at night that was attached to an overnight drainage bag. LPN-A reviewed the EMR and confirmed there were no physician orders addressing when the drainage bag should have been changed or instructions for cleaning or disinfecting the bag. LPN-A stated staff were expected to follow physician orders and facility protocols related to catheter care and infection prevention practices.During interview on 5/20/26 at 9:57 a.m. registered nurse case manager (RN)-A stated there was an order in the computer for the condom catheter to be applied at bedtime and removed at HS. RN-A stated the drainage bag change schedule should have been included in the physician orders and the bag should have been changed weekly. RN-A reviewed the EMR and confirmed there were no orders related to changing, cleaning, or disinfecting the drainage bag.During interview on 5/20/26 at 10:46 a.m. the director of nursing (DON) stated the facility expected catheter drainage equipment to have clear physician orders and nursing instructions regarding care, cleaning, monitoring, and replacement schedules. The DON stated catheter care should have included monitoring output and assessing for signs and symptoms of irritation or infection, including regular skin checks. The DON further stated drainage bags should have been changed weekly and documented on the treatment administration record (TAR). The DON confirmed the facility was unable to provide evidence orders or documented guidance were in place for R1's condom catheter drainage bag care.The facility policy titled, Condom/External Catheter Care, dated 1/2025, identified male external catheters were used for residents with urinary incontinence and required daily care to maintain cleanliness, safety, and proper functioning. The policy directed staff to remove, dispose of, and replace external catheters every 24 hours and to clean and assess the penis daily for redness, bruising, or open areas that could indicate improper fit or skin breakdown. The policy further instructed staff to practice good hygiene, including handwashing and cleaning of the penis during catheter application and drainage bag emptying, and to ensure proper application techniques to avoid complications and injury.The facility policy titled, Disinfection of Urinary Drainage Bag, revised 12/2023, identified the purpose of the policy was to clean and disinfect urinary drainage bags and prohibit the growth of bacteria. The policy directed staff to cleanse catheter and tubing connection points with an alcohol swab prior to disconnecting the drainage bag, disinfect the drainage bag daily when removed from the resident, rinse the inside of the bag with 55-65 cc of vinegar, allow the exterior to air dry, and change the drainage bag to a new appliance on bath day. The policy further identified staff were to monitor and record urinary output and maintain appropriate catheter care supplies in the resident room.

Based on observation, interview, and record review, the facility failed to ensure residents received routine bathing and grooming services necessary to maintain personal hygiene and dignity, including failure to provide scheduled weekly bathing and failure to assist with facial hair grooming for 2 of 6 residents (R2 and R21) reviewed for activities of daily living (ADL) care.Findings include:R2's admission Minimum Data Set (MDS) dated [DATE], identified R2 had intact cognition and required assistance with activities of daily living (ADL)'s. R2's diagnoses included primary generalized osteoarthritis, atrial fibrillation, urinary tract infection (last 30 days), thyroid disorder, depression, chronic pain syndrome, urge incontinence, suicidal ideations, and weakness.R2's care plan printed 5/19/26, identified a self-care deficit related to falls. The care plan identified interventions and goals which included R2 would accept assistance with self-cares and would be dressed, groomed, and bathed per preferences. Interventions included assist of one staff member with dressing, assist of one staff member with grooming, assist of one staff member with bathing, provide assistance with oral cares in the morning, at bedtime, and as needed, and honor dressing and personal hygiene preferences.R2's bathing documentation from 4/1/26 to 5/19/26, identified R2 had scheduled bathing services once weekly. Documentation indicated R2 received a bath on 4/2/26, 4/26/26, 4/30/26, 5/12/26, and 5/15/26. R2 refused a bath on 4/16/26. Further review failed to identify documentation R2 received weekly bathing as scheduled, as the time between some completed baths exceeded one week. The record failed to identify additional refusals or documentation explaining why scheduled bathing services were not completed.During observation and interview on 5/17/26 at 10:41 a.m. R2's hair was standing up and appeared very greasy. R2 had a few long white chin hairs approximately one and a half to two inches in length. During interview, R2 stated she did not get a bath very often due to the facility being short staffed. R2 further stated she did not have access to tweezers, a shaver, or a mirror. R2 stated the chin hairs bothers me and I don't like them at all, and stated, when you notice them others can as well.During observation on 5/18/26 at 4:47 p.m. R2 was sitting at a table in the dining room. R2's hair was messy, standing up, and appeared greasy. R2 continued to have long white hairs present on her chin.During observation on 5/19/26 at 9:11 a.m. R2 was wheeling down the hallway in her wheelchair from the dining room to her room. R2's hair appeared brushed. Long white chin hairs continued to be present.R2's electronic medical record (EMR) failed to provide documentation to indicate grooming assistance had been offered or provided related to facial hair care.R21's comprehensive MDS dated [DATE], indicated intact cognition and required assistance with ADL's, including bathing. R21's diagnoses included cancer, cirrhosis (scarring of the liver that affects liver function), diabetes mellitus (a condition affecting blood sugar regulation), hip fracture (a break in the upper portion of the leg near the hip joint), malnutrition (lack of proper nutrition due to inadequate intake or absorption), anxiety disorder (a condition involving excessive worry or fear), and depression (a mood disorder causing persistent sadness or loss of interest).R21's care plan printed 5/19/26, identified a self-care deficit related to femur fracture. The care plan identified goals for the resident to accept assistance with self-cares and to be dressed, groomed, and bathed per preferences. Interventions included occupational therapy (OT) per physician order, follow OT instructions, assist of one staff member with dressing, assist of one staff member with grooming, assist of one staff member with bathing, and provide assistance with oral cares in the morning, at bedtime, and as needed.R21's bathing documentation from 4/14/26 to 5/19/26, indicated bathing services once weekly. R21 refused a bath on 4/16/26 and received baths on 4/20/26, 4/30/26, and 5/12/26. Further review failed to identify documentation R21 received weekly bathing as scheduled, as the time between some completed baths exceeded one week. The record failed to identify additional refusals or documentation explaining why scheduled bathing services were not completed.During interview on 5/17/26 at 12:46 p.m. R21 stated I have been here since middle of April and I have yet to have a bath or shower. R21 stated part of the issue was she had a lot of wounds and staff were waiting to get approval from the physician before giving her a shower, but stated that has been a while. R21 further stated she had only had her hair washed once with a shampoo shower cap while in bed.During interview on 5/20/26 at 9:44 a.m. licensed practical nurse (LPN)-A stated R2 and R21 required assistance with all activities of daily living (ADL's) and stated neither R2 nor R21 refused cares. LPN-A further stated residents were expected to receive at least one bath per week.During interview on 5/20/26 at 9:44 a.m. nursing assistant (NA)-A stated she had never heard that either R2 or R21 refused bathing and stated both residents required assistance with bathing. NA-A further stated if she noticed facial hair on a female resident, she would assist the resident with shaving. NA-A stated both residents should receive a bath weekly.During interview on 5/20/26 at 9:57 a.m. registered nurse (RN)-A stated residents were expected to receive bathing at least once weekly unless they refused, and staff were expected to try to follow resident preferences. RN-A stated R2 would occasionally require a lot of convincing, but staff were generally able to encourage her to participate in care. RN-A stated R2 had previously lived in assisted living and had been very independent. RN-A further stated R2 required assistance with grooming and the facial hair should be shaved. RN-A stated the facility had a facility-owned shaver staff could use and the expectation was staff would assist the resident and address facial hair if noticed by staff. RN-A further stated she would have expected a bath to occur for R2 and R21 between 4/30/26 and 5/12/26. RN-A stated both residents were scheduled for Thursday evening bath days. RN-A stated if a resident refused bathing, the refusal should be documented in the medical record. RN-A further stated bathing schedules were discussed during morning meetings and, if bathing was noted to be overdue by a week, the scheduler would assist on the floor to help ensure additional baths were completed.During interview on 5/20/26 at 10:46 a.m. director of nursing (DON) stated each resident had their own bathing preferences and staff were expected to ensure those preferences were followed. The DON stated residents should receive bathing at least once weekly. The DON further stated staff were expected to assist residents with shaving facial hair when needed.Review of the facility policy titled Activities of Daily Living (ADLs)/Maintain Abilities Policy, updated 3/31/23, identified the facility was responsible to provide person-centered care and services that honored and supported each resident's preferences, choices, values, and beliefs. The policy further identified the facility would provide necessary care and services to ensure residents' abilities in activities of daily living (ADL's) did not diminish unless unavoidable due to the resident's clinical condition. The policy identified the facility would provide care and services related to hygiene needs, including bathing, dressing, grooming, and oral care. The policy further identified residents unable to complete ADL's independently would receive necessary services to maintain grooming and personal hygiene.

Based on interview and record review, the facility failed to ensure an interdisciplinary team (IDT) assessment was completed to determine whether self-administration of medication was clinically appropriate and safe prior to permitting self-administration of nebulizer treatments, for 1 of 1 resident (R1) reviewed for self-administration of medications.Findings include:R1's comprehensive Minimum Data Set (MDS) dated [DATE], identified R1 had intact cognition and required assistance with activities of daily living (ADL's). R1's diagnoses included atrial fibrillation (an irregular and often rapid heart rhythm), heart failure (a condition in which the heart cannot pump blood effectively), benign prostatic hyperplasia (BPH; enlargement of the prostate gland that can affect urination), stroke (damage to the brain caused by interrupted blood flow), malnutrition (lack of proper nutrition due to inadequate intake or absorption), anxiety disorder (a condition involving excessive worry or fear), and depression (a mood disorder causing persistent sadness or loss of interest).R1's signed physician orders dated 4/29/26, identified an order for Ipratropium-Albuterol 0.5-2.5 mg/3 mL (milliliters) nebulizer treatments administered three times daily, initiated on 3/25/26.R1's electronic medical record (EMR) identified a physician order initiated on 5/18/26, indicated R1 was permitted to self-administer nebulizer treatments following staff setup. The EMR lacked evidence an interdisciplinary team (IDT) self-administration assessment had been completed prior to implementation of the order to determine whether self-administration of the nebulizer was clinically appropriate and safe.Further R1's EMR lacked evidence an assessment had been completed to determine R1's competency and safety to self-administer the nebulizer medication and treatment. The EMR further failed to identify documentation addressing R1's ability to understand the medication purpose, follow treatment directions, safely operate nebulizer equipment, recognize side effects or adverse reactions, or ensure safe administration and storage of the medication and equipment.During observation on 5/17/26 at 1:27 p.m. R1 was observed with nebulizer equipment and medication available in the resident room.During interview on 5/19/26 at 11:57 a.m. R1 stated nursing staff set up the medication cup for the nebulizer treatment and then left the room while the treatment was running. R1 stated staff later returned to ensure the machine was turned off. Staff cleaned the nebulizer mask after the treatment was completed.During interview on 5/20/26 at 9:44 a.m. licensed practical nurse (LPN)-A stated she set up the nebulizer treatment and later returned to ensure the machine was no longer running. LPN-A further stated the nebulizer mask was cleaned and placed on a paper towel to air dry.During interview on 5/20/26 at 9:57 a.m. registered nurse (RN)-A stated a self-administration assessment was completed for residents who wished to self-administer medications and then submitted to the provider for review and an order. RN-A confirmed a self-administration assessment had not been completed for R1 and stated the assessment should have been completed to ensure R1 could safely and appropriately self-administer the medication.During interview on 5/20/26 at 10:46 a.m. director of nursing (DON) stated residents wishing to self-administer medications should have had a full assessment completed to evaluate their ability and competency. The DON stated staff were expected to contact the provider for an order and confirmed the self-administration assessment should have been completed prior to a resident being permitted to self-administer medications.Review of the facility policy titled Self-Administration of Medications, revised 2/2024, identified residents could self-administer medications only after the interdisciplinary team (IDT) determined the practice was clinically appropriate and safe. The policy indicated the IDT was responsible for assessing residents' cognitive and physical abilities and evaluating factors including the resident's ability to understand medication labels and instructions, comprehend the medication's purpose and potential side effects, safely administer medications, and safely store medications. The policy further indicated approval for self-administration was to be documented in the medical record and care plan, periodically reassessed based on changes in condition, and residents determined unable to safely self-administer medications were to receive medication administration from nursing staff.

Based on interview and record review, the facility failed to develop and implement comprehensive, person-centered care plans to address significant medical conditions and medication-related risks, including failure to care plan anticoagulant therapy for 2 of 2 residents (R1 and R3) reviewed for anticoagulant medications, and failure to care plan cardiac conditions, pacemaker presence, and condom catheter use for 1 of 2 residents (R1) reviewed for cardiac care needs.Findings include:R1's comprehensive Minimum Data Set (MDS) dated [DATE], identified R1 had intact cognition and required assistance with activities of daily living (ADL's). R1's diagnoses included atrial fibrillation (an irregular and often rapid heart rhythm), heart failure (a condition in which the heart cannot pump blood effectively), benign prostatic hyperplasia (BPH; enlargement of the prostate gland that can affect urination), stroke (damage to the brain caused by interrupted blood flow), malnutrition (lack of proper nutrition due to inadequate intake or absorption), anxiety disorder (a condition involving excessive worry or fear), depression (a mood disorder causing persistent sadness or loss of interest), and presence of a cardiac pacemaker (an implanted device used to regulate heart rhythm). The MDS further identified R1 received anticoagulant medications.R1's signed physician orders dated 4/29/26, indicated Eliquis (apixaban) anticoagulant medication dated 3/12/26, and an order to apply a condom catheter at bedtime (HS) and remove when getting up for the day dated 3/15/26.R1's comprehensive care plan printed 5/20/26, failed to identify interventions or monitoring related to anticoagulant medication use, including bleeding risk, monitoring for adverse effects, or staff awareness of anticoagulant precautions. Further, care plan lacked evidence of interventions related to R1's cardiac conditions, presence of a pacemaker, or use of a condom catheter, including monitoring for skin integrity or resident-specific catheter care preferences.R3's admission Minimum Data Set (MDS) dated [DATE], identified R3 had severe cognitive impairment and required assistance with activities of daily living (ADL's). R3's diagnoses included non-traumatic brain dysfunction (impaired brain function not caused by injury), unspecified dementia without behavioral, psychological, mood, or anxiety disturbances (decline in memory and thinking abilities), non-Alzheimer's dementia (cognitive decline not caused by Alzheimer's disease), anxiety disorder (a condition involving excessive worry or fear), and mood affective disorder (a mental health condition affecting mood and emotional state). The MDS further identified R3 received anticoagulant medications.R3's signed physician orders dated 5/4/26, indicated an order for Eliquis (apixaban) anticoagulant medication.R3's comprehensive care plan printed 5/19/26, lacked evidence of anticoagulant therapy, bleeding risk precautions, monitoring for adverse effects, or interventions related to anticoagulant medication use.During interview on 5/20/26 at 9:57 a.m. registered nurse case manager (RN)-A stated the care plan was a community effort involving the MDS coordinator, director of nursing (DON), herself, and the other case manager. RN-A stated R1's condom catheter should have been referenced on the care plan to address monitoring for skin integrity and the resident's preferred care needs. RN-A reviewed R1's care plan and confirmed the resident had a pacemaker, and that cardiac conditions had not been addressed on the care plan and should have been. RN-A further confirmed R1's anticoagulant medication had not been addressed on the care plan and should have been. RN-A stated it was important for significant diagnoses, devices, and medications to be care planned, especially because the facility utilized agency staff, so all staff were aware of the resident's care needs. RN-A also reviewed R3's care plan and confirmed anticoagulant therapy had not been addressed and should have been included in the care plan.During interview on 5/20/26 at 10:46 a.m. director of nursing (DON) stated R1's condom catheter should have been addressed on the care plan for monitoring of output, skin integrity, and signs and symptoms of irritation or infection. The DON stated regular skin checks should have been completed, and drainage bags were expected to be changed weekly, which would have been documented on the treatment administration record (TAR). The DON stated the catheter was disposable and the care plan was important so staff were aware of the residents' needs and it guided resident care. The DON further stated R1's cardiac conditions and presence of a pacemaker should have been addressed on the care plan so staff were aware of the resident's cardiac history, monitoring needs, and potential complications. The DON stated anticoagulant medications should also have been included in the care plan so staff could monitor for changes and be aware of the residents' conditions and risks associated with anticoagulant use. The DON confirmed anticoagulant therapy had not been addressed on R1's or R3's care plans and should have been included.The facility's policy titled Comprehensive Care Plans, revised 1/25, identified the facility would develop and maintain individualized, person-centered care plans that addressed each resident's diagnoses, medical conditions, physician orders, treatments, devices, medications, and identified risks. The policy further identified care plans were intended to guide staff in the delivery of care, ensure continuity of care between caregivers, and include appropriate monitoring and interventions to address changes in condition, medication-related risks, skin integrity concerns, and specialized medical needs.

Based on interview and document review, the facility failed to clarify R5's oxygen (O2) order, reconcile the O2 order, and administer O2 as ordered for 1 of 1 (R5) resident reviewed for oxygen therapy. Findings include: Review of State Agency (SA) report, dated 9/21/25 at 7:17 p.m., identified R5's family member noticed an oxygen tank in R5's room that was not in use since their admission to the facility. R5's undated, current Minimum Data Set (MDS) list identified R5 was admitted [DATE] with diagnoses of obstructive sleep apnea and chronic obstructive pulmonary disease (COPD). R5's 9/19/25, Orders Discharge Report identified R5 was to take oxygen (O2) 2 liters (L) by inhalation route at bedtime. R5's 9/19/25, Admission/Initial Data Collection assessment sheet identified in the respiratory status section related to oxygen needs was left blank. R5's 9/19/25, 48-Hour Care Plan identified R5 had an alteration in oxygen/gas exchange. The goal was to have adequate gas exchange with no cyanosis (bluish discoloration of lips, hands and nails occur due to lack of oxygen in the blood), shortness of breath, oxygen saturation greater than 90% on room air and a normal respiratory pattern. Interventions for nursing staff to monitor oxygen saturation as ordered and as needed, document on respiratory status, inform the medical provider of changes, and monitor for cyanosis, accessory muscle use, shortness of breath, increased respirations, or difficulty coughing up sputum. However, the care plan lacked indication and parameters for O2 therapy. R5's September Treatment Administration Record (TAR) identified R5 was to receive 2 liters of O2 at bedtime and was to start on 9/19/25. However, the order was transcribed as a nursing order vs. a physician's order, resulting in R5 not receiving oxygen therapy until 9/23/25. Observation and interview on 9/24/25 at 9:03 a.m., with R5 was in her room reported wearing a nasal cannula connected to an oxygen concentrator that was set at 2 liters (L). R5 reported O2 therapy was not administer until approximately 3 days later. On one occasion after her admission, an employee on the evening shift informed R5 that she did not need the O2 at night unless her oxygen saturation was under 90%. R5 noted she had no difficulty breathing at night. Staff removed her O2 this morning after and was only to receive 02 therapy at night. When asked how that made R5 feel, R5 voiced that R5 did not agree with the employee response and was not happy. R5's, September 2025 vitals sign sheet identified on:9/19/25, 122/63 blood pressure, pulse 77, 94% oxygen saturation on room air, and 18 respirations.9/20/25, 168/57 blood pressure, pulse 63, 96% oxygen saturation on room air, and 18 respirations.Overall, R5's medical record lacked vital sign assessment for 9/21, 9/22, and 9/23/25 before administration of O2 therapy. R5's 9/20/25 through 9/23/25, progress notes lacked evidence that R5 was to receive O2 therapy at night. Interview on 9/24/25 at 9:13 a.m., with licensed practical nurse (LPN)-A identified R5 was to have O2 at night, however, she had not entered R5's room this morning to assess R5 and was not aware R5 was still on O2 therapy this morning. Interview on 9/24/25 at 10:54 a.m., with director of nursing (DON), initially set up R5's oxygen tank and tubing and placed it in R5's room when R5 was admitted to the facility. Nursing staff was expected to review and implement R5's orders as directed and communicate updates during staff handover to certified nursing assistants (NA) of R5's treatment plan. Interview on 9/24/25 at 3:05 p.m., with LPN-B identified the health information manager inputs admission orders on point click care (PCC) (online electronic medical record software) and review and cosigns the orders. R5's O2 orders was placed as a nursing order incorrectly and acknowledged the O2 order was to be placed as a physician order. R5's physician was not called to clarify the O2 and provide a diagnosis for O2 use. After reviewing R5's medical record on PCC, she identified R5 had no vital sign assessments for 9/21, 9/22, and 9/23/25 and acknowledged that R5's O2 orders was not followed as prescribed. Interview on 9/24/25 at 5:00 p.m., with regional nurse consultant identified R5's care plan should have included indications and parameters of O2 use. Review of undated, current Oxygen Administration checklist identified nursing staff was to verify practitioner's order for use of oxygen therapy, gather necessary supplies and equipment, perform a baseline assessment that was to include vital signs, breath sounds, oxygen saturation level and physical assessment before administering oxygen therapy. Request of oxygen therapy policy was requested and not received during survey window.

Based on interview and document review, the facility failed to ensure adequate supply of medication was obtained and administered as ordered for 1 of 3 sampled residents (R1) reviewed for pharmacy services.Findings include: Review of State Agency (SA) report on 9/15/25 at 8:30 a.m., identified the facility had not inform R1's family member that R1 did not receive her antibiotics and had missed 2 of 4 doses and nursing staff did not have access to retrieve emergency medications. R1's 8/25/25, Hospitalist Progress note identified R1 had a fall and obtained a hip fracture. On 9/2/25, while hospitalized R1 obtained a fever of 102 degrees (Fahrenheit). On 9/06/25, R1 had loose stools and was tested positive for clostridium difficile (C diff) (bacteria in the gut that causes severe diarrhea) on 9/06/25. R1's labs identified elevated white blood cell count (WBC) of 20.9. Vancomycin therapy was to start for R1's infection on 9/06/25 and had orders to continue administration of antibiotic therapy on R1's discharge summary. R1's September 2025, Medication Administration Record (MAR) identified R1 had a diagnosis of neoplasm (cancer) of the digestive organs, COPD, enterocolitis due to C -diff and right femur fracture. The MAR identified R1 had been prescribed vancomycin (antibiotic) 125 milligram (mg) four times a day for C-diff and was to take it in the morning, afternoon, evening and at night that started on 9/11/25 and ended 9/16/25. The MAR identified on 9/14/25 at 8:00am, 9/14/25 at noon, and 9/15/25 at 4:00 p.m., total of 3 doses of antibiotics was missed. R1's 911/25, 48 Hour Care Plan identified R1 was on enteric (minimize transmission of pathogens that cause gastrointestinal infections) precautions related diagnosis of clostridium difficile (C-diff). The goal was for nursing staff to follow enteric precautions, use appropriate communication to follow evidenced base practice and for staff to put on and take off personal protection equipment (PPE) per enteric precautions when providing high contact cares when entering R1's room. However, the baseline care plan lacked indication of antibiotic use for C-diff. R1's 9/12/25, Daily Skilled Note assessment sheet identified R1 had no active infections and was not on antibiotic therapy. R1's progress notes identified on: 1) 9/14/25 at 2:27 p.m., local pharmacy Polaris was informed that R1's vancomycin capsules was to be sent to the facility in liquid form. R1 agreed to receive vancomycin as an oral solution and the on-call provider was notified to send over R1's prescription for liquid vancomycin to be administered.2) 9/14/25 at 11:00 p.m., during nurse handover communication and narcotic count, R1's family member voiced concerns that R1 had missed scheduled doses of vancomycin. Nursing staff confirmed had missed scheduled doses earlier in the day. Both the physician and administrator was notified of the missed antibiotic dose. R1's family member was reassured and informed the local pharmacy was to be deliver the antibiotics to the facility later in the evening. Additionally, R1 was scheduled for a 5:00 p.m. dose, the medication was removed from the Cubex (machine that dispenses medications). A new order for vancomycin liquid was delivered to the facility at 10:00 p.m., on 9/14/25 and R1 received her second dose of the antibiotic that evening. Staff nurse called the family and left a voicemail that R1 had received her scheduled medications.Interview on 9/22/25 at 1:24 p.m., with interim director of nursing (DON) was to assign nursing staff access to the Ekit, which was called the Medbank (Cubex). The Medbank was located between the 200 and 300 unit. The process of enrollment was to include each nurse and/or trained medication aide (TMA) name to be registered in the system and was given a 4 digit pin number to access the system. Protocol of removing medications from the Medbank permitted TMA's access to remove general medications, except for narcotics. Nurses were permitted to remove emergency medications, including controlled narcotics but those required a pin number that was provided by the local pharmacy. Inside the medication room displayed a list of medications named the Medbank List that was to include what type of medication was stored in the Medbank and could be reviewed by the nurses and TMA's, when needed. Review of the undated, current Medbank List identified oral vancomycin 125 mg was noted to be in stock. Interview on 9/22/25 at 1:34p.m., with registered nurse (RN)-A identified she was assigned to work as a nursing aide on the floor on 9/14/25 during the morning shift on the 100 unit. A female agency staff nurse who worked on the100 unit had informed RN-A that R1 antibiotic was not available to administer to R1. RN-A called the pharmacy to informed them of the missing dose and requested the antibiotic to be sent to the facility. Pharmacy notified RN-A that the antibiotic was no longer available as a capsule but had a liquid form available for administration. R1 agreed to take the antibiotic as an oral solution and RN-A informed the agency nurse, administrator, and R1's physician of the missing antibiotics. She did not have access to the Medbank, was not aware that the vancomycin was stored in the Medbank, and did not reach out to other nurses in the building for assistance to remove the antibiotic from the Medbank. She was trying to work smarter, not harder and made the decision to call the pharmacy to send additional doses of the antibiotic to the facility, instead. Observation and interview on 9/22/25 at 2:15 p.m., with trained medication aide (TMA)-A and licensed practical nurse (LPN)-B identified medications could be removed from the Medbank (medication dispense machine), as known as the Ekit, under resident's name on the machine. LPN-B identified medications could be removed under the cycle count option displayed on the screen, type the name of the medication and a list was to appear that listed the quantity held, dosages available, and when the medication was last retrieve. Review of EKIT screen identified vancomycin had a quantity of 5 left in the machine and was last removed on 9/13/25 at 7:06 p.m. Interview on 9/22/25 at 2:33 p.m., with family member (FM)-A identified she had concerns with R1 not receiving her antibiotics. The facility had to call pharmacy on several occasions for additional doses to be sent to the facility. On, 9/14/25 FM-A approached a nurse on the 100 unit to verify if R1 had received the antibiotic. The agency nurse identified R1 had not received the antibiotic as ordered and appeared to not know how to retrieve the antibiotic from the Medbank. Interview on 9/22/25 at 3:01pm, TMA-B had worked at the facility over 5 years and was knowledgeable on how to operate the Medbank. The facility nursing staff and agency staff was provided access to the Ekit and could remove medications, when needed. She completed initial training on the Medbank when hired but was not aware of when the facility had provided additional training on the Ekit for the facility nurses. Interview on 9/23/25 at 1:09 p.m., with pharmacy technician identified R1's antibiotics was sent to the facility initially on 9/11/25 at 10:27 p.m., with a total supply of 7 capsules. The supply was to last no more than 2 days, and the antibiotic remaining doses was to be removed from the Medbank, by staff nurses at the facility. Once the Medbank was depleted of the antibiotic supply, nurses was expected to notify the pharmacy and place a request by phone, fax or email for additional doses to be delivered to the facility. Interview on 9/23/25 at 1:13 p.m., with licensed pharmacist identified R1 was to continue on her antibiotics for 8 days. She was not sure why R1 did not receive her antibiotics as scheduled and identified the facility had options to retrieve the medication from the Medbank if a dose was needed. If R1 had continued the antibiotic as prescribed, R1's infection would have improved. Interview on 9/23/25 at 4:05 p.m., with licensed practical nurse (LPN)-B identified she had worked at the facility under a year. The Medbank was available to nursing staff who administered medications on the units to residents. Nursing staff was directed to notify her when there was difficulty retrieving medications from the Medbank during her working hours. The facility also had an on-call nurse staff could reach out to on the weekends or overnight with troubleshooting problems with Medbank. She could not remember the last time the facility had conducted an in-service or training on the Medbank, but was aware both nurses and TMA's was given access to use the Medbank. Interview on 9/23/25 at 4:10 p.m., with LPN-C had been trained on the Medbank, years prior and was hired with a knowledge on how to operate the Medbank. She identified during her time working at the facility, several nursing staff have requested assistance from her to remove medications from the Medbank, when medications were not available on the medication cart or in the medication room. If there was a troubleshooting issues with the Medbank on the evening shift, she was directed to reach the on-call nurse, after hours for assistance. Interview on 9/23/25 at 4:25 p.m., with LPN-A identified the facility had implemented use of the Medbank approximately four years ago. In the past year, she was not aware if the facility had conducted in-service or training for nursing staff to use the Mebank. On one occasion, she had experienced troubleshooting issues and was directed to call the local pharmacy for assistance and the number was located near the Ekit. Interview on 9/24/25 at 7:32 a.m., with the administrator had asked the nursing staff if they had training on the Medbank. The nursing staff identified they did, however, nursing staff had not signed any paperwork to identify training was completed. Interview on 9/24/25 at 8:17 a.m., with LPN-C had worked at the facility for 2 years. She identified she was not sure if training was provided to nursing staff on how to operate the Medbank. If she had troubleshooting issues, she would call the pharmacy, who was more efficient in assisting her with operation of the Medbank. Further interview on 9/24/25 at 8:30 a.m., with interim DON was to expect nursing staff to follow physician orders and administer medications as prescribed. In addition, facility nurses were provided training on the Medbank, however, she was not aware if agency staff had received training on the Medbank, upon hire. Interview on 9/24/25 at 10:05 a.m., with RN-B had worked on 9/13/25 and 9/14/25 on the evening shifts. On 9/13/25, he identified R5's antibiotics was not available on the medication cart or in the med room. He informed a staff nurse on the unit for assistance to remove the antibiotic from the Medbank, because he did not have access. RN-B acknowledged he had worked at the facility on several occasions and was not issued access to retrieve medication from the pyxis. R5 was administered the antibiotics. He then called the pharmacy for a replacement of the antibiotics to be delivered to the facility and made a progress note of the situation. During handover communication to the oncoming nurse on 9/14/25 that morning, RN-B communicated to the oncoming day nurse that pharmacy was called during the evening to have R1's antibiotics deliver to the facility, however, had not arrived. When he arrived to work the evening shift on 9/14/25, he reviewed R1's MAR and identified she had missed doses of her antibiotic. The antibiotic order was changed from capsules to solution that evening and the supply of liquid antibiotic was available in the facility for R1 to receive her antibiotic dose as scheduled. Review of undated, current Medbank flowsheet identified medication that was not available in the medication cart or in the medication room in the overflow bin, nursing staff was to check to see if the medication was available in the Medbank (pyxis). If the medication was available in the Medbank, nursing staff was to administer the medication, call pharmacy to inform them the resident is out of medication and would need to send dose on next run, document in PCC that medication was taken from the Medbank, inform clinical staff to follow up when medication was not sent timely by pharmacy, floor or clinical nurse was to update on the communication form of the incident. If the medication was not available in the Medbank, facility nurses was to call the physician of the missed medication, obtain an order to hold dose until obtained from pharmacy or provide an alternative medication that is in the Medbank, document notification in PCC what the physician orders was, call pharmacy to order the medication and send it on the next run, document communication in PCC to be reviewed by clinical staff and findings of why the medication was not able to be sent, notify residents family of physician orders and reason for medication was not available to be administer, and floor or clinical nurse was to fill out communication form of the incident. Training documentation and Medbank policy was requested, however, not received during survey.

