Every finding on record at MN Veterans Home-Fergus Falls

Based on interview, observation and document review the facility failed to provide adequate supervision and monitoring to prevent resident to resident physical abuse for 1 of 1 resident (R1) reviewed for abuse when R2, who had a history of verbal and physical aggression towards staff and residents went into R1's room, allegedly grabbed him by the neck and threw him to the floor before leaving the room with R1's cane. Following the incident, the facility failed to provide adequate supervision and monitoring to ensure residents were protected from physical abuse putting them at the likelihood for serious harm, impairment or death when R2 continued to exhibit behaviors such as wandering into other resident rooms unsupervised. The IJ began on 4/10/26 at 1:50 p.m., when R2 entered R1's room and was seen exiting the room with R1's cane. R1 reported to facility staff, R2 entered his room and touched his belongings, R1 reported he got up from his chair, told R2 to stop, R2 placed his hand around R1's neck and threw him down to the floor. The administrator and director of nursing (DON) were notified of the IJ on 4/27/26 at 5:00 p.m. The facility implemented corrective action by 4/24/26 and therefore is issued as past non-compliance. R1 R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 was admitted to the facility on [DATE], from home/community. R1 had moderately impaired cognition and moderate difficulty with hearing. R1 had verbal behavioral symptoms directed toward others (threatening others, screaming, cursing at others) and wandered one to three days out of seven. R1 was independent with toileting, transfers, and ambulation with a cane. R1's diagnoses included non-traumatic brain dysfunction, arthritis, Alzheimer's disease, Non-Alzheimer's Dementia (e.g. Lewy body dementia, vascular or multi-infarct dementia, mixed dementia, frontotemporal dementia, and dementia related to stroke), and depression. R1's height was 5 feet 5 inches and weighed 234 pounds. He was taking antipsychotic, antidepressant, and antiplatelet mediations. R1's St. Louis University Mental Status (SLUMS) (a tool for detecting cognitive impairment in older adults) dated 3/24/26, identified a total score of 13 out of 30, to indicate cognitive impairment or possible dementia. A lower score in this range indicated more pronounced cognitive deficits that could be indicative of dementia. R1's progress notes from 3/25/26 through 4/26/26, identified: On 3/25/26 at 3:22 a.m., During rounds [R1] tried to barricade his door shut. Quiet and stayed in his room tonight. 3/26/26 at 9:09 p.m., [R1] received first scheduled dose of Seroquel 50 mg, not effective. Was one of the more agitated/restless shifts that he has had in the evening in the past week. 3/2026 at 12:23 p.m., [R1] sundown's hard after lunch and can become verbally aggressive with family and others as well fixated and upset about not being able to go home. 4/1/26 at 3:45 p.m., [R1] grew frustrated when he tried to ask peer what he was doing and did not respond. [R1] stated to peer what are you stupid, you never answer me? Peer grew agitated at name calling and put up fist and drew near [R1]. He raised cane and threatened to strike peer. Recreation staff placed self in between residents and deescalated the two. 4/5/26 at 8:42 p.m., [R1] was out of his room on the south unit and a resident walked near, reached out and grasped his cane. [R1] yelled at the other resident in a threatening tone and raised his cane at the resident. Staff remained 1:1 with resident due to both residents not wanting to be in their rooms. Anger lasted approximately 20 minutes. 4/7/26 at 3:03 p.m., physical therapy (PT) was asked to see if [R1] was appropriate to use front wheeled walker (FWW) as resident raised his cane toward another resident. [R1] demonstrated walking with his cane, which was appropriate and stable. [R1] had diagnoses of polyarthritis and lumbar spinal stenosis which could affect his balance so it would be best to stay with some assistive device but did not need a FWW. [R1] showed the cane to PT and described how he made it by using the natural curves in the diamond willow. He was very proud of the cane he had made. 4/9/26 at 9:38 p.m., [R1] looked for his jacket, was in the laundry cart to be washed. NA located it and told him about it being in the wash cart. He became upset and ripped the jacket from NA's hands. He was upset and angry and later apologized to NA. 4/10/26 at 1:55 p.m., [R1] was noted to be yelling out from his room. [R1] sat up against the wall on the floor inside room doorway and left elbow was bruised and slightly swollen. Lifted [R1] off the floor with Hoyer and placed in recliner. [R1] stated that guy came into my room, started moving some of my stuff, I got up out of my recliner, and went over to him to tell him to stop. Then that guy grabbed my neck to choke me, threw me on the ground and took my cane. 4/10/26 at 6:20 p.m., [R1] complained of right elbow tenderness. Purple bruising present, swelling estimated the size of a golf ball. Offer to send to ER for x-ray and stated he would go in morning if it was still bothering him. Ice applied. 4/11/26 at 1:15 p.m., [R1] was quiet this shift. Out for meals then returned to his room. Right arm elbow is tender. Did not allow staff to assist with cares this a.m. pleasant with all interactions. 4/11/26 at 4:39 p.m., 24 follow-up: complained of elbow pain. Applied ice two times a day shift. Bruise on buttock was larger. 4/12/26 at 11:35 a.m., Right elbow had bruising all the way around joint, light purple in color with one darker circular area noted on the posterior and one darker bruise on the anterior side. Range of motion (ROM) within normal limits. 4/14/26 at 12:50 p.m., [R1] had been pleasant this shift. Pain in lower back, right elbow and arm. 4/13/26 at 12:20 p.m,. Fall related to 4/10/26, incident involved another resident who initiated physical aggression towards [R1]. Contusion to right elbow has absorbed and now had bruising around right elbow. Bruising also noted to left elbow and left buttock due to resident landing /falling on floor because of incident. No new fall interventions put into place due to nature of incident. Other interventions put into place to keep both residents involved separated. 4/19/26 at 8:58 a.m., [R1] had a memory this a.m. of a traumatic event that occurred in the past week. The memory felt very real to [R1], which can be typical for post traumatic stress disorder (PTSD) diagnosis. Emotional support provided by staff. Details of memory are inconsistent. To assure this was a memory and not a new incident DON reviewed camera footage from the a.m. Other resident [R2] involved in past incident did not appear to have entered [R1's] room this a.m. 4/19/26 at 10:49 a.m., [R1] came to day room and started talking about other peer. Stated if he saw him, he was going to hurt him and lay him out, threatened that he would hit this peer with his cane if he saw him. The other resident [R2] was 1:1 with staff for safety and had been kept out of sight of [R1]. Staff attempted to redirect him which seemed to escalate his agitation even more. He started to accuse stuff you got someone to take other peer away when I am the one that he hurt. [R1] seemed to be remembering the incident and insistent that it happened today at 6:00 a.m. DON reviewed camera footage which revealed no accident had occurred this morning. 4/20/26 at 12:22 p.m [R1] was pleasant and at times walked around peer he had incident with on 4/10/26 without being fearful of him. R1's nursing assistant (NA) behavioral documentation from 3/29/26 through 4/26/26, (29 days) indicated R1's behavioral symptoms included: 3/29/26 at 1:32 a.m., through 4/2/26 at 11:52 p.m., 16 entries, no behaviors. 4/3/26 at 1:58 p.m., wandering 4/3/26 at 8:28 p.m., through 4/5/26 at 1:07 p.m., 6 entries, no behaviors. 4/5/26 at 10:06 p.m., and 10:07 p.m. yelling/screaming. 4/6/26 at 12:31 a.m., through 4/9/26 at 2:06 p.m., 9 entries, no behaviors. 4/9/26 at 10:04 p.m., yelling/screaming. 4/10/26 at 5:20 a.m., through 4/19/26 at 1:59 a.m., 26 entries, no behaviors. 4/19/26 at 1:50 p.m., yelling/screaming, abusive language, and threatening behavior (see progress notes on this date). 4/19/26 at 9:06 p.m., through 4/26/26 at 11:55 p.m., 21 entries, no behaviors. There was a total of 83 entries, 78 entries with no behaviors, and 5 entries with behaviors. R1's Psychiatric visit progress note dated 3/26/26, identified [R1] had a history of progressive dementia and Alzheimer's. [R1] seemed to be doing well during the day but clearly had some sundowning that started early afternoon and can become problematic at night. [R1] has not been combative, worked as a police officer and laid carpet. He was calm and thought process was clearly confused and slightly repetitive. During an interview on 4/22/26 at 2:50 p.m., FM stated [R1] had gotten confused and forgetful, leading to his admission to the facility. At one point, [R1] had a cloth barrier placed across his doorway to discourage residents from coming into his room. Prior to the incident with [R2], R1 kept his door open. Since the incident with [R2], R1 kept his door closed to prevent [R2] from coming into his room. Even though R1 had poor recall, he was able to tell FM the details of the encounter with [R2]. R1 told FM he stood up and told [R2], you cannot take things. R1 stated he [R2] started to choke [R1] and threw him down onto the floor. R1 told FM, he ended up on the floor with a sore elbow that turned black and blue. FM did not recall noticing marks on R1's neck. FM stated R1's explanation of the incident was accurate. FM felt R1 would most likely remember a good part of what happened especially when [R2], laid his hands on him. She had seen [R2] wandering around the unit and was surprised it happened. FM felt the staff were good at keeping the two of them (R1 and R2) apart and placed at different spots in dining room when eating meals. FM stated [R1] has had no issues with any other residents that she was aware of since admission. During a follow up interview on 4/27/26 at 3:35 p.m., FM stated in the past, prior to R1's decline in cognition, if an intruder came into their home he would have gotten angry, would not attack but would asked them why they were there and told them, This is my place get out. R1 was a retired police officer and was careful, making sure the doors were closed, locked, and secure at nighttime. R1 was protective but never violent. FM was not aware of R1 making false allegations of violence against him, he was very social and never seemed to get angry. During an observation and interview on 4/23/27 at 9:37 a.m., R1's room door was closed with a cloth barrier draped across the doorway. R1 sat in his recliner, fully dressed, and well groomed. R1 stated FM visited last week and was not able to recall FM's visit the day before. R1 identified he had five children, their names, and where they lived. R1 stated he had not fallen until about two weeks ago, had a sore elbow and right side since then. R1 stated he left the door to his room open and a gentleman who lived there entered his room, while he [R1] sat in his recliner. This man [R2] went through my stuff across my room, by my door and started taking things. I told him, 'get out of here!' R1 stated he stood up and walked over to him. R2 then placed his hands on R1's neck and choked him. He was a big man and strong. He slammed me down on the floor onto my right side. R1 stated he bruised his right elbow. The nurses offered to send him to the emergency room but he did not go. R1 stated his right hand and thumb still hurt/throbbed and he felt is was slightly puffy. R1 stated, That man was not in my room long, only five minutes or less, taking things and putting them in his arms. R1 stated, If that man came into my room again, he will not get another chance to hurt me again. Geez, being a cop for all those years and I could not even defend myself. R1 stated he yelled for help and staff came. R2 R2 quarterly MDS dated [DATE], identified R2 was admitted to the facility on [DATE], from home/community. R2 had minimal difficulty hearing, sometimes understood others, responded adequately to simple, direct communication only. R2 had severely impaired cognition with disorganized thinking or incoherence that fluctuated (comes and goes, changes in severity), and delusions (misconceptions or beliefs that are firmly held, contrary to reality). R2 wandered one to three days out of seven. He was independent with ambulation. R2's diagnoses included: non-traumatic brain dysfunction, Alzheimer's disease, non-Alzheimer's dementia, and depression. R2 was five feet, eight inches tall and weighed 216 pounds. R2 took antipsychotics and antidepressant medications. R2's SLUMS examination dated 5/5/25, identified a total score of 10 out of 30. A score range of 1 to 20 points indicated cognitive impairment or possible dementia. R2's physician and nursing orders identified: Escitalopram Oxalate (antidepressant) give 20 mg tablet by mouth in the evening related to Alzheimer's disease. Start date: 9/15/25 at 2:45 p.m. Mirtazapine (antidepressant) oral tablet give 30 mg by mouth one time a day to help with sleep and irritation. Start date: 3/12/26 at 5:00 p.m. Olanzapine (antipsychotic) oral tablet give 10 mg by mouth one time a day for agitation related to Alzheimer's Disease. Start date: 3/12/26 at 4:00 p.m. End date: 4/16/26 at 11:30 a.m. Olanzapine oral tablet give 10 mg by mouth two times a day for agitation related to Alzheimer's Disease. Start date: 4/16/26 at 5:00 p.m. Quetiapine Fumarate (antipsychotic) oral tablet give 25 mg by mouth every morning and at bedtime for mood. Start date: 4/11/26 at 6:00 a.m. End date: 4/16/26 at 11:21 a.m. Quetiapine Fumarate oral tablet give 50 mg by mouth as needed two times a day (bid) as needed (PRN) for agitation/restlessness. Start date: 4/10/26 at 4:30 p.m. End date: 4/16/26 at 11:21 a.m. N.O. Document behaviors every shift, document non-pharm and pharm interventions used for behavioral management. Document facial expressions, tone of voice, body language/gestures. Document activity/whereabouts. Every shift for behavior charting. Start date: 4/14/26 at 2:45 p.m. R2's Electronic Medication Administration Record (EMAR) and Treatment Administration Record (TAR) for April 2026, identified: Audible Door Sensor Alarm. Please monitor functioning and document amount of times triggered by resident each shift. Start date 4/24/26 at 10:45 p.m. Triggered on 4/24/26, three times on night shift. Triggered on 4/25/26 and 4/26/26/26 p.m., ten times on p.m. shift. Silent Alarm (bed). Please monitor functioning and document amount of times triggered by resident each shift. Started date: 4/24/26 at 10:45 p.m. Triggered 4/24/26 four times night shift, 4/25/26 a.m. one time day shift, ten times p.m. shift, and zero times night shift. Triggered on 4/26/26, three times on day shift, five times on p.m. shift and zero times on night shift. Silent Alarm (recliner). Please monitor functioning and document amount of times triggered by resident each shift. Start date: 4/24/26 at 10:45 p.m. Triggered: 4/24/26, through 4/26/26, zero times on all three shifts. R2's care plan dated 4/13/26, identified: Behavior/Mood. He may exhibit behaviors related to Alzheimer's /dementia and depression. Staff were directed to: effective 9/18/25- keep R2 occupied during times of restlessness/sundowning as those seemed to be times he wandered into other resident rooms; effective 9/18/25- engage him in meaningful cleaning or tinkering tasks; effective 9/18/25- anticipate his needs, be creative to keep him busy and out of situations that have the potential to cause another resident to yell at him as that can be a trigger for him to act-out physically; effective 1/12/26- if difficult to redirect or resistive to cares, reapproach task with male caregiver assist as resident at times is more receptive to males; effective 1/30/26- monitor whereabouts frequently due to him wandering into private spaces and his actions of touching and taking other residents' belongings as this is not always welcome by others; effective- 4/13/26- often on the move, entered rooms and others' spaces and unaware of others' personal space. Does not respect DO NOT ENTER signs. When approached by other residents, he can be unpredictable in his response; effective 4/22/25- when having behaviors, if not bothering others or super disruptive, do not redirect; effective Allow him to tinker. Non-pharm interventions liked to garden, work for a paycheck. Redirect, remove from environment if appropriate, provide activity, likes ice cream, look for unmet need and assist, redirect to toilet and assist if resident appears that he is about to void in inappropriate places, ask him to babysit baby doll, organize items, and fix things. R2 was at risk for elopement related to impaired safety awareness and history of elopement when at home. Staff were directed to monitor his whereabouts frequently due to him wandering into private spaces as this placed him at risk of his peers becoming aggressive with him and he may return aggression. Psychosocial wellbeing. R2 wandered about his environment and had dementia like behaviors related to the early onset of Alzheimer's disease. He went into other resident rooms and may take their things without realizing it was not his. Staff were directed to anticipate needs and redirect as able when needed. Therapeutic Recreation. Will need invitations, reminders and escorts to small and large groups and nearly constant redirection due to his impaired cognition and impulsiveness. Staff were directed to encourage independent leisure pursuits of cleaning, straightening, sweeping, folding towels, wiping tables. Please give him tasks around the unit to help him feel purposeful. He enjoyed being outdoors but needed constant redirection as he had little safety awareness and was impulsive. He liked to rake and water the grass but needed supervision. R2's progress behavior notes from 1/12/26, through 4/26/26, identified: On 1/12/26 at 8:52 p.m., 1/13/26 at 8:52 p.m., 1/15/26 at 9:44 p.m. [R2] walked in and out of other resident rooms. He had another resident's clothes on, taking things from one room to another, turning chairs over, rearranging furniture, and pulled fire alarm. Unable to redirect at times. On 1/15/26 at 8:31 p.m., [R2] was difficult to redirect this afternoon. He approached a table with two peers seated for supper, took papers and clothing protectors off table. Another resident told [R2] to leave in an angry voice, staff stood between residents and tried to de-escalate the situation. [R2] wanted to go outside, and fight. [R2] then turned and swung the clothing protector at staff and knocked over the other resident's milk. Staff stood between residents and [R2] held up his arm as to hit staff but was only verbally aggressive. On 1/21/26 at 8:12 p.m., [R2] became agitated, irritable around 3:00 p.m. and made several angry comments stated, I'm not going to let these punks boss me around. He took other resident's belongings (walkers) and became agitated when staff attempted to remove item to prevent altercations with other residents. [R2] stated I am not going to give it back, this is mine. Staff allowed him space due to increased agitation. On 1/21/26 at 10:09 a.m., [R2] continued to wander in and out of private areas, taking others personal belongings. He does have aggressive tendency mostly in the evening hours and had the potential to hit or become physically aggressive almost daily. On 1/23/26 at 10:13 p.m., noted in [other] resident's room twice, redirectable. On 1/26/26 at 8:49 p.m., [R2] walked by a table in dining room with two male peers sitting at it and touched peer's walker. [Peer] stated that is not yours several times. Nurse immediately intervened between the two residents. She cupped [peer's] elbow as he attempted to hit [R2]. Then [R2] threw approximately three or four closed fist punches towards [peer's] face: hitting him twice in the forehead. Staff placed her arms around [peer], attempted to block [R2's] punches and was hit a couple of times in the arm by [R2]. Door between north and south dining area was now locked until manager's team meeting to review incident. On 1/27/26 at 9:22 p.m., Wandering unit and went into two other resident rooms on south side, redirectable. Tried to exit out of the courtyard south side door, redirected by staff multiple times. On 1/29/26 at 9:07 p.m., Took nap and woke up angry very busy went into the three different resident rooms on the north unit side. On 2/10/26 at 9:06 p.m., Resistive to cares. [R2] removed garbage can from medication cart. After supper he went into a peer's room and was going to pick up an item and peer said, that's mine. Re-directed out of the peer's room. On 2/17/26 at 1:44 p.m., [R2] incontinent of BM. Staff assisted him and became upset, resisting and hitting out. Additional staff assisted and distracted him. On 2/19/26 at 9:21 p.m.,. [R2] urinated in dayroom and in the sunporch. Very busy wandered around unit and went into peers' room and redirected. On 2/21/26 at 6:12 a.m., [R2] very active beginning of shift, going into other resident room. Not agitated and easily re-directed. Very busy pacing around. Stayed up until 3:00 a.m. On 2/21/26 at 10:27 p.m., [R2] was served supper and received [peer's] utensils. [Peer] stated give it back to me! [R2] was mad and agitated, moved to another [peer's] table. [Peer] protected his utensils and stated, don't get mestaffs [sic]. [R2] held up the fork towards [peer]. Writer tried to redirect, de-escalate, and tried to move [R2] from the area. He was mad and stated to writer I can hurt anyone. [R2] Calmed down more than one hour later. On 2/24/26 at 9:24 p.m., [R2] incontinent of bowel refused to go to bathroom, withdrawn and irritable. Ambulated about the south and north village, tried to open doors and went into other peers' rooms. On 2/28/26 at 8:38 p.m., Around supper time [R2] agitated/restless more than usual. He started to upset some of the other residents at his table. One of the other residents raised his hands up and in a joking manner as if in a boxing motion. [R2] became very agitated, had to be separated from the other resident, and placed at another table. [R2] stated to the nurse do you want me to beat that guy up for you? [R2] was kept away from other residents until they went to bed. On 3/4/26 at 8:45 a.m., Staff reported this a.m. notice [R2's] increased agitation/behaviors with cares since discontinuation of olanzapine. Fax sent to provider. No new orders. On 3/7/26 at 1:53 p.m., per kitchen staff report, [R2] upset a peer when he attempted to take his walker out of the dining room. Peer intervened and said, [NAME] leave that alone it's mine. Peer repeatedly replied, who said it's yours? [R2] stepped away from peer and walker and went in a different director. Monitor. On 3/10/26 at 9:23 p.m., After supper [R2] wandered around the unit and went into a north side peers' room. Staff attempted to get him to come out of the room, sat on peer's bed and laid down. Peer upset and asked him to exit the room. [R2] left the room. On 3/11/26 at 8:43 p.m., R2] very agitated this evening after supper. Wandered around quite a bit into resident rooms (with some of them getting upset), removed items out of other resident rooms and hard to redirect out of the rooms. [R2] attempted to push another resident in a wheelchair, upset the other resident (was getting angry/upset). Several staff approached [R2] multiple times to get him away from the resident in the wheelchair. On 3/12/26 at 8:40 a.m., increase in two psych medications today. Wandered around unit off and on, less agitated/aggressive and more directable. On 3/13/26 at 9:29 p.m., [R2] wandered about unit, seemed on edge and short with staff, and redirectable at times. On 3/16/26 at 5:15 a.m., [R2] wandered all shift on both north and south units. Finally asleep by 4:45 a.m. On 3/18/26 at 11:13 a.m., [R2] was on antipsychotics for wandering, aggression, and multiple behaviors. His mood was worse in the p.m. hours, medications do seem to help some. On 3/24/26 at 9:48 a.m., Behavior rounds: [R2] seemed to sundown shortly after lunch. Keep resident on south side of village if able due to history of physical aggression towards residents that live on the north side. If difficult to redirect or resistive to cares, reapproach task with male caregiver. On 3/27/26 at 9:21 p.m., [R2] sleepy, wandered into a peer's room and laid down on his bed. Staff brought him to his room to lay down. Urinated in front of the curtain by entrance On 3/28/26 at 4:55 p.m., prior to supper [R2] was agitated, wandering between north and south side. At one point on the north side came up with two residents, appeared to possibly touch one of the residents' drink/sodas. The resident sitting at the table became visibly upset at [R2] had somewhat of verbal altercation of which [R2] raised his arm and stood somewhat over the sitting resident, looked down at him, made a comment about beating him up. The writer stepped in between the residents, took [R2's] hand and walked away from the table. No physical interaction occurred, however, there was a possibility it could have escalated. [R2] was monitored to attempt to prevent him from coming over to the north side again. On 3/28/26 at 8:46 p.m., [R2] was agitated once daughter left. Wandering unit, hard to redirect. On 3/30/26 at 8:23 p.m., While attempting to administer medications in the afternoon, [R2] grabbed this writer's arm forcefully and stated, I'm not gonna do that. Writer removed hand, disengaged him and gave him space. Irritable throughout the afternoon and early evening. On 4/8/26 at 8:30 p.m., Wandering, pushing furniture, going into other resident rooms and often will take their food or candy if not noticed right away. Continued behaviors but redirectable. On 4/10/26 at 2:00 p.m., [R2] was noted to be coming out of another resident room with a cane. This was an ongoing behavior of this resident to wander throughout the unit, entering other resident rooms and moving things around. The resident of who [R2] entered stated the resident came into my room and moved things around, then choked me and threw me to the ground. Removed cane from [R2], monitor, currently not agitated currently oriented to self only. On 4/10/26 at 4:00 p.m., and 4:48 p.m., Called mental health provider unable to reach, left message. Called primary provider updated regarding [R2's] behavior and received PRN for agitation. On 4/10/26 at 6:00 p.m., transferred to medical facility ED in van with facility staff. On 4/10/26 at 6:07 p.m., In lieu of another incident of aggression by [R2] towards another resident who did not appreciate him wandering into his room, touching their belongings, writer had a long conversation with his [R2] wife about next steps, sent to ED for evaluation of psychiatric inpatient to evaluate his continued aggression. Discussion also had that they may not admit him as he is usually calm natured, but a quick anger and become physical or verbal when he is confronted by peers and told to not do or touch something. That was not something easily treated without the potential of over sedation. Family aware that made it hard for the facility to manage as he is almost constantly wandering about the village unit, in and out of resident rooms commons areas, fidgeting and touching everything without constant supervision. It was hard to predict when a behavior may occur from any resident on the Village. They [family] are aware they [facility] may need to start discharge planning to a different facility to ensure everyone's safety. Family voiced understanding. If not admitted to the medical center family will help over the weekend to increase our ability to monitor [R2's] whereabouts on the unit more closely. On 4/10/26 at 6:28 p.m., provided [R2] with 1:1 supervision by recreation staff immediately after incident until he was transported to the ER. He was calm, cooperative, and did not recall an incident occurring. On 4/10/26 at 8:55 p.m., ED provider had talked to psych medical doctor (MD), administered 50 mg of Seroquel (Quetiapine Fumarate). Will be sending [R2] back to facility with written orders: Seroquel scheduled twice a day (b.i.d.) and PRN. On 4/10/26 at 10:22 p.m., [R2] returned to facility with his wife. A new psych visit will be requested for next week. If conditions worsen return to ED. Discussed with wife if family would be available during specific times on Saturday and Sunday. Maybe difficult due to grandchild sporting event. On 4/11/26 at 5:45 a.m., [R2] slept all shift after he arrived back to facility at 10:22 p.m. Every 15-minute checks completed for his shift. On 4/11/26 at10:51 a.m., Woke up at 9:00 a.m., ate breakfast and was calm. Staff continued every 15-minute checks. Spoke with wife, she will be coming in at 2:00 p.m. to sit with resident as he becomes more agitated and busier in the afternoons. On 4/11/26 at 1:35 p.m., Staff provided very 15-minute checks, gets busy, wandering, busy easily redirected. On 4/11/26 at 2:21 p.m., Wife here sitting in [R2's] room with him. Continuing to monitor. On 4/11/26 at 10:27 p.m., Wife here from 2:00 p.m. to 4:00 p.m. [R2] has been pleasant currently sitting with staff. On 4/13/26 at 12:06 p.m., scheduled an appointment for 4/16/26 with psych. On 4/13/26 at 10:03 p.m., [R2's] Behaviors heightened before supper time. He was hard to redirect and refused cares multiple encouragements. When given PRN Seroquel noted to be calmer. On 4/14/26 at 1:18 p.m., remained 1:1 for this shift. On 4/14/26 at 10:18 p.m., [R2] busy this shift wandering, moving furniture. Had 1:1 starting at 4:00 p.m. to 10:00 p.m. On 4/15/26 at 4:14 a.m., slept almost entire shift, no behaviors. Continue frequent checks. On 4/15/26 at 1:45 p.m., [R2] walked around courtyard, attempting to break off branches and flowers. Recreation staff attempted to distract and remove from [NAME] and tried to sneak a peak down back of pants as there was a foul odor [R2] grabbed staff's fingers and said, If you touch me again, I'll break every finger on your hand. Proceeded to squeeze hand and lead recreation staff with him for approximately 15 seconds then let go. On 4/16/26 at 12:05 p.m., [R2] seen by psychiatric provider. New orders received: discontinue scheduled Seroquel (no need for two antipsychotics), change Zyprexa to 10 mg po every a.m. and 10 mg po every 5:00 p.m. (when available), add Zyprexa 5 mg po every six hours PRN for agitation or aggression. On 4/16/26 at 9:21 p.m., No behaviors this shift. Wife here for activity and had 1:1 from 4:00 p.m. to 9:00 p.m. On 4/16/26 at 5:37p.m., Late entry 4/14/26. Wife returned writer's call. Discussed possible discharge planning maybe needed for resident related to recent behaviors or an inpatient behavioral hospital stay. Writer asked if family would be able to come and be with resident. Wife does not live locally and indicated family would not be able to come. On 4/17/26 at 22:19 p.m., No noted aggressive behaviors. He did have some unrecognizable type of conversation, wandering, but no noted issues. On 4/18/26 and 4/19/29, no behaviors noted. On 4/19/26 at 1:28 p.m., Walking around, wandering around unit today. Typical baseline. Has walked around peer he had incident on 4/10/26. [R2] did not appear fearful when he has walked by peer or when peer walked by him. Did not appear to remember incident or other resident involved. On 4/20/26 at 9:39 p.m., Beginning of shift [R2] had increased agitation and not able to redirect. He received Zyprexa 5 mg which was effective. On 4/23/26 at 9:25 p.m., [R2] wandering in south and north units and into other resident rooms, rearranging furniture. Used redirection, positive reinforcement and distractions. Confused and not aggressive responses. On 4/24/26 at 10:16 p.m., [R2] was very agitated, took food from another resident's plate, walked around with the dinner plate and silverware, very hard to redirect. Currently 1:1 with staff person. On 4/26/26 at 12:46 p.m., Required more supervision as he wandered, unable to stay on task, easily redirectable but required frequent redirection. R2's psychiatric visit progress note dated 1/22/26, identified [R2] as having a lot of behaviors, not sleeping well, seemed to have his days and night

