Every finding on record at Neilson Place

Based on interview and document review, the facility failed to ensure staff utilized the appropriate personal protective equipment (PPE) during high contact cares for 3 of 4 residents (R66, R67, R49) reviewed for enhanced barrier precautions. In addition, the facility failed to implement timely airborne precautions for 1 of 2 residents (R16) reviewed for transmission-based precautions.ENHANCED BARRIER PRECAUTIONS: R66 R66's comprehensive MDS dated [DATE], identified R66 had severe cognitive impairment and diagnoses included traumatic brain dysfunction, quadriplegia and seizure disorder. R66 used a feeding tube. R66's care plan revised 1/7/26, identified R66 needed enhanced barrier precautions (EBP) (an infection control strategy in nursing homes requiring staff to wear gowns and gloves during high-contact resident care, such as bathing, dressing, or device care) due to gastrotomy (G-tube) (a medical device inserted through the abdomen directly into the stomach to deliver nutrition, fluids, and medication when oral intake is unsafe or insufficient.) Personal protective equipment (PPE) was available immediately outside of R66's room. Staff were to wash their hands upon entering and leaving R66's room. PPE was to be removed prior to leaving R66's room. During an observation on 3/2/26 at 7:38 p.m., an EBP sign hung outside R66's door and a plastic 3-tiered cart contained gowns, gloves and surgical masks. RN-D entered R66's room to administer G-tube medications. registered nurse (RN)-D did not put on a gown but did wear gloves while touching R66 and R66's bed and belongings. During an interview on 3/2/26 at 7:48 p.m., RN-D stated staff used gowns and gloves during personal cares, like bedtime cares. Upon review of the EBP sign outside R66's room, RN-D stated she should have worn a gown during G-tube medication administration. During an interview on 3/3/26 at 2:30 p.m., RN-C stated staff were expected to wear a gown and gloves for any resident care planned for EBP when staff were doing anything where they were touching the resident and that included G-tube medication administration. R66 was on EBP because R66 had a G-tube specifically so that was the only reason R66 needed EBP. Staff were protecting R66 and that's why they were expected to wear a gown. During an interview on 3/5/26 at 4:34 p.m., licensed practical nurse (LPN)-A, the infection preventionist (IP), stated EBP was used for indwelling medical device, surgical wound, targeted MDRO, or a healed surgical wound. On top of standard precautions – gown and glove w/ high contact cares including anytime you come in contact with the resident or their belongings ie: combing hair, repositioning, cleaning, and/or transferring. R67 R67's annual MDS dated [DATE], identified R67 was cognitively aware and diagnoses included heart failure, chronic obstructive pulmonary disease (COPD), morbid obesity and had a fall with major injury. The untitled care sheet dated 3/4/26, failed to identify R67 needed EBP. R67's C diff NAAT with Reflex to Toxin A/B dated 8/26/25, identified C diff tcdB [NAME] NAAT was detected but the toxins were not detected. (If the initial NAAT is positive, it indicates the potential for infection. The reflex to toxin test confirms if the bacteria are actively producing toxins, which is essential for diagnosing active colitis) R67's care plan revised 7/4/25, identified R67 required assist of two staff for bed mobility but did not identify R67 required EBP. During an observation on 3/4/26 at 8:26 a.m., there was an EBP sign outside R67's door with a 3- tiered plastic cart with gowns, surgical masks and gloves. Nursing assistant (NA)-B and NA-C, without putting on gowns or gloves, transferred R67 from her recliner to her bed and provided morning cares before taking R67 to breakfast. During an interview on 3/4/26 at 8:50 a.m., NA-B stated R67 no longer required EBP because R67 previously had a wound that was healed. R67 reviewed R67's care sheet and stated EBP was not care planned and staff must have forgotten to remove the sign. During an interview on 3/4/26 at 9:39 a.m., LPN-B stated R67 was on EBP due to a history of C. diff and R67 used nebulizers. Staff were expected to wear gowns, gloves and a mask if needed during any personal care. Any time staff were touching R67. During an interview on 3/4/26 at 1:45 p.m., NA-C stated she did not remove the soiled gloves after providing BM care to R67 and should have because you didn't want to get that stuff all over everything. NA-C stated she and NA-B should have followed the EBP and wore gowns and gloves as well. NA-C stated she didn't know R67 was on EBP and did not work in the unit often. During an interview on 3/5/26 at 4:34 p.m., LPN-A stated staff should have been wearing gowns and gloves. We might need to make that clearer, probably on the care sheet. R49: R49's quarterly MDS dated [DATE], identified R49 was cognitively impaired and had diagnoses including Alzheimer's disease, diabetes, urine retention, and indwelling foley catheter. R49 required staff assistance for catheter care. R49's care plan dated 11/17/25, identified R49 had an indwelling foley catheter and required staff assistance for transfers. Staff were required to wear personal protective equipment (PPE) including gowns and gloves for high contact resident care including transferring and urinary catheter care. On 3/3/26 at 2:59 p.m., NA-A was assisting R49 into the resident's room and stated she was going to help R49 into bed. NA-A placed R49's wheelchair parallel to the bed and put on a pair of gloves. NA-A was used hands on assistance to transfers R49 onto the bed. NA-A moved the wheelchair away from the bed and reached under R49's legs and lifted them onto R49's bed. NA-A gathered supplies and proceeded to empty R49's catheter bag. NA-A failed to wear a gown while transferring R49 to bed and while emptying R49's catheter. NA-A stated R49 was on enhanced barrier precautions (EBP) because the resident had a catheter, and staff were supposed to wear gowns and gloves during direct cares including while transferring the resident to/from bed and while emptying the resident's catheter. NA-A stated the gown, and gloves were to protect the residents from my germs and me/staff from spreading any of her germs to other residents. NA-A stated she failed to wear a gown during transferring and emptying R49's catheter. On 3/3/26 at 4:15 p.m., RN-A stated residents with wounds and/or catheters were placed on enhanced barrier precautions and staff were to wear gowns and gloves when completing high contact cares with the residents. The PPE was to help prevent the spread of infections to/from the residents/staff. On 3/4/26 at 4:34 p.m., LPN-A stated EBP was used when residents had an indwelling medical device, surgical wound, targeted multidrug-resistant organism (MDRO), or a healed surgical wound. On top of standard precautions staff were required to wear gowns and gloves when performing high contact cares including anytime staff encountered the resident or their belongings. High contact cares included combing hair, repositioning, cleaning, and transferring the resident. Staff knew when and why a resident was on EBP by seeing a sign on their door, a PPE cart outside their room, through shift-to-shift report and by reviewing the residents' care plan. The information should also be on the NA care sheets. LPN-A stated staff should have worn a gown and gloves when transferring R49 from the wheelchair to the bed and when completing catheter cares. On 3/5/26 at 2:40 p.m., the director of nursing (DON) stated EBP was used when a resident had an open wound, an indwelling medical device or a surgical wound. Staff were instructed to wear a gown and gloves with high contact care including transferring residents and catheter care. Staff should have worn a gown during R49's transfer and catheter care and staff should wash their hands and/or use hand sanitizer anytime they go from dirty to clean. TRANSMISSION BASED PRECAUTIONS: R16's quarterly MDS dated [DATE], identified R16 had moderate cognition and diagnoses included chronic kidney disease, adult failure to thrive, and dementia. R16's care plan updated 3/3/26, identified R16 tested positive for COVID-19 and was on airborne with contact precautions and staff were to wear gown, gloves, N95 respirator and eye protection when entering R16's room. R16's physician orders dated 3/3/26 at 5:00 p.m., identified a one-time lab order for a QUAD respiratory panel (a test to detect the most common pathogens for COVID-19, Influenza A, Influenza B and Respiratory Syncytial Virus (RSV)) due to nasal congestion. R16's progress note dated 3/3/06, at 6:09 p.m., identified staff were to monitor R16 for symptoms of nasal congestion. A QUAD respiratory panel had been ordered and was pending. Airborne/contact precautions initiated. R16's physician orders dated 3/13/26, identified R16 was to be on airborne with contact precautions due to COVID-19 infection. A time was not listed on the order. On 3/4/26 at 7:06 a.m., a sign was observed at the facility entrance identifying [NAME] unit was positive for COVID-19 (a contagious respiratory illness that can attack body systems including the lungs and respiratory system) and all visitors were to wear face masks. On 3/4/26 at 8:18 a.m., LPN-B stated R16 tested positive for COVID-19 when the provider was rounding at the facility in the afternoon on 3/3/26. LPN-B was uncertain of the exact time R16 was tested although thought it was before the evening meal. LPN-B stated she told staff she was going to place R16 in isolation but had not immediately done so. Later that evening, LPN-B observed R16 seated at a dining room table, along with two other residents, eating the evening meal. LPN-B stated ideally R16 should have been placed in airborne and contact precautions immediately after staff identified symptoms including nasal congestion. The facility failed to immediately place R16 on isolation precautions resulting in two other residents being exposed to COVID-19. On 3/5/26 at 2:29 p.m., RN-B stated he worked the evening shift on 3/3/26 and was notified R16 had stomach discomfort and was not feeling well. RN-B couldn't remember the exact time, but stated sometime after the evening meal, LPN-A told him R16 tested positive for COVID-19 and would be placed on airborne/contact precautions. RN-B stated he had not seen R16 the rest of the evening and was uncertain if or what time LPN-B had placed R16 in precautions. The facility Standard, Enhanced Barrier, and Transmission-Based Precautions policy dated 7/7/25, identified EBP expanded the use of personal protective equipment beyond situations in which exposure to blood and body fluids was anticipated and referred to the use of gown and gloves during high-contact resident care activities that provided opportunities for transfer of MDROs to staff hands and clothing. EBP was also used for residents with indwelling medical devices (i.e., indwelling urinary catheters), even if the resident was not known to be infected or colonized with an MDRO. High-contact resident care activities included transfers and indwelling medical device care. The policy further identified airborne isolation/precautions was used for illnesses including COVID-19 and staff were to wear PPE including N95, gown, gloves and eye protection when providing direct care to resident's positive for COVID-19.

Based on observation, interview and document review, the facility failed to ensure food service equipment used in 3 of 4 facility kitchenettes ([NAME], Strawberry and Elderberry) were kept in a clean and sanitary condition to prevent potential food-borne illness. This had the potential to affect 86 of 87 residents, visitors and staff who consumed food prepared in the kitchenettes. In addition, the facility failed to ensure frozen food items were stored in a manner to reduce the risk of cross contamination in 1 of 4 freezers (Strawberry Unit) used in the facility's kitchenettes. This had the potential to affect all 19 residents who resided on the Strawberry unit and could potentially consume the items. Findings include: On 3/3/26, at 11:28 a.m. lunch food service was observed on [NAME] wing. Dietary aide (DA)-A was serving residents their lunch meal. DA-A stated the unit currently had 13 residents as one resident was in the hospital. The stove and attached griddle in the unit appeared dirty. There was greasy appearance with charred food bits scattered around the burners and base of stove. A thick, dark, substance was built up on the sides of the splash guard of the griddle that separated the griddle and stove/burners. The griddle base appeared to have a thin layer of used greasy substance built up over the surface of the griddle. DA-A stated the stove, and griddle were used for breakfast, as each unit prepared the resident breakfast as well as needed per resident request for different food items. A tour of the facility's kitchenettes located in each of the four wings of the facility was conducted on 3/5/26, at 2:25 p.m. with the dietary manager (DM)-B.-On Strawberry unit, a gas cooking stove with an attached griddle was observed in the unit's kitchenette. The stove and griddle were used in the mornings when the dietary staff prepared resident breakfasts and as needed with individual resident requests. The stove top and between each of the four burners, had black thick and greasy appearance. The griddle area had greasy black buildup spattered over the splash guard. Lumps of dark black substances were visible in the grates of the stove between the burner areas. Grease and dark, thick, buildup was noted on all surfaces around the burners. The back splash of the stove had visible black and spattered greasy substance scattered over the surface. The sides of stove had drip marks and buildup visible. An upright freezer, located on Strawberry unit had a half full opened bag of cooked frozen pasta. Many of the pasta noodles in the open bag were coated with a thick layer of ice and the pasta bag was lying on the bottom shelf of the upright freezer with the top of the bag gaping open. The bag was clear and free of markings with nothing to indicate what was in the bag, expiration date or date it had been opened. Another clear bag was on the bottom shelf of the freezer with half used, open meat links, The bag lacked identifying information of what was in the bag, expiration date or date it had been opened. DM-B stated she thought it contained breakfast sausage links. -On [NAME] unit, a gas cooking stove with an attached griddle was observed in the unit's kitchenette. The stove and griddle were used in the mornings when the dietary staff prepared resident breakfasts and as needed with individual resident requests. The stove top and between each of the four burners, had black, thick and greasy appearing buildup. The griddle area had greasy buildup spattered over the splash guard. The back splash of the stove had visible spattered greasy substance scattered over the surface.-On Elderberry unit, a gas cooking stove with an attached griddle was observed in the unit's kitchenette. The stove and griddle were used in the mornings when the dietary staff prepared resident breakfasts and as needed with individual resident requests. The stove top and between each of the four burners had black, greasy appearing buildup. The griddle area had greasy buildup spattered over the splash guard. The back splash of the stove had visible spattered greasy substance scattered over the surface. Lumps of dark black substances were visible in the grates of the stove between the burner areas. Grease and dark, thick, buildup was noted on all surfaces around the burners. The back splash of the stove had visible black and spattered greasy substance scattered over the surface. When interviewed on 3/5/26, at 2:40 p.m. DM-B stated there was currently no cleaning schedule set up for maintenance cleaning of the equipment such as the stove. The facility currently used a daily cleaning schedule; however, it did not include to clean the stove top, griddle and splash guards. The stoves in the three units did need to be cleaned and was on her list of things to get completed. Food could be potentially contaminated when cooking on the unclean equipment. The grates on the stove could be removed and deep cleaned, and she would see the stoves in the kitchenettes were cleaned. DM-B stated it was important for staff to label and date the food in the freezer to know what the food was and when it could no longer be used and needed to be thrown out. DM-B removed both bags of food from the freezer on Strawberry unit and threw them into the garbage. DM-B stated there would be no way to tell how old the food was, when the suggested expiration date was or when it had been opened. The facility policy General Sanitation-Food and Nutrition dated 6/27/25, identified cleaning and sanitizing equipment surfaces was a two-step process. Surfaces were to be cleaned and rinsed before being sanitized. All food contact surfaces would be washed, rinsed and sanitized:a. After each use.b. When working with one kind of food to another.c. Any time there is an interruption during a task with the tools or items being used or with any that may have been contaminated.When cleaning fixed/immobile equipment such as mixers and slicers, removable parts would be washed and sanitized. Non-removable parts were to be cleaned with detergent and hot water, rinsed, air dried and sprayed with sanitizing solution at effective concentration, If any foodcontact surfaces were contaminated during reassembly, staff were to re-sanitize. The facility policy Food Supply Storage- Food and Nutrition dated 3/7/25, identified foods that had been opened or prepared were to be placed in an enclosed container, dated, labeled and stored properly.