Based on observation, interview, and document review, the facility failed to provide sufficient staffing to ensure residents received the care and assistance they needed in a timely manner for 3 of 4 residents (R1, R2, R4) reviewed for staffing. Findings include: R1 R1's Minimum Data Set (MDS) admission assessment dated [DATE], identified R1 had intact cognition, no rejection of cares, and no behaviors. R1 required staff assist with dressing, bed mobility, transfers, and toileting. R1 was frequently incontinent of bowel and urine and had pain almost constantly and received scheduled and as needed pain medication. R1's diagnoses included rheumatoid arthritis (a chronic inflammatory condition that primarily affect the joints, causing pain, swelling and stiffness), anxiety, depression, pressure ulcer of left buttock, and polyneuropathy (disorder that damages the nerves and causes weakness, numbness, and burning pain). R1 also has one stage four pressure ulcer (extends into muscle, tendon, and ligaments, and can expose bone). R1's care plan last revised on 9/9/25, identified R1's area of vulnerabilities as depression, anxiety, mobility impairment, claustrophobia (fear of small spaces). R1 was alert and oriented x 3 and able to communicate her needs. R1 was restless at night and liked to get up in her wheelchair and will refuse cares if pain is too much. R1 was to be turned, repositioned or offloaded every 2-3 hours and as needed. R1 required assist with transfers, toileting, peri care after each incontinent episode, bathing, dressing, personal hygiene, During an interview on 9/11/25 at 9:32 a.m., R1 stated it would take a minimum of an hour before anyone would come and help and on weekends it was worse. R1 stated on Sunday 9/7/25, she couldn't get anyone to help me and I finally had enough and wanted to go to the hospital. R1 further reported she would call for staff if her incontinent pad was wet or she wanted to transfer to her wheelchair however, because it took so long for her call light to get answered, she stated, I finally got so scared that I would sleep in my wheelchair which isn't good for me. My medication was supposed to be delivered at 7 a.m. however, sometimes she would not receive her medications until 10:30-11:00 a.m. and some of them were pain medications for her rheumatoid arthritis. R1 further identified on the morning of her hospitalization, she urinated in her chair because no one would help her and she developed burns on the back of her legs from urine. R1 also stated she never refused any cares. R1 indicated sometimes staff would tell her that there was only one nurse aide to take care of the entire hallway. During an interview on 9/10/25 at 4:31 p.m., family member (FM)-A indicated R1 was hospitalized on [DATE], with an infected wound on R1's buttocks. FM-A stated the family was not notified that R1 went to the ED because the nurse said she was too busy. FM-A also noted that R1 complained about call lights not being answered in a timely manner and not getting medications on time and sometimes did not receive them at all. FM-A indicated the concern was brought to R1's care conference and the facility said they would send the call light response times however, did not follow through. FM-A visited R1 on Saturday 9/6/25, and R1 had not received her medications yet that were due at 7am; they were four hours late. FM-A also contacted staff after noticing the toilet was overflowing with feces and the room stunk however, no one responded to assist. FM-A stated R1 would not return to the facility after hospitalization. The facility's Grievances Log included a grievance entry dated 8/11/25, R1 had a concern that it was difficult to receive assistance from midnight to 3:00 a.m. Staff were nowhere to be found, and call light waiting times were long during this time period. The resolution/follow-up indicated call light times were reviewed and director of nursing (DON) educated staff on timely call light response and spoke with the cart nurses to also watch call light time and assist with answering call lights and rounds. R1's Extended Wait Time (call light log) dated 8/28/25 to 9/11/25, included but was not limited to the following reset times (time from when light is activated to when it is cleared): -8/28/25 at 6:05 a.m., 63 minutes and 30 seconds (greater than one hour).-8/28/25 at 8:04 a.m., 27 minutes and 28 seconds.-8/28/25 at 11:24 a.m., 21 minutes and 31 seconds.-8/28/25 at 5:38 p.m., 22 minutes and 8 seconds.-8/28/25 at 6:59 p.m., 23 minutes and 0 seconds.-8/29/25 at 5:56 p.m., 21 minutes and 41 seconds.-8/29/25 at 7:02 p.m., 22 minutes and 43 seconds.-8/30/25 at 8:44 a.m., 37 minutes and 41 seconds.-8/31/25 at 7:30 p.m., 31 minutes and 16 seconds.-8/31/25 at 10:03 p.m., 40 minutes and 33 seconds.-9/1/25 at 5:16 a.m., 120 minutes and 27 seconds (greater than 2 hours).-9/1/25 at 11:23 a.m., 22 minutes and 44 seconds.-9/1/25 at 9:22 a.m., 51 minutes and 11 seconds.-9/2/25 at 8:40 a.m., 31 minutes and 14 seconds.-9/2/25 at 3:48 p.m., 35 minutes and 58 seconds.-9/2/25 at 6:57 p.m., 22 minutes and 46 seconds.-9/3/25 at 8:52 a.m., 75 minutes and 4 seconds (greater than one hour).-9/3/25 at 10:20 a.m., 45 minutes and 52 seconds.-9/3/25 at 5:32 p.m., 22 minutes and 40 seconds.-9/3/25 at 6:25 p.m., 40 minutes and 46 seconds.-9/4/25 at 5:00 a.m., 48 minutes and 51 seconds.-9/4/25 at 6:13 a.m., 74 minutes and 58 seconds (greater than one hour).-9/4/25 at 8:34 a.m., 29 minutes and 46 seconds.-9/4/25 at 3:11 p.m., 26 minutes and 5 seconds.-9/4/25 at 11:35 p.m., 51 minutes and 3 seconds.-9/5/25 at 2:00 a.m., 22 minutes and 39 seconds.-9/5/25 at 5:41 p.m., 40 minutes and 19 seconds.-9/5/25 at 6:32 a.m. 65 minutes and 23 seconds (greater than one hour).-9/5/25 at 9:37 a.m., 35 minutes and 14 seconds.-9/5/25 at 10:46 a.m., 23 minutes and 46 seconds.-9/5/25 at 5:50 p.m., 50 minutes and 55 seconds.-9/6/25 at 8:50 a.m., 37 minutes and 39 seconds.-9/6/25 at 9:40 a.m., 74 minutes and 18 seconds (greater than one hour).-9/6/25 at 1:01 p.m., 38 minutes and 52 seconds.-9/6/25 at 4:40 p.m., 27 minutes and 38 seconds.-9/6/25 at 5:14 p.m., 57 minutes and 23 seconds.-9/7/25 at 7:50 a.m., 40 minutes and 3 seconds. R2 R2's MDS significant change assessment dated [DATE], indicated R2 had intact cognition, was able to make his needs known, and no rejection of cares. R2 had impairments of both upper and lower extremities, uses a wheelchair, and is frequently incontinent of bowel and bladder. R2's diagnoses included kidney disease, congestive heart failure, morbid obesity, major depressive disorder, and diabetes. R2's care plan last revised on 9/11/25, indicated R2's areas of vulnerability were weakness, diabetes, poor motivation to do things for himself, and history of being a victim of verbal abuse. R2 was at risk for falls and was to have call light within reach at all times. R2 was alert and oriented x3 and is able to communicate his needs. R2 was on a diuretic (removes excess fluid) and required assistance with transfers, dressing, personal hygiene, bathing, and toileting. During an interview and observation on 9/10/25 at 3:41 p.m., R2 was in his room, with his bed unmade and blood spots on his sheets. R2 stated staffing is horrible here, takes a long time to get your call light answered. R2 identified it could take over an hour to get staff to answer his call light in the evening and on weekends. R2 also said he has missed showers and fallen because he could not wait for help anymore and then stated, I get in trouble for transferring without staff, but I just couldn't wait anymore. R2's call light log dated 8/28/25 through 9/11/25, included but was not limited to the following reset times:-8/28/25 at 8:39 a.m., 26 minutes and 26 seconds.-8/28/25 at 12:25 p.m., 20 minutes and 44 seconds.-8/28/25 at 12:54 p.m., 36 minutes and 58 seconds.-8/29/25 at 8:59 p.m., 33 minutes and 46 seconds.-8/30/25 at 12:05 p.m., 22 minutes and 57 seconds.-8/31/25 at 7:08 a.m., 26 minute and 3 seconds.-8/31/25 at 8:48 a.m., 22 minutes and 4 seconds.-8/31/25 a.m. at 10:12 a.m., 34 minutes and 45 seconds.-8/31/25 at 5:12 p.m., 31 minutes and 10 seconds.-8/31/25 at 6:12 p.m., 29 minutes and 57 seconds.-8/31/25 at 7:51 p.m., 26 minutes and 11 seconds.-9/1/25 at 7:09 a.m., 27 minutes and 41 seconds.-9/1/25 at 10:38 a.m., 24 minutes and 49 seconds.-9/1/25 at 12:47 p.m., 20 minutes and 37 seconds.-9/1/25 at 1:42 p.m., 21 minutes and 48 seconds.-9/2/25 at 6:05 a.m., 20 minutes and 52 seconds.-9/2/25 at 11:25 a.m., 26 minutes and 29 seconds.-9/2/25 at 1:24 p.m., 40 minutes and 23 seconds.-9/2/25 at 2:38 p.m., 20 minutes and 55 seconds.-9/2/25 at 6:09 p.m., 110 minutes and 37 seconds (greater than one hour).-9/2/25 at 8:33 p.m., 31 minutes and 12 seconds.-9/2/25 at 10:59 p.m., 29 minutes and 0 seconds.-9/3/25 at 2:43 p.m., 26 minutes and 12 seconds.-9/3/25 at 4:06 p.m., 55 minutes and 54 seconds.-9/3/25 at 6:44 p.m., 45 minutes and 42 seconds.-9/4/25 at 7:15 a.m., 20 minutes and 45 seconds.-9/4/25 at 9:03 a.m., 23 minute and 18 seconds.-9/4/25 at 3:58 p.m., 25 minutes and 5 seconds.-9/4/25 at 4:53 p.m., 26 minutes and 23 seconds.-9/4/25 at 7:18 p.m., 32 minutes and 52 seconds.-9/4/25 at 9:39 p.m., 32 minutes and 22 seconds.-9/5/25 at 9:45 a.m., 36 minutes and 29 seconds.-9/5/25 at 4:27 p.m., 20 minutes and 22 seconds.-9/5/25 at 5:16 p.m. 39 minutes and 39 seconds.-9/5/25 at 8:38 p.m., 26 minutes and 33 seconds.-9/6/25 at 8:39 a.m., 34 minutes and 23 seconds.-9/6/25 at 2:31 p.m., 29 minutes and 12 seconds.-9/7/25 at 12:49 a.m., 27 minutes and 27 seconds.-9/7/25 at 12:06 p.m., 20 minutes and 12 minutes.-9/7/25 at 5:32 p.m., 21 minutes and 42 seconds.-9/8/25 at 8:16 a.m., 35 minutes and 8 seconds.-9/8/25 at 2:14 p.m., 22 minutes and 12 seconds.-9/8/25 at 3:18 p.m., 34 minutes and 12 seconds.-9/8/25 at 7:21 p.m., 69 minutes and 40 seconds (greater than one hour).-9/9/25 at 10:52 a.m., 30 minutes and 13 seconds.-9/9/25 at 12:28 p.m., 20 minutes and 37 seconds.-9/9/25 at 1:25 p.m., 21 minutes and 55 seconds.-9/9/25 at 5:56 p.m., 27 minutes and 22 seconds.-9/9/25 at 7:40 p.m., 38 minutes and 7 seconds.-9/10/25 at 8:17 a.m., 32 minutes and 43 seconds.-9/10/25 at 1:11 p.m., 26 minutes and 49 seconds.-9/6/25 at 9:03 a.m., 43 minutes and 38 seconds.-9/6/25 at 12:24 p.m., 24 minutes and 12 seconds.-9/6/25 at 2:40 p.m., 30 minutes and 43 seconds.-9/6/25 at 3:47 p.m., 102 minutes and 13 seconds (greater than one hour).-9/6/25 at 5:54 p.m., 31 minutes and 12 seconds.-9/6/25 at 6:26 p.m., 25 minutes and 9 seconds.-9/6/25 at 11:07 p.m., 44 minutes and 6 seconds.-9/6/25 at 9:08 p.m., 32 minutes and 2 seconds.-9/7/25 at 9:09 a.m., 39 minutes and 35 seconds.-9/7/25 at 10:31 a.m., 38 minutes and 45 seconds.-9/7/25 at 12:53 p.m., 26 minutes and 46 seconds.-9/7/25 at 1:59 p.m., 35 minutes and 37 seconds-9/7/25 at 3:15 p.m., 22 minutes and 1 second.-9/7/25 at 6:48 p.m., 73 minutes and 13 seconds (greater than one hour).-9/8/25 at 6:31 a.m., 25 minutes and 59 seconds.-9/8/25 at 7:19 a.m., 109 minutes and 45 seconds (greater than one hour).-9/8/25 at 9:59 a.m., 39 minutes and 32 seconds.-9/8/25 at 12:46 p.m., 28 minutes and 21 seconds.-9/8/25 at 3:05 p.m., 21 minutes and 0 seconds.-9/8/25 at 3:58 p.m., 21 minutes and 44 seconds.-9/8/25 at 4:32 p.m., 24 minutes and 47 seconds.-9/8/25 at 8:18 p.m., 35 minutes and 54 seconds.-9/8/25 at 9:08 p.m., 26 minutes and 36 seconds.-9/9/25 at 7:23 a.m., 22 minutes and 13 seconds.-9/9/25 at 8:19 a.m., 51 minutes and 6 seconds.-9/9/25 at 9:17 a.m., 48 minutes and 13 seconds.-9/9/25 at 1:23 p.m. 45 minutes and 33 seconds.-9/9/25 at 5:50 p.m., 23 minutes and 53 seconds.-9/9/26 at 6:36 p.m., 37 minutes and 21 seconds.-9/9/25 at 7:44 p.m., 24 minutes and 49 seconds.-9/9/25 at 9:00 p.m., 32 minutes and 38 seconds.-9/10/25 at 6:51 p.m., 50 minutes and 22 seconds.-9/10/25 at 3:11 p.m., 42 minutes and 5 seconds.-9/10/25 at 4:50 p.m., 23 minutes and 0 seconds.-9/10/25 at 6:35 p.m., 94 minutes and 18 seconds.-9/11/25 at 8:35 a.m., 59 minutes and 27 seconds.-9/11/25 at 9:39 a.m., 28 minutes and 10 seconds.-9/11/25 at 12:31 p.m., 29 minutes and 24 seconds. R4 R4's MDS quarterly assessment dated 8/27/25, indicated she had modified independence for daily decision making and had no rejection of cares. R4 was dependent on staff for toileting, transferring, dressing, personal hygiene, bed mobility, toileting, and showering. R4 was always incontinent of bowel and bladder, received scheduled and as needed pain medications, and was at risk for pressure ulcers with no turning and repositioning programs. R4's diagnoses included diabetes, morbid obesity, osteoarthritis, irritable bowel syndrome, mild cognitive impairment, and insomnia. R4's care plan last revised 2/5/25, indicated R4 was alert and oriented and able to communicate needs. R4's areas of vulnerability were limited mobility, depression, chronic pain syndrome, anxiety disorder, adjustment disorder, paranoia, morbid obesity, making attention seeking comments and false accusations towards staff and other residents. R4 was a fall risk and was to have call light within reach. R4 was to always have two staff with cares, receive diabetes medication as ordered by the doctor. R4 has a behavior of no using call light appropriately and will yell out at staff instead of using call light or will put call light on and still call out and will go up and down the hallways seeking staff and will open resident's doors to find staff. R4 requires assist of two for toileting with bedpan and prefers to have incontinent product changed as close to 8:30 a.m. as possible. Required two assist with dressing, personal hygiene, and bed mobility and is to be repositioned every 2-3 hours and prefers to get up at 9:30 a.m. and back to bed at 11:30 a.m. During an observation and interview on 9/11/25 at 11:26 a.m., R4 was lying in bed with a hamper full of dirty linens and wrappers and empty glass on the floor. R4 indicated she had not received any morning cares yet and stated, I am always the last one. R4 stated, it takes forever for them [nursing staff] to come when I put a call light on, further indicated she puts her call light on at 7:00 am and sometimes it is 10:00 a.m. before it is answered. R4 identified she did not get her shower the day before because she was told there were only two staff on and there was not time. R4 reported she felt like she got treated like dirt and makes me feel sad and depressed. R4 indicated she did not receive her meds on time in the evening and that she was a diabetic and rarely received a snack in the afternoon. R4 also expressed that she was embarrassed that her room smelled like urine. R4 indicated she had talked to the administrator about her concerns and stated she told the administer, you get mad at me because I yell out but you don't come and help me, I wouldn't do that if they came in and helped me, even the little things they don't help me with. R4s call light log dated 8/28/25 through 9/11/25, included the following reset times:-8/28/25 at 5:19 p.m., 44 minutes and 36 seconds.-8/29/25 at 6:39 p.m., 20 minutes and 44 seconds.-8/30/25 at 7:54 a.m., 20 minutes and 31 seconds.-8/30/25 at 9:25 a.m., 23 minutes and 59 seconds.-8/30/25 at 11:1 a.m. 50 minutes and 55 seconds.-8/30/25 at 7:41 p.m., 37 minutes and 20 seconds.-8/31/25 at 11:11 a.m., 28 minutes and 34 seconds.-8/31/25 at 12:32 p.m., 27 minutes and 32 seconds.-8/31/25 at 6:53 p.m., 61 minutes and 32 seconds (greater than one hour).-9/1/25 at 8:32 a.m., 60 minutes and 44 seconds (greater than one hour).-9/1/25 at 12:24 p.m., 52 minutes and 29 seconds.-9/1/25 at 1:56 p.m., 32 minutes and 26 seconds.-9/1/25 at 5:43 p.m., 98 minutes and 0 seconds (greater than one hour).-9/1/25 at 7:35 p.m., 59 minutes and 8 seconds.-9/2/25 at 8:12 a.m., 21 minutes and 52 seconds.-9/2/25 at 10:46 a.m., 27 minutes and 53 seconds.-9/2/25 at 12:28 p.m., 44 minutes and 10 seconds.-9/2/25 at 1:36 p.m., 32 minutes and 34 seconds.-9/2/25 at 2:14 p.m., 49 minutes and 36 seconds.-9/2/25 at 6:38 p.m., 126 minutes and 14 seconds.-9/3/25 at 9:04 a.m., 35 minutes and 19 seconds.-9/3/25 at 12:31 p.m., 53 minutes and 7 seconds.-9/3/25 at 1:32 p.m., 37 minutes and 6 seconds.-9/3/25 at 5:56 p.m., 35 minutes and 6 seconds.-9/3/25 at 7:26 p.m., 32 minutes and 36 seconds.-9/3/25 at 8:34 p.m., 32 minutes and 46 seconds.-9/4/25 at 8:54 a.m., 45 minutes and 37 seconds.-9/4/25 at 12:39 p.m., 32 minutes and 41 seconds.-9/4/25 at 1:24 p.m., 70 minutes and 12 seconds (greater than one hour).-9/4/25 at 6:26 p.m., 91 minutes and 36 seconds (greater than one hour).-9/5/25 at 4:01 p.m., 41 minutes and 4 seconds.-9/5/25 at 6:01 p.m., 76 minutes and 11 seconds (greater than one hour).-9/5/25 at 8:17 p.m., 33 minutes and 14 seconds. During an interview on 9/11/25 at 11:10 a.m., nursing staff (NS)-A wanted to assure her anonymity but identified the facility had a lot of residents that had behaviors and require two people for cares and transfers. NS-A stated staff do the best they could however, there was not enough staff and lots of residents complained about call light wait times. NS-A stated, it is really tough, and administration tells us we need to chart more to get more staff but there is no time to chart, we can't even take care of the basic needs of the residents. NS-A also indicated morning medication pass started at 6:15 a.m. and often ended at10:30 a.m. because they were being asked to assist with resident cares and to administer medications. NS-A identified; meds should be administered within an hour of the scheduled time and confirmed most of the medications were given late. NS-B stated, some residents wet themselves because we [staff] do not get to them in time, baths get missed, and meals sometimes are cold by the time we get to them. During an interview on 9/11/25 at 11:45 a.m., NS-B stated, we never have enough staff to meet the needs of the residents. NS-B indicated night shift typically completed last rounds at 4:00 a.m. and it was almost 10:00 a.m. and day staff still had not cared for the residents yet. NS-B also identified call lights were always on and lots of extended wait times and often staff still had not cared for the initial forty residents before the other residents were returning from breakfast and had their lights on to use the bathroom. NS-B stated staff are running constantly and residents complain about the long call light wait times and take it out on us but there is nothing we can do. NS=B identified the concerns have been brought to management and the response was that staff did not get their charting done so they cannot provide any more staff. Facility policy titled Call Light Policy last updated 5/16/23, identified the purpose of the protocol is to identify that residents, when in their rooms, toilet, and bathing areas, have a means of directly contacting caregivers and the facility has a process to routinely ensure the call light system for residents is operational. Definition of functioning properly is all portions of the system are functioning, and the calls are being answered. The policy does not define expected call light response time. During an interview on 9/11/25 at 1:05 p.m., NS-C identified that it was hard to monitor the call lights because there was no audible sound until it was extended, and the kiosk was hard for some staff to see the numbers. NS-C indicated that more staff was needed because many of the residents needed two staff and often staff gets pulled to assist and then there delays in treatments or medication administration. NS-C identified many residents complained about the long call light wait times and administration was aware of the concern. During an interview on 9/15/25 at 10:58 a.m., NS-D stated, staffing is so bad, makes me want to cry. NS-D indicated there were times when there was a nurse and a nursing assistant (NA) at night for 33-35 residents and staff could not keep up with the needs of the residents. The residents waited a long time to get their call lights answered and heard extended wait time for call lights, all the time. NS-D further identified medications were often late and residents would get upset but there was nothing I could do. NS-D stated the lack of staffing caused increased falls, missed baths, residents not getting changed, not getting cleaned up, and overall resident dissatisfaction. During an interview on 9/11/25 at 12:25 p.m., the interim director of nursing stated, there was a copious amount of call lights and resident complain all time. The DON identified she was aware of the long wait times and the goal for responding to call lights was 6-7 minutes. The DON indicated if a call light was on for over 10 minutes, the extended wait time would be heard on the two way radios the nurse aides (NA)s carry on them however, the extended wait time was so frequent, the NA's had to shut them off on the two way radios just to have a conversation. The DON stated, call lights show up on the kiosk, but I hear them [extended wait times] so much that I don't even hear them anymore The DON felt staffing was adequate however, the staff had to work smarter not harder and the situation depended on which staff were working. During an interview on 9/12/25 at 4:10 p.m., the administrator indicated she had been staffing over budget and felt the nursing staff needed to learn how to work together and it depended on the staff working on a particular day. The administrator verified there had been 5 admits in the previous two days and staffing was adjusted accordingly. Facility policy titled Resident Rights and Notification of Resident Rights dated 1/2024, included, it was the practice of this facility to uphold the rights of all residents. The Facility Assessment last updated 2/11/25, identified the purpose of the assessment was to determine what resources were necessary to care for residents competently during both day-to-day operations and emergencies. The assessment was used to make decision about direct care staff needs as well as capabilities to provide services to the residents in the facility. When assessing potential residents for admission, the interdisciplinary team (IDT) worked together to ensure they had the proper equipment, resources, and staff to meet the resident's needs. The acuity of the residents was evaluated daily. The administrator, director of nursing, and other IDT members reviewed RUG levels (resource utilization group score which shows the type and quantity of care required for each individual resident) and CMI (case mix index value used for determining the allocation of resources to care for and or treat the residents in the group). The facility's average CMI is 0.9959. Staff plan/individual staff assignment was to ensure an adequate number of staff, resident acuity, population, CMI, and census was assessed daily and used to determine daily staffing needs. Staffing and census were reviewed each morning during morning meeting. The number of admissions and discharges assisted in determining sufficient daily staffing. Staff (nursing) required during normal operations: 2 direct nurses depending on census, 2-3 nursing supervisors per day, 4-5 certified nursing assistants (CNA)s day and evening, 2-3 CNA's overnights, one administrator, and one director of nursing.

Based on document review, interview and observation, the facility failed to implement proper infection control when two nursing assistants were observed not following enhanced barrier precautions or hand hygiene during direct care for 3 of 5 (R2, R4, R5) residents reviewed for infection prevention.Findings include:Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents know to be infected with multi-drug resistant organisms as well as those at increased risk of multi-drug resistant organism acquisition (residents with wounds or indwelling medical devices)R2's face sheet dated 11/3/25, indicated R2 was admitted [DATE] and had diagnoses of type II diabetes, mood disorder due to known physiological condition with depressive features and obesity.R2's Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated she was severely cognitively impaired and had behavioral symptoms directed towards others. She was dependent on staff for all activities of daily living.During an observation on 11/3/25 at 1:05 p.m., nursing assistants (NA)-A and NA-B prepared to assist R2 with cares and both NAs donned gloves. R2 was rolled to the side and NA-B provided perineal cares, removed the soiled brief and placed a new brief. NA-B did not change gloves or complete hand hygiene after removing soiled brief. NA-B applied cream to R2's perineal area and then removed her gloves. NA-B adjusted the bedding linens and emptied the trash can. NA-A and NA-B removed their gloves when they exited R2's room and then completed hand hygiene.R4's face sheet dated 11/3/25, indicated R4 was admitted on [DATE] and had diagnoses of unspecified injury of cervical spinal cord, neuromuscular dysfunction of bladder, radiculopathy lumbosacral region (pinched nerve in spine), retention of urine and anxiety.R4's Quarterly MDS assessment dated [DATE], indicated R4 was cognitively intact and was dependent on staff for activities of daily living.R4's care plan dated 11/3/25 indicated resident is currently on enhanced barrier precautions related to catheter use. Staff to don/doff personal protection equipment (PPE) per enhanced barrier precautions while providing high contact cares.R4's November Medication Administration Record (MAR) indicated R4 had the following orders:-Suprapubic urinary catheter placed on 10/8/25. Catheter is recommended to be exchanged every 3-4 weeks and should be completed per facility/agency protocol. Start date 10/15/25.-Change foley/suprapubic catheter bag on shower day. Start date 2/2/25.-Monitor catheter output every shift. Start date 2/11/25.-Staff to follow enhanced barrier precautions (EBP) every shift. Start date 7/19/24. During an observation on 11/3/25 at 12:50 p.m., R4's door had a enhanced barrier sign posted on the door. The sign indicated which personal protective equipment (PPE) staff should don (put on) when providing high contact cares. Nursing assistants (NA)-A and NA-B were observed preparing to provide care to R4. NA-A put gloves on and brought the mechanical lift into R4's room. NA-B put gloves on and assisted in attaching the sling to the lift. Neither NA-A nor NA-B donned a gown as the posted sign directed. NA-A attached the catheter bag to the sling, R4 was transferred from her wheelchair to her bed. NA-A pulled down R4's pants and opened the brief, some fecal matter was present in the brief. NA-A provided perineal care with wipes and removed the dirty brief. NA-A changed gloves but did not complete hand hygiene. NA-A touched the mechanical lift and the catheter bag while transferring R4 to the toilet. NA-A started moving R4's personal items around the room while R4 was using the bathroom and opened up a clean brief. R4 continued to use the bathroom, NA-B moved the mechanical lift to the hallway. NA-A and NA-B doffed (removed) gloves and completed hand hygiene.During an interview on 11/3/25 at 1:20 p.m., NA-A and NA-B donned gloves and went to assist R4 finish in the bathroom. NA-A and NA-B entered the room with no gown. R4 was transferred from the toilet to the bed, NA-B lowered the mechanical lift and unhooked the catheter bag. NA-A and NA-B removed the sling. NA-B provided perineal care. NA-B removed her gloves but did not complete hand hygiene. NA-B applied cream to R4's perineal area and placed a clean brief. R4 was dressed and transferred to recliner chair by both aides. NA-A changed gloves but did not complete hand hygiene before emptying the catheter bag. NA-A and NA-B removed gloves as they exited the room.During an interview on 11/3/25 at 12:09 p.m., NA-A stated she should have worn a gown when emptying the catheter. She explained she was not paying attention to the signs on the doors. NA-A explained EBP entails a full gown, mask, gloves and face shield to help anyone from getting exposed to illnesses. Some residents just had Covid -19 infections which is why some other residents have EBP signs on the doors. R5 was not currently being catheterized, but there is a sign on the door to be overly cautious. Hand hygiene should be completed when leaving the room and after completing perineal care.R5's face sheet dated 11/2/25, indicated R5 was admitted on [DATE] and had diagnoses of aftercare following joint replacement surgery, Crohn's disease, retention of urine, heart failure, mild cognitive impairment of unknown origin, and history of stroke.R5's Quarterly MDS assessment dated [DATE], indicated R5 was cognitively intact and was moderately dependent on staff for activities of daily living.R5's November and October MAR lacked an order for enhanced barrier precautions or straight catheterization.R5's care plan dated 11/3/25 did not include interventions related to enhanced barrier precautions or catheterization. During an observation on 11/3/25 at 1:15 p.m., R5's door had an EBP sign posted on the door. NA-A donned gloves and no gown before entering R5's room. NA-A wetted a washcloth and wiped R5's perineal area. NA-A dried the area with a dry washcloth and applied Nystatin powder. R5 pulled his pants up independently. NA-A did not change gloves or complete hand hygiene and began moving the bedside table and television remote.During an interview on 11/3/25 at 2:04 p.m., NA-B stated EBP should be followed when emptying or changing catheters. She didn't wear a gown when providing cares to R4 because she wasn't emptying or changing the catheter. EBP means the resident has a contagious illness. Hand hygiene should be complete after every glove change and gloves should be changed before and after cares.During an interview on 11/3/25 at 2:21 p.m., the licensed practical nurse (LPN)-A and care coordinator stated staff should wear a gown when they see an EBP sign on a resident's door. Staff should complete hand hygiene before and after the go into a room. After prompting, LPN-A expanded hand hygiene should also be done after providing perineal care. LPN-A stated it is her job to put up and remove EBP signs. When asked if R5 required EBP, she stated he has a rash but no open areas and did not have a catheter anymore so he would not require EBP. LPN-A went to go verify if R5 had an EBP sign on the door. She stated she would check with his wound nurse if she wanted to continue EBP and keep the sign posted.During an interview on 11/3/25 at 3:20 p.m., registered nurse (RN)-A stated EBP should be followed when there is an outbreak or if a resident has a wound or a catheter. Staff should wash hands before and after completing patient cares. The nurse manager or the infection control nurse should oversee having the correct infection control signs on each resident's door. RN-A stated R5 did not have a catheter or a wound. He used to have a wound on his leg which is what the EBP was for, but another staff may have forgotten to remove the EBP sign.During an interview on 11/3/25 at 3:35 p.m., the director of nursing (DON) stated there has been recent education on EBP and contact precautions. There have been a few infection prevention audits completed. There was some staff confusion about thinking EBP was only needed for catheter cares. EBP should be worn for anything hands on, including toileting, transfers and linen changes. Staff should be completing hand hygiene before entering rooms, leaving rooms and once their hands are soiled. Hands should be washed after changing gloves. The nurse manager oversees making sure infection control signs are correct, the DON also periodically checks to verify signage is correct.The facility policy, Enhanced Barrier Precautions, last revised 4/2024 directs that staff should implement enhanced barrier precautions for residents with wounds, indwelling medical devices, and infections.The facility policy, Handwashing Policy, last revised 02/2024 directs that handwashing should be completed after changing incontinence products, after touching garbage, etc. when conducting a procedure requiring the use of gloves, proper hand hygiene shall be completed before and after using gloves. If hands are not visibly soiled, an alcohol-based hand sanitizer can be used.

Based on observation, interview and document review, the facility failed to include the resident representative in development and implementation of the plan of care for one of one residents (R1) reviewed for residents rights.R1's quarterly minimum data set (MDS) dated [DATE], included R1 had moderate cognitive impairment and diagnoses of traumatic brain injury, stroke, and hemiplegia and hemiparesis (weakness or partial paralysis on one side of the body).R1's face sheet dated 8/28/25, included a contact for family member (FM)-A with the contact type of A/R Responsible Party and POA (power of attorney) Care.On 8/27/25 at 1:10 p.m., R1 was observed sitting in her power wheelchair with feet resting uncovered. Bilateral great toes (both big toes) were noted to have dark red, scab like appearance at base of toenail. No redness or drainage noted.R1's In-House Senior Services Consent form signed 4/16/21, included R1 would consent to podiatry in house.Provider order dated 7/30/25, included an order for a podiatry referral for foot care and bilateral toe sores.R1's progress notes included a late entry created on 8/28/25 and backdated for 7/31/25, included the podiatry order was discussed with R1 and she declined. Progress note failed to include update to resident representative and provider for refusal of service.R1's care conference summary dated 7/18/25, included an appointment should be set up for a nerve block injection.Email from health information manager (HIM) to care coordinator (CC)-A on 7/18/25, included an order was needed from R1's provider for the nerve block injection and requested assistance to obtain the order from the rounding provider.During interview on 8/28/25 at 10:16 a.m., CC-A stated she usually talked with the resident when a referral came in to see if they would like to pursue it. CC-A stated she spoke with R1 about the order for a podiatry referral but did not put a note in her chart at that time. CC-A stated R1's daughter was her decision maker and that she did not contact R1's daughter to inform her of the podiatry referral. CC-A confirmed R1's family requested an appointment for a nerve block inject be set up during the care conference. CC-A stated she informed HIM of the appointment request and was unsure what the status of the appointment was.During interview on 8/28/25 at 10:52 a.m., FM-A confirmed she was the decision maker and POA for R1. FM-A confirmed she had not been updated on the referral for podiatry to address R1's ingrown toenails. FM-A confirmed R1 has had nerve block injections in the past that the facility had coordinated. FM-A confirmed the family requested R1 have another appointment for a nerve block at the last care conference due to an increase in discomfort for R1. FM-A stated she had not had any updates on the nerve block appointment since the care conference.During interview on 8/28/25 at 11:47 a.m., HIM confirmed she set up appointments when a new order or referral came in and at the request of a family member or resident. HIM stated the facility had a podiatrist that came to the facility. Other residents choose to go to an outside clinic for podiatry needs. HIM stated she would not have been updated on a resident refusal after the appointment was set up so she was unsure if R1 refused podiatry. HIM confirmed CC-A informed her of the request for R1 to have an appointment set up for a nerve block. HIM stated she attempted to set up the appointment but was unable to due to needing a new order. HIM stated she sent an email to CC-A to request a new order be obtained for the nerve block injection. HIM confirmed she had not received the new order for the nerve block for R1.During interview on 8/28/25 at 12:30 p.m., regional nurse consultant (RNC) stated if a resident had a resident representative, they should have been updated and involved when a new order was obtained, or a consent was needed. RNC stated the provider should have been updated if the resident or family refused an order or referral. RNC stated a request for an appointment brought up during a care conference should have been addressed by the care team. The HIM and care coordinator should have worked together to get an order and set up the appointment. RNC confirmed an appointment request from 7/18 should have been addressed by 8/28. RNC stated it was important to have the resident and resident representative involved in planning of care for continuity of care and ensuring the resident's needs were met.Facility policy for care conferences requested and not provided.

Based on observation, interview, and document review, the facility failed to provide needed care and services to 3 of 3 residents (R2, R4, R5) whose changes in health status were not adequately assessed and physician's orders and treatments were not administered. Findings include: Physician Orders and Lab Draws R2's admission Minimum Data Set (MDS) dated [DATE], indicated R2 had renal insufficiency, diabetes mellitus and depression. The MDS further indicated R2 received dialysis. R2's Care Plan dated 4/08/25, indicated R2 was at risk for complications related to dialysis and alteration in oxygen/gas exchange, respiratory status staff were instructed to keep medical doctor informed of changes. R2's Hospital Discharge Orders dated 3/26/25, indicated diabetic diet, no need to follow a low salt diet, eating salt would be good (no fluid restriction was ordered). R2's physicians orders dated 3/28/25, indicated to take vital signs after dialysis one time a day every Monday, Wednesday, and Friday. A Provider Rounding Note at dialysis dated 3/31/25, from certified nurse practioner (CNP) indicated concern for on-going output from ostomy (a surgically created opening in the body, typically on the abdomen, to allow waste to exit the body), R2 received fluid replacement during dialysis and phosphorus supplements for low phosphorus. Facility called, order to supplement phosphorus from 500 milligrams (mg) twice daily to 1000 mg twice daily, in addition to give patient plenty of fluid high sodium high phosphorous foods. Review of R2's Physician's orders dated 3/31/25, indicated regular diet, fluid restriction with high sodium diet. In addition, to give K-phosphorus oral tablet give 500 mg by mouth twice daily (1000 mg daily). R2's medical record lacked evidence the K-phosphors medication order was increased to 1000 mg twice daily or that R2 was removed from a fluid restricted diet to a fluid pushing diet. A Dialysis Communications Record dated 4/25/25, indicated a blood pressure reading upon arrival to dialysis of 83/49. two liters (L) of normal saline was given pretreatment along with 500 milliliters (ml) of normal saline. The Communication Record provided orders to start twice daily blood pressures. Review of R2's medical record failed to indicate twice daily blood pressures were started. Review of R2's blood pressures indicated the following blood pressures from 4/25/25 to 5/01/25: 5/01/25- 96/56 taken at 5:43 p.m. 4/30/25- 76/43 taken at 3:23 p.m. 4/29/25- 117/62 take at 1:46 p.m. standing (related to resident fall per policy) 4/29/25-116/68 taken at 1:47 p.m. lying (related to resident fall per policy) 4/29/25-110/72 taken at 1:48 p.m. sitting (related to resident fall per policy) 4/29/25- 93/56 taken at 12:07 a.m. During interview on 5/05/25, at 1:35 p.m., clinical manager (CM)-A for R2's outpatient dialysis unit stated for the last week R2 had arrived at their unit with low blood pressures. It had been communicated to the facility on the Communication Record on 4/25/25, to start checking R2's blood pressures twice daily. CM-A stated R2 has had extreme outputs from her ostomy, having to empty it up to twice every two hours which could lead to dehydration and low blood pressures. In addition, the CM stated they had called the facility but difficulty reaching a nurse and left a voice message with the nurse manager on 4/28/25, to give R2's orders for Hydrocortisone and Midodrine hydrocortisone (HCL) (medications to increase blood pressure). CM-A stated R2 would inform them she never received her medications prior to dialysis and blood pressures were not checked prior to dialysis. CM-A stated it was her understanding R2 had only received her morning medications prior to dialysis on the morning of 5/2/25 but that the facility could also not get a blood pressure reading that morning and still sent her. Upon arrival to dialysis they had to take her reading manually and her blood pressure was 62/45, they attempted to give fluids of two liters but were unable to get her blood pressure up high enough to run dialysis and had to send her to the emergency department (ED). During interview on 5/05/25 at 2:24 p.m., nurse manager (NM) stated she was out sick on 4/28/25 through 4/29/25, and when she returned to work on 4/30/25 she received the voice message and transcribed the order but R2 had already left for dialysis that day at 5:00 a.m. The NM stated R2 received her mediations as ordered on 5/2/25, prior to dialysis and was sent to the ED from dialysis due to being hypotensive. R2's orders dated 4/24/25, from medical doctor (MD) indicated an order for basic metabolic panel (BMP) a common blood test that checks the levels of several important substances in your blood, providing information about your body's metabolism, kidney function, and fluid balance in the am (morning). Review of R2's medical record lacked evidence the lab draw was completed by the facility. During interview on 5/07/25 at 10:59 a.m., nurse manager (NM)-A stated their lab company comes out every Monday, Wednesday, and Friday when R2 is at dialysis so the nurses at the facility have to draw R2's blood. NM-A stated the health information (HI) staff who no longer worked at the facility did not acknowledge the order until 4/28/25, and she was out sick on 4/28/25 and 4/29/25. The NM-A stated she did attempt to draw R2's blood on 4/30/25 and 5/01/25 and was unsuccessful and on 5/2/25, R2 was sent to the hospital. NM-A stated she did not inform the physician, nor did she inform the director of nursing (DON). Review of R2's records lacked evidence of attempted blood draws. During interview on 5/07/25 at 11:15 a.m., the facility's nurse practitioner (NP)-A stated the BMP lab was ordered to be taken on the morning of 4/25/25, and was never completed. In addition, there had been no communication the blood draw was unable to be be completed as ordered. On 5/02/25, the resident had to be sent to the hospital due to low blood pressure and what she was informed was low potassium and other electrolytes. NP-A stated if these labs were completed timely, it may have prevented her hospitalization. Facility Hemodialysis Policy dated 11/22/19, indicated The Facility will ensure that residents who require dialysis, receive such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goal and preferences. The Policy further indicated under Communication and Plan of Care information regarding the resident's dialysis treatment will be gathered from the discharging hospital, referral information, resident interview, and examination. Information will include but is not limited to, the location and frequency of their dialysis treatment, the type and location of their dialysis access site, medications, fluid, and diet restrictions. Ongoing communication and collaboration for the development and implementation of the dialysis plan of care should be maintained by the facility and the dialysis team. Physician Orders and Lab Draws R4's quarterly MDS dated [DATE], indicated R4 had anemia, HTN, diabetes mellitus, Hyponatremia and received daily insulin. In addition, R4's MDS indicated he was medically complex. R4's nurse practitioner orders dated 4/23/25, indicated labs to be completed on Monday 4/28/25, for complete blood count (CBC), BMP, A1C (check for long lasting blood sugar levels), thyroid stimulating hormone (TSH), in addition to compression socks on in a.m., off in p.m. During interview on 5/07/25 at 11:20 a.m., NP-A stated the orders were placed for R4 due to concerns of edema and congestive heart failure (CHF), and she wanted the labs completed prior to her next visit at the facility on 4/30/25. NP-A stated when she arrived for her visit on 4/30/25, she found the labs were not completed and there were no compression socks for R4. At that time R4 presented pale with edematous (full of fluid) and had to be sent to the ED. R4's Physicians Orders indicated Ok to send to ED for evaluation of SOB, weight gain, edema, history of hyponatremia. Review of R4's medical record indicated no labs were completed on 4/30/25. R4's After Visit Summary dated 4/30/25, indicated R4 was seen for extremity swelling, and diagnosed with acute on chronic congestive heart failure. The Summary indicated R4 was given a diuretic Lasix at 1:15 p.m. at the emergency department (ED). During interview on 5/07/25 at 1:48 p.m., clinical coordinator (CC) stated R4 already orders for compression stockings and refused to wear them, so she never re-ordered them. In addition, the CC stated the health information (HI) sets up the labs and was not sure why they were not completed for R4. During observation and interview on 5/07/25 at 2:00 p.m., nursing assistant (NA)-B stated she worked full time with R4 and she was never informed to put compression stockings on him. NA-B stated if she were informed, she would at least attempt to put them on. NA-B then proceeded to enter R4's room to look for the compression stockings when R4 stated the ones he has were too tight but was willing to try a larger size. While NA-B opened his top dresser drawer there was two packages with each containing a single compression stocking, one was opened and the other was not. During interview on 5/08/25 at 11:00 a.m., regional director of nursing services (RD) stated they need to measure R4 for new compression stockings. During interview on 5/08/25 at 3:40 p.m., the director of nursing (DON) stated she found out today from their lab company on 4/28/25, the staff who was supposed to complete the lab draws called in, therefore no lab draws were completed at the facility. The DON further stated they have no system in place to know when labs are completed, and it is something they could look into. Physician Orders R5's admission MDS dated [DATE], indicated R5 was medically complex, had heart failure, seizure disorder and traumatic brain injury. The MDS further indicated R5 was cognitively intact, used a wheelchair, walker and needed supervision with activities of daily living. R5's Hospital Discharge Orders dated 4/25/25, indicated order for lacosamide (anticonvulsant) 150 milligrams (mg) take one tablet by mouth two times daily in addition to Keppra (anticonvulsant) 1500 mg twice daily. The Hospital discharge orders additionally listed lacosamide as an allergy of R5's . R5's [NAME] Manor Rehabilitation Center Allergy Report dated 4/24/25, indicated R5 had allergy to lacosamide. Entered by facility health information (HI). An Aeris portal Communication Note dated 5/07/25 (13 days after admission to facility), indicated a late entry written by the facility's director of nursing (DON), which stated, Writer called Aeris for clarification on lacosamide medication due to allergy to medication. Resident had order on dc (discharge) summary from hospitalization on 4/25/25 of lacosamide 150 mg BID (twice daily). Resident had not received medication since admission, internal process being completed at this time. Resident has received scheduled Keppra 1500 mg BID, no seizure activity noted at this time. Triage provider stated to hold medication 5/07/25 and update neurology 5/08/25. During interview on 5/07/25 at 11:40 a.m., NP stated she followed up with the NM on the floor asking why R5 was still not on lacosamide. The NP stated the NM informed her the neurologist had not returned her call yet. NP stated R5 had not had a seizure luckily but could not believe it had been since admission and there had been no follow through with R5's medication order due to an allergy. NP stated she spoke to R5's family member (FM)-A and it never was a true allergy and R5 had been taking the medication for at least the last month. During interview on 5/08/25 at 2:00 p.m., R5's family member (FM)-B stated there was no true allergy to the medication and at one time R5 experienced bradycardia (low heart rate) but found that was not related to her medication lacosamide. FM-B stated R5 had been on the medication prior to being admitted to the facility. Medication and Treatment Orders policy dated 2/2024, indicated orders for medications will be transcribed accurately and in a timely fashion, only authorized licensed practitioners, or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record. Medication Error Procedure policy dated 1/2020, indicated the interdisciplinary team evaluates medication usage to prevent and detect adverse consequences and medication-related problems. Medication errors should be assessed, documented, and reported according to federal and/or state guidelines as appropriate. Medication errors will be rectified according to standard of practice and facilities pharmacy policy for preventing and detecting adverse consequences and medication errors.