Based on observation, interview and document review, the facility failed to implement standards of practice to ensure a safe transfer for 1 of 3 residents (R1) reviewed for accidents when staff failed to properly attach the lift sling to the ceiling lift bar. This resulted in actual harm when R1 fell from the lift during a staff assisted transfer, sustained a large 5 centimeter (cm) contusion (a severe injury caused by a direct blow to the head leading to bruising/swelling of the brain tissue)/hematoma (blood leaks from tiny brain vessels causing swelling) to the occipital scalp (rearmost portion of the head constitutes the posterior section of the brain and skull) and was sent to the emergency department (ED) requiring medical evaluation and pain that persisted requiring medication for discomfort. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 was admitted to the facility on [DATE], from a skilled nursing facility.R1 had a moderate difficulty hearing, unclear speech (slurred or mumbled), highly impaired vision, sometimes understood simple direct communication, severely impaired cognition, disorganized thinking, and physical behavioral symptoms directed toward others (hitting, kicking, pushing, scratching, grabbing). R1 was dependent upon staff for all activities of daily living (ADLs), transfers, and incontinent of bowel and bladder. Diagnoses included non-traumatic brain dysfunction, Alzheimer's (brain cells die over time, brain shrinks and causes dementia/memory loss), aphasia (a disorder that affects how you communicate, speech and as well as the way you write and understand both spoken and written language), seizure disorder, and muscle weakness. R1's care plan Kardex dated 12/1/25, identified transfers: two staff assist with ceiling lift to transfer use sit on comfort size large sling. May leave ceiling lift sling under when in wheelchair. Handwritten on the Kardex with a line drawn directly to the above information: Please note change two staff for all transfer and different sling type sit on comfort size large. R1's care plan dated 12/1/25, identified impaired mobility/transfers due to generalized weakness and impaired cognition and not understanding directions. Staff were directed on 10/28/25, transfer with one staff assist with ceiling lift. Use Basic Basic (all around sling) size large sling. May leave ceiling lift sling under when in wheelchair. Two staff assist with transfers when having increased behaviors. Care plan transfer section revised on 12/1/25, two staff assist with all transfers using ceiling lift. Use Sit on Comfort size large sling.R1 had severe cognitive impairment due to dementia with illogical or disorganized speech. R1 was frequently anxious and often resistive to cares related to dementia and Parkinson's (a movement disorder of the nervous system that causes tremors, stiffness, slowing of movement and trouble with balance that raises the risk for falls) with delusions (a type of psychotic disorder with an unshakable belief in something that was untrue). R1's progress notes from 11/30/25 through 12/2/25, identified:-On 11/30/25 at 3:55 p.m. Fall Note: Nursing assistants (NA) stated during a transfer from bed to wheelchair R1 fell from the ceiling lift, heard a pop and his left leg went up and fell backwards from the sling. He landed on his back, first hitting his buttocks on the floor mat. Called local medical center and verbal order received to send to ED. Hematoma noted to back left side of head, unable to check eyes. Assessed vitals and level of consciousness. Assisted up with ceiling lift and four staff. Ice applied to back of head. Kept by nursing staff until he could be transferred-On 11/30/25 at 3:55 p.m. Plan of Care note: Writer, registered nurse (RN)-B was called by NA to R1's room. Reported he fell during transfer via lift. He was on the floor with floormat behind. Neuro vital signs started. See contusion on the back of the head, ice pack applied. A bleeding wound was seen on the right posterior arm, applied Opti foam dressing. -On 11/30/25 at 4:50 p.m. he left facility via van and transported to ED. -On 11/30/25 at 10:53 p.m. he returned in wheelchair from ED. Assessed for injuries. Bruising to back of the head and skin tear to forearm. CT scan of head and neck showed no evidence of injuries. Possible mild concussion. Follow up with primary provider for reassessment in 3 to 5 days. -On 12/1/25 at 8:56 p.m. 24-hour follow-up from fall yesterday. He does not have any additional injuries noted. Pain to back of head due to fall, scheduled Tylenol and Tramadol which was helpful in management of discomfort. Continue to monitor for signs and symptoms of concussion which has not been noted. -On 12/1/25 at 10:33 p.m. NAs reported R1 fell from the ceiling lift during a transfer from bed to wheelchair. They heard a pop, and his left leg went up and he fell downwards to the floor with buttocks landed on fall mat, and upper half went backward from the sling. -On 12/2/25 at 11:06 a.m. Interdisciplinary team (IDT) reviewed fall from ceiling lift in his room on 11/30/25 at 3:55 p.m. Two staff were present at time of fall and was believed that one of the sling straps came off during the transfer causing him to fall. He hit his head and sent to ED for evaluation. Computed tomography (CT) scan (an advanced imaging test that used x-rays and a computer to create detailed, cross section pictures of inside the body) indicated no internal injury. R1's sling was changed to a full body lift sling that did not require crossing of the leg straps and care plan updated to use two staff for all transfers. Staff involved were immediately retrained. -On 12/2/25 at 10:05 p.m. he had a bruise at the back of the head about 6 by 6 cm in diameter (approximately 2.36 inches), still swollen area surrounding it, wabbly and soft to touch. Skin tear on right forearm still present, cleansed and applied Opti foam dressing. R1's emergency department (ED) visit dated 11/30/25, identified he presented for assessment of injury sustained after he rolled backwards out a Hoyer lift falling approximately 12 to 18 inches striking the back of his head on the ground. Exam noted a large 5 mm contusion/hematoma to the occipital without evidence of depressed skull fracture and a small skin tear to the right forearm without evidence of active bleeding or repairable laceration with a possible mild concussion sustained. Due to his advanced dementia, he is non-verbal at baseline and therefore the history and physical (HP) is primarily obtained by verbal report provided by nursing home staff prior to his arrival to ED. Fall was witnessed by nursing staff no loss of consciousness, nausea/vomiting, headache or appreciate and changes to his mental status considering his baseline dementia. Facility 5-day report dated 12/5/25, identified two NAs crossed the lift sling leg straps between R1's legs. NA-B stood on left side of the bed and hooked the Basic Basic lower leg sling strap onto the ceiling lift. NA-A stood on the right side of the bed and hooked up the sling straps (did not identify how many and which one(s)) onto the ceiling lift. NA-B walked away from the left side of bed and towards the wheelchair to assure it was ready to go. NA-B turned around to go back to bed and NA-A had initiated the lift, raised him 3 to 4 inches off the bed, and pulled him away from the bed and towards the chair. NA-A hear a hard snap, but nothing broke on the sling. NA-B approached the end of the bed and heard a pop/thud noise, and he quickly slipped through the sling, buttocks landing on the floor mat first, fell backwards, and right leg remained elevated in the sling strap. NA-A stated happened so fast, unsure what he hit his head on other than the floor mat and received a goose egg. NA-A was the staff member responsible for hooking up the sling loop that came off the ceiling lift hanger bar. Registered nurse (RN-A) evaluated R1, was responsive and appeared at baseline. RN-A noted nothing wrong with sling, motor or hanger bar of the ceiling lift after incident and completed immediate re-education and competency training on NA-A and NA-B the evening of the incident. R1 was sent to ED and head CT indicated no internal injury. Lift sling was changed to a fuller body lift sling that did not require any crossing of leg straps and care plan updated to use two staff for all transfers. Through interviews and reenactments of events it was substantiated that the incident took place as described. Staff did not assure the lift strap was secured. Review of a facility document written by director of nursing (DON) identified on 12/1/25, DON, RN-A, nurse educator, RN-C, and RN-D went into a vacant room and set up same as R1's room to recreate the incident that happened on 11/30/25 with R1. Immediately noted due to ceiling lift strap being of a non-stiff material was hard to get the strap to stay on the hanger bar and not fall off or in the correct position to stay hooked. If tension was placed on the strap by pulling it into place or raising the lift, stayed in place but not in the correct position inside the hanger bar hook. Much manipulation was needed before being successful to keep it in place and elevate the ceiling lift enough to provide tension enough to get the sling strap to pull out of place crating the popping noise they heard. They were unable to get the person in the lift very high off the mattress to start to move them away from the bed towards the chair before the strap would come off the lift. After all interviews and reenactments were attempted, it was substantiated the incident took place as described by NA-A and NA-B, there was no malice, just an unfortunate accident that may have been precipitated by the left leg sling strap not being fully hooked to the lift bar correctly. During an observation on 12/3/25 at 11:15 a.m. NA-C and NA-D entered R1's room, washed hands and applied gloves. NA-C pushed bed out from the wall and positioned herself on the left side of the bed and NA-D checked his pants and verified dry. NA-D moved the ceiling lift over to his bed and lowered it down in front of him. NA-C and NA-D connected the sling loops on their side to the ceiling lift bar. Lift sling was black, size large, and cover his buttocks. The upper and lower sling loops were hooked up to the ceiling lift bar by each NA. NA-D used the ceiling remote control to lift him off the bed slightly and rechecked loop connections to ceiling lift bar. Then continued to raise him off the bed, moved him over to above the wheelchair, lowered him down, and disconnected the loops from the ceiling lift. During an interview on 12/3/25 at 3:28 p.m. NA-A stated R1 laid in a low bed with fall mat positioned on floor next to bed. She stood on right side of bed, NA-B stood on left side between bed and wall and completed a check and change. His yellow basic sling was located underneath him, the sling loops were crossed between his legs and loops hooked up to the ceiling lift machine. She was unsure as to which loops she attached to the ceiling lift. She had the remote, lifted him off the bed approximately 9 inches, high enough to swing legs off the bed, the straps seemed tight without slack in the loops, and attached to the ceiling lift bar. NA-B came around to the bottom of the bed prior to when she lifted him off the bed and stood on her left side. She transferred him off the bed and moved towards the wheelchair then heard a loud pop sound and he fell from the sling onto the floor on his buttocks. The sling hung from the ceiling lift bar; the left lower leg loop came unhooked from the right side. He laid on his back, legs directly straight out in front of him, unable to recall if he had hit his head, stated ouuuuu, asked if he hurt and answered yes. He had a big bump on the back of his head and left inner wrist skin tear, slightly bleeding. The sling was inspected by the nurse, removed from his room. He was lifted off the floor and into the wheelchair with the same ceiling lift. She received education later that night after 10:00 p.m. from the staff nurse when R1 returned from the hospital was transferred back into bed with the ceiling lift. She had worked on the floor and transferred residents with lifts after the incident. Then, later completed education on the computer, read the education document and signed off on the sheet. During a follow-up interview on 12/4/25 at 12:26 p.m. NA-A stated the nurses working the day of the fall RN-A and RN-B worked with her and NA-B while R1 was transferred off the floor with the ceiling lift and into his wheelchair. She continued working her shift and transferred three to four residents after the incident with the ceiling lift, which included R1's roommate (used the same ceiling lift) and transferred him, with the assistance of NA-B, from recliner back to bed. Later in the shift at about 10:30 p.m. RN-A completed the competency check off list while she transferred R1 from wheelchair to the bed after he returned from ED. During an interview on 12/3/25 at 4:40 p.m. RN-B stated she received a message on 11/30/25 at 3:55 p.m. over the walkie and asked her immediately to come to R1's room. He laid on his back on the floor on top of the fall mat, head positioned halfway down from his bed. She asked both NA's what happened they informed her he fell, and they could not recall what really happened. The sling hung from the ceiling lift. He had sustained a skin tear on the right wrist, the back of his head was swollen, and a large bump could be seen when a new sling was placed underneath him. She informed the staff a Hoyer should be used to lift him off the floor. No inspection had been completed on the ceiling lift prior to when it was used again on the same resident. One of the NA's indicated they could use the ceiling lift. She was in the room when R1 was lifted off the floor with the ceiling lift and placed into his wheelchair. He was at his baseline, body ridged, and no pain. Education on lift transfers and sign off sheet were placed in the break room on 12/1/25. During an interview on 12/4/25 at 10:53 a.m. maintenance supervisor (MS) stated the ceiling lift inspection was completed last by a local medical company 12/3/25, on all ceiling lifts in facility and passed. Once a resident has fallen from a lift, the lift should have been taken out of service to make sure there was not anything wrong with the lift and help prevent further falls if it was the lift. His ceiling lift remained in his room and unsure if the lift was used after the incident. He returned to work on 12/1/25, informed of a fall from the ceiling lift, removed the machine from the room and replaced it with one that had been inspected. His ceiling lift was inspected and tested on [DATE], by the medical company and no concerns were noted. On 12/4/25 at 11:39 a.m. director of nursing (DON) stated education will be placed today for staff on the policy to remove the lift and sling from service if there is any incident that occurred with a device.During an interview on 12/4/25 at 1:15 p.m. RN-A stated she arrived at R1's room approximately five minutes after the fall occurred. He laid on his back on the floor perpendicular to the bed. She assessed his head and noted a goose egg bruise on the back side of his head about the size of the palm of her hand approximately 5 cm in diameter and a couple dots of blood noted on right wrist/lower forearm from a superficial small abrasion. It was obvious he had hit his head; the bruise was instantly there. He was in pain stated ahhh ahhh ahhh when she cradled the back of his head, barely touching it with her hand. He was asked if it hurt and stated yes. Range of motion (ROM) of all 4 extremities and vitals were completed. The sling hung from the ceiling lift. She asked NA-A what happened and NA-A stated did not know, it happened so fast. Loops should have been properly hooked up into the ceiling lift bar and double checked they were secure prior to the lift and transfer. The ceiling lift was not taken out of commission during her shift that ended at 10:30 p.m. The sling was removed immediately and placed in DON's office. Another sling was in his dresser drawer and used with the same ceiling lift he fell from to transfer him from the floor to the wheelchair. She assisted NA-B with the ceiling lift transfer after the fall. The facility had a portable Hoyer lift and used if a resident was on the floor due to a fall. In hindsight, we should have opted for a better way to transfer him off the floor and used the Hoyer lift. Something went wrong, and R1 fell from the ceiling lift, unsure what and how it happened. Would have been important to have made sure it was not a mechanical error from the ceiling lift and/or lift sling. The nurses should have made that decision and in the moment tried to get him off the floor and made sure he was ok. There was a new intervention added to his care plan the next day, black sling (supported his bottom with no opening) instead of the yellow one. He was sent to ED approximately one hour after fall. The first one to two hours after he was sent in, she completed paperwork and tasks. The two NAs were not removed from the floor, continued to work with several residents that remained up and required assistance to bed. There were other residents that required the use of the ceiling lift on the [NAME] wing, both NAs worked together. She was unsure if they used ceiling lifts after incident or if they were safe working together on the floor, and did not observe transfers until she completed her tasks, later in the shift. Towards the end of the shift the two NAs were taken to another resident's room, the lift competency was completed during ceiling lift transfer, and observed while they asked questions. The education documents placed in the staff break room was communicated through shift change and she had not read it yet. During an interview on 12/4/25 at 3:15 p.m. NA-B stated she had pushed R1's bed out from the wall and positioned herself between the wall and the bed on the left side. He laid on top of a yellow lift sheet, and crossed the loops between his legs. She initially hooked up the right lower side, shorter green loop to the left side of the ceiling lift bar, then realized it should have been the longer gray loop, switched it, and tugged on it to make sure it was secure. NA-A hooked up the other three loops to the ceiling lift bar, two on top green shorter loops and the left lower gray loop hooked up to the right side of the ceiling lift bar. Usually, she completed a double check on all the loops of the sling to assure they were connected to the ceiling lift properly but did not do that this time and should have, instead she pushed the bed back against the wall (positioned approximately 20 inches from floor), walked over to the right side of the bed and moved the wheelchair. She walked back over to the end of R1's bed, NA-A had already lifted him up off the bed approximately 9 inches and his legs hung down at a slight angle. She had witnessed in the past, sling loops let go from the ceiling lift when not enough tension was on the strap prior to a transfer. She had noted prior to R1's transfer the left lower loop located on the right side of the ceiling lift bar did not have enough tension on the loop, the strap folded and hung down, and when raised up the tension tightened up the strap. She did not check the loop again when he was raised off the bed, prior to the fall, and that side let go. She heard a big thud, sounded like a sling loop came loose and seen the lower left loop became unhooked from the right side of the ceiling lift bar. The sling lift strap flew out between his legs, he slide out of the sling lift, fell onto the floor mat (1 1/2 inches thick), and his right leg hung from the sling still attached to the ceiling lift machine, while he laid on the floor. His upper body was shaking while he hung onto the straps, gave him more security, which made the transfer a bit more difficult. R1 was lifted off the floor with the same ceiling lift by her and RN-A and we reviewed what happened at that time. The ceiling lift was used to transfer his roommate back to bed after the incident without difficulty. She reviewed the education sheet today, was her first day back to work. Unsure if she received education prior to when she completed other lifts that evening, and anxious about using a lift after the incident. She did not know what caused R1's fall on 11/30/25. During an interview on 12/4/25 at 4:31 p.m. lift supplier representative stated he parented with the lift supplier company and completed annual ceiling lift inspections to assure everything was operating correctly and carried the proper load. The Basic Basic sling was gold colored with gray trim and had two different loops, green (shorter) used on top and gray (longer)used on bottom, located on all four ends. This sling should have been crossed between the legs prior to the transfer. If the loops of the sling were placed properly into the ceiling lift it would have taken a person to manipulate it using human force and work it out of the steel bull horn located on the ceiling lift. Either it was not hooked up properly, loop tore, or carry bar snapped. Important to ensure the loops were hooked up properly for patient safety and help prevent a fall. Most likely was not hooked up into the carry bar properly and if that happened, they should have had a certified inspector look at the lift. The ceiling lift machine should have been taken out of service if there was a failure of the lift. Staff should have been trained properly before being allowed to lift/transfer another resident. Until they determined how and what happened they should have removed the machine and sling form the room until the cause could have been determined and inspect the sling and ceiling lift. During an interview on 12/4/25 at 5:43 p.m. DON stated the sling reference book according to the manufacture was used on 4/11/25, to determine the sling size and type use for R1. The sling used during R1's transfer and fall on 11/30/25 was appropriate. He had Parkinson's, ridged, and NAs requested he be reassessed for comfort reasons due the Basic Basic sling went up and crossed between the legs. He was reassessed after the fall and changed to the black full body lift sling, more comfortable and assist of one to two due to he grabbed and shook when stimulated. She was called right after R1 fell from the ceiling lift during a transfer. The ceiling lift was still in position, sling had remained attached on three out of the four sides and his right leg had to be removed from the lift. RN-A assessed the ceiling lift, speculated it was not the lift that caused the fall, seemed more like the sling loops, hanger bar was not damaged, and used the same lift to transfer him from floor to wheelchair after the fall. She was contacted after they had used the ceiling lift and would have instructed them to take it out of service instead per facility policy for safety purposes for him and his roommate (used to transfer both after fall). Alternative option would have been the EZ way body lift machine. The expectation would be to follow facility policy. RN-A was informed to observe the lift transfer with R1 when he returned to facility. The two NAs involved in the incident were not taken off the floor that night, did not expect them to be, they did not do anything intentional. At 5:00 p.m. she talked with NA-A and then NA-B. NA-A worked with residents while NA-B was in dining room assisting residents. RN-A had informed her she had talked to both NAs, gave them the education on lift and straps, unaware of what time the education was completed. She had received conflicting information from the staff involved. There was always slack in the sling strap until tension was applied, for some reason there was enough tension on the tip of the hanger bar when resident was raised it snapped off the bar from the lift. She would have expected the staff to recheck the loops of the sling and if not hooked appropriately call it out and fix it. Staff should work as a team and was important for the safety of the resident. We completed a reenactment of the fall from the ceiling lift and decided more education was needed to make sure the staff placed the loop of the sling into the hanging bar. We planned on changing the competency check list, language was vague and should have had a required double check included, which was not included prior to the incident. The outcome was that staff did not hook up the loops properly to the ceiling lift and R1 fell out of sling to the floor. Facility Demonstration/Return Demonstration for Equipment Ceiling lift last revised 1/2025, identified Strap- must check the lifting strap prior to each transfer for fraying, wear and damage before using the hoist. Any irregularities mean I SHOULD NOT use the hoist and fill out a work order. Lying Position- After sling was placed properly per sling type, place leg straps beneath the resident's thighs, bring them up between the legs and cross them over each other. Bring lifting hanger over the center of the resident to be lifted and place the hanger parallel to the resident's shoulders. All four lift straps are now ready to be attached, and the lifting sling can be mounted on the lifting hanger. The competency did not identify the sling loops should be doubled checked once the resident was ready to be lifted off the bed and/or again after slightly lifted off the bed to confirm they are securely fastened to ensure they will not unhook during the transfer. Facility Demonstration/Return Demonstration for Equipment Ceiling lift last revised 1/2025, page 3 identified I have been shown how to operate a ceiling lift and have been educated on the various types of slings. I have had the opportunity to ask questions. I understand how to properly use the lift and understand I will use the correct care planned type and size of sling for resident transfers. Both NA-A and NA-B signed this agreement on 11/30/25, time was not documented. Facility policy Standard of Work: Lift, Ceiling - Operating and Daily Maintenance instruction dated 1/7/25, identified all resident equipment should be used appropriately and according to manufacturer's direction. This will ensure that safe resident transfer is provided. Place the leg straps beneath the resident's thighs, bring them up between the legs and cross them over each other (unless using an hourglass or sit on sling). Attach the lifting hanger sling on the lifting hanger: place the lifting hanger parallel to the resident's chest. Attach the hooks that face the resident to the uppermost set of straps (from the back). Attach the lowermost set of straps (from the legs) to the hooks that face away from the user. Check that the straps are placed correctly in a horizontal position on the hooks and are secure on the hooks of the lifting hanger before starting to lift. During the lifting procedure make sure the leg supports do not slide towards the groin of the resident. The resident can now be transferred. Guldmann ceiling lifts allow for one staff to operate and transfer the resident unless care planned for additional staff support. Staff education provided on 12/2/25, identified mechanical lift training with all nursing staff upon hire, annually, and as needed. The training includes nursing staff must check the lifting strap to each transfer for fraying, ware and damage before using the hoist. Any irregularity meant I SHOULD NOT use the hoist and fill out a work order. Attach the four appropriate sheet loops to the lifting hanger and use remote to lift resident. Caution! Be careful when attaching the lifting slings' straps on the hooks. Check that the straps have been completely placed in the lifting hanger's hooks. When pressing the buttons on the hand control, check again that all straps remain correctly placed in the lifting hanger and use remote to lift resident. REMINDER: Ensure ALL straps are secure on hanger hooks by slowly lifting resident up PRIOR to moving resident from wheelchair/bed/toilet. Ready - ask the resident if they are ready for the transfer? Are the staff ready? Is the equipment ready? Set -Are the sling straps on the hanger bar? Does the resident have shoes on? GO- all parties are ready to go for the transfer. Facility policy Vulnerable Adult-Resident Protection Plan dated 6/21/23, identified purpose: to establish policies and procedures that ensure that all residents that live at the facility were protected from any and all abuse, neglect, misappropriation of resident property, exploitation, and harm in accordance with federal law and state statute and that they maintain the highest practicable physical, mental and psychosocial well-being of each resident. Investigation protocol to consider: While the investigation is being conducted, suspected individuals will have their employment status reviewed and appropriate actions taken, after approval by the Administrator or designee. Provision of therapeutic misconduct which: An individual makes an error in the provision of therapeutic conduct to a Vulnerable Adult that results in injury or harm, which reasonably requires the care of a physician. Identify and take corrective action and implement measures designed to reduce the risk of further occurrence of this error and similar errors. Facility policy Mechanical Transfer Devices dated 2/10/25, identified purpose was to identify standard guidelines for the safe operation of standing assist mechanical lifts and full body mechanical lifts and to ensure the safety of facility staff when transferring, lifting, and moving residents. The appropriate mechanical device will be used for a resident requiring more than minimal assistance to enable nursing staff to lift, transfer, position, and move the resident safely per the resident's care plan and the facility Safe Resident Handling Program, in accordance with the equipment manufacturer's recommendations and all State and Federal rules and regulations. If an adverse event occurs, the stand or lift involved and sling, if applicable, will be placed out of service immediately by facility staff. The items will be kept in a secure place pending inspection/investigation by designated staff. Facility staff will receive training for both the standing assist and the full body mechanical lifts during their orientation/probation period, as needed, and annually as appropriate. Training will be in accordance with the stand or lift manufacturer's recommendations and documented in staff members' education record. Staff will demonstrate competency in the use of any mechanical stand or lift before assisting/lifting a resident.