Based on observation, interview and document review, the facility failed to ensure clinical justification and ensure non-pharmacological interventions were utilized prior to initiation of an antipsychotic for 1 of 6 (R6) residents reviewed for psychotropic medications. Findings include: R6's significant change Minimum Data Set (MDS) dated [DATE], identified R6 had severe cognitive impairment and was dependent on staff for all activities of daily living (ADLs). R6 had not exhibited any behavioral symptoms. Diagnoses included Alzheimer's disease, failure to thrive, pneumonia, diabetes and congestive heart failure. R6's Psychotropic Medication Use Care Area Summary (CAA) dated 1/27/26, identified R6 was taking antipsychotic medication. Staff monitored for adverse effect sides and effectiveness and target behaviors. R6's care plan with last review date 3/3/26, identified a potential problem related to psychotropic drug use with a goal for reduction of targe behaviors of wandering, exit seeking and inappropriate comments. A problem start date was listed as 1/24/26. Interventions included to administer the medication as ordered and monitor for side effects. Another problem dated 12/2/25 listed behavioral symptoms of making inappropriate comments to staff, attempts to leave facility and dementia and confusion to what was going on. Staff were directed to identify self when approaching, administer medications as ordered, re-orientate to three spheres as needed and monitor for side effects of medication. R6's most recent Physician Order Report dated 3/4/26, identified Seroquel (an antipsychotic medication to treat schizophrenia and bipolar) 25 milligrams (mg) to be given at bedtime related to dementia, psychotic disturbance, mood disturbance and anxiety with a start date of 1/6/26. R6's Point of Care monitored for behaviors of wandering, physical behavioral symptoms toward others, verbal behavioral symptoms toward others and rejection of care. Review of behavioral symptom documentation 12/1/25 to 2/28/26, identified two incidents of wandering, two incidents of physical behavioral symptoms toward others, three incidents of verbal behavioral symptoms toward others and one incident of rejection of care for the three-month period. On 3/3/26, at 9:37 a.m. R6 was observed lying in bed, dressed in hospital gown. Nursing assistants (NA)-B and NA-I entered R6's room with two unidentified nursing students and a mechanical lift. NA-B obtained a wash basin with warm water, and both aides assisted resident to wash and dress. R6 mumbled nonsensical words out loud but did not attempt to physically resist care and was unable to participate with dressing at all. The aides assisted R6 from bed to his wheelchair with the use of a mechanical lift. R6 made no attempt to participate or to resist care. NA-I stated R6 was always a mechanical lift as he was unable to stand. Staff assisted R6 out to the dining room. R6 was unable and made no attempt to propel his wheelchair. R6's Nursing Progress notes were reviewed 1/1/26 through 3/4/26. On 1/1/26 and 1/3/26 made attempts to leave facility which were easily redirected by staff. And on 1/2/26 and 1/3/26 R6 rejected care. R6's medical record was reviewed and lacked evidence a comprehensive assessment, to include medical justification, for the use of Seroquel was completed prior to the initiation of the medication. When interviewed on 3/3/26, at 4:54 p.m. NA-J stated she had worked with R6 and had never seen him restless or agitated but had heard he could be. R6 did not like to be changed so could be a little resistive with that but NA-J had never seen R6 wander or attempt to leave the facility. During interview on 3/3/26, at 4:59 p.m. registered nurse (RN)-C stated when R6 was first admitted to the facility in October, he would exit seek occasionally, but R6 was not wandering now. R6 had a decline in condition and was unable to wander. The medication Seroquel had been started about the same time of his decline in condition. RN-C stated she did not think the medication was helping with R6's lethargy and decline in condition. During interview on 3/4/26, at 10:45 a.m. NA-B stated R6 may have wandered a little when he first was admitted but did not do so now. R6 was unable to walk and had not been able to walk since a little before Christmas. R6 could be a little resistive with cares and had tried to hit out at staff but nothing that could not be handled. NA-B did not think R6 had bad behaviors at all. When interviewed on 3/4/26, at 10:50 a.m. licensed practical nurse (LPN)-B stated R6 had a hospitalization in early January and had not been able to walk after that. R6 had no wandering or behaviors after the hospitalization and LPN-B could not remember R6 ever having any hard to deal with behavior. LPN-B was not sure why Seroquel had been ordered for R6, but he did have some sundowning and would have exhibited more behaviors in the evenings or at night. During interview on 3/4/26, at 12:33 p.m. RN-C stated she could not remember why Seroquel had been started. R6 may have been a case where he came back from the hospital with the medication ordered and they had missed it or it may have been physician initiated. R6 was definitely someone they would be looking at to try to discontinue the medication. Right before R6 got sick and ended up in the hospital, he did exhibit significant behaviors of wandering and RN-C felt staff had not done a good job of documenting R6's behaviors when they had occurred. The medication Seroquel was definitely not appropriate for R6 now and they should be looking at that. Review of the physician progress notes identified the physician had dictated R6 was often up late at night, had difficulty getting to sleep and then sleeping during the day. RN-C stated there would be other options to try before prescribing an antipsychotic medication. RN-C did not believe any other options were attempted other than just starting the Seroquel. During interview on 3/5/26, at 4:45 p.m. the director of nursing (DON) stated a psychotropic medication would be added if there would be a danger to self or others or could be for an emotional outcome as well. R6 had been admitted to the facility in October 2025, and the Seroquel had been started on 1/6/26. The Seroquel was at a pretty low dose. Review of the physician note did identify the medication had been started for sleep. The provider would have been aware nothing else had been tried previously. Targeted behaviors and other things for sleep should have been implemented prior to starting the antipsychotic. The facility policy Psychotropic Medications dated 12/9/25, identified residents would be free from any chemical restraint imposed for the purposes of discipline or convenience and not required to treat the resident's medical symptoms. Based on a comprehensive assessment of a resident, the facility must ensure that residents who have not used psychotropic drugs were not given those drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. Before administration of non-emergency psychotropic medications, the following must be competed: a. documentation in the plan of care observations of mood, symptoms or behaviors that caused the resident distress and/or endangered the resident or others and response to interventions used. b. the behavior committee and or care plan team would ensure the care plan was updated and would reflect non-pharmacological interventions to be used and the physician and family would be notified of the change in condition. After reviewing the mood and behavior documentation, if the behavior committee and/or care plan team determined psychotropic medications necessary, the reduction committee must be notified. If the reduction committed determined initiating the medication was warranted, the committee nurse would ensure the physician was contacted with description of the behavior, attempted interventions and committee recommendations. Obtain an order for an appropriate medication, in an appropriate dose and corresponding diagnosis, as well as medical symptoms from the physician.

Based on observation, interview and document review, the facility failed to ensure a significant change in status assessment (SCSA) was completed within required timeframe to help facilitate timely person-centered care planning for 1 of 3 residents (R21) reviewed for Minimum Data Set (MDS) accuracy.Findings include:R21's quarterly Minimum Data Set (MDS) dated [DATE], identified R21 required setup or supervision with dressing and grooming and ambulation was not attempted due to safety. R21's Interdisciplinary Assessment form dated 9/12/25, identified walking was not attempted due to safety concerns. R21's progress note dated 9/21/25, quarterly MDS review, identified R21 was coded as not applicable on her quarterly MDS as R21 was non ambulatory at the time. R21's annual MDS dated [DATE], identified R21 was independent with upper and lower extremity dressing and grooming and ambulation was listed as not applicable. Diagnoses included Alzheimer's disease, and heart disease. R21's Interdisciplinary Assessment form dated 12/2/25, identified walking was not attempted. R21's care plan dated 12/17/25, identified a problem of self-care deficit related to Alzheimer's disease. A goal was listed to maintain ambulation ability. R21 was to ambulate with nursing staff to and from meals and bathroom with a full wheeled walker and assist with one. R21 was to maintain her current independence with dressing and staff were directed to provide assist of one with dressing morning and evening. R21's quarterly MDS dated [DATE], identified R21 required moderate assistance with upper extremity dressing and grooming, was dependent with lower extremity dressing and ambulation was listed as not applicable. Diagnoses included Alzheimer's disease, and heart disease. During interview on 3/5/26, at 11:05 a.m. registered nurse (RN)-F stated if a resident had a significant change she would be notified by the nurse managers as well as staff working with the resident. The facility required a significant change MDS if a resident had declined in two areas such as with ADL's or weight loss. RN-F reviewed R21's MDS and felt the February quarterly should have been a significant change MDS due to the new dependence with dressing and toileting. RN-F thought it had just gotten missed that the dependencies were new decline for R21.During interview on 3/5/26, at 4:30 p.m. the director of nursing (DON) stated a significant change MDS should have been completed if there was a decline in ADL abilities with a resident. The facility policy MDS 3.0 RAI (Resident Assessment Instrument)- Rehab/Skilled & Therapy and Rehab dated 10/27/25, identified the following procedures: Procedure: Significant Change MDS1. When a significant change is identified, the professional employee identifying the change would notify the social worker, RN coordinator or designated employee so that a timeline may be established and communicated to team members. The team member who identified the change would document in the progress notes - MDS that a significant change had occurred and would identify whether the change was an improvement or a decline and in what areas. The MDS/Care Plan Notification (GSS #278) would be routed to interdisciplinary team members to inform them of the significant change.The Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) 3.0 User's Manual, dated October 2025, indicated a significant change in status assessment (SCSA) was required when various criteria were met. The manual directed a significant change is a major decline or improvement in a resident's status that: would not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline was not considered self-limiting; Any decline in an ADL physical functioning area (e.g., self-care or mobility) (at least 1) where a resident is newly coded as partial/moderate assistance, substantial/maximal assistance, dependent, resident refused, or the activity was not attempted since last assessment and did not reflect normal fluctuations in that individual's functioning; - Resident's incontinence pattern changes or there was placement of an indwelling catheter; - Emergence of unplanned weight loss problem - Emergence of a new pressure ulcer at Stage 2 or higher, a new unstageable pressure ulcer/injury, a new deep tissue injury or worsening in pressure ulcer status; - Resident begins to use a restraint of any type when it was not used before; and/or - Emergence of a condition/disease in which a resident is judged to be unstable

Based on observation, interview, and document review, the facility failed to ensure foot pedals were removed from the wheelchair as directed by the care plan for 2 of 3 residents (R21, R6) reviewed for falls. Findings include:R63's admission Minimum Data Set (MDS) dated [DATE], identified R63 had a severe cognitive impairment and diagnoses that included dementia. R63 was at risk for falls.R63's care plan revised 3/2/26, identified R63 was at risk for falls due to weakness, cognition and history of falls. Interventions included footrest on wheelchair when transporting only. The untitled nurse aide care sheet undated, identified R67's footrests on wheelchair when transporting.During an observation on 3/3/26 at 9:03 a.m., nursing assistant (NA)-G assisted R63 with R63's morning cares.At 9:18 a.m., NA-G wheeled R63 to the dining room table. NA-G did not remove R63's footrests and walked away.At 11:14 a.m., R63 was seated in her wheelchair at the dining room table. R63 continued to have the footrests on and her feet were up against the table pedestal. During an interview on 3/3/26 at 11:47 a.m., NA-G stated she always left R63's footrests on and only takes the footrests off when R63 was transferred out of her wheelchair. NA-G stated she did this because staff would just take off with R63 and not put on the footrests. During an interview on 3/3/26 at 2:01 p.m., registered nurse (RN)-C stated R63's footrests should have been removed and placed into the bag on the back of R63's wheelchair. R63 was more likely to try to climb over the footrests and potentially fall.During an observation on 3/4/26 at 9:50 a.m., NA-H assisted R63 to the dining room. R63 was sitting in her wheelchair at the dining table with the footrests on and her feet up against the table pedestal. NA-H did not remove R63's footrests and left the dining room. There was no bag on the back of R63's wheelchair for the footrests.During an interview on 3/4/26 at 9:51 a.m., NA-H stated she did not know R63 well but did get R63 up that morning. NA-H stated she was unaware R63 should have the footrests only for transportation. NA-H then placed R63's feet on the floor and turned the footrests away from the front of R63 but left the footrests connected to the wheelchair. During an interview on 3/5/26 at 1:40 p.m., the director of nursing (DON) stated staff were expected to follow the resident care plans for the safety of all residents.A care plan policy was requested but not received.

Based on observation, interview, and document review, the facility failed to ensure routine personal hygiene cares (i.e.,toileting assistance and/or nail care) were offered and/or completed for 2 of 3 residents (R63, R46) reviewed for activities of daily living (ADLs) and whom were dependent on staff for such cares. Findings include: R63's admission Minimum Data Set (MDS) dated [DATE], identified R63 had a severe cognitive impairment and diagnoses that included dementia. R63 required supervision with eating, substantial assistance with oral hygiene, upper body dressing, and personal hygiene, and was dependent on staff for all other cares areas. R63's care plan revised 3/2/26, identified R63 had an alteration in urinary elimination due to incontinence. R63's toileting plan included: Toilet before/after meals and at bedtime. R63 was to bed checked for incontinence at night during repositioning. R63's goal was to have 1 or less episodes of urinary incontinence per day and 3 or less episodes of bowel incontinence per week. The untitled nurse aide care sheet undated, directed staff to toilet R63 when R63 gets up, after meals, and before bed. During an observation on 3/3/26 at 9:03 a.m., nursing assistant (NA)-G assisted R63 with her morning cares. R63 was incontinent of urine. NA-G did not offer toileting nor toileted R63. R63 was wheeled to the dining room for breakfast. At 11:26 a.m., R63 continued to sit at the dining room table. R63 had not been offered toileting. At 11:34 a.m., registered nurse (RN)-G assisted R63 into R63's room and stated NA-G would take R63 to the bathroom before lunch and left the room. At 11:36 a.m., NA-G brought R63 into the bathroom and transferred R63 onto the toilet using the sit-to-stand aid. R63 incontinence brief was wet with urine and R63 immediately voided when R63 sat down on the toilet. During an interview on 3/3/26 at 11:47 a.m., NA-G stated she did not toilet R63 when NA-G assisted R63 with morning cares and should have. During an interview on 3/3/26 at 1:52 p.m., RN-G stated residents were expected to be at least checked and changed every 2 hours or whatever was care planned. R63 was supposed to be toileted every 2-3 hours. During an interview on 3/3/26 at 2:01 p.m., RN-C stated R63 was more of a check and change and, if R63 was alert, R63 may sit on the toilet. Staff were expected to follow R63's care plan. During an interview on 3/5/26 at 1:40 p.m., the director of nursing (DON) stated staff were expected to follow the care plan for toileting. During an interview on 3/5/26 at 2:50 p.m., the administrator stated staff were expected to follow the care plan for toileting. R46: R46's annual MDS dated [DATE], identified R46 had moderate cognitive impairment and was dependent with dressing and toileting and required setup and supervision with grooming. Diagnoses included dementia, diabetes, and neurogenic bladder. R46's care plan dated 2/12/26, identified R46 had a self-care deficit related to weakness, history of cerebral vascular accident. Staff were directed to assist R46 with bathing. The care plan lacked any guidance or direction on fingernail care including what, if any, preference for length R10 had or how often they should be checked or clipped. On 3/4/26, at 1:58 p.m. R46 was observed seated in his wheelchair in his room with NA-F also present. R46's fingernails were long on both his hands extending a centimeter or more beyond his fingertips. R46 stated he knew his fingernails were very long and he preferred to keep his fingernails short. R46 stated he asked a staff member a few days previously if they would trim his fingernails for him. The staff had agreed to assist him with the task but never returned. NA-F stated he thought R46 was diabetic and so a nurse would have to trim his nails. It was the facility policy the aides were not allowed to trim finger or toenails of diabetic residents. NA-F stated he would find out and if able would make sure he came back later to trim R46's nails or ask the nurse to do so. On 3/5/26, at 5:28 p.m. R46 was again observed seated in his wheelchair in the dining room. R46 again stated his fingernails were very long. R46 stated no one had come to trim them for him. The staff member he had asked to trim them told him she would but then said she did not have time. During interview on 3/5/36, at 5:30 p.m. licensed practical nurse (LPN)-E stated diabetic residents nails were done by the nurses. LPN-E was not aware R46 had wanted his fingernails trimmed. Staff should have trimmed his nails when he had requested it or as soon as reasonably possible. LPN-E would check with R46 and try to trim his nails that evening. During interview on 3/5/26, at 5:33 p.m. the director of nursing (DON) stated staff should trim resident nails when it was requested. An activities of daily living (ADL) policy was requested but not received.