Based on interview and document review the facility failed to thoroughly investigate and protect residents for an allegation of abuse for 3 of 3 residents (R3, R5 and R6) when the facility received an external, anonymous email alleging allegations of abuse by facility staff. Findings include: R3 minimum data set (MDS) dated [DATE], indicated moderately impaired cognition and displayed verbal behavioral symptoms toward others. R5 MDS dated [DATE], indicated moderately impaired cognition and no behavioral symptoms. R6 MDS dated [DATE], indicated cognition intact and was social isolated at times. Facility was sent an anonymous email dated 4/28/25 at 9:04 a.m., which indicated .residents are getting neglected and abused daily, wounds are not getting completed. TMAs (trained medication aides) are doing insulin sticks, charting nursing assignments. TMAs are also changing residents catherer [sic] and placing a new catherer [sic] not just the bag on NOC (nocturnal) shift. No showers are getting completed. [Facility administrator] does not care about the residents is all about cash flow for the company. [Administrator]refused to listen to our concerns regarding cares and neglect and abuse. [TMA-A] was doing dressing changes in the morning shift to help nurses out in the morning. [TMA-A] has been giving insulin in the AM shift. [TMA-B] is TMA witness abusing the resident [R5]. [NA-C] we witnessed her slapping [R3]. [TMA-C] verbally abusing the residents. [Licensed Practical Nurse (LPN-B) is a nurse came to work high intoxicated. [Licensed Practical Nurse (LPN)-D] is LPN through ESHIFT Abusing the resident [R4]. We are reporting this to the state. Facility investigation dated 4/28/25, identified an email from an unknown source. Facility completed an investigation which included a full house of resident interviews, staff interviews, wound audits, shower audits, insulin audits and catheter placement audits. All audits and interviews were completed efficiently within the designated 2-hour timeframe, ensuring all tasks were performed in a timely manner and remained within the scope of practice. Report summary found allegations to be unsubstantiated. Additionally, investigation report revealed residents in question had confirmed that the reported events never occurred. All relevant audits were reviewed and verified, with no issues or discrepancies flagged during the process. Review of facility investigation failed to indicate interviews with all identified employees in the abuse complaint, failed to identify remove of employee during the investigation or protections put in place for residents and failed to identify a partial/non biased party completing the investigation. When interviewed on 5/9/25 at 2:13 p.m., administrator stated she had overseen the investigation but stayed out of the process as she was named in the abuse allegation. Administrator stated the social worker and other management completed interviews with the residents, but staff interviews were completed by herself. Administrator in training stated there was no suspensions of staff during the investigation and she was not interviewed. She additionally added, the data collect for the investigation was reviewed by herself and she concluded there was no abuse. The administrator identified she was not aware of facility policy indicated a separate party was to investigate when administration was an alleged perpetrator. Facility policy titled Abuse Prohibition/Vulnerable Adult Policy, revision date 4/2025, indicated if the alleged perpetrator is a supervisor or department head, the person will notify the alleged perpetrator's supervisor or the [NAME] President of Social Service & Behavioral Health. Staff will take immediate and appropriate actions to prevent further abuse, neglect, exploitation, and mistreatment from occurring while the investigation is in progress.

Based on interview, and record review, the facility failed ensure ongoing commuication and collaboration with dialysis services for 1 of 1 resident (R2) who had orders not implemented. Findings include: R2's admission Minimum Data Set (MDS) dated [DATE], indicated R2 had renal insufficiency, diabetes mellitus and had depression. The MDS further indicated R2 received dialysis. R2's Care Plan dated 4/08/25, indicated R2 was at risk for complications related to dialysis will attend dialysis and will have no uncontrolled bleeding from fistula, shunt, or central line. The care plan directed staff to ask resident how she feels about doing dialysis, communicate with dialysis social worker as needed, for uncontrolled bleeding call 911, treatment and dressing change per protocol to dialysis site per MD order, send communication sheet folder to dialysis with each run, fluid restriction per order. In addition, the Care Plan indicated and alteration in oxygen/gas exchange, respiratory status staff were instructed to keep medical doctor informed of changes. R2's Care Plan lacked to indicate R2 was hypotensive and to check blood pressures, in addition to resident was not to receive fluid restrictions. Review of care plan dated 4/8/25 lacked detail on how the communication would be utilized between the facility and dialysis, what information was expected to be communicated (blood pressure reading) and who was responsible to ensure follow up on communication from dialysis. Additionally, care plan indicated a fluid restriction and then identified she was not to receive a fluid restriction. R2's Hospital Discharge Orders dated 3/26/25, indicated diabetic diet, no need to follow a low salt diet, eating salt would be good (no fluid restriction was ordered). R2's physicians orders dated 3/28/25, indicated to take vital signs after dialysis one time a day every Monday, Wednesday, and Friday. A Provider Rounding Note at dialysis dated 3/31/25, from certified nurse practitioner (CNP) indicated concern for on-going output from ostomy (a surgically created opening in the body, typically on the abdomen, to allow waste to exit the body), R2 received fluid replacement during dialysis and phosphorus supplements for low phosphorus. Facility called, order to supplement phosphorus from 500 milligrams (mg) twice daily to 1000 mg twice daily, in addition to give patient plenty of fluid high sodium high phosphorous foods. Review of R2's Physician's orders dated 3/31/25, indicated regular diet, fluid restriction with high sodium diet. In addition, to give K-phosphorus oral tablet give 500 mg by mouth twice daily (1000 mg daily). R2's medical record lacked evidence the K-phosphors medication order was increased to 1000 mg twice daily (2000 mg daily) or that R2 was removed from a fluid restricted diet to a fluid pushing diet. A Dialysis Communications Record dated 4/25/25, indicated a blood pressure reading upon arrival to dialysis of 83/49, and two liters (L) of normal saline was given pretreatment along with 500 milliliters (ml) of normal saline. The Communication Record provided written orders to start twice daily blood pressures. Review of R2's medical record failed to indicate twice daily blood pressures were taken after 4/25/25 Review of R2's blood pressures indicated the following blood pressures from 4/25/25 to 5/01/25: 5/01/25- 96/56 taken at 5:43 p.m. 4/30/25- 76/43 taken at 3:23 p.m. 4/29/25- 117/62 take at 1:46 p.m. standing (related to resident fall per policy) 4/29/25-116/68 taken at 1:47 p.m. lying (related to resident fall per policy) 4/29/25-110/72 taken at 1:48 p.m. sitting (related to resident fall per policy) 4/29/25- 93/56 taken at 12:07 a.m. During interview on 5/05/25, at 1:35 p.m., clinical manager (CM)-A for R2's outpatient dialysis unit stated for the last week R2 had arrived at their unit with low blood pressures. It had been communicated to the facility on the Communication Record on 4/25/25, to start checking R2's blood pressures twice daily. CM-A stated R2 has had extreme outputs from her ostomy, having to empty it up to twice every two hours which could lead to dehydration and low blood pressures. In addition, the CM-A stated they had called the facility but had difficulty reaching a nurse and left a voice message with the nurse manager on 4/28/25, to give R2's orders for Hydrocortisone and Midodrine hydrocortisone (HCL) (medications to increase blood pressure). CM-A stated R2 informed them she never received her medications and blood pressures were not checked prior to dialysis. CM-A stated it was her understanding R2 had only received her morning medications prior to dialysis on the morning of 5/2/25, but that the facility could also not get a blood pressure reading that morning and still sent her. Upon arrival to dialysis, they had to take her reading manually and her blood pressure was 62/45, they attempted to give fluids of two liters but were unable to get her blood pressure up high enough and sent her to the emergency department (ED). During interview on 5/05/25 at 2:24 p.m., nurse manager (NM) stated she was out sick on 4/28/25 through 4/29/25, and when she returned to work on 4/30/25 she received the voice message and transcribed the order but R2 had already left for dialysis that day at 5:00 a.m. The NM stated R2 received her mediations as ordered on 5/2/25, prior to dialysis and was sent to the ED from dialysis due to being hypotensive. NM did not know who or if anyone checked the voicemail when she was away from work. Facilities Hemodialysis Policy dated 11/22/19, indicated The Facility will ensure that residents who require dialysis, receive such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goal and preferences. The Policy further indicated under Communication and Plan of Care information regarding the resident's dialysis treatment will be gathered from the discharging hospital, referral information, resident interview, and examination. Information will include but is not limited to, the location and frequency of their dialysis treatment, the type and location of their dialysis access site, medications, fluid, and diet restrictions. Ongoing communication and collaboration for the development and implementation of the dialysis plan of care should be maintained by the facility and the dialysis team.

Based on interview and document review the facility failed to report to the state agency (SA) for 3 of 3 residents (R3, R5 and R6) reviewed when R3, R5, R6 were named in an external complaint of alleged abuse by facility staff and no report was made within two hours. Findings include R3 face sheet, undated, indicated R3 diagnoses of unspecified dementia with anxiety, hypertension, diabetes, chronic obstructive pulmonary disease. R5 face sheet, undated, indicated R4 diagnoses of unspecified dementia, cognitive communication deficit, post-traumatic stress disorder, anxiety, Parkinson's disease. R6 face sheet, undated, indicated R5 diagnoses of hemiplegia and hemiparesis, epilepsy, adjustment disorder with disturbance of conduct, major depressive disorder, anxiety, traumatic subarachnoid hemorrhage with loss of consciousness. Facility was sent an anonymous email dated 4/28/25 at 9:04 a.m., which indicated .residents are getting neglected and abused daily, wounds are not getting completed. TMAs (trained medication aides) are doing insulin sticks, charting nursing assignments. TMAs are also changing residents catherer [sic] and placing a new catherer [sic] not just the bag on NOC (nocturnal) shift. No showers are getting completed. [Facility administrator] does not care about the residents is all about cash flow for the company. [Administrator]refused to listen to our concerns regarding cares and neglect and abuse. [TMA-A] was doing dressing changes in the morning shift to help nurses out in the morning. [TMA-A] has been giving insulin in the AM shift. [TMA-B] is TMA witness abusing the resident [R5]. [NA-C] we witnessed her slapping [R3]. [TMA-C] verbally abusing the residents. [Licensed Practical Nurse (LPN-B) is a nurse came to work high intoxicated. [Licensed Practical Nurse (LPN)-D] is LPN through ESHIFT Abusing the resident [R4]. We are reporting this to the state. Facility failed to report allegations of abuse to the SA within two hours of receiving alleged allegations. When interviewed on 5/8/25 at 2:13 p.m., administrator in training stated her role was to make the SA reports for the facility. Administrator stated the email was not reported to the SA due to there was no valid information, and I believe it is an incorrect document. Administrator stated the email allegations were investigated within the 2-hour time frame with resident interviews and was able to conclude the allegations were unsubstantiated. Administrated stated she was not aware of the regulations indicating to report first and then start an investigation. Facility policy titled Abuse Prohibition/Vulnerable Adult Policy revision date 4/2025, indicated if were suspicion of neglect, exploitation, or misappropriation of resident property must be reported to OHFC online reporting process not later than 2 hours if the incident resulted in serious bodily injury. If the suspected neglect, exploitation, or misappropriation of resident property did not result in serious bodily injury, the reports must be made within 24 hours. Notify the Minnesota Department of Health (MDH) on the notification website immediately after discovery of the incident.

Based on interview and document review, the facility failed to provide timely notification to a provider for a change in condition related to low blood pressures for 1 of 1 resident (R2) who received dialysis and was already hypotensive. Findings include: R2's admission Minimum Data Set (MDS) dated [DATE], indicated R2 had renal insufficiency, diabetes mellitus, and depression. The MDS further indicated R2 received dialysis. R2's Care Plan dated 4/08/25, indicated R2 was at risk for complications related to dialysis and alteration in oxygen/gas exchange, respiratory status directed staff to keep medical doctor informed of changes. R2's physicians orders dated 3/28/25, indicated to take vital signs after dialysis one time a day every Monday, Wednesday and Friday. Review of R2's blood pressures indicated the following from 4/01/25 to 5/01/25: 5/01/25- 96/56 4/30/25- 76/43 4/29/25- 93/56 4/22/25 -107/67 4/18/25- 111/69 4/17/25- 109/67 4/16/25-112/69 4/15/25-101/60 4/13/25- 111/67 4/11/25-107/96 4/10/25-92/56 4/09/25-92/52 4/08/25-92/58 4/02/25-97/58 4/01/25-100/62 During interview on 5/05/25 at 2:24 p.m., nurse manager (NM) stated she was unaware of the low blood pressure on 4/30/25, of 76/43 and was not sure if R2's physician or nurse practitioner (NP) was notified. NM stated the NP comes out weekly and checks the residents vital signs, so she should know, but probably could have been notified. During interview on 5/07/25 at 9:13 a.m., R2's NP stated she last saw R2 on 4/16/25, and her physcian saw her on 4/24/25. NP stated R2 was hypotensive due to her previous hospitalizations and from looking at the facility's portal, neither the NP or physician had been informed of R2's low reading on 4/30/25 of 76/43. NP added, that was concerning because a reading of 76 was very low for R2 and she would have had the staff retake the blood pressure and if it was still that low, she would probably have sent R2 into the emergency department (ED). The NP further stated it would only be standard nursing practice for the nurses to call and report a blood pressure that low even if there were not specific parameters on her blood pressure medications. In addition, NP stated she was unaware R2 was sent from dialysis on 5/02/25, to the ED with a blood pressure reading at dialysis of 62/45 and was now in the intensive care unit. Facility policy Notification of Changes Policy dated 3/2024, indicated It is the policy of this facility that changes in a resident's condition or treatment be shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician or delegate (hereafter designated as the physician). Nurses and other care staff are educated to identify changes in a resident's status and define changes that require notification of the resident and/or their representative, and the resident's physician, to ensure best outcomes of care for the resident.

Based on observation, interview and document review, the facility failed to consistently track and monitor dishwasher temperatures for both the wash and rinse cycles, and take timely action to correct the temperatures for 1 of 1 dishwasher observed. The facility also failed to consistently date fresh and frozen items at the time they are opened, or placed into a container, and failed to remove items which were beyond the acceptable date of use from the refrigerator. The facility failed to consistently verify temperatures were within the desired range in the refrigerators and freezers to assure food integrity. In addition, food temperature monitoring lacked consistency of completion following food preparation and prior to serving. This had the potential to affect all 50 current residents, as well as staff and visitors, who ate food served from the kitchen. Findings include: Dishwashing Temperature Monitoring: On 3/3/25 at 12:08 p.m., dietary aide (DA)-A was observed as she was finishing up in the dish room and was transitioning to meal service. DA-A stated the desired temperature was 150 degrees Fahrenheit for washing dishes. If the temperature was not at 150 degrees, the dishwasher racks needed to be run through again until the temperature was up to 150 degrees Fahrenheit (F). DA-A stated the rinse temperature was to be at 160 degrees F. DA-A stated if the temperature was not at 160, the rinse racks needed to be run through again until the rinse temperature reached the 160 degrees F. On 3/3/25 at 6:27 p.m., DA-B was observed to be washing dishes. When asked what the temperature checks were prior to starting the dishwashing process, DA-B stated she had not yet checked the temperature, as she had been taught to check the temperatures at the end of the dishwashing process. DA-B stated monitoring the dishwasher temperature was important as the temperature needed to be high enough to kill bacteria and germs. DA-B stated this was important because if the temperature was not high enough, and the germs weren't yours, it could make people sick. A review was completed of the March dishwashing temperature logs. Upon review of the dishwashing log, it was noted there was one shift at noon on 3/2/25 when temperatures were not logged, in addition two evenings (3/1/25 and 3/2/25) were not logged. On 3/2/25, it was noted with the morning wash cycle the temperature was only at 147 degrees F, versus the desired 150 F. All other temperatures recorded were within the desired range. The directions on the bottom of the temperature log for March indicated staff were to report if the wash temperature was less than 150 degrees F, and if rinse temperature was less than 160 degrees F. A subsequent copy received of the March Dishwashing Record High Temperature log was amended to reflect the rinse cycle was to be at 180 degrees F. An untitled document dated 3/3/25 at 7:15 p.m., from the administrator indicated she had completed a review of the dishwashing process to assess its temperature performance on this date. The note indicated: During the wash cycle, I observed the temperature ranged from 135 to 145 degrees F. The document additionally indicated In the rinse cycle, the temperature increased to a range of 180 degrees F to 190 degrees F. The administrator was unaware of the desired range for wash temperature. A review for the February temperature log was unable to be completed as the temperature log was not located. A review of the January Dishwashing Record High Temperature log was completed from 1/1/25 through 1/31/25. The log lacked documentation as follows: 1/1/25-1/7/25: Morning, Noon, and Evening meals. 1/8/25: Morning and Noon. 1/9/25 through 1/11/25: Morning, Noon, and Evening meals. 1/12/25 through 1/14/25: Evening meal. 1/15/25 and 1/16/25: Noon meal. 1/17/25: Evening meal. 1/18/25: Morning, Noon, and Evening meals. 1/19/25 through 1/21/25, as well as 1/23/25: Evening meal. 1/24/25: Morning, Noon, and Evening meals. 1/25/25: Morning and Noon meals. 1/26/25 and 1/27/25: Evening meal. 1/28/25: Morning, Noon and Evening meal. 1/29/25 through 1/31/25: Evening meal. Upon review of the temperatures logged for January, the following was noted: During the morning wash cycle, of the 16 entries made, only eight met the temperature requirement of 150 degrees F or greater. A review of the 16 rinse cycles recorded, only four of the 16 met the required temperature level identified on the document as 160 degrees F. During the noon wash cycle, there were 14 entries made. Of the 14 entries made, 11 entries were 150 degrees F or greater. A review of the 14 entries for the rinse cycle, there were four of 14 entries with a rinse temp of 160 degrees F or greater. The remaining 10 entries did not meet the required temperature. A review of the evening wash cycles identified there were four entries completed out of 31 opportunities. Of the four entries completed, there were three entries which met the required wash temperature of 150 degrees F or greater. The evening rinse temperature documentation indicated there were three of four entries which were 160 degrees F or greater. On 3/3/25 at 12:19 p.m., the dishwasher logs were reviewed with culinary director (CD). CD stated if the dishwasher was not up to temperature, the dishes were not properly cleaned. CD went on to say there would be the potential for bacteria presence, which could make people sick. CD stated she was unaware of any outbreaks of Norovirus, or other patterns of illness. At this time, a review was completed with CD regarding the absence of temperature logging in January. CD stated it was important to assure the dishwasher was at the right temperature and this was done with routine monitoring. CD was unable to locate the dishwasher temperature log for February. On 3/5/25 at 7:28 a.m., CD stated upon review of the CMA-180 dishwasher company manual, she became aware the required rinse temperature is to be at 180 degrees F or hotter to meet the manufacturer recommendations. Previously, the staff had been instructed to have the rinse cycle at 160 degrees F. CD stated staff education has been completed for this, and log has been updated to reflect the proper temperature for the rinse cycle. A review of the company manual for the CMA-180 dishwasher was completed. The CMA-180 dishwasher was a high temp dishwasher. The manual outlined the required cycle temperatures as being 155-160 degrees F for the wash cycle, and 180-195 degrees F for the rinse cycle. The manual directed staff to check the machine operating temperatures and adjust as needed. The manual went on to direct staff: After the machine has warmed up for five to ten minutes, observe the wash and rinse cycles. The wash temperature must be at 155 degrees F minimum. The rinse temperature must be at 180 degrees F minimum. The undated facility policy, Dishwashing Machine Use, identified staff required to operate the dishwashing machine were to be trained in all steps of dishwashing machine process by the supervisor or designee proficient in all aspects of proper use and sanitation. The facility policy identified the wash solution temperatures were to be at 150 degrees F. The policy further directed the hot water sanitation rinse may not be more than 194 degree F, and no less than 180 degrees F. The policy directed staff to check temperatures with each dishwashing machine cycle and record the results in a facility approved log. The facility policy directed staff to monitor the gauge frequently during the dishwashing machine cycle and report to supervisor if it was below the desired temperatures. Food Storage: On 3/03/25 at 11:32 a.m., during the initial tour with CD, a tour was completed with the walk-in cooler and freezer. Upon entering the walk-in cooler, there was a tray of 30 containers of covered gelatin, dated 2/21/25. CD stated food was to be used within seven days of preparation, and this should not be used. An undated container, which was larger than a gallon, was noted to contain spinach. CD stated any undated foods would need to be disposed of. Upon entering the walk-in freezer, there was a large 20 bound bag of ice, which had clumped together, placed on the floor of the freezer. CD stated this had been used when the ice machine was not working. On the floor, next to the ice, was a box of blackened bananas. Upon viewing with CD, it was noted there were approximately five to six bunches of bananas, with five to six bananas per bunch. CD stated she had not gotten to making banana bread. While in the freezer, a ten-pound box of stew meat was noted to be opened and undated, with approximately 50% remaining. CD stated that was from the previous Friday when they had beef stew. On an upper freezer shelf, there were three packages of hot dog buns, containing 8 buns each. There were crystals within the bag. Although the bags were unopened, there was no date on the bag from the distributor. CD stated it had been a while since they served hot dogs and removed the bags of buns. Additionally in the freezer, there was an undated three-gallon container with approximately 1/3 of the container left, of sherbet. In addition to the sherbet, there was a second undated three-gallon container of ice cream with approximately 1/2 of the container remaining. There were no crystals noted on either the ice cream or sherbet. On 3/3/25 at 11:40 a.m., the reach in refrigerator was observed and was noted to have one undated salad with approximately four other salads. CD stated these are prepared for daily use. In addition, there was an undated gallon container of shredded cheese, approximately 1/4 to 1/2 full. Upon review of the reach in freezer, there was an undated open sleeve of French toast with six slices present. In addition, there was also an undated sleeve of waffles which had four waffles remaining. An undated facility policy, Food Receiving and Storage, identified food shall be received and stored in a manner that complies with safe food handling processes. The policy identified all foods stored in the refrigerator or freezer were to be covered, labeled and dated (use by date). Although the policy identified food in designated dry storage areas shall be kept at least 18 inches off the floor, it lacked direction for storage of food in the walk-in cooler or freezers. Temperature Logs Freezer/Refrigerators: On 3/03/25 at 11:27 a.m., an initial kitchen tour was completed with the culinary director (CD). With the tour, a review was completed of the walk-in cooler and freezer, as well as the reach in cooler and freezer. A review was completed of the temperature logs for both the freezer and refrigerators for March. The temperatures for the refrigerator ranged between 36-40 degrees F, and the freezer temperatures ranged from -1 to -3 F. Morning [NAME] (MC)-A stated the temperatures were checked daily, prior to food prep. All temperatures recorded for March were within the desired range. A review of the February log was completed for the dates 2/1/25 through 2/28/25. The log lacked documentation on the following dates: 2/1/25, 2/5/25, 2/8/25, 2/14/25, 2/15/25, 2/18/25, 2/19/25, 2/22/25, 2/23/25, and 2/27/25. Of the 28 possible entries, there were 10 entries lacking. It was identified with the temperature checks that were performed that all readings were within the desired ranges. A review of the January log was completed for the dates of 1/1/25 through 1/31/25. The log lacked documentation on the following dates: 1/1/25 (Documentation lacking for the walk-in cooler and freezer), 1/2/25, 1/11/25, 1/12/25, 1/20/25, 1/21/25, 1/22/25, 1/25/25, and 1/26/25. All temperatures except for two were within the desired range. On 1/1/25, the reach in refrigerator was at 41 degrees F, and on 1/28/25, the reach refrigerator was at 42 degrees F. There were no subsequent elevations of temperatures with the walk-in refrigerator. An undated facility policy, titled Refrigerators and Freezers, identified the acceptable temperatures for refrigerators were 35 to 40 degrees F and less than 0 degrees F for freezers. The policy indicated designated employees were to check and record refrigerator temperatures daily with the first opening and at first closing in the evening. Food Temperature Monitoring: On 3/3/25 at 11:31 a.m., meal preparation was observed with MC-A, with appropriate temperature checks performed. A review of temperature log was completed with findings as noted below: A review of the March temperatures were noted to be consistently completed for breakfast and lunch and were noted to be within the desired range. The temperature log for the evening meal was completed on only one occasion out of three opportunities, which was within the desired range. A review of the February food temperature log identified the breakfast log was lacking 10 entries out of 28 days: 2/1/25, 2/5/25, 2/9/25, 2/14/25, 2/15/25, 2/18/25, 2/19/25, 2/22/25, 2/23/25, and 2/27/25. A review of the February food temperature log for the noon meal indicated there were 11 entries missing out of 28 days:2/1/25, 2/5/25, 2/8/25, 2/9/25, 2/14/25, 2/15/25, 2/18/25, 2/19/25, 2/22/25, 2/23/25 and 2/27/25. A review of the February food temperature log for the evening meal indicated there were 22 entries missing out of 28 days: 2/1/25, 2/3/25, 2/4/25, 2/6/25, 2/8/25, 2/9/25, 2/10/25, 2/11/25, 2/12/25, 2/14/25, 2/15/25, 2/16/25, 2/1/9/25, 2/20/25, 2/21/25, 2/22/25, 2/23/25, 2/24/25, 2/25/25, 2/26/25, 2/27/25 and 2/28/25. A review of the February meal temperature log identified it lacked documentation for 43 of 84 meals served. A review of the January food temperature log identified the breakfast log was lacking 10 entries out of 31:1/2/25, 1/4/25, 1/11/25, 1/12/25,1/20/25,1/21/25, 1/22/25, 1/25/25, 1/26/25, and 1/28/25. A review of the January food temperature log for the noon meal indicated there were 12 entries missing out of 31 days: 1/1/25, 1/2/25, 1/4/25, 1/11/25, 1/12/25,1/18/25, 1/20/25, 1/21/25, 1/22/25, 1/25/25, 1/26/25, and 1/28/25. A review of the January food temperature log for the evening meal indicated there were 30 entries missing out 31. The only day there was an entry in the temperature log was on 1/3/25. The meal temperature log lacked documentation for 52 of 93 meals served. The entries present were within the desired temperature range. A review of the Resident Council Meeting Minutes was completed. On 1/10/25, the Resident Council Meeting Minutes, reflected the room trays were cold in the evenings. The follow up on this concern was delegated to CD. On 3/5/25, at 7:28 a.m. a review was completed with CD regarding the temperature monitoring of meals, especially for the evening meals. CD stated upon gathering documents for review, she noted there were gaps in monitoring, especially for the evening meals. CD stated she had been alerted of the concerns with cold food addressed by Resident Council. CD feels this was related to a delay in serving the trays once they go out to the floor. CD stated she had begun to track tray delivery time to help determine the cause of cold room trays but had only one tracking sheet available for 2/17/25 to 2/26/25. CD stated it was important to ensure food was at the proper temperature to prevent food borne illness related to bacteria. If the food is at the correct temperature, it assures it is cooked. In addition to food safety, proper temperature increases the joy of the food, stating Nobody wants cold food. The facility policy, dated April of 2019, identified the danger zone for food temperatures was between 41 degrees F and 135 degrees F. The policies goes on to identify this temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. The policy outlined the parameters of temperatures to be maintained for food safety and directed staff to maintain proper hot and cold temperatures during food service.

Based on observation and interview, the facility failed to identify presence of over the counter medications in resident room for 1 of 1 residents (R30) observed to have medications in their room. The medication lacked orders from the medical provider for use, as well as assessment for proper storage and and self administration of medication. In addition, the facility failed to ensure an assessment was completed to determine safe medication administration for 1 of 1 resident (R15) observed to self administer medication through a nebulizer (breathing treatment). Findings include: R30's quarterly Minimum Data Set (MDS) dated [DATE], indicated R30 was cognitively intact, and required assistance with performance of activities of daily living (ADL's). R30's diagnoses included anemia (a blood disorder in which the blood has a reduced ability to carry oxygen), heart failure (a chronic condition where the blood doesn't pump blood effectively), hypertension (high blood pressure), end stage renal disease (a chronic kidney disease where the kidneys lose their ability to filter waste and excess fluids from the blood), venous insufficiency (a disease of the veins in the legs which causes blood to pool in the legs), diabetes mellitus (a group of diseases that affects how your body uses sugar), and depression. R30's March medication administration record (MAR), printed on 3/4/25 indicated R30 had prescriptions for the following medications: Medication for diabetic management: Insulin Glargine Subcutaneous Solution (Insulin Glargine) Ozempic Subcutaneous Solution Peninjector (Semaglutide), NovoLOG Injection Solution (Insulin Aspart) Inject as per sliding scale: Vitamins and supplements: Multivitamin Oral Tablet (Multiple Vitamin) Cyanocobalamin Tablet 1000 MCG Folic Acid Oral Tablet 1 MG (Folic Acid) Thiamine HCl Oral Tablet 50 MG Vitamin D3 Tablet 5000 UNIT Zinc Sulfate Oral Capsule 50 MG Vitamin D3 Tablet (Cholecalciferol) Medications for heart conditions: Toprol XL Oral Tablet Extended Release 24 Hour Apixaban Oral Tablet During initial screening on 3/3/25, at 3:13 p.m., R30 was sitting in his wheelchair at his bedside. R30 had his bedside table near him. On the top of the table, the following medications were noted in open site, in a plastic, shoe box size container: - Iron tablets: 65 mg tablets. There was one over the counter (OTC) bottle with 100 tablets on the label. R30 also indicated he had some in an unlabelled bottle, inside of another bottle with cash on the outside, so was not visible. R30 stated he took one tablet daily. Iron supplement is used for low blood iron, or anemia. - Berberine 800 mg/Milk [NAME] 105 mg: R30 stated he was not using this supplement. Berberine is identified as being a supplement which may benefit heart conditions, blood sugar regulation, for bacteria, and also reduce swelling. - [NAME] and ACV Gummies 500 mg: R30 stated that he used one gummie every three to four days. This supplement is noted to be used for weight loss. R30 stated he has not used this product from this bottle and bottle was observed to be unopened. - Ashwaghanda 600 mg and Shiajit 300 mg supplement: This supplement was noted to be used to boost energy and decrease stress. R30 stated he has not used this product and product was observed to be unopened. - Sugar Defender 60 ml bottle with approximately 1/6th of the bottle used. This product is advertised as a supplement to balance blood sugar, control cravings, and promote weight loss. A review of medical record was completed and it was noted R30 had recently had lab work done to check his iron levels on 2/28/25, and the results of the iron was noted to be low at 44, with a normal range being 65-175 mcg/dL (metric unit of measurement). The medical record indicated the lab results were sent to the provider to review on 2/28/25. A review of the record lacked indication of physician follow up or subsequent orders for iron. R30's medical lacked indication of any orders for iron supplements. On 3/4/25 at 2:19 p.m., R30 was observed for wound care. Although wound care was provided by wound care nurse practitioner, clinical coordinator (CC)-B assisted with the process. While in room for wound care observation, R30 was noted to have medications as noted above, remained in place on top of bedside stand, readily viewed when in the room. On 3/5/25 at 9:37 a.m., CC-B, confirmed upon record review, lab work had been completed for R30 and had been faxed to the provider for review on 2/28/25. CC-B stated with a low iron level, as observed in lab work, she would anticipate a follow-up fax/order potentially for an iron supplement. CC-B stated resident was not currently on ferrous sulfate (iron) but received a multivitamin. CC-B was unaware of R30 keeping any medications in his room and at his bedside. CC-B was unaware of what the policy was for medications at bedside but would follow up on this. CC-B stated if R30 did not have orders to keep medications in his room then medications cannot be kept in his room. CC-B stated it was her expectation if staff members were to observe medications at bedside, they would report to her what was seen and she would then investigate, and follow up with the provider. CC-B stated medications found at bedside were to be removed until orders were obtained and the resident was assessed to be safe with self administration and storage. Following initial interview, a room visit was made with CC-B. At this time, CC-B observed medications at bedside. At this time, R30 informed CC-B he was taking iron tablets twice daily. CC-B informed resident he was not allowed to keep medications in his room until orders were obtained and assessments were completed. R30 would not allow medications to be removed. CC-B stated she would follow up with director of nursing (DON) and administrator to review situation and remove medications. On 3/6/25, at 11:50 a.m., DON stated it was her expectation residents would not have medications in the room unless they were ordered by the provider and resident had been assessed to safely self administer and store the medications. DON stated when found in the room without orders or assessment, the medications were to be removed until this was completed. DON expected the resident was educated as to why the medication needed to be removed until further assessment was done and orders obtained. The DON stated a self administration assessment for medication was completed with residents upon admission, reviewed annually, and updated as needed to assure the resident was cognitively and physically able to take meds. This assessment included the evaluation of the resident's vision, ability to open bottles, expressed understanding of medication, their use, dosing, and potential application of medications/powders/ointments ordered. 40938 R15's quarterly Minimum Data Set (MDS) dated [DATE], indicated R15 was cognitively intact, was independent with activities of daily living (ADL's). R15's diagnoses included chronic obstructive pulmonary disease (COPD), pneumonia, shoulder pain, anxiety, depression, and respiratory failure. R15's order summary report dated 2/1/25, directed staff to administer albuterol sulfate (medication to open airways, and treat air flow blockage) nebulization solution 1.25 milligrams(mg)/3 milliliters (ML) one vial via nebulizer two times daily. However R15's orders failed to include a provider order to self-administer albuterol sulfate. Review of R15's electronic medical record (EMR) failed to include an assessment of R15's ability to safely administer nebulizer solution after facility staff set up medication. R15's care plan failed to identify residents ability to safely administer medications. On 3/5/25 at 7:27 a.m., R15 was sitting in the wheelchair in doorway of room, licensed practical nurse (LPN)-B placed R15's albuterol medication in the reservoir of the mask, set the mask into holder on nebulizer machine and exited the room. LPN-B stated the nurses set up the medication, R15 did the breathing treatment on her own after breakfast. When interviewed on 3/06/25 at 10:59 a.m., clinical manager (CM)-A confirmed R15 did not have an order to self-administer albuterol nor was there a self-administration of medication assessment completed when she had admitted to the facility in 2024, stating It got missed. When interviewed on 3/06/25 at 11:50 a.m., director of nursing (DON) stated there was an assessment to be completed upon admission and as needed to see if they are able to cognitively and physically able to take meds. Open bottles, vision, understanding of meds, use, dosing, potential application, with an order in place for the process. This process is reviewed as needed, and annually. Facility policy Self-Administration of Medications dated 2/2024, indicated the interdisciplinary team (IDT) assessed each residents cognitive and physical abilities to determine whether self-administrating medications was safe and clinically appropriate, which would be documented in the medical record and care plan. The policy further identified self administered medications were stored in a safe and secure place, which was not accessible by other residents. If safe storage was not possible in the resident's room, the medications of resident's room, the medications were stored on a central medication cart or medication. Additionally, the policy stated any medications found at the bedside that are not authorized for self administration are turned over to the nurse in charge for return to the family or responsible party. The facility policy, Medication and Treatment Orders, last revised 2/2024, indicated drugs and biological orders must be recorded on the physician's orders sheet in the resident chart.