Based on interview and document review, the facility failed to provide sufficient protection to other residents while the investigation was completed for 1 of 3 residents (R1) who was reviewed for accidents. This had the potential to affect all 9 residents who required staff assistance with total body lift transfers.Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified he was admitted to the facility on [DATE], from a skilled nursing facility. He had severely impaired cognition, disorganized thinking, and physical behavioral symptoms directed toward others (hitting, kicking, pushing, scratching, grabbing). He was dependent upon staff for all transfers. Diagnoses included non-traumatic brain dysfunction, Alzheimer's (brain cells die over time, brain shrinks and causes dementia/memory loss), aphasia (a disorder that affects how you communicate, speech and as well as the way you write and understand both spoken and written language), seizure disorder, and muscle weakness. R1's care plan dated 12/1/25, identified impaired mobility/transfers due to generalized weakness and severely impaired cognition. Staff were directed on 10/28/25, transfer with one staff assist with ceiling lift. Use Basic Basic (all around sling) size large sling. May leave ceiling lift sling under when in wheelchair. Two staff assist with transfers when having increased behaviors. Care plan transfer section revised on 12/1/25, two staff assist with all transfers using ceiling lift and use Sit on Comfort size large sling.R1's progress notes from 11/30/25 through 12/2/25, identified:-On 11/30/25 at 3:55 p.m. Fall Note: Nursing assistant (NA) alerted nurse during a transfer from bed to wheelchair he fell from the ceiling lift, heard a pop and his left leg went up and fell backwards from the sling. He landed on his back, first hitting his buttocks on the floor mat. Called local medical center and verbal order received to send to ED. Hematoma noted to back left side of head, unable to check eyes. Assessed vitals and level of consciousness. Assisted up with ceiling lift and four staff. Ice applied to back of head. Kept by nursing staff until he could be transferred-On 11/30/25 at 3:55 p.m. Plan of Care note: Writer, registered nurse (RN)-B was called by NA to R1's room. Reported he fell during transfer via lift. He was on the floor with floormat behind. Neuro vital signs started. See contusion on the back of the head, ice pack applied. A bleeding wound was seen on the right posterior arm, applied Opti foam dressing. -On 11/30/25 at 4:50 p.m. he left facility via van and transported to ED. -On 11/30/25 at 10:53 p.m. he returned in wheelchair from ED. Assessed for injuries. Bruising to back of the head and skin tear to forearm. CT scan of head and neck showed no evidence of injuries. Possible mild concussion. Follow up with primary provider for reassessment in 3 to 5 days. -On 12/2/25 at 11:06 a.m. Interdisciplinary team (IDT) reviewed fall from ceiling lift in his room on 11/30/25 at 3:55 p.m. Two staff were present at time of fall and was believed that one of the sling straps came off during the transfer causing him to fall. He hit his head and sent to ED for evaluation. Computed tomography (CT) scan (an advanced imaging test that used x-rays and a computer to create detailed, cross section pictures of inside the body) indicated no internal injury. R1's sling was changed to a full body lift sling that did not require crossing of the leg straps and care plan updated to use two staff for all transfers. Staff involved were immediately retrained. -On 12/2/25 at 10:05 p.m. he had a bruise at the back of the head about 6 by 6 cm in diameter (approximately 2.36 inches), still swollen area surrounding it, wabbly and soft to touch. Skin tear on right forearm still present, cleansed and applied Opti foam dressing. R1's emergency department (ED) visit dated 11/30/25, identified he presented for assessment of injury sustained after he rolled backwards out a Hoyer lift falling approximately 12 to 18 inches striking the back of his head on the ground. Exam noted a large 5 mm contusion/hematoma to the occipital without evidence of depressed skull fracture and a small skin tear to the right forearm without evidence of active bleeding or repairable laceration with a possible mild concussion sustained. Fall was witnessed by nursing staff no loss of consciousness, nausea/vomiting, headache or appreciate and changes to his mental status considering his baseline dementia. Facility 5-day report dated 12/5/25, identified two NAs crossed the lift sling leg straps between R1's legs. NA-B stood on left side of the bed and hooked the Basic Basic lower leg sling strap onto the ceiling lift. NA-A stood on the right side of the bed and hooked up the sling straps (did not identify how many and which one(s)) onto the ceiling lift. NA-B walked away from the left side of bed and towards the wheelchair to assure it was ready to go. NA-B turned around to go back to bed and NA-A had initiated the lift, raised his 3 to 4 inches off the bed, and pulled him away from the bed and towards the chair. NA-A hear a hard snap, but nothing broke on the sling. NA-B approached the end of the bed and heard a pop/thud noise, and he quickly slipped through the sling, buttocks landing on the floor mat first, fell backwards, and right leg remained elevated in the sling strap. NA-A stated happened so fast, unsure what he hit his head on other than the floor mat and received a goose egg. NA-A was the staff member responsible for hooking up the sling loop that came off the ceiling lift hanger bar. RN-A evaluated R1, was responsive and appeared at baseline. RN-A noted nothing wrong with sling, motor or hanger bar of the ceiling lift after incident and completed immediate re-education and competency training on NA-A and NA-B the evening of the incident. R1 was sent to ED and head CT indicated no internal injury. Lift sling was changed to a fuller body lift sling that did not require any crossing of leg straps and care plan updated to use two staff for all transfers. Through interviews and reenactments of events it was substantiated that the incident took place as described. Staff did not assure the lift strap was secured. Review of a facility document written by director of nursing (DON) identified on 12/1/25, DON, RN-A, nurse educator, RN-C, and RN-D went into a vacant room and set up same as R1's room to recreate the incident that occurred on 11/30/25. Immediately noted due to ceiling lift strap being of a non-stiff material was hard to get the strap to stay on the hanger bar and not fall off or in the correct position to stay hooked. If tension was placed on the strap by pulling it into place or raising the lift, stayed in place but not in the correct position inside the hanger bar hook. Much manipulation was needed before being successful to keep it in place and elevate the ceiling lift enough to provide tension enough to get the sling strap to pull out of place crating the popping noise they heard. After all interviews and reenactments were attempted, it was substantiated the incident took place as described by NA-A and NA-B, there was no malice, just an unfortunate accident that may have been precipitated by the left leg sling strap not being fully hooked to the lift bar correctly. During an interview on 12/3/25 at 3:28 p.m. NA-A stated R1 laid in a low bed with fall mat positioned on floor next to bed. She stood on right side of bed, NA-B stood on left side between bed and wall and completed a check and change. His yellow basic sling was located underneath him, the sling loops were crossed between his legs and hooked the loops up to the ceiling lift machine. She was unsure as to which loops she attached to the ceiling lift. She had the remote, lifted him off the bed approximately 9 inches, high enough to swing legs off the bed, the straps seemed tight without slack in the loops, and attached to the ceiling lift bar. NA-B came around to the bottom of the bed prior to when she lifted him off the bed and stood on her left side. She transferred him off the bed and when moved towards the wheelchair heard a loud pop sound he fell from the sling onto the floor on his buttocks. The sling hung from the ceiling lift bar; the left lower leg loop came unhooked from the right side. He laid on his back, legs directly straight out in front of him, unable to recall if he had hit his head, stated ouch asked if he hurt and answered yes. He had a big bump on the back of his head and left inner wrist skin tear, slightly bleeding. The sling was inspected by the nurse, removed from his room. He was lifted off the floor and into the wheelchair with the same ceiling lift. She received education later that night after 10:00 p.m. from the staff nurse when R1 returned from the hospital was transferred back into bed with the ceiling lift. She had worked on the floor and transferred residents with lifts after the incident. Then, later completed education on the computer, read the education document and signed off on the sheet. During a follow-up interview on 12/4/25 at 12:26 p.m. NA-A stated RN-A and RN-B worked with her and NA-B and transferred R1 off the floor with the ceiling lift and into his wheelchair. She continued working her shift and transferred three to four residents after the incident with a ceiling lift, which included R1's roommate (used the same ceiling lift) with the assistance of NA-B, from recliner back to bed. Later in the shift at approximately10:30 p.m. RN-A completed the competency check off list while she transferred R1 from wheelchair to the bed after he returned from ED. The education document located in the staff break room was reviewed also. During an interview on 12/3/25 at 4:40 p.m. RN-B stated she received a message on 11/30/25 at 3:55 p.m. over the walkie and asked her immediately to come to R1's room. He laid on his back on the floor on top of the fall mat, head positioned halfway down from his bed. She asked both NA's what happened they informed her he fell, and they could not recall what really happened. The sling hung from the ceiling lift. He had sustained a skin tear on the right wrist, the back of his head was swollen, and a large bump could be seen when a new sling was placed underneath him. She informed the staff a Hoyer should be used to lift him off the floor. No inspection had been completed on the ceiling lift prior to when it was used again on the same resident. One of the NA's indicated they could use the ceiling lift. She was in the room when R1 was lifted off the floor and placed into his wheelchair. He was at his baseline, body ridged, and no pain. Education on lift transfers and sign off sheet were placed in the staff break room on 12/1/25. During an interview on 12/4/25 at 10:53 a.m. maintenance supervisor (MS) stated once a resident has fallen from a lift the lift should have been taken out of service to make sure there was not anything wrong with the lift and help prevent further falls if it was the lift. His ceiling lift remained in his room and unsure if the lift was used after the incident. He returned to work on 12/1/25, informed of a fall from the ceiling lift, removed the machine from the room and replaced it with one that had been inspected. On 12/4/25 at 11:39 a.m. director of nursing (DON) stated education will be provided today for staff on the policy to remove the lift and sling from service if there is any incident that occurred with a device.During an interview on 12/4/25 at 1:15 p.m. RN-A stated she arrived at R1's room approximately five minutes after the fall occurred. He laid on his back on the floor perpendicular to the bed. She assessed his head and noted a goose egg bruise on the back side of his head about the size of the palm of her hand approximately 5 cm in diameter and a couple dots of blood noted on right wrist/lower forearm from a superficial small abrasion. It was obvious he had hit his head; the bruise was instantly there. He was in pain stated ahhh ahhh ahhh when she cradled the back of his head, barely touching it with her hand. He was asked if it hurt and stated yes. Range of motion (ROM) of all 4 extremities and vitals were completed. The sling hung from the ceiling lift. She asked NA-A what happened and stated did not know it happened so fast. Loops should have been properly hooked up into the ceiling lift bar and double checked they were secure prior to the lift and transfer. The ceiling lift was not taken out of commission during my shift that ended at 10:30 p.m. The sling was removed immediately and placed in DON's office. Another sling was in his dresser drawer and used to same ceiling lift he fell from to transfer him from the floor to the wheelchair. She assisted NA-B with the ceiling lift transfer after the fall. The facility had a portable Hoyer lift and used to if a resident was on the floor due to a fall in hindsight, we should have opted for a better way to transfer him off the floor and used the Hoyer lift. Something went wrong, and R1 fell from the ceiling lift, unsure what and how it happened. Would have been important to have made sure it was not a mechanical error from the ceiling lift and/or lift sling. The nurses should have made that decision and in that moment tried to get him off the floor and made sure he was ok. There was a new intervention added to his care plan the next day, black sling (supported his bottom with no opening) instead of the yellow one. He was sent to ED approximately one hour after fall. The first one to two hours after he was sent in, she completed paper and tasks and the two NAs were not removed from the floor, continued to work with several residents that remained up and required assistance to bed. There were other residents that required the use of the ceiling lift on the [NAME] wing, both NAs worked together, unsure if they used ceiling lifts after incident, unsure if they were safe working together on the floor, and did not observe transfers until she completed her tasks, later in the shift. Towards the end of the shift the two NAs were taken to another resident's room, and the lift competency was completed, and a ceiling lift transfer was observed while they asked questions. The education documents placed in the staff break room was communicated through shift change and she had not read that document yet. During an interview on 12/4/25 at 3:15 p.m. NA-B stated she had pushed R1's bed out from the wall and positioned herself between the wall and the bed on the left side. He laid on top of a yellow lift sheet, Basic Basic. and [NAME] crossed the loops between his legs. She initially hooked up the right upper side, shorter green loop to the left side of the ceiling lift bar, then realized it should have been the longer gray loops, switched it, and tugged on it to make sure it was secure. NA-A hooked up the other three loops to the ceiling lift bar, two on top green shorter loops and the left lower gray loop hooked up to the right side of the ceiling lift bar. Usually, she completed a double check on all the loops of the sling to assure they were connected to the ceiling lift properly but did not do that this time and should have, instead pushed the bed back against the wall (positioned approximately 20 inches from floor) and walked over to the right side of the bed and moved the wheelchair. She walked back over to the end of R1's bed, without her nearby, NA-A had already lifted him up off the bed approximately 9 inches and his legs hung down at a slight angle. She had witnessed in the past, sling loops let go from the ceiling lift when not enough tension was on the strap prior to a transfer. She had noted prior to R1's transfer the left lower loop located on the right side of the ceiling lift bar did not have enough tension on the loop, the strap folded down and hung down, and when raised up the tension tightens up the strap. She did not check the loop again when he was raised off the bed, prior to the fall, and that side that let go. She heard a big thud, sounded like a sling loop came loose and seen the lower left loop became unhooked from the right side of the ceiling lift bar. The sling lift strap flew out between his legs, he slid out of the sling lift, fell onto the floor mat (1 1/2 inches thick), and his right leg hung from the sling still attached to the ceiling lift machine, while he laid on the floor. His upper body was shaking while he hung onto the straps, gave him more security, which made the transfer a bit more difficult. R1 was lifted off the floor with the same ceiling lift by her and RN-A and reviewed what happened at that time. The ceiling lift was used to transfer his roommate back to bed after the incident without difficulty. She reviewed the education sheet today, was her first day back to work. Unsure if she received education prior to when she completed other lifts that evening after R1's fall and anxious about using a lift after the incident. She did not know what caused R1's fall on 11/30/25. During an interview on 12/4/25 at 4:31 p.m. lift supplier representative stated he parented with the lift supplier company and completed annual ceiling lift inspections to assure everything was operating correctly and carry the proper load. The Basic Basic sling was gold colored with gray trim and had two different loops, green (shorter) used on top and gray (longer)used on bottom, located on all four ends. This sling should have been crossed between the legs prior to the transfer. If the loops of the sling were placed properly into the ceiling lift it would have taken a person to manipulate it using human force and worked it out of the steel bull horn located on the ceiling lift. Either it was not hooked up properly, loop tore, or carry bar snapped. Important to ensure the loops were hooked up properly for patient safety and help prevent a fall. Most likely was not hooked up into the carry bar properly and if that happened, they should have had a certified inspector look at the lift. Staff should have been trained properly before being allowed to lift/transfer another resident. Until they determined how and what happened the ceiling lift machine should have removed and sling from the room until the cause could have been determined and sling and ceiling lift inspected. During an interview on 12/4/25 at 5:43 p.m. DON stated She was called right after R1 fell from the ceiling lift during a transfer. The ceiling lift was still in position, sling had remained attached on three out of the four sides and his right leg had to be removed from the lift. RN-A assessed the ceiling lift, speculated it was not the lift that caused the fall, seemed more like the sling loops, hanger bar was not damaged, and used the same lift to transfer him from floor to wheelchair after the fall. She was contacted after they had used the ceiling lift and would have instructed them to take it out of service instead per facility policy for safety purposes for him and his roommate (used to transfer both after fall). Alternative option would have been the EZ way body lift machine. The expectation would be to follow facility policy. RN-A was informed to observe the lift transfer with R1 when he returned to facility. The two NAs involved in the incident were not taken off the floor that night, did not expect them to be, they did not do anything intentional. At 5:00 p.m. she talked with NA-A and then NA-B. NA-A worked with residents while NA-B was in dining room assisting residents. RN-A had informed her she had talked to both NAs, gave them the education on lift and straps, unaware of what time the education was completed. She had received conflicting information from the staff involved. There was always slack in the sling strap until tension was applied, for some reason there was enough tension on the tip of the hanger bar when resident was raised it snapped off the bar from the lift. She would have expected the staff to recheck the loops of the sling and if not hooked appropriately call it out and fix it. Staff should work as a team and was important for the safety of the resident. After a reenactment of the fall from the ceiling lift was completed on 12/1/25, it was identified more education was needed to make sure the staff placed the loop of the sling into the hanging bar. We planned on changing the competency check list, language was vague and should have had a required double check included, which was not included prior to the incident. The outcome was that staff did not hook up the loops properly to the ceiling lift and R1 fell out of sling onto the floor. Facility policy Vulnerable Adult-Resident Protection Plan dated 6/21/23, identified purpose: to establish policies and procedures that ensure that all residents that live at the facility were protected from any and all abuse, neglect, misappropriation of resident property, exploitation, and harm in accordance with federal law and state statute and that they maintain the highest practicable physical, mental and psychosocial well-being of each resident. Investigation protocol to consider: While the investigation is being conducted, suspected individuals will have their employment status reviewed and appropriate actions taken, after approval by the Administrator or designee. Provision of therapeutic misconduct which: An individual makes an error in the provision of therapeutic conduct to a Vulnerable Adult that results in injury or harm, which reasonably requires the care of a physician. Identify and take corrective action and implement measures designed to reduce the risk of further occurrence of this error and similar errors. Facility Demonstration/Return Demonstration for Equipment Ceiling lift last revised 1/2025, identified Strap- must check the lifting strap prior to each transfer for fraying, wear and damage before using the hoist. Any irregularities mean I SHOULD NOT use the hoist and fill out a work order. Lying Position- After sling was placed properly per sling type, place leg straps beneath the resident's thighs, bring them up between the legs and cross them over each other. Bring lifting hanger over the center of the resident to be lifted and place the hanger parallel to the resident's shoulders. All four lift straps are now ready to be attached, and the lifting sling can be mounted on the lifting hanger. The competency did not identify the sling loops should be doubled checked once the resident was ready to be lifted off the bed and/or again after slightly lifted off the bed to confirm they are securely fastened.Facility Demonstration/Return Demonstration for Equipment Ceiling lift last revised 1/2025, page 3 identified: I have been shown how to operate a ceiling lift and have been educated on the various types of slings. I have had the opportunity to ask questions. I understand how to properly use the lift and understand I will use the correct care planned type and size of sling for resident transfers. Both NA-A and NA-B signed this agreement on 11/30/25, time was not documented. Facility policy Standard of Work: Lift, Ceiling - Operating and Daily Maintenance instruction dated 1/7/25, identified all resident equipment should be used appropriately and according to manufacturer's direction. This will ensure that safe resident transfer is provided. Place the leg straps beneath the resident's thighs, bring them up between the legs and cross them over each other (unless using an hourglass or sit on sling). Attach the lifting hanger sling on the lifting hanger: place the lifting hanger parallel to the resident's chest. Attach the hooks that face the resident to the uppermost set of straps (from the back). Attach the lowermost set of straps (from the legs) to the hooks that face away from the user. Check that the straps are placed correctly in a horizontal position on the hooks and are secure on the hooks of the lifting hanger before starting to lift. During the lifting procedure make sure the leg supports do not slide towards the groin of the resident. The resident can now be transferred. Guldmann ceiling lifts allowed one staff to operate and transfer the resident unless care planned for additional staff support. Facility policy Mechanical Transfer Devices dated 2/10/25, identified if an adverse event occurs, the stand or lift involved and sling, if applicable, will be placed out of service immediately by facility staff. The items will be kept in a secure place pending inspection/investigation by designated staff. Facility staff will receive training for both the standing assist and the full body mechanical lifts during their orientation/probation period, as needed, and annually as appropriate. Training will be in accordance with the stand or lift manufacturer's recommendations and documented in staff members' education record. Staff will demonstrate competency in the use of any mechanical stand or lift before assisting/lifting a resident. Staff education document provided on 12/2/25, identified mechanical lift training with all nursing staff upon hire, annually, and as needed. The training includes nursing staff must check the lifting strap to each transfer for fraying, ware and damage before using the hoist. Any irregularity meant I SHOULD NOT use the hoist and fill out a work order. Attach the four appropriate sheet loops to the lifting hanger and use remote to lift resident. Caution! Be careful when attaching the lifting slings' straps on the hooks. Check that the straps have been completely placed in the lifting hanger's hooks. When pressing the buttons on the hand control, check again that all straps remain correctly placed in the lifting hanger and use remote to lift resident. REMINDER: Ensure ALL straps are secure on hanger hooks by slowly lifting resident up PIROR to moving resident from wheelchair/bed/toilet. Ready - ask the resident if they are ready for the transfer? Are the staff ready? Is the equipment ready? Set -Are the sling straps on the hanger bar? Does the resident have shoes on? GO- all parties are ready to go for the transfer.