Based on observation, interview and document review, the facility failed to ambulate residents as directed for 1 of 1 resident (R21) reviewed for mobility decline.Findings include:R21's progress note dated 9/21/25, quarterly MDS review, identified R21 was coded as not applicable on her quarterly MDS as R21 was non ambulatory at the time. R21's Interdisciplinary Assessment form(s) identified:9/12/25, identified walking was not attempted due to safety concerns.12/2/25, identified walking was not attempted. R21's medical record lacked a comprehensive assessment to determine potential safety concerns or new interventions were needed.R21's care plan with revision date 12/17/25, identified a problem of self-care deficit related to Alzheimer's disease. A goal was listed to maintain ambulation ability. R21 was to ambulate with nursing staff to and from meals and bathroom with a full wheeled walker and assist of one. R21's quarterly Minimum Data Set (MDS) dated [DATE], identified R21 had severe cognitive impairment and required moderate assistance with upper extremity dressing and grooming, was dependent with lower extremity dressing and ambulation was listed as not applicable. Diagnoses included Alzheimer's disease, and heart disease. R21's undated nurse aide care plan sheet directed staff to assist R21 to ambulate to meals and bathroom each day.R21's point of care task completion sheet for February and March 2026, did not identify an ambulation task for R21 and ambulation had not been recorded as attempted or completed. On 3/4/26, at 7:25 a.m. R21 was observed wheeling herself in her wheelchair from her room to the dining room for the breakfast meal. Staff was observed in the dining room, however, made no attempt to stop R21 and offer to assist her to ambulate to the meal. During interview on 3/4/26, at 9:29 a.m. nursing assistant (NA)-F stated R21 was pretty independent and the staff just checked on her in the mornings to see that she was dressed appropriately and that she had toileted. NA-F just checked on her after breakfast and at end of his shift. Otherwise R21 was independent. When interviewed on 3/5/26, at 9:56 a.m. licensed practical nurse (LPN)-E stated R21 walked minimal distances. R21 was supposed to be walked to dine, and she knew the aides had tried a few days ago but by the time they had gotten around to R21, she was already at the dining room table waiting for her meal. LPN-E thought R21 was able to ambulate, but she had never seen her walk very far at all. LPN-A thought no one was asking R21 to walk and they should be asking her. LPN-A thought R21 was capable of walking though because she noticed when family took her out, they did not bring the wheelchair and only brought R21's walker with them. The last time LPN-A could remember seeing R21 ambulate was a few months ago. During interview on 3/5/26, at 10:16 a.m. NA-A stated she had checked with the charge nurse and staff were supposed to ask R21 to ambulate. NA-A had not asked R21 to walk for a long time, but she planned to try that after lunch.During interview on 3/5/26, at 11:05 a.m. registered nurse (RN)-F stated R21 must not have ambulated at all during the observation periods of the MDS when they were doing the look back. RN-F knew R21 did ambulate because when family took her out, they did so with the walker, but RN-F was not aware if R21 ambulated at the facility. The care plan directed staff to ambulate R21 to meals but was not an assigned task for the aides. The aides did not document ambulation at all for R21 as an error had been made and the task had not been assigned to them. On 3/5/26, at 11:18 a.m. NA-A approached R21 in her room and offered to assist R21 to ambulate to the dining room for lunch. R21 agreed and NA-A put a gait belt on R21 and assisted her to stand. R21 ambulated with wheeled walker, gait belt and assist of one with wheelchair following behind her to the dining room. R21 required frequent verbal prompts to direct ambulation for safety and moderate physical assistance but was able to ambulate to the dining room area with assistance. During interview on 3/5/26, at 4:30 p.m. the director of nursing (DON) stated if a task was care planned then it should be completed or at the minimum, offered to the resident. If staff were unable to get to an assigned task on their care sheet, they should let the charge nurse know. Anything on the aide care sheets needed to be completed. If the aides missed the opportunity to walk R21 to the dining room at mealtimes they should have offered it at other times throughout the day. There should be something in the chart to document the task, so the aides could record if offered and refused or completed or not completed. The DON was not sure if that was something they had just missed for R21. The facility policy Restorative- Nursing Care Implementation and Screening dated 12/8/25, identified each resident would receive restorative nursing care to the extent possible, based on individual strengths, needs and problems as defined in nursing assessments. The restorative care would be outlined in the resident's nursing care plan. Residents would be provided appropriate treatment and services to attain/maintainfunctional abilities in activities of daily living. Any resident who was unable to carry out independent activities of daily living would receive necessary services to prevent further diminishing of independent abilities in bathing, dressing/undressing, grooming, transfer and ambulation, toileting, eating and use of speech, language or other functional communication systems.

Based on observation, interview and document review, the facility failed to ensure residents with side rails were comprehensively assessed prior to use/and or reassessed for appropriate continued use for 2 of 3 residents (R6, R63) reviewed who had side rails. Findings include: R6: R6's significant change Minimum Data Set (MDS) dated [DATE], identified R6 had severe cognitive impairment and was dependent on staff for all activities of daily living (ADLs). R6 had not exhibited any behavioral symptoms. Diagnoses included Alzheimer's disease, failure to thrive, pneumonia, diabetes and congestive heart failure. The MDS identified side rails or restraints were not in use. R6's care plan dated 3/3/26, identified R6 had a self-care deficit due to weakness. Staff were directed to assist R6 to turn and reposition and use of bilateral upper bed rails to assist. R6 required use of side rails to assist with mobility and repositioning with a goal R6 would remain free from injury associated with side rail use. Staff were directed to assess R6's need for side rails with changes in condition and annually, educate resident and family regarding risks and benefits of side rail use and ensure side rails were used only for medically necessary purposes such as positioning and bed mobility. R6's medical record lacked a consent for bed rails and an assessment to determine if R6 was able to use a side rail to assist with his mobility: including but not limited to what alternatives were provided before installing bed rails and ensure the assessment included medical diagnoses, conditions, symptoms, size and weight, sleep habits, medications, underlying medical conditions, cognition, communication, risk of falling and mobility along with risk versus benefits of use. On 3/3/26, at 9:37 a.m. R6 was observed lying in bed, dressed in hospital gown. 1/4 length side rails were located on each side of the bed. R6's bed was in low position to the floor, and a cushioned mat lie on the floor next to the bed. The bed was positioned against the wall. Nursing assistants (NA)-B and NA-I entered R6's room with two unidentified nursing students and a mechanical lift. NA-B obtained a wash basin with warm water, and both aides assisted resident to wash and dress. R6 was observed to mumble nonsensical words out loud but did not attempt to physically resist care and was unable to participate with dressing at all. The nursing assistants did not prompt R6 to grab the side rails on the bed or attempt to place his hands onto the side rails to encourage him to assist with rolling onto his side to wash and dress. NA-B stated R6 did not use the bed side rails to turn and often would push against the side rails when staff were rolling him to his side, interfering with cares. NA-I stated she thought the side rails were on each side of the bed for R6's safety and to keep him from falling out of the bed. The aides assisted R6 from bed to his wheelchair with the use of a mechanical lift and brought him out to the dining room. When interviewed on 3/4/26, at 2:30 p.m. licensed practical nurse (LPN)-F stated if a patient did not have, want or need side rails, a side rail assessment would not be completed. When residents did have or need side rails then an assessment would be done by nursing. During interview on 3/4/26, at 4:55 p.m. registered nurse (RN)-C stated one of the past directors of nursing (DON) had the staff stop doing side rail assessments, claiming they were not needed, but they had started doing the consent forms again. Generally, RN-C printed out a consent for resident or family to sign, and the consent identified what the side rails were needed for, such as positioning and things like that. The facility did not use an actual assessment form to assess resident side rail use or to ensure they were not being used as a restraint. When R6 was first admitted to the facility he had been able to use the side rails to assist with positioning, but he would never be able to use the side rails now. R6 should have been re-evaluated for side rail use when a significant change MDS had been completed, but that had not been done. During interview on 3/5/26, at 4:45 p.m. the DON stated the use of side rails was to be addressed with annual, quarterly and significant change MDS assessments. R6's use of side rails on the bed should have been reassessed when his significant change MDS had been completed. Side rail assessments should be done on admission and with significant change in condition and only be used if benefitting the resident for independence. R63: R63's admission MDS dated [DATE], identified R63 had a severe cognitive impairment and diagnoses that included dementia. R63 required supervision with eating, substantial assistance with oral hygiene, upper body dressing, and personal hygiene, and was dependent on staff for all other cares areas. The MDS identified R63 did not use a restraint and did not use bed rails. R67's Side Rails Assessment and Consent 1 dated 2/14/26, identified R63 used side rails for boundary limitations and family request. R63 used the top half side rails on each side all the time. Benefits included: Aiding in turning/sitting/repositioning within the bed. *Providing a handhold for getting into or out of bed; Providing a feeling of comfort and security. *Reducing risk of a resident falling from bed when transported or when resting, Providing easy access to bed controls, call bells, light cords, and personal items. Potential Risks included: Strangling, suffocating, bodily injury or death when a resident or part of their body is caught between the spaces in the rail or between the bed or mattress and the rail; More serious injuries from falls when resident climbs over a rail or bar; Skin bruising, lacerations, tears, and abrasions when body parts bump against rail; and Feeling isolated or unnecessarily restricted. Preventing R63 from exiting a bed. The assessment failed to identify alternatives tried and failed before the installation of the bed rail and include resident specific information. R63's care plan revised 3/2/26, failed to identify R63's side rails. During an observation on 3/3/26 at 9:03 a.m., NA-G assisted R63 with morning cares. At 9:04 a.m., NA-G rolled R63 to her left side using R63's drawsheet, then removed R63's incontinent brief. NA-G did not tell R63 to use the side rails nor placed R63's hand on the side rails. R63 did not use the side rails nor participate in the task. At 9:06 a.m., NA-G rolled R63 to her back. R63 did not participate nor used the side rails At 9:08 a.m., NA-G rolled R63 to her right side. NA-G did not tell R63 to use the side rails nor placed R63's hand on the side rails. R63 did not use the side rails nor participate in the task. During an interview on 3/3/26 at 9:14 a.m., NA-G stated R63 used the side rails sometimes. Staff would just tell R63 to grab ahold of the side rails and R63 just did it. NA-G stated she didn't tell R63 to use the side rails because NA-G just rolled R63. NA-G stated sometimes R63 would understand and sometimes she wouldn't, but NA-G should have encouraged R63 to use the side rails. During an interview on 3/3/26 at 2:01 p.m., registered nurse (RN)-C stated when R63 was admitted , R63 was using the side rails to assist with bed mobility but needed to be reassessed due to declining since admission. Boundary limitations should never be used, and family requests still should show R63 was able to use the device. Staff were expected to report residents who required total dependence on staff and not using the side rails so it could be removed. During an interview on 3/4/26 at 9:51 a.m., NA-H stated she just took the drawsheet and just kind of turned R63. R63 didn't really participate, and NA-H did most of the work. R63 did understand verbal cues but just kind of laid there. During an interview on 3/4/26 at 10:39 a.m., RN-E stated R63 was admitted to the facility for physical therapy. R63 was very weak and lethargic. R63 did not use the side rails for bed mobility. It was a boundary limitation for R63 because R63 tried to get out of bed. RN-E spoke with R63's family and they were adamant R63 had side rails for safety. RN-E stated a device to keep a resident in bed was a restraint. RN-E stated she educated R63's family and they signed the consent for siderails for boundary limitations. That's what the facility did when a resident's family insisted on side rails. During an interview on 3/5/26 at 1:40 p.m., the director of nursing (DON) stated R63's side rail assessment should not say boundary limitations. Side rails were to be used only to assist with bed mobility. Family should be educated regarding the risks of using a side rail because that would be a restraint. R63's side rails were ¾ rails, so they were unable to keep R63 in bed. R63 should be reassessed to determine if side rails were a safe intervention for R63 because side rails were supposed to help keep R63's independence. During an interview on 3/5/26 at 2:50 p.m., the administrator stated staff were expected to comprehensively assess side rails to ensure resident safety. A side rail policy was requested but not received.

Based on observation, interview, and document review, the facility failed to ensure care planned fall interventions were implemented for 1 of 3 residents (R1) reviewed for falls. This resulted in actual harm for R1 who fell and sustained a fracture requiring surgical repair. The facility implemented corrective action prior to the start of survey, and this is issued in past noncompliance. R1's Resident Face Sheet indicated she was admitted to the facility on [DATE] and re-admitted , following hospitalization, on 11/13/25. R1's diagnosis included displaced fracture of right femur. Alzheimer's disease, dementia, history of sacral fracture and failure to thrive. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated she was independent with bed mobility, sit to stand and required supervision for ambulation. R1's significant change MDS dated [DATE], indicated she was dependent for bed mobility, transfers, and indicated ambulation not attempted due to medical condition. R1's care plan dated 11/3/25, identified a risk for falls related to a history of falls, balance deficit and cognitive deficits. Care planned interventions dated 6/6/23, included bed at transfer height, hourly purposeful rounding, footrests for transportation and while at dining table. The care plan further identified cognitive loss/dementia as exhibited by confusion and forgetfulness. R1's Fall Risk Observation dated 11/5/25, indicated diminished safety awareness and indicated she required the use of assistive devices. The observation identified a high risk for falls. Fall Scene Huddle Worksheet dated 11/11/25, indicated at 7:30 a.m., R1 had an unwitnessed fall in the hallway. The worksheet indicated R1 had foot pedals on the chair and indicated possibly tripped on wheelchair or barrier from flood. R1's Hospital admission History and Physical dated 11/11/25, indicated fall with hip fracture. Will proceed with surgery. R1 had a fall at the nursing home. Obvious hip deformity noted. Found to have right femoral fracture. R1's Resident Progress Notes identified the following: 11/11/25, Writer came on shift and R1 was in her wheelchair sitting next to the storage cove. R1 had foot pedals on her wheelchair and a blanket wrapped around her that overnight staff had placed. R1 did not have hip protectors on. Writer was in the dining room administering medications and nursing assistants (NA)'s were in other resident rooms when writer heard a yell and a crash. Staff arrived to find R1 laying on the floor against a plastic barrier on her right side. Upon assessment R1 was very uncomfortable and would not allow writer to lift right leg. R1 was sent to the ED. 11/13/25, R1 was admitted to the hospital post fall and underwent a right hip nailing (a surgical procedure used to repair a broken hip by placing a metal rid or nail inside the center of the broken thigh bone (femur). During observation on 12/9/25 at 9:26 a.m., R1 was lying on her back in bed and appeared to be asleep. R1 did not respond to knock on her door. During interview on 12/5/25 at 3:59 p.m., licensed practical nurse (LPN)-A stated R1 had dementia and had a fall history. LPN- A stated prior to her fall, R1 was always attempting to walk independently but was not steady at all. LPN-A stated R1 was not directable and had recently been trying to get out of her chair again. During interview on 12/5/25 at 4:03 p.m., registered nurse (RN)-A stated R1 self-transferred a lot from her wheelchair, so staff frequently checked on her. RN-A stated prior to her recent fall, R1 was able to stand up and walked by herself but required staff supervision. During interview on 12/9/25 at 9:36 a.m., trained medication aide (TMA)-A stated R1 used to ambulate on her own, staff would assist R1 into a chair, then she would get antsy and would get up and start walking. TMA-A stated sometimes it meant R1 needed to use the bathroom and said if staff saw R1 ambulating they would walk with her then put her back in her wheelchair or in a recliner. When R1 fell, she had foot pedals on her wheelchair and should not have. The foot pedals should have been used only when transporting her in her wheelchair. TMA-A stated the pedals may have contributed to her fall. During interview on 12/9/25 at 10:46 a.m., nursing assistant (NA)-A stated the day R1 fell, she and another staff were in another resident room and heard the nurse call for help. NA-A said when she came out of the room, R1 was on the floor, leaning against a plastic barrier. NA-A said prior to the fall R1 had been seated in her wheelchair next to the plastic barrier because the overnight staff had gotten her out of bed and dressed for the day. NA-A stated because R1 would attempt to stand up out of her wheelchair, R1 should not have had the foot pedals on her chair. During interview on 12/9/25 at 10:15 a.m., RN-B stated the day R1 fell, she received a call from staff about the fall. When RN-B went to the unit, R1 had already been placed back into her wheelchair. RN-B said foot pedals should been removed when not transporting R1. During interview on 12/9/25 at 11:52 a.m., the director of nursing (DON) reviewed the care plan and acknowledged R1 should not have had foot pedals on the wheelchair when she was seated in a common area. Facility policy Care Plan dated 12/1/25, indicated residents will receive and be provided with the necessary care and services to attain or maintain the highest practicable well-being in accordance with the comprehensive assessment. The noncompliance that began on 11/11/25 was corrected prior to the start of survey when the facility implemented a corrective action plan on 11/12/25. Actions taken included education related to the importance of following the care plan and initiated care plan audits for residents at risk for falls. The education and audits were verified through interview and document review. The facility was able to demonstrate monitoring of the corrective action and sustained compliance.