Based on observation, interview and record review, the facility failed to address resident requests for further therapy evaluation for 3 of 3 residents (R30, R1, and R212) reviewed for choices. Findings include: R30: R30's Quarterly Minimum Data set (MDS) dated [DATE], indicated R30 was cognitively intact, and required assistance with performance of activities of daily living (ADL's). The MDS indicated there were no concerns regarding mood and behavior. The MDS identified R30 had intact cognition. R30's diagnoses included anemia (a blood disorder in which the blood has a reduced ability to carry oxygen), heart failure (a chronic condition where the blood doesn't pump blood effectively), hypertension (high blood pressure), end stage renal disease (a chronic kidney disease where the kidneys lose their ability to filter waste and excess fluids from the blood), venous insufficiency (a disease of the veins in the legs which causes blood to pool in the legs), diabetes mellitus (a group of diseases that affects how your body uses sugar), and depression. During initial interview on 3/3/25 at 2:42 p.m., R30 stated he was no longer allowed to use his electric wheelchair due to historic problems with use. R30 acknowledged he had hit a resident who was in the middle of the hallway. R30 went on to state the other resident had some cognitive deficits. At that time he was also low on iron and wasn't right. R30 stated he had recently been seen by neurology and had received an order for the evaluation by therapy for use of an electric wheelchair. He had pursued follow up for this. At that time, R30 was provided with the previous notification dated 5/17/23. This document, titled Power Operated Vehicle and Scooter Policy, last revised 2/2012, had written indicators which identified R30 had a medical change, as well as a lack of following therapy recommendations. The document also had a hand written notation which indicated R30 ran into another resident. R30 indicated the use of the electric wheelchair was important to him as he was unable to get into the bathroom with his current manual wheelchair. R30 stated although he was set up to perform oral hygiene, and to shave, it was difficult to do without a mirror and sink. R30 also stated his activity attendance had decreased when he had to propel his manual wheelchair, as it was physically taxing. R30 stated this impacted his participation in non-structured activities, wheeling up and down the halls, and socializing with other residents. Although R30 had received assistance with propelling his wheelchair, this was inconsistent related to staff availability. R30's care plan, revised on 6/19/24, indicated R30 is alert and oriented to person, place, and time. The care plan indicated R30 had experienced episodes of confusion/not making sense. The care plan directed staff to seek out occupational (OT) or speech therapy (SLP) to complete cognitive testing as needed. The care plan also identified R30 had an alteration in mobility related to lymphedema, autonomic neuropathy, lack of sensation to lower extremities, and weakness. The problem statement indicated on 10/6/23, R30 was noted to run lower extremities into nearby objects while in power wheelchair. The entry dated 2/2/24 indicated R30 was noted to run into another resident's wheelchair with power wheelchair and had not stopped. R30 was noted to be going an excessive speed. The problem statement, revised on 6/10/24, indicated Power wheelchair removed indefinitely. The care plan directed staff to follow OT and physical therapy (PT) instructions for mobility function. The care plan identified R30 was transferred with a Hoyer (brand name of mechanical lift) and was non-ambulatory. The care plan indicated the primary locomotion was a manual wheelchair. The care plan lacked any indication to direct staff to assist to propel him extended distances, or to and from activities, or meals. Additionally, the care plan lacked any perimeters to outline the requirements for, a formal re-evaluation for consideration of resumed use of the electric wheelchair. Upon review of medical record, it was noted on 2/26/25 R30 had been seen by neurology. The progress note identified R30 had a history of chronic neuropathic pain related to diabetes mellitus (DM)2 and metabolic syndrome. During R30's consult visit on 2/25/25, the provider indicated Would like to do a power chair eval (evaluation), good cognition and good hand motion. The progress went on to to state the provider believed this would go well with PT training for safety for this, and should improve community access. On 3/4/25 at 2:39 p.m., clinical coordinator (CC)-B and wound care nurse practitioner (WCNP) were exiting R30's room. While in the room with R30, CC-B stated to R30 and surveyor an evaluation was set up for R30. As we continued to the nurse's station, CC-B stated the although order for evaluation had been received and discussed during the interdisciplinary team (IDT) meeting, which included therapy, administration, and clinical coordinators, the IDT does not feel this was a safe option for R30, therefore they would not be proceeding with the evaluation. CC-B stated this was due to his past history with the use of an electric wheelchair. CC-B stated she was unaware if there were any parameters or guiding points as to when this was to be reviewed and reassessed, and was unaware of any guidelines for reassessment. CC-B stated although the IDT had decided for R30 not to be re-assessed, the decision had not been documented, relayed to the ordering provider, or relayed to R30. On 3/6/25, at 11:50 a.m. the director of nursing (DON) stated it was her expectation if an evaluation had been ordered, it would be completed. If the evaluation was determined to be not appropriate, it would be her expectation the staff would follow up in discussion with the provider who ordered the evaluation. R1: R1's quarterly MDS dated [DATE], identified R1 was cognitively intact. The MDS identified R1 was independent with eating, and required no assistance from staff. R1's was on a therapeutic diet, but lacked indication of need for mechanically altered diet. The MDS lacked any areas of dental concerns. R1's medical diagnoses included chronic obstructive pulmonary disease (COPD), anemia, hypertension, diabetes mellitus, and osteoarthritis. R1' care plan identified R1 had an alteration in dental care due to no teeth. The care plan identified R1 has full upper and lower dentures, however, states they are loose but do not interfere with talking or eating. This was last revised on 11/30/24. Additionally, the care plan identified R1 was a potential for altered nutritional status due to need for a therapeutic diet. The care plan directed staff R1 may have bread per speech therapy (ST). The care plan identified R1 was to receive large portions of protein. The care plan lacked any indicators R1 could not have peanut butter. On 3/3/25 at 5:32 p.m., R1 expressed The place is getting stupid. I have eaten peanut butter all my life and now they say I can't have it because of my diet. R1 stated he was told that peanut butter was too sticky. R1 stated he was given no further rationale other than that and was told by dietary staff providing meals. On 3/5/25 at 7:42 a.m., the culinary director (CD) reviewed R1's dietary card. This identified resident on consistent carbs for his diabetes. R1 was to be on a soft food diet, bite size. R1 was assessed by speech therapy and determined that it was authorized for him to have bread. CD stated R1 had a swallowing problem. As noted in the MDS, the resident is edentulous, however did have a set of dentures on his dresser which he preferred not to wear. CD stated she had verified the peanut butter dietary restrictions with the director of therapies (DOT) and was informed R1 was unable to have peanut butter, as this was related to the International Dysphagia Diet Standardization Initiative. CD stated R1 had historically received peanut butter and jelly sandwiches for a snack. CD stated she had been informed peanut butter restriction had been determined by ST. Documents titled Therapy to Nursing Communication Form dated 1/10/25, indicated R1 was on a dysphagia advanced diet, Level 6 diet and bite sized. A subsequent communication form on 1/23/25, indicated it was OK for R1 to have bread. A review of the ST assessment of 1/23/25, identified R1 may have bread. On 3/5/25 at 9:59 a.m., CC-B was interviewed regarding the resident's limitation of peanut butter and stated she was unaware of the dietary restriction for resident regarding peanut butter. On 3/5/25 at 11:08 a.m., ST stated she had been approached regarding R1's ability to have peanut butter. R1 stated when a resident who was on soft and bite sized diet, she would not recommend peanut butter. This was implemented as resident is edentulous and chose not to wear dentures. ST stated her last assessment was related to R1's ability to have bread and did not address R1's desire to have peanut butter. ST stated it was the facility policy to follow the IDDSI diet without exceptions. On 3/6/25 at 10:03 a.m., CC-B stated she had received an order for speech evaluation which would determine if R1 was able to have peanut butter safely. On 3/6/25 at 11:50 a.m., the director of nursing stated if R1 had historically eaten peanut butter without difficulty without dentures, it would be her expectation that an evaluation would be completed to determine if R1 was able to demonstrate the ability to do so safely. DON stated it was her expectation, if R1 was not to have peanut butter due to safety concerns, this would be known by the CC-B, nursing staff, and dietary staff and implemented accordingly. If R1 was deemed safe to have peanut butter, an appropriate dietary order would be sought and put into place, and staff would follow that order. R212: R212's quarterly MDS assessment, dated 1/28/25, indicated R212 was cognitively intact. R212 was identified as requiring use of a wheelchair and receives assist with all aspects of mobility. R212's medical diagnoses included malignant neoplasm (a type of abnormal and excessive growth of tissue) of unspecified part of the right bronchus or lung, cancer, anemia, coronary artery disease (type of heart disease which affects the main blood vessels that supply blood to the heart, called the coronary arteries), hypertension, malnutrition, anxiety disorder, depression, and pain related to neoplasm. On 3/3/25 at 7:05 p.m., R212 stated she had previously been able to use a walker for transfer and now requires the use of an EZ stand (a mechanical lift used to assist resident in an upright standing position, to transfer between bed, wheelchair, and bathroom). R212 stated she actively performed leg exercises three times a day, with twenty repetitions to maintain strength and mobility. R212 demonstrated this by raising leg even to her hip flexure, while sitting in a chair. R212 stated she had expressed this before to staff, however, she had received no further information regarding this. R212's care plan initiated on 8/15/24, indicated R212 had alteration in mobility related to malignant neoplasm of ovary, anxiety, malignant neoplasm of right lung, and weakness. The care plan directed staff to provide assist with bed mobility, to boost up in bed, and to get feet into, and out of the bed. Staff were directed to assist with locomotion of her wheelchair, provide assist of one with movement in bed, and in/out of bed with assist of two with the use of an EZ stand for transfer. A review of narrative notes of 2/6/25, written by previous administrator, indicated resident stated What I really want is to see a physical therapist. In this narrative, the former administrator explained hospice residents typically do not receive therapy services. The narrative note identified R212 replied that she was aware of this. The narrative note went on to indicate the prior administrator would look into this, and would ask CC-B to assist. A review of further documentation reflected no further follow up was completed. On 3/4/25 at 4:09 p.m., CC-B stated she was unaware of this request of R212 for physical therapy evaluation. CC-B stated she would follow up with physical therapy regarding a possible screen or assessment. On 3/5/25 at 8:19 a.m., director of nursing stated R212 had been assessed for mobility upon her admission to the facility. DON stated R212 had a subsequent evaluation 9/26/24 following a fall. R212 had been weak with a bathroom transfer, and the recommendation was for the resident to use EZ stand. The narrative note from physical therapy indicated Resident is on hospice and not appropriate for therapy. DON stated she was unsure as to why the request on 2/6/25 was not acted upon. DON stated she was unaware of the request. Upon subsequent interview on 3/6/25 at 11:50 a.m., DON stated she and the clinical coordinators reviewed the narrative notes on a daily basis. When requests are made, the expectation was when clinical coordinator became aware, they would follow through. Additionally, DON stated if staff were referring a request to another person, this should be done via email for tracking purposes, as well acknowledgement of the concern. The facility policy, Resident Rights Policy, dated 1/2024, identified that is the practice of the facility to uphold the rights of all residents. The policy further states the residents of the facility will access to the information regarding the Combined Federal and State [NAME] of Rights in writing via the electronic admissions process. The residents will acknowledge the receipt of the documents. The policy further states the resident can stated a physical copy upon admission, or at any time by requesting a copy from social services, and identified a copy of the bill of rights was posted in the facility. The policy lacked any information or direction how to assure the actual rights were implemented on behalf of the resident, or of what the actual rights were.

Based on observation, interview, and document review, the facility failed to meet the oral health needs for 1 of 1 resident (R5) reviewed for routine dental services. R5's quarterly Minimum Data Set (MDS) dated [DATE], identified an admitted [DATE], R5 had intact cognition, diagnoses of heart failure, chronic kidney disease and limitation of activities of daily living due to disability. R5's oral/dental evaluation dated 1/21/25, identified R5's teeth were observed to have plaque or debris in localized areas between teeth with several teeth missing and staff would assist with setting up dental appointments and transportation. During observation on 3/3/25 at 2:56 p.m., R5's teeth had a significant amount of built up white/grey debris on her front teeth and several missing teeth on her upper left side. R5 denied pain or difficulty with eating. R5 stated she could brush her own teeth with staff assistance for set up of her toothbrush and toothpaste at the sink. R5 stated she didn't remember when she last had a dental check-up but thought she was due for one as it had been years. When interviewed on 3/5/25 at 8:34 a.m., nursing assistant (NA)-E stated staff assist R5 with set-up at her bathroom sink with her toothbrush and toothpaste and could normally brush her own teeth. NA-E stated the facility nurses were responsible for setting up resident dental appointments when needed. When interviewed on 3/5/25 at 8:39 a.m., clinical manager (CM)-A stated the facility procedure for offering resident assistance with routine dental appointments and transportation occured with the completion of the initial admission assessments and MDS. CM-A confirmed this should have been done for R5 with her admission in October of 2024 but was missed. When interviewed on 3/5/25 at 12:04 p.m., the director of nursing (DON) stated the facility procedure and expectation was for residents to be assessed for oral/dental needs and assisted with making needed appoints upon admission. The DON stated staff should confirm the date of the last dental appointment and determine if the resident needed or wanted assistance with setting up an appointment and transportation. The DON confirmed this was missed for R5. The facility policy Dental Services dated December 2013. Identified Routine and emergency dental services are available to meet resident's oral health need in accordance with the resident assessment and plan of care and personnel would be responsible for assisting the resident/family in making dental appointments and transportation arrangements as necessary.

Based on observation, interview, and document review, the facility failed to maintain sanitary conditions for mechanical lifts for 6 of 6 residents (R35, R47, R9, R27, R3, R2) who used a mechanical lift for transfers. This had the potential to affect other residents who used a mechanical lift for transfers. In addition, the facility failed to ensure hand hygiene while providing personal cares to prevent the spread of infections for 2 of 2 residents (R3, R9) observed during personal cares. Findings include: Mechanical lifts: During an observation on 3/4/25 at 10:19 a.m., nursing assistant (NA)-D wheeled R35 into his room and brought in the Hoyer lift (a mechanical lift to lift a person who is non-weight bearing for transfers). Clinical coordinator (CC)-A went to R35's room and applied a gown and gloves as R25 was on enhanced barrier precautions (Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs). NA-D also applied a gown and gloves. NA-D and CC-A transferred R35 to the bed with use of hoyer lift. Once the transfer was complete CC-A took off the gloves and gown, washed her hands pushed the Hoyer lift into the hallway, and walked away without sanitizing the Hoyer lift. The Hoyer lift was brought into R9's room at 11:44 a.m., RN-A and NA-D assisted R9 from her bed to her wheelchair. RN-A removed the hoyer from the room placed it in the hallway and walked away without sanitizing the machine. During an observation on 3/4/25 at 11:00 a.m., NA-A brought a mechanical standing lift into R3's room. NA-A applied the mechanical sling to R3. NA-A and NA-C assisted R3 to a standing position and transferred R3 to the bathroom. When R3 was finished using the bathroom, NA-C and NA-A assisted R3 to her recliner. NA-A pushed the mechanical standing lift into the hallway and walked away without sanitizing the machine. During an observation on 3/4/25 at 1:23 p.m., NA-C and NA-B brought the Hoyer lift out of R9's room and took the Hoyer down the hallway to R47's room. NA-C and NA-B applied gowns and gloves as R47 was in enhanced barrier precautions, NA-C then pushed the Hoyer to lift into R47's room. During an observation on 3/5/25 at 8:39 a.m., NA-D brought the mechanical standing lift into room R27's room applied gloves, and hooked R27 up to the mechanical standing lift. The activity director (AD) entered the room and assisted with the transfer. Once done with the transfer AD took the mechanical standing lift and placed it in the hallway. AD then walked away without sanitizing the mechanical standing lift. During an observation on 3/5/25 at 8:40 a.m., the Hoyer lift was in R9's doorway, NA-D pushed the lift into the room. NA-D provided morning care and attached R9 to the Hoyer lift. NA-A came into the room and assisted with the transfer. After the transfer was complete NA-A took the Hoyer lift out of the room placed it in the hallway and walked away without sanitizing the Hoyer lift. At 10:19 a.m., NA-D took the Hoyer lift to R2's room. During an observation on 3/4/25 at 10:42 a.m., NA-A retrieved the mechanical standing lift from the hallway brought it into R3's room. NA-A applied a lift sling around R3. NA-C lifted R3 from the recliner transferred R3 into the bathroom and lowered R3 onto the toilet. When R3 said she was finished on the toilet, NA-C lifted R3 from the toilet. NA-A took a wet wipe and provided perineal care. NA-A discarded the wet wipe into the garbage and pulled up R3's brief and pants. NA-A then removed their gloves pushed R3 back to her recliner and lowered her into her recliner. NA-A placed the mechanical standing lift into the hallway and walked away without sanitizing her hands or the mechanical standing lift. During an interview on 3/4/25 at 11:07 a.m., NA-A indicated she believed the night shift cleans the mechanical standing lifts and Hoyer lifts but was unsure and said she would find out. NA-A confirmed she did not sanitize the mechanical standing lift after use in R3's room. During a follow-up interview on 3/5/25 at 10:50 a.m., NA-A indicated mechanical standing lifts and Hoyer lifts were supposed to be washed with soap and water on overnights, but could not verify as NA-A does not work the overnight shift. NA-A verified she did not sanitize the Hoyer lift after use in R9's room. During an interview on 3/5/25 at 10:55 a.m., NA-D indicated mechanical standing lifts and Hoyer lifts should be sanitized when coming out of a resident's room when the resident is on enhanced barrier precautions and once a day. NA-D indicated she typically tries to sanitize the mechanical standing lifts and Hoyer lifts when she has time. NA-D confirmed she did not sanitized Hoyer lift between R9's and R2's rooms. During an interview on 3/5/25 at 2:31 p.m., activities director (AD) indicated mechanical lifts should be sanitized between residents. AD confirmed she did not sanitize the mechanical standing lift after assisting the NA-D with transferring R27. The activities director's expectation would be for nursing assistants to clean the mechanical lifts unless they requested AD to clean the machine. During an interview on 3/5/25 at 11:07 a.m., CC was unable to verify how often the medical standing lifts and Hoyer lifts should be cleaned and or sanitized. CC confirmed she did not sanitize the Hoyer lift after use with R35. During an interview on 3/5/25 at 11:28 a.m., RN-A indicated mechanical standing lifts and Hoyer lifts should be cleaned between residents. RN-A verified she did not clean the mechanical standing lift or Hoyer lift as she was passing medications. Her expectation would be for the nursing assistant to clean the lifts unless the nursing assistant requested help. During an interview on 3/5/25 at 12:14 p.m., director of nursing (DON) indicated the mechanical standing lifts and Hoyer lifts should be sanitized after every resident use to prevent contamination. During the review of the policy titled Mechanical Lifts dated 2/14, indicated mechanical lifts per manufacturer guidelines and Monarch Healthcare Management Policy and Procedure. To transfer a resident from bed to chair: #17 disinfect lift after use. To put the resident back to bed: #15 Disinfect lift after use. Hand hygiene: R3's annual Minimum Data Set (MDS) dated [DATE], identified R3 was cognitively intact with diagnoses that included, schizoaffective disorder (a mental health condition that combines aspects of schizophrenia and mood disorder), diabetes mellitus (impaired ability to produce or respond to insulin) and hypertension (high blood pressure). R3's MDS identified that R3 needed substantial/maximal assistance for toileting hygiene, upper body dressing, and personal hygiene. R3 was dependent on staff for lower body dressing. R3's care plan revised on 1/30/25, identified R3 had an alteration in elimination and increased incontinence due to urgency. R3 required assistance with toileting, and staff assisted with perineal cares in the morning, bedtime, and as needed. Staff needed to check incontinent products and assist in changing incontinent products as needed. During an observation on 3/4/25 at 10:42 a.m., NA-A retrieved the mechanical lift from the hallway brought it into R3's room. NA-A applied a lift sling around R3. NA-C lifted R3 from the recliner transferred R3 into the bathroom and lowered R3 onto the toilet. When R3 said she was finished on the toilet, NA-C lifted R3 from the toilet. NA-A took a wet wipe and provided perineal care. NA-A discarded the wet wipe into the garbage and pulled up R3's brief and pants. NA-A then removed their gloves pushed R3 back to her recliner and lowered her into her recliner. NA-A During an interview on 3/4/25 at 11:07 a.m., NA-A confirmed she did not remove the gloves after doing perineal cares. NA-A indicated she was not trained to take off gloves after performing perineal cares and did not want to touch a resident without gloves. R9 R9's quarterly Minimum Data Set (MDS) dated [DATE], identified R9 as being cognitively intact with diagnoses that included, paraplegia (a type of paralysis that affects the lower half of the body) hypertension (high blood pressure), anxiety, and depression. R9's MDS identified that R9 needed substantial/maximal assistance for personal hygiene and lower body dressing. R9 care plan revised on 2/25/25, identified R9 had alternation in elimination weakness and paraplegia. R9 required assistance with perineal cares in the morning, bedtime, and as needed. R9 required assistance with incontinent products and to change incontinent products as needed. During an observation on 3/5/25 at 8:40 a.m., NA-D went into R9's room and asked R9 if she wanted to get dressed. NA-D got a basin of warm water and wipes. NA-D applied gloves. NA-D warmed the wipes in the warm water and applied soap. NA-D provided perineal care and discarded the wipe in the garbage. NA-D took a second wipe and rinsed off the soap. NA-D rolled R9 to the side right removed the soiled brief and discarded the soiled brief in the garbage. NA-D then provided perineal care to her coccyx and buttock area with a wet wipe with soap, then rinsed off the soap with a clean wipe and discarded the wipe into the garbage. NA-D did not remove gloves and grabbed the clean brief and tucked the brief under R9 then had R9 roll to her left side and adjusted the brief. NA-D assisted R9 roll to her back, then applied a protective ointment to the perineal area. NA-D then rolled R9 to the right side, and NA-D applied the protective ointment to her buttocks and coccyx area. NA-D assisted R9 to roll to her back and NA-D fastened R9 brief. NA-D took the bed controller and put the bed down slightly. NA-D dumped the basin of water then dried the basin and placed the basin in the closet. While in the closet NA-D grabbed two pairs of pants and had R9 pick which pants she wanted to wear. Then went back to the closet and proceeded to touch and separate the clothing looking for a matching top. NA-D took the outfit to the bed and assisted R9 with putting on her pants. NA-D took the bed controller and lifted the head of the bed. NA-D noted there was not a sling for the mechanical lift, and NA-D said she needed to retrieve a sling. NA-D removed gloves and exited the room. During an interview on 3/5/25 at 11:06 a.m., NA-D confirmed she did not change gloves after removing the solid brief and continued to touch clean objects in the room such as clothes and the bed controller. NA-D indicated the normal practice was to change gloves after removing a soiled brief. During an interview on 3/5/25 at 11:07 a.m., CC stated she expected when doing perineal care, staff wipe from front to back and use different wipes on different sides. CC expected staff to remove gloves after perineal care. During an interview on 3/5/25 at 12:14 p.m., DON indicated it is her expectation once staff is done with the dirty cares, gloves should be removed before continuing cares. Review of the policy titled Handwashing Policy dated 2/2024, stated proper hand washing techniques should be used to protect the spread of infection. Hand washing shall be completed: after changing incontinent products or cleaning up after someone who has used the toilet. Hand washing and gloves- When conducting a procedure requiring the use of gloves, proper hand washing shall be completed before donning gloves and after removing gloves.

Based on observation, interview, and document review the facility failed to identify heat register as safety hazard for 1 of 1 resident's (R1) bed that was too close to the heat who had a history of sleeping with his legs off the bed. This deficient practice resulted in an immediate jeopardy (IJ) for R1. The IJ began on 3/1/24, when the facility failed to ensure R1's bed was a safe distance from the heat source, R1 was found with is left foot on top of the heater which resulted in multiple second degree burns to the foot and required admission to hospital burn unit for treatment. The administrator and director of nursing (DON) were notified of the IJ on 3/6/24 at 4:51 p.m. The facility implemented corrective action and the deficient practice was corrected on 3/1/24, prior to the survey and was issued at past non-compliance. Findings include: Second degree burn: is also called partial thickness burn. These burns involve the outer layer of skin (epidermis). They can extend to the middle skin layer (dermis). Second degree burns can be very painful and often take several weeks to heal. Facility reported incident (FRI) submitted on 3/1/24 at 1:45 a.m., indicated facility staff noted R1's legs were dangling over the side of the bed and touching the top of the heat register. Also indicated R1's bed was pushed close to the wall that had the heat register mounted. Facility staff initially noted R1 to have new blisters on the bottom of his left toes. R1's diagnoses list last updated 3/5/24, indicated R1's diagnoses included diabetes, muscle weakness, non-pressure chronic ulcer of the right foot, autonomic neuropathy (damage to the nerves that control automatic body functions), meralgia paresthetica (compression of the nerve to the thigh which affects sensation but doesn't impact the ability to move the leg), and second degree burn of left foot. R1's quarterly minimum data set (MDS) dated [DATE], identified R1 to have moderate cognitive impairment and no behaviors. R1's care plan dated 7/10/23, indicated R1 is a fall risk and staff are directed to keep the bed in low position. R1's areas of vulnerability included mobility impairment, hard of hearing, diabetes, and refusal to walk. R1 requires staff assist of two to transfer with mechanical lift and for turning and repositioning. Staff were directed to encourage R1 to assist by using bed rails. Further identifies R1 has extremely fragile skin that is highly susceptible to skin tears. Care plan update on 3/1/24 indicated R1 had a burn to left foot from heat source in room. As a result of R1's burn and complications of diabeties identiifed an increased risk for infections. R1's March 2024 treatment administration record (TAR) informed and directed staff to keep R1's bed a good distance away from the heat register by the window. Tosses and turns at noc (night) especially, laying sideways with LE (lower extremity) on heat register if too close to it. Always have Rooke Boots [offloading boots] in place. Start date was 2/25/24 at 6:30 p.m. R1's progress notes on 3/1/24 at 3:17 a.m., indicated at 12:15 a.m., nursing assistant (NA) noted R1 lying on his bed with feet hanging by the bed, the bed was close to the heater. The right foot had an offloading boot on but the offloading boot for the left foot was off and R1's left foot was laying on the heater. R1 was not in pain and was confused. R1's left forefoot was noted to have blisters with the size of two (2) centimeters (cm) x three (3) cm; big toe had a skin tear of 0.5 cm x 0.5 cm, and every single toe had a blister with the same size. R1's progress notes on 3/1/24 at 5:31 p.m., indicated R1 was being transferred from wound clinic to hospital Burn Unit. R1's progress notes on 3/5/24 at 5:09 a.m., indicated R1 returned from the hospital at 7:30 p.m. on 3/4/24. R1's Wound Progress Note by certified nurse practitioner (CNP)-A on 3/1/24 at 5:04 p.m., indicated R1 had kicked off his offloading boot and foot went off the side of the bed onto the heat register. Uncertain how long the foot was on the register but had developed significant blisters. Identifies extensive blistering on the plantar (sole of the foot) of the left foot covering all metatarsal heads and great toe through the 5th toes. All blisters on toes and metatarsal heads were debrided (remove dead tissue from the skin) using forceps and scissors. Toenails of the 2nd-5th toes are removed. Measurements provided of the left foot burns as follows: (length x width x depth) plantar was 5.5 cm x 6.2 cm x. 0.1 cm; plantar metatarsal head under great toe 1.2cm x 1.4 cm x 0.1cm; 5th toe plantar 2.8 cm x 2.4 cm x 0.1 cm; 4th toe plantar 3.3cm x 3.5 cm x 0.1 cm; great toe plantar 5/2 cm x 5 cm x 0.1 cm; 3rd toe plantar 4.1cm x 3.6 cm x 0.1 cm. Further noted due to the extent of the burns and R1's underlying co morbidities it was advised to transfer to a burn unit. R1's hospital Interagency Transfer Form dated 3/4/24, indicated R1 had presented with 2% TBSA (total body surface area) partial superficial and partial deep 2nd degree burns to left foot and toe. R1 had discharge orders for daily dressing changes to the left foot and appointments to follow up. During an observation and interview on 3/5/24 at 4:45 p.m., R1 was in his bed with family sitting bedside. Bed position was turned perpendicular to the wall with the heating register. Head of bed was approximately 2 feet away from the wall. R1 had protective boots on both feet and lower legs. R1 stated he had just returned from the hospital after burning his foot on the heat register. R1 explained he moved around in bed on his own and favored laying on his right side facing the wall towards the window (the wall also holds the heat register). Family member (FM)-A indicated R1's bed had been up against that wall since he was admitted a couple of years prior, and he liked laying on his side and looking out the window. FM-A indicated that a note was taped to the windowsill for a week or two prior to R1's burn that warned staff to keep the bed away from the wall because the heater was too hot. FM-A did not know why the note had been taped there or where it was at the time of this interview (there was no note taped to the windowsill). FM-A further indicated R1 had poor circulation in his legs and had wounds on his right foot that weren't healing but that prior to the burn, his left foot was without any wounds. FM-A reported that R1 had required surgery on his leg a few weeks prior to increase the blood flow to help heal the wounds on the right leg. FM-A was afraid of R1's ability to heal the left foot burns because of his poor circulation. During observation and interview on 3/6/24 at 10:04 a.m., the maintenance director indicated the surface temperature of baseboard heat registers were not routinely checked. If a resident complains of the temperature in their room, they used a heat gun to check the general room air temperature but clarified, they did not check the surface temp of the heat registers. Observation of heat register temperatures included: room [ROOM NUMBER]'s heat register was 109 degrees Fahrenheit (F) on the side and was 169 degrees(F) over the actual air vent. room [ROOM NUMBER]'s heat register was 73 degrees (F) on the side of and 120 degrees (F) over the air vent. During an interview on 3/6/24 at 9:55 a.m., nursing assistant (NA)-A indicated the heat registers get pretty hot and have heard some staff complaints about how hot it gets on their pant legs when they are by them but was not aware of any resident injuries until R1's. NA-A stated R1 moved in bed a lot, often would find R1's legs hanging over the side of the mattress, and would put them back into bed. R1 usually wore the protective boots on his lower legs but the left one had fallen off. NA-A explained there had been a note dated 2/25/24, hanging on the windowsill telling staff to keep the bed away from the heater but had been taken down after the incident. During an interview on 3/6/24 at 10:45 a.m., NA-B stated. R1 swung his legs off the bed towards the window all the time and R1 constantly kicked off the boot protectors, he hated those. During an interview on 3/7/24 at 8:20 a.m., RN-A indicated R1 was known to be restless at night and a few weeks prior, she observed R1 laying sideways in bed and feet were on the heater. R1 was wearing the protective boots at that time but the boots were warm to touch. RN-A moved the bed away from the heat register and locked the brakes. RN-A stated she could not remember the exact day but did indicate that she made a progress note in his record, put instructions in the TAR, placed a note on R1's windowsill, and told other nurses to pass it on. RN-A was not sure what happened after that. During an interview on 3/6/24 at 12:15 p.m., the director of nursing (DON) indicated she was not aware of any potential safety risks related to R1 and the heat registers until after the incident on 3/1/24. DON expected stafff notify her of any safety concerns and brought forward to the interdisciplinary team for review. During an interview on 3/6/24 at 12:00 p.m., the administrator indicated during their investigation of R1's burns, it was discovered that registered nurse (RN)-A had recognized a potential risk of R1 getting burned by the heat register, put a sign up on the windowsill in his room and put something in the treatment record but did not notify the nurse manager or administration for proper follow through to protect R1. Administrator stated the expectation was to have all potential safety risks addressed immediately for safety and then passed through the proper channels for follow-up. During an interview on 3/11/24 at 4:11 p.m., CNP-A reported being notified of the incident late morning on 3/1/24 and evaluated R1 later that afternoon. R1 was noted to have very significant blisters that had been partially unroofed [blister popped] already so had to debride them. Further indicated, because of the significance of the blisters and the complexity of R1 medical conditions, consulted with the burn unit and they advised to have him transferred for further evaluation. The facility Safety Policy dated 3/09 indicates their objective to develop and implement a system that will address the following components: management commitment and resident/employee involvement; environment and worksite analysis, hazard prevention and control, and safety and health training. The facility implemented the following corrective actions on 3/1/24: R1's bed moved away from wall; perimeter mattress applied to R1's bed, and therapy screen for input regarding room arrangement and bed mobility. Resident skin checks were completed. All high-risk residents were identified, and rooms rearranged for safety. Staff education on how to identify and report potential behaviors or resident' changes to ensure they're evaluated to reduce safety hazards within the environment and associated resident harm Audits of bed placement implemented. On 3/5/24 and 3/6/24 staff were able to articulate appropriate bed placement and the safety risk heaters pose to residents.