Based on observation, interview and document review, the facility failed to accurately assess and implement safe smoking interventions for 1 of 1 resident (R17) reviewed for smoking. Findings include: R17's quarterly Minimum Data Set (MDS) dated [DATE], indicated R17 had diagnoses which included chronic obstructive pulmonary disease (COPD) hypertension (elevated blood pressure), and stroke. Identified R17 had severe cognitive impairment and was independent with activities of daily living (ADL's) which included transfers and toileting. Identified R17 used tobacco. R17's annual Care Area Assessment (CAA) dated 5/1//24, identified interventions were in place to address safety needs. R17's care plan revised 4/27/21, identified the facility had determined R17 was a modified independent smoker. Care plan identified facility was to store R17's cigarettes and give R17 one cigarette at a time to smoke independently. R17's smoking assessment dated [DATE], indicated R17 was safe to dispose of ashes and smoking material completely. Assessment indicated R17 did not have any visible burns on clothing or wheelchair cushion. Indicated R17 was safe to smoke independently without supervision and did not require a smoking apron. R17's smoking assessment dated [DATE], indicated R17 was safe to dispose of ashes and smoking material completely. Assessment indicated R17 did not have any visible burns on clothing or wheelchair cushion. Indicated R17 was safe to smoke independently without supervision and did not require a smoking apron. During an observation on 2/4/25 at 9:15 a.m., R17 was standing at the nurses station. R17 received one cigarette from registered nurse (RN)-A. R17 walked into the smoking room which was located about 40 feet from the nurse's station. R17 put the cigarette into the wall lighter. (a small hole within a metal box located on the wall) and lit the cigarette. R17 sat down in the chair and began smoking the cigarette and as R17 was smoking the cigarette ashes began falling on his lap. R17 had not made any effort to remove the cigarette ashes from his pants and continued smoking. R17 placed the cigarette which was still burning in an ashtray and walked back to the nurses station and received another cigarette from RN-A. R17 walked back into the smoking room and picked up his previous cigarette and used it to light the new cigarette then placed the first cigarette still burning into the ashtray. R17 smoked the second cigarette as ashes continued to fall onto his lap. R17 made no effort to remove the cigarette ashes from his lap and continued smoking. R17 then placed the second cigarette which was still burning into the ashtray. R17 made no effort to extinguish either of the two cigarettes. R17 then left the smoking room and went back to his room. During an observation on 2/4/25 at 9:51 a.m., R17 came out of his room and walked to the nurse's station and received one cigarette from RN-A. R17 walked into the smoking room and used the wall lighter to light the cigarette. R17 sat down in the chair and had visible holes in the black sweatpants he was wearing. R17 began smoking the cigarette and ashes began falling onto his lap. R17 made no effort to remove the cigarette ashes from his pants and continued smoking R17 placed the cigarette which was still burning into the ashtray. R17 made no effort to extinguish the cigarette, got up from the chair, several ashes were noted on the floor as R17 left the smoking room and walked back to his room. During an inventory of R17's clothing on 2/4/25 at 9:26 a.m., RN-A identified two pair of blue pants with large burn-holes, one pair of gray pants with burn-holes, and the black sweatpants R17 was wearing had several burn-holes in them. During an interview on 2/4/25 at 10:02 a.m., laundry aide (LA)-A stated she was aware of the burn-holes in R17's pants. LA-A stated she was not sure how long the burn-holes had been on R17's pants. During an interview on 2/4/25 at 11:00 a.m., nursing assistant (NA)-A stated R17 was a smoker and the nurses stored R17's cigarettes for him. NA-A stated R17 was able to smoke in the smoking room without supervision or a smoking apron. NA-A stated she was aware of the burn-holes in R17's pants however, was unsure how long the burn-holes have been there. During an interview on 2/4/25 at 11:10 a.m., NA-B stated R17 was a smoker and the nurses stored R17's cigarettes for him. NA-A stated R17 was able to smoke in the smoking room without supervision or a smoking apron. NA-A stated she was aware of the burn-holes on R17's pants however, was unsure how long the burn-holes have been there. During an interview on 2/4/25 at 11:36 a.m., RN-A stated she had completed smoking assessments on R17 by observing R17 smoke through the window however, had never gone into the smoking room while R17 was smoking. RN-A stated she was aware of the burn-holes on R17's pants however, was not sure how long the holes had been there. RN-A stated she was not sure why the smoking assessments stated there were no visible holes on R17's clothing. RN-A stated for safety reasons her expectation was that staff should have been offering a smoking apron or supervise R17 while smoking. During an interview on 2/4/25 at 12:13 p.m., RN-B stated she had observed R17 smoking through the window however, had never gone into the smoking room while R17 was smoking. RN-B stated she was aware of the burn-holes present on R17's pants and was not sure how long the holes had been there. RN-B stated she had assumed R17 was safe to smoke unsupervised and did not require a smoking apron. During an interview on 2/4/25 at 12:17 p.m., RN-C stated she had not visualized R17 smoking. RN-C stated when the nurses completed a visual smoking assessment on R17, it was usually by visualizing the window. RN-C stated she was aware of the burn-holes present on R17 clothing however, was unsure how long the holes had been there. RN-C stated another assessment was going to be completed to ensure R17's safety while smoking. During an interview on 2/4/25 at 12:42, director of nursing (DON) stated she was aware of the burn-holes present on R17's clothing. DON stated she was unsure how long the holes have been on the clothing or if any of the burn-holes had happened recently. DON stated her expectation was that R17 was safe while smoking and that another smoking assessment was to be completed and that safety interventions would be implemented off of that new smoking assessment to ensure R17 was safe while smoking. Review of a facility policy titled Smoking and Tobacco Policy revised 5/1/19 identified residents ho smoke would have a smoking assessment quarterly and upon change of condition. Identified smoking interventions were based on the individualized smoking assessment. Residents will follow the plan of care. Violations of the rules or agreed to interventions may result in the loss of the smoking privilege or may lead to smoking restrictions.

Based on observation, interview and document review, the facility failed to ensure professional standards of practice were followed during medication set-up and administration of insulin with a Novolog insulin pen ( rapid-acting insulin, used to improve blood sugar control in people with diabetes mellitus) for 1 of 2 residents (R15) who received insulin without the pen primed according to manufacturer's recommendations. Findings include: R15's quarterly Minimum Data Set (MDS) dated [DATE], identified R15 had intact cognition with diagnosis of type two diabetes (DM), and received injections of insulin. R15's care plan revised 5/31/24, identified staff were to administer medications as prescribed. R15's Medication Review Report signed 12/18/24, identified Semglee Pen-100 units/milliliter, inject 12 units Subcutaneously (an injection just under the skin into the fatty tissue) two times daily for DM. During an observation of medication pass on 2/3/25 at 6:10 p.m., registered nurse (RN)-D prepared R15's medication which included her evening, Semglee insulin. RN-D removed the Semglee insulin pen from the medication cart, removed the tip, attached a needle to the end of the pen, dialed the dose to the ordered 12 units, picked up an alcohol wipe, went to R15's room and administered the 12 units of insulin to R15. RN-D then removed the needle from the end of the pen, placed it in the sharps container and sanitized his hands. RN-D did not prime the pen (waste 2 units of insulin to remove the air bubbles) per manufacturer's instructions prior to drawing up the 12 units of insulin. During an interview on 2/5/25 at 9:33 a.m., RN-D verified he had not primed the insulin pen prior to dialing up the 12 units of Semglee for R15 per manufacturer's recommendations. RN-D stated he was aware the insulin pen should have been primed prior to dialing up the insulin to ensure the accurate dosage of insulin was administered. During an interview on 2/5/25 at 9:35 a.m., consultant pharmacist (CP) stated it was important to always prime an insulin pen prior to drawing up the dosage to ensure the residents received the correct dosage of insulin. During an interview on 2/5/25 at 10:27 a.m., director of nursing (DON) stated her expectation was that the insulin pen would have been primed prior to dialing up the insulin dose for R15 to ensure the proper dose of insulin was administered. Review of the Semglee insulin manufacture's package insert dated 2021, identified the need to perform an airshot before each injection to ensure the any air bubbles were removed. The process directed: Attach a new needle, Select a dose of 2 units on the dosage selector, hold the pen with the needle pointing upward, tap the insulin reservoir to move any air bubbles to the top of the reservoir, press the injection button all the way in, and check to see if insulin comes out of the needle tip. Repeat if no insulin comes from the needle, then dial the selector to the ordered insulin dose and administer as ordered. Review of a facility policy titled Medication Administration Standard revised 5/23, identified staff would follow appropriate standards and protocols when administering medications.

Based on interview and document review the facility failed to report to the state agency (SA) an injury of unknown origin alleged to be caused during transfer with a mechanical lift for 1 of 3 resident reviewed for neglect of care. Findings include: R2's quarterly Minimum Data Set, dated dated dated [DATE], indicated moderate cognitive impairment. A facility incident report dated 8/11/22, indicated R2 had an appointment at the wound clinic on 8/11/22, and reported at the appointment that his left ankle hurt and that he had injured it in a Hoyer lift (mechanical lift). The incident report was updated on 8/29/22, and indicated R2's medical record was reviewed and there was no noted incident in which he had an injury while using the ceiling lift. An untitled provider note dated 8/15/22, indicated R2 was being treated at care center for left lower extremity ulcerations and had been complaining of pain to the medial left ankle for approximately four weeks. R2 reported an injury to his ankle involving his Hoyer lift. Staff at the care center were consulted and were not aware of any injury. Exam consistent with a ligament sprain. Plan: wear Tri-lock brace on ankle daily for three weeks, remove to perform range of motion. Recommend icing ankle and taking anti-[CONDITION(S)] medication, elevate ankle and wear compression garment to help reduce swelling. R2's facility Progress Notes revealed the following: 7/5/22, R2 told writer that the day before yesterday he was lifted up in the ceiling lift and his left leg was twisted. R2 reported his leg hurt from hip to ankle and requested to speak to the unit coordinator. The note indicated the shift supervisor was notified. Record review lacked evidence of an investigation following R2's report of injury from the ceiling lift. 8/11/22, R2 went out to physician for wound care. Left ankle exam performed due to complaint of Hoyer injury to the ankle. X-ray to left ankle completed in reference to ankle related injury to Hoyer lift. 8/12/22, Wound clinic called to report results of left ankle x-ray. X-ray did not reveal any fractures or other acute bony abnormalities. There was some soft tissue swelling which correlated with where R2 was having pain and may be indicative of a medial ankle sprain. 8/17/22, Writer received call from wound center on 8/15/22, indicating a recommendation for an ankle brace to R2's left ankle due to reports of pain from R2 at his last appointment and suspected sprain to left ankle diagnosis. During interview on 8/31/22, at 1:37 p.m. the director of nursing (DON) stated after R2 reported getting hurt on the lift (referring to the 8/11/22 progress note), the team combed back through the charting for an incident in the lift and there was nothing. At 1:45 p.m. the DON stated if injuries were reported they looked at things like if the injury was in a suspicious area, does the resident feel safe, does the resident know what happened or if there was a reasonable explanation for the injury. The DON state ultimately it was up to herself and the administrator to determine and an injury of unknown origin was reportable. The DON stated they felt R2's incident was not reportable based on the fact that there was no no visible injury, even though the medical record lacked evidence an assessment of the injury was completed when R2 first made the report on 7/5/22. The DON further stated she and the administrator had talked through it and did not believe it was credible due to R2's cognition. Facility policy titled Vulnerable Adult/Resident Protection Plan dated 7/2/21, identified an injury of unknown origin as an injury in which the source of the injury was not observed by any person or the source of the injury could not be explained. The policy indicated abuse allegations, including injuries of unknown source were reported per state and federal law.

Based on interview and document review the facility failed to investigate an injury of unknown origin for 1 of 3 residents reviewed for neglect of care. Findings include: R2's quarterly Minimum Data Set, dated dated dated [DATE], identified moderate cognitive impairment and indicated he required extensive assistance to transfer. R2's care plan dated 6/14/22, indicated impaired mobility related to weakness and gait instability. The care plan directed staff to transfer R2 using a ceiling lift. A facility incident report dated 8/11/22, indicated R2 had an appointment at the wound clinic on 8/11/22, and reported at the appointment that his left ankle hurt and that he had injured it in a Hoyer lift (mechanical lift). The incident report was updated on 8/29/22, and indicated R2's medical record was reviewed and there was no noted incident in which he had an injury while using the ceiling lift. The report indicated R2 was not an accurate historian of events, especially details. An untitled provider note dated 8/15/22, indicated R2 was being treated at care center for left lower extremity ulcerations and had been complaining of pain to the medial left ankle for approximately four weeks. R2 reported an injury to his ankle involving his Hoyer lift. Staff at the care center were consulted and were not aware of any injury. Exam consistent with a ligament sprain. Plan: wear Tri-lock brace on ankle daily for three weeks, remove to perform range of motion. Recommend icing ankle and taking anti-[CONDITION(S)] medication, elevate ankle and wear compression garment to help reduce swelling. R2's facility Progress Notes revealed the following: 7/5/22, R2 told writer that the day before yesterday he was lifted up in the ceiling lift and his left leg was twisted. R2 reported his leg hurt from hip to ankle and requested to speak to the unit coordinator. The note indicated the shift supervisor was notified. Record review lacked evidence of an investigation following R2's report of injury from the ceiling lift. 8/11/22, R2 went out to physician for wound care. Left ankle exam performed due to complaint of Hoyer injury to the ankle. X-ray to left ankle completed in reference to ankle related injury to Hoyer lift, He does not use a Hoyer lift, utilizes ceiling lift which legs/feet are not involved. He has dementia diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Documentation was reviewed and no documentation found about an incident of pain or bumping his ankle/feet during a transfer. 8/12/22, Wound clinic called to report results of left ankle x-ray. X-ray did not reveal any fractures or other acute bony abnormalities. There was some soft tissue swelling which correlated with where R2 was having pain and may be indicative of a medial ankle sprain. 8/17/22, Writer received call from wound center on 8/15/22, indicating a recommendation for an ankle brace to R2's left ankle due to reports of pain from R2 at his last appointment and suspected sprain to left ankle diagnosis. During interview on 8/31/22, at 1:37 p.m. the director of nursing (DON) stated after R2 reported getting hurt on the lift (referring to the 8/11/22 progress note), the team combed back through the charting for an incident in the lift and there was nothing. The DON stated R2 used a ceiling lift and not a Hoyer but acknowledged the lift was used in and out of the tub which could have involved his feet and legs. The DON stated when the dictation came back from the physician it said R2 had been complaining of this for four weeks. The DON further stated R2 was not an accurate historian. Review of R2's care plan did not reveal a history of or reasons for current deficits/concerns related R2's ability to accurately report abuse, medical conditions or injuries. On 8/31/22, at 2:11 p.m. registered nurse (RN)-A stated she was part of the follow up related to the injury report dated 8/11/22. RN-A stated after speaking with the DON regarding the concern, she went through her e-mails and saw she had been notified that R2 reported an injury in the ceiling lift on 7/5/22. RN-A stated while she had no documentation, she was sure she would have followed up with R2. Facility policy titled Vulnerable Adult/Resident Protection Plan dated 7/2/21, identified an injury of unknown origin as an injury in which the source of the injury was not observed by any person or the source of the injury could not be explained. The policy directed all reports of abuse, neglect injuries of unknown origin to be promptly and thoroughly investigated.

Based on observation, interview and document review, the facility failed to ensure residents were assisted with eating for 1 of 1 residents (R2) reviewed who needed staff assistance to eat. Findings include: R2's annual Minimum Data Set (MDS) dated [DATE], identified R2 had severe cognitive impairment and required supervision and physical assist of one with eating. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's nutritional status Care Area Assessment (CAA) dated 9/1/21, identified R2 had a moderately high body mass index (BMI) of 26.5 and needed mechanically altered textures due to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's diet order was minced and moist. Further, R2 had a potential for chewing difficulty, choking and/or aspiration. R2's current care plan reviewed 9/1/21, identified an intervention initiated on 9/6/19, identified R2 had a potential for nutritional decline (weight loss/dehydration, chewing/swallowing impairments) with progression of dementia. R2 needed texture modifications related to his dementia and age. Staff were directed to deliver, set up and assist during meals, observe for choking, swallowing problems or dehydration and report as needed. During continuous observation on 10/5/21, at 8:58 a.m. R2 was served his breakfast in the dining room. All other residents had finished their breakfast and R2 was the last resident trying to eat his meal in the dining room. Staff did not attempt to provide R2 with assistance with eating; however, R2 was spilling food onto himself and the floor. - At 9:16 a.m. R2 continued to attempt to eat his meal. R2 used a large bowl and a regular spoon to scrape hot cereal towards himself. While R2 was able to spoon some hot cereal into his mouth, more hot cereal went over the edge of the bowl and landed on the table edge, floor or onto R2's clothing protector. - At 09:17 a.m. licensed practical nurse (LPN)-A applied gloves and approached R2. LPN-A repositioned R2's food for R2 to be able to spoon into his mouth, but did not offer to assist R2 with eating. R2 continued to attempt to eat his meal by himself. - At 9:23 a.m. R2 ate food that had fallen onto his clothing protector by picking it up with his hands, then picked up his fork and attempted to fork hot cereal into his mouth. - At 9:26 a.m. R2 continued to eat his hot cereal with his fork while hot cereal dripped onto the table, the floor and onto R2's clothing protector. No staff attempted redirection for R2 nor had offered assistance. During interview on 10/5/21, at 9:31 a.m. LPN-A stated that day was not a normal day for R2. R2 normally rose every day at 7:30 a.m. and ate breakfast with the other residents. R2 needed fasting lab work that morning which delayed his breakfast. LPN-A stated R2 was fairly independent and only needed assistance when food was falling off his plate. The care plan probably was not updated from when R2 was previously sick and R2 no longer required assistance. During an interview on 10/7/21, at 2:19 p.m. registered nurse (RN)-A stated R2 should have been assisted while eating whether that meant sitting with, watching or cueing. During an interview on 10/7/21, at 3:36 p.m. the director of nursing (DON) stated the residents in the memory care unit were difficult as their abilities changed daily and the care plan provided varying levels of assistance and supervision. R2 required supervision with eating, but would rely on RN-A because she knew the residents best. The staff were expected to follow the care plan to provide the assistance each resident required. The facility policy Activities of Daily Living (ADLs) dated 12/9/19, indicated ADL care and assistance would be provided and managed by the nursing department to ensure that the resident was provided the assistance needed to complete ADL needs while encouraging the resident to exercise highest level of independence. The policy defined the level of assistance as follows: 1. Independent - performed self-care in a specific area without assistance or help from staff, nor need for any staff oversight, with/without assistance devices and within a reasonable time. No set up or physical help from staff. 2. Supervision - staff were to provide cues and/or reminding. 3. Limited assistance - Needed set up/placement of items needed to perform cares. May need minimal physical assistance. Staff provided guided maneuvering of limbs or other non-weight bearing assistance. 4. Extensive assistance - Needed physical assistance in performing a portion of cares. Resident involved in activity. Staff provided weight bearing support. 5. Total dependence - Needed full staff assistance with all tasks.

Based on observation, interview and document review, the facility failed to provide timely repositioning services for 3 of 3 residents (R21, R67, R2) reviewed who were at risk for pressure ulcer development and dependent upon staff for repositioning. Findings include: R21's quarterly Minimum Data Set (MDS) dated [DATE], identified R21 had moderate cognitive impairment and required extensive to total assistance with all activities of daily living. The MDS further identified R21 was at risk of developing pressure ulcers. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R21's current care plan dated 2/26/20, identified R21 had skin breakdown to his coccyx and buttock crease and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan directed staff to assist with repositioning every two hours when sitting and when laying down and encourage R21 to lay down between meals and activities. Any refusals were to be documented. R21's Tissue Tolerance assessment dated [DATE], identified R21 was unable to reposition himself and utilized boots, pillows and pressure relieving mattress while in bed. R21 was repositioned every two hours according to his care plan. He presently had breakdown on his coccyx area and Aquafor was used when incontinent. R21's Braden Scale (for predicting pressure ulcer risk) dated 9/18/21, identified R21 was moderate risk for developing pressure ulcers. R21's Quarterly Skin Risk Factors dated 9/24/21, identified R21 had chronic skin break down to his bottom as R21 was not able to reposition himself in wheelchair or bed due to his MS. R21 was able to alert to staff when he wanted to lay down and be repositioned. He had no open areas and Aquafor was applied to his bottom for prevention. R21 had a Foley catheter in place. He had times of refusing to be repositioned either in bed or his wheelchair. During continuous observation on 10/6/21, at 7:09 a.m. nursing assistant (NA)-D pushed R21 from his room in a high-backed wheelchair with an attached headrest, to the television sitting area near the nursing station. R21 was dressed and the wheelchair was reclined slightly. -At 7:16 a.m. licensed practical nurse (LPN)-B provided R21 his morning medications. -At 7:24 a.m. LPN-B brought R21 to a conference room behind the nurses' station, administered his insulin and then returned him to the common sitting area. -At 8:40 a.m. LPN-B wheeled R21 to the dining room and sat him at a table. -At 9:11 a.m. registered nurse (RN)-B obtained R21's breakfast order, brought the completed meal slip to the dietary aid and returned to the table with beverages for R21. -At 9:17 a.m. R21 received his meal and RN-B provided total feeding assistance to R21. -At 9:47 a.m. R21 completed eating his meal and RN-B wheeled him from the dining room to his room and positioned his wheelchair next to the bed. RN-B did not offer repositioning to R21. On 10/6/21, at 9:58 a.m. NA-E stated R21 got up a little after 7:00 a.m. (2 hours and 49 minutes prior) and he required repositioning every two to three hours. She was just going to his room now. NA-E entered R21's room and transferred him to the bed utilizing a ceiling lift. R21 stated he felt a little bit of pain on his bottom from sitting. NA-E stated R21 currently had three open areas; one on the right buttock crease and two on the coccyx. They applied Aquafor (moisturizing skin protestant) and [MEDICATION(S)] (moisture barrier ointment) on the areas for protection and encouraged R21 to lay down every day to get off his bottom. When asked to clarify R21's repositioning schedule, NA-E displayed a care plan posted on the inside of R21's closet door and identified it directed R21 required repositioning every two hours. She stated breakfast was really hard for staff as they had a lot of people to get up and a lot who liked to sleep in. Due to this, it was usually three hours in the morning before they could reposition R21 and then every two hours after that. During interview on 10/6/21, at 10:20 a.m. RN-B stated R21 was to be repositioned every two hours. His skin was compromised in the past and they used Aquafor as a barrier cream. R21's last bath note indicated the areas on his bottom were continuing to heal. RN-B and LPN-B both stated they were not aware of any open areas to R21's bottom. On 10/6/21, at 10:49 a.m. RN-B entered R21's room and asked R21 to rate the pain in his bottom. R21 stated the pain was a five on a 1/10 scale. RN-B stated the issues to R21's bottom developed and resolved quickly and were areas of excoriation (an abrasive or tearing injury to the surface of the body) from shearing (force generated when the skin is moved against a fixed surface such as a bony skeleton moving in an opposite direction to the surface skin). She measured and described the areas as follows: Area 1 (right of coccyx): 2.0 x 1.0 centimeters (cm). The area was blanchable. Area 2 (right of Area 1): 0.2 x 0.4 cm. The area was blanchable. Area 3 (coccyx) 2.2 x 0.4 cm The area was blanchable. Area 4 (right gluteal crease) 3.1 x 0.4 cm. The area was blanchable with blood. During interview on 10/7/21, at 3:44 p.m. RN-C stated R21 had an ongoing chronic issue with the skin integrity on his bottom. The areas opened and closed repeatedly. He should be repositioned every two hours and three hours was too long for him to sit. During interview on 10/7/21, at 4:51 p.m. the director of nursing (DON) stated she would have expected R21 be repositioned or offered repositioning as directed by his care plan. R67's significant change MDS dated [DATE], identified R67 had severe cognitive impairment and required assistance with for all transfers. R67 was at risk for pressure ulcers; however, did not have any current pressure ulcers. The MDS included a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R67's current care plan dated 7/30/21, identified R67 was at risk for skin breakdown related to dementia, a possibility of non-adequate meal intake and age. R67 used a rock-king chair and staff were directed to assist R67 with all transfers with a ceiling lift; and take R67 to the nearest toilet on a routine basis as R67 was unable to get there by himself. However, the care plan did not identify frequency of R3's repositioning needs. R67's Skin Risk Factors -MVH dated 8/2/21, identified R67 was at high risk for skin injury. R67 had limited ability to communicate his needs with staff and R67 relied on staff to anticipate needs and complete cares. R67's Tissue Tolerance Assessment -MVH dated 8/21/21, identified R67 had a recent change in condition and was no longer able to reposition himself in bed or in his chair. Staff needed to anticipate R67 needs and reposition every two hours. During a continuous observation on 10/6/21, at 7:02 a.m. R67 was observed to sit in his rock-king chair in the dining room. - At 8:28 a.m. R67 continued to sit in the dining room in his rock-king chair. R67 was not repositioned during this time nor did R67 reposition himself. At this time, R67 was served his breakfast. - At 8:57 a.m. R67 had finished his breakfast but continued to sit in his rock-king chair in the dining room. - At 9:30 a.m. NA-A approached R67 and removed R67's clothing protector. NA-A did not attempt to reposition R67 . NA-A assisted R67 from the dining room and wheeled R67 in front of the TV in the common area. - At 10:00 a.m. NA-A stated he was assigned to the southside and was basically assigned to every resident on that side. Repositioning of residents was not tracked in any form for any resident because they were repositioned every two hours. At that time, NA-A stated R67 was last repositioned before 7:00 a.m., but it must have been close to seven. - At 10:05 a.m. NA-A assisted R67 with repositioning. During interview on 10/6/21, at 10:09 a.m. LPN-A stated every resident was to be repositioned every two hours. It should be every two hours. Sometimes, time just goes against us. During interview on 10/7/21, at 3:42 p.m. the DON and the administrator stated staff were expected to follow the care plan for repositioning. R2's annual MDS dated [DATE], identified R2 had severe cognitive impairment and required assistance with repositioning. R2 was at risk for pressure ulcers; however, did not have any current pressure ulcers. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's current care plan reviewed 3/8/21, identified an intervention initiated on 9/20/21, that R2 had impaired mobility related to dementia and directed staff to aid with transfers and mobility. Interventions included R2 needed one to two staff along with a mechanical standing lift to transfer R2. The care plan additionally direct staff to reposition R2 every two hours and/or as needed. During observation on 10/6/21, at 8:27 a.m. R2 was assisted to the dining room for his breakfast meal. R2 was sitting in his wheelchair with a pressure reducing cushion. - At 9:24 a.m. R2 wheeled himself away from the dining room table. NA-A did not offer to reposition R2. - At 10:40 a.m. the surveyor intervened and NA-A and NA-B repositioned R2. NA-A was unable to confirm the last time R2 was repositioned. During interview on 10/6/21, at 10:48 a.m. NA-B stated the staff were to keep track of each resident's reposition time because they needed assistance every two hours. That way, you know the time and you don't guess. During interview on 10/7/21, at 3:42 p.m. the DON and the administrator stated staff were expected to follow the care plan for toileting and repositioning. The Skin Integrity: Assessment and Management policy revised 5/2/18, directed the facility would implement preventive measures for skin breakdown to include an individualized turning and repositioning schedule for residents with decreased mobility. The policy also directed the frequency of position changes would be titrated for the individual resident.