Based on observation, interview and document review the facility failed to ensure 1 of 3 residents (R1) reviewed for use of electric wheelchairs in the community was free from involuntary seclusion. This resulted in actual psychosocial harm for R1 when the facility took away her personal mobile equipment (power wheelchair), which restricted R1's access to her community (including family), causing increased depressive symptoms, isolation and withdrawal from usual activities. Findings include: R1's admission Record indicated she admitted to the facility on [DATE]. Diagnosis included diabetes, arthritis, right above the knee amputation, post-traumatic stress disorder, depression and anxiety. R1's significant change Minimum Data Set (MDS) dated [DATE], identified intact cognition and indicated she displayed no behaviors during the assessment period. The MDS indicated R1 was independent with transfers. 4/8/25, PHQ-9 (patient health questionnaire) assessment (a self-report tool used to assess the severity of depression) score was 11 which indicated moderate depression. 6/27/25, PHQ-9 score was 16 which indicated moderate to moderately severe depression. R1's care plan dated 5/9/25, indicated she had a history of utilizing her motorized wheelchair off campus. The care plan identified the following approaches:1. R1 will notify staff when leaving facility and expected return time.2. R1 will utilize safety features when using wheelchair: Flag, seat belt, horn, reflectors.3. Staff to assist R1 to get in wheelchair.4. Staff to assist R1 in charging wheelchair.5. R1 will not leave facility without battery fully charged.6. If Resident had a change in condition facility would reevaluate R1's ability to safely operate wheelchair.7. R1 will operate wheelchair in low speed only.8. If R1 utilized wheelchair in an unsafe or reckless manor or under the influence of any alcohol or non-prescription drugs the facility had ability to prohibit the use of the wheelchair in facility and campus. R1's Progress Notes indicated the following:-4/30/25, Occupation therapy note: R1 received her power wheelchair this date and demonstrated ability to transfer from manual chair to power chair, power chair to toilet and power chair to bed. R1 demonstrated appropriate use of controls. At this time R1 was instructed to keep the speed set at level one. R1 demonstrated ability to maneuver the wheelchair in her room, bathroom, up to table, in hallway, on/off elevator and with use of elevator controls. R1 used dressing stick to aid with getting the leg rest out of the way. R1 had a sensor system on the wheelchair which alerted her if she came too close to an object (due her limited neck range of motion). Plan to further assess R1 outdoors, R1 was instructed to only use the power wheelchair indoors at this time, until outdoor assessment and recommendations could be completed. -5/8/25. R1 told staff that she had a dentist appointment and she was planning on taking her wheelchair over so staff could cancel Medivan. Staff did not have appointment on the calendar for R1 and therefore no Medivan was set up. R1 was informed of this and that she had not been assessed to take her wheelchair outside of the facility. Resident then went down to therapy to ask about this. Administrator, therapy staff and writer attempted to talk to R1 about concerns and safety of crossing a busy highway with a new chair. R1 stated that she didn't have battery issues, and it was a new wheelchair so there should be no issues. She was informed that there still could be issues. Staff also brought up concerns about the lack of shoulder on the road and how she would deal with it if she got herself in a position where she tipped the wheelchair. Resident again stated she didn't think that would happen as she wasn't stupid and would not get herself in that situation. Staff attempted to explain to resident that we had concerns for safety. She stated she had taken it to the store the previous day and didn't have issues. When asked what store she just stated, the store. R1 felt the facility was just trying to be controlling. Resident did relent to taking Medivan to appointment, but later facility received a call from Medivan that she had not stayed for pickup. R1 was already back at the facility at that time. Therapy has now said that R1 was safe outside of building on facility grounds. -5/9/24, Writer and registered nurse (RN)-A reviewed R1's care plan with her regarding use of electric chair. It was read to her, she signed care plan and stated she understood what was read to her. -5/13/25, R1 left at 1:00 p.m. for appointment via Medivan to go to behavior health and had not returned. Attempted to call personal cell phone. R1 did not answer and voicemail was full. -5/13/25, Writer received call from unit nurse at 7:00 p.m. reporting that R1 had not returned from 1:00 p.m. appointment. Nurse reported R1 took Medivan to her appointment with her electric wheelchair and stated there was no indication or communication that R1 was going elsewhere after her appointment. Directed staff to attempt to reach R1 via number listed on her face sheet. Arrived at facility, confirmed R1 was not on the campus, confirmed location of her appointment, and called police department. A different staff member called to report R1 was spotted in town south of the facility and that R1 reported to staff she was headed back to facility. R1 returned to facility at 8:30 pm and reported no concerns to unit staff.5/14/25, While R1 was out of the building for a procedure, management team discussed issues they were having with R1. Since receiving her electric scooter, R1 had been leaving the facility without letting staff know and had left an appointment before transportation arrived to pick her up. The previous day R1 had not returned after an appointment. Staff had located her, and she did return. After reviewing it was decided to remove R1's electric scooter. -5/14/25, R1 returned from appointment and went to her room. R1 came out of her room crying, stated she was leaving and told staff they could throw away all of her stuff. -5/14/25, at approximately 12:15 p.m. R1 had gone to the therapy room and accused them of having her scooter They let her know they didn't have it. She talked with her therapist and requested a meeting. Administrator, director of nursing (DON) and social worker met with R1 who was demanding to leave against medical advice (AMA). R1 wanted her scooter and wanted to go out when she wanted. Staff tried multiple times and ways to go over safety concerns, but she refused to listen. R1 left the room stating she was leaving. R1 wheeled down the driveway toward the street. The administrator stayed with her. After a few minutes R1 returned to the building. Facility had staff sitting and watching R1's door so staff would know if she came out of her room. -5/15/25, R1 left her room and went to the elevator. Nurse on the unit asked to ride with her and said R1 would not speak to her. Writer went to the lower floor and R1 was going outside so activity director (AD) was asked to follow R1 who went to the cookie food truck in the parking lot. R1 was talking to people outside who were identified as R1's family. When R1 saw the AD, she asked if she was spying on her. 5/20/25- IDT weekly review: R1 had been approved for electric scooter but then was non-complaint with guidelines for leaving facility. R1 was aware she was to come back after appointments and not cancel transportation. She twice did not return in a timely manner, nor did she let staff know she wasn't returning. R1 had stayed in her room most of time since placed back in regular wheelchair but had gone to appointments and returned without issues. R1's Outpatient Supportive and Palliative Care Progress Note dated 6/25/25, indicated R1's priority was making sure her kids were safe and increase her independence. If she saw her kids, she had hope and drive to become independent. When she didn't see her kids, she became depressed, hopeless and lost her drive to improve. The note indicated there was conflict at the facility currently and it caused R1 much emotional distress, depression and anger. R1 had thought if becoming homeless would be a better option since she would have freedom. R1 confirmed she was not currently planning to leave the facility AMA, she just feels desperate and hopeless and thinks about it because she feels she has no other options. R1 was not suicidal but had a serious mental health history and there was concern about her current state of her mental health with the increasing stress of the situation. During interview on 7/1/25 at 10:44 a.m., the interim DON stated he had only been at the facility for three weeks and said he was familiar with the situation. The DON said R1 was appropriate for independent living with services and the facility was actively working on it. In regard to the removal of R1's power chair, the DON said he would rather have a rights violation than have her out overdosing or getting hit by a bus. During observation and interview on 7/1/25 at 11:08 a.m., R1 was lying in bed watching television. There was a manual wheelchair next to her bed. R1 said the facility had taken her scooter away on May 15th while she was out of the facility for a medical procedure. R1 said she had gone to visit her kids and had taken the bus there and drove her wheelchair back to the facility. R1 said she used the cross walks, pushed the buttons and did everything safe the way she should have. R1 said the facility told her they had taken her chair away because she hadn't signed out. R1 said she had not had any accidents with the scooter and said she had passed the facility driving test. During interview on 7/1/25 at 1:52 p.m., occupational therapist (OT)-A stated they had pursued getting R1 the power chair because she had so many problems getting around in the manual chair outside the facility. OT-A said R1 was assessed as safe to use the power chair and was able to use the controls, navigate, make turns and move around stationary objects. OT-A said they did not assess specifically for safety in the community but said R1's chair had a flag, lights and if she got too close to an object her chair would vibrate. OT-A said R1 did quite well and said she thought R1 would do okay in the community. During interview on 7/1/25 at 2:05 p.m., NA-A and NA-B were interviewed. NA-B said he was working the day R1's chair had been taken away. NA-B said he had seen R1 out the window in the manual wheelchair, outside, and R1 was allegedly leaving the premises. NA-B said he was asked to stay late that day to be a sitter because they were worried she would elope. NA-B said R1 told him she felt her wheelchair had been wrongfully taken away. NA-B said he had noticed R1 was secluding herself more and said she used to come out and initiate her needs. NA-A said R1 used to come out to meals and had not been coming out since the chair was taken away. NA-A said R1 indicated she felt more isolated. During interview on 7/1/25 at 2:10 p.m., licensed social worker (LSW)-A stated R1 had been using her power chair to go to appointments and said she had been evaluated by therapy. LSW-A said R1 was upset about not having her chair and said she could tell R1 was more withdrawn. LSW-A said, it was a nice piece of independence for her and said she had noticed R1 had not been coming out of her room.During interview on 7/1/25 at 2:23 p.m., the social services coordinator said she had completed the PHQ-9 assessment for R1 and said the most recent one was focused on R1 not having her power chair. During interview on 7/1/25 at 2:38 p.m., RN-B stated the decision to take R1's chair away had been made by the administrator, DON and corporate staff and it was taken away because R1 had gone to an appointment and had not return after. RN-B said R1 was not happy about it. RN-B said R1 was not cognitively impaired and had been assessed as safe to use the chair in the facility and on the grounds. During interview on 7/1/25 at 2:56 p.m., the administrator stated R1 had gone through the process of getting the power chair and in mid-May she was planning to go across the street for a dentist appointment. The administrator said they did not feel it was safe and R1 agreed to take the Medivan but when the van went back to pick R1 up she had already left. The administrator said the next incident was when R1 had gone to see her kids and had driven back to the facility in the chair. The administrator said at that point the interdisciplinary team met with corporate leadership and they felt R1 was not making safe decisions. When asked about less restrictive alternatives, the administrator said she felt R1 had the ability to be as independent in a manual chair as she was in the power chair but said with the power chair she could go further away. In regard to the sitter outside R1's door, the administrator said they were afraid R1 would leave AMA. The administrator acknowledged R1 was her own decision maker and could leave the facility if she wanted to. The administrator said she aware R1 was very upset. During interview on 7/1/25 at 3:56 p.m., the DON stated he knew the chair had been taken away after R1 did not return from an appointment and a second incident when staff had to convince her not to leave. The DON acknowledged R1 had tried to leave because they took her chair. The DON said there was no question of R1's ability to operate the chair appropriately, and said the problem was more about her not communicating where she was going to be. The DON said there was a concern about her history of drug use and the prevalence in this area but said he was not aware of any drug use while at the facility. When asked about less restrictive alternatives, the DON said R1 was still able to have the same independence in the manual chair as she had in the power chair, but she covered more distance in the power chair. During interview on 7/2/25 at 12:22 p.m., mental health practitioner (P)-A stated R1 had a delicate mental health balance and had been sober for quite a while. P-A said R1 suffered from depression and said when she last saw R1 she could see it all over her that something really bad was happening. P-A said R1 was not currently suicidal but said it could happen if her back continued to be up against the wall. P-A said R1 had felt her only option was to leave AMA and become homeless. During interview on 7/2/25 at 11:28 a.m., the administrator said she had no reason to believe R1 would go out into the community to seek illegal substances. Facility policy Restraints dated 10/29/24, indicated residents were free from any physical or chemical restraint imposed for the purpose of discipline or convenience and not required to treat the residents' medical condition. Convenience was described as any action taken by the location to control a residents' behaviors or manage a resident's behavior with a lesser amount of effort by the location and not in the resident's best interest.

Based on observation, interview and document review the facility failed to ensure respect and dignity for 1 of 3 residents (R1) reviewed when her personal power chair was removed from her room and use without her consent. Findings include: R1's admission Record indicated she admitted to the facility on [DATE]. Diagnosis included diabetes, arthritis, right above the knee amputation, post-traumatic stress disorder, depression and anxiety. R1's significant change Minimum Data Set (MDS) dated [DATE], identified intact cognition and indicated she displayed no behaviors during the assessment period. The MDS indicated R1 was independent with dressing, personal hygiene and transfers and did not ambulate. R1's care plan dated 5/9/25, indicated she had a history of utilizing her motorized wheelchair off campus. The care plan identified the following approaches: 1. R1 will notify staff when leaving facility and expected return time. 2. R1 will utilize safety features when using wheelchair: Flag, seat belt, horn , reflectors. 3. Staff to assist R1 to get in wheelchair. 4. Staff to assist R1 in charging wheelchair. 5. R1 will not leave facility without battery fully charged. 6. If Resident had a change in condition facility would reevaluate R1's ability to safely operate wheelchair. 7. R1 will operate wheelchair in low speed only. 8. If R1 utilized wheelchair in an unsafe or reckless manor or under the influence of any alcohol or non-prescription drugs the facility had ability to prohibit the use of the wheelchair in facility and campus.R1's Progress Notes indicated the following:-5/8/25, R1 told staff that she had a dentist appointment and she was planning on taking her wheelchair over so staff could cancel Medivan. Staff did not have appointment on the calendar for R1 and therefore no medivan had been set up. R1 was informed of this and that she had not been assessed to take her wheelchair outside of the facility. R1 went to therapy to ask about it and administrator, therapy staff and writer attempted to talk to R1 about concerns and safety of crossing a busy highway with a new chair. R1 stated that she didn't have battery issues and it was a new wheelchair so there should be no issues. She was informed that there still could be issues. Staff also brought up concerns about the lack of shoulder on the road and how she would deal with it if she got herself in a position where she tipped the wheel chair. Resident again stated she didn't think that would happen as she wasn't stupid and would not get herself in that situation. Staff attempted to explain to R1 that we had concerns for safety. She stated she had taken it to the store the previous day and didn't have issues. When asked what store she just stated, the store. R1 felt that staff was just trying to be controlling. R1 did relent to taking medivan to appointment but staff received a call from Medivan that she had not stayed for pickup. R1 was already back at the facility at that time. Therapy has now said that R1 was safe outside of building on facility grounds.5/13/25, Writer received a call from unit nurse at 7:00 p.m. reporting that R1 had not returned from 1:00 p.m. appointment. Nurse reported R1 took medivan to appointment with her electric wheelchair and stated there was no indication or communication that she was going elsewhere after her appointment. Directed staff to attempt to reach R1 via number listed on her face sheet. Writer arrived at facility, confirmed R1 was not on the campus, confirmed location of her appointment, and called police department. A different staff member called to report resident was spotted in town south of facility and that resident reported to staff she was headed back to facility. 5/14/25, While R1 was out of the building for a procedure, management team discussed issues they were having with R1. Since receiving her electric scooter, R1 had been leaving the facility without letting staff know and had left appointment before transportation arrived to pick her up. The previous day R1 had not returned after an appointment. Staff had located her and she did return. After review it was decided to remove R1's electric scooter. During interview on 7/1/25 at 10:44 a.m., the interim DON stated he had only been at the facility for three weeks and said he was familiar with the situation. The DON said R1 was appropriate for independent living with services and the facility was actively working on it. In regard to the removal of R1's power chair, the DON said he would rather have a rights violation than have her out over dosing or getting hit by a bus. During observation and interview on 7/1/25 at 11:08 a.m., R1 was lying in bed watching television. There was a manual wheelchair next to her bed. R1 said the facility had taken her scooter away on May 15th while she was out of the facility for a medical procedure. R1 said she had gone to visit her kids and had taken the bus there and took her wheelchair back to the facility. R1 said she used the cross walks, pushed the buttons and did everything safe the way she should have. R1 said the facility told her they took her chair away because she hadn't signed out. R1 said she had not had any accidents with the scooter and said she had passed the facility driving test. During interview on 7/1/25 at 2:38 p.m., RN-B stated the previous DON, administrator and corporate staff made the decision to take R1's chair away and said R1 was not happy about it. RN-B said the chair was taken away because R1 went to an appointment and took the bus somewhere after and used her wheelchair for transport and no one knew where she was. RN-B said R1 had intact cognition and had been assessed safe to use the power chair in the facility and outside on the grounds. RN-B said R1 was her own decision maker. RN-B said R1 did not follow the rules of signing out and the facility was responsible for her when she left the facility so she was considered an elopement risk. During interview on 7/1/25 at 2:56 p.m., the administrator said the day R1 did not return immediately after her appointment she had received a call that R1 had not returned and did not answer her phone. She said minutes later she got another call that R1 was seen driving back to the facility in her chair. The administrator said the next morning they met as a team along with the corporate administrator and they determined she was not making safe decisions so the chair was taken away. The administrator said she aware R1 was very upset. During interview on 7/1/25 at 3:56 p.m., the DON stated he knew the chair had been taken away after R1 did not return from an appointment and a second incident when staff had to convince her not to leave. The DON acknowledged R1 had tried to leave because they took her chair. The DON said there was no question of R1's ability to operate the chair appropriately but more about her not communicating where she was going to be. The DON said there was a concern about her history of drug use and the prevalence in this area but said he was not aware of any drug use while at the facility. When asked about less restrictive alternatives, the DON said R1 was still able to have the same independence in the manual chair as she had in the power chair but she covered more distance in the power chair.A resident rights policy was requested but not received.