Based on observation, interview, and record review the facility failed to ensure pressure ulcer management and care were provided to prevent deterioration or development of pressure ulcers for 2 of 3 residents (R2, R4) reviewed for pressure ulcers. This resulted in actual harm for R2 when physician ordered treatments were not followed causing deterioration of the ulcer and delayed healing of a Stage 4 pressure ulcer. Findings include: R2's face sheet was dated 9/27/22 identified R2 was admitted to facility May 2022 with a stage 4 pressure ulcer to her left upper buttock, coccyx area. Stage 4 pressure ulcer is defined as full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. R2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's significant change Minimum Data Set (MDS) dated [DATE], indicated that R2 was cognitively intact, required extensive assist of 2 staff for toilet use, and extensive assist of one staff for bed mobility, transfers, walking in room, dressing, personal hygiene, and bathing. R2 had impaired range of motion to lower extremities and frequently incontinent of bladder and bowel. Further, the MDS identified R2 had a stage 4 pressure ulcer. Interventions included: pressure relieving devices on bed and in wheelchair, turning and repositioning program, and received pressure ulcer care. R2 care plan dated 5/7/22, identified R2 had a stage 4 pressure ulcer on her coccyx and was at risk for further pressure ulcers. Interventions included: -Monitor skin daily during cares, weekly skin inspection by nurse, treatment to open areas per orders, weekly measurements, and assessment of wound (start date 5/7/22). -Avoid laying on back, monitor dressing every shift for intactness and adherence. Dressing changes Monday, Wednesday, Friday and PRN if soiled. Monitor/document/ report to MD changes to skin status: appearance, color, wound healing, signs and symptoms of infection, wound size and stage. requires supplemental protein, ensure that resident is repositioned every 2-3 hours from side to side to avoid pressure to coccyx (start date 5/18/22). -Requires a pressure reliving mattress on bed. Interventions included pressure redistribution mattress on bed and cushion in chair, weekly assessment and measurements of wound, and hyperbaric oxygen therapy at wound clinic (start date 6/6/22.) R2's undated admission skin concerns document had an outline of a body with an arrow pointing to the coccyx area. The only information indicated on the form was R2 had pressure ulcer that measured 4.0 x 4.0 centimeters (cm) with tunneling. R2's Initial wound ostomy consultant (WOC) NP-B visit dated 5/13/22 had wound measuring 2.5 x 1.5 x 2.0 cm with tunneling at 9 o'clock position. R2's record identified on 6/9/22, NP-B made a referral for R2 to be seen in the wound clinic for management of the stage 4 pressure ulcer. R2's record further identified between 5/13/22 to 7/15/22, R2 was seen by NP-B weekly for wound debridement and had three times a week dressing changes. The weekly assessments and the Tissue Tolerance Test form dated 7/19/22 identified R2's pressure ulcer was non-healing. R2's record then identified a new order for wound vac on 7/18/22 and first wound clinic appointment was on 7/22/22. R2's progress note dated 6/16/22, indicated R2 had an [CONDITION(S)] infection in her sacral (coccyx)wound. Subsequent lab report dated 7/11/22, continued to have [CONDITION(S)] infection to R2's wound. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -wound vac at 125 mm of mercury (Hg) -remove previous adhesive from skin and cleanse wound with VASHE (wound cleaner) and leave VASHE soaked gauze in wound for 3-5 minutes. Pat dry. Apply skin prep around wound and let dry -cut small strip of white foam to pack into tunnel at 9 o'clock and leave tail out -cut approximately one inch round piece of black foam and pack into wound -take a stoma ring and shape to a circle and place around wound -cut four strips of drape to make a windowpane dressing -change dressing every day shift Monday, Wednesday, and Friday (later changed on 9/7/22 to wound clinic will change dressing on Tuesday's and Friday's at the facility.) During an interview on 9/27/22 at 2:00 p.m. wound clinic registered nurse (RN)-H indicated there were several problems with the facility completing R2's wound vac dressing changes per the physician orders. There were times the facility did not send the correct supplies with R2 for dressing changes and other time when R2 would show up with no dressing at all. RN-H indicated on 8/24/22, R2's treatment orders changed to leave out the white foam, but the facility continued to use it until 9/13/22. RN-H stated there were several phone calls made to the director of nursing (DON) and nursing staff about the dressing change issues. RN-H was not aware of the dates the facility was contacted, but would have been after R2's appointments when an issue was identified. RN-H explained because of the mismanagement by the facility with the three times a week dressing, treatment orders were changed on 9/7/22 to twice weekly with the wound clinic doing one of the dressing changes. RN-H stated the mismanagement slowed down the healing of the R2's ulcer, however after the change there had been improvements to the wound. RN-H stated R2 reported she had no dressing on her wound over this last weekend. R2's Wound clinic visit notes identified the following: -7/22/22, initial visit, unable to do wound vac dressing as proper dressing supplies not sent from facility. Wound measurements were 3.0 x 2.8 x 2.5 cm. Order written for position changes every 1-2 hours. R2's care plan was not revised to reflect 1-2 hour reposition schedule. -8/12/22 wound vac falling off due to large amount of stool under the tape and in the foam and being pulled into the wound vac through the tubing, measurements 3.7 x 2.5 x 2.5 cm. -8/24/22, wound vac not able to be used last several days due to staffing at nursing home, measurements 3.0 x 4.0 x 2.2 cm. -8/31/22, nursing home staff still having issues with getting VAC replaced. Wound clinic has communicated with nursing home multiple times. Wound clinic now to change on days that she sees the provider, once weekly. Wound vac not in place for several days. Measurements 2.8 x 4.5 x 2.2 cm. -9/7/22, dressing changes continue to be an issue with nursing home. Changed dressing to Tuesdays and Fridays, with Tuesdays dressing done at the wound clinic. Did not send the dressing supplies for dressing change. Measurements 3.0 x 3.3 x 2.5 cm. -9/13/22, came in with white foam only in, which was discontinued on 8/24/22. R2 stated she didn't think that dressing had been changed since 9/7/22 until 9/12/22. Measurements 2.1 x 3.3 x 1.5 cm. Wound Vac dressing changes moved to Tuesdays and Fridays. R2's care plan was not revised to reflect the change to appointments. -9/20/22, no wound vac supplies were sent with R2 to appointment. Measurements 2.5 x 4 x 1.5 cm. -9/27/22, arrived with stool in VAC. Measurements 2.2 x 2.5 x 1.5 cm. During an observation on 9/27/22, at 9:40 a.m. R2 laid in her bed, nursing assistant (NA)-D was assisting R2 with personal morning hygiene cares. NA-D assisted R2 to roll to her left side, NA-D removed the incontinent garment. The wound vac dressing was clean and appropriately placed on R2's coccyx. The wound vac settings were also observed to be correct according to physician order. During an interview on 9/27/22, at 10:00 a.m. R2 stated she received hyperbaric oxygen therapy five days a week. R2 indicated she was able to make slight position changes alone however needed assistance from staff to make major changes. R2 indicated staff did not come to assist her with position changes every 1-2 hours and she usually had to call for them to help her reposition. R2 stated she had pain during the dressing changes, would ask for medications, but did not always receive them. During an interview on 9/26/22, at 4:20 p.m. RN-B articulated R2 was seen by the wound clinic for dressing changes on Tuesday's and on Friday's the wound vac dressing was changed by the facility staff. RN-B indicated they were unaware of any concerns pertaining to the wound vac dressing changes done by the facility. RN-B further indicated nursing would notify the DON first then RN-B if there had been any issues. Attempt was made to contact R2's physician on 9/27/22 at 2:00 p.m., a return call was not received. During an interview on 9/27/22, at 4:20 p.m. director of nursing (DON) stated it was expected wound cares were completed as ordered by NP or physician. DON indicated the facility licensed staff did wound vac training about a year to year and half ago and had two nurses who were very proficient. DON stated she had become aware the wrong dressings were being used about two weeks ago. The right order was put into the computer and the white foam dressing were removed from R2's room. Even though the wound clinic notes in the R2's record identified from 7/22/22 to 9/27/22 indicated ongoing issues with the wound vac such as the wrong dressing was applied, fecal matter in the wound vac, foam dressing was pulled in through the tubing, and the wound vac was not in place. R4 R4's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R4's Braden assessment (risk assessment for development of PU) dated 8/5/22, identified R3 was at mild risk for developing pressure ulcers. R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated that R2 was cognitively intact, required extensive assist of two staff for bed mobility and transfers, extensive assist of one staff for dressing, toilet use, personal hygiene. The MDS identified R4 was occasionally incontinent of bladder and frequently incontinent of bowel. R2 was at risk for pressure ulcers and had moisture associated skin damage (MASD). R4 required pressure reducing device on bed and wheelchair and received non-surgical dressing changes with ointments/medication applied to other areas besides feet. R4's tissue tolerance test (TTT- the ability of the skin and its supporting structures to endure the effects of pressure, without adverse effects) assessment dated [DATE] identified R4 was able to make major position changes himself but did not always do so. The form identified staff were to prompt R4 to turn and reposition every 2-3 hours and as needed and encourage R4 to get up in wheelchair. Review of R4's care plan dated 4/7/21, indicated that R4 had an alteration skin integrity; with open area to right lower leg and history of lower leg ulcer. History of refusing cream for dry skin and liquid protein supplement. Interventions included: -Monitor skin for breakdown and signs/symptoms of infection and report to physician -Document on skin condition and keep physician informed of changes -Monitor skin integrity daily during cares, weekly skin inspection by nurse -Risk and benefits completed for refusal of turning and repositioning (dated 4/20/21), -Prompt to turn and reposition every 2-3 hours and PRN and assist as needed (dated 4/7/21) Review of R4's weekly skin inspections and notes from NP-B from 8/22/22 through 9/22/22 identified R4 had developed a deep tissue pressure injury to buttocks. -Weekly skin inspection dated 8/22/22, indicated R4 had a 1.0 x 1.5 centimeter (cm) on his left buttock that was deep red to purple in color that was not open. Ointment applied, pillows placed under hips, and weight offloaded. -Physician visit dated 8/25/22, nurse practitioner (NP)-B identified left buttock deep tissue injury measuring 1.0 x 1.5 x 0 cm. (Deep tissue injury is defined as intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface) The note directed staff to monitor for friction during repositioning and to to keep clean and dry due to incontinence. Treatment order: cleans, pat dry, and apply Calmoseptime (ointment to prevent and heal skin irritations) to area twice daily and as needed. -Weekly pressure wound note dated 9/2/22, NP-B identified left buttock was healed and closed. Continue treatment. -Weekly skin inspection dated 9/22/22 indicated no skin concerns. R4's record lacked weekly monitoring of the skin to ensure the area remained healed. R4's record lacked a comprehensive pressure ulcer assessment that identified risk factors including decreased mobility, medication that impaired healing, co-morbities, refusals/rejection of care and treatment, cognitive status, incontinence status, nutrition and hydration, and pressure points for turning and reposition needs. Continuous observation on 9/27/22 that started at 10:20 a.m. and ended 1:20 p.m. identified R3 was not turned/repositioned for almost 3 hours with a resulting red area on his right hip. -At 10:20 a.m. R4 was laid in his bed on his right side with his call light within reach. Head of bed elevated to approximately 60 degrees. -At 10:35 a.m. R4 continued to lay in the same position. -At 11:05 a.m. R4 put his call light on. Nursing assistant (NA)-C entered R4's room, emptied the urinal, and provided gave R4 a pack of crackers. NA-C did not offer or encourage R4 to change positions. -At 11:20 a.m. R4 continued to lay in the same position. -At 11:35 a.m. R4 continued to lay in the same position as he talked on his cell phone. -At 11:44 a.m. R4 continued to lay in the same position on his right side. NA-D entered R4's room and emptied R4's urinal. NA-D did not prompt, offer, or encourage R4 to reposition -At 12:00 p.m. unknown housekeeper entered R4's room. R4 conversed with the housekeeper while remaining on his right side. Between 12:01 p.m. and 12:27 p.m. R4 continued to lay on his right side in the same position. -At 12:27 p.m. NA-D took lunch tray into R4's room and placed the tray on the bedside table. NA-D asked R4 if he needed anything else. After R4 stated no, NA-D left the room without attempting or offering to reposition R4 off his right side. R4 laid on his right side while eating his lunch. -At 12:45 p.m. R4 was done eating his lunch. At 12:55 p.m. unknown kitchen staff member entered R4's room and removed the tray. -At 1:15 p.m. NA-D was not aware of when R4 had last been repositioned. NA-D entered R4's room, NA-D asked R4 to reposition to his back which he was able to do. NA-D pulled the pillow out from right hip area. R4's right hip had a red area the size of a softball. The red area had indentations about 1/4 inch deep where he had been laying on the wrinkles of his bedding. During an interview on 9/26/22, at 1:05 p.m. R4 stated he did not think he had been out of bed in the past year because he had bad hips and knees that were painful. R4 indicated he laid on his right side because his left hip and knee hurt worse than the right. R4 stated he was able to turn himself with the assist of the positioning bar over his bed. R4 stated that he has had open areas on his bottom in the past, but did not think he had any open areas currently. R4 indicated that staff did not prompt or remind him to reposition, he would use the positioning bar when he wanted to move. During an interview on 9/27/22, at 11:08 a.m. NA-C stated staff would wash R4 up daily, turn and reposition him every two hours, and empty his urinal. NA-C indicated R4 would sometimes refuse cares but staff would go back and re-approach. During an interview on 9/27/22, at 11:45 a.m. NA-D stated R4 was supposed to be repositioned every two to three hours. NA-D stated sometimes they would put calmoseptime lotion on his bottom; he did not have any open areas. During an interview on 9/27/22, at 3:40 p.m. licensed practical nurse (LPN)-A indicated R4 was at risk for pressure ulcers. R4 sometimes refused cares, but staff would go back and re-approach R4. LPN-A stated R4 usually would allow staff to perform tasks o the second approach. LPN-A indicated refusals were supposed to be documented. During an interview on 9/28/22, at 1:30 p.m. RN-B indicated a tissue tolerance test was completed on R4 today; RN-B indicated the reddened area to R4's right hip had resolved since identified yesterday (9/27/22). During an interview on 9/27/22, at 4:00 p.m. director of nursing (DON) reviewed R4's record and verified that R4 was missing some weekly skin assessments. It was her expectation that they were completed. DON also indicated that she usually reviews the weekly skin inspection documentation weekly but did not keep a record of her audits. When asked about how they get the time frame for repositioning DON stated from the Tissue Tolerance Test (TTT) done yearly. DON stated that R4 was already on an air mattress and that R4 did not always cooperate with his cares, but expected staff to attempt and document refusals. Facility policy Skin Assessment and Wound Management policy dated 5/27/22, included 5) a weekly skin inspection will be completed by licensed staff. Pressure Wounds, New Skin Problem: when a pressure ulcer is identified, the following actions will be taken; 1) notify MD/treatment ordered, 3) complete education with resident/resident representative including risks and benefits, 4) initiate weekly pressure wound evaluation, update care plan. The policy did not address modality's for pressure ulcer prevention, did not addressing identification or staging, following physician orders, wound vacs, nor direction for completing comprehensive assessments.

Based on interview and documentation review, the facility failed to provide adequate supervision for 1 of 6 residents (R1) who required 24 hour care/supervision resulting in R1 eloping from the facility when the door safety alarm did not sound. This failure resulted in an immediate jeopardy (IJ) when R1 propelled self 0.2 miles away from the facility, alone. The IJ began on 11/15/20, when housekeeper (HK)-A mistakenly disarmed the alarmed door and R1 eloped from facility in a wheelchair crossing a city street, a railroad track, and a major highway before being located at a local gas station by police. The administrator, director of nursing (DON), and regional director of operations were notified of the immediate jeopardy at 12:10 p.m. on 12/1/20. However, the facility had implemented several action plans including conducting a thorough investigation, placing R1 on 1:1 supervision, checking all residents with a wanderguard and its functionality, auditing of doors that have alarms, educating all staff on the elopement policy and door alarm activation/deactivation. The IJ was corrected as of 11/16/20, and issued at past non-compliance. Findings include: R1's Minimum Data Set ((MDS) dated [DATE], indicated R1 had severe cognitive impairment and required extensive assistance with transfers and activities of daily living. R1's care plan revised 11/17/20, indicated R1's [DIAGNOSES REDACTED]. The care plan also indicated R1 was at risk for falls, had a self-care deficit and was at risk for elopement due to a history of attempts to exit the building. R1's elopement risk evaluation dated 11/15/20, indicated R1 was at risk for elopement. R1's brief interview for mental status dated 11/5/20, rated R1 as having severe cognitive impairment. The facility investigation report dated 11/20/20, indicated on 11/15/20, at approximately 5:55 p.m. R1 left the building out of an unarmed door at the end of lane 1. A missing person code was called and staff swept the facility and the outside perimeter with no sign of R1. Registered nurse (RN)-A called 911 at which time the police informed RN-A that at 6:09 p.m., R1 was at the gas station across the street, 0.2 miles away from the facility. R1 was wearing a jacket, footwear, and sweat pants. R1 was returned to the facility and placed on 1:1 monitoring. Skin check performed with no new concerns. MD and R1's spouse were notified. Staff education initiated. All code alerts checked for placement and function. Door arming verification. A written facility interview with HK-A dated 11/16/20, read: I did see hear (R1) set the alarm off on Sunday. I went over to the door and saw it wasn't locked. I used my key and turned the red sign over. I locked it and left. I have a key on my chain all housekeeping employee's do. Following this interview, staff were educated that when HK-A turned the key, it did not lock the door rather disarmed the safety alarm. Turning the key does not lock the door from the inside out rather locked the door from the outside in. HK-A was educated and directed to alert a nurse if a door setting needed to be changed. R1's progress noted dated 11/15/20, at 1:51 p.m. indicated R1 had made two attempts to exit the building through the north and south exit doors earlier in the day. The alarms did sound and R1 was returned to the facility day area. Staff attempted to sit with R1, offered activities and attempted to call R1's wife. However, R1 was still agitated and was administered as needed [MEDICATION NAME] (antipsychotic). During interview on 11/30/20, at 12:32 p.m. nursing assistant-B stated R1's safety was at risk if he eloped from the facility due to the potential for tipping over in his wheelchair and getting hurt. NA-B verified R1 had attempted to exit the facility doors in the past, but he had never actually gotten out of the facility until the event on 11/15/20. During interview on 11/30/20, at 12:46 p.m. the environmental service director (ESD) verified he was aware of R1's elopement and stated one of his staff had unintentionally disarmed the exit door when she thought she had locked it. The ESD was unsure as to what time of the day HK-A had disarmed the door. During interview on 11/30/20, at 1:12 p.m. HK-A verified R1 had attempted to elope from the facility earlier in the day, and stated, I made a big mistake when she had mistakenly turned off the safety alarm to the exit door on lane 1 when she thought she had locked it. HK-A stated following this discovery, she had received education on the door's safety alarm mechanism and how it works and also directed to inform a nurse whenever an alarm needs to be turned off or to ensure activation. HK-A verbalized the importance of maintaining the safety alarm's functionality in order to ensure resident safety. During interview on 11/30/20, at 1:47 p.m. family member (FM)-A stated the facility staff had notified her that R1 had eloped from facility through an unlocked door and was found at a gas station, without any injuries. FM-A stated she had called the facility back to find out more information about the incident and was told R1 was receiving 1:1 supervision. FM-A added, R1 was at risk when out of the facility on his own, therefore she had been in the process of getting R1 into a more secured facility. During interview on 11/30/20, at 2:29 p.m. with the administrator and DON, the administrator stated she had reviewed camera footage and was able to develop a time line of the incident. The administrator stated R1 exited facility at 5:48 p.m. and just prior to exiting the building, R1 had been at the nurse's cart with RN-A. When RN-A entered a room, R1 wheeled himself to the end of the hall and exited the building without the alarm sounding. The administrator stated about three minutes later, RN-A exited the room she had been in and began looking for R1. When R1 was unable to be found, RN-A called the police and was informed R1 was located at a local gas station. The administrator stated in order for R1 to get to the gas station, he had to have first crossed St.(NAME)Avenue and then highway 12. The DON stated R1 often looked for his previous boss. The administrator verified R1 was at risk when out in the community, alone. The administrator and DON stated following the incident, R1 was placed on 1:1 supervision for a week followed by every 15 minute checks, then every 30 minutes checks and all the staff were immediately trained on the functionality of the door safety alarms and elopements. In addition, all residents at risk for elopement were checked for wanderguard placement and functionality and all door alarms were also audited for proper functioning. The administrator verified it was important for the door alarms to be functioning properly in order to alert the staff of any elopement attempts. The DON and administrator stated since the incident, R1 had made no further attempts to elope from the facility. During interview on 11/30/20, at 3:04 p.m. RN-A stated R1 often roamed throughout the facility and in/out of other resident rooms. RN-A stated on 11/15/20, prior to R1 eloping, he had been agitated and attempted to leave the facility earlier in the day and was administered [MEDICATION NAME] for the agitation. Just before the elopement, RN-A stated R1 was by her side as she passed medications and when she went into a room at approximately 5:50 p.m., and exited the room about five minutes later, R1 was gone. RN-A stated no alarms had sounded. RN-A immediately alerted the staff and all began searching for him inside the facility as well as facility grounds, but were unable to locate R1. RN-A called 911 to report R1 missing and was informed 6:09 p.m. that R1 was at a local gas station. RN-A stated R1 had cognitive impairment and was at risk when out in the community, alone. RN-A stated that earlier in the day when R1 attempted to elope, the alarm had sounded therefore the door alarm was not rechecked for functionality, prior to R1's actual elopement. During interview on 11/30/20, at 4:19 p.m. the ESD verified HK-A had not been educated on the door alarms functionality prior to R1's elopement, but was educated following the incident. The ESD stated he was not sure why housekeeping staff even had key access to the alarms. During interview on 12/1/20, at 10:10 a.m. the administrator stated as of 11/16/20, all employees were educated on elopement and the alarming/disarming of the exit doors. When asked, the administered verified the railroad tracks that R1 had crossed are still active tracks for the railroad. During interview on 12/1/20, at 11:02 a.m. licensed practical nurse (LPN)-A verified that after R1 had eloped from the facility, she had received training on resident elopements door alarms. LPN-A stated nurses are now the only staff that can disarm a door alarm. During interview on 12/1/20, at 11:03 a.m. health unit coordinator verified she had received education regarding elopement protocol and how to check door alarms to ensure they are activated/turned on and that the night shift nurse checks the alarms every night to make sure they are working. During interview on 12/1/20, at 11:05 a.m. nursing assistant (NA)-A verified the facility had provided education on the proper elopement procedure and how to make sure the door safety alarms remained activated. During interview on 12/1/20, at 11:10 a.m. HK-B verified the facility retrained all staff on elopement procedures and door alarm functionality. HK-B stated she was responsible to clean the exit doors therefore she had a key to the doors/alarms and was trained about [AGE] years ago on how to properly activate and deactivate the door alarms. HK-B stated it was important to make sure the alarms remained activated in order to prevent the at risk residents from eloping from the facility. During interview on 12/1/20, at 11:15 a.m. dietary aide (DA)-A verified she was recently trained on facility elopement procedures and the door alarms. DA-AD stated if the dietary staff witnessed a resident attempting to leave the facility, they were to stay with the resident and summon for a nurse. During interview on 12/1/20, at 11:35 a.m. the certified occupational therapy assistant (COTA) stated about 1-2 weeks ago, the facility had trained all staff about elopements and the functionality of exit door alarms. During interview on 12/1/20, at 2:20 p.m. the medical director stated R1 had dementia, but was able to accurately answer some questions and at times, knew right from wrong. However, the medical director stated R1 was not safe to be out in the community alone and especially now with the cold weather. The facility's Elopement Guideline policy dated 11/17 indicated a specific system had been developed to notify staff that an external door had been opened in an area accessible to residents. Only the Administrator (or designee) may authorize the disabling of the alarm system and was responsible for the method of monitoring for residents' safety and resetting the alarm and the charge nurse or designee would test resident personal alarms/devices according to the manufacturer's recommendations. The past non-compliance IJ which began on 11/15/20, was removed prior to the abbreviated survey due to multiple action(s) taken by the facility to correct the identified non-compliance. These actions included conducting a thorough investigation, identifying the root cause, placing R1 on 1:1 supervision, checking all residents with a wanderguard and its functioning, auditing all doors with alarms, educating all staff on the elopement policy and procedures and door alarm activation/deactivation. As a result, the IJ was removed and the identified non-compliance was corrected as of 11/16/20.

Based on observation, interview and document review, the facility failed to implement proper infection control processes including: implementation of contact precautions, analysis of culture results to ensure appropriate treatment and precaution interventions, utilization of appropriate cleaning agents to sanitize resident areas and equipment to prevent and control transmission of highly infectious multi drug resistant organisms (MDRO) extended spectrum beta-lactamases (ESBL) and a highly infectious spore forming bacterium ([MEDICAL CONDITION], otherwise known as [DIAGNOSES REDACTED].) resulting in 6 of 59 residents (R53, R30, R46, R7, R23, R204) diagnosed with [REDACTED]. Diff of which two residents had precautions delayed in implementation by 38 days (R53) and 30 days (R7) who were diagnosed with [REDACTED]. These failures resulted in an Immediate Jeopardy (IJ) with the potential for serious harm, injury, or death for the 12 of 59 residents who resided at the facility. In addition to the resident(s) in immediate jeopardy, the facility failed to implement timely tracking and trending of infections, appropriate laundry practices and ensure hand hygiene was maintained resulting in the potential for harm that is not immediate jeopardy for 3 of 59 residents (R155, R18, R306). The Immediate Jeopardy (IJ) began on [DATE], when the facility failed to verify results of a urine culture for R53 that had been collected two days prior. R53 was determined to have ESBL in the urine and no contact precautions were implemented. The director of nursing (DON) and the administrator were notified of the immediate jeopardy on [DATE] at 4:45 p.m. The IJ was removed on [DATE], but non-compliance remained at the lower scope and severity of G, isolated with actual harm occurring to R205 who had ESBL and died from urosepsis. Findings include: R204's quarterly Minimum Data Set ((MDS) dated [DATE], indicated the resident had intact cognition and required extensive assistance of two staff to complete activities of daily living (ADL's) including dressing, grooming, and mobility. The MDS indicated R204 had an indwelling catheter. The MDS also indicated R204's medical [DIAGNOSES REDACTED]. In addition, the resident's current progress notes indicated R204 was currently on contact precautions due to a [DIAGNOSES REDACTED]. Diff). R53's quarterly MDS dated [DATE], indicated R53 was cognitively intact and required extensive assistance of two staff to complete ADL's. The MDS indicated R53 was continent of bladder with occasional incontinence of bowel and indicated R53's medical [DIAGNOSES REDACTED]. R53's progress notes indicated R53 contact precautions had been implemented for a [DIAGNOSES REDACTED]. R30's quarterly MDS dated [DATE], identified the resident as having moderate cognitive impairment requiring extensive assistance of one with dressing, grooming and toileting. The MDS also indicated R30 was occasionally incontinent of bladder and bowel and identified [DIAGNOSES REDACTED]. R30 was on contact precautions for ESBL in the urine identified [DATE]. R7's quarterly MDS dated [DATE], indicated R7 was cognitively intact and required extensive assistance from two staff for dressing, grooming, toileting and mobility. The MDS identified R7 was incontinent of bowel and bladder and was not on a toileting program. The MDS identified [DIAGNOSES REDACTED]. R7 was placed on contact precautions for ESBL in the urine on [DATE], 28 days after diagnosis. R46's quarterly MDS dated [DATE], indicated R46 was cognitively intact and required extensive assitance of one to complete ADLs including dressing, grooming, and mobility. The MDS indicated R46 had an indwelling urinary catheter and was incontinent of bowel. The MDS identified [DIAGNOSES REDACTED]. The MDS also indicated R46 had a history of [REDACTED]. R46 was on contact precautions for ESBL in the urine identified with a urine culture of [DATE]. R205's quarterly MDS dated [DATE], indicated R205 was cognitively intact and received extensive assistance with ADLs including dressing, grooming, and mobility. The MDS identified R205 was occasionally incontinent of bladder and identified [DIAGNOSES REDACTED]. The facility's infection control logs indicated R205 was treated with an antibiotic for a UTI ,[DATE]-[DATE] at the facility, and was transfered to the hospital [DATE]. R23's admission MDS identified cognitive impairment and need for extensive assistance with dressing, grooming, toileting, and mobility. The MDS identified R23's medical [DIAGNOSES REDACTED]. The facility's infection control logs indicated R23 had been admitted to the facility [DATE] with [MEDICAL CONDITION], requiring contact precautions. In addition, the log indicated the resident was treated for [REDACTED]. On [DATE], at 12:47 p.m. a pocket style supply unit, with signage, was observed on R30's room door indicating: Contact Precautions. The pocket unit contained yellow disposable gowns, gloves, and a gold topped SaniWipes container. On [DATE] at 12:53 p.m. a pocket style Contract Precautions unit was observed on the door of R204's room. At that time, housekeeper (HK)-A stated R204 was on contact precautions for [MEDICAL CONDITION] and bleach was used for cleaning everything in the resident's room. HK-A stated staff were to wear a gown and gloves at all times when in the room. HK-A stated new mop heads were applied when entering R204's room, and were placed into a yellow linen bag to bring to laundry once the room had been cleaned. HK-A stated red bags are used for garbage. HK-A stated the room was cleaned twice a day. On [DATE], at 1:14 p.m. HK-A was observed in the entryway of R30's room where she donned a disposable gown and gloves before she entered. HK-A then placed a fresh mop head on the mop and entered the room to clean. Upon completion of mopping the floor, HK-A exited the room, went to the housekeeping cart, and obtained a toilet bowl brush, and the container it was stored in, and returned to the room. From outside the room, HK-A could be heard cleaning the toilet bowl with a brush. HK-A was observed wiping down surfaces in the room with white disposable cloths, which HK-A stated were bleach wipes. As HK-A exited the room, she took the toilet bowl brush in it's container from the room and placed it on the top of her cart. HK-A stated she had cleaned the toilet bowl with toilet bowl cleaner and had used no special solution. HK-A stated she had used bleach in the mop water. HK-A removed the soiled mop head from the mop and placed it in a bag to take to laundry. HK-A then placed a new mop head on the mop. HK-A proceeded to take the toilet brush in it's container from the top of the cleaning cart and placed in R30's room on the floor of the closet. HK-A stated You would think the brush should be kept in the room, and verified there had been no toilet bowel brush in the room when she went in to clean. HK-A stated R30 had been on contact precautions for a long time, but was unable to specify when the precautions had been implemented. On [DATE], at 1:42 p.m. R23 was also observed to have a contact precautions hanging supply unit on the outside of door to her room. On [DATE], at 1:44 p.m. HK-A was observed dressed in a yellow disposable gown, wearing gloves while cleaning R204's room. HK-A requested a toilet bowl brush and container from HK-B for R204's room as there was no toilet bowl brush in the room. HK-B stated a supply of toilet bowl brushes and containers were kept in each janitor's closet and were replaced frequently. HK-B stated the [DIAGNOSES REDACTED] toilets were cleaned with bleach. HK-B obtained a new toilet bowl brush and container and provided it to HK-A. On [DATE], at 3:14 p.m. licensed practical nurse (LPN)-D stated R23 and R204 were on infection control precautions related to active [DIAGNOSES REDACTED]. LPN-D stated people entering the room were required to gown and glove. Upon exiting the room, LPN-D stated staff were to remove and dispose of the gown and gloves in the red bag in the resident's room. LPN-D stated staff were then to wash their hands with soap and water, as the alcohol hand sanitizer was not effective against [DIAGNOSES REDACTED]. Additionally, LPN-D stated prior to exiting the room, staff were to wipe off the bottom of their shoes with bleach wipes, disposing of them appropriately. On [DATE], at 6:56 p.m. R204 stated the toilet bowl brush and container were not currently in his room and were not routinely kept there. R204 stated the staff generally kept the toilet bowl brush and container on their cleaning cart. On [DATE], at 9:50 a.m. R53 was observed being moved from a double bed to a room across the hall where she would not have a roommate. At 10:09 a.m. LPN-E stated R53 was identified as having ESBL in her urine culture when reviewing information on the infection control logs. LPN-E stated she was unsure when the culture had been completed, but would follow up to determine the exact date. At 10:21 a.m., LPN-E reported the urine culture had been sent in (MONTH) and they had just received the results this morning. LPN-E confirmed if results were not recieved from the lab, staff were supposed to call and follow up. LPN-E was unsure as to the time frame recommended for follow up but stated, any nurse can call and follow up. LPN-E stated R53 had been treated with antibiotics in (MONTH) for a urinary tract infection, however, LPN-E was uncertain if the organism was sensitive to the antibiotic used. LPN-E stated if a resident was started on an antibiotic before the culture was received, staff should have followed up on the culture to ensure the correct antibiotic was ordered. On [DATE], at 1:41 p.m. HK-C stated when a room had contact precautions in place, she put on a disposable gown, and wore two pairs of gloves as an additional precaution. HK-C stated she also applied a mask due to the use of the cleaners. HK-C stated the chemicals were in the containers for washing the floor. HK-C stated she changed out the mop head before going to other rooms and stated the room was wiped down with SaniWipes from the gold top containers. HK-C stated the mop head was changed prior to going into other rooms, as well as completion of a change of water and cleaning solution. HK-C stated the garbage was disposed of in the red bags in the room, and the laundry was to be placed in the yellow bags in the room. HK-A stated she cleaned all of the furniture with alcohol. HK-C stated she also cleaned the walls with the alcohol and disposable cloths (from the gold topped SaniWipes container). HK-C stated not all resident's on contact precautions have the same problem. HK-C stated the director of nursing (DON) had instructed her to double bag for both clothing and garbage. On [DATE], at 2:05 p.m. nursing assistant (NA)-A stated when a resident was on contact precautions staff were to put on disposable gowns and gloves before they enter the room. NA-A stated the gowns and gloves were carefully removed and disposed of prior to exiting the room, and handwashing was completed with the use of soap and water. NA-A stated staff wiped down the bottom of their shoes with SaniWipes from the gold topped container before they left the room. NA-A stated when staff had used equipment, such as the mechanical lifts, for the residents who had contact precautions, the equipment was supposed to be wiped down with SaniWipes from the purple topped container before they exited the room. NA-A stated R30 had been on contact precautions for several months, as had R23. NA-A stated R204 had been on precautions for a period of time also. NA-A stated R53 had just been placed on precautions that day. On [DATE], at 2:12 p.m. NA-C reviewed the procedure for contact precautions and stated the supplies used were kept on the door caddy/pocket style contact precautions unit. NA-C stated the SaniWipes with the gold tops were to be used as they were bleach based. NA-C stated if a lift was used in a room where contact precautions were in place, staff were to clean the lift with the gold top (bleach) SaniWipes prior to exiting the room. NA-C stated the cleaning was done the same for both [DIAGNOSES REDACTED] and ESBL. NA-C confirmed R53's precautions had just been implemented that morning for an organism in her urine. On [DATE], at 2:23 p.m. NA-G stated R7 and R46 were on contact precautions due to ESBL. NA-G stated R46 had been on precautions for a longer period of time (unsure if weeks or months), and R7's contact precautions had been implemented on [DATE]. NA-G stated staff were to gown and glove while providing care and were to remove the gown and gloves and dispose of them in the room before exiting. NA-G stated hands were to be washed prior to exiting the room. NA-G stated when a lift was used, it was to be wiped down with bleach wipes before exiting the room. On [DATE], at 2:43 p.m. registered nurse (RN)-B stated R53 had been started on infection control precautions after having been diagnosed with [REDACTED]. RN-B stated R7 had just been started on contact precautions on [DATE] or [DATE], for ESBL. RN-B stated infection control precautions implemented were dependent on what organism was identified. RN-B stated interventions were put in place to protect those residents who don't have the infection, including those in shared rooms. RN-B stated contact precautions implemented with ESBL included use of disposable gowns and gloves. RN-B stated resident rooms were cleaned by the housekeeping staff, and indicated the housekeeping staff were also responsible for cleaning the mechanical lifts. RN-B stated nursing staff were to clean the patient lifts if they brought them in and out of the room. RN-B stated staff were to use the purple topped SaniWipes to clean the lifts. RN-B stated she was unsure as to what the gold topped SaniWipes were used for. RN-B then obtained the products for reference and identified the gold top SaniWipes were effective for both [DIAGNOSES REDACTED] and ESBL. On [DATE], at 3:07 p.m. LPN-A stated R7 and R53 were started on contact precautions that day. LPN-A stated neither resident had an active infection at this time however, when infected with ESBL, residents were placed on long term precautions. On [DATE], at 3:32 p.m. LPN-E stated R53 was diagnosed with [REDACTED]. LPN-E stated contact precautions had just been implemented for R7 on [DATE]. LPN-E stated the purpose of infection control precautions was to keep staff, residents, and other visitors safe. LPN-E stated everyone entering the rooms were to use gowns and gloves when in the room. On [DATE], at 3:42 p.m. the DON stated stated she had not been informed of the positive culture reports for R7 and R53 for ESBL on the fourth and the fourteenth of (MONTH) respectively. The DON confirmed when infection control precautions were not implemented appropriately and/or in a timely manner, infection could spread. The DON stated, I would say it has spread. The DON stated part of the infection control process included periodic monitoring of staff performance through audits to ensure proper hand hygiene, gowning and gloving was performed by staff. However, the DON stated no such audits had been implemented at this time. The DON also stated family and visitors of residents who required precautions needed to be educated as to the precautions they should follow. The DON stated she had updated R53's spouse regarding precautions to take. The DON stated if staff expected to handle any infected materials, they should gown and glove. Further, the DON stated, Upon completion of cares, staff are to remove their gown and gloves and dispose of them. They should perform handwashing with soap and water, and clean their shoes off with disinfecting wipes. The DON stated staff would use regular disinfectant (the purple top) for ESBL and staff were to use the bleach ones (gold top) for [DIAGNOSES REDACTED] . The DON stated any equipment brought in and out of infected resident's rooms needed to be cleaned with the appropriate wipes. The DON stated the purple top SaniWipes would not be effective if used for residents with [DIAGNOSES REDACTED]. The DON stated daily cleaning was conducted for resident rooms where residents have [DIAGNOSES REDACTED]., and housekeeping uses bleach. The DON stated cleaning for resident's rooms where the resident has ESBL could be achieved with regular disinfectants. On [DATE], at 9:30 a.m. HK(s)-A and B were at the housekeeping cart. HK-B stated bleach was not used in the cleaning process and stated the products currently used for floor care included a P&G (Proctor and Gamble) Proline Disinfecting Floor Cleaner II and Mr Clean Professional Finished Floor Cleaner. The products were observed in the janitor's supply closet and the materiel safety data sheets were viewed. The janitor's closet did not contain any liquid bleach and HK-A stated she used the Mr Clean Professional Finished Floor Cleaner in the mop water for all rooms, including those on infection control precautions. HK-B stated staff currently used Comet Sanitizing Spray for cleaning the surfaces in the rooms. HK-B stated although there was a Comet Sanitizing Solution which had bleach, they were currently using the product without bleach. On [DATE], at 8:42 a.m. HK-D stated she currently used the PG Professional Disinfectant Floor Cleaner II for resident rooms when the residents were on infection control precautions, otherwise HK-D stated she used MR Clean Finished Floor Cleaner. HK-D stated she had not been instructed to use any other products for cleaning which included bleach products. On [DATE], at 8:55 a.m. the Environmental Service Director (ESD) provided the production sheet for the PG Professional Disinfectant Floor Cleaner II which indicated it was effective to use when cleaning rooms with ESBL however, the product was not indicated for use when a resident was infected with [DIAGNOSES REDACTED]. The ESD did not have a technical bulletin for the MR Clean Professional Floor Cleaner. On [DATE], at 2:04 p.m. NA-F was observed during provision of cares with R27. NA-F was observed to lock R27's wheelchair and swing away the foot rests after placing R27's feet on the floor. NA-F provided step by step direction as she applied a lift harness. The standing lift was moved into place and R27 was assisted to a standing position and into the bathroom. Once in the bathroom, NA-F assisted with clothing adjustment and pulling down of incontinence product without applying gloves. R27 was assisted into a seated position onto the toilet with lowering of the lift. Once R27 was seated, NA-F put on gloves without performing hand hygiene. NA-F obtained incontinence wipes and placed them on the back of the toilet. R27 was assisted into a standing position and was provided with assistance to complete incontinence cares with the use of wipes. NA-F then removed gloves and assisted R27 into an upright position. NA-F did not wash hands or apply gloves. NA-F then applied a clean incontinence brief and pulled up R27's slacks. R27 was assisted from the bathroom to the bed with the use of the standing lift. Once R27 was seated on the bed, NA-F removed the harness and removed the lift. NA-F assisted R27 to pivot on the bed and assisted her to a laying position. NA-F then assisted R27 to position in bed with pillow placement, shoes removed, and applied a blanket. NA-F moved the lift to the doorway of the room and proceeded to the bathroom to wash hands. NA-F washed her hands using good scrubbing techniques and dried thoroughly with paper towels. After drying her hands, NA-F turned off the faucet with a paper towel. NA-F removed the lift from the room and placed it near the soiled utility room. NA-F stated R27 had been incontinent of urine and she should have applied gloves prior to removing brief and stated handwashing should have been performed immediately after removing her gloves. NA-F stated resident lifts were wiped down at the beginning and the end of each shift, or in between if a lift became visibly soiled, or if a staff person's hands were visibly soiled prior to handling the lift. NA-F stated she was unaware of any other requirement for cleaning the lifts. On [DATE], at 2:26 p.m. NA-A was observed to assist R23 to the toilet. NA-A stated R23 continued to have loose stools. NA-A was observed to wear a disposable gown and gloves. When R23 indicated he was done on the toilet, R23 was assisted to a standing position and was assisted with wiping. R23 stated he was becoming weak and was observed to start attempting to sit down on the toilet and was assisted to sit down. NA-A removed soiled gloves, washed and dried hands and applied new gloves. R23 was again assisted to stand and cares were completed. R23 was then assisted to his wheelchair. NA-A gathered garbage which went into the bag in the room. NA-A then wiped off the bottom of her shoes with a bleach wipe and removed gloves by holding the edge cuff and rolling it into the second glove. NA-F removed the disposable gown, rolling it into itself and disposing into the bagged receptacle in the room. NA-F performed hand hygiene then turned off the faucet with her ungloved hand. NA-A stated she should have turned off the faucet with a paper towel. INFECTION CONTROL TRACKING AND TRENDING: On [DATE], at 3:43 p.m. the facility provided policies for the Infection Prevention and Control program, antibiotic stewardship program, and the initial logs for February. The DON stated she was awaiting additional information before she was able to provide the logs for November, (MONTH) and January. The DON provided the logs for November, December, and (MONTH) at approximately 7:00 p.m. This information included the Monthly Resident Infection Statistics, Monthly Employee Health Statistics, Resident Monthly Summary, employee illness log, Employee Health Statistics and included the Meeker Manor facility map with color coded indications. A review of the facility log titled Monthly Resident Infection Statistics revealed: (MONTH) (YEAR). The information logged include; Type of infection/infection site; Symptoms; Onset date; McGeer Criteria met: yes/no; Facility or community acquired; Lab, imaging, culture date, results; Type of organism; Antibiotic resistant organism: yes/no; Drug, dose, frequency; Start/end date, total days of treatment; Outcome; Adverse effects (if applicable). The log identified 15 events. Of these 15 events, 2 included the same individual with change of antibiotic therapy. The log identified 5 of the 15 events were related to a urinary tract infection. The log identified 4 of the 5 UTI's were facility acquired, with 1 of 5 acquired in the community prior to admission. The log lacked documentation of the organism identified for the community acquired UTI. The log identified 9 episodes related to upper/lower respiratory infections (LRI's/URI's) and pneumonia, with 2 of the entries identifying the same resident whose symptoms had not resolved. The log lacked any tracking for symptoms of illness not treated with antibiotics, for example: nausea, vomiting, diarrhea, or fungal infections. A facility map was included with the infection log and identified location of the resident who had the infection, however, it lacked any review of the information for correlation of infections related to location, shared room/bathroom, or shared staff. A document titled Resident Monthly Summary dated (MONTH) of (YEAR) indicated there were 5 LRI and identified 4 as facility acquired and 1 as community acquired. The document indicated there was 1 episode of facility acquired pneumonia, and 2 occurrences of community acquired pneumonia. The log indicated there were 4 instances of facility acquired UTI's and 1 community acquired UTI. The log additionally identified 1 occurrence of skin infections for a total of 14 infections. The summary indicated ,[DATE] UTI's did not meet McGeer's criteria (A tool used to determine if evaluation with urine analysis and/or culture for a UTI was indicated based on presenting symptoms). The analysis identified no trends or correlation noted among resident infections, however, did identify an increase in infection rate at 5.75%. The summary did not identify any interventions implemented, training performed or audits completed. The quality improvement/conclusions/actions/and outcomes indicated facility would continue to track and trend resident and employee infections. The Resident Monthly Summary for (MONTH) of (YEAR) indicated 15 infections. Of the identified infections, ,[DATE] infections were related to UTI, 5 infections were related to respiratory infections, ,[DATE] was related to yeast infections, ,[DATE] was related to preventative treatment with antibiotic prior to surgery, 2 skin infections, and 1 eye infection. The log indicated the cultures for only 3 of the 5 UTI infection, one of the results identified R46 was diagnosed with [REDACTED]. Upon review of the data, R306 and R46 had UTI's listed for both (MONTH) and December. A facility map was attached with rooms identified with presence of infection. The Resident Monthly Summary from (MONTH) of (YEAR) provided a recap of the numbers and indicated there were no trends or correlations noted among the resident. The analysis did indicate and increase infection rate from 5.75% to 6.49%. The analysis lacked correlation of any patterns of infections related to location, shared facilities, or staff. The analysis also lacked analysis of repeat infection symptoms presentation. The summary did not identify any interventions implemented, training performed or audits completed. The quality improvement/conclusions/actions/and outcomes indicated facility would continue to track and trend resident and employee infections. The Resident Monthly Summary for (MONTH) of 2019 indicated 26 infections. Of the identified infections, 7 were related to UTI, 3 of the 26 were identified as having the [DIAGNOSES REDACTED]., 7 were noted to be respiratory in nature, 2 were related [MEDICAL CONDITION], 4 were identified as a skin infection, 2 residents were identified as having a eye infection, and 1 infection was related to a surgical infection. R7 and R53's urine was identified as having cultured out with ESBL. An identified UTI indicated as community acquired did not have the results of the U/C. The Resident Monthly Summary for (MONTH) of 2019 identified a breakdown of infections related to categories and indicated whether the infection was facility or community acquired. A facility map identified where residents with infections were located. The analysis indicated there were no trends or correlations, however it did identify there were 2 new cases of ESBL in urine. The quality improvement/conclusions/actions/and outcomes indicated facility would continue to track and trend resident and employee infections. Additionally, the document identified Hand hygiene and contact precautios (sic) education and reminders. The summary did not indicate what would be done or how this would evaluated. The summary did identify an increase in facility infections to 9.16%. The Resident Monthly Infection Statistics for (MONTH) of (YEAR) identified 7 instances of infections, with 3 being related to UTI's. The log identified 1 of the UTI's was acquired from the community, however, did not include the organism identified. A facility map with locations of residents with infection was not provided at this time. A record review was completed for resident's with noted patterns which included the following: R53 was identified in the Monthly Resident infection logs as having a urinary tract infection with the onset date of [DATE]. A record review was completed and the progress notes identified on [DATE], the facility had faxed residents doctor about residents complaint of bladder pain, frequency, and burning with urination. Staff also informed the physician R53 had odorous urine. The physician authorized a UA/UC. Additionally, R53 was [MEDICATION NAME] milligram (mg) twice daily for five days for a urinary infection. A urine culture collected on [DATE], was read on [DATE], as having mixed bacteria with a new specimen suggested. An order was received in follow up from the physician to recheck a UA/UC if UTI symptoms were present [MEDICATION NAME] on [DATE]. The review of the infection control log indicated the McGeer's criteria was not met for UTI. Analysis did not reflect review of antibiotic stewardship with the provider who had implemented treatment prior to receiving culture results, and culture results being received as mixed flora. R53 completed full course of therapy and was asymptomatic [MEDICATION NAME]. R53 was identified as having symptoms of bladder pain, burning, and frequency in the progress notes of [DATE]. The documentation also reflected staff reported a strong odor with urine. The symptoms reported did not meet McGeer's criteria. The physician was contacted and a UA/UC was ordered. Physician orders [REDACTED]. The UA/UC showed many [MEDICATION NAME] cells and the lab results reflected the identified specimen was not suitable for culture. The narrative notes lacked documentation to indicate the facility had followed up with the physician regarding the culture results to clarify if a second culture was to be done to determine growth and sensitivity. The documentation also failed to identify if the physician was consulted regarding indication for continued therapy. The progress notes for [DATE], identified resident continued to express complaints of burning and foul odor and antibiotic therapy continued. The narrative note of [DATE], identified R53 had [MEDICATION NAME] had no further symptoms of a UTI. R53 was again identified on the (MONTH) (YEAR) Tracking Sheet has having been diagnosed with [REDACTED]. A review of R53's record indicated a urine culture report of [DATE] which identified growth on [DATE] of greater than 100,000 colonies of a gram negative rod. The record indicated resident was treated from [DATE]- [DATE] [MEDICATION NAME] Tablet ,[DATE] mg two times a day for pneumonia, however, lacked any indicated treatment for [REDACTED]. A review of the sensitivity report did not identify [MEDICATION NAME] for sensitivity analysis. R53 had been