Based on observation, interview and document review, the facility failed to provide supervision while eating, for 1 of 1 residents (R2) reviewed for nutrition and who were at risk for choking and aspiration. Findings include: R2's annual Minimum Data Set (MDS) dated [DATE], identified R2 had severe cognitive impairment and required supervision (oversight, encouragement and cueing) with eating. Diagnoses included Alzheimer's disease and [CONDITION(S)] (loss of ability to understand or express speech). R2's Nutritional Status Care Area Assesmment (CAA) dated [DATE], identified R2 needed mechanically altered textures related to a diagnosis of dementia and broken or missing teeth. R2 was to receive a Minced & Moist diet. R2's Nutrition Assessment - V2 dated [DATE], identified R2 had poor dentition and required close monitoring for chewing difficulties, discomfort or pain and required a mechanically altered diet. R2's current care plan reviewed ,d+[DATE]//21, identified an intervention initiated on [DATE] which identified R2 needed texture modifications related to dementia and age. Interventions included were directed to deliver, set up and assist during meals; observe for choking; swallowing problems; dehydration and to report as needed and staff were to monitor R2 for chewing/swallowing difficulties related to his memory issues and his age. R2's physician orders dated [DATE], identified R2 was to receive a regular diet with a minced and moist texture and thin liquids. During a continuous observation on [DATE], at 8:58 a.m. R2 was served his breakfast meal in the dining room. All other residents had finished their breakfast and R2 was the last resident eating in the dining room. R2's meal was set up and R2 began eating independently. - At 9:05 a.m. licensed practical nurse (LPN)-A left the dining room to assist other residents. At this time, R2 was not in sight of any staff and continued to eat independently. R2 does not have signs/symptoms of choking or aspiration. - At 9:17 a.m. LPN-A returned to the medication cart parked at the edge of dining room. R2 continued to eat independently. - At 9:16 a.m. R2 continued to attempt to eat his meal by himself. - At 9:17 a.m. LPN-A applied gloves and approached R2. LPN-A repositioned R2's food for R2 to be able to spoon into his mouth, but did not offer to assist R2 with eating. R2 continued to eat his meal independently. - At 9:20 a.m. LPN-A left the dining room. No staff were in sight of R2 who continued to attempt to eat his meal while he continued to spill hot cereal onto his clothing protector, but was without signs/symptoms of choking or aspiration. - At 9:22 a.m. LPN-A returned to the dining room, but did not attempt to assist R2 with his meal. R2 continued to attempt to spoon hot cereal into his mouth, but dripped hot cereal from his spoon onto his clothing protector before reaching his mouth. - At 9:28 a.m. dietary Aide (DA)-A returned to R2's side of the kitchenette. LPN-A had again left the dining room. DA-A stated she was not a nursing assistant, but was trained in CPR and the [MEDICATION(S)] maneuver. DA-A tried to watch the residents especially when the nursing staff were busy, because it was like a community. However, she would expect them to tell her when she needed to watch residents. During interview on [DATE], at 9:31 a.m. LPN-A stated that day was not a normal day for R2. R2 normally rose every day at 7:30 a.m. and ate breakfast with the other residents. R2 needed fasting lab work that morning which delayed his breakfast. R2 was fairly independent and only needed assistance when food was falling off his plate. Additionally, the care plan probably was not updated from when R2 was previously sick and R2 no longer required assistance. LPN-A she was watching R2 and always had him out of the corner of her eye; however, LPN-A did leave the dining room because she had tasks for other residents. R2 did not have any trouble and LPN-A was sure R2 was identified as a choking risk because he was on a mechanically altered diet but did really well. During interview on [DATE], at 10:09 a.m. nursing assistant (NA)-C stated staff should stay in the dining room until at least most of the residents were done eating; however, if there was one resident left eating there must always be someone in the dining room to watch. Staff would know who was at risk for choking or aspiration risk due to the diet type, but was unable to say if R2 was at risk. NA-C stated she was unsure why R2 was not supervised while eating. During an interview on [DATE], at 2:19 p.m. registered nurse (RN)-A stated R2 should not have been left alone in the dining room and should have been assisted with his meal. Whether that meant sitting, watching or cueing. RN-A would have to find the policy that addressed supervision or assistance in the dining room to determine exactly what R2's needs were. During interview on [DATE], at 3:36 p.m. the director of nursing (DON) stated the residents in the memory care unit were difficult as their condition and abilities changed daily. This was why the care plan provided varying levels of assistance and supervision. R2 required supervision with eating, but would rely on RN-A because she knew the residents best. The staff were expected to follow the care plan to provide the assistance each resident required. The facility policy Activities of Daily Living (ADLs) dated [DATE], indicated ADL care and assistance would be provided and managed by the nursing department to ensure that the resident was provided the assistance needed to complete ADL needs while encouraging the resident to exercise highest level of independence. The policy defined the level of assistance as follows: 1. Independent - performed self-care in a specific area without assistance or help from staff, nor need for any staff oversight, with/without assistance devices and within a reasonable time. No set up or physical help from staff. 2. Supervision - staff were to provide cues and/or reminding. 3. Limited assistance - Needed set up/placement of items needed to perform cares. May need minimal physical assistance. Staff provided guided maneuvering of limbs or other non-weight bearing assistance. 4. Extensive assistance - Needed physical assistance in performing a portion of cares. Resident involved in activity. Staff provided weight bearing support. 5. Total dependence - Needed full staff assistance with all tasks. A facility policy regarding supervision dining practices was requested, but not received.

Based on interview and document review, the facility failed to provide routine indoor visitation according to the Centers for Disease Control (CDC) guidance when a facility was not in COVID-19 outbreak status for 2 of 3 residents (R1, R3) who were able to voice concerns about indoor visitation. This practice had the potential to affect all 96 residents residing in the facility. Findings include: The CDC guidance Updated Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 Vaccination dated 4/27/21, identified indoor visitation could be permitted for all residents when the county positivity rate was less than 10%, more than 70% of residents in the facility are fully vaccinated, and the facility was not in outbreak status. The COVID-19 Nursing Home Data for the week of 6/15/21 through 6/28/21, identified Ottertail county's positivity rate for the week was 2.5%. On 7/7/21, at 1:27 p.m. the director of nursing (DON) stated the facility was in non-outbreak status since 6/4/21, with the last COVID-19 staff case reported on 5/20/21. During interview on 7/7/21, at 2:53 p.m. the long term care ombudsman (LTCO) (a trained advocate for residents of nursing homes to resolve problems) stated she had been trying to work with R1 and countless other residents regarding concerns and complaints due to the facility's visitation policy. Prior to the week of 7/1/21, only two visitors per resident and no one under 18 were allowed even though the facility administration had assured her visitation would be determined on a case by case basis. Further, residents were just told no, no timelines were given and no process was specified. The entire process to obtain a visitation exception was very ambiguous and not resident centered. The visitation exception request originally took five weeks for R1 because they were continually told by facility administration family could visit the resident outside the facility. However, when LTCO began working with R1's family regarding this it was snowing and then it was 100 degrees Fahrenheit (F) outside. The facility made no alternative visitation opportunities for inclimate weather. Finally, an meeting was scheduled and R1 was approved for a visit with her grandchildren, but they were denied access to the building when they arrived due to more than one child present. Additionally, the LTCO continued to receive resident complaints. Another resident, R3 was furious because he wanted to see his grandchildren and had been denied. LTCO provided information from the State Agency as well as the CDC indicating there were no restriction for children under the age of 18, but the facility administration was unwilling to update their policy due to their leadership in Minneapolis and stated they could not because children fiddle with their masks. R1's annual Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact. R1's care plan dated 4/6/21, indicated R1's family was supportive and active with care, was coping with visitor restrictions and required additional emotional support and/or resources. The care plan directed staff to encourage ongoing family involvement and invite R1's family to attend special events, activities, meals, and support services. On 7/7/21, at 3:15 p.m. R1 stated she was not able to see her grandchildren or great-grandchildren within the facility building, but the facility was starting to open again. She told staff she was concerned, after such a long time period, her family would not want to come to visit her anymore. Further, she visited her great-grandchildren in recent weeks because they had taken her out of the facility for an outing and she had an outdoor visit. However, she was not allowed to see her great-grandchildren inside the building and she needed to see them outdoors or to go on an outing with them. It's not ideal. On 7/7/21, at 3:45 p.m. family member (FM)-A stated she spoke with the facility staff and LTCO in hopes to resolve her concerns regarding visitation. At that time, FM-A was told visitation was a case by case decision and exceptions to the under age 18 restriction could be obtained. FM-A stated an exception had been approved and on 6/28/21, R1's granddaughter-in-law arrived at the facility along with R1's two great-grandchildren. They planned to walk through the facility to an inner courtyard which housed a [MEDICATION(S)] playground while being escorted by staff. However, FM-A stated they were told they were not allowed in the building because there were two children, not one. Because of this, R1 visited with her great-grandchildren but had to do so in another outdoor area of the building which prevented entry to the building. When FM-A asked why one child was alright, but not two, she was told it was the facility policy to only allow 2 visitors per resident in the building at a time. R3's quarterly MDS dated [DATE], indicated R3 was cognitively intact. R3's care plan dated 4/26/21, identified R3 and R3's family were coping with restrictions related to COVID-19 protocols and precautions and R3 was at the risk for psychosocial effects such as depression, withdrawal from social situations, and emotional strain. The care plan directed staff to encourage family to provide window visits as able, phone calls, essential caregiver visits as allowed, and video chats. Further, recreation staff and/or social services would assist with the use of a streaming device. On 7/7/21, at 3:26 p.m. R3 stated visits had been going fine with his wife, but he couldn't see his great-grandchildren without special permission. R3 did not understand why, if the doors can be open, visitors could not come whenever they wanted. R3 stated he had not seen his great-grandchildren since the beginning of the pandemic even though he and his family had been fully vaccinated. The facility staff had told him he could arrange a special appointment for his great-grandchildren to visit, but only one could come at a time, it must be set up ahead of time, and they must come through the back door. It's not like a regular visit. I don't know. Oh my God, it's all kinds of rules. You have to say something like they're coming in two weeks. Life doesn't work like that. It's ridiculous. R3 then stated had not requested a visit because he does not know when they can come. On 7/7/21, at 4:54 p.m. FM-B stated she lived five hours away and had not been able to visit yet, but R2's wife had been to scheduled visits. R2's adult granddaughter brought R2's wife to the facility and they were both allowed to visit, but the visits were limited to less than ½ hour in length and needed to be scheduled ahead of time. FM-B stated she was told this was due to the all the government restrictions placed due to COVID-19. On 7/7/21, at 4:04 p.m. nursing assistant (NA)-A stated before COVID-19 resident visitors could come at anytime, but after the restrictions were put into place, visitors needed to schedule visits. However, NA-A could not verify who was allowed to visit or when they could visit and directed the surveyor to check with the front office. On 7/7/21, at 4:06 p.m. registered nurse (RN)-A stated visitors could and could not visit openly. If the visitor was willing to do an outside visit, the visit was able to happen at any time. This was decided by the county positivity rate and if the facility was in an COVID-19 outbreak. Visits were also scheduled Monday through Friday in designated rooms so there were not too many visitors at the facility at one time, to ensure the residents and staff were safe. RN-A then stated grandchildren visiting depended on the age. Because of this, he would need to call the DON or another director during the evening or on a weekend to determine if visitation would be allowed for a grandchild. RN-A verified he was unaware of what the current policy stated regarding children and would have to look in the policy book, but would call the DON if no other staff were aware. On 7/7/21, at 4:13 p.m. licensed practical nurse (LPN)-A stated residents could have visitors whenever they wanted, but due to COVID-19 visitors needed to schedule an appointment prior to coming. LPN-A stated visitors under the age of 18 were not allowed in the building and when visitor appointments were scheduled ages were confirmed prior. LPN-A stated she would direct requests to a unit director on weekends or evenings if she received a request for a child to visit. However, LPN-A stated residents were allowed to visit with children outdoors. During interview with the DON on 7/7/21, at 4:19 p.m. the DON indicated visitation for visitors under age 18 was by exception because the facility's medical director had stood firm regarding this topic. The DON further explained anyone under 18 who entered the building needed to be escorted by an adult companion and a staff member to the designated visiting area. Some factors that were considered were: Could the child be a vector ( any living agent which carries and transmits an infectious pathogen into another living organism)? Could the child keep a mask on? Could the child spread COVID-19? The whole building would be in an outbreak and visitation would shut down if the facility staff could not keep the child masked. Children could visit as long as they were outside and did not enter the building, but again stated indoor visitation would be allowed by exception. However, stated only one child and one adult could be escorted in for a visit and one adult with two toddlers would not be allowed to visit because it did not meet the visitation policy. The DON denied being aware of any visitors having been turned away or having not been allowed to visit their loved-one, but then stated residents were always encouraged to go on outings with their families and friends. Further a resident could go on an outing with their family while unmasked, not social distance and be allowed to return to the facility unrestricted but believed this was less risky than a child that may or may not follow mask guidelines within the facility. The DON stated visitation has been a frequent topic with residents, resident council and with LTCO; however, while visitation policy and procedures remained unchanged and the residents who were most vocal were going on outings with grandchildren outside the building. During interview with the administrator and DON on 7/7/21, at 4:30 p.m. the administrator indicated the facility's visitation policy stated no one under the age of 18, only two visitors at a time and visits must be scheduled ahead of time due to limited space. Because they allowed only 12 visitors in the building at one time, outdoor visits were always encouraged. The administrator stated their current county positivity rate was low, their resident vaccination rate was greater than 70%, and they were not in an outbreak status. Additionally, QSO 20-39 revised 4/27/21, directed nursing homes to not restrict visitation if the criteria above were met nor does it state children were not allowed. The administrator did state they had addressed these concerns with agency management; however, they were cautious to open visitation further and policy/procedure had remained unchanged. At that time, the DON stated we can always be more strict not lesser. The facility policy Minnesota Department of Veteran Affairs Operation Procedure: FF-COVID -19 Indoor Visitation dated 3/26/21, indicated visits would be allowed for residents so long as rules and guidelines were followed to reduce the potential for the spread of COVID - 19. The procedure went on to state visits must be scheduled in advance with no walk-ins allowed; each visit would be scheduled for 20 minutes to allow for cleaning time before and after each visit; visits would be monitored by a facility staff member or volunteer; a maximum of two adult visitors per visit would be allowed; persons under age 18 were not allowed to visit, and visits/appointments could be canceled at any time by the facility and were at the facility's discretion. The Center's for Medicare and Medicaid Quality, Safety and Oversight (QSO) memo 20-39 revised 4/27/21, indicated nursing homes should allow indoor visitation at all times and for all residents (regardless of vaccination status), except for a few circumstances when visitation should be limited due to a high risk of COVID-19 transmission. These scenarios include limiting indoor visitation for: -Unvaccinated residents, if the nursing home's COVID-19 county positivity rate is greater than 10% and less than 70% of residents in the facility are fully vaccinated; -Residents with confirmed COVID-19 infection, whether vaccinated or unvaccinated until they have met the criteria to discontinue Transmission-Based Precautions; or -Residents in quarantine, whether vaccinated or unvaccinated, until they have met criteria for release from quarantine. The memo further indicated facilities shall not restrict visitation without a reasonable clinical or safety cause and must facilitate in-person visitation consistent with the applicable CMS regulations.

Based on observation, interview and document review, the facility failed to ensure all residents were accounted for after 1 of 4 residents (R2) sounded the exit alarm while exiting the building. In addition, the facility failed to comprehensively assess for and develop person centered interventions to reduce the risk of wandering/elopement for 4 of 4 residents (R2, R1, R3, R4) reviewed who had previously exited the building and did not sustain any injury Findings include: During a facility tour on 11/17/20, at 1:00 p.m. each wing was observed and each wing had double doors with a wanderguard system on each of the doorways. The east wing and the memory unit double doors were separated by a small room with glass exit doors on either side. One exit door opened to an outside fenced courtyard. The opposite exit door opened to the facility campus, a road, and neighboring houses lined across the road. This exit door was called the Park Street exit. Both exit doors had alarms on them, however, the exit doors did not have wanderguard alarms. The doors on both units were not visible from the nurses station of the east or memory care units. The director of nursing (DON) stated the wanderguard alarms were located on the double doors of each wing and could not be placed on the facility exit doors due to the magnetic locking system used by the wander guard system. R2's admission Minimum Data Set ((MDS) dated [DATE], indicated R2 had minimal cognitive impairment and required supervision with transfer and ambulation. The MDS identified R2 exhibited wandering behaviors that did not place him at risk or intrude on others. R2 had a [DIAGNOSES REDACTED]. The facility's Self Preservation assessment form identified risk factors for wandering and elopement. The form used a check list system that included the following information: level of orientation, behaviors, recent experiences such as room change, level of mobility, diagnoses, medications, history of wandering, safety factors, risk factors, negative feelings related to nursing home placement and interdisciplinary team (IDT) recommendations. How the score was determined was not indicated on the form. R2's Self Preservation assessment completed on 8/27/20, indicated R2 was at moderate risk for wandering. The form indicated IDT recommended the placement of a wander guard and to be accompanied to all outside appointments. No further interventions were identified or implemented. R2's progress note(s) identified the following: - 8/27/20, at 1:35 p.m. R2 had attempted to leave the facility a minimum of five times since his arrival. R2's daughter called and spoke with him and this calmed him down. A wander guard was placed. - 9/4/20, at 5:33 a.m. R2 was awake and packing his suitcase. R2 stated he was moving somewhere tomorrow. R2 seemed confused about his situation. When assisted, R2 did remain in his bed. - 9/8/20, at 11:05 p.m. R2 was exhibiting exit seeking behaviors. R2 had his luggage packed and stated he was leaving. R2 was dressed and ambulated toward the exit doors. Staff was able to redirect R2 back to his room, where he remained the rest of the night. - 10/8/20, at 5:35 p.m. R2 was exhibiting exit seeking behaviors. R2 asked staff how to get out of the building as he wanted to go home. Staff reoriented R2. R2 continued to search for a door to exit for 30 to 45 minutes. R2 settled down and went to his room. - 10/21/20, at 11:35 a.m. R2 was asking for his suitcase and wanted to get out of the facility. He was redirected with good response. - 10/23/20, at 3:06 p.m. R2 was moved to a new room on the east wing of the facility. The facility incident report dated 11/3/20, at 12:15 p.m. indicated staff heard the facility exit door alarm go off. The responding nurse went to the alarmed door and checked for residents near and/or outside of the door. No residents were seen. The responding nurse then cleared the alarm. Later, the responding nurse received a telephone call indicating another nurse had found R2 outside of the facility in the parking lot. The nurse went out to assist R2 back into the building. They were unable to redirect R2 and a third staff member was called to assist. The three staff members were able to redirect R2 back into the facility and back to his room safely. R2's daughter was called to help redirect R2. Signs were made to assist R2 with where his room was. The wander guard was checked to ensure it was working properly. R2 had exited the facility through the exit door named the Park Street exit. On 11/12/20, a note was added to the facility incident report dated 11/3/20, which indicated R2 had dementia and was often confused as to where he was at. R2 was easily redirected when he was confused. He had made no further attempts to exit the facility. R2 walked independently with a walker and became confused with directions. Signs have been placed in common areas and on R2's room door with his name. Staff would continue to monitor R2 and guide R2 in right direction when confused. R2's medical record lacked evidence R2 was comprehensively reassessed to identify and address the ongoing risk of elopement despite continued wandering behaviors and making several statements and/or attempts to elope. Further, R2 was not reassessed following the 11/3/20, elopement from the building including circumstances surrounding the elopement along with potential causative factors and patterns in an effort to reduce the incidences of elopement. R2's care plan revised 10/8/20, indicated R2 was at risk for elopement related to dementia. Interventions included: make (R2) feel secure and safe in the facility, call his daughter to calm him down when he tried to leave the facility, encourage him to verbalize his feelings, redirect him when he made attempts to elope and reorient him to his room and unit and would require an escort for all outside . Interventions related to R2's risk for elopement were dated 10/8/20. Although, R2 had a successful elopement from the facility, R2's interventions remained unchanged. During observation on 11/17/20, at 2:22 p.m. R2 was seated in a chair with the television on in the east lobby area with four other residents. R2 was fully dressed and had a light coat on and was sleeping. -At 3:25 p.m. R2 awoke and reached for his walker, stood up and started walking down the hall in the direction of his room. R2 asked an unidentified nurse where his room was and the nurse verbally directed R2 down the east hall to the room with his name on the door. R2 turned and started to ambulate toward the opposite hall than which the nurse had directed him. R2 stated he would go out that door, referring to a door on the opposite wing. The unidentified nurse was able to redirect R2 back to his own unit with verbal redirection and walked him to his room. On 11/18/20, at 11:40 a.m. registered nurse (RN)-A was interviewed and explained she had heard the exit door alarm go off and when the alarm panel was checked, it was flashing Park Street exit. RN-A stated she immediately went to the exit door and looked around outside but could not see anyone around. RN-A stated the exit doors would alarm from staff or maintenance going through them but staff still checked the exits when they alarmed to be sure it had not been a resident. She returned to the nursing station and cleared the alarm and returned to her work duties. RN-A stated she did not initiate a facility head count to ensure all residents were safely inside the building. They would not typically do a full resident count, but they would check for those at risk to elope and make sure they were in the building. Further she did not think it was a resident with a wanderguard that set off the alarm because the wanderguard system did not alarm. About 5 minutes after shutting off the alarm, RN-A stated she received a telephone call from a nurse in the parking lot who indicated R2 was outside in the parking lot. RN-A stated she immediately went out to the lot to try to bring R2 back into the building. R2 was resistive and needed to call for further staff assistance to bring R2 back into the facility. When interviewed on 11/18/20, at 11:58 a.m. RN-B stated the exit door alarms would sometimes alarm because the wind would set them off. When an exit door alarm sounded, she would call the nurse on unit where the alarm was sounding and have her check to see what had triggered the alarm. When she got the all clear from the unit nurse, she would clear the alarm. RN-B stated if no resident was seen when a door alarmed, the staff would check on the residents that were at risk for elopement. During interview on 11/18/20, at 11:56 a.m. nursing assistant (NA)-B stated if an alarm sounded staff would check the alarming exit door and look for residents. If no residents were seen by the exit door, the staff would check and make sure their wanderers were around. NA-B indicated they would not do a full resident head count. R1's quarterly MDS dated [DATE], identified R1 had severe cognitive impairment and required supervision with transfers and ambulation. The MDS identified R1 had wandering behaviors. [DIAGNOSES REDACTED]. R1's Self Preservation assessment dated [DATE], identified R1 was at moderate risk for wandering. The IDT checked off the recommendation to use of a wander guard alert and staff was not to leave R1 unattended when out of the facility for medical appointments. No further interventions were identified or implemented. R1's progress notes from 7/21/20, through 11/17/20, identified the following: - 7/21/20, at 1:44 p.m. R1 was exhibiting exit seeking behaviors. R1 attempted to exit the facility through the courtyard doors. The staff redirected R1 to his bedroom. - 9/2/20, at 12:46 p.m. R1 exhibited wandering behaviors through out both north and south sides of the unit. R1 was difficult to redirect and staff was unable to determine what R1 was searching for. - 9/22/20, at 9:32 p.m. R1 exhibited wandering behaviors through out the shift. Distraction was not always effective and when it was, the behavior only ceased briefly. - 10/15/20, at 8:46 p.m. a Self Preservation assessment was completed and indicated R1 was at moderate risk for wandering. The IDT recommended to continue use of the wander guard and to accompany R1 to all outside appointments. No further interventions were identified or implemented to reduce the chances for elopement even though progress notes in September 2020, identified R1 was wandering and distraction was not always effective. - 11/7/20, at 2:24 p.m. staff were unable to locate R1. A search was conducted of the unit. A radio call to all staff was made to alert all staff to search for R1. The facility received a phone call from a neighboring home owner reporting R1 was at their front door. The facility staff retrieved R1 from their front door. R1 was unable to indicate why he had exited the facility. The officer of the day (OD) indicated no alarms or code yellow had sounded to alert staff of R1's exit from the facility. The staff checked all the exit doors with R1 and the doors did lock and the alarm did sound code yellow as it was supposed to. Staff were encouraged to be extra diligent and monitor R1's whereabouts closely. R2 had exited the facility through the exit door named the Park Street exit. - 11/13/20, at 11:27 a.m. R1 had a quarterly MDS completed. R1 continued to wander frequently and the facility would continue the current focus, goals and interventions. No further assessment was completed. During observation on 11/17/20, at 2:08 p.m. R1 was wandering about the memory care unit. R1 was pleasant, however, was unable to communicate effectively. R1 attempted to enter other resident rooms and required staff redirection to the day room. Staff responded timely and R1 was receptive to the redirection. R1's medical record lacked evidence R1 was comprehensibly reassessed to identify and address the ongoing risk of elopement despite continued wandering behaviors and making several statements and/or attempts to elope. Further, R1 was not reassessed following the 11/7/20, elopement from the building including circumstances surrounding the elopement along with potential causative factors and patterns in an effort to reduce the incidences of elopement. R1's care plan reviewed 11/10/20, identified R1 had severe cognitive impairment and was at risk for elopement related to dementia. R1 wandered around the facility and did go into other's spaces. Interventions directed the following: encourage to verbalize his feelings, intervene right away when (R1) entered other resident rooms and redirect him to the day room, redirect away from fire alarm pull stations, redirect when making attempts to elope, re-orientate him to his room and unit, escort to all outside appointments along with identifying (R1) had wander guard placed on his right wrist. Interventions related to risk for elopement were dated 4/17/19. Although, R1 had a successfully eloped from the facility, R1's interventions remained unchanged. During interview on 11/18/20, at 8:25 a.m. LPN-A stated when a code yellow (an alert identifying to staff a resident with a wanderguard exited the door) goes over the intercom, the staff on the memory unit do not hear it. LPN-A indicated the alarm sounded on the east and west wings and the charge nurse would notify the memory unit staff via their talkies and the alarmed sounded as it could not be heard in the memory care wing. LPN-A stated staff had to put in a code at the alarming door, to stop the alarm from sounding and that most of the staff were aware of the code. LPN-A stated the charge nurse had told her the code had never sounded when R1 exited the facility on 11/7/20. The facility had been having trouble with the alarm system before and if a resident with a wander guard stood by the door long enough, the door would unlock and the resident could go through. LPN-A verified the wander guard alarm should have sounded code yellow when R1 passed through them, as well as the exit door alarm should have sounded when R1 opened the facility exit door. LPN-A stated she did not know why both alarms did not sound. LPN-A stated she thought the same thing had happened the previous week when R4 had exited the facility. During interview on 11/18/20, at 9:30 a.m. NA-A stated R1 must have been standing by the double doors long enough for the alarm to disengage. NA-A indicated R1 did not seem to intentionally try to exit the facility and staff tried to engage R1 with conversation or snacks when he was wandering, which was effective. R3's quarterly MDS dated [DATE], indicated R3 had moderate cognitive impairment and was independent with transfer and ambulation. The MDS indicated R3 was also independent with mobility on and off the unit. R3 had a [DIAGNOSES REDACTED]. R3's physician orders [REDACTED]. R3's Self Preservation assessment completed on 8/6/20, indicated R3 was at moderate risk for wandering. IDT recommendations were to continue use of the wander guard and not to be left unattended during outside appointments. No further interventions were identified or implemented. R3's progress notes identified the following: - 7/24/20, at 11:18 a.m. a code yellow alert sounded. R3 had gotten outside from the Park street exit and was redirected immediately back to his unit. R3's wander guard was tested and was working properly. - 8/17/20, at 2:23 p.m. a coed yellow alert sounded. An LPN found R3 outside the Park street exit, walking away from the building. R3 immediately returned to the facility when called. The wander guard was working properly. - 9/4/20, at 12:56 p.m. code yellow park street exit sounded. R3 was found coming out of a room on the memory unit and was redirected back to the east wing and his room. - 9/22/20, at 9:46 a.m. R3 was found on the west wing and was redirected back to the east wing. - 11/2/20, at 3:12 p.m. staff heard the east wing door open and went to check it. Staff observed R3 exit the Park Street exit and attempted to redirect R3 back into the facility. R3 was combative and unable to redirect. R3 ran across the facility lawn, crossed Park Street and began banging on windows and doors of the neighboring homes, with staff following. Staff eventually got R3 to return to the facility. R3's incident reports dated 7/24/20, 8/17/20, and 11/2/20, each identified R3 would become easily confused. R3 had a wander guard on and staff would continue to monitor. No further interventions were added to R3's care plan to reduce wandering and elopement attempts. R3's medical record lacked evidence R3 had been comprehensibly reassessed to identify and address the ongoing risk of elopement despite continued wandering behaviors and having several statements and/or attempts to elope. There was no evidence R3's wandering, nor the circumstances surrounding the elopement attempts, had been accounted for and assessed for possible contributing factors and solutions. R3's care plan revised 9/1/20, indicated R3 was at risk for elopement related to a [DIAGNOSES REDACTED]. The risk for elopement was identified on 4/21/20. Although R3 had a successful elopement from the facility, R3 had no interventions listed for safety and prevention of his identified risk for elopement. During observation on 11/17/20, at 2:14 p.m. R3 wandered to the east hall wing, frequently going toward the double exit doors of the east wing. Staff frequently redirected R3 back to the common lobby area. -At 3:24 p.m. R3 again wandered to the east hall wing. Staff frequently redirected R3 back to the common lobby area and was able to divert R3's attention with conversation and television in the lobby. -At 3:40 p.m. R3 began following an unidentified staff member as she made rounds. When she entered a room, R3 would pause and immediately follow the next staff member to be near them. -At 4:15 p.m. R3 began to follow a resident down the east hall wing. An unidentified staff member approached R3 and began discussing the supper meal choices with R3. R3 followed the staff member out of the wing into the lobby area. During interview on 11/18/20, at 11:56 a.m. NA-B stated when a code yellow sounded, staff would go to the door and look for residents and then tell the nurse all clear. NA-B indicated R3 was usually just going for a walk when going up and down the halls and she would usually give him a snack and the newspaper or turn on the television as a diversion. NA-B indicated she thought R3 was looking for his wife, when walking up and down the halls. R4's annual MDS dated [DATE], indicated R4 had severe cognitive impairment and was independent with transfer and ambulation, however, required supervision on and off the unit. R4 had a [DIAGNOSES REDACTED]. R4's Self Preservation assessment completed on 10/15/20, indicated R4 was a moderate risk for wandering. IDT recommendations were to continue use of the wander guard and not to be left unattended during outside appointments. No further interventions were identified or implemented. R4's progress note(s) identified the following: - 10/29/20, at 2:38 p.m. a code yellow was going off, when memory care unit staff received a phone call from the east wing staff. East wing staff indicated R4 had been found outside of the Park street exit. Staff had responded promptly and R4 was brought back to his unit. - 10/29/20, at 1:50 p.m. indicated the code yellow alarm was going off and staff responded to the alarm promptly. Staff found R4 outside of the facility and promptly returned him to his room. the wanderguard was checked on his return and determined to be working properly. The staff concluded R4 had stood near the door long enough for the lock to disengage, thus allowing R4 to exit through the doors. R4's care plan revised on 9/2/20, indicated R4 was at risk for elopement related to his history of wandering and dementia. The care plan directed staff to make (R4) feel secure and safe in the facility, encourage family participation when available, wander guard placement and an escort for all outside appointments. Interventions related to risk for elopement were dated 9/2/20. Although, R4 had a successful exited the facility on 10/29/20, R4's interventions remained unchanged. R4's medical record lacked evidence R4 had been comprehensibly reassessed to identify and address the ongoing risk of elopement despite continued wandering behaviors and having several statements and/or attempts to elope. There was no evidence R4's wandering, nor the circumstances surrounding the elopement attempts had been accounted for and assessed for possible contributing factors and solutions. During interview on 11/18/20, at 12:48 p.m. RN-B stated if an outside door alarm sounded and they could not determine the cause, the staff would check their wanderers and make sure they were there. RN-B indicated sometimes the staff would do a head count, especially if it was winter. RN-B stated there were so few doors that just had the exit alarm on them that it wasn't a problem. RN-B stated the only real problem was the exit door between the east and memory unit doors. When interviewed on 11/18/20, at 10:28 a.m. the DON stated if a code yellow alarmed (wanderguard alarm), the resident's picture would show on the system behind the nurse's station. If staff did not see that resident at the exit, they were expected to go and look for the resident on the unit. If the resident was found outside, staff were to bring the resident back into the facility, assess for injury and assure the wander guard was functioning properly. They would try to determine why the resident left with staff interviews and rounds on the unit. They would try to determine if the resident was exit seeking or more related to the resident's dementia or a behavior. Incident reports were reviewed at daily meetings. The DON identified R1's elopement had been reviewed and she was told the wander guard alarm and the Ademco system alarm had not sounded. The DON indicated both alarms were checked within minutes of R1's return to the facility and both alarms were working properly when checked. The DON stated she did not know why either alarm did not sound in that instance. The DON stated they did place furniture near the memory unit double doors and a do not enter sign on the double doors to distract R1 from attempting to leave until the alarm company could come and check the alarm system the next day. The DON stated sometimes a resident will stand by the wander guard doors long enough that the lock would disengage as a safety feature, however the alarm would still sound. Further, the facility used the Self Preservation form to assess for wanderguard use, the forms were filled out quarterly and as needed, that form was the facility's comprehensive assessment. During interview on 11/18/20, at 12:15 p.m. the administrator stated when a resident exits the building the facility completes an investigation. The investigation included checking the door alarms and wander guards for function. The administrator stated an elopement investigation was not like a fall investigation, because it was always related to whether the alarms or doors were functioning. The administrator stated if a reason was determined for the elopement you would find it on the incident reports or if it was determined the resident was wandering more the IDT would look at that to see if placement on the memory unit was needed. The administrator stated the double doors on the wings had the wander guard system with magnetic locks. The exit doors of the facility had the Ademco system alert in place. The staff would still have to respond to the exit alarm and determine why it was sounding, but the alarm was silenced behind the nurses station. The administrator indicated the facility had recently purchased a screech alarm and intended to install it on the Park Street exit door, as that exit door was identified as the door the residents were able to exit more frequently. This alarm would be heard on both the east wing and the memory unit and would require the staff to physically go to the door to disable the alarm. The facility had not installed the alarm yet, as the staff had not been trained on it, but planned to train staff and place the alarm by the end of the following week. The administrator stated it was not the facility's policy to do a resident head count if an alarm sounded; however it would not be a bad idea to add that to the policy. The facility's policy titled Wander Management and Door Alarm System with revision date of 3/19, indicated a resident's risk for wandering would be determined during pre-admission assessment and if a need was determined, a wander guard would be placed. If at any time during a resident's stay, a wander risk was identified, a wander guard may be placed. This would be reviewed quarterly and as needed. The policy indicted the Park Street exit door did not have a magnetic lock and was not connected to the wander guard system because a resident would have to pass through a door that is connected to the system with a magnetic lock immediately before reaching this exit door. All staff were responsible to respond to a sounding alarm immediately. Upon each alarm, it must be determined which resident set off the alarm and their current location before the alarm is reset. If a resident exited the building, the resident will be assessed and redirected back into the building.