Based on observation, interview and document review the facility failed to ensure cleaning of shared glucometers between patient use for 3 of 3 residents (R3, R4, R5) reviewed for infection control. Findings include: R4's Resident Face Sheet included a diagnosis of diabetes mellitus (DM) and long-term use of insulin. R4's Physician Order Report dated 4/4/25, identified an order for blood glucose monitoring before meals and at bedtime. R4's Vitals Report identified a blood glucose check was done 4/4/25 at 12:20 p.m. R3's Resident Face Sheet included a diagnosis of DMII. R3's Physician Order Report dated 4/4/25, identified an order for blood glucose monitoring four times a day and as needed. R4's Vitals Report identified a blood glucose check was done 4/4/25 at 11:54 a.m. R5's Resident Face Sheet included a diagnosis of DMII and long-term use of insulin. R5's Physician Order Report dated 4/4/25, identified an order for blood glucose monitoring before meals and at bedtime. R4's Vitals Report identified a blood glucose check was done 4/4/25 at 12:04 p.m. During observation on 4/4/25 at 11:52 a.m., registered nurse (RN)-A used a glucometer and checked R5's blood sugar in the dining room. RN-A then returned to the medication cart. No disinfectant wipes were observed on the medication cart. At 12:00 p.m., RN-A walked down the hall to R6's room with a glucometer in his hand. When RN-A returned to the medication cart, the glucometer was not in his hand. At 12:16 p.m. RN-A went to R4's room with a glucometer. RN-A returned to the medication cart and pulled two glucometers from his pocket and placed them on the medication cart. During interview on 4/4/25 at 12:27 p.m., RN-A confirmed he had checked blood glucose levels for R4, R5 and R6. RN-A said the residents did not have their own glucometers and they were shared between the residents. RN-A stated he had not been instructed to clean the glucometers between use. During interview on 4/4/25 at 1:05 p.m., the infection preventionist (IP) stated nurses were trained to clean the glucometers between uses during orientation. The IP said every resident should have their own glucometers assigned to them and should have been kept in their room or in the medication cart. The IP said glucometers should be cleaned between uses whether they were shared or not. Facility policy Blood Glucose Monitoring, Disinfecting and Cleaning dated 9/25/24, indicated blood glucose meters should be cleaned and disinfected after each use whether the meter is shared between residents or assigned to a resident. Cleaning and disinfecting can be completed by using a commercially available environmental protection agency registered disinfectant or germicide wipe.

Based on interview and document review the facility failed to develop and implement care planned interventions to address refusal of cares for 1 of 3 residents (R1) reviewed for deteriorating skin condition. Findings include: R1's Resident Face Sheet indicated he admitted to the facility on [DATE], with diagnosis that included congestive heart failure, hypertension, cellulitis of right lower limb, Esysipelis and mild cognitive impairment. R1's Skin Risk Assessment with Braden Scale dated 11/2/24, indicated he required assistance of a mechanical lift and was frequently incontinent. The assessment identified open lesions on the foot, edema and reduced urinary output. R1's Braden evaluation for risk of skin breakdown indicate he was at risk. R1's care plan dated 11/18/24, identified a self-care deficit due to weakness. The care plan directed staff to encourage participation in grooming and indicated he required substantial assistance for grooming and toileting. The care plan identified incontinence and directed staff to keep skin dry and intact. The toileting plan indicated before and after meals and at bedtime and directed staff to check for incontinence at night with repositioning. The care plan was updated 2/5/25, to include an alteration in behavioral state as evidenced by refusal of cares, choosing to stay in soiled brief, chucks. The care plan directed staff to document refusals of care and re-approach R1 when refused care. R1's Resident Progress Note dated 12/15/24, indicated power of attorney (POA) in this evening. POA reported that R1 would refuse care and sit for days in feces. POA reported if R1 refused care, staff should call and POA would get on phone to have him wash up. R1's Physician Progress Note dated 2/5/25, indicated pubic area rash, appears resident had been incontinent for an extended period. See attached photos. Abrasions, multiple, scattered. Erythema and rash present. Significant maceration to genitals and bilateral posterior upper thighs. The note indicated R1 was started on Amoxicillin 500 milligrams three times daily for seven days with extension if needed. R1's discharge Minimum Data Set (MDS) dated [DATE], identified intact cognition and indicated he displayed rejection of care behaviors 1-3 days during the assessment period. The MDS indicated R1 required substantial to maximal assistance for transfers and was dependent on staff for toileting and bathing. During interview on 2/21/25 at 10:50 a.m., POA-A said one time while R1 was at the facility he sat in the same soiled incontinent brief for at least 48 hours. POA-A said she had told staff to call if R1 was non-compliant, but no one ever called. POA-A stated a few days before they took R1 home the smell was so bad coming down the hall they decided to take R2 home out of the facility. POA-A stated there was a concern for bed sores and said R1's buttocks was purple, like leather and had multiple wounds on it. During interview on 2/21/25 at 2:18 p.m., registered nurse (RN)-B stated R1 did not like to use a urinal and would urinate in a cup. RN-B said it was hit or miss whether he would allow treatments to be done or not. RN-B said when R1 was incontinent, staff tried to change him, but he would say no. RN-B said staff should have re-approached R1 or let a nurse know if he refused and said, part of the time they did. Regarding calling the POA for assistance, RN-B stated, I honestly can't say we did, but was not sure why. RN-B stated the care plan was updated on 2/5/25, because she had not realized the refusal of cares were not on the care plan. During interview on 2/21/25 at 3:52 p.m., Nursing assistant (NA)-A stated she would offer cares to R1 but said he did not want her to provide care. NA-A stated she helped with R1's care here and there. NA-A said almost every time she arrived to work her shift, R1 was wet and/or soiled and said there was a very strong odor in the hall that bothered other residents. NA-A stated staff never received any interventions related to refusals until R1 was scheduled to discharge. During interview on 2/21/24 at 4:00 p.m. RN-A stated R1 had been very hard to deal with at times and stated he had behaviors in which he would yell and scream and kick staff out of his room. RN-A stated she had only worked with R1 a couple times and said he could be very nice. RN-A said only certain staff were able to get R1 to stand up and get cleaned up. RN-A said if R1 had been refusing cares staff would get her but said it did not work. RN-A stated she was unaware R1's POA's could be called if he refused cares. During interview on 2/25/25 at approximately 2:00 p.m. the interim director of nursing (as of 2/25/25) stated the facility tried to acknowledge resident preferences but said if refusals put a resident at risk, interventions should have been implemented along with physician notification. Facility policy Care Plan dated 12/2/24, indicated each resident will have an individualized, person-centered, comprehensive plan of care that will include measurable goals and timetables directed toward achieving and maintaining the resident ' s optimal medical, nursing, physical, functional, spiritual, emotional, psychosocial, and educational needs. Any problems, needs and concerns identified will be addressed through use of departmental assessments, the Resident Assessment Instrument (RAI) and review of the physician ' s orders.

Based on interview and document review the facility failed to ensure toileting and hygiene tasks were performed for 1 of 3 (R1) residents reviewed resulting in worsening skin condition that required physician ordered treatment. Findings include: R1's Resident Face Sheet indicated he admitted to the facility on [DATE], with diagnosis that included congestive heart failure, hypertension, cellulitis of right lower limb, Esysipelis and mild cognitive impairment. R1's Skin Risk Assessment with Braden Scale dated 11/2/24, indicated he required assistance of a mechanical lift and was frequently incontinent. The assessment identified open lesions on the foot, edema and reduced urinary output. R1's Braden evaluation for risk of skin breakdown indicate he was at risk. R1's care plan dated 11/18/24, identified a self-care deficit due to weakness. the care plan directed staff to encourage participation in grooming and indicated he required substantial assistance for grooming and toileting. The care plan identified incontinence and directed staff to keep skin dry and intact. The toileting plan indicated before and after meals and at bedtime and directed staff to check for incontinence at night with repositioning. Alteration in behavioral state as evidenced by refusal of cares and choosing to stay in soiled brief, chucks was added 2/5/25. R1's Point of Care History dated 1/5/25 through 2/5/25, identified rejection of care behavior four times over a period of 30 days/ 90 shifts: 1/27/25, 1/29/25, 2/1/25 and 2/5/25. R1's Physician Progress Note dated 2/5/25, indicated pubic area rash, appears resident had been incontinent for an extended period. See attached photos. Abrasions, multiple, scattered. Erythema and rash present. Significant maceration to genitals and bilateral posterior upper thighs. The note indicated R1 was started on Amoxicillin 500 milligrams three times daily for seven days with extension if needed. R1's discharge Minimum Data Set (MDS) dated [DATE], identified intact cognition and indicated he displayed rejection of care behaviors 1-3 days during the assessment period. The MDS indicated R1 required substantial to maximal assistance for transfers and was dependent on staff for toileting and bathing. During interview on 2/21/25 at 10:50 a.m., power of attorney (POA)-A stated R1 had a number of visitors, and a few times had received complaints from his friends. POA-A said one-time R1 sat in the same soiled incontinent brief for at least 48 hours. POA-A said she had told staff to call if R1 was non-compliant, but no one ever called. POA-A stated a few days before they took R1 home the smell was so bad coming down the hall they decided to take home out of the facility. POA-A stated there was a concern for bed sores and said R1's buttocks was purple, like leather and had multiple wounds on it. POA-A stated she brought R1 a planner to write things down every day because staff contradicted everything, he told them and was getting paranoid. During Interview on 2/21/25 at 11:17 a.m., POA-B stated R1 was known to be non-complaint with care but said I do believe some staff didn't care. POA-B stated R1's room stunk like body odor and yeast and said R1 would urinate in a plastic cup and put it into a urinal. POA-B said R1 was not always the most helpful patient. POA-B said when R1 discharged , most of his groin and thighs were a red, irritated mess, really red and irritated. POA-B said when R1 was at the facility, if the door to his room was open, he could smell him coming down the hall and said it was not out of the ordinary to find R1 sitting in an incontinent brief in his own feces. POA-B further said he told staff if R1 was not compliant to call. During interview on 2/21/25 at 1:36 p.m., an anonymous staff member stated had never had a problem with R1 refusing cares and stated had a hard time believing R1 would adamantly refuse care. Anonymous staff member stated instead of completing cares and treatment staff would just mark that he refused. The staff member stated there were nursing assistant (NA)'s that would not go check on R1 and said one day R1 sat in a wet brief and chair until approximately 10:00 p.m. and a second time R1 was still sitting in a urine soaked brief at 3:30 p.m., even though staff had been asked to provide care at 1:30 p.m. During interview on 2/21/25 at 2:18 p.m., registered nurse (RN)-B stated R1 did not like to use a urinal and would urinate in a cup. RN-B said it was hit or miss whether he would allow treatments to be done or not. RN-B said when R1 was incontinent, staff tried to change him, but he would say no. RN-B said staff should have re-approached R1 or let a nurse know if he refused and said, part of the time they did. Regarding calling the POA for assistance, RN-B stated, I honestly can't say we did, but was not sure why. RN-B stated she had observed the odor coming from R1's room when the door was open but said, he was okay with the door being closed. RN-B stated on 2/5/25, the provider told her she need to come to R1's room and after getting him up, the provider took photos and left the room. RN-B stated R1 had redness in his groin and on his upper thighs and had stool between his butt cheeks. RN-B said the brief was definitely wet along with the chucks and the chair underneath. RN- B stated she had not seen R1's skin prior to that. RN-B further stated the provider seemed upset. During interview on 2/21/25 at 3:08 p.m., nursing assistant (NA)-C stated she had never had any trouble getting R1 to wash up. NA-C stated R1 would holler and was cantankerous but said she would re-approach him and explain she needed to provide cares he would allow it. NA-C stated frequently when she started her shift, she would find R1 saturated and said you could wring out his brief. NA-C stated some of the staff just did not go in an offer to help him because they did not want to deal with him. NA-C stated before R1 discharged she saw his skin and said, oh my word. During interview on 2/21/25 at 3:52 p.m., NA-A stated R1 required a stand lift to do cares and never wanted to get up and go to the dining room. NA-A stated she would offer cares to R1 but said he was not a fan of her. NA-A said she stayed away from R1 after an incident when she brought him disposable cups because he would urinate in them and R1 grabbed onto her shirt and yelled at her. NA-A stated she helped with R1's care here and there and said R1 was kind of icky. NA-A said R1 hardly ever kept a brief on and sat with a sheet over him. NA-A said staff would come in and find R1 wet and soiled and while cleaning him, he would start urinating. NA-A said she fully believed R1 had some control and thought maybe it was done on purpose. NA-A said almost every time she arrived to work her shift, R1 was wet and/or soiled and said there was a very strong odor in the hall that bothered other residents. NA-A stated staff never received any interventions related to refusals until R1 was scheduled to discharge. During interview on 2/21/24 at 4:00 p.m. RN-A stated R1 had been very hard to deal with at times and stated he had behaviors in which he would yell and scream and kick staff out of his room. RN-A said R1 had been sexually inappropriate and said NAs told her he was looking at their butts and down their shirts and would masturbate while they were in the room. RN-A stated she had only worked with R1 a couple times and said he could be very nice. RN-A said only certain staff were able to get R1 to stand up and get cleaned up. RN-A said if R1 had been refusing cares staff would get her but said it did not work. RN-A stated she was unaware R1's POA's could be called if needed. RN-A further stated other residents were complaining of the smell in the hallway and said it was horrendous. During interview on 2/25/25 at 11:19 a.m., R1 stated he felt his care at the facility had been satisfactory but said when it came to keeping him clean, he did not get the help he needed. R1 said he needed the assistance of a machine to stand and when he asked staff for assistance, by the time they came back he had already soiled himself. R1 stated he did not refuse care and said when staff came to assist him, he said yes, but said they took 2-3 hours to come back. R1 said regarding bathing, staff would ask him after supper and he would agree, then no one would return until around 10:00 p.m. R1 said staff did not offer or provide cares every two hours as directed by the plan of care. During interview on 2/25/25 at 11:52 a.m., anonymous resident (AR)- A stated oof-[NAME], the smell coming down the hallway. AR- A stated it went on for weeks and said it smelled like R1 was rotting. AR said staff told him R1 was the cause of the smell and told him R1 did not shower. AR-A sated the smell was offensive. During interview on 2/25/25 at 11:57 a.m., AR-B stated there used to be a resident at the end of the hall who lived in his recliner, pooped in it, and said the stink coming out of the room was unbearable. AR-B said his room was next door. AR-B stated he told R1 to keep his door shut and said the smell was so bad he would almost gag. AR-B said the NA's told him what had been happening. During interview on 2/25/25 at 1:10 p.m., NA-B said R1 never asked for anything other than breakfast and lunch. NA-B stated right before R1 discharged she took care of him and said she asked two other staff to assist her and said that was the only time she had ever seen staff change R1. NA-B said she had never heard R1 tell staff no and said staff just had not gone in and checked on him. During interview on 2/25/25 at 1:17 p.m., photos of R1's skin dated 2/25/25, were observed with RN-B. RN-B described R1's skin as follows: Lower abdomen, groin and inner thigh were red from moisture. Buttocks impacted stool in rectum, redness from moisture and pressure of sitting covering both buttocks from upper thighs to just above his knees. RN-B stated staff had not reported the condition of R1's skin to her. During interview on 2/25/25 at approximately 2:00 p.m. the interim director of nursing (as of 2/25/25) stated the facility tried to acknowledge resident preferences but said if refusals put a resident at risk, interventions should have been implemented along with physician notification. Facility policy Refusal of Treatment, Right to Choose dated 10/15/24, indicated refusal of treatment will be documented consistently in the medical record and will be countered by discussion with the resident regarding the health and safety consequences of the refusal and the availability of any therapeutic alternatives that may exist. When a resident chooses not to follow treatment which is prescribed by the physician or a member of the healthcare team, appropriate employees should attempt to determine why the resident is making this choice. Inform the resident about the health risk/benefit and safety consequences, as well as the availability of other existing therapeutic alternatives. Inform the resident ' s physician of the resident ' s choice. If the physician changes an order to align with the resident ' s desire, employees are to comply with the new order. However, if the physician is not able to change the order to align with the resident ' s wishes, employees should continue to offer the treatment as ordered and document all attempts.