Based on interview and document review, the facility failed to recognize, comprehensively assess and implement timely medical treatment resulting in neglect of care for 1 of 1 residents (R54) reviewed who was subsequently hospitalized and died due to severe dehydration [MEDICAL CONDITION]. These findings constituted an immediate jeopardy (IJ) situation, and substandard quality of care, for R54 when the facility failed to implement appropriate, systemic corrective action(s) to prevent similar occurrences after R54's death. The IJ began on [DATE], when R54 developed objective signs of a significant, deteriorating change in condition which were not assessed and left untreated. R54's family and physician were not notified of these findings, nor was any medical treatment sought or implemented to correct them resulting in R54's admission to the hospital and subsequent death following critical laboratory values and severe dehydration. On [DATE], at 1:24 p.m. the administrator, director of nursing (DON), regional director of operations (RDO) and regional nurse consultant were notified of the IJ for R54. The IJ was removed on [DATE], at 2:50 p.m., however, non-compliance remained at isolated actual harm which was not immediate jeopardy (Level G). Findings include: A Common Entry Point Intake Form dated [DATE], identified a reported complaint regarding R54's care while at the facility. R54 was identified as showing signs of a bladder infection after a few weeks of admission which were not tested for the presence of a urinary tract infection [MEDICAL CONDITION]. R54's health was listed as very poor as a result of the facility's care, and R54 was discharged to a local assisted living facility. The day following discharge, R54 was admitted to the hospital for an infection and dehydration. R54 expired on [DATE]. The facility's Abuse Prevention / Vulnerable Adult Plan dated ,[DATE], identified neglect as, . the failure of the facility, its employees or service providers to provide goods or services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. R54's Admission Record dated [DATE], indicated an admission to the facility on [DATE], from an acute care hospital. R54's family member (FM)-A was listed as his emergency contact and accounts receivable (A/R) responsible party. R54's preadmission Hospital Discharge Pre-Placement Report dated [DATE], indicated R54 had been admitted to the acute care hospital for a UTI, and listed FM-A as R54's emergency contact and designated caregiver. The most recent laboratory value(s) listed for R54 included: Sodium 138 (normal range 135 - 145) and potassium 4.0 ( normal range 3.5 - 5.1). Further, R54's Hospital Orders Discharge Report dated [DATE], identified R54 discharged from the acute care hospital to the facility in Stable condition with Good rehabilitation potential, and indicated therapy should screen him for rehabilitation in the nursing home. R54's 14-day prospective payment system Minimum Data Set ((MDS) dated [DATE], indicated R54 had severe cognitive impairment, displayed no rejection of care behaviors, and required extensive assistance with activities of daily living (ADLs). In addition, the MDS indicated R54 used an indwelling Foley catheter (a flexible tube that passes through the urethra and into the bladder to drain urine), had no current infections or identified weight loss, and did not have a chronic disease or condition which would result in a life expectancy of less than six months. R54's Provider Orders for Life Sustaining Treatment (POLST) dated [DATE], identified R54 as requesting DNR/DNI (do not resuscitate or intubate). A section labeled, Medical Treatments, had an X written next to an the option, Comfort-Focused Treatment (Allow Natural Death), to indicate the resident wanted measures such as relief from pain and suffering through any means necessary, using oxygen and manual treatment of [REDACTED]. On the backside of the POLST, an additional section labeled, Additional Patient Preferences (Optional), included options to select for other care modalities to be implemented including nutrition via a feeding tube, and use of antibiotics. However, this section was left blank with no evidence it had been reviewed or discussed. Further, the POLST had printed instructions for healthcare providers along the bottom of the backside which directed, This POLST should be reviewed periodically and included several examples of when to review including: a change in care setting or with a change in the patient's health status. The POLST was signed as being completed by registered nurse (RN)-A on [DATE], along with R54's attending physician signature [DATE], and FM-A's signature with no date. R54's Initial/Comprehensive Care Plan dated [DATE], identified R54 had poor cognition and required assistance to complete his ADL's. The care plan also indicated R54 used a Foley catheter, and indicated staff were directed to monitor for signs and symptoms of UTI and monitor catheter output. Separate sections of the care plan labeled, Dehydration, Hospice and Infection, were labeled as not applicable and were left uncompleted. R54's progress note(s) dated ,[DATE] to [DATE], were reviewed and identified the following entries: On [DATE], R54 admitted to the nursing home from the acute care hospital. R54 was described as being alert but unable to communicate needs to the staff, and having a Foley catheter in place. On [DATE], nursing staff identified poor output of dark amber urine in Foley catheter bag, and started a new Treatment Administration Record (TAR) intervention to monitor his urine output indicating Push fluids (related to) high risk of dehydration. On [DATE], R54 had 350 cc (cubic centimeters) of urine output on the overnight shift. The note further indicated R54, Drinks water with straw very well. On [DATE], R54 continued on Medicare A for weakness, and had a . good day with no behaviors. On [DATE], dictation identified, (R54) admitted from (acute care hospital) for rehab and strengthening with plans to return home with wife. Later on [DATE], R54 was seen by social services for an assessment, speech was mumbled and writer could not make anything out that he said. On [DATE], R54 developed a 101 degrees Fahrenheit (F) temperature and was given Tylenol. A later note on [DATE], indicated at approximately 3:00 p.m. R54's face was flushed (red) and his skin was warm to touch. He had a 101.3 F temperature, bloody urine and staff pushed 360 cc of water. Staff notified FM-A who stated R54 . has a history of multiple UTI's. The on-call physician was notified and ordered a urinalysis and culture (UA/UC) and intramuscular (IM) antibiotic. Nursing staff administered the IM antibiotic and recorded, Plan to continue to push fluids to get a fairly good U/A. The note did not indicate the UA/UC was collected prior to starting the antibiotic, to ensure proper identification of of the bacteria to determine if it was susceptible to the prescribed antibiotic, [MEDICATION NAME]. On [DATE], a note was entered regarding the ordered UA/UC on [DATE], including: Instructed it (UA/UC) would be inaccurate due to [MEDICATION NAME] (antibiotic administration). A subsequent note on [DATE], indicated R54 displayed weakness and confusion, and included: He did not have any behaviors this shift. No concerns. A later note on [DATE], identified R54 had not voided much pm (evening) shift, very little output. The notes indicated a new Foley was inserted and patent. R54's urine was described in the documentation as continues to be cranberry colored but no clots. On [DATE], notes indicated FM-A had completed a tour of a local assisted living facility and had plans for R54's discharge. The notes indicated the assisted living and FM-A had indicated they were .looking at a potential move in date for him of ,[DATE]. On [DATE], R54 notes indicated the resident was receiving Medicare A benefits and care for weakness. (R54) had a good day. Resident had no behaviors. On [DATE], (R54) had a good evening. Resident needs total help with (activities of daily living) and transfers. On [DATE], R54's urine was described as clear urine with no blood noted. On [DATE], R54 was seen by the physician for a face-to-face visit for discharge orders and a wheelchair. A corresponding Visit Note dated [DATE], completed by R54's attending physician (MD)-E, indicated R54 had [MEDICAL CONDITION] (enlarged prostate), severe dementia and [MEDICAL CONDITION]. MD-E referenced a set of laboratory tests completed on [DATE], which identified R54's sodium level as 149 (normal range 135 to 145) and potassium level as 5.1 (normal range 3.5 to 5.1). MD-E's review of systems note indicated it was limited due to R54's dementia however, no acute symptoms or distress was recorded. Further, MD-E documented a physical examination of R54 as, fair, doesn't talk, stooped forward on wheelchair. There was no evidence in the record of any information the facility had provided MD-E with for review during this appointment to ensure he was aware of R54's current clinical status, nor any evidence MD-E had been made aware R54's UA/UC had not been completed as ordered. Later on [DATE], at 8:21 p.m. several medications were recorded as not provided with dictation from the nurse including: unable due to decrease in condition. An additional note on [DATE], identified, (R54) not very verbal this shift. Vitals ,[DATE] 121 pulse. 97% (room air) 96.7(F) . did not take any medications due to declined condition. Did not eat dinner. At end of shift was informed there was no output from catheter. Night nurse is going to bladder scan and possibly irrigate. Resident is DNR and wife is out of town until [DATE] (sic). Will continue to monitor. On [DATE], the progress notes indicated R54 was unable to take his provided dietary supplement and that seven medications were not provided, . unable to take due to condition. On [DATE], R54 continued to not take his provided dietary supplement or medications. The nursing staff recorded due to condition, or unable to take, on these refused items. On [DATE], notes indicated R54 was not accepting medications, Resident would not swallow medication, kept spitting out. A later note on [DATE], at 6:00 p.m. indicated, Contacted (FM-A) (regarding) condition of resident. Resident appears to be declining, has not been eating or taking medications. Vitals are as follows: ,[DATE] 111 pulse. More verbal than Friday evening when writer last worked but still not as verbal as he usually is. Output has not be (sic) obtained at this time but on Friday evening there was no output at that time. Wife appreciated call. Will continue to monitor. The note lacked any evidence a plan for treatment for [REDACTED]. Further, more recorded entries were recorded on [DATE], of R54 continuing to not take medication, . unable to take due to condition. On [DATE], the notes indicated R54 was spitting out medications and not drinking his provided dietary supplement. The notes indicated R54 was discharged from the facility at 1:45 p.m. On [DATE], a discharge MDS summary was completed by social services which identified R54 had severe dementia and had a DNR status. In addition, social services documented, Writer reviewed the meal intake form and noted poor intake/poor appetite approximately 5 days. The note lacked any other information identifying R54's health condition on discharge from the facility. R54's medical record was reviewed and lacked evidence R54 had been comprehensively assessed on [DATE], to determine if any acute or potentially reversible disease processes had been identified or treated. The record lacked evidence the ordered UA/UC on [DATE], had ever been completed, nor any evidence R54 had been started on fluid intake monitoring or a hydration program despite being identified at high risk for dehydration by nursing on [DATE], and despite elevated sodium levels being identified on [DATE]. R54's medical record also lacked evidence FM-A or MD-E were notified of R54's acute decline in condition after his physician visit on [DATE], evidenced by medication refusals, poor intake, altered mental status with decreased verbal interaction(s), and decreased or lack of urinary output. As a result, there was no evidence medical interventions were developed and/or attempted to treat the visible signs of decline. On [DATE], at 10:23 a.m. FM-A was interviewed and stated R54 admitted to the nursing home on [DATE], from the acute care hospital with the intention of getting therapy in an attempt to help R54 ambulate again. FM-A said in no way was R54 considered to be in a terminal condition, or ready for just comfort care. FM-A explained she'd been in to visit R54 on [DATE], and he'd appeared to be his normal self. FM-A said she'd flown out of stated on ,[DATE] and returned late on [DATE]. FM-A stated when she went to the nursing home on [DATE], to help arrange R54's discharge to a local assisted living facility, R54 appeared disheveled, was moaning and groaning, and was just hanging in his wheelchair. FM-A stated R54's eyes were mattered closed with debris and he was crusty inside and out with (dried) food. FM-A stated she thought R54 should be seen by a physician at that time however, wanted to just get him out of the facility, so the decision was made to just transfer him to the local assisted living facility where they immediately helped him into a recliner chair and started to get him cleaned up. During the interview, FM-A further stated that the following morning ([DATE]), she'd received a call from the assisted living facility who indicated R54 needed to be seen in the hospital so transferred R54 via ambulance to the local hospital emergency department (ED). FM-A stated when she'd arrived at the ED, R54 had already been started on intravenous therapy (IV) and was non-responsive. FM-A stated the ED physician told her R54's sodium level was over 170. FM-A said R54 was diagnosed with [REDACTED]. FM-A stated the physician had told her he had never seen sodium that high. The following morning, the hospital called and stated R54's vitals were declining, so the decision was then made to keep him comfortable, and R54 died on [DATE]. FM-A stated she still had the image of R54 when he discharged the nursing home in her mind and wished it would go away, adding the whole situation involving R54's care in the nursing home and subsequent hospitalization was like going to Hell and back. FM-A stated she had never been notified of R54's apparent decline in condition and medication refusals until she was called on [DATE], adding she absolutely should have been contacted so a plan could have been developed, since she was his advocate and care decision maker. When interviewed on [DATE], at 1:57 p.m. nursing assistant (NA)-C stated she remembered R54 used to just yell out a lot and shout randomly. NA-C stated there was a big difference in R54 after he moved to the long-term care side (on [DATE]) and he seemed to decline with yelling out more, becoming harder and harder to do cares for, was sleeping more during the day and not wanting to help himself as much. NA-C stated she did not recall any issues with R54's intake or urinary output. During interview on [DATE], at 3:11 p.m. licensed practical nurse (LPN)-A stated R54 had been admitted to the nursing home for rehab and had then transferred to the long-term care wing. LPN-A stated R54's base line would be just talking gibberish out loud most of the time, and she felt his condition declined from his admission to his discharge as he was not as perky and was more tired looking, while in his wheelchair. On [DATE], at 3:24 p.m. during interview with LPN-B, she stated she was the nurse who authored several of the progress note(s) in R54's medical record on or after [DATE]. LPN-B confirmed R54 was not considered to be in terminal condition, nor was he on comfort cares, when he was admitted for rehabilitation with a plan to discharge to an assisted living facility. LPN-B reviewed R54's progress note(s) in the medical record and stated she remembered on [DATE], R54 seemed to change in condition and literally would not swallow. LPN -B added, (R54) was very verbal prior to that, explaining he would be at times abrasive and curse at staff. However on [DATE], he had changed from verbal to nothing. LPN-B stated the changes were new for R54, and he was suddenly just different on [DATE]. LPN-B stated she had been concerned about R54 because his blood pressure was reading low for him, and had wondered if R54 should be seen by a physician; however, had decided it was more of a something's off situation and given his DNR status, felt it was not an emergency. LPN-B added that she assumed his sudden changes were just a progression of his dementia. LPN-B stated she had not contacted FM-A with her concerns regarding his change in condition because she had been told FM-A did not want to be disturbed while out of state unless it was a complete emergency. LPN-B acknowledged she did not recall notifying the physician of R54's change of condition saying, I don't remember doing it. After reviewing R54's medical record, LPN-B stated FM-A and R54's physician should have been contacted about the change of condition when it occurred on [DATE]. On [DATE], at 8:23 a.m. registered nurses (RN)-A and RN-B were interviewed. RN-A explained R54 had been admitted to the nursing home for rehabilitation and staff were trying to help FM-A find an assisted living setting for him. RN-A stated she was the one who helped complete R54's POLST with FM-A on [DATE], and explained she had spoken to FM-A and asked if R54's heart stopped or he quit breathing, what she would want done for him. RN-A stated FM-A had responded keep him comfortable, so she'd selected the comfort focused treatment option on the POLST. RN-A stated she did review the backside options with FM-A (regarding tube feedings, antibiotics, etc) however, FM-A didn't give me an answer so RN-A had just encouraged FM-A to think about it and let me know. RN-A acknowledged she had never re-approached FM-A to clarify her wishes regarding antibiotic use or artificial means of nutrition/hydration. RN-A stated she had just faxed the POLST to R54's physician for signature and forgot about it. During the same interview, RN-A stated R54's physician had evaluated him on [DATE] however, was unaware whether staff had informed the physician of any concerns regarding R54's declining status. RN-A stated staff were expected to contact the physician and notify the family with any significant changes in condition. RN-A confirmed there was no evidence in the medical record to demonstrate whether either R54's physician, or FM-A, had been contacted when R54's change of condition was first recorded. RN-A further stated FM-A had given instructions not to contact her unless there was an emergency situation when she'd left the state for vacation. After reviewing R54's medical record, RN-A stated it was evident R54 had experienced an acute change of condition and was deteriorating, so FM-A and the physician should have been contacted on [DATE]. In addition, RN-A stated when she reviewed R54's collected meal intakes, supplement intakes, urinary output and progress note(s), they all demonstrated R54 was declining and having an acute change of condition as his previously recorded outputs and intakes were higher. RN-A stated she was the only nurse manager working in the facility during R54's admission to the nursing home, and upon review of R54's record she said she was frustrated no direct care staff had reported his change of condition and decline to her. RN-A stated this was the first time she was learning of these changes, and stated the medical record entries demonstrated a decline and added she was not previously aware the facility had a completed physician note for the visit completed on [DATE], adding this was the first time she had even seen it. Further, RN-A explained R54's orders for the UA/UC and IM antibiotic had been given at the same time on [DATE] however, a later note entered in the record identified the UA was not able to be collected as the nurse gave the antibiotic prior to obtaining the sample of urine. RN-A verified that could have caused an incorrect reading and tainted sample, and nursing staff should have obtained the UA sample prior to giving the antibiotic. RN-A reviewed R54's medical record and verified the ordered UA/UC on [DATE] was not collected. RN-B also called the laboratory and they had no results for any UA/UC collected for R54. RN-A stated if she had been notified of R54's changes in condition, they could have been assessed, including review of the vital signs along with intake and output records, and she would have immediately contacted FM-A and the physician to develop a plan of treatment. RN-A also explained the facility did not routinely monitor fluid intake and output for someone using a catheter as this process had recently changed around the time R54 admitted to the nursing home. The nursing staff were just monitoring people on fluid restrictions. RN-A was then provided and reviewed the following information: R54's Follow Up Question Report dated [DATE] to [DATE], identified R54's recorded meal intakes for the three provided meals at the facility. These indicated the following: On [DATE], R54 consumed 26 - 100% of all three provided meals. On [DATE], R54 consumed 26 - 75% of two provided meals; however, there was nothing recorded for a third meal. On [DATE], R54 consumed only 26 - 50 % of one meal; the other two meals were recorded as him consuming 0 - 25% of the meal. On [DATE], R54 was recorded as consuming only 0 - 25% of two provided meals; however, there was nothing recorded for a third meal. On [DATE], R54 was recorded as consuming only 0 - 25% of two provided meals; however, there was nothing recorded for a third meal. On [DATE], R54 was recorded as consuming ,[DATE]% of one meal, and 0 - 25% of another provided meal; however, there was nothing recorded for a third meal. On [DATE], R54 consumed only ,[DATE]% of one provided meal, and there was no data recorded for a second or third meal, and, On [DATE], R54 consumed 76 - 100% of only one provided meal. The report lacked any evidence indictating what the provided meal was (i.e. toast versus pasta), nor evidence if R54 had been offered and/or declined meal(s) on the days with missing meal(s) present and nothing recorded. Further, there was no recorded fluid intakes provided to demonstrate how much water and/or liquids R54 had consumed throughout the day(s). R54's Treatment Administration Record (TAR) dated [DATE] to [DATE], identified an intervention to obtain R54's urinary output each shift from his Foley catheter, starting on [DATE]. The following was identified: [DATE]: AM (shift): 150 cc output recorded, PM: 200 cc output recorded, N[NAME] (night): Blank and not recorded. [DATE]: AM: Not completed, PM: Blank and not completed, N[NAME]: 200 cc output recorded. [DATE]: AM: 200 cc output recorded, PM: Blank and not completed, N[NAME]: 250 cc output recorded. [DATE]: AM: 200 cc output recorded, PM: 100 cc output recorded, N[NAME]: 300 cc output recorded. [DATE]: AM: 200 cc output recorded, PM: 200 cc output recorded, N[NAME]: 150 cc output recorded. [DATE]: AM: Blank and not completed, PM: Blank and not completed. There were no recorded urine characteristics (i.e. color, clarity, odor) recorded on R54's TAR. Further, R54's Medication Administration Record [REDACTED]. These identified the following: On [DATE], R54 was recorded as consuming 100% of all three provided supplements. On [DATE], R54 was recorded as consuming 100% of one provided supplement, and 50% of the other two provided supplements. On [DATE], R54 was recorded as consuming 100% of two provided supplements, and sips of the third supplement. On [DATE], R54 was recorded as consuming 100% of two provided supplements, and sips of the third supplement. On [DATE], R54 was recorded as consuming 100% of one provided supplement, and 50% of the other two provided supplements. On [DATE], R54 was recorded as consuming 50% of two provided supplements, and 25% of the other one provided supplement. On [DATE], R54 was recorded as consuming 25% of one provided supplement, and nothing for the other two provided supplements. On [DATE], R54 was recorded as consuming none of the three provided supplements, and, on [DATE], R54 was recorded as consuming none of the two provided supplements. RN-A confirmed after review of the data, it was demonstrated based on the provided meal intake(s), and collected urinary output readings, R54 was declining and having an acute change of condition as his previously recorded outputs and intakes were higher. RN-A stated R54's POLST should also have been reviewed in accordance with the directions printed on it. RN-A added if R54's change of condition had been assessed timely and treated it's possible R54 may not have been hospitalized and died . Review of R54's medication administration records (MAR) demonstrated R54 had received no other antibiotic medication(s) while residing at the facility from [DATE], to [DATE]. The MAR indicated [REDACTED]. On [DATE], at 9:44 a.m. the director of nursing (DON) was interviewed. The DON verified the backside of R54's POLST should not have been left blank. The DON added, even though the section was listed as optional, she felt the section should be completed for every resident as it was best practice. She also stated the nursing staff should have had a conversation with R54's family in the moment when the change of condition was identified. The DON reviewed R54's medical record with the surveyor and confirmed the notes and entries on and after [DATE], reflected a significant change in condition for R54 which should have been reported to his physician and family, so a plan of care could be decided on. The DON stated nursing staff were supposed to report changes of condition to herself or the nurse manager adding if they had been notified, and R54 had been assessed and treated, then (R54's) hospitalization and subsequent death could have potentially been avoided. R54's emergency room Record - Final Report dated [DATE], indicated R54 presented to the ED via emergency medical service (EMS) on [DATE], because of an altered level of consciousness over the past week .which got worse as days go by. R54's vital signs were recorded as follows: blood pressure ,[DATE], heart rate 116, respirations 24, and, temperature 98.2 F. R54 was identified as lethargic and unresponsive. The ED physician indicated R54 was started on IV fluids, IV antibiotics and laboratory tests were completed. R54's corresponding Patient Chart Report printed [DATE], identified a sodium level in the ED over 170 mmol/L (millimoles per liter); and posted a reference range of ,[DATE]. The report identified R54's sodium result was . greater than the linearity range of the instrument. R54's hospital Progress Note - Final Report dated [DATE], indicated R54 was seen in the hospital by MD-E. MD-E indicated R54 was, . admitted yesterday due to altered mental status and was found to have critical [MEDICAL CONDITION] (high sodium level) of more than 170. R54 had just admitted to the assisted living facility from the nursing home and, . hasn't been eating or drinking for the past ,[DATE] days. R54 was aggressively hydrated with no improvement in his sodium level, and was also started on an antibiotic [MEDICAL CONDITION] (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death) and UTI. An assessment was listed by MD-E which identified R54 had: critical [MEDICAL CONDITION] secondary to dehydration, an acute kidney injury secondary to dehydration [MEDICAL CONDITIONS] secondary to a UTI. Further, R54 was recorded has having agonal breathing with [MEDICAL CONDITION] and would, . very likely pass (die) today. R54's subsequent hospital Discharge Summary - Final Report dated [DATE], indicated R54 expired on [DATE], at 12:03 p.m. On [DATE], at 12:03 p.m. MD-E was interviewed and explained R54's baseline mentation was typically just moaning a little on a constant basis. MD-E stated on [DATE], R54 had blood work completed which was not perfect but did not appear too bad either, and on [DATE], he'd seen R54 for a face to face visit as he needed a new wheelchair and was discharging to the assisted living facility. MD-E stated he had never received any notification that R54 had been declining or had a change of condition after his face to face visit on [DATE], until R54 was admitted to the hospital for severe [MEDICAL CONDITION]. MD-E explained [MEDICAL CONDITION] is almost always from dehydration and not eating or drinking. MD-E stated he had also not been informed the UA/UC ordered [DATE] had not been obtained. MD-E further stated the changes in status R54 demonstrated, such as poor output and alertness, or mentation changes, are definitely signs of dehydration and the staff should have updated him with those observations and findings. MD-E explained if he had been notified of R54's change in condition and declining clinical picture on [DATE], he would have immediately ordered blood work versus relying on the results he had drawn on [DATE]. MD-E stated if the elevated sodium had been identified then, it could have been addressed and corrected sooner which could have changed the outcome, and clarified, I would have to say yes, it would have prolonged (R54's) life. Further, MD-E stated, Critical [MEDICAL CONDITION], is ultimately what lead to R54's death, and again reiterated if nursing staff had noticed a change in condition for R54, Somebody should have said something. On [DATE], at 8:27 a.m. the DON and administrator were interviewed. They explained the assisted living had contacted them shortly after R54 discharged and asked, Why did he come so disheveled? The administrator stated they were unaware R54 had sustained such a significant change in his condition which led to his hospitalization and subsequent death. The DON stated she remembered seeing R54's progress note(s) in the computer on and after [DATE], which indicated a deteriorating condition; however, the DON explained, (We) took it as regular dementia decline. Further, they clarified there had been no systemic changes or processes reviewed pertaining to resident assessment or change(s) in condition since R54 expired on [DATE]. The facility's Patient Status Change policy dated [DATE], included: Monarch Health Management will notify the resident's physician and other responsible persons in the event of an accident or other significant change in a patient's emotional, mental or physical condition. The policy lacked any more detailed procedure to direct staff on how to accomplish this. The