Based on interview and document review, the facility failed to ensure allegations of neglect of care following an elopement were thoroughly investigated to prevent further incidents of elopement for 1 of 2 residents (R2) who exited the building without supervision. Findings include: R2's admission Minimum Data Set ((MDS) dated [DATE], indicated R2 had minimal cognitive impairment and required supervision with transfer and ambulation. The MDS identified R2 exhibited wandering behaviors that did not place him at risk or intrude on others. R2 had a [DIAGNOSES REDACTED].>R2's initial report to the State Agency (SA) dated 11/3/20, identified a report was submitted for potential neglect of care related to R2's elopement from the facility on 11/3/20, at 12:15 p.m. R2 exited the building, without injury. The report identified R2 exited the building through the Park Street exit door. The alarm sounded. A nurse responded and did not see a resident. Another nurse pulled into the parking lot and called the facility to report R2 was wandering in the parking lot. The wanderguard alarm did not sound; however the exit alarm did. The facility tested the wanderguard alarm and identified R2's wanderguard pendant and the wanderguard alarm on the door was functioning and they were not sure why R2 exited the building or why the wanderguard system did not alert staff to R2 exiting the door. R2's investigative report submitted to the SA on 11/9/20, identified the facility reviewed R2's care plan and the care plan was followed. Further, the facility reviewed their policy and the policy was followed and no changes were made to the facility policy. The investigation summary identified the following RN (registered nurse) heard door alarm ringing and alarm stated E. Park St. Exit. RN went to the alarming door to check for residents. No residents were noted to be outside by the RN. RN soon received a call from the front office that another nurse who was in the front parking lot was with resident, (R2), outside in the front parking lot. RN immediately attended to resident outside. RN and other nurse were unable to initially redirect (R2). Unit Coordinator provided assistance and was able to direct him back inside. Resident was escorted to his room safely. (R2) stated that he was going home to his barracks. (R2) was redirected back into facility safely. RN notified (R2's) daughter via phone and she assisted to help redirect resident. Signs were made to help assist resident where his room is, and to not exit the park street corridors. Wander guard system was also tested to ensure working properly. Resident wears a wander guard due to wandering tendencies. However, the door alarm that sounded was a back up system that alarms anytime the door opened. The wander guard device should have activated the magnetic locks. It is unknown how the resident got past the wander guard equipped doors. However, staff located (R2) very quickly and he was assessed and found to have no injuries. Staff will monitor resident for further wandering concerns. Three staff were identifed to have contributed to the investigation. Action taken to prevent reoccurrence to the subjected resident was identified as Signs were made to help orientate resident to where his room was, Wander guard system was also tested to ensure working properly. Resident wore a wander guard due to wandering tendencies. However, the door alarm that sounded was a back up system that alarms anytime the door opened. The wander guard device should have activated the magnetic locks. It is unknown how the resident got past the wander guard equipped doors. However, staff located(NAME)very quickly and he was assessed and found to have no injuries. Staff will monitor resident for further wandering concerns. The investigation did not identify causative reasons for the alarm not functioning and what they did to ensure the alarm would function if another resident wandered to the Park Street exit. Further, the investigation did not identify R2 was assessed for wandering and elopement behaviors to implement resident centered interventions to attempt to prevent further elopement attempts. Notes regarding the internal investigation ie .actual staff interviews obtained and details on what was investigated were requested and were not received. During interview on 11/18/20, at 12:15 p.m. the administrator stated when a resident exits the building the facility completes an investigation. The investigation included checking the door alarms and wander guards for function. The administrator stated an elopement investigation was not like a fall investigation, because it was always related to whether the alarms or doors were functioning. The administrator stated if a reason was determined for the elopement you would find it on the incident reports or if it was determined the resident was wandering more the IDT would look at that to see if placement on the memory unit was needed. The facility did not keep any further investigation documents to review as the information was in the five day investigation and IDT notes. Further, the double doors on the wings had the wander guard system with magnetic locks. The exit doors of the facility had the Ademco system alert in place. The staff would still have to respond to the exit alarm and determine why it was sounding, but the alarm was silenced behind the nurses station. The facility had not altered their policy to ensure verification of all residents was completed when an alarm sounded, and a resident was not identified to trigger the alarm, to ensure all residents were accounted for. The facility policy revised 2/23/17, identified the following regarding investigation: it is the policy of the agency that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated. The investigation is the process used to try to determine what happened. All staff will cooperate during the investigation to assure the resident is fully protected. The designated facility personnel will begin the investigation immediately. The policy identified how to complete an investigation for allegations of abuse, injuries of unknown source, involuntary seclusion and misappropriation of property. The policy did not identify how to conduct an investigation regarding incidents of potential neglect of care; however, the policy identified results of the investigation would be recorded and tied to the report ; Nursing and/or designee will document resident's behaviors and environmental concerns at the time of the incident, as well as observations made of resident's behavior during the investigation; nursing and/or designee would identify and implement appropriate interventions for the resident involved, all other residents and to prevent future co-occurrence The follow-up investigative notes would be submitted to the appropriate state agency following state policy for reporting.

Based on observation, interview, and document review, the facility failed to cease communal dining practices per the Centers for Medicare & Medicaid Services (CMS) QSO-20-14-NH directive dated 3/13/20, in order to control and prevent the transmission of COVID-19. This practice had the potential to affect 94 of 95 residents who resided in the facility and ate in three facility dining rooms. Findings include: During a tour of the East wing on 5/12/20, at 11:54 a.m. staff were observed wheeling and assisting residents off the unit. At this time, licensed practical nurse (LPN)-A stated all the residents were being assisted to the main dining room. When asked what alternatives to communal dining had been implemented, LPN-A stated the facility had never ceased communal dining rather, expanded the space in the dining room into the attached chapel and breezeway and added more tables to allow for distancing when in the dining room. LPN-A stated all facility residents ate their meals in the dining room. LPN-A stated the tables had been spread out as much as they could be and for the most part, were set up in a way to ensure six foot distancing was maintained when dining. LPN-A also stated only one to two residents were seated at each table and that each resident and staff member knew to be mindful about maintaining appropriate distancing when entering and exiting the dining room. LPN-A stated in the event of a COVID-19 positive resident, the facility had a plan in place to halt communal dining and have the residents eat in their rooms, however, this would not be implemented until a COVID-19 positive resident or community member was identified. LPN-A stated at no time were the staff or residents told that they had to eat in their rooms or halt communal dining. At 11:55 a.m. nursing assistant (NA)-A verified all the East and West unit residents ate their meals in the same dining room unless a resident requested to eat in their room, which occasionally occurred. NA-A stated a curtain had initially been placed in the main dining room so that each unit was separated in order to prevent any potential spread of the COVID-19 virus between the units. However, NA-A stated the curtain had been taken down and replaced with hazard/caution tape. NA-A stated two to three residents sat at each table and that the level of assistance a resident required determined the number of residents at each table. NA-A verified since the start of the COVID-19 pandemic, there had been no changes to the facility's dining practices and at no time had communal dining been halted rather, the focus was to keep each resident on their respective unit. During tour of the West wing on 5/12/20, at 12:01 p.m. staff were observed wheeling and assisting residents off the unit. At 12:09 p.m. registered nurse (RN)-A verified all of the residents on the West unit were out of their rooms for the lunch meal. RN-A indicated they separated the East and West unit residents in the dining room and spread the residents throughout the room to maintain six foot social distancing however, had not discontinued communal dining at this time. At 12:15 p.m. upon entry to the dining room, the room was noted to be divided into two sections. Hazard/caution tape was used to cordon off an area in the center of the room, between the two sections. One section was designated for West unit residents and consisted of 15 tables with 32 residents seated 2-3 to a table. Additionally, five staff members were seated at several of the tables. The tables were round and approximately five feet in diameter and not all tables were spaced six feet apart. One table was noted to have three residents and two staff seated next to the residents while assisting them to eat. At this time, a male resident, seated in a wheelchair at a table with two other residents was observed to cough with audible secretions heard without covering his mouth or performing hand hygiene. No staff had approached the resident to encourage covering the mouth or offer and assist him with hand hygiene following the cough. Shortly thereafter, another resident was heard to cough without staff response. On the other side of the hazard/caution tape was an area designated for East unit residents and consisted of 10 tables with 21 residents and six staff members seated 2-4 to a table. A breezeway area, set up outside the main dining area, contained four tables with eight residents seated two to a table in a single row. The tables were arranged so that the wheels of the wheelchairs of two residents at adjacent tables and seated back to back were approximately 1 foot apart. At 12:31 p.m. the dining services supervisor (DSS) indicated they had spaced out the dining area and expanded into the chapel area as well as divided the dining room into specified sections for the East unit and West unit residents and tried to maintain social distancing. The DSS stated the facility had considered having the residents eat in their rooms and stagger meal times, but had not implemented either option. DSS indicated he could not say when or if such a plan would be implemented as it was up to leadership. DSS indicated the breakfast meal was an open style breakfast which occurred from 7:30 a.m. to 9:00 a.m. so the dining area was less crowded however, stated the evening meal was very similar to the noon meal. At 12:31 p.m. upon entrance to the Village unit, two dining rooms were noted to be separated by an open door/walkway. Each dining room held six tables, with two to four residents seated at each table eating their meals. The North dining room was noted to have one table with four residents eating with two staff seated next to them assisting the residents to eat. In the South dining room, staff were noted to be seated at a table with two residents while assisting the residents to eat. At 12:34 p.m. dietary aide (DA)-A stated 11 residents ate in the North dining room and nine in the South dining room. DA-A stated none of the Village unit residents ate in their rooms and when asked, denied any changes to the dining practices having been implemented since the start of the COVID-19 pandemic. DA-A stated other than having daily health screenings performed upon arrival to work and having to wear masks and face shields when working, nothing else had changed with his daily work details or dining practices. At 12:39 p.m. NA-B verified the facility continued communal dining and stated none of the residents ate in their rooms. NA-B stated during dining, the staff try to keep the residents socially distanced, but added, the residents do congregate. NA-B stated the dining tables were approximately five feet in diameter but not six feet apart from each other. At 12:43 p.m. licensed practical nurse (LPN)-B stated there had been not a whole lot of changes made to dining practices and as of yet, there were no residents who ate their meals in their rooms. LPN-B stated when all the residents were in the dining room, the staff do the best they can to maintain the appropriate six foot distancing. NA-B also stated that the residents would continue to participate in communal dining until the facility had a few positive cases of COVID-19 at which time, the residents would be directed to eat in their rooms. NA-B verified no plan had been implemented to halt communal dining and added, the staff would hate to see the residents confined to their rooms. At 1:32 p.m. the director of nursing (DON) and administrator indicated they were aware of the CMS directive however, verified the facility had not ceased communal dining and indicated the plan was to implement residents eating in their rooms once a positive COVID-19 case was identified in the facility or transmission was present in the community. Centers for Medicare & Medicaid Services (CMS) QSO-20-14-NH dated 3/13/20, directed facilities to cancel all communal dining and all group activities, such as internal and external group activities. The direction was effective immediately. CMS QSO-20-28-NH dated 4/24/20, provided updated guidance directing residents may eat in dining rooms, however nursing homes should adhere to social distancing, such as being seated at separate tables at least six feet apart. It was further noted eating in dining areas with appropriate social distancing only applied to residents without signs or symptoms of a respiratory infection and without a confirmed [DIAGNOSES REDACTED].

Based on observation, interview and document review, the facility failed to provide dignified treatment for 1 of 1 residents (R1) who received unrequested perineum grooming and lacked cognitive capacity to consent to this provision of care. Findings include: R1's annual Minimum Data Set ((MDS) dated [DATE], identified R1 had severe cognitive impairment and [DIAGNOSES REDACTED]. R1's MDS further identified R1 required extensive assistance with hygiene and total assistance with bathing. R1's care plan revised 9/6/19, identified R1 required extensive assitance with dressing, grooming, bathing, and hygiene related to her dementia and physically unable. R1's care plan identified R1 had a facial trimmer for when she had facial hair that needed trimming kept in the nurses cart. R1's care plan did not include direction to staff for perineum grooming. R1's medical record lacked documentation that R1 had received unrequesed perineum grooming. On 10/29/19, at 1:04 p.m. during observaiton, nursing assistant (NA)-A was in R1's room applying ceiling lift sling to R1. NA-A then transferred R1 to the bathroom, removed her slacks and brief, then lowered her to the toilet. NA-A indicated R1 had her pubic hair recently shaven, but did not know why. R1's pubic hair appeared to be recently shaven, with short stubbly hair. NA-A indicated she was not aware of any other residents who had received perineum grooming. On 10/29/19, at 1:46 p.m. NA-B indicated she had completed morning cares with R1, and noted R1's pubic hair was shaven. NA-B indicated she had never seen another resident at the facility with their pubic hair shaven. On 10/29/19, at 2:35 p.m. NA-C indicated she was made aware NA-D had shaven R1's pubic hair and it was a very big deal, and thought NA-D had been written up. NA-C indicated she had figured out NA-D had shaven R1's pubic hair, because NA-D had given R1 a bath and had told her that day that she had shaved R1's arm pits. NA-C indicated NA-D stopped talking then, but did not tell her that she had shaven R1's pubic hair. On 10/29/19, at 3:05 p.m. registered nurse (RN)-A indicated she had been working the day R1's received perineum grooming. RN-A indicated she was not working on R1's wing, and no one had brought it to her attention. RN-A indicated it was the next day or two that RN-D called and asked if I was aware who had shaven R1's pubic hair. RN-A indicated RN-D asked her because a nursing assistant had reported that she had noted R1's pubic hair was shaven the day before, when RN-A was working. RN-A indicated she had never heard any more about the incident. On 10/29/19, at 3:26 p.m. administrator indicated the facility became aware of R1's pubic hair shaven by a nursing assistant on 10/13/19, which occurred on 10/12/19. Administrator indicated on 10/17/19, NA-D was interviewed by acting director of nursing (ADON) and NA-D had received disciplinary action due to not consulting with a nurse before providing perineum grooming to R1. On 10/29/19, at 5:38 p.m. NA-E indicated she would not perform perineum grooming for a resident unless it was care planned. NA-E indicated she had never received training to shave a resident's pubic hair and thought it was odd to do so. NA-E indicated she had not seen any other residents with their perineum area shaven at the nursing home. On 10/29/19, at 5:44 p.m. NA-F indicated she would not shave a resident's perineum area, and had never been trained to do so. NA-F indicated she observed it when she took care of R1 on 10/14/19, and reported it to RN-A right away. NA-F said RN-A was aware of it at that time. On 10/29/19, at 5:13 p.m. RN-B indicated she was aware that R1's pubic hair had been shaven by a nursing assistant. RN-B confirmed it was not the usual facility practice to allow nursing assistants to shave resident's pubic hair and indicated the nursing assistant should check with the nurse first. RN-B confirmed it was not dignified and that it could be considered maltreatment due to being done in the resident's private area and R1 was cognitively impaired. On 10/29/19, at 5:25 p.m. RN-C confirmed it was not the facility's usual practice to shave a pubic hair, no, not at all'. RN-C indicated it would need to be ordered by a physician or requested by family. RN-C indicated she would never direct the unlicensed staff to shave a resident's pubic hair, or would not do it herself. RN-C confirmed it was not dignified care. On 10/29/19, multiple unsuccessful attempts were made to contact NA-D by phone regarding her reason for shaving R1's perineal area. On 10/29/19, at 6:03 p.m. acting director of nursing (ADON) confirmed she was made aware of the incident on 10/13/19. ADON indicated she provided education and disciplinary action for NA-D regarding the incident. ADON indicated R1's family member (FM)-A was notified of the incident, as well as the nurse practitioner. ADON confirmed it was not a usual facility practice to provide perineum grooming for their residents. At 7:05 p.m. during follow up interview ADON indicated it would depend on the residents wishes, even if they were cognitively impaired, if it was or was not considered undignified care. ADON indicated it would depend on the residents wishes if she would expect a nursing assistant to shave a resdient's pubic hair, but then indicated no she would not. On 10/30/19, at 9:11 a.m. during a return phone call interview FM-A indicated he was informed that R1's pubic hair had been shaven by a nursing assistant. FM-A indicated the nurse who contacted him explained what had happened, and R1 had told him nothing about the incident. FM-A felt it turned out ok, since he was not aware of any problems from the incident. The facility policy titled Activities Of Daily Living (ADL), revised 5/2/18, identified the objective was to establish guidelines for implementation of rehab nursing programs in the areas of dressing, hygiene, grooming and eating. Resident functioning at their highest level of independence in basic self-cares will be promoted. Grooming/hygiene was identified to emphasis on appearance and dignity. The policy further identified changes in specific ADL areas would be reviewed and documented by licensed nurse.