Based on interview and document review the facility failed to follow care planned intervention for the use of a gait belt for 1 of 3 residents (R1) reviewed. This resulted in actual harm when R1 fell while ambulating with staff assistance and sustained bilateral sacral fractures (a break in the bone at the back of the pelvis). The deficient practice was corrected prior to the start of the survey therefore, was issued at past non-compliance. Findings include: R1's Resident Face Sheet identified an admitted [DATE] and a latest return date of 12/16/24. R1's diagnosis included osteoarthritis, age related osteoporosis and impaired mobility. R1's care plan dated 10/25/22, identified a self care deficit due to morbid obesity and pain in right knee. The care plan indicated R1 was not ambulating and chose not to get out of bed and indicated a history of sitting in chair at home and not walking much. R1's annual Minimum Data Set (MDS) dated [DATE], identified intact cognition. The MDS indicated R1 had upper and lower extremity impairments, required substantial to maximal assistance to stand, supervision or touching assistance for transfers and did not ambulate. An untitled care guide dated 12/12/24, indicated R1 required assistance from one staff using a gait belt and walker, following with wheelchair to ambulate. A facility Live Event report dated 12/20/24, indicated on 12/15/24 at 1:40 p.m., R1 fell while ambulating with staff assistance and was sent to the emergency department (ED). Injuries indicated fracture/dislocation. The report indicated R1 was ambulating with a nursing assistant (NA) to her left side and was using a walker. A licensed nurse was behind her with a wheelchair. R1 got to the nurses station desk and reached for a pen, the walker fell forward to the ground and the resident landed on top of it. R1 complained of pain rated 8/10 and was sent to the ED. R1's Resident Progress Notes identified the following: 12/15/24, R1 was walking next to the nurses station with NA. R1 reached for a pen on the desk and the walker went forward. R1 fell on top of the walker. The walker was removed from beneath her. R1 complained of hip pain rated 8/10 and was sent to the ED for assessment. 12/15/24, R1's family member called and updated facility R1 remained in the hospital with a right sacrum fracture and possible left sacrum fracture. R1's hospital Discharge Summary dated 12/16/24, indicated R1 presented to the ED after a a fall. fell at facility when her walker got placed away from her and when trying to reach her walker she fell down. Found to have bilateral sacral insufficiency fractures. Orthopedics recommended conservative management, partial weight bearing to her right lower extremity and weight as tolerated as she progresses and pain tolerates. During observation on 12/20/24 at 8:54 a.m., R1 was lying in bed in her room with the lights off. During interview on 12/20/24 at 9:01 a.m., R1 was asked about her fall and said I let go of the walker and then I went. R1 stated at the time of the fall staff had not used a gait belt when assisting her to walk. R1 stated her bottom was sore and she was unable to get up and walk. R1 stated, it hurts and said even turning to the side hurt the one leg. During interview on 12/20/24 at 9:13 a.m., physical therapist (PT)-A stated the purpose of a gait belt was to help with stability and reduce the risk for falls. PT-A stated when using a gait belt, staff were able to support or correct moments of instability or loss of balance and said if a resident leaned too far forward or to the left or right the belt could help prevent a fall. During interview on 12/20/24 at 10:54 a.m., NA-A stated prior to the fall R1 was able to transfer with supervision and was care planned to walk with assistance using a transfer belt and the wheelchair following behind her. NA-A stated since the fall R1 was wanting to stay in bed and not getting up. NA-A was unsure but said it was due to either the pain or the fear of falling. NA-A stated staff had received education on the care plan and use of the gait belts after the incident. During interview on 12/20/24 at 12:19 p.m. NA-B stated she had been walking with R1 in the hallway and had seen two pens on the floor so she had picked them up. NA-B stated R1 reached for one of the pens and fell and landed on top of the walker. NA-B stated she had not used a gait belt when ambulating with R1 and said, I don't know why. NA-B stated she had received education related to use of the gait belt, reviewing the care plan daily and following the care plan. During interview on 12/20/24 at 1:17 p.m., registered nurse (RN)-A stated the day R1 fell , she received a call from staff who reported staff were walking with R1 who reached to grab a pen off the desk and fell forward onto the walker. RN-A stated staff had not been following the care plan intervention to use the gait belt. RN-A stated if the gait belt had been used staff would have been able to grab onto the belt and prevent the fall. RN-A stated care planned interventions were listed on the care plan and stated staff should have been aware. RN-A stated any resident who required and kind of touching assistance required the use of a gait belt. During interview on 12/20/24 at 11:35 a.m. RN-B stated on the day R1 fell she had seen NA-B walking with her in the hall and assisted with pushing the wheelchair behind. RN-A stated she had noticed R1 was wearing a robe and had been shuffling her feet. RN-B stated she did not see R1 reach over for the pen and said all she had seen was the walker. RN-A said R1 flipped over the walker and landed on her back with the walker underneath her. RN-B stated she had not noticed if a gait belt had been used but said unless a resident was independent the staff should know to always use a gait belt. Facility policy Mobility Support and Positioning dated 5/6/24, indicated unless contraindicated, a gait belt should be used for all residents who require assistance with ambulation. The caregiver should walk in step with the resident holding onto the gait belt with palm up. The purpose of the gait belt is to ensure the caregiver can control the residents center mass if he or she loses their balance. Prior to the start of the survey the facility initiated education related to the transfer belt policy and use of gait belts and completed an audit of care guides to ensure accuracy. The education was verified through interview and document review.

Based on observation, interview and document review, the facility failed to maintain clean and sanitary conditions of kitchen equipment and ensure hairnets were worn when preparing resident meals, to prevent the spread of food born illness. This had the potential to affect 69 out of 69 residents that received food out of the kitchen or kitchenette. Findings include: Mixer: During an initial tour of the main kitchen on 12/3/24 at 7:02 a.m., a large industrial mixer was on the counter. The underside of the mixer head, which sat over the mixing bowl, was coated in a tan colored food debris on the underside. There was a white dust covering the mixing bowl arms. During an observation of the large industrial mixer on 12/5/24 at 11:20 a.m., the underside of the mixer head continued to be coated with a tan colored food debris. DA-B stated, that's bad, really bad and equipment should be thoroughly cleaned after every use to prevent contamination of food. During an interview on 12/5/24 at 4:59 p.m., the administrator stated staff were expected to clean kitchen equipment after every use to prevent contamination of food and to prevent foodborne illness. Ice and Water Dispenser: During an observation on 12/4/24 at 11:26 a.m., the [NAME] units kitchenette's ice and water dispenser was dribbling water. Inside the clear acrylic spout was a black colored tar-like substance stuck to the ridges and corners. DA-A stated he did not how often the ice and water dispenser were cleaned because it was done by the maintenance department. DA-A stated he had no idea how long the black colored substance was in the spout and stated he was only responsible for cleaning the drip tray. During an interview with the facilities manager (F)-A and DA-B on 12/5/24 at 10:20 a.m., F-A stated the ice and water dispensers were cleaned by a contracted service quarterly; however, the front of the machine, including the spout was cleaned by dietary staff. The spout was removable and should be cleaned at least every couple of days. DA-B stated she was unaware the spout was removable and stated dietary staff would need education how to clean the ice and water dispenser. During an interview on 12/5/24 at 4:59 p.m., the administrator stated she expected a policy/procedure directing cleaning of the ice and water dispenser and staff education so that everyone was aware to complete the task to prevent transmission of foodborne illness. The facility policy Sanitation for Hosp and NH Kitchens revised 1/30/24, identified the facility would ensure a sanitary environment for storage of food in the floor kitchens by Weekly; an assigned NFS employee will clear all kitchenettes including a weekly sanitation checklist of the following: - Removing any outdated foods and ensuring all foods are labeled and dated. - Cleaning and sanitizing refrigerators, including freezer compartment. - Cleaning and sanitizing microwave. - Straightening and sanitizing cupboards, drawers, and counter tops. - Restocking assigned items. - Coffee / hot water machine is cleaned per vendor recommendation. - Food belonging to a specific patient or resident will meet the same requirements as listed above. However, the policy failed to identify the cleaning procedure of the mixer and/or the ice and water dispenser. Hairnets During the initial tour of the main kitchen on 12/3/24 at 7:02 a.m., dietary aide (DA)-D was wearing a baseball cap with her long hair not fully contained under the cap and was not wearing a hairnet. DA-D was preparing bacon and potatoes. DA-D went into the bathroom and put her hair in a bun and covered with a hairnet and stated, every morning I put my hair up in a bun and the one time I don't of course state shows up. DA-D proceeded to pack up the bacon and potatoes to take the units for breakfast service. During an interview with the facilities manager (F)-A and DA-B on 12/5/24 at 10:22 a.m., DA-B stated staff were expected to wear a hairnet when preparing food to prevent foodborne illness. 41575 On 12/4/24, at 4:03 p.m. a brief tour of the kitchenette located on Elderberry Neighborhood was conducted. Dietary aide (DA)-E was preparing the area to begin supper service and had placed the supper food in the unit's steam tables. DA-E had short black hair and was not wearing a hair net to cover his hair. DA-E immediately took a hairnet from the container at the kitchenette entrance and put it on. DA-E stated he usually wore a hairnet and had just forgotten. The facility policy Employee Hygiene and Dress revised 6/12/24, identified hairnets or hair restraints and beard nets or beard restraints are used when cooking, preparing, assembling food or ingredients. This includes dish rooms and storage areas. Hair is to be covered completely. The 2022 FDA Food Code, identifies shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food.