Based on interview and document review, the facility failed to ensure the responsible party and physician were notified timely of a deteriorating condition for 1 of 2 residents (R54) reviewed for change of condition. This resulted in actual harm for R54 when he developed signs and symptoms of severe dehydration which were not communicated timely to the responsible party or his physician resulting in subsequent hospitalization and death. Findings include: A Common Entry Point Intake Form dated [DATE], identified a reported complaint regarding R54's care while at the facility. R54 was identified as showing signs of a bladder infection after a few weeks of admission which were not tested for the presence of a urinary tract infection [MEDICAL CONDITION]. R54's health was listed as very poor as a result of the facility's care, and R54 was discharged to a local assisted living facility. The day following discharge, R54 was admitted to the hospital for an infection and dehydration. R54 expired on [DATE]. R54's Admission Record dated [DATE], indicated an admission to the facility on [DATE], from an acute care hospital. R54's family member (FM)-A was listed as his emergency contact and accounts receivable (A/R) responsible party. R54's preadmission Hospital Discharge Pre-Placement Report dated [DATE], indicated R54 had been admitted to the acute care hospital for a UTI, and listed FM-A as R54's emergency contact and designated caregiver. The most recent laboratory value(s) listed for R54 included: Sodium 138 (normal range 135 - 145) and potassium 4.0 ( normal range 3.5 - 5.1). Further, R54's Hospital Orders Discharge Report dated [DATE], identified R54 discharged from the acute care hospital to the facility in Stable condition with Good rehabilitation potential, and indicated therapy should screen him for rehabilitation in the nursing home. R54's 14-day prospective payment system Minimum Data Set ((MDS) dated [DATE], indicated R54 had severe cognitive impairment, displayed no rejection of care behaviors, and required extensive assistance with activities of daily living (ADLs). In addition, the MDS indicated R54 used an indwelling Foley catheter (a flexible tube that passes through the urethra and into the bladder to drain urine), had no current infections or identified weight loss, and did not have a chronic disease or condition which would result in a life expectancy of less than six months. R54's Provider Orders for Life Sustaining Treatment (POLST) dated [DATE], identified R54 as requesting DNR/DNI (do not resuscitate or intubate). A section labeled, Medical Treatments, had an X written next to an the option, Comfort-Focused Treatment (Allow Natural Death), to indicate the resident wanted measures such as relief from pain and suffering through any means necessary, using oxygen and manual treatment of [REDACTED]. On the backside of the POLST, an additional section labeled, Additional Patient Preferences (Optional), included options to select for other care modalities to be implemented including nutrition via a feeding tube, and use of antibiotics. However, this section was left blank with no evidence it had been reviewed or discussed. Further, the POLST had printed instructions for healthcare providers along the bottom of the backside which directed, This POLST should be reviewed periodically and included several examples of when to review including: a change in care setting or with a change in the patient's health status. The POLST was signed as being completed by registered nurse (RN)-A on [DATE], along with R54's attending physician signature [DATE], and FM-A's signature with no date. R54's Initial/Comprehensive Care Plan dated [DATE], identified R54 had poor cognition and required assistance to complete his ADL's. The care plan also indicated R54 used a Foley catheter, and indicated staff were directed to monitor for signs and symptoms of UTI and monitor catheter output. Separate sections of the care plan labeled, Dehydration, Hospice and Infection, were labeled as not applicable and were left uncompleted. R54's progress note(s) dated ,[DATE] to [DATE], were reviewed and identified the following entries: On [DATE], R54 admitted to the nursing home from the acute care hospital. R54 was described as being alert but unable to communicate needs to the staff, and having a Foley catheter in place. On [DATE], nursing staff identified poor output of dark amber urine in Foley catheter bag, and started a new Treatment Administration Record (TAR) intervention to monitor his urine output indicating Push fluids (related to) high risk of dehydration. On [DATE], R54 had 350 cc (cubic centimeters) of urine output on the overnight shift. The note further indicated R54, Drinks water with straw very well. On [DATE], R54 continued on Medicare A for weakness, and had a . good day with no behaviors. On [DATE], dictation identified, (R54) admitted from (acute care hospital) for rehab and strengthening with plans to return home with wife. Later on [DATE], R54 was seen by social services for an assessment, speech was mumbled and writer could not make anything out that he said. On [DATE], R54 developed a 101 degrees Fahrenheit (F) temperature and was given Tylenol. A later note on [DATE], indicated at approximately 3:00 p.m. R54's face was flushed (red) and his skin was warm to touch. He had a 101.3 F temperature, bloody urine and staff pushed 360 cc of water. Staff notified FM-A who stated R54 . has a history of multiple UTI's. The on-call physician was notified and ordered a urinalysis and culture (UA/UC) and intramuscular (IM) antibiotic. Nursing staff administered the IM antibiotic and recorded, Plan to continue to push fluids to get a fairly good U/A. The note did not indicate the UA/UC was collected prior to starting the antibiotic, to ensure proper identification of of the bacteria to determine if it was susceptible to the prescribed antibiotic, [MEDICATION NAME]. On [DATE], a note was entered regarding the ordered UA/UC on [DATE], including: Instructed it (UA/UC) would be inaccurate due to [MEDICATION NAME] (antibiotic administration). A subsequent note on [DATE], indicated R54 displayed weakness and confusion, and included: He did not have any behaviors this shift. No concerns. A later note on [DATE], identified R54 had not voided much pm (evening) shift, very little output. The notes indicated a new Foley was inserted and patent. R54's urine was described in the documentation as continues to be cranberry colored but no clots. On [DATE], notes indicated FM-A had completed a tour of a local assisted living facility and had plans for R54's discharge. The notes indicated the assisted living and FM-A had indicated they were .looking at a potential move in date for him of ,[DATE]. On [DATE], R54 notes indicated the resident was receiving Medicare A benefits and care for weakness. (R54) had a good day. Resident had no behaviors. On [DATE], (R54) had a good evening. Resident needs total help with (activities of daily living) and transfers. On [DATE], R54's urine was described as clear urine with no blood noted. On [DATE], R54 was seen by the physician for a face-to-face visit for discharge orders and a wheelchair. A corresponding Visit Note dated [DATE], completed by R54's attending physician (MD)-E, indicated R54 had [MEDICAL CONDITION] (enlarged prostate), severe dementia and [MEDICAL CONDITION]. MD-E referenced a set of laboratory tests completed on [DATE], which identified R54's sodium level as 149 (normal range 135 to 145) and potassium level as 5.1 (normal range 3.5 to 5.1). MD-E's review of systems note indicated it was limited due to R54's dementia however, no acute symptoms or distress was recorded. Further, MD-E documented a physical examination of R54 as, fair, doesn't talk, stooped forward on wheelchair. There was no evidence in the record of any information the facility had provided MD-E with for review during this appointment to ensure he was aware of R54's current clinical status, nor any evidence MD-E had been made aware R54's UA/UC had not been completed as ordered. Later on [DATE], at 8:21 p.m. several medications were recorded as not provided with dictation from the nurse including: unable due to decrease in condition. An additional note on [DATE], identified, (R54) not very verbal this shift. Vitals ,[DATE] 121 pulse. 97% (room air) 96.7(F) . did not take any medications due to declined condition. Did not eat dinner. At end of shift was informed there was no output from catheter. Night nurse is going to bladder scan and possibly irrigate. Resident is DNR and wife is out of town until [DATE] (sic). Will continue to monitor. On [DATE], the progress notes indicated R54 was unable to take his provided dietary supplement and that seven medications were not provided, . unable to take due to condition. On [DATE], R54 continued to not take his provided dietary supplement or medications. The nursing staff recorded due to condition, or unable to take, on these refused items. On [DATE], notes indicated R54 was not accepting medications, Resident would not swallow medication, kept spitting out. A later note on [DATE], at 6:00 p.m. indicated, Contacted (FM-A) (regarding) condition of resident. Resident appears to be declining, has not been eating or taking medications. Vitals are as follows: ,[DATE] 111 pulse. More verbal than Friday evening when writer last worked but still not as verbal as he usually is. Output has not be (sic) obtained at this time but on Friday evening there was no output at that time. Wife appreciated call. Will continue to monitor. The note lacked any evidence a plan for treatment for [REDACTED]. Further, more recorded entries were recorded on [DATE], of R54 continuing to not take medication, . unable to take due to condition. On [DATE], the notes indicated R54 was spitting out medications and not drinking his provided dietary supplement. The notes indicated R54 was discharged from the facility at 1:45 p.m. On [DATE], a discharge MDS summary was completed by social services which identified R54 had severe dementia and had a DNR status. In addition, social services documented, Writer reviewed the meal intake form and noted poor intake/poor appetite approximately 5 days. The note lacked any other information identifying R54's health condition on discharge from the facility. R54's medical record was reviewed and lacked evidence FM-A or MD-E were notified of R54's acute decline in condition after his physician visit on [DATE], evidenced by medication refusals, poor intake, altered mental status with decreased verbal interaction(s), and decreased or lack of urinary output. As a result, there was no evidence medical interventions were developed and/or attempted to treat the visible signs of decline. On [DATE], at 10:23 a.m. FM-A was interviewed and stated R54 admitted to the nursing home on [DATE], from the acute care hospital with the intention of getting therapy in an attempt to help R54 ambulate again. FM-A said in no way was R54 considered to be in a terminal condition, or ready for just comfort care. FM-A explained she'd been in to visit R54 on [DATE], and he'd appeared to be his normal self. FM-A said she'd flown out of stated on ,[DATE] and returned late on [DATE]. FM-A stated when she went to the nursing home on [DATE], to help arrange R54's discharge to a local assisted living facility, R54 appeared disheveled, was moaning and groaning, and was just hanging in his wheelchair. FM-A stated R54's eyes were mattered closed with debris and he was crusty inside and out with (dried) food. FM-A stated she thought R54 should be seen by a physician at that time however, wanted to just get him out of the facility, so the decision was made to just transfer him to the local assisted living facility where they immediately helped him into a recliner chair and started to get him cleaned up. FM-A stated on the following morning ([DATE]), she received a call from the assisted living facility who indicated R54 needed to be seen in the hospital so transferred R54 via ambulance to the local hospital emergency department (ED). FM-A stated when she'd arrived at the ED, R54 had already been started on intravenous therapy (IV) and was non-responsive. FM-A stated the ED physician told her R54's sodium level was over 170. FM-A said R54 was diagnosed with [REDACTED]. FM-A also stated the physician had told her he had never seen sodium that high. The following morning, the hospital called and stated R54's vitals were declining, and the decision was then made to keep him comfortable, and R54 died on [DATE]. FM-A stated she still had the image of R54 when he discharged the nursing home in her mind and wished it would go away, adding the whole situation involving R54's care in the nursing home and subsequent hospitalization was like going to Hell and back. FM-A stated she had never been notified of R54's apparent decline in condition and medication refusals until she was called on [DATE], adding she absolutely should have been contacted so a plan could have been developed, since she was his advocate and care decision maker. On [DATE], at 3:24 p.m. during interview with LPN-B, she stated she was the nurse who authored several of the progress note(s) in R54's medical record on or after [DATE]. LPN-B confirmed R54 was not considered to be in terminal condition, nor was he on comfort cares, when he was admitted for rehabilitation with a plan to discharge to an assisted living facility. LPN-B reviewed R54's progress note(s) in the medical record and stated she remembered on [DATE], R54 seemed to change in condition and literally would not swallow. LPN -B added, (R54) was very verbal prior to that, explaining he would be at times abrasive and curse at staff. However on [DATE], he had changed from verbal to nothing. LPN-B stated the changes were new for R54, and he was suddenly just different on [DATE]. LPN-B stated she had been concerned about R54 because his blood pressure was reading low for him, and had wondered if R54 should be seen by a physician however, had decided it was more of a something's off situation and given his DNR status, had not felt it was an emergency. LPN-B added that she assumed his sudden changes were just a progression of his dementia. LPN-B confirmed she had not contacted FM-A with her concerns regarding his change in condition because she had been told FM-A did not want to be disturbed while out of state unless it was a complete emergency. LPN-B acknowledged she did not recall notifying the physician of R54's change of condition saying, I don't remember doing it. After reviewing R54's medical record, LPN-B stated FM-A and R54's physician should have been contacted about the change of condition when it occurred on [DATE]. On [DATE], at 8:23 a.m. registered nurses (RN)-A and RN-B were interviewed. RN-A explained R54 had been admitted to the nursing home for rehabilitation and staff were trying to help FM-A find an assisted living setting for him. RN-A stated she was the one who helped complete R54's POLST with FM-A on [DATE], and explained she had spoken to FM-A and asked if R54's heart stopped or he quit breathing, what she would want done for him. RN-A stated FM-A had responded keep him comfortable, so she'd selected the comfort focused treatment option on the POLST. RN-A stated she did review the backside options with FM-A (regarding tube feedings, antibiotics, etc) however, FM-A didn't give me an answer so RN-A had just encouraged FM-A to think about it and let me know. RN-A acknowledged she had never re-approached FM-A to clarify her wishes regarding antibiotic use or artificial means of nutrition/hydration. RN-A stated she had just faxed the POLST to R54's physician for signature and forgot about it. During this interview, RN-A stated R54's physician had evaluated him on [DATE] however, was unaware whether staff had informed the physician of any concerns regarding R54's declining status. RN-A stated staff were expected to contact the physician and notify the family with any significant changes in condition. RN-A confirmed there was no evidence in the medical record to demonstrate whether either R54's physician, or FM-A, had been contacted when R54's change of condition was first recorded. RN-A further stated FM-A had given instructions not to contact her unless there was an emergency situation when she'd left the state for vacation. After reviewing R54's medical record, RN-A stated it was evident R54 had experienced an acute change of condition and was deteriorating, so FM-A and the physician should have been contacted on [DATE]. In addition, RN-A stated when she reviewed R54's collected meal intakes, supplement intakes, urinary output and progress note(s), they all demonstrated R54 was declining and having an acute change of condition as his previously recorded outputs and intakes were higher. RN-A stated she was the only nurse manager working in the facility during R54's admission to the nursing home, and upon review of R54's record she said she was frustrated no direct care staff had reported his change of condition and decline to her. RN-A stated this was the first time she was learning of these changes, and stated the medical record entries demonstrated a decline, but R54's POLST had not been reviewed again because she'd been unaware of the decline. RN-A stated if she had been notified of R54's changes in condition, they could have been assessed, including review of the vital signs along with intake and output records, and she would have immediately contacted FM-A and the physician to develop a plan of treatment. On [DATE], at 9:44 a.m. the director of nursing (DON) was interviewed. The DON verified the backside of R54's POLST should not have been left blank. The DON added, even though the section was listed as optional, she felt the section should be completed for every resident as it was best practice. She also stated the nursing staff should have had a conversation with R54's family in the moment when the change of condition was identified. The DON reviewed R54's medical record with the surveyor and confirmed the notes and entries on and after [DATE], reflected a significant change in condition for R54 which should have been reported to his physician and family, so a plan of care could be decided on. The DON stated nursing staff were supposed to report changes of condition to herself or the nurse manager. R54's emergency room Record - Final Report dated [DATE], indicated R54 presented to the ED via emergency medical service (EMS) on [DATE], because of an altered level of consciousness over the past week .which got worse as days go by. R54's vital signs were recorded as follows: blood pressure ,[DATE], heart rate 116, respirations 24, and, temperature 98.2 F. R54 was identified as lethargic and unresponsive. The ED physician indicated R54 was started on IV fluids, IV antibiotics and laboratory tests were completed. R54's corresponding Patient Chart Report printed [DATE], identified a sodium level in the ED over 170 mmol/L (millimoles per liter); and posted a reference range of ,[DATE]. The report identified R54's sodium result was . greater than the linearity range of the instrument. R54's hospital Progress Note - Final Report dated [DATE], indicated R54 was seen in the hospital by MD-E. MD-E indicated R54 was, . admitted yesterday due to altered mental status and was found to have critical [MEDICAL CONDITION] (high sodium level) of more than 170. R54 had just admitted to the assisted living facility from the nursing home and, . hasn't been eating or drinking for the past ,[DATE] days. R54 was aggressively hydrated with no improvement in his sodium level, and was also started on an antibiotic [MEDICAL CONDITION] (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death) and UTI. An assessment was listed by MD-E which identified R54 had: critical [MEDICAL CONDITION] secondary to dehydration, an acute kidney injury secondary to dehydration [MEDICAL CONDITIONS] secondary to a UTI. Further, R54 was recorded has having agonal breathing with [MEDICAL CONDITION] and would, . very likely pass (die) today. R54's subsequent hospital Discharge Summary - Final Report dated [DATE], indicated R54 expired on [DATE], at 12:03 p.m. On [DATE], at 12:03 p.m. MD-E was interviewed and explained R54's baseline mentation was typically just moaning a little on a constant basis. MD-E stated on [DATE], R54 had blood work completed which was not perfect but did not appear too bad either, and on [DATE], he'd seen R54 for a face to face visit as he needed a new wheelchair and was discharging to the assisted living facility. MD-E stated he had never received any notification that R54 had been declining or had a change of condition after his face to face visit on [DATE], until R54 was admitted to the hospital for severe [MEDICAL CONDITION]. MD-E explained [MEDICAL CONDITION] is almost always from dehydration and not eating or drinking. MD-E further stated the changes in status R54 demonstrated, such as poor output and alertness, or mentation changes, are definitely signs of dehydration and the staff should have updated him with those observations and findings. MD-E explained if he had been notified of R54's change in condition and declining clinical picture on [DATE], he would have immediately ordered blood work versus relying on the results he had drawn on [DATE]. MD-E stated if the elevated sodium had been identified then, it could have been addressed and corrected sooner which could have changed the outcome, and clarified, I would have to say yes, it would have prolonged R54's life. Further, MD-E stated critical [MEDICAL CONDITION] is ultimately what lead to R54's death, and reiterated if nursing staff had noticed a change in condition for R54, Somebody should have said something. The facility's Patient Status Change policy dated [DATE], included: Monarch Health Management will notify the resident's physician and other responsible persons in the event of an accident or other significant change in a patient's emotional, mental or physical condition. The policy lacked any more detailed procedure to direct staff on how to accomplish this.

Based on observation, interview, and document review, the facility failed to ensure allegations of abuse were identified timely; failed to ensure appropriate action was taken to immediately provide resident protection; and failed to thoroughly investigate the allegations for 1 of 1 residents (R44) who felt shamed and was unable to sleep following an incident with R36 who offered her money and touched her breasts when she did not want him to. In addition, the facility staff were unaware or knew why R44 was placed on 15 minute checks, and there were subsequent encounters between R44 and the perpetrator (R36). Furthermore, there was conflicting information in the investigation. These allegations of abuse, and lack of facility investigation and protections resulted in an immediate jeopardy (IJ) situation for R44. The IJ began on 7/14/18, at an unknown time, when R44 approached and self-reported to the facility staff that on that day R36 offered her money in exchange for touching her breasts, and she did not want him to. The facility failed to identify potential sexual abuse and immediately protect R44, or thoroughly investigate the circumstances to determine if actual abuse occurred. The facility administrator and director of nursing (DON) were notified on 7/26/18, at 5:00 p.m. of the IJ. The IJ was removed 7/27/18, at 3:50 p.m. however, non-compliance remained at the lower scope and severity of a D which is isolated with potential for more than minimal harm. Findings include: R44 was sexually abused when she was coerced into taking money in exchange for R36 (male resident) to touch and fondle her breasts. Once the incident occurred, R36 continued to enter R44's room, without her consent which caused R44 to become fearful, scared and afraid, resulting in making it difficult for her to sleep. Although R44 told the facility multiple times she did not want R36 in her room, the facility did not provide adequate protection for R44, after the sexual abuse occurred. R44's OBRA Admission Minimum Data Set ((MDS) dated [DATE], indicated she was cognitively intact, required extensive assistance of one staff with activities of daily living (ADLs), and used a wheelchair for mobility. R44's care plan dated 5/02/18, indicated [DIAGNOSES REDACTED]. R44's Care Area Assessment (CAA) dated 4/27/18, indicated she required assistance with ADLs, was alert and oriented, had deficits in judgement, and was impulsive. R36's OBRA Admission MDS dated [DATE], indicated he was cognitively intact, and required extensive assistance of two staff with ADLs. R36's Initial Comprehensive Care Plan dated 6/6/18, indicated he was alert and orientated, and had weakness. The care plan further indicated R36 had no behaviors. R36's CAA dated 6/13/18, indicted he was alert and orientated, and received therapy due to a fall at his previous living situation. The CAA indicated R36 planned to return home. A Facility Investigation Report submitted to the Office Of Facility Health Complaints (OHFC) on 7/14/18, at 11:29 p.m. indicated R44 reported to the nurse on duty that another resident (R36) had gone into her (R44's) room, closed the door, and offered her money to allow him to touch her breast, which he did. The report indicated the victim (R44) asked him to stop, which he did, then he left the room. The report further indicated R44 did not want R36 to touch her breast. An Internal investigation was initiated. A Facility Investigation Five Day Report dated 7/23/18, at 6:19 p.m. indicated R44's care plan was reviewed, and the administrator met with R44 to discuss the incident. The investigation report originally indicated R44 did not accept the cash, she did not want R36 to touch her. After a conversation, R44 informed the facility she did in fact accept the $10 in cash. R44 stated she and the alleged perpetrator (R36) went into her room, and closed the door behind them. R44 said someone knocked on the door, and asked them to keep the door open. R36 then suggested they go down to his room. R44 stated she followed R36 to his room, they closed the door, and she allowed him to touch her breast. R44 stated she did not want another encounter with R36, and wished for him to stay away from her. The facility indicated on the report R44 was placed on 15 minute checks, R36 was informed of R44's wishes to not meet with him again, and R36 agreed. During interview on 7/25/18, at 1:54 p.m. the administrator stated there was an incident between R44 and R36 that occurred on Saturday, 7/14/18, and she was unsure what time it occurred. The administrator stated she was informed by the director of nursing (DON) about the incident, then reported the incident to the State Agency (SA) later that evening. The administrator stated she completed the investigation, and R44 informed her that R36 offered her $10 in exchange to touch her breasts. Further, the administrator stated R44 was placed on 15 minute checks, then the facility decided to also place R36 on 15 minute checks. The administrator stated she talked with R36, and he did admit to offering R44 money so he could touch her breasts. The administrator stated she informed R36 that R44 did not want this to happen again. Although the incident between R44 and R36 occurred on 7/14/18, there was no mention of the incident in the medical record for either resident. Review of R44's progress notes identified the following: On 7/16/18, at 10:40 a.m. R36 was observed in R44's room, and then left her room. R36 went outside shortly after R44 went outside, and stated, I'm going outside but I'm using a different door. Staff redirected R44 to go outside in the courtyard near the south nursing station, so she could be supervised by staff. R44 stated she would knock on the door if R36 came around her. On 7/25/18, at 12:30 p.m. at 11:00 a.m. that morning, R36 was observed by a staff member coming out of R44's room. R36 stated, (R44's) busy. Staff asked R44 about R36 coming into her room, and R44 stated she was going to see her case worker and was leaving, and so R36 left her room. R44 also stated R36 did not touch her, or do anything else to her. As a result of the 7/14/18, incident, the facility initiated monitoring of R44 and R36. Both residents had a Resident Check List (RCL), and staff were directed to monitor and document R44's and R36's where abouts every 15 minutes for their safety. R44's 15 minute monitoring began on 7/18/18, at 10:30 a.m. (four days after the incident occurred). Review of R44's 15 minute checks did not identify that R36 was in R44's room on 7/25/18, at 11:00 a.m. but identified R44 was in the lobby during that time. R36's RCL indicated monitoring began on 7/18/18, at 10:00 a.m. and was stopped on 7/23/18, at 11:15 a.m. Although the facility implemented RCL for each resident, they were not consistently monitored to ensure resident safety. During an initial interview on 7/23/18, at 8:45 a.m. R44 stated she was in her room in her electric wheelchair when R36 came into her room and gave her $10. R44 stated she asked R36, What for, I don't want your money. R36 told R44 he wanted her to show him her breasts, and he wanted to touch her breasts. R44 stated she tried giving R36 his $10 back, but he continued to touch her breasts. R44 stated she did not want him to do this. R44 stated she had reported this to a nurse who was working the night the incident occurred. R44 also stated the DON and the administrator were both aware of the incident, and they were both aware she wanted R36 to stay away from her. During an additional interview with R44 on 7/25/18, at 5:00 p.m. R44 stated R36 came into her room, gave her $10.00, and stated he wanted to play with her breasts and she told him no. R44 then stated R36 pulled on her shirt and rubbed her breast and continued to pull her shirt down and rubbed on her breast which made her feel awful. She identified R36 came into her room again after the incident. R44 state, (R36) just comes into my room without knocking on my door. R44 further stated she did not want R36 to come into her room. During a subsequent interview on 7/26/18, at 10:07 a.m. regarding the incident on 7/14/18, R44 stated, When he touched me, I wanted to hit him but I cant. After the incident I wanted to get away for awhile, go to town or do something. I cried after it happened. I didn't want to say anything but I knew I should, so I told the nurse and had her shut the door when I told her. R44 stated it made her feel dirty and feel sexually harassed and abused. R44 added, When he came into my room the last time (7/25/18) I was upset. My door was open and I told him he needed to move, which he did, and backed his wheel chair out of the room, and I closed the door in my room. R44 further indicated it made her feel humiliated and upset. While R44 was describing the incident her eyes became watery, and teary. R44 stated she was worried the incident would happen again, adding she had not been sleeping, and she was afraid. R44 reiterated she did not want R36 in her room. During interview 7/26/18, at 10:53 a.m. R36 stated he had been at the facility for several months, and the administrator talked with him shortly after the incident occurred on 7/14/18. R36 stated the administrator told him that R44 did not want him to come around her. After the administrator talked to him, R36 said he told the administrator, OK. R36 did not disclose he went back into R44's room on 7/16/18, and 7/25/18, after he was told by the administrator not to go into her room, and he had agreed to say out of her room. Review of the facility 15 minute monitoring for R44 and R36 identified the following: During interview on 7/25/18, at 7:00 p.m. nursing assistant (NA)-H stated she worked with R44, and was not aware of any incident between R44 and another resident. NA-H further stated she was not aware R44 was on 15 minute checks or monitoring. In addition, NA-H checked her nursing assistant care sheet, and verified there was no direction for monitoring for R44. During interview on 7/25/18, at 7:21 p.m. NA-I stated she has worked with R44, and R44 had no behaviors. NA-I stated she was supposed to keep an eye on R44 every 15 or 30 minutes. NA-I further stated she was aware of an incident between R44 and another resident last week, but was not certain of what happened. During interview on 7/25/18, at 7:27 p.m. resident companion (RC)-A stated she was not aware of any behaviors with R36, or if there was any special monitoring for R44 or R36. During interview on 7/25/18, at 7:51 p.m. NA-J stated she was not aware of any monitoring for R44, and she was not aware of any incidents between R44 and any other resident. During interview on 7/26/18, at 10:58 a.m. NA-F stated R36 was on 15 minute checks, and was not aware of the reason. NA-F stated nurses and nursing assistants are to document the 15 minute checks on a sheet at the nurses station. During interview on 7/26/18, at 11:05 a.m. NA-G stated R36 was on 15 minute checks because of another resident, but was not sure which resident. NA-G stated she documents R36's location every 15 minutes. During interview on 7/26/18, at 11:09 a.m. licensed social worker (LSW)-A stated on Monday, 7/23/18, she had heard bits and pieces of the incident between R44 and R36, but she was not involved. LSW-A further stated situations like this were discussed at morning meeting, but she had to step out during the meeting. LSW-A further stated she had not talked to R44 after the incident with R36, because LSW-A was on leave on 7/24/18. During interview on 7/26/18, at 11:54 a.m. with the administrator and DON, the DON stated she was informed of the incident on 7/14/18, around 9:00 p.m. when RN-D informed her what occurred. The DON stated she informed the administrator of the incident, and the administrator filed a report to the SA. After she was informed of the incident, the DON stated she placed R44 on 15 minute checks, and a few days later decided R36 also needed to be placed on 15 minute checks. The DON stated when she was told about the incident she told the two nurses who were working that day, licensed practical nurse (LPN)-D, and RN-B to keep an eye on both residents. The DON stated she did not tell the nurse who was caring for R36 what actually occurred, because she wanted to keep R44's incident confidential. In addition, although the administrator stated R44 was placed on 15 minute checks, and a few days later R36 was also placed on 15 minute checks, the reports indicated both were placed on 15 minute checks on 7/18/18. During interview on 7/26/18, at 2:20 p.m. LPN-B stated they were doing 15 minute checks on R44 to monitor her location. LPN-B further stated she found out about the incident through a nursing report, and indicated R44 had issues with another resident, but was not sure why. During interview on 7/26/18, at 2:35 p.m. R44 stated the incident happened so fast he (R36) gave her the money and she took it and said, What is this for? R36 told her he wanted to touch her breasts, and she told him, I don't want your money but he would not take the money back. R44 indicated he touched her breasts through her shirt, and then removed her shirt strap, put his hand down her shirt and touched her breast. R44 stated she felt assaulted, and felt R36 tried to bribe her with the money. After the first incident occurred, R44 stated R36 told her again that he would give her another $10 to touch her breasts. R44 stated she told R36, I don't want you to do this! R44 stated she did not go to his room, and confirmed the incident occurred in her room. During interview on 7/26/18, at 4:36 p.m. RN-B stated the facility stopped R36's 15 minute checks after their morning meeting on Monday, 7/23/18. RN-B stated no additional incidents occurred, and she was directed by the administrator to stop the 15 minute checks, even though R36 was in R44's room after the 15 minute checks were stopped. During observation on 7/27/18, from 9:40 a.m. until 2:20 p.m. R44 was not observed to have contact with R36. The facility's Abuse Prevention/Vulnerable Adult Plan undated, indicated abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain or mental aguish. The policy identified sexual abuse as non-consensual sexual contact of any type with a resident. The policy also directed to that immediately, upon learning of an incident, staff will take necessary steps to protect residents from possible subsequent incidents of misconduct or injury while the matter is being investigated. The facility policy directed to immediately report to the Minnesota Adult Reporting Center (MAARC). The facility policy also directed the facility's investigation team would review all incident reports regarding residents. The IJ that began on 7/14/18, was removed on 7/27/18, at 3:50 p.m. when the facility conducted an investigation of the incident, and additional training was provided to the DON and administrator, R44 had been placed on 15 minute checks, R36 was placed on 1:1 for close monitoring to ensure other residents were free from abuse, all verbal residents were interviewed to ensure they were free from abuse, neglect, mistreatment and exploitation, the facility Abuse Prevention/Vulnerable Adult Plan was reviewed, all staff were educated on the Abuse Prevention/Vulnerable Adult Plan, staff were educated on the reason for resident monitoring, and the administrator and DON were educated on the Abuse Prevention/Vulnerable Adult Plan specific to reporting resident abuse and sexual abuse. On 7/27/18, from 3:15 p.m. to 3:45 p.m. front line staff and nurses were interviewed, and stated they were educated on the Abuse Prevention/Vulnerable Adult policy, and the rational for R44 and R36's increased monitoring. The noncompliance remained at the lower scope and severity level of D which is isolated with potential for more than minimal harm.

Based on observation, interview, and document review, the facility failed to secure adequate pain medications to allow prescribed medication to be administered as ordered to prevent episodes of pain and discomfort for 2 of 2 residents (R11, R250) reviewed for pain management. This resulted in actual harm for R11 who demonstrated severe physical symptoms of pain on multiple occasions. Findings include: R11's significant change Minimum Data Set ((MDS) dated [DATE], identified [DIAGNOSES REDACTED]. The MDS also indicated R11 required extensive assistance to complete activities of daily living (ADLs) and was severely cognitively impaired. R11 was identified as enrolled in Hospice effective 4/25/18. A corresponding Care Area Assessment (CAA) completed on 5/14/18, identified R11's level of pain impacted her sleep, limited her day to day activities, was rated as severe, and was noted to occur frequently. The assessment indicated [REDACTED]. R11 was also noted to have pain in her buttocks. The CAA identified pain had improved since R11 had enrolled in Hospice. The desired outcome for care was palliative with symptom relief. R11's care plan revised 7/23/18, indicated [REDACTED]. R11's care plan indicated staff were to implement non-pharmacological interventions including repositioning, television in R11's room, warm blanket, family/friends company, and music. In addition, the care plan directed staff to monitor R11's level of pain with the use of a flow sheet or FLACC (Face, Legs, Activity, Cry, Consolability)/Dementia scale, with a pain assessment per protocol. The care plan indicated R11 received medications as ordered by the primary provider (physician), and staff were to monitor for the effectiveness of the medications as well as potential side effects. Staff were also to encourage R11 to verbalize discomfort, and use rest periods. The care plan directed staff to turn and reposition R11 every two to two and a half hours, and to lift, not slide her to decrease friction, and to encourage R11 to lie on her sides while in bed to offload her bottom. R11's pain evaluation completed on 4/30/18, identified R11 had experienced pain frequently over the last five days. The evaluation indicated the pain had impacted her sleep, limited her day to day activities, and was rated by R11 as severe. At the time of the assessment, R11 was using [MEDICATION NAME] and [MEDICATION NAME] (narcotic pain medications) to manage her pain. The assessment indicated staff were to administer medications as ordered and to monitor for effectiveness. The assessment also indicated staff were to monitor for increased signs and symptoms of pain and intervene as needed. On 7/23/18, at 7:15 a.m. R11 was observed in the dining room vocalizing moaning sounds. Family member (FM)-A responded to R11 and inquired as to whether she was hurting. As the meal progressed FM-A asked R11 at 7:23 a.m. if she was crying because she hurt. R11 continued to moan. At 7:27 a.m. FM-A was heard again asking R11 if she was crying because she hurt, to which R11 responded, Yes. FM-A was heard telling R11 she had received pain medications, adding they, must not be working. Let's eat quick and then get you laid down. R11 was reclined back in her wheelchair as FM-A assisted her to eat. At 7:29 a.m. R11 was heard moaning out loud, and FM-A was dabbing R11's eyes with a tissue. R11 was wheeled out of the dining room by FM-A at 7:30 a.m. On 7/23/18, at 8:35 a.m. R11 was observed resting in bed. R11 made moaning vocalizations, however, did not verbalize a response when asked whether she was experiencing pain. On 7/23/18, at 11:30 a.m. R11 was observed resting on her bed. R11 displayed facial grimacing, with her eyebrows and forehead furrowed with moisture in the corner of her eyes. R11 was making rhythmic moaning noises, without discernible words. A review of the electronic records indicated a pain assessment was completed on 7/23/18, by registered nurse (RN)-B. The pain assessment indicated [REDACTED]. The document indicated, Resident states pain is occasional, and rated 4/10 at worst (10 being the worst), and does interfere with sleep and daily activities. The assessment further indicated R11 received scheduled [MEDICATION NAME] (pain medication) 10 milligrams (mg) at 8:00 a.m., and 5 mg at 4:00 p.m. in addition to orders for [MEDICATION NAME] (narcotic) 10 mg and Tylenol 650 mg as needed. However, the assessment indicated the medications had not been used during the assessment period. Interventions identified for use of the pain medications included administration of medications as ordered, monitoring for effectiveness, monitor resident for signs and symptoms of pain, and intervene as needed. The assessment also indicated staff were to update the care provider as needed. The assessment did not indicate notification of Hospice regarding the pain assessment completion, or of concerns regarding effectiveness of the current pain regime. On 7/23/18, at 4:03 p.m. a call was placed to the Hospice agency to inquire whether about any contact regarding pain management for R11. The Hospice director (HD) stated she had not received any calls in follow up, and there had been no notification or contact regarding R11's increased pain level. The hospice registered nurse (HRN)-A who was R11's case manager was currently out of the office, but the HD stated she would advise her of the call and follow up. The HD stated when a resident is enrolled in Hospice and has increased pain, it was the expectation of Hospice for the nursing facility to contact the 24-hour nurse call line to advise them of the pain, so evaluation and coordination of current interventions could be done, with subsequent development of an appropriate plan of care for R11. On 7/24/18, at 2:28 p.m. R11 was observed in her room resting on her bed lying on her back. R11 was resting quietly with relaxed facial expressions. On 7/25/18, at 2:14 p.m. R11 was observed in her wheelchair with her legs elevated on the foot rests. R11's eyes were closed, her brows were furrowed, and R11 was moaning in a constant, rhythmic pattern. HRN-A was present in the room. Nursing assistant (NA)-G entered the room to provide cares, and placed R11's right leg on a pillow to provide full leg support. R11 continued to cry out with a moaning sound. Registered nurse (RN)-B entered the room to provide assistance. NA-G and RN-B assisted with placing a mechanical lift sling under R11, while R11 continued to constantly moan which intensified with physical movement. R11 was transferred to her bed, and the mechanical lift sling was removed. An acidic odor was noted in R11's room and HRN-A was unsure whether it was related to R11's foot wound, or bowel incontinence, so HRN-A requested staff check her incontinence brief. Incontinence care was provided by NA-G and RN-B with no noted incontinence of bowel. R11 had an open area on her coccyx with no dressing in place. HRN-A stated this area was not present when she had last seen R11 for evaluation. RN-B stated their Wound Care Consultant (WCC) had instructed them to leave the area open without placement of a dressing. HRN-A placed an Allevyn Sacral Dressing (foam moisture absorbing dressing that breathes) to the affected areas on the coccyx. R11 had ceased moaning while measurements were obtained, but resumed moaning and vocalizations which intensified with any increased movement. R11 was observed to hold her upper body in a semi-fetal position. Once R11 was repositioned, RN-B asked R11 where the pain was located. R11 continued with moaning vocalizations and did not identify where her pain was located. RN-B removed the pillows, and R11's vocalizations intensified. HRN-A offered suggestions to shift the pillow down to assure R11's heel was floating. A blanket was placed to provide less support/pressure than a pillow in an attempt to improve R11's comfort level. R11 vocalized crying out and moaning when her entire leg was moved. RN-B asked R11 to rate her pain however, R11 only amplified vocalizations with moaning. HRN-A rubbed R11's hand and arms, offering words of reassurance. HRN-A also asked RN-B about R11's recent pain medication status. RN-B stated she would follow up and exited the room. During interview with NA-G, following provision of cares on 7/25/18, at 2:46 p.m. NA-G stated when R11 was observed to be uncomfortable as evidenced by verbalizations, vocalizations, moving in chair, and facial expressions. NA-G stated she would assist with repositioning R11, offer to lay R11 down, and would advise the nurse if those measures were not beneficial in providing comfort. During the observation at that time, R11 began to cry out loudly, tear up, and displayed facial grimaces of her brows and forehead being furrowed. R11 also emitted a continuous moaning sound. On 7/25/18, at 2:47 p.m. licensed practical nurse (LPN)-A entered R11's room to administer [MEDICATION NAME] liquid. When asked when the resident had previously received dosing of [MEDICATION NAME], LPN-A stated R11 had not received the [MEDICATION NAME] liquid for several days. At 2:49 p.m., R11 continued to cry out with her lips quivering and tears present in both of her eyes. LPN-A offered to provide R11 assistance to contact FM-A. R11 continued to cry responding, Mmmmmm. R11's lips continued to quiver, and tears were observed in the corners of both eyes. LPN-A placed a call to FM-A at 2:51 p.m. LPN-A held the phone to R11's left ear and R11 was observed to purse her lips, and to furrow her brows and forehead. R11's eyes were squinted closed, and R11 was actively crying with vocalizations and tears present. R11 cried into the phone, Help me, help me, help me. At this time, the head of the bed was elevated, R11 was lying on her back, pillows were under her right leg, and HRN-A and LPN-A were observed to rub R11's shoulder and arm in a comforting motion. At 2:55 p.m. R11 continued to call out. LPN-A stated R11 did not consistently take her [MEDICATION NAME] (pain medication) for pain management. The HRN-A stated she had not been informed of R11's increased pain and added the [MEDICATION NAME] dosing had been increased two weeks ago, but the Hospice agency had not been informed of R11's refusals to take her medication. At 2:58 p.m. while being comforted by staff, R11 spoke into the telephone to FM-A, It hurts. R11 continued to call out in an amplified tone of pain, and continued to moan. During this interaction, LPN-A stated R11 had [MEDICATION NAME] (anti-anxiety) for symptom control when asked what interventions have been effective. LPN-A stated R11 had a family friend (FF)-A who visited frequently, and indicated FF-A may be more aware of what provided R11 comfort. LPN-A stated the television was put on as a distraction, but was not helpful. LPN-A was not aware of other non-pharmacological interventions implemented to provide R11 comfort. LPN-A stated R11 had not received her morning dose of [MEDICATION NAME] because there had been no supply available. LPN-A was unsure when the last dose of [MEDICATION NAME] had been administered, and stated she would follow up with the previous shift to check. During a visit with R11 on 7/25/18, at 3:04 p.m. HRN-A stated this was the worse pain she had observed R11 experience. HRN-A stated she had not been notified by staff of the increased pain observed. HRN-A stated they had worked with FM-A, R11's primary medical provider, and the facility on R11's pain management. HRN-A said R11's [MEDICATION NAME] had been increased two weeks ago, and stated she had intended to consult with the hospice pharmacy and evaluate for a possible need to increase R11's [MEDICATION NAME] dosing. However, HRN-A stated Hospice had not been informed R11 had refused her medications, or that the facility was out of R11's [MEDICATION NAME] supply. HRN-A stated she would have expected the facility to advise Hospice of R11's refusal to take the medication, of any symptoms of R11 exhibiting increased pain, and of any lack of supply of [MEDICATION NAME]. HRN-A stated when she had increased the dosing two weeks ago she had verified with FM-A to assure an adequate supply was available. HRN-A stated the hospice medical director could have facilitated a refill of medications if needed, and if alerted. HRN-A stated the facility not having [MEDICATION NAME] available for administration was concerning. On 7/25/18, at 3:26 p.m. HRN-A continued to massage R11's hands and lower arms, and R11 was observed to decrease both the intensity and frequency of her vocalizations. R11 responded, Both when asked if she was sad or in pain. HRN-A continued to massage R11's hands and offered to pray with R11. R11 started verbalizing a prayer out loud and continued to repeat this prayer, with her facial expression becoming more relaxed as evidenced by decreased furrowing of her brows, and absence of tears. On 7/25/18, at 3:30 p.m. LPN-A returned to the room and informed HRN-A the last dose of [MEDICATION NAME] had been given the previous evening, and verified no morning dose of [MEDICATION NAME] had been given. LPN-A stated the pharmacy had been contacted to refill the medication and was awaiting a prescription. LPN-A stated the [MEDICATION NAME] supply was monitored by facility staff and also by the pharmacy, and stated R11's medical doctor (MD)-A had been in the facility that day conducting rounds, but staff had not obtained a written prescription for the [MEDICATION NAME] refill during rounds. On 7/25/18, at 3:38 p.m. HRN-A stated the facility was responsible for ordering the [MEDICATION NAME]. HRN-A said the lack of [MEDICATION NAME] for dosing was of concern to her, and stated it was irresponsible of the facility. A review of the medication administration sheet, in correspondence with the narcotic count book, R11 had last received [MEDICATION NAME] on 7/24/18 at 4:48 p.m. The documentation also reflected refusal of [MEDICATION NAME] dosing the morning of 7/24/18. A review of the medication sheet for 7/25/18, indicated a refusal of morning dose of [MEDICATION NAME], however, the individual narcotic record for R11 indicated a count of zero following the 4:45 p.m. 7/24/18, dose. A review of the Medication Administration Record [REDACTED]. On 7/25/18, at 5:46 p.m. LPN-A stated R11 had received a second dose of [MEDICATION NAME] for pain management. LPN-A stated the [MEDICATION NAME] should be delivered in time for the evening dose. On 7/26/18, at 7:00 a.m. FM-A was at the resident's bedside. R11 was observed in bed, resting on her back with the head of her bed raised. R11 stated, Good morning. FM-A stated she had been with R11 since early morning, and stated R11 was resting more comfortably at this time. On 7/26/18, at 10:45 a.m. R11 was observed in bed, and was noted to be awake. R11's facial expression was noted to be free from furrowed brows, squinted/tearful eyes, and pursed lips. Trained medication assistant (TMA)-A was in with R11, and stated R11 had received her routinely scheduled [MEDICATION NAME], and an additional dose of [MEDICATION NAME] for pain management and was doing well. When asked, R11 responded she was, Pretty good. During conversation on 7/26/18, at 10:58 a.m. HRN-A stated she had been contacted by the the facility the prior evening after R11 had received the second PRN dose of [MEDICATION NAME], and was notified R11 was actively dying. A Hospice visit was offered to the facility and the facility declined. HRN-A stated R11 was demonstrating increased shallow breathing following the second dose of [MEDICATION NAME]. HRN-A stated R11's lethargy and shallow breathing may have been related to the dosing of [MEDICATION NAME]. HRN-A stated historically, R11 had taken only one dose of [MEDICATION NAME] as needed throughout the course of a day. HRN-A stated R11 being out of [MEDICATION NAME] made a huge difference for her for pain, and receiving two doses of [MEDICATION NAME] impacted her response. HRN-A stated she used a dementia scale for pain with FLACC and would have classified R11 as a score of eight to nine on a scale of one to ten, indicating severe pain. On 7/26/18, at 11:24 a.m. a call was received from FM-A. FM-A stated she had seen R11 on 7/19/18, and again on 7/22/18. FM-A described R11's pain on 7/22/18, as really bad. FM-A reported on 7/22/18, R11 had been crying, and had stated she was having pain in her buttocks, legs and back, and had been laying all day. FM-A stated R11 had been observed on 7/22/18, to cry for about two and a half hours. FM-A said she contacted staff and requested they transfer R11 into bed. FM-A stated staff stopped by a few times, but added, sometimes when I am there they just let us be. FM-A stated, The nurse on Sunday told me (R11) had refused medications on occasion and they had discussed alternate routes. FM-A stated she was at the facility on 7/23/18, at 7:00 a.m. and R11 was crying at the breakfast table. FM-A stated R11 had been just sitting there kind of moaning. FM-A stated when R11 was asked what was wrong, R11 stated her butt hurt and was crying. FM-A stated if R11 was experiencing pain, she should have received pain medication, and stated staff had not asked her what types of things R11 might find soothing. FM-A stated R11 previously had watched old time television like the Andy Griffith show, and stated R11 enjoyed country western music. Although FM-A said R11 had been out to music activities, FM-A was unaware of whether R11 had music provided in her room. FM-A stated she was not aware R11 had not received her [MEDICATION NAME] on 7/25/18, and stated the [MEDICATION NAME] had been very effective for R11 historically. FM-A further stated R11 did not like to use [MEDICATION NAME] as needed because she did not like the way the medication made her feel. FM-A stated she had contacted the administrator approximately the third week in (MONTH) regarding transferring R11, because R11 would call out in pain with moment. FM-A stated they had since been much better about trying to keep her comfortable. A review of the treatment administration record for pain management was reviewed and noted R11 was recorded as exhibiting no pain from the 15th to the 25th of (MONTH) during the 6:00 a.m. to 2:30 p.m. shift. R11's pain levels from the 2:30-10:00 p.m. for the same period was rated with zero to one. R11's pain monitoring sheets for the 11:00 p.m. to 6:00 a.m. shift, indicated R11's pain levels were all recorded at zero with the exception of 7/26/18, at which time the pain level was recorded at one. On 7/27/18, at 1:37 p.m. the director of nursing (DON) stated if a resident was noted to experience pain with movement, staff could try to medicate before assisting the resident to reposition. When the pain assessment completed 7/23/18, was reviewed with the DON, the DON stated she would expect Hospice to be contacted regarding R11's increased presence of pain, to review current interventions and modify her plan of care as necessary. A review was completed with the level of pain recorded on the treatment administration record in comparison to the narrative notes and medications administered. The DON stated the level of pain recorded should correspond with the interventions in place. The DON stated she was unaware R11 had not received her morning dose of [MEDICATION NAME] until she was informed she was out of [MEDICATION NAME] in the afternoon. The DON stated controlled substances are ordered from the pharmacy through a routine refill process. The DON stated if staff note the supply is down to a one day supply, they were supposed to fax and call the pharmacy to advise them of this. The DON stated at the time they were out of medication, the pharmacy was to be called and a plan of action coordinated. The DON further confirmed she was unaware of the need for a prescription form from MD-A until he had left the facility following rounds. On 7/27/18, at 3:35 p.m. the administrator stated she had spoken to FM-A regarding R11's status. The administrator stated she had discussed FM-A's concerns regarding management of comfort for R11. The administrator stated at times it was difficult to determine the underlying causes for vocalizations as R11 had made moaning vocalizations in a positive manner with pet visits. The administrator also stated FM-A had expressed concerns with R11's comfort interventions, especially when turning and repositioning the resident. R250's undated Admission Record identified R250 was admitted to the facility on [DATE]. R250's admission orders [REDACTED]. R250's undated, Initial/ Comprehensive Care Plan section for pain and comfort was blank and did not identify R250's risk for pain, any goals, or interventions to manage pain. R250's Pain Evaluation dated 7/21/18, indicated R250 had frequent lower back pain,and rated her pain a 3 out of 10. The evaluation indicated R250 had been taking [MEDICATION NAME] 50 mg as needed for pain, and indicated the pain did not interfere with her sleep but did interfere with her activities of daily living. On 7/23/18, at 11:21 a.m. R250 was observed lying in her bed. At that time, R250 stated she had chronic lower back pain, and rated her pain a 6 out of 10. R250 described the pain as throbbing, and stated she had been prescribed [MEDICATION NAME] and it helped relieve her pain, but stated it had been 4-5 days since she received any [MEDICATION NAME] because she had been told by facility staff she was out of the medication. R250 stated other medications did not help, so she had stopped asking for medication. On 7/25/18, at 2:28 p.m. R250 was lying in her bed. She sat up to the edge of her bed and placed her right hand on her lower back and grimaced. Once seated at the edge of her bed, she removed her hand from her back and was no longer grimacing. She stated she had not heard what was going on with her pain medication and was now rating her pain at a 7 out of 10. She stated her pain was better with movement, and lying in bed most of the day did not help relieve her pain. R250's MAR for (MONTH) (YEAR), identified R250 received 15 doses of [MEDICATION NAME] 50 mg from 7/12/18, until 7/17/18. No further doses of [MEDICATION NAME] 50 mg were administered. During interview on 7/25/18, at 2:36 p.m. NA-B stated R250 was very independent and had little interaction with her, but if she was having pain she would let the trained medication aid or nurse know. During interview on 7/25/18, at 2:42 p.m. TMA-A stated R250 had not complained of any pain. On 7/25/18, at 5:16 p.m. the medication cart was reviewed with LPN-A. LPN-A stated R250 did not have any [MEDICATION NAME] on the medication cart, and no longer had an order for [REDACTED]. LP:N-A stated R250 had not been asking for pain medications for about the last week, and added staff should be asking R250 to rate her pain when they gave her pain medications. During interview on 7/25/18, at 6:50 p.m. RN-A stated R250 had chronic back pain, and had been admitted with [MEDICATION NAME] to manage her pain. RN-A stated she was responsible for completing the baseline care plan, and verified it was not completed. RN-A said a baseline care plan should have been developed to include interventions for pain control. RN-A was not aware until that afternoon that R250 had been complaining of back pain, had requested pain medications, or that R250 was out of [MEDICATION NAME]. RN-A stated she left a message with the on-call physician and called the pharmacy to get her pain medication. RN-A stated the TMA or nurse on the cart should have re-ordered R250's pain medication when there were 5 doses left. RN-A stated if there were only 2 doses left and additional pain meds had not been received, the pharmacy should have been called. RN-A stated the facility could have definitely done more to manage R250's pain. A facility policy for pain management was requested, but was not received.