Based on interview and document review, the facility failed to ensure incidents of potential abuse were immediately reported to the State Agency (SA), no later than 2 hours after knowledge of the allegation of abuse, for 2 of 3 residents (R1, R2) reviewed for allegations of abuse. Findings include: R1's annual Minimum Data Set ((MDS) dated [DATE], identified R1 had severe cognitive impairment and [DIAGNOSES REDACTED]. R1's MDS further identified R1 required extensive assistance with hygiene and total assistance with bathing. R1's care plan revised 9/6/19, identified R1 required extensive assitance with dressing, grooming, bathing, and hygiene related to her dementia and physically unable. R1's care plan did not include direction to staff for perineum grooming. R1's medical record lacked documentation that R1 had received unrequesed perineum grooming. The facility report titled Office Memorandum Investigation Report dated 10/22/19, identified the following: -a report was received on 10/13/19, that R1's pubic hair was shaven and was not apart of R1's usual grooming. R1's plan of care was not followed, and R1 was provided care/treatment that went beyond the scope of certified nursing assistant duties. -10/16/19, RN-D was interviewed and confirmed the incident was reported to her 10/13/19, by NA-H and NA-I that R1's pubic hair had been shaven. RN-D indicated NA-H and NA-I had thought they reported it to LPN-A on the morning of 10/12/19, and they thought R1 was shaven on 10/11/19. -10/16/19, LPN-A was interviewed and she indicated that she had been informed on 10/12/19, by NA-H and NA-I that R1 had her pubic hair shaven. LPN-A indicated she thought R1 had been shaven on 10/1/19, when she had a bath and had not completed a skin check on 10/11/19, due to R1 receiving a secondary bath, and skin checks were completed on resident's primary bath day. LPN-A had indicated she forgot to report it. -10/17/19, NA-D was interviewed, and admitted to shaving R1's pubic hair. NA-D said she felt R1's pubic hair did not look clean, and thought it hurt her, so proceeded to shave her. - acting director of nursing (ADON) statement identified she was notified on 10/13/19, by Administrator. Internal investigation and questions to resident to rule out harm or neglect was completed. The facility Office Memorandum Investigation Report, dated 10/22/19, failed to identify that the SA was notified of allegations of abuse, prior to the completion of an investigation. On 10/29/19, at 3:05 p.m. registered nurse (RN)-A indicated the usual facility process for reporting any allegations of abuse is to contact management as soon as possible, and management had time limits to report to the state agency. RN-A indicated she was called by RN-D 10/13/19, or 10/14/19, and asked if she was aware R1 had her pubic hair shaven on 10/12/19, when she was working. RN-A indicated RN-D was informed of the incident by a nursing assistant on 10/13/19. RN-A indicated she had not been made aware of the incident on 10/12/19, when she was working. On 10/29/19, at 3:26 p.m. administrator confirmed he had been informed on 10/13/19, that R1 had received unrequested perineum grooming by a nursing assistant on 10/12/19. Administrator indicated the facility had completed an investigation, but did not report it to the state agency, since they had not substantiated it as abuse or neglect. Administrator indicated during the investigation, which began on 10/13/19, he felt they had determined within 20 minutes that nursing assistant (NA)-D had shaven R1's pubic hair, but felt it not necessary to report the allegation of abuse. Administrator confirmed the ADON had not discussed the purpose of shaving R1's pubic hair until 10/17/19, when NA-D returned back to work, and determined that it was not maltreatment or abuse. Administrator indicated the facility followed the usual process to report allegations of abuse or neglect within 2 hours to the state agency. On 10/29/19, at 6:03 p.m. ADON indicated she was made aware of the incident by the administrator on the afternoon of 10/13/19. ADON indicated they discussed the findings with conversations the administrator had with nurses on 10/13/19, and it was discussed more on 10/14/19, when they developed a plan for the investigation. ADON indicated they had determined on 10/13/19, they did not suspect harm. ADON confirmed the first time she spoke to NA-D about shaving R1's pubic hair was on 10/17/19, when she had returned to work. ADON indicated based on R1's assessment and response they had determined it was not maltreatment or harm. On 10/29/19, at 6:45 p.m. during follow up interview Administrator confirmed he was notified of the incident by phone on 10/13/19. Administrator indicated no one had alleged R1 had been assaulted, abused, injured or neglected. Administrator confirmed he had not made a report to the state agency for allegations of abuse, because he felt he did not have suspicion of abuse or neglect. Administrator indicated that he would have reported the incident, if RN-D had not found out any answers. Administrator confirmed NA-D who had shaven R1's pubic hair, was not interviewed until 10/17/19, 5 days after the incident occurred; but felt he had enough answers in that initial 2 hours, and in the initial 24 hours, that abuse or neglect had not occurred. R2 R2's quarterly MDS dated [DATE], identified R2 had significant cognitive impairment and [DIAGNOSES REDACTED]. R2's MDS further identified R2 required extensive assistance with all activities of daily living (ADLs) R2's care plan revised 4/1/19, identified R1 had a history of [REDACTED]. Interventions included; monitor interactions with other female residents due to history of being inappropriate, encourage R2 to keep a healthy distance, and to monitor and ensure that other female residents were safe. R2's progress note dated 3/29/19, identified R2 had been observed rubbing R4's breast over her shirt. Staff separated R2 from R4 and staff were notified to keep them away from each other. R2 did not appear to understand what occurred but R4 indicated R2 had been bothering her because he was touching her breast. Director of Nursing (DON) was notified and nursing supervisor. R4's power of attorney was updated and attempt made to leave message with R2's family member. Progress note indicated would continue to monitor. R2's family member was attempted to be contacted and R4's POA was notified. R2's incident report identified on 3/29/19, at 8:00 p.m. R2 was observed rubbing R4's breast. Staff separated R2 from R4 and 10 minutes later R4 was asked if R2 had bothered her, and R4 indicated yes, because R2 had grabbed her breast. The report identified the nursing supervisor and DON were notified. R2's family member had been contacted and updated and believed there was no harm, and R2 did not understand. R2 and R4 were to be kept separated and monitored. The facility SA report reviewed identified the allegation of sexual abuse, sexual contact with lack of capacity to consent, occurred on 3/29/19, at 8:00 p.m. with R2 and R4. The SA report was submitted by the facility on 3/30/19, at 9:47 a.m., 13 hours after the incident occurred. On 10/29/19, at 2:30 p.m. NA-C indicated she was aware R2 had touched a female resident's breast in the past. NA-C indicated the staff kept a close eye on him, and had not observed another incident since then. On 10/29/19, at 5:31 p.m. RN-C confirmed she had been present when R2 touched the female resident's breast. RN-C indicated she had notified DON by phone within 15 minutes after the incident. On 10/29/19, at 6:27 p.m. Administrator indicated R2's sexual abuse allegation was not substantiated by the faciltiy so it was not reported to the state agency within the required 2 hours, but was reported within 24 hours. Administrator indicated the facility had determined no harm, because the female resident showed no signs of fear, but he felt the facility needed to report the allegation to the state agency because of the seriousness of R2 inappropriately touching a female resident. The facility's policy titled Vulnerable Adult/Resident Protection Plan effective date 5/2/19, identified any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation or misappropriation shall immediately report the incident to their supervisor or the Officer of the Day (OD). That staff will then immediately ensure that the proper notifications are made to the facility leadership (i.e. Facility Administrator, Director of Nursing, Director of Social Services or designee) and state agency per state and federal requirements.

Based on interview, and document review, the facility failed to complete a thorough investigation to assure residents were safe, following an allegation of abuse, for 2 of 3 residents (R1, R2) investigated for abuse. Findings include; R1's annual Minimum Data Set ((MDS) dated [DATE], identified R1 had severe cognitive impairment and [DIAGNOSES REDACTED]. R1's MDS further identified R1 required extensive assistance with hygiene and total assistance with bathing. R1's care plan revised 9/6/19, identified R1 required extensive assistance with dressing, grooming, bathing, and hygiene related to her dementia and physically unable. R1's care plan did not include direction to staff for perineum grooming R1's medical record was reviewed, and lacked any documentation of allegation of abuse, incident, or investigation, after the facility was notified R1 had received unrequested perineum grooming. The facility report titled Office Memorandum Investigation Report dated 10/22/19, identified the following: -a report was received on 10/13/19, that R1's pubic hair was shaven and was not apart of R1's usual grooming. R1's plan of care was not followed, and R1 was provided care/treatment that went beyond the scope of certified nursing assistant duties. -10/16/19, RN-D was interviewed and confirmed the incident was reported to her 10/13/19, by NA-H and NA-I that R1's pubic hair had been shaven. RN-D indicated NA-H and NA-I had thought they reported it to LPN-A on the morning of 10/12/19, and they thought R1 was shaven on 10/11/19. -10/16/19, LPN-A was interviewed and she indicated that she had been informed on 10/12/19, by NA-H and NA-I that R1 had her pubic hair shaven. LPN-A indicated she thought R1 had been shaven on 10/1/19, when she had a bath and had not completed a skin check on 10/11/19, due to R1 receiving a secondary bath, and skin checks were completed on resident's primary bath day. LPN-A had indicated she forgot to report it. -10/17/19, NA-D was interviewed, and admitted to shaving R1's pubic hair. NA-D said she felt R1's pubic hair did not look clean, and thought it hurt her, so proceeded to shave her. - acting director of nursing (ADON) statement identified she was notified on 10/13/19, by Administrator. Internal investigation and questions to resident to rule out harm or neglect was completed. The facility Office Memorandum Investigation Report, dated 10/22/19, failed to identify a thorough, investigation was completed to protect other residents in the facility. On 10/29/19, at 1:04 p.m. nursing assistant (NA)-A was in R1's room applying ceiling lift sling to R1. NA-A then transferred R1 to the bathroom, removed her slacks and brief, then lowered her to the toilet. NA-A indicated R1 had her pubic hair recently shaven, but did not know why. R1's pubic hair appeared to be recently shaven, with short stubbly hair. NA-A indicated she was not aware of any other residents who had received perineum grooming. On 10/29/19, at 2:35 p.m. NA-C, indicated she was aware R1's pubic hair had been shaven a few weeks ago by NA-D. NA-C felt it was not done for bad intentions, and she felt NA-D may have thought R1 should be shaven to keep her cleaner. NA-C felt NA-D had shaven R1's pubic hair, because she had given her a bath that day, and informed her that she had shaven R1's arm pits. On 10/29/19, at 3:05 p.m. RN-A, indicated she was called on 10/13/19, or 10/14/19, by RN-A asking if she was aware R1 had her pubic hair shaven by a staff member. RN-A said she had worked that day, but had not been made aware of the incident. RN-A said she did not know if the facility had determined what happened, and indicated she had not heard anything more about the incident. On 10/29/19, at 3:26 p.m. Administrator indicated the facility had completed an internal investigation regarding R1 receiving unrequested perineum grooming by a nursing assistant. Administrator confirmed the facility had not completed a report or documentation in R1's medical record. ON 10/29/19, at 6:03 p.m. acting director of nursing (ADON) indicated she was made aware of the incident 10/13/19. ADON indicated she had discussed the findings with Administrator on 10/13/19, and 10/14/19, and they developed a plan for the investigation. ADON indicated as part of the investigation, she had interviewed RN-D and LPN-A who had worked that weekend, and NA-D when she returned to work on 10/17/19. ADON confirmed she had not interviewed any other staff members, or any residents during the investigation. ADON indicated the usual facility practice was not to interview other residents, for the discretion of the employee. ADON indicated if there was suspicion of abuse, they would have investigated differently. On 10/29/19, at 6:45 p.m. Administrator indicated he thought only three staff had been interviewed, and no residents were interviewed. Administrator indicated the facility would have been aware if any other residents had received unrequested perineum grooming, because of weekly skin inspections. Administrator indicated other residents were protected, because NA-D was off work until 10/17/19, when she returned to work, ADON talked to her about it and disciplinary action was provided. R2 R2's quarterly MDS dated [DATE], identified R2 had significant cognitive impairment and [DIAGNOSES REDACTED]. R2's MDS further identified R2 required extensive assistance with all activities of daily living (ADLs) R2's care plan revised 4/1/19, identified R1 had a history of [REDACTED]. Interventions included; monitor interactions with other female residents due to history of being inappropriate, encourage R2 to keep a healthy distance, and to monitor and ensure that other female residents were safe. R2's progress note dated 3/29/19, identified R2 had been observed rubbing a female resident's breast over her shirt. Staff separated R2 from the female resident, and staff were notified to keep them away from each other. R2 did not appear to understand and the female resident indicated R2 had been bothering her because he was touching her breast. Director of Nursing (DON) was notified and nursing supervisor. Female resident's power of attorney was updated and attempt made to leave message with R2's family member (FM)-[NAME] Progress note indicated would continue to monitor. R2's incident report identified on 3/29/19, at 8:00 p.m. R2 was observed rubbing R4's breast. Staff separated R2 from R4 and 10 minutes later R4 was asked if R2 had bothered her, and R4 indicated yes, because R2 had grabbed her breast. The report identified the nursing supervisor and DON were notified. R2's family member had been contacted and updated and believed there was no harm, and R2 did not understand. R2 and R4 were to be kept separated and monitored. The facility investigation submitted to SA provided by facility submitted 4/3/19, at 12:29 p.m. identified care plans and policy was followed. The investigation identified R2 and R4's care plans were both updated following the event. The investigation further identified RN-E was interviewed, who was notified of the event, LPN-A who was a witness and LPN-B. Details of interview were not included in the report. The facility investigation failed to include a thorough investigation of the allegations of sexual abuse, and failed to include other staff and resident interviews were completed to assure other residents in the facility were safe. On 10/29/19, at 5:31 p.m. RN-C indicated she was working when R2 had put his hand on a female resident's breast. RN-C said they separated R2 from the female resident right away then she had contacted the DON within 15 minutes. On 10/29/19, at 6:15 p.m. ADON indicated she had not been part of the investigation of alleged sexual abuse by R2. ADON confirmed the total investigation was included in the incident and VA (vulnerable adult) report provided. On 10/29/19, at 6:27 p.m. Administrator indicated a thorough investigation of the allegation of sexual abuse by R2 would include interview of the residents involved, any staff that witnessed it and review of their medical records. Administrator indicated he would also expect the staff to monitor the female resident to determine if she had any change in behavior, appearance of being scared, or she would not come out of her room after the incident. Administrator also indicated he would expect other residents to be protected by monitoring R2 after the incident to make sure not inappropriate sexual touch had not occurred between R2 and other female residents. Administrator stated other residents may also have needed to be interviewed, if they had witnessed what occurred but it would have depened on the situation. The facility's policy titled Vulnerable Adult/Resident Protection Plan effective date 5/2/19, identified that all reports of abuse would be promptly and thoroughly investigated. Key elements of the investigation included obtaining resident statement or observations, resident roommate statement, involved staff and witnesses. The facility failed to include the possible need to obtain interviews of other residents and staff of other areas and shifts to determine if pattern of abuse was present and to protect the residents in the facility.

Based on interview and document review, the facility failed to develop an abuse policy that included all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported to the Administrator, State Agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within the required time frames. This deficient practice had the potential to affect all 102 residents residing in the facility. Findings include: Review of the facility's policy titled Vulnerable Adult/Resident Protection Plan effective date 5/2/19, included the following; - Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation or misappropriation shall immediately report the incident to their supervisor or the Officer of the Day (OD). That staff will then immediately ensure that the proper notifications are made to the facility leadership (i.ie Facility Administrator, Director of Nursing, Director of Social Services or designee) and state agency per state and federal requirements. -The following regarding therapeutic error must be considered when reporting is determined, included the following examples; -does not result in harm or injury . or if the injury or harm that required care did not result in substantial acute or chronic injury or illness, or permanent disability above and beyond the Vulnerable Adults's pre- existing condition. -is immediately reported and recorded internally in order to evaluate and identify corrective action -is sufficiently documented for review and evaluation -is not part of a pattern of errors by the individual -Elder Abuse Act: Reporting 2 hour limit identified: If the events that cause the reasonable suspicion result in serious bodily injury to a resident, the covered individual shall report the suspicion immediately, but no later than 2 hours after forming the suspicion. All other reporting-within 24 hours-if the event that cause the reasonable suspicion does not result in serious bodily injury to a resident, the covered individual shall report the suspicion no later then 24 hours after forming the suspicion. The policies failed to include all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the the State Survey Agency. On 10/29/19, at 3:26 p.m. administrator confirmed the facility's policy titled Vulnerable Adult/Resident Protection Plan effective date 5/2/19, was the facility's current policy. Administrator and surveyor reviewed content of the policy. Administrator confirmed the federal regulation reporting timelines were not included in the facility's current policy.

Based on observation, interview, and document review the facility failed to provide housekeeping services to ensure a clean environment for 1 of 1 resident (R53) who had strong odors in the room and failed to maintain personal care equipment for 1 of 1 resident (R3) who was observed to utilize a dirty wheelchair. Findings include: R53's annual Minimum Data Set (MDS), dated [DATE], identified R53 was severely cognitively impaired and had [DIAGNOSES REDACTED]. The MDS also indicated R53 required extensive assistance with dressing and personal hygiene, bed mobility and toileting and was totally dependent on two staff for transfers and bathing. Further review of the MDS indicated R53 was frequently incontinent of urine and continent of bowel with no toileting program. Review of R53's current care plan revised on 5/8/19, revealed R53 was incontinent of bowel and bladder, required staff assistance with toileting every 2 hours while awake, to check first and third rounds at night and as needed. The care plan also indicated R53 required assistance with personal hygiene. During observations on 6/17/19 at 11:22 a.m. R53 was seated in his recliner, covered with a blanket resting with his feet up on the foot rest of the recliner and had his call light with in reach. R53 room had a strong odor of urine noted permeating in the room and into the hallway of the west wing. During observations on 6/18/19 at 8:21 a.m. R53's room had a moderate odor of urine noted permeating in the room and into the hallway of the west wing. - at 2:35 p.m. R53 was seated in his recliner, covered with a blanket resting with his feet up on the foot rest of the recliner and had his call light with in reach. R53's room had a moderate odor of urine noted permeating in the room and into the hallway of the west wing. During observations on 6/20/19 at 8:33 a.m. R53's room had a strong odor of urine noted permeating in the room and into the hallway of the west wing. On 6/20/19 at 8:33 a.m. maintence foreman (MF) confirmed the strong urine odor that permeated out into the hallway of R53's room. The MF indicated resident rooms get were cleaned on a weekly basis and staff would clean the rooms more if needed. The MF indicated nursing staff would let housekeeping know if the rooms needed to be cleaned more. The MF indicated staff tried to provide a more thorough cleaning when offensive odors were present. The MF indicated he was not sure where the urine smell was coming from and indicated he did not always know about these kinds of things because housekeeping usually took care of it. The MF stated the room should have been cleaned and indicated staff should have investigated the cause of the offensive odor in order to properly remove it. On 6/20/19 at 8:39 a.m. housekeeper (HK)-A confirmed the strong urine odor permeated out into the hallway of R53's room. HK-A indicated she did not know where the strong urine smell was coming from and indicated they cleaned R53's room once a week. HK-A indicated when they have urine odor smells like this, they use an enzyme cleaner to remove the smell and would attempt to find the source of the urine smell. R3's quarterly MDS, dated [DATE], identified R3 was cognitively intact and had [DIAGNOSES REDACTED]. The MDS also indicated R3 required extensive assistance of one staff with dressing, personal hygiene, toileting, bathing and required extensive assistance of 2 staff for bed mobility, transfers and utilized a wheel chair. Review of R3's current care plan revised on 6/14/19, revealed R3 had impaired mobility related to [DIAGNOSES REDACTED]. During observations on 6/17/19 at 9:00 a.m. R3 was in his room seated in his electric wheel chair watching TV. R3's black electric wheel chair had a black cushion on the seat of it, on the left side of the wheel chair there was old, dried up food particles built up in the crease of the wheel chair and the black seat cushion. R53 also has a blue side cushion on the left side which was stained and spattered with a white substance and had dried, old food particles, spatters all over the left wheel base of his electric wheel chair. - at 12:55 p.m. R3 was in his room seated in his electric wheel chair watching TV. R3's black electric wheel chair continued to have old, dried up food particles built up in the crease of the wheel chair and the black seat cushion. R53 also has a blue side cushion on the left side which was stained and spattered with a white substance and had dried, old food particles, spatters all over the left wheel base of his electric wheel chair. During observations on 6/18/19 at 9:46 a.m. R3 was seated in his electric wheelchair and was wheeling down the hallway when he stopped to say hi. R3's wheelchair continued to have old, dried up food particles built up in the crease of the wheel chair and the black seat cushion. R53 also had a blue side cushion on the left side which was stained and spattered with a white substance and had dried, old food particles, spatters all over the left wheel base of his electric wheel chair. - at 7:21 p.m. R3 was in his room seated in his electric wheel chair watching TV. R3's black electric wheel chair continued to have old, dried up food particles built up in the crease of the wheel chair and the black seat cushion. R53 also has a blue side cushion on the left side which was stained and spattered with a white substance and had dried, old food particles, spatters all over the left wheel base of his electric wheel chair. On 6/19/19, at 11:47 a.m. R53 was seated in his electric wheelchair in his room with the tubing of the urinary catheter bag tangled up in R53's right wheel of his electric wheelchair. NA-A entered the room, assisted with untangling the catheter bag and changed the tubing. R53 continued to be seated in his electric wheelchair watching TV with dried food particles built up in the crease of the wheelchair and the black seat cushion. R53 had a blue cushion on the left side stained and spattered with a white substance and dried old food particles spattered all over the left wheel base of R53's electric wheelchair. - at 4:36 p.m. R53 drove his electric wheelchair down the hallway of the west wing. He continued to have old, dried food particles built up in the crease of the wheelchair and on the black seat cushion. R53 also had a blue side cushion on the left side which was stained and spattered with a white substance and had dried, old food particles, spatters all over the left wheel base of his electric wheel chair and the foot rest. -at 5:45 p.m. staff assisted R53 back to his room via electric wheel chair after supper due to R53's hands being tired. R53's wheelchair continued to have old, dried up food particles built up in the crease of the wheel chair and the black seat cushion. R53 also had a blue side cushion on the left side which was stained and spattered with a white substance and had dried, old food particles, spatters all over the left wheel base of his electric wheel chair and the foot rest. On 6/20/19 at 8:39 a.m. HK-A confirmed R53's electric wheelchair and cushion were visibly soiled with old dried food and food splatters. HK-A indicated nursing was responsible for cleaning the wheel chairs and had cleaning schedules for the wheel chairs. HK-A indicated R53's electric wheelchair should have been cleaned and she would have expected nursing staff to be cleaning them on a regular basis. On 6/20/19 at 8:50 a.m. registered nurse (RN)-B confirmed R53's electric wheel chair and cushion were visibly soiled with old dried food and food splatters. RN-B verified it was the responsibility of night shift nursing staff to clean the wheelchairs and indicated staff had a wheelchair cleaning schedule. RN-B verified R53's wheelchair was scheduled to be cleaned every other week. RN-B stated R53's wheelchair was in need of cleaning. RN-B further stated R53 did spill food during meals and staff should have been wiping his wheel chair down when it was visibly soiled. On 6/20/19 at 3:18 p.m. the director of nursing (DON) confirmed the above findings and indicated staff were expected to clean wheelchairs as scheduled and when visibly soiled. The DON also indicated she did not know the source of the strong urine smell in R53's room and would have expected staff ensured the rooms were cleaned and odor-free. DON stated staff should have informed maintenance and housekeeping when strong odors were noted so they could address it. Review of facility policy titled, Cleaning Standard for Resident Rooms, revised on 8/28/18, indicated each nurses aid and general maintenance worker will plan their assignments to include the cleaning of the resident immediate living area to insure it was safe and clean. Review of facility policy titled, New Wheelchair Washing Process, undated indicated it is our expectation that all wheel chairs be washed/cleaned at least twice per month.