Based on observation, interview and document review, the facility failed to develop and implement an infection control surveillance plan for identifying, tracking, monitoring for 2 of 2 residents (R277, R278) who had diarrhea; and failed to ensure all resident potential infection symptoms were tracked along with providing a monthly written analysis of infections; and failed to ensure enhanced barrier precautions (EBP) were followed for 1 of 1 residents (R10, R2) with wound care and indwelling medical devices; and failed to ensure staff utilized masks in the appropriate manner on 1 of 3 units affected by COVID-19 in an effort to reduce the potential spread of illness. This had the potential to affect 71 residents residing in the facility. Findings include: SURVEILANCE/ ANALYSIS: R277's admission Minimum Data Set (MDS) dated [DATE], identified no cognitive impairment. R277's diagnosis included UTI. R277's progress note dated 11/22/24, identified was having loose stools. During an interview on 12/5/24 at 4:46 p.m., registered nurse (RN)-B stated R277 had been having loose stools since the weekend and just received an order for loperamide (a medication used to treat various forms of diarrhea). The consistency of a bowel movement should be documented by either the nursing assistant or the nurse. It was not a required thing but should have been documented. Information regarding loose stools should have been reported to the day nurse. Then the day nurse would have reported them to the infection control nurse. R278's admission MDS dated [DATE], identified no cognitive impairment. R278 was continent of bowel and bladder. R278's diagnoses identified sepsis (severe infection in the body), UTI, and respiratory failure. R278's progress notes and bowel documentation lacked any identification of the consistency of bowel movements During an interview on 12/5/24 at 4:50 p.m., licensed practical nurse (LPN)-B (the infection preventionist) stated R278 was seen by a provider in the facility and ordered a lab test for C. Diff. due to R278 having loose stools. She was surprised because she was unaware of R278 had loose stools and was not documented. Further, LPN-B was not aware R277 was having loose stools the past few days. Both residents resided on the same unit. The facility provided monthly infection control (line list) the form identified the unit, resident name, type of infection, date of onset, testing performed and results, antibiotic or antimicrobial used, length of therapy, if criteria was met and time out was performed, and if it was facility acquired or community acquired. - The monthly infection control log (line list) for September 2024, identified six residents with pneumonia, four residents with a urinary tract infection (UTI), two residents with a tooth infection, two residents with a skin infection, one resident with a blood infection, one resident with a lower respiratory infection, one resident received a prophylactic antibiotic, three residents fromprevious month and carried forward but did not identify reason for antibiotic. All the residents were treated with an antibiotic. It identified eight residents with COVID and one was treated with an antimicrobial. There were no listed infections or resident infection symptoms which were not treated with antibiotics (i.e. common cold symptoms, viral infections). The facility failed provide an analysis of the infections to include patterns or what interventions were implemented to reduce incidences of further infection related to the COVID, pneumonia, or UTIs. The monthly infection control log (line list) for October 2024, identified eight residents with a UTI, three with osteomyelitis (a serious infection in the bone), two with pneumonia, one resident with clostridioides difficile (C. Diff) (a bacteria that causes diarrhea and colitis (an inflammation of the colon) and can be life-threatening), one resident with a lower respiratory infection. All the residents were treated with an antibiotic. It identified one resident with COVID and was treated with an antimicrobial. There were no listed infections or resident infection symptoms which were not treated with antibiotics (i.e. common cold symptoms, viral infections). The facility failed to provide an analysis of the infections to include patterns or what interventions were implemented to reduce incidences of further infection related to UTIs, or osteomyelitis. The monthly infection control log (line list) for November 2024, identified nine residents with a UTI, two with a skin infection, two with a COPD exacerbation, one with pneumonia, 4 on prophylaxis. All the residents were treated with an antibiotic. It identified three residents with COVID and were treated with an antimicrobial. There were no listed infections or resident infection symptoms which were not treated with antibiotics (i.e. common cold symptoms, viral infections). The facility failed to provide an analysis of the infections to include patterns or what interventions were implemented to reduce incidences of further infection including UTI's, respiratory, skin infections and COVID. The monthly infection control log (line list) for December 2024 was requested, but not received. During an interview on 12/5/24 at 4:50 p.m., (LPN)-B stated she did the infection prevention surveillance on a spreadsheet form. LPN-B tracked antibiotic usage and tracked COVID on the same form. There was a different spread sheet she would track high risk symptoms on, (a copy of the spread sheet was requested but not received). LPN-B got information daily from the day nurses on each of the units, by reading progress notes and looking for new antibiotics prescribed. LPN-B would have expected staff would chart pertinent information regarding resident showing sign or symptoms of illness. Which included fever, nausea, vomiting, diarrhea, cough. There were not any high-risk symptoms happening at this time and she was not tracking anything. It was important to monitor for loose stools when resident had been on antibiotics because they were at a higher risk to develop C. Diff. which is very contagious. LPN-B was not aware R277 was having loose stools the past few days and would have expected staff to share the information with her. She did not know of the residents who had loose stools and was not monitoring them. During an interview on 12/5/24, at 5:31 p.m., the director of nursing (DON) stated she would have expected staff to document signs and symptoms of infection and for the infection preventionist to have followed up to ensure health of all residents. The facility's Surveillance policy dated 9/3/24 identified surveillance is designed to identify and report evidence of infection. Collecting, documenting and analyzing data will be done by the infection preventionist or the designated staff member. 40943 EBP: R10's significant change MDS dated [DATE], identfiied R10 was cognitively intact and had diagnoses that included quadriplegia, type 2 diabetes, and neuromuscular dysfunction of bladder. R10 had a stage 4 pressure ulcer, a colostomy and an indwelling catheter and was receiving intravenous medications. R10's care plan revised 11/19/24, identified R10 had an infection to a sacral wound (a region located at the base of the spine in the pelvic area) wound and had a need for enhanced barrier precautions due to indwelling urinary catheter and chronic wound. The following interventions were identified: - Post signage on door or wall outside of resident room - PPE available immediately outside of resident room. Staff to wash their hands upon entering and leaving room. PPE to be doffed prior to leaving resident room. - Provide education to resident or representative on the need for and duration of EBP. Encourage resident or representative to discuss feelings reoardino EBP. - Physical and occupational therapy to use EBP in common areas when therapy activities have risk for repeated contact, including but not limited to transfer practice, ambulation, balance training, toileting practice. - Standard precautions along with gown and gloves during high contact resident care activities such as: dressing bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, repositioning, device care or use (central line, urinary catheter, feeding tube, tracheostomy, etc.) and wound care (any skin opening requiring a dressing). PPE to be doffed prior to exiting room. R2's quarterly MDS dated [DATE], identified R2 had a severe cognitive impairment and diagnoses that included traumatic brain injury and quadriplegia. R2 used a feeding tube for all his nutritional needs. R2's care plan revised 10/16/24, identified R2 had a need for enhanced barrier precautions do to having a feeding tube. The following interventions were identified: - Post signage on door or wall outside of resident room - PPE available immediately outside of resident room. Staff to wash their hands upon entering and leaving room. PPE to be doffed prior to leaving resident room. - Provide education to resident or representative on the need for and duration of EBP. Encourage resident or representative to discuss feelings reoardino EBP. - Physical and occupational therapy to use EBP in common areas when therapy activities have risk for repeated contact, including but not limited to transfer practice, ambulation, balance training, toileting practice. - Standard precautions along with gown and gloves during high contact resident care activities such as: dressing bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, repositioning, device care or use (central line, urinary catheter, feeding tube, tracheostomy, etc.) and wound care (any skin opening requiring a dressing). PPE to be doffed prior to exiting room. During an observation on 12/4/24 at 10:39 a.m., there was an enhanced barrier sign and a plastic three drawer cart containing gowns outside R10's door. Nursing assistant (NA)-C entered R10's room without donning a gown and provided R10 with assistance for morning cares, emptied R10's colostomy bag into a graduate lined with a trash bag, provided catheter care came into close contact with R10 and R10's bed, wheelchair and belongings. - At 10:41 a.m., NA-C picked up R10's ceiling lift sling from the floor and placed the sling under R10. - At 10:56 a.m., NA-C provided R10 his call light and left the room. - At 10:58 a.m., NA-C returned to the room accompanied by NA-A. Neither NA-C or NA-A donned a gown and assisted to transfer R10 into his wheelchair via a full body mechanical lift. NA-C and NA-A came into close contact with R10 and R10's bed and wheelchair. - At 11:10 a.m., NA-C and NA-A left the room and went to R2's room. There was a enhanced barrier precautions sign and a plastic three drawer cart containing gowns outside R2's door. Neither NA-C or NA-A donned a gown. NA-C and NA-A assisted with repositioning R2 and NA-C left the room while NA-A assisted R2 with his hand/arm braces. - At 11:12 am., NA-C pointed to the enhanced barrier precautions sign hanging outside R2's door and stated whenever staff went into a room with that sign and there was a cart available, staff needed to put on a gown and gloves during cares. Staff always donned a gown and gloves every time, however, NA-C stated she must have forgot to donn a gown prior to entering R10 or R2's room. - At 11:16 a.m., NA-A pointed to the enhanced barrier sign outside R2's door and stated the only time staff needed to wear a gown was when staff changed R2's incontinent brief or something where you're going to have contact with bodily fluids. NA-A did not donn a gown prior to going into R10 or R2's room because I didn't get into anything like that. However, NA-A then pointed to the sign again and stated according to that, evidently you need to wear a gown for everything. During an interview on 12/5/24 at 8:09 a.m., licensed practical nurse (LPN)-A stated, when a resident was placed on enhanced barrier precautions, staff were expected to wear a gown and gloves whenever they're going to be in contact with the residnet; like cares. Anything where they're going to touch the resident. During an interview on 12/5/24 at 11:34 a.m., registered nurse (RN)-A stated staff were expected to follow enhanced barrier precautions guidelines to the prevent the potential transmision of microorganisms. During an interview on 12/5/24 at 2:35 p.m., the director of nursing (DON) stated staff were expected to follow enhanced barrier precautions guidelines for any resident with an invasive device, wound care and/or an multi-drug resistant organism (MDRO). Gowns and gloves were expected any time a resident needed care that required contact with the resident. The facility provided Multidrug-Resistant Organisms, MRSA VRE CRE and ESBL policy revised 4/12/24, identified Enhanced Barrier Precautions would be used for all residents with any of the following: - wounds an/or indwelling medical devices (e.g. central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status - infection or colonization with a [NAME] or targeted MDRO when Contact Precautions did not apply Facilities may consider applying Enhanced Barrier Precautions to residents infected or colonized with other epidemiologically important MDROs based on facility policy The personal protective equipment (PPE) would be used during high contact resident care activities: - dressing - bathing/showering - transferring - providing hygiene - changing linens - changing briefs or assisting with toileting - device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator) - wound care: any skin opening requiring a dressing The policy identified the PPE required included gown and glove prior to high contact care activity (change PPE before caring for another resident) (Face protection may also be needed if performing activity with risk of splash or spray) 42075 MASKS: On 12/3/24 at 7:03 a.m., registered nurse (RN)-B stated there was one staff member and one resident that tested positive for COVID over the weekend. The facility tested the units where the staff member worked including [NAME], [NAME] and Strawberry. The three units were in outbreak status due to the positive staff member. All residents on these units tested negative on 12/1/24. One resident was positive prior to admission 12/1/24. An email to all facility staff from licensed practical nurse (LPN)-B dated 11/18/24, identified all neighborhoods/units remained in COVID outbreak status due to continued staff and resident positive cases and identified all staff were required to wear a mask in all neighborhoods. During interview on 12/4/24 at 11:36 a.m., LPN-B stated the facility was currently in a COVID outbreak due to multiple staff and a resident being positive. The most recent positive result was a staff member who completed a home test over the past weekend. During observation on 12/5/24 at 9:23 a.m., dietary aide (DA)-A was in the [NAME] unit kitchenette pouring drinks and dishing food onto a plate for a resident. DA-A's face mask was under the chin and not covering the mouth or nose. DA-A proceeded to carry the drink and plate of food to the table where residents were seated, returned to the kitchenette, poured a cup of liquid from the dispenser and carried the cup to the resident. DA-A was not observed to pull the mask over nose prior to dishing up or delivering the food, or upon returning to the kitchenette. On 12/5/24 at 9:25 a.m., DA-A was standing in the kitchenette and as state surveyor (SA) approached, DA-A pulled the mask over his mouth and nose. DA-A stated staff were supposed to wear face masks that securely covered the mouth and nose all the times including during prepping, cooking, dishing, and serving food, and when in close proximity to residents. DA-A stated he worked on all units in the facility and was aware that three of the units were required to wear PPE because of a COVID outbreak. DA-A stated he recently worked on [NAME], which was COVID positive at the time, but did not answer when asked the date he last worked on [NAME]. DA-A stated staff were to wear face masks to prevent the spread of germs to residents, themselves, and other staff. DA-A stated he worked on all units prepping, cooking and serving food to the residents. Further, DA-A stated he was not wearing his face mask over the mouth or nose while pouring drinks, prepping, or delivering food to residents and had only pulled the mask up because SA had approached. On 12/5/24 at 10:33 a.m., RN-A stated the facility was currently in COVID outbreak and all staff, including dietary staff, were required to wear face masks under the chin and over the nose whenever working at the facility. RN-A stated all staff had been trained on how to appropriately wear PPE including face masks. On 12/5/24 at 10:43 a.m., the facilities manager (F)-A stated the facility followed recommendations from the infection preventionist regarding when to wear PPE including face masks. Staff were directed to wear face masks at all times and to ensure the mask was under their chin and over their nose. the F-A stated dietary staff were educated and instructed to wear face masks at all times including when prepping, cooking, dishing food, serving food, at all times when they were in the kitchen/kitchenette and where residents were and especially now since the facility was currently in a COVID outbreak. A policy on mask use while in COVID outbreak status was requested and not received.

Based on observation, interview, and document review, the facility failed to provide routine oral care and shaving assistance to 1 of 5 residents (R23) reviewed for activities of daily living (ADLs) and who were dependent on staff for their care. Findings include: R23's quarterly Minimum Data Set (MDS) dated [DATE], identified R23 was cognitively intact, had a diagnosis that included hemiplegia (one side paralysis or weakness) due to a history of a stroke. R23 had an indwelling catheter and a feeding tube. R23 was dependent on staff for all care activities. R23's care plan revised 12/3/24, identified R23 had a self-care deficit due to left sided hemiparesis related to a history of stroke. Staff were directed to provide assist of one for grooming. The care plan did not direct shaving on certain days or how often and when oral cares would be completed. During an observation on 12/3/24 at 4:31 p.m., R23 was lying in bed with his head of bed elevated 45 degrees. R23 had a sheet covering R23 to his waist and R23 was not wearing a shirt. R23 was unshaven with approximately a 1/4 inch of beard growth. During an observation on 12/5/24 at 9:46 a.m., nursing assistant (NA)-A and NA-B entered R23's room. After putting on a gown and gloves NA-A and NA-B provided morning care assistance to R23. - At 10:08 a.m., NA-A and NA-B removed their gowns and gloves to exit R23's room, however, R23 was not offered shaving assistance or oral cares. NA-B stated R23 was always shaved on his bath day and sometimes R23 would shave on his own, but shaving should have been offered. NA-A stated they do oral cares for R23 throughout the day because R23 had a feeding tube, but oral cares should have been offered. During an interview on 12/5/24 at 11:23 a.m., registered nurse (RN)-A stated all residents should be offered shaving and oral care assistance during cares. During an interview on 12/5/24 at 2:33 p.m., the director of nursing stated shaving and oral cares should have been offered during cares. During an interview on 12/5/24 at 4:59 p.m., the administrator stated shaving and oral cares should be offered during cares per policy. The facility policy Activities of Daily Living revised 12/4/23, identified the facility would ensure any resident who was unable to carry out activities of daily living would receive necessary services to maintain good nutrition, grooming and personal and oral hygiene.

Based on interview and document review the facility failed to comprehensively assess and develop interventions to reduce or prevent continued weight loss for 1 of 1 resident (R30) reviewed for nutrition. We should also righ notification to he Dr at F580 . jsut need peices of it the record showing weight losss and interviews they should notify dr. Findings include: R30's quarterly Minimum Data Set (MDS) dated [DATE], identified R30 had severe cognitive impairment and required moderate to maximum assist with all activities of daily living (ADLs). R30's weight was 114 pounds, Diagnoses included Alzheimer's and congestive heart failure. R30's MDS IDT assessment dated [DATE], identified R30 had no difficulty with chewing or swallowing and required one person assist to eat at times. R30's height, weight, weight loss or gain and appetite was not completed on the assessment form. R30's care plan dated 12/2/24, identified R30 had a potential for weight loss. R30 was to receive a regular diet and offer point of service choice of foods. R30 was weighed weekly with the following weights documented: - 6/7/24 123 lbs. - 7/12/24=117 lbs. (a 4.88% wt loss in one month) - 8/16/24=112 lbs. - 9/20/24=110 lbs. (a 13% wt loss in three months) -10/18/24=107 lbs. -11/15/24=106 lbs. R30's medical record lacked evidence her ongoing weight loss was assessed and evaluated. There was no evidence dietary assessments were completed at admission, quarterly or with a identified decrease in weight. On 12/04/24, at 12:10 PM R30 was seated in dining room eating her lunch. R30 had eaten all her desert of cake and was trying to eat some of the lunch meal provided. R30 attempted to use her fork and poke two slices of bread and bring it to her mouth to eat. The bread was too heavy for the fork and kept dropping onto R30's lap. After several attempts, R30 picked the bread up with her hands and took two bites. Staff were in the dining room; however, did not offer R30 assistance to eat. When interviewed on 12/4/24, at 11:20 a.m. trained medical assistant (TMA)-A stated staff could not do much to get R30 to eat. It just depended on what kind of day R30 was having. Some days she would not eat a thing and other days she would. During interview on 12/4/24, at 5:50 p.m. registered nurse (RN)-D stated they had a dietician on staff that the facility shared with other facilities. The dietician did a lot of her documentation on paper and not sure where any of it was. The facility just hired a new dietician in the past three or four weeks and the new dietician was reviewing all the resident charts to see where all the residents were at. RN-D stated the nursing assistants obtained resident weights weekly on their bath days. They were supposed to notify the nurse when a weight loss was noted; however, the aides did not get a good look at all the resident weights and so would not necessarily know when a weight loss occurred week to week. The nurses inputted the weights on the resident's medication administration record (MAR) and when they brought up the MAR to enter the weight, the residents previous wt was listed. The nurses were also able to click on the history and review more weights for a quick look back. RN-D was not sure why the weight los was not noted by the nurses when they entered them on the MAR weekly. The nurses should have noted the significant weight discrepancies and requested the nursing assistants to reweigh the patient. If determined accurate, the nurses should have reported to the unit manager and/or dietary. On review now, RN-D did see R30 had lost weight. During interview on 12/5/24, at 11:22 a.m. the dietician stated she monitored resident weights on a monthly basis. R30's quarterly assessment identified a 7.5% weight loss, which would have put her on high risk. When the dietician identified a high-risk resident, she monitored them at least monthly and documented a progress note for resident. Dietary assessments were required on admission and with quarterly MDS assessments. The dietician did not see a dietary assessment had been completed at all for R30, so she assessed R30 today and documented a progress note. The progress note dated 11/5/24, identified a review of R30's weights and intakes, with possible consideration of initiating a nutritional supplement. When interviewed on 12/5/24, at 11:50 a.m. RN-C stated the floor nurses were supposed to be evaluating resident weights when they entered them in to the resident's MAR. RN-C was surprised dietary assessments were not completed as one should have been done when R30 was admitted . The previous dietician was keeping an eye on resident weights and RN-C would collaborate with the dietician and discuss new interventions as well as notifying the residents primary care provider. RN-C would have also expected a dietary assessment to have been completed during R30's quarterly review in September. The previous dietician would discuss weight loss with residents or residents that should be monitored but the previous dietician did not always document her findings in the resident's charts. During interview on 12/5/24, at 4:13 p.m. RN-D stated she generally notified the physician as soon as she noticed a resident's weight was going down. The weight loss did not even have to be significant, as she just wanted to give the provider a heads up, even if it was just noticing their food intake had declined. When interviewed on 12/5/24, at 4:27 p.m. the director of nursing (DON) stated she would have expected nurses to evaluate a resident's weight weekly and notify the provider for resident weight loss or gains. R30's weight loss should have been addressed during her quarterly reassessment. The facility expected residents to have dietary assessments to be completed on admission and with quarterly reassessments at the minimum. During interview with the administrator and administrator designee on 12/5/24, at 4:50 p.m. the administrator stated he would expect dietary assessments to be completed on admission and with all reassessments. The facility expected nurses to monitor resident weights and report any concerns to dietary. The facility policy Weight and Height dated 10/15/24, identified the purpose was to ensure the resident maintained acceptable parameters of nutritional status regarding weight. Based on comprehensive assessment the facility would ensure that a resident would maintain appeasable parameters of nutritional status such as body weight, unless their clinical condition demonstrated it was not possible. The licensed nurse would notify the director of food and nutrition (DFN) within 24 hours regarding any significant weight change. A significant weight change was defined as five percent in 30 days, 7.5% in 90 days and 10% in 180 days. The licensed nurse should immediately notify the medical provider of any significant weight change.

Based on observation, interview, and document review, the facility failed to ensure required nurse staffing information was consistently posted on a daily basis. This had potential to affect all 72 residents, staff, and visitors who could wish to review this information. Findings include: On 12/3/24, at 6:45 a.m. adjacent to the front doors was a wall-mounted, particle board which had a paper document hung with a thumbtack titled Daily Staffing for Tuesday November 26, 2024 and identified a census of 70. The document listed staff scheduled hours per shift for each nursing job class. However, the posting was dated 11/26/24, seven days prior. When interviewed on 12/5/24, at 2:40 p.m. medical records (MR)-I stated she was responsible for the daily staffing posting. MR-I thought she had posted for the holiday weekend but must not have done so. MR-I was working on system to ensure she did not forget to post staffing daily. It was important to have the posting updated every day so staff, family and state knew how many residents were in the building and that the facility was sufficiently staffed. On 12/5/24, at 4:27 p.m. the director of nursing stated the facility expected the daily staff posting to be posted consistently every day. A joint intervew with the administrator and administrator designee was conducted on 12/5/24, at 4:49 p.m. The administrator stated the staff posting was expected to be posted and updated daily. It was important as a way to communicate with family, visitors, and residents for staff ratio and census. A policy regarding the nurse staff posting was requested but not received.

Based on interview and document review the facility failed to immediately identify code status and act on resident wishes for 1 of 3 residents (R1) reviewed for resuscitation status. This resulted in an immediate jeopardy for R1 when staff initiated cardiopulmonary resuscitation (CPR) against R1's wishes. The IJ began on [DATE], at approximately 5:40 p.m. when R1 was found by a nursing assistant (NA)-A in the common area of the unit. R1 was pale, lips blue and unable to speak. R1 was administered the Heimlich Maneuver, CPR was initiated and was sent to the hospital where she subsequently required mechanically assisted ventilation. The IJ was identified on [DATE], and the administrator was notified of the IJ on [DATE], at 11:13 a.m. The immediate jeopardy was removed on [DATE], as the deficient practice was corrected prior to the start of the survey and was therefore issued at past noncompliance. Findings include: R1's Advance Health Care Directive dated [DATE], indicated R1 wanted CPR attempted if R1's heart or breathing stopped based on current health. However, in the future if her health changed her agent or R1, if able, would discuss CPR with the health care team. R1's hospital history and physical dated [DATE], identified patient is DNR (do not resuscitate). R1's Physician Order Report dated [DATE], identified a code status: DNR, dated [DATE]. R1's annual Minimum Data Set (MDS) dated [DATE], identified intact cognition. R1's care plan dated [DATE], identified an advanced directive of DNR. Long term goal identified an advance directive would be followed. The care plan directed staff to determine code status upon admission and quarterly thereafter. R1's undated, Resident Face Sheet indicated R1 was readmitted to the facility on [DATE]. Diagnosis included respiratory failure, chronic obstructive pulmonary disease and dysphagia (difficulty swallowing). R1's face sheet identified a DNR status. R1's Resident Progress Note dated [DATE], identified at approximately 5:40 p.m. writer was alerted to watch R1 in the dining room. R1 was having dyspnea (shortness of breath) and was slouched to the side with green stuff draining out of her nose and mouth. Writer tipped R1's head up to open the airway and called another nurse. R1 was removed from the dining room and 911 was called. The team assisted R1 to the floor and initiated CPR as advance directives indicated full code. Emergency services (EMS) worked on R1 and brought her to the emergency department. During interview on [DATE] at 11:07 a.m., registered nurse (RN)-A stated she received a phone call at home on [DATE], and staff reported to RN-A, R1 had coded [heart and breathing stopped] and CPR was initiated. R1 had been DNR for a long time. RN-A stated the facility previously utilized a resuscitation form but transitioned to use a Provider Orders for Life Sustaining Treatment (POLST) form a few months prior. RN-A stated the paper chart was the fastest place to find the code status and said the next place to look was the banner in the electronic record. (When the electronic record was accessed for a resident, a banner presented at the tope of the record which included the resident name and just below was the residents code status). R1 had a care conference on [DATE], at which time her code status was reviewed, and the director of nursing (DON) attended the care conference. During interview on [DATE] at 11:27 a.m., licensed practical nurse (LPN)-A stated she was working on a different unit the evening of [DATE]. The phone on the unit alerted a 911 call had been placed. LPN-A looked at the phone to determine which unit had placed the 911 call and immediately called the unit. LPN-A stated the (former) DON answered the phone and said the call was made on behalf of R1. When LPN-A arrived on the unit LPN-A asked why staff was administering CPR as R1 was DNR and the DON said there was no POLST in the chart'; although, the code status was easily found on the banner in the electronic record and said the information was manually entered by staff. Further, R1 recently had a care conference, attended by the DON and R1's DNR status had been discussed. During interview on [DATE] at 11:47 a.m., RN-B (interim DON) stated she was working on [DATE] and one of the nurses came to her and reported what was happening. RN-B stated R1's status was DNR. When RN-B arrived on the unit staff had not yet started CPR. The DON was holding R1's advance directive and despite multiple staff telling the DON R1 was DNR, the DON insisted staff initiate CPR. RN-B stated when the POLST form could not be found, staff should have looked at the banner in the electronic record to verify the code status. RN-B said following the incidents, three ring binders were implemented that contained each resident's POLST document for immediate verification. During interview on [DATE] at 2:30 p.m., the (former) DON stated she was working on [DATE], and explained the following events. DON was working on the unit when a nursing assistant asked her to keep an eye on R1 while she grabbed an emesis bag. The DON went to the dining room and found R1 gasping and gagging with green stuff coming out of her mouth and nose. The DON called LPN-B for help, and they brought R1 to the nurse's station from the dining room. The DON retrieved R1's paper chart while LPN-B was performing the Heimlich maneuver and could not find a POLST form in the chart. R1's chart contained an advance directive that indicated CPR. The DON showed the advance directive to LPN-B who said she thought R1 was DNR. The DON reiterated she also thought R1 had been DNR but said, this is what we got, referring to the advance directive in the chart. The DON stated another nurse came to the unit and also questioned R1's status being full code. When emergency services arrived, DON pulled a document from R1's electronic record that identified R1 had requested DNR. EMS did chest compressions and used the LUCAS ([NAME] University Cardiopulmonary Assist System device provides mechanical chest compressions to patients in cardiac arrest). The DON confirmed she had not verified R1's code status with the electronic record but, a few weeks prior, the DON was involved in a conversation with R1 about a hospice consult so the DON was confused on what the status was. On [DATE] at 2:55 p.m., the licensed nursing home administrator (LNHA) and campus administrator (CA) were interviewed. The LNHA stated when the incident occurred on [DATE], the DON had looked in R1's paper chart for the code status. The LNHA was not sure if any other staff looked in other locations for the code status. The LNHA stated there had been inconsistent information as to what should have been done. The CA stated R1 had a signed document in the paper chart as well as the banner and physician's orders in the electronic record identifying a DNR status. The CA stated the DON had erred on the side that it was better to do CPR and she had to make a split decision. The CA said the DON had been out a few weeks and thought R1 had changed her mind during that time. The CA stated moving forward, staff were directed to use the banner as the primary source of information that was fed by the POLST form. The CA stated POLST forms were now in binders on each unit and readily available. The CA stated staff received education and daily audits were being performed to ensure accuracy. During interview on [DATE] at 3:12 p.m., LPN-B stated she had been working on [DATE] and the DON had asked her to come to the dining room. When LPN-B got to R1, her lips were blue/purple and LPN-B tried to lift R1's head and arm up. Staff brought R1 to the nurses' station from the dining room and placed R1 on the floor to check her pulse and initiate CPR. LPN-B stated the DON looked for R1's code status. During interview on [DATE] at 8:07 a.m., doctor of nursing practice (DNP)-A stated she had been part of the discussions with R1 and her family regarding code status. DNP-A stated the situation was unfortunate and felt it could have been prevented. R1 had been DNR for over a year and said, what if the advance directive had said DNR and the banner said full code? DNP-A stated there was no excuse for what happened and R1 having to go through that process and family having to live though that too. DNP-A reviewed R1's chart which identified R1's DNR wishes in multiple places. DNP-A stated the whole time R1 was hospitalized she was on a ventilator, was vomiting and had to be suctioned continuously. When asked about LUCAS, DNP-A stated there was nothing left of her and said there was a potential for bruising and broken bones. The facility policy Advance Directive including Cardiopulmonary resuscitation and Automated External Defibrillator dated [DATE], indicated the following: If cardiac arrests occurs, CPR must be initiated unless the resident has: a. A valid DNR order on file that includes the medical order issued by a physician or other authorized non-physician practitioner. b. A valid Advanced Direction on file that includes written instructions such as a living will or durable power of attorney for healthcare, recognized under state law (whether statutory or a recognized by the courts of the state), and relating to the provision of healthcare when the individual is incapacitated. The policy indicated each day the nursing staff will print a report of all advance directive orders and keep them in a three-ring binder easily accessible to nursing staff. Any advance directive forms will also be kept in this binder. The IJ that began on [DATE], was removed on [DATE], when it was verified through interview and document review the facility had reviewed their policy for advance directives, educated staff to the policy and procedure for immediate verification of advance directives and initiated the use of a binder for immediate verification of code status along with a daily audit process to ensure accuracy.

Based on observation, interview and document review the facility failed monitor and develop and implement interventions to reduce the risk of pressure ulcers for 2 of 3 residents (R1,R4) reviewed. This resulted in actual harm to R1 who developed new and worsening pressure ulcers. Findings include: R1 Admission Observation dated 1/2/24, identified bruises and pressure sores. The observation did not identify location, size or stage of pressure sores. R1's Skin Risk assessment dated [DATE] indicated a Braden Scale for predicting pressure ulcer risk identifed a score of 13, inidcating he was at moderate risk for skin breakdown. R1's Physician Order Report dated 1/2/24 through 2/29/24, identified an order dated 1/2/24, that indicated: weekly skin check. Special instructions: Use wound management module to document wounds/ulcers. R1's Admission Minimum Data Set (MDS) dated [DATE], identified intact cognition and indicated he did not display rejection of care behaviors. The MDS indicated R1 had upper and lower extremity impairments and required substantial/maximal assistance with toileting, had an indwelling catheter and was continent of bowel. R1's pressure ulcer care plan created 2/19/24, indicated R4 had deep tissue injuries, pressure ulcers, and areas of maceration. the care plan directed staff to turn and reposition every two hours, perform wound observations as ordered and as needed, assess the pressure ulcer for location, stage, size (length, width,and depth), presence/absence of granulation tissue and epithelia at least weekly or as ordered and avoid friction and shearing forces during transfers or position changes. R1's Progress Notes identified the following: 1/2/24, indicated R1 had a stage II (arterial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough [type of nonviable tissue that occurs as a byproduct of the inflammatory process] or bruising) pressure sore to his coccyx that measured approximately 1 centimeter (cm) x 0.4 cm, wound bed red with minimal slough noted, surrounding skin had bleachable redness, R1 to be turned every two hours or as needed, heels were boggy and had blanchable redness. A correlating Wound Management Report identified a stage II pressure ulcer on R1's coccyx measuring 1 cm x .4 cm with a light amount of exudates. Tissue type indicated slough. 1/11/24, Wound on coccyx is covered with Mepilex. Nurse did not get measurements of wound. Wound has Sanguineous drainage (refers to the leakage of fresh blood produced by an open wound) absent edema and redness. The note lacked evidence a skin assessment was completed. 1/22/24, New Mepilex placed to coccyx and heels. The note lacked evidence a skin assessment was completed. 1/30/24, R1 continued with wound on coccyx, new Mepilex dressing applied to both coccyx and heels. The note lacked evidence a skin assessment was completed. 2/16/24. indicated R1's skin was assessed with physician and hospice nurse. R1 had a deep tissue injury (pressure ulcer in which area of skin may look purple or dark red, or there may be a blood-filled blister) to right calf that measure 9.5 cm x 0.5 cm, right heel had a non-stageable ulcer (full-thickness pressure injuries in which the base is obscured by slough and/or eschar) that measured 4.5 cm x 3 cm, left calf had a deep tissue injury that measured 6 cm x 1 cm, deep tissue injury to left ankle measuring 3.5 cm x 0.5 cm, left heel had a non-stageable wound that measured 2.5 cm x 3 cm, right shin had a deep tissue injury measuring 5.5 cm x 1.2 cm, stage II pressure ulcer noted to left side of back measuring 1.5 cm x 1.8 cm, coccyx has non-blanchable redness/maceration, two open areas to coccyx that measured 1.5 cm x 0.7 cm with a depth of 0.2 cm, non-blanchable area to right gluteal cleft 1 cm x 1 cm. Each area cleansed with normal saline, Mepilex dressing applied to both heels, both calves, and on back, protective barrier applied to coccyx. physician ordered to wash resident up twice daily, change shirt daily, reposition-side to side every two hours and as needed. Correlating Wound Management Detail Reports dated 2/16/24, identified wounds to R1's left heel, right and left calves and coccyx. 2/22/24, Written by registered nurse (RN)-B Resident had a bed bath this morning, given by hospice nurse. Wounds were measured and Mepilex placed on his heels, back and right shin,. The other areas were left open to air. The areas measured as follows: Right calf 9.5 cm x 0.5 cm, right heel 4.5 cm x 4 cm, left calf 6 cm x 0.8, left ankle 3 cm x 0.5 cm, left heel 2 cm x 3 cm, right shin 5.4 cm x 1.2 cm , back 1 cm x 0.8 cm, coccyx scattered small openings, right gluteal cleft 0.8 cm x 0.7 cm. Other areas of his body are clear, no other open areas. Resident did not tolerate the treatment well, it was very painful. 2/22/24, written by RN-B, this nurse called hospice nurse to find out more extensive information about the wounds on this resident and her findings. Wound Management section charted. Correlating Wound Management Detail Reports dated 2/22/24, identified wounds to R1's left heel, right and left calves and coccyx. During observation on 2/27/24, at 10:07 a.m. R1 was laying in bed watching television. R1 had an air mattress on his bed and had protective boots on his feet. During interview on 2/28/24 at 7:59 a.m., nurse practitioner (NP)-A stated on 2/16/24, she was in the facility and was called in to do a skin assessment on R1. NP-A stated she had seen some changes in R1's skin integrity and a lapse of treatment prevention interventions. NP-A said R1 was not wearing his heel protectors and had a pillow behind him but said the repositioning wedges had been shoved under a television stand. NP-A stated R1 had a lot of new skin integrity issues and said things were not being done. NP-A said with R1's condition she would have expected some decline but not to the degree she saw. NP-A said she questioned if R1 was being repositioned, received adequate hygiene assistance and said he should have had an air mattress. On 2/28/24 at 2:04 p.m., the director of nursing stated R1 had come from the hospital with a wound on his coccyx and had a treatment plan in place. The DON stated she knew R1's heels had been boggy upon admission but said prior to the assessment on 2/16/24, she had not been aware the wounds had progressed. The DON stated on 2/16/24, they had found wounds on R1's heels had opened and he had wounds on his shins, calves and back. The DON stated routine skin inspections had not been completed and documentation was lacking following the identification of the wounds and the care plan lacked interventions. The DON stated when a wound was noted, the nurse should have completed an incident report and immediate interventions should have been implemented. The DON stated they were working on education for staff. The DON stated after R1's wounds were assessed the facility made sure all residents had skin assessments completed. During interview on 2/29/24 at 10:30 a.m., nursing