Based on observation, interview, and document review, the facility failed to conduct a comprehensive assessment/reassessment related to pressure ulcers and implement pressure ulcer interventions to reduce the risk of development of multiple pressure ulcers for 2 of 2 residents (R24, R11) who were reviewed for pressure ulcers. This resulted in actual harm for R24 and R11 who developed multiple pressure ulcers as a result of friction and shear without adequate interventions. Findings include: Pressure Ulcer stages defined by the National Pressure Ulcer Advisory Panel (NPUAP): Stage 1 Pressure Injury: Non-blanchable [DIAGNOSES REDACTED] of intact skin Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. R24's annual Minimum Data Set ((MDS) dated [DATE], identified R24 had intact cognition and was able to communicate her needs and wishes. The MDS identified R24 was noted to have an indwelling urinary catheter in place to manage urinary functions, and was incontinent of bowel. The MDS indicated R24 received extensive assistance to complete tasks of daily living (ADLs) which included transfers, turning and repositioning, and personal cares. The MDS identified [DIAGNOSES REDACTED]. The MDS identified R24 was at risk for the development of pressure ulcers, and identified pressure reduction devices for R24's chair and bed. R24 was also identified as receiving treatment/ointment other than for foot problems, however, the MDS did not identify R24 had any skin problems. R24's Care Area Assessment (CAA) worksheet dated 5/4/18, indicated R24 was at risk for pressure ulcers related to multiple risk factors that included obesity, diabetes, neurological diseases, chronic pain, and muscle spasms. The CAA indicated R24 would receive staff assistance to turn and reposition every two hours, use of a pressure reduction mattress, and a cushion in the wheelchair. R24's care plan revised on 7/6/18, identified R24 received assistance to complete her ADLs related to her level of strength. The care plan indicated R24 required extensive assistance of two staff to turn and reposition in bed every two hours, and as necessary. The care plan also directed staff to provide R24 with assistance to complete personal hygiene including skin cleansing, and completion of incontinence cares every two hours. The care plan identified R24 went to the Wound, Ostomy, Continence (W[NAME]) nurse at the hospital for wound follow up, and as needed (PRN). The care plan was revised on 7/10/18, to identify an abrasion on R24's right buttocks. The care plan identified staff were to monitor skin integrity during cares, and to complete weekly documentation. The care plan lacked identification of weekly wound care services provided by Integrated Wound Care (wound care consultant). The nursing assistant care sheet identified under the heading Offload Reposition Assist of two. The care sheet lacked the frequency of every two hours repositioning as directed by the care plan. During observation on 7/23/18, at 9:02 a.m. nursing assistant (NA)-K provided assistance to complete personal dressing and grooming for R24. NA-K completed peri cares, and proceeded to provide cleansing to abdominal folds. Upon turning onto the left side to complete cares, R24's coccyx, gluteal cleft, labia, rectal area, and skin extending down from buttocks to upper thighs were covered with white cream. NA-K proceeded to wash this area with soap and water and applied [MEDICATION NAME]. NA-K stated the nurses will come in to assess areas if there are concerns. NA-K stated at times the area is So sore that it bleeds adding the areas were bleeding last week. During observation of personal care on 7/23/18, at 9:14 a.m. R24 right gluteal cleft and upper thigh had an area macerated with a slough-like appearance and measured approximately 18 centimeters (cms) by 23 cms in a triangular shape. R24's left buttocks had a smaller area measuring approximately 13 cms by 13 cms. R24 also had an area on her labia, which registered nurse (RN)-B described as, Scabs. The area had approximately a 5 cm area with light yellow (serous) drainage. RN-B stated these areas were considered friction or sheering, adding a pressure area would not be blanchable. During observation on 7/26/18, at 7:21 a.m. personal cares were provided with NA-F, NA-L, and RN-B. Upon removing the incontinence product, RN-B stated R24's areas had a build up of tissue or scabs. During provision of care, R24 commented the area was Sore and It burns. RN-B completed measurement of the areas as follows: Left buttocks area was 17 cm by 11.6 cm and was described by RN-B as oval in shape. The alteration in skin integrity on the labia and perirectal area was measured by RN-B at 3.7 cm by 2.4 cm. Right buttocks area measured at 9.9 cm by 9.5 cm. During interview with RN-B (during provision of cares) RN-B stated R24 should be off loaded (shifting and removing pressure from affected areas) and repositioned every two to two and a half hours. R24 commented aloud that on 7/25/18, she was assisted to bed at approximately 9:10 p.m. and was not assisted to reposition until she put her call light on after 5:00 a.m. to request repositioning (over seven hours between being turned and repositioned). Immediately following the provision of cares and skin measurements on 7/26/18, at 7:21 a.m. RN-B reviewed the plan of care for R24 which directed staff to turn and reposition R24 at least every two hours and more often as requested. RN-B stated the presence of an incontinence pad would cause increased moisture sweat/body heat, which would keep the wound moist, not letting it dry out, increasing effects of friction and pressure. RN-B stated she was unaware of R24 not being repositioned, adding R24 had not informed her of this concern. A review of the Integrated Wound Care (Wound Care Consultant, WCC) progress note was completed with RN-B on 7/26/18, at approximately 7:45 a.m. which identified the following findings: 6/5/18: R24 was identified to have a single partial thickness buttock wound with a listed duration of 1 week. The wound was a mixed disease which was not healed, and measured 9 centimeters (cm) length by (X) 7 cm width; with an area of 63 squared (sq) cm. 6/12/18: A single partial thickness buttock wound was listed with measurements recorded of 2 cm length X 2 cm width; with an area of 4 sq cm. A scant amount of serous drainage (clear, thin, watery drainage) was noted, with the peri-wound skin being normal. 6/19/18: A single partial thickness buttock wound was listed with measurements recorded of 0.5 cm length X 0.5 cm width; with an area of 0.25 sq cm. Again, scant serous drainage was observed and the surrounding skin was normal. The dictation identified, The wound is improving. 6/26/18: A single partial thickness buttock wound was listed with measurements recorded of 0.5 cm length X 0.5 cm width; with an area of 0.25 sq cm. Again, scant serous drainage was observed and the surrounding skin was normal. The dictation identified, The wound is improving. 7/3/18 : R24 was now identified to have two buttock wounds. Right buttocks: Partial thickness mixed disease with a status of not healed. Measurement of 1 cm in length by 3 cm in width. Left buttocks: Mixed pressure/ friction area, not healed. Measurements of 1 cm in length by 5 cm in width. Wound status: Deteriorating. A wound care visit by WCC was not completed on the week of 7/10/18. 7/17/18: Right buttocks: Measured 14 cm by 14 cm. Skin status denoted as improving. Left buttocks: Mixed pressure and friction. Deteriorating. A measurement of the area was not documented by the wound care nurse. 7/24/18: Right buttocks: Partial thickness mixed disease. Not healed. Measurement: 14 cm x 16 cm. Left buttocks: Mixed pressure/friction. Deteriorating. Measurement: 14 cm by 16 cm. After this review on 7/26/18, RN-B stated with a deterioration in skin condition, an assessment should have been done to address the potential causes of the deterioration. A review of the facility documents titled, Weekly Pressure Wound Evaluation, were reviewed from 5/29/18, to 7/26/18, which identified the following: 5/29/18: Coccyx: (site unspecified): Shearing with no recorded measurements. No staging was completed of the wound. A Date wound identified was recorded of 5/22/18. Further, Coccyx sheering has improved and not as red and irritated this week. 6/5/18: Coccyx (site unspecified): Shearing with no recorded measurements. No staging was completed of the wound. Further, Sheering (sic) is looking less red and more pink, less painful for the resident. 6/12/18: Coccyx (site unspecified): Shearing with no recorded measurements. No staging was completed of the wound. Further, Sheering (sic) has decreased in size and now only over the center coccyx and not past the buttock. 6/19/18: Coccyx (site unspecified): Shearing with no recorded measurements. No staging was completed of the wound. A Date wound identified was now recorded of 6/19/18. Further, Sheering (sic) is only around the coccyx area and slightly pink. Almost healed. 7/3/18: Three wounds were now listed. Coccyx (Site unspecified) : Sheering: 1 cm x 3 cm. Stage 2 Coccyx (Site unspecified) ; Sheering: 1 cm x 5 cm. Stage 2 Coccyx (Site unspecified) : Sheering: (no measurement) Stage 1 Narrative note indicates that coccyx is close to being healed, with the exception of two open areas on her left coccyx. 7/10/18: No documentation to reflect areas on coccyx. Addressed skin concerns with legs. 7/17/18: Coccyx (Site unspecified) : Sheering: 14 cm by 14 cm Narrative note identified R24 received assist of two to transfer with a mechanical lift but did not identify frequency of turning, repositioning, or offloading. 7/20/18: Buttocks (Site unspecified): Type: Pressure. No size or stage documented. 7/24/18: Buttocks/Upper thigh: Pressure: Size 14 cm by 16 cm. 7/26/18: Right buttocks: Pressure (No staging or size identified). Left buttocks: Pressure: (No staging or size identified). Narrative note indicated R24 was educated as to risk and benefits and reviewed with the director of nursing (DON), which included decreased healing time and increased pain. A review of the nursing assistant care documentation was completed for R24 for the months of (MONTH) and July, (YEAR), and documentation was unavailable for 14 days during this period of 56 days possible. On 12 occasions it was noted to be greater than four hours between checks or repo (repositioning). The documentation had no record of resident refusing to be turned or repositioned. On 7/27/18, at 1:18 p.m. the DON indicated R24's open areas were noted in the documentation on 7/26/18, by RN-B as a pressure ulcer. The DON stated she was unaware R24 was not being turned and repositioned every two hours, however, stated she was aware R24 would refuse to do so at times. The DON stated refusals should be reflected in staff's documentation. The DON stated when a skin area is not improving, assessment for potential cause should be completed, and staff should monitor for consistent repositioning. The DON stated staff had reviewed the risks and benefits with R24 on 7/26/18, which included potential worsening of the skin condition, delay in healing, and alteration in comfort if not routinely repositioned. The benefits of routine repositioning would be prevention of further deterioration of skin breakdown, improved healing, and comfort. The DON stated she did have not have specific information or documentation of R24's refusal to turn or reposition, and stated this should have been documented if this had occurred. The DON stated review of risks and benefits of routine turning and positioning is a routine process for residents with skin care concerns, however, she was unable to provide any documentation to reflect this had been completed, nor was it included on R24's care plan prior to 7/26/18. The WCC was called on 7/27/18, at 2:46 p.m. regarding R24's skin condition. The WCC returned the phone call on 8/1/18, at 4:45 p.m. The WCC stated she does consultation for skin care, and received a consultation for R24 on 6/5/18. The WCC stated R24's skin condition was caused by a mix of things: pressure, friction, and shearing. The WCC stated the pressure ulcer had deteriorated as identified in the progress notes, and there were multiple areas that were involved for R24. This was related to lack of frequency of repositioning R24, the process of repositioning R24, and items underneath R24 while laying on her bed or up in her wheelchair. R11's significant change MDS dated [DATE], indicated R11 exhibited severe cognitive impairment and received extensive assistance to complete her ADLs including mobility and personal cares. R11's [DIAGNOSES REDACTED]. The MDS identified R11 was identified as having a Stage 1 pressure ulcer or greater, was at risk for development of additional pressure ulcers, and R11 had an unhealed Stage 1 pressure ulcer. R11's most severe stage of pressure ulcer was noted to be eschar/unstageable. R11 was identified as having a pressure reduction chair and bed, and received pressure ulcer care. Review of the Hospice Interdisciplinary note on 7/20/18, identified a wound on R11's buttocks had healed. R11's care plan revised on 7/24/18, identified R11 was at risk for alteration in skin integrity related to immobility, incontinence, weight loss, and [DIAGNOSES REDACTED]. Staff were directed to lift, not slide to decrease friction. Staff were also directed to encourage R11 to lie on her side while in bed to offload the pressure on her bottom. The care plan identified that the care plan was updated regarding the pressure ulcer on the coccyx on 7/23/18, and turning and repositioning was changed on 7/24/18 (during survey) from every 2 hours to every 2 1/2 hours. During observation on 7/23/18, at 8:33 a.m. R11 was resting on her bed on her back with a mat on the right side of the bed, with the bed in the low position. Review of the facility progress note of 7/23/18, indicated R11 received a bed bath that morning and had, Pressure ulcers on right heel and coccyx. Resident heel has no change, and coccyx is smaller and is light red in color. R11 was being repositioned every 2- 21/2 hours and as needed (PRN). The note indicated R11 was incontinent of bowel and bladder, and wore an incontinence pad to aide in keeping the skin dry. The documentation did not reflect a plan of treatment for [REDACTED]. During observation on 7/24/18, at 2:28 p.m. R11 was observed in her room resting on her her back, with two pillows under her right leg to support her foot off of the bed. There were no additional pillows in place to attempt to alleviate pressure from the coccyx. A review of the WCC wound note of 7/24/18, indicated R11 had a reddened area on her coccyx 1 cm x 1 cm as WCC had noted per the narrative assessment by the nurse manager on 7/17/18, however, the WCC did measure the wound at the visit. The narrative note directed staff to apply a [MEDICATION NAME] (soft silicone foam dressing minimizes trauma to the pressure ulcer) dressing border to R11's coccyx, and change every three days. Additional interventions outlined by the WCC included for staff to reposition R11 every two to two and a half hours, air mattress to bed, pressure reduction cushion in wheelchair per hospice recommendations, daily skin checks with cares, and weekly skin assessments by nurse. The WCC documentation indicated R11 preferred to lay down in bed. During observation on 7/25/18, at 2:14 p.m. R11 was seated in her wheelchair with her legs elevated on foot rests. R11 was sitting with her eyes closed, brows furrowed, and moaning in a constant, rhythmic pattern. The hospice nurse was present in room. NA-G entered R11's room in response to R11 crying out. NA-G proceeded to reposition R11's right leg, however, R11 continued to cry out with a moaning noise. RN-B then entered the room to provide NA-G assistance to transfer R11 into bed. R11 continued with a constant moan while being assisted to transfer to the bed with the use of mechanical lift. An acidic odor was noted in the room and hospice registered nurse (HRN)-A was unsure if this was related to the pressure ulcer or bowel incontinence, and requested R11's incontinence brief be checked. R11 had not been incontinent of bowel, however, R11 had an open area present on her coccyx with no dressing in place. HRN-A stated this area was not present when she last saw R11. The coccyx had drainage on the incontinence brief which was described by HRN-A as circular, blood tinged drainage and measured 2.5 cm by 2 cm. The coccyx also had two areas on the left side which were moist and HRN-A stated it appeared, as if it could slough. The area on the left measured 2.5 cm by 1 cm, and the second measured 1.8 by 0.6 cm. On the right side of the coccyx there was an open area 2.5 cm by 1.7 cm with a center bridge of slough present measuring 0.3 cm in width and 1.0 cm in length. RN-B stated the WCC had instructed them to leave the area open without placement of a dressing. The HRN-A placed an Allevyn sacral dressing (dressing that removes fluid) to the open areas on the coccyx. Once R11 was positioned, RN-B asked R11 where her pain was. RN-B offered to remove some of R11's pillows and R11's vocalizations of pain intensified. HRN-A offered suggestions to shift the pillow down and assure R11's heel was floating. During interview following provision of cares at 7/25/18, at 2:46 p.m. NA-G stated R11 was uncomfortable as evidenced by verbalizations/vocalizations, moving in the chair, and facial expressions. NA-G stated she would assist to reposition, offer to lay down, and then would advise the nurse if this was not beneficial in providing comfort. NA-G stated the importance of positioning for areas identified on R11's right foot but did not indicate any specific interventions to alleviate pressure on R11's coccyx. NA-G stated she was unsure of specific interventions for this. On 7/25/18, at 3:36 p.m. HRN-A met with RN-B and requested orders for wound care to R11's coccyx. RN-B stated the WCC followed the resident for skin care needs. HRN-A stated the area on R11's coccyx had been healed with most recent visit. A copy of the Hospice Interdisciplinary Team (IDT) note identified on 7/20/18, indicated a wound on R11's buttocks was healed at that time. On 7/26/18, at 11:24 a.m. family member (FM)-A stated R11's pain level on 7/22/18, was really bad. On that day, FM-A stated R11 was observed crying out, stating her back and coccyx hurt once she had been gotten up for lunch. FM-A stated R11 cried continuously for about two and a half hours on 7/22/18, and attempts at diversion by propelling her in the wheelchair and reclining the wheelchair were of little benefit. FM-A stated R11 ceased crying once assisted into bed per family request. This was a period of greater than three hours between repositioning. FM-A stated staff will usually not intervene or provide care to R11 when family is visiting. FM-A stated on 7/23/18, at 7:00 a.m. R11 was noted to be crying and moaning while up in her wheelchair, and she expressed pain in her coccyx. FM-A stated she had spoken to the facility about the frequency of repositioning for R11 towards the end of June, and had agreed upon a plan to turn and reposition her every one and a half hours. FM-A stated earlier in July, FM-A stated there was a period of one week between visits and upon her return visit, she observed R11 had developed a bedsore. On 7/27/18, at 1:37 p.m. the DON stated she was aware R11 had a reddened coccyx, but was unaware of any open areas on R11's coccyx. The DON stated with observation of the reddened open area of the coccyx, the medical provider should be contacted. The DON stated staff should re-evaluate the turning and repositioning program to assure completion, and determine if anything should be done differently. The DON noted on 3/29/18, a tissue tolerance (to determine the length of time pressure can be tolerated to an area of the body) assessment was completed for R11. The DON stated a subsequent tissue tolerance assessment should have been completed with the development of a pressure area, a significant change, and with enrollment into Hospice. The DON state R11 met all three identified triggers for evaluation. The DON stated she was unaware of any concerns addressed by R11's family. On 7/27/18, at 3:35 p.m. the administrator stated she had spoken to FM-A regarding the family's concerns about R11 not being positioned timely, and R11's pain management. The administrator stated she had followed up with staff regarding the concerns related to turning and repositioning. The administrator stated it was difficult to determine the underlying cause of R11's vocalizations at times, because R11 made similar vocalization in a positive response to pet visits. On 7/27/18, at 2:46 p.m. The WCC was called to review current skin conditions, and plan of treatment for [REDACTED]. Initial measurements of R11's Stage 3 pressure ulcer on the coccyx were 2.5 cm by 2.5 cm. The narrative note of 7/24/18, by the WCC was based on the nurse manager's measurement of 7/17/18, which indicated wound measurement as a 1 cm x 1 cm reddened area on R11's coccyx. A review of measurements obtained with HRN-A on 7/25/18, at 2:14 p.m. identified R11 was observed to have had drainage on the incontinence brief which was described by HRN-A as circular, blood tinged drainage, and measured 2.5 cm by 2 cm. The coccyx also had two areas on the left side which were moist and HRN-A stated it appeared, as if it could slough. The area on the left measured 2.5 cm by 1 cm, and the second measured 1.8 by 0.6 cm. On the right side of the coccyx there was an open area was 2.5 by 1.7 cm with a center bridge of slough present measuring 0.3 cm in width and 1.0 cm in length. The WCC stated the underlying cause of the pressure ulcers was from pressure, and stated it was important to reposition R11 every two hours. The WCC stated these areas were caused from sitting in wheelchair, and laying in bed on her back. The WCC stated it was important to reposition R11 every two hours, utilize the pressure reduction mattress on the bed, and the pressure reduction cushion in her wheelchair. A facility policy titled, Skin Assessment and Wound Management dated 7/20, directed updates with ongoing skin problems would be relayed to the providers as indicated. The policy did not identify specific interventions to be implemented if the skin condition was noted to be deteriorating.

Based on interview and record review, the facility failed to ensure policy and procedures for disposal of Fentanyl patches were followed for 8 of 8 residents, R1, R2, R3, R4, R5, R6, R7, and R8, reviewed who received a Fentanyl patch for pain. This resulted in actual harm for R1 when the resident went unresponsive and was sent to the hospital. R1 was found to have two sets of Fentanyl patches on. Findings include: R1's admission Minimum (MDS) data set [DATE], indicated the resident had severe cognitive impairment and required extensive assistance with all ADL's (activity's of daily living). R1's physician orders [REDACTED]. R1's facility Admission/ Readmission Assessment Face Sheet dated [DATE], indicated the resident received Fentanyl Patch 37.5 mcg. Review of R1's Progress Notes indicated the following: R1's Progress Note dated [DATE], directed staff to apply 25 mcg transdermally (on the skin) at bedtime every 3 days for pain, Remove old patch, 2nd nurse to co-sign and verify removal. Placed last night to equal 37.5 mcg patch per (licensed practical nurse-H). R1's Progress Note dated [DATE], indicated at 8:00 p.m. R1 told the nurse she had to go to bathroom for a BM (bowel movement). Writer took her and just before wanted to get her up she became very pale, tilted her head back and became unresponsive for a few seconds. When she came back she had a big emesis. She became unresponsive again and writer quickly checked code status which was a 'full code' CPR. When writer got back to her she was alert. She vomited more and became unresponsive again. Writer with help of NA/R (nursing assistant) laid her on floor. All of a sudden res stopped breathing, became unresponsive, and no pulse (apical) Writer started CPR starting with chest compressions. Writer did approx (approximately) 6 compressions and res responded, woke up; did more vomiting. Ambulance arrived at 2015 (8:15 p.m.) and took res to ER (emergency room ). When res left she was alert and pleasant. R1's hospital Progress Note- Final report dated [DATE], indicated, After admission, staff found her current Fentanyl patches from [DATE], plus her old patches from [DATE] that had not been removed. They removed them. She has woken up and is doing much better. The assessment of the admission was, Syncope multifactorial, combination of postoperative anemia, diarrhea, dehydration, and medication error with duplicate Fentanyl patches present. R1's Patient Transfer Form, Medical Summary Completed by Physician dated [DATE], indicated the primary [DIAGNOSES REDACTED]. Review of R1's Medication Administration Record [REDACTED] day(s) for pain *Remove old patch, 2nd nurse to co-sign and verify removal.* R1 received the Fentanyl patches on [DATE], however, the MAR indicated [REDACTED] R1's MAR for [DATE], indicated the resident received Fentanyl Patches on [DATE]. However, the MAR indicated [REDACTED] Review of R1's Narcotic Record indicated the resident received a 12.5 mcg and a 25 mcg patch on [DATE], and on [DATE]. The Narcotic Record only had one nurses signature. When interviewed on [DATE], at 3:55 p.m. registered nurse (RN)-F stated she removed R1's Fentanyl patches on [DATE], and had another nurse witness the destruction. RN-F could not remember specifically who the other nurse was, and stated the other nurse did not sign off witnessing the destruction of the Fentanyl patch's because there was no where for a second signature on the MAR indicated [REDACTED]. R2's admission MDS dated [DATE], indicated the resident had no cognitive impairment and required limited assistance with ADL's. R2's physician orders [REDACTED]. Apply one patch transdermally every 72 hours for pain and remove per schedule. R2's MAR for [DATE], indicated the Fentanyl patch was applied and removed 10 times. The MAR indicated [REDACTED]. R2's [DATE], MAR indicated [REDACTED]. The MAR indicated [REDACTED]. R2's Individual Narcotic Record was reviewed from [DATE] to [DATE]. The Narcotic Record had only one nurses signature 13 out of 14 times. R3's quarterly MDS dated [DATE], indicated the resident had severe cognitive impairment and required extensive assistance with all ADL's. R3's physician orders [REDACTED]. First nurse to remove, second nurse to co-sign. R3's [DATE] MAR indicated [REDACTED]. The MAR indicated [REDACTED]. R3's [DATE] MAR indicated [REDACTED]. The MAR indicated [REDACTED]. R3's Individual Narcotic record was reviewed from [DATE], to [DATE]. The Narcotic record had only one nurses signature eight out of 15 times. R4's quarterly MDS dated [DATE], indicated the resident had no cognitive impairment and was independent with all ADL's. R4's physician orders [REDACTED]. R4's [DATE], MAR indicated [REDACTED]. The MAR indicated [REDACTED]. R4's [DATE], MAR indicated [REDACTED]. The MAR indicated [REDACTED]. R4's Individual Narcotic record was reviewed from [DATE], to [DATE]. The Narcotic record had only one nurses signature 11 out of 14 times. R5's quarterly MDS dated [DATE], indicated the resident had severe cognitive impairment and required extensive assistance with all ADL's. R5's physician orders [REDACTED]. Remove old patch, second nurse to co-sign and verify removal. R5's [DATE], MAR indicated [REDACTED]. The MAR indicated [REDACTED]. R5's [DATE], MAR indicated [REDACTED]. All four disposals were signed by a second nurse. R5's Individual Narcotic Record was reviewed from [DATE] to [DATE]. The Narcotic record had only one nurses signature 10 out of 14 times. R6's quarterly MDS dated [DATE], indicated the resident had severe cognitive impairment and required extensive assistance with all ADL's. R6's physician orders [REDACTED]. Apply one patch transdermally every 3 days for pain. Remove old patch, second nurse to co-sign and verify removal. R6's [DATE], MAR indicated [REDACTED]. The MAR indicated [REDACTED]. R6's [DATE] MAR indicated [REDACTED]. All five were signed by two nurses. R6's Individual Narcotic Record was reviewed from [DATE] to [DATE]. The Narcotic record had only one nurses signature nine out of 15 times. R7's quarterly MDS dated [DATE], indicated the resident had moderate cognitive impairment and required extensive assistance with all ADL's. R7's physician orders [REDACTED]. Apply one patch transdermally every 72 hours for pain. Remove old patch, second nurse to co-sign and verify removal. R7's [DATE], MAR indicated [REDACTED]. The MAR indicated [REDACTED]. R7's [DATE] MAR indicated [REDACTED]. All five were signed by two nurses. R7 Individual Narcotic Record was reviewed from [DATE] to [DATE]. The Narcotic record had only one nurses signature nine out of 15 times. R8's quarterly MDS dated [DATE], indicated the resident had no cognitive impairment and required extensive assistance with all ADL's. R8's physician orders [REDACTED]. Apply one patch transdermally every three days for pain. Remove old patch, second nurse to co-sign and verify removal. R8's [DATE], MAR indicated [REDACTED]. The MAR indicated [REDACTED]. R8's [DATE] MAR indicated [REDACTED]. All five were signed by two nurses. R8 Individual Narcotic Record was reviewed from [DATE] to [DATE]. The Narcotic record had only one nurse signature eight out of 13 times. When interviewed on [DATE], at 9:00 a.m. licensed practical nurse (LPN)-C stated after removal of a Fentanyl patch it is wrapped in a tissue and flushed down the toilet. LPN-C stated after removing a patch another nurse is shown the patch but is not always present when flushing it down the toilet. LPN-C stated the second nurse does not sign witnessing the destruction because there is no where for two nurses to sign in the residents medical record. When interviewed on [DATE], at 9:45 a.m. LPN-D stated two nurses witness the destruction of the Fentanyl patches and both nurses should be signing on the residents MAR, however, there is not always a spot for both nurses to sign the destruction. When interviewed on [DATE], at 9:50 a.m. LPN-E stated two nurses witness the Fentanyl patch destruction, however, there is not always a spot for the second nurse to sign it was witnessed. LPN-E also stated the facility used an electronic MAR for all residents and depending on how the initial medication order was placed in the computer would determine if there was an area for a second nurse to sign for the destruction. When interviewed on [DATE], at 3:25 p.m. director of nursing (DON) stated staff were expected to have two nurses destroying the used Fentanyl patches and both should be signing off in the narcotic book. DON stated she had reviewed residents MAR's and narcotic records who had been on Fentanyl patches and discovered staff had not been obtaining two signatures when destroying them. The facility policy titled Fentanyl Removal, Application and Destruction dated ,[DATE], indicated, Take the used patch to the locked medication room (without touching adhesive sides), complete Fentanyl destruction log or Medication Disposal Form, with two licensed nurses wrapping used fentanyl patch in toilet paper and flushing down the sewer. Two licensed nurses must verify destruction and sign the proper form for proof of destruction.

Based on interview and record review, the facility failed to ensure medication was administered according to facility policy and procedure to prevent significant medication error for 1 of 8 residents, R1, who received a [MEDICATION NAME] for pain. This resulted in actual harm for R1 when the resident went unresponsive and was sent to the hospital. R1 was found to have two sets of [MEDICATION NAME]es on. Findings include: R1's admission Minimum (MDS) data set [DATE], indicated the resident had severe cognitive impairment and required extensive assistance with all ADL's (activity's of daily living). R1's physician orders [REDACTED]. R1's facility Admission/ Readmission Assessment Face Sheet dated [DATE], indicated the resident received [MEDICATION NAME] Patch 37.5 mcg. R1's Progress note dated [DATE], indicated, Apply 25 mcg [MEDICATION NAME] (on the skin) at bedtime every 3 days for pain, Remove old patch, 2nd nurse to co-sign and verify removal. Placed last night to equal 37.5 mcg patch per (licensed practical nurse-H). R1's Progress Note dated [DATE], indicated, At 8:00 p.m. resident stated to nurse that she had to use the bathroom for a BM (bowel movement). Writer took her and just before wanted to get her up she became very pale, tilted her head back and became unresponsive for a few seconds. When she came back she had a big emesis. She became unresponsive again and writer quickly checked code status which was a 'full code' CPR. When writer got back to her she was alert. She vomited more and became unresponsive again. Writer with help of NA/R (nursing assistant) laid her on floor. All of a sudden res stopped breathing, became unresponsive, and no pulse (apical) Writer started CPR starting with chest compressions. Writer did approx (approximately) 6 compressions and res responded, woke up; did more vomiting. Ambulance arrived at 2015 (8:15 p.m.) and took res to ER (emergency room ). When res left she was alert and pleasant. R1's hospital Progress Note- Final report dated [DATE], indicated, After admission, staff found her current [MEDICATION NAME]es from [DATE], plus her old patches from [DATE] that had not been removed. They removed them. She has woken up and is doing much better. The assessment of the admission was, [MEDICAL CONDITION] multifactorial, combination of postoperative [MEDICAL CONDITION], diarrhea, dehydration, and medication error with duplicate [MEDICATION NAME]es present. R1's Patient Transfer Form, Medical Summary Completed by Physician dated [DATE], indicated the primary [DIAGNOSES REDACTED]. Review of R1's Medication Administration Record [REDACTED] day(s) for pain *Remove old patch, 2nd nurse to co-sign and verify removal.* R1 received the [MEDICATION NAME]es on [DATE], however, the MAR indicated [REDACTED] R1's MAR for [DATE], indicated the resident received [MEDICATION NAME] Patches on [DATE]. However, the MAR indicated [REDACTED] Review of R1's Narcotic Record indicated the resident received a 12.5 mcg and a 25 mcg patch on [DATE], and on [DATE]. The Narcotic Record only had one nurses signature for both dates. When interviewed on [DATE], at 9:00 a.m. licensed practical nurse (LPN)-C stated after removal of a [MEDICATION NAME] it is wrapped in a tissue and flushed down the toilet. LPN-C stated after removing a patch another nurse is shown the patch but is not always present when flushing it down the toilet. LPN-C stated the second nurse does not sign witnessing the destruction because there is no where for two nurses to sign in the residents medical record. When interviewed on [DATE], at 9:45 a.m. LPN-D stated two nurses witness the destruction of the [MEDICATION NAME]es and both nurses should be signing on the residents MAR, however, there is not always a spot for both nurses to sign the destruction. When interviewed on [DATE], at 9:50 a.m. LPN-E stated two nurses witness the [MEDICATION NAME] destruction, however, there is not always a spot for the second nurse to sign it was witnessed. LPN-E also stated the facility used an electronic MAR for all residents and depending on how the initial medication order was placed in the computer would determine if there was an area for a second nurse to sign for the destruction. When interviewed on [DATE], at 3:25 p.m. director of nursing (DON) stated staff were expected to have two nurses destroying the used [MEDICATION NAME]es and both should be signing off in the narcotic book. DON stated she had reviewed residents MAR's and narcotic records who had been on [MEDICATION NAME]es and discovered staff had not been obtaining two signatures when destroying them. When interviewed on [DATE], at 3:55 p.m. registered nurse (RN)-F stated she removed R1's [MEDICATION NAME]es on [DATE], and had another nurse witnessed the disposal. RN-F could not remember specifically who the other nurse was, and stated the other nurse did not sign off witnessing the destruction of the [MEDICATION NAME]es because there was no where for a second signature on the MAR indicated [REDACTED]. The facility policy titled [MEDICATION NAME] Removal, Application and Destruction dated ,[DATE], indicated, Take the used patch to the locked medication room (without touching adhesive sides), complete [MEDICATION NAME] destruction log or Medication Disposal Form, with two licensed nurses wrapping used [MEDICATION NAME] in toilet paper and flushing down the sewer. Two licensed nurses must verify destruction and sign the proper form for proof of destruction.