Based on observation, interview and document review, the facility failed to ensure interventions were implemented to reduce the risk of falls for 1 of 4 residents (R41) who had multiple falls in the facility. Findings inlcude: R41's quarterly Minimum Data Set (MDS), dated [DATE], indicated R41 had [DIAGNOSES REDACTED]. The MDS further indicated R41 had severe cognitive impairment and exhibited no behaviors. The MDS identified R41 required extensive assistance with bed mobility, transfers, locomotion, dressing, toileting, personal hygiene, bathing and R41 had not walked. Additionally, the MDS indicated R41 was frequently incontinent of bladder and occasionally incontinent of bowel and was not on a toileting program. Futher, the MDS identified R41 had one fall without an injury since the last assessment. R41's annual Care Area Assessments (CAA) dated 1/3/19, indicated R41 had a history of [REDACTED]. The CAA indicated R41 had restricted mobility which required staff assistance with toileting tasks as well as the presence of urinary urgency. Further, the CAA indicated R41 had severe cognition impairment and required staff to provide reminders, cues and guidance as needed. Review of R41's Falls Risk assessment dated [DATE], indicated R41 had a high risk for falls. The assessment indicated R41 had a history of [REDACTED]. - R41's Falls Risk assessment dated [DATE], indicated R41 had a moderate risk for falls. The assessment further indicated R41 had a history of [REDACTED]. - R41's Falls Risk assessment dated [DATE], identified R41 had a high risk for falls. The assessment further identified R41 had a history of [REDACTED]. R41's care plan revised 6/19/19, indicated R41 was at risk for falls due to falling asleep while sitting up in bed, attempting to reach for objects and when attempting to crawl out of bed believing he needed to go to work. The care plan indicated R41 had severe cognitive impairment and required extensive assistance from staff with transfers and toilet transfers. The care plan instructed staff to lock controls on R41's hi-low bed, remind R41 to use the call light, check under the fall mat to ensure it had not been soaked in urine and to apply non-skid sock to his left leg. The care plan further instructed staff to remind R41 to ask for assistance when toileting needs arise, ensure urinal is within reach, leave a mountain dew within reach, place a silent alarm on bed and to leave R41's wheelchair next to his bed. On 6/19/19, at 12:45 p.m. R41 was lying on his right side, in his bed. His eyes were closed and he had oxygen tubing in is nostrils. R41's wheelchair was parked on the floor matt, next to R41's bed. R41's urinal was situated on top of the trash can, located approximately five feet away from R41's bed. On 6/19/19, at 12:59 p.m. R41 was heard to be calling Help and observed to have his left foot touching the floor mat and R41 had both hands on the right siderail. R41's pants were noted to be down to his knees and his incontinent brief had been pulled down below his buttocks. R41's incontinent brief and pants had been soiled with a moderate amount of brown semi-formed stool. R41's urinal continued to be situated on top of the trash can located five feet away near R41's bedside stand. Nursing assistant (NA)-A and NA-B entered the room and assisted R41 to transfer to his wheelchair, wheeled him into the bathroom and assisted him to the toilet. R41's incontinent product was soiled with both urine and stool and there was a moderate amount of stool noted his wheelchair seat. NA-A and NA-B proceeded to assist R41 with personal cares and then assisted him to transfer back into his bed. NA-A provided R41 with a blanket, applied oxygen per nasal cannula and placed call light within reach. NA-B placed fall mat on the floor and parked wheelchair with brakes locked next to his bed. NA-A placed trash can that had urinal situated on it next to R41's bed right next to the wheelchair. NA-A and NA-B exited the room at that time. On 6/19/19, at 1:18 p.m. NA-A stated R41 required total assistance with many areas of his activities of daily living (ADL'S) which included transfers and toileting. NA-A further stated R41 had multiple falls and many of his falls were related to R41 having the urge to go to the bathroom. NA-A indicated R41 many times could not reach his urinal as staff forgot to place the urinal close by positioned on the trash can. NA-A verified R41 had the urge to use the bathroom earlier which led to R41 attempting to call out and transferring himself. NA-A stated R41 was not reliable to use his call light consistently however R41 was able to inform staff when he had the urge to toilet. NA-A stated R41's toileting plan included toileting R41 after breakfast and then wait for R41 to inform staff when he felt the urge to toilet. On 6/20/19, at 9:27 a.m. registered nurse (RN)-C stated R41 was at high risk for falls and R41 had multiple falls in the facility. RN-C indicated many of the falls were related to R41's urge to use the bathroom. RN-C stated R41's fall prevention strategies included placing the urinal on the trash can next to R41's bedside, placing the fall mat on the floor on top of the non-skid strips next to his bed and a bed alarm. RN-C stated the non-skid strips were placed on the floor since R41 did not have accurate aim when using the urinal independently and as a result the urine would often spill onto the floor next to his bed. RN-C indicated R41 was on a toileting plan which included staff checking with R41 every two hours to see if R41 required assitance with toileting. RN-C further indicated R41 had severe cognitive impairment and could not be relied upon to use his call light to communicate toileting needs. On 6/20/19, at 10:40 a.m. nurse manager (NM)-B stated R41 had a lack of awareness and could not be relied upon to consistently use his call light to communicate his needs. NM-B indicated R41 was at high risk for falls and R41 had seven falls since (MONTH) 2019. NM-B stated many falls were related to R41 reaching for his urinal or his mountain dew soft drink. NM-B stated she expected the urinal was placed on the trash can within R41's reach as a falls prevention intervention. Review of R41's incidents reports from 1/25/19, through 6/3/19, revealed the following: - On 1/25/19, at 7:45 a.m. R41's bed alarm sounded and R41 was found by staff to be seated on the edge of the bed. Staff assisted R41 to stand and both the staff person and R41 slipped on the floor due to urine spill located under the floor mat. R41 stated he had been attempting to get up on his own. New non-skid strips were applied to the floor under the fall mat as a result and a reminder sign was placed next to R41's bed to remind staff to lock the bed. - On 2/1/19, at 6:05 a.m. R41's bed alarm sounded and R41 was found sitting on the floor next to his bed. R41 stated he had needed to use the bathroom. R41 was assisted off the floor with the use of a lift and transferred to the toilet where he had a large loose bowel movement (BM). No new safety interventions were placed as a result of the fall nor was the toileting care plan updated. - On 4/17/19, at 11:05 p.m. R4's bed alarm sounded and R41 was found seated on the floor mat on the floor next to his bed. R41 was returned to his bed via lift and R41's brief was noted to be wet with urine and staff changed the brief. No new safety interventions were made as a result of the fall nor was the toileting care plan updated. - On 4/22/19, at 11:50 p.m. R41 was found to be partially seated on his garbage can. The garbage can was noted to be tipped on it's side just underneath R41's left buttock. Staff noted a large BM was present in the garbage can as well as on the bed sheets and side rail. Post-fall review indicated R41 received a laxative that evening and staff were asked to not give the laxative at night. No new safety interventions were implemented as a result of the fall nor was the toileting care plan updated. - On 5/3/19, at 2:29 p.m. R41 was found seated on the floor next to his bed. R41 stated he needed to go to the bathroom. Post-fall review indicated R41 had tried to use the urinal but was not placed close enough at his bedside for him to use. Staff were reminded to place the urinal at the bedside to prevent further falls. No new safety interventions were placed as a result of this fall nor was the toileting care plan updated. - On 5/9/19, at 1:45 p.m. R41's bed alarm sounded and R41 was noted to be on the floor. Staff noted R41 was incontinent and indicated R41 purposely got on the floor due to the incontinence. No new safety interventions were placed as a result of the fall nor was the toileting care plan updated. - On 6/3/19, at 11:35 p.m. R41's alarm sounded and R41 was found seated on the floor next to his bed. Post-fall review indicated R41 had been trying to reach for his urinal that was hooked on his wastebasket. Staff attempted to locate a special bed that had the capability of placing the urinal on the side rail for R41 to easily access and none of the beds were available for use. No new safety interventions were placed as a result of the fall nor was the toileting care plan updated. On 6/20/19, at 2:49 p.m. director of nursing (DON) stated R41 had multiple falls and many of the falls were related to toileting needs. DON confirmed R41's care plan and confirmed R41's toileting interventions should have been updated or revised due to the multiple falls R41 had. DON further confirmed R41 had multiple falls related to R41 reaching for his urinal due to toileting needs and DON stated it was expected R41's urinal was within reach at all times. Review of facility policy titled Fall Risk and Prevention last revised 2/14/18, indicated staff were expected to complete a falls risk assessment for each resident upon admission, quarterly and more often if a resident had two falls in one week or three falls in one month. The policy instructed staff to complete safety rounds on all residents at the beginning, middle and end of their shifts to become accustomed to resident routines as well as proactively meet the resident needs. The policy indicated interventions would be developed to reduce the risk of falls for all residents. Further, the policy identified a falls committee had been formed and the committee would review all fall incident reports daily during the regular work week to determine the need for new interventions. The policy indicated all staff would receive training on falls prevention upon hire and annually thereafter.

Based on observation, interview and document review, the facility failed to comprehensively assess and implement pressure relieving interventions for 1 of 1 resident (R258) with a current facility acquired unstageable pressure ulcer. This deficient practice resulted in actual harm for R258 when a stage two (2) pressure ulcer worsened to an unstageable pressure ulcer. Findings include: R258's quarterly Minimum Data Set ((MDS) dated [DATE], identified R258 was cognitively intact and had [DIAGNOSES REDACTED]. The MDS identified R258 required extensive assistance with dressing, personal hygiene, walking in the corridor and required limited assistance with transfers and toileting. The MDS identified R258 was not at risk for developing pressure ulcers, had no current pressure ulcers or healed pressure ulcers and was on a turning and repositioning program. Further the MDS identified R258 had no other skin conditions. R258's Skin Risk Factor form dated 1/27/18, identified R258 was at low risk for developing pressure ulcers and had no skin ulcers or areas of skin concern. R258's Skin Risk Factor form dated 2/24/18, identified R258 was at low risk for pressure ulcer development and had a current pressure ulcer on his right heel. R258's Tissue Tolerance Assessment form dated 2/23/18, identified R258's skin was intact, had an old scabbed over heel which was covered with an Allevyn dressing and monitored by nursing. The form revealed R258 had a standard cushion in his wheelchair. The form lacked any indication of a repositioning plan or pressure relieving interventions for R258's facility acquired right heel unstageable pressure ulcer. R258's care plan revised 4/3/18, revealed R258 was at risk for skin breakdown, was independent in repositioning and directed facility staff to encourage him to lay down to relieve pressure from his buttocks The care plan revealed R258 wore regular socks vs gripper socks when he wore his shoes due to possible pressure concerns. R258's care plan lacked any identification of R258's right heel unstageable pressure ulcer or any pressure relieving interventions for his right heel. On 4/2/18, at 4:56 p.m. R258 was seated in a cushioned wheelchair. He wore black sweat pants, a blue T-shirt, suspenders and white and red New Balance tennis shoes. R258 stated he had a blister on his right heel from the back of his shoe. He indicated the blister started a couple of months ago and had erupted within the last month. R258 stated he had a bandage over the sore and indicated he still wore the same tennis shoes. R258 stated staff had not talked to him about options for pressure relief at his heel and denied being aware to remove his shoes to promote healing. On 4/3/18, at 3:19 p.m. R258 was seated in a recliner in his room in an upright position with his tennis shoe clad feet rested on the floor. R258 stated his right heel was sore and burned at times. R258 stated the back of the shoe rested directly over the sore on his right heel. On 4/4/18, at 7:06 a.m. R258 was seated in a wheelchair, dressed in gray slacks, blue shirt, suspenders and his white and red tennis shoes. At that time, licensed practical nurse (LPN)-A wheeled R258 out of his room and to the nurses station. On 4/4/18, at 7:59 a.m. R258 was seated in a wheelchair with his tennis shoes on both feet in the dining room. R258 used both feet and his arms to propel himself down the hall, towards his room from the dining room. On 4/4/18, at 9:44 a.m. R258 was seated in a tub chair with nursing assistant (NA)-E and registered nurse supervisor (NS)-A present. NA-E removed his shoes and socks. An Allevyn (dressing used to aid in healing) dressing was rolled up on itself above an open pressure ulcer on R258's right heel. R258's right heel had an open sore above his heel on his Achilles tendon. At that time, NS-A confirmed R258's right heel ulcer had hard red edges and the wound bed was covered in slough tissue. NS-A stated R258 currently had an unstageable pressure ulcer due to the presence of the slough tissue. On 4/4/18, at 9:59 a.m. NS-A stated R258's right heel pressure ulcer had initially developed as a fluid filled blister and had drained out while he was hospitalized in February, (YEAR). NS-A stated at that time the facility's wound team, which was comprised of NS-A and physical therapy directed/certified wound specialist (WCC)-A, measured R258's pressure ulcer weekly. She stated she felt R258's right heel pressure ulcer was caused by his shoes. NS-A stated R258 had a history of [REDACTED]. On 4/4/18, at 10:04 a.m. R258's medical record was reviewed with NS-A and she confirmed R258's right heel pressure ulcer was noted on 1/15/18, as a skin tear which measured 2.0 centimeters (cm) in length and 1 cm in width. NS-A indicated she did not feel the measurements and type of wound were accurate. NS-A confirmed on 1/29/18, R258 had a fluid filled blister on his right heel which measured 0.5 cm by 0.5 cm. She confirmed on 2/2/18, R258 continued to have a fluid filled blister on his right heel which measured 0.6 cm by 0.6 cm and confirmed R258's heel ulcer was not staged. NS- A confirmed R258 had a previous stage 2 pressure ulcer on his right heel which had healed in (MONTH) of (YEAR). NS-A confirmed R258's medical record lacked an indication of what potentially caused R258's pressure ulcer. Further, NS-A confirmed R258's medical record did not address the use of shoes, and indicated the facility had not considered different shoes and use of shoes for R258. On 4/4/18, at 10:24 a.m. R258 was seated in a tub chair in the tub room with NA-E, NS-A and WCC-A present. R258's right heel was open to air, had raised hard edges, which were a dark pink and a thick white/yellowish tissue covered the wound bed. At that time NS-A and WCC-A confirmed R258's pressure ulcer had 85% sough tissue which covered the bed of the wound and 15% [MEDICATION NAME] tissue on the inner walls of the pressure ulcer. WCC-A stated R258's right heel pressure ulcer had worsened from a stage 2 to an unstageable pressure ulcer. WCC stated she felt R258's right heel pressure ulcer was caused by friction from the back of his tennis shoes. R258's right heel unstageable pressure ulcer was covered with an Allevyn dressing. R258 stated the sore was painful, especially when his shoe rubbed on the sore or when it was touched. NS-A stated she had been unaware of R258's complaints of pain, and indicated she felt it was incidental when something touched the ulcer. NA-E then assisted R258 to donn compression stockings, socks and both of his tennis shoes. On 4/4/18, at 11:59 a.m. R258 stated he has had his current tennis shoes for approximately 3 months and had previously had the same brand and type of tennis shoes, in a different color. On 4/4/18, at 12:10 p.m. licensed practical nurse (LPN)-A stated she was unsure how long R258 had worn his current shoes and indicated R258 had always worn tennis shoes. She stated she was not aware of any pressure relieving interventions for R258's unstageable right heel pressure ulcer. LPN-A stated R258 could take a few steps in his room but overall needed assistance for transfers and ambulation due to shortness of breath. On 4/4/18, at 12:13 p.m. NA-D stated R258 used to walk around independently and currently was able to take a few steps in his room. NA-D stated R258 needed assistance with dressing and grooming, which included applying and removing his stockings and shoes. NA-D stated R258 had a sore on his right heel which he has had for a few months. She stated she was not aware of any pressure relieving interventions. On 4/4/18, at approximately 12:30 p.m.WCC stated she felt R258's right heel unstageable pressure ulcer was caused by friction from his tennis shoe and indicated he had a history of [REDACTED]. She stated they had not been able to identify a cause of R258's previous right heel pressure ulcer, however, felt possibly it was related to R258 had worn gripper socks instead of regular socks. WCC confirmed R258's wound assessments did not identify any possible causative factors or any pressure relieving interventions. On 4/4/18, at 12:42 p.m. RN-A stated R258 required assistance from facility staff with his cares such as dressing, transfers and ambulation. She stated she felt R258's health had declined and indicated she felt he had a harder time breathing. RN-A stated she was unsure of when R258's right heel pressure ulcer presented and was unaware of any pressure relieving interventions. On 4/4/18, at 1:20 p.m. NS-A stated she had spoken with R258 in the past about the risks and benefits of continuing to wear his shoes. NS-A confirmed R258's medical record lacked any documentation of the education and she could not recall the last time she had spoken to R258 about pressure relieving interventions. Review of R258's Wound Assessment Details Reports from 1/15/18, to 4/4/18, revealed the following: -1/15/18, identified R258 had a skin tear on his right heel which measured 2.0 cm x 1.0 cm and was superficial. The report revealed R258's skin was 50% intact and 50% bright pink or red and revealed R258 had reported pain from the sore and had rated the pain at a six (6) on a numeric scale (0 being no pain and 10 being the worst imaginable). The report further revealed a dressing was applied to R258's right heel. The report lacked causative factors for R258's right heel skin tear. -1/29/18, identified R258 had blister on his right heel which measured 0.50 cm x 0.50 cm and had no depth. The report identified the right heel blister had 50% intact skin and 50% bright pink or red skin and revealed R258 had continued to report pain at a level of 6 on a numeric pain scale. The report revealed a dressing was present and the area was improving. The report lacked information of possible causative factor or pressure relieving interventions for R258's right heel facility acquired stage 2 pressure ulcer (Stage 2 pressure ulcer: partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured blister). - 2/2/18, identified R258 had a blister on his right heel which measured 0.60 cm x 0.60 cm and had no depth. The report identified the right heel blister had 50% intact skin and 50% bright pink or red skin and revealed R258 had reported pain at a level of 5 on a numeric pain scale. The report revealed an Allevyn dressing was applied and R258's blister would continue to be monitored. The report lacked information of possible causative factor or pressure relieving interventions for R258's right heel stage 2 pressure ulcer. -2/8/18, identified R258 had a blood filled blister on his right heel which measured 1.00 cm x 0.70 cm and had an unknown depth. The report identified the blister had 100% purple ecchymosis (a discoloration of the skin resulting from bleeding underneath) and R258 had reported pain at a level of 8 on a numeric pain scale. The report identified R258 had a history of [REDACTED]. The report further revealed an Allevyn dressing was applied and indicated staff were to assist with pressure relief. The report lacked information of possible causative factor or pressure relieving interventions for R258's right heel stage 2 pressure ulcer. - 2/14/18, identified R258 had a blister on his right heel which measured 1.00 cm x 0.65 cm and had 100% ecchymosis skin over the blister and had reported a pain level of a 7 on a numeric scale. The report identified a dressing was in place and R258's heel would continued to be monitored. The report lacked information of possible causative factor, did not address the use of shoes, or pressure relieving interventions for R258's right heel stage 2 pressure ulcer. - 2/15/18, identified R258 had a facility acquired stage 2 pressure ulcer on his right heel which presented as an intact blister with 100% ecchymosis. The report identified R258 stage 2 pressure ulcer measured 1.0 cm x 0.70 cm, and had an unknown depth. The report identified R258's ulcer had not changed. The report lacked information of possible causative factor for R258's right heel pressure ulcer or any pressure relieving interventions. -2/23/18, identified R258 had a facility acquired stage 2 pressure ulcer on his right heel in the form of a blister, measured 1.0 cm x 0.7 cm and was covered with 100% ecchymosis skin and R258 continued to report pain at a level of a 7 on a numeric scale. The report identified a part of R258's blister had reabsorbed the fluid and had a scab present on the ulcer. The report identified R258's stage 2 pressure ulcer was covered with an Allevyn dressing and would continue to be monitored. The report lacked information of possible causative factor for R258's right heel pressure ulcer, did not address R258's shoes or any pressure relieving interventions. -3/1/18, identified R258 had a facility acquired stage 2 pressure ulcer on his right heel in the form of a blister, measured 1.0 cm x 0.70 cm and was covered with purple ecchymosis and continued to report pain at a level of 7 on a numeric scale. The report identified R258's right heel pressure ulcer was improving. The report lacked information of possible causative factor for R258's right heel pressure ulcer or any pressure relieving interventions. -3/8/18, identified R258's facility acquired right heel stage 2 pressure ulcer was covered with hard necrotic tissue (dead or devitalized tissue), and measured 1.0 cm x 0.60 cm and had an unknown depth. The report revealed R258 reported pain at a level of 5 on a numeric scale. The report identified R258's right heel pressure ulcer was covered with an Allevyn dressing and would continue to be monitored. The report did not identify a change in the pressure ulcer stage from a stage 2 pressure ulcer to an unstageable pressure ulcer (wound bed cannot be visualized due to the presence of slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed.) or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound). The report lacked information of possible causative factor for R258's right heel pressure ulcer, did not address the use of R258's shoes, or any pressure relieving interventions. -3/16/18, identified R258's facility acquired right heel pressure ulcer remained a stage 2, covered with hard, firm necrotic tissue which was 100% adhered to the ulcer and measured 0.80 cm x 0.60 cm and continued to report pain at a level of 5 and was especially sore when his shoes were applied or removed. The report questioned if different shoes would help eliminate the problem, however, lacked documentation of any further analysis or R258's possible causative factors in the worsening of his unstagable pressure ulcer. The report revealed R258 had been seen by podiatry and had no recommendations. The report lacked information of possible causative factor for R258's right heel pressure ulcer or any pressure relieving interventions. -3/22/18, identified R258's facility acquired right heel pressure ulcer remained a stage 2, covered with hard, firm necrotic tissue which was adhered to the wound bed and measured 0.60 cm x 0.90 cm and an unknown depth. The report identified R258 continue to report pain at a level of a 5 on a numeric pain scale. The report identified R258's right heel pressure ulcer was covered with an Allevyn dressing and would continue to be monitored. The report lacked information of possible causative factor for R258's right heel pressure ulcer or any pressure relieving interventions. -3/30/18, identified R258's facility acquired right heel pressure ulcer remained a stage 2, covered with hard, firm necrotic tissue which was adhered to the wound bed and measured 0.60 cm x 0.60 cm, an unknown depth and was improving. The report identified R258 continue to report pain at a level of a 5 on a numeric pain scale. The report identified R258's right heel pressure ulcer was covered with an Allevyn dressing and would continue to be monitored. -4/4/18, identified R258's facility acquired right heel had an unstageable pressure ulcer, measured 0.60 cm x 0.60 cm, unknown depth due to 85% slough tissue covered the wound bed. The report identified R258's unstageable pressure ulcer had 15% [MEDICATION NAME] tissue present and the ulcer edges were distinct and intact. The report identified R258's right heel pressure ulcer had worsened to an unstageable pressure ulcer. The report identified R258 continue to report pain at a level of a 5 on a numeric pain scale. The report identified R258's right heel pressure ulcer was covered with an Allevyn dressing and would continue to be monitored. The report lacked information of possible causative factor for R258's right heel pressure ulcer, and did not address the use of R258's shoes. The report revealed R258 was encouraged to raise his legs when in chair. R258's Admit/Readmit Screener form dated 2/23/18, revealed R258 had been readmitted to the facility from the hospital due to [MEDICAL CONDITION] exacerbation and [MEDICAL CONDITION]. The form identified R258 had an area on his heel which was scabbed over and covered with an Allevyn. The form lacked measurements of R258's unstageable pressure ulcer. R258's medical record lacked any further documentation of an assessment of R258's stage 2 pressure ulcer, and assessment when R258's pressure ulcer worsened to an unstagable heel pressure ulcer. On 4/4/18, at 1:44 p.m. R258's primary geriatric nurse practitioner (GNP)-A stated she was unaware R258 had a current unstageable pressure ulcer on his right heel. GNP-A stated she could not recall facility staff notifying her of R258's pressure ulcer due to the volume of her patient load. GNP-A stated the facility had a wound team and she felt confident the facility team would have assessed and implemented interventions to promote healing. She stated she would expect the team to complete a comprehensive assessment upon the development of R258's pressure ulcer that included causative factors and identify pressure relieving interventions. On 4/4/18, at 1:55 p.m. a telephone call was placed to R258's primary physician, a message was left. On 4/4/18, at 1:57 p.m. the director of nursing (DON) stated she expected a comprehensive assessment to be completed when R258's pressure ulcer developed and with any changes. She stated she would expect pressure relieving interventions to be identified and implemented. The DON stated if R258 had refused any pressure relieving interventions, she would expect nursing staff to educate R258 on the risks and benefits of not relieving pressure from his right heel and to be documented in his medical record. R258's medical record lacked any further physician orders [REDACTED]. Review of R258's physician progress notes [REDACTED]. The physician progress notes [REDACTED]. R258's outpatient progress note from podiatry, dated 10/13/17, listed R258 had routine nail care and foot check, and had thickened, discolored nails. The note indicated R258's nails and calluses/corns had been trimmed and was to follow up in 3 months. The note lacked documentation of any current pressure ulcers for R258. R258's medical record lacked any further documentation of podiatry visits, or follow up. On 4/5/18, at 9:52 a.m. a group interview was conducted with DON and assistant director of nursing (ADON). The DON and ADON reviewed R258's medical record and confirmed the following: - R258's medical record lacked documentation on probable or possible causative factors which attributed to R258's right heel pressure ulcer, nor any pressure relieving interventions. -R258's medical record lacked documentation his provider was notified of his current right heel unstageable pressure ulcer. -R258's medical record lacked any indication R258 had received education on the risks and benefits of refusing to relieve pressure from his right heel. -R258's medical record revealed he had been hospitalized in (MONTH) and (MONTH) of (YEAR), both of which had noted lower extremity [MEDICAL CONDITION]. -R258's care plan lacked any documentation of R258's right heel pressure ulcer or any pressure relieving interventions. A facility policy titled, Skin Integrity: Assessment and Management revised 8/1/17, revealed it was the policy of the facility to promote efficient management of skin concerns unique to the residents of a long term care facility. The policy identified the facility's procedure included five fundamental steps which included avoidance or relief of pressure, friction and shearing, keeping skin clean and dry, supportive therapy of nutrition and hydration and assessment and treatment. The policy directed facility staff to provide residents and family education on skin integrity. The policy revealed definitions of different stages of pressure ulcers which included; stage 2 pressure ulcer, a superficial skin loss that includes the epidermis but not the dermis, may appear as an abrasion, blister or a shallow crater and the wound base may be moist and pink. The policy identified an unstageable ulcer as a 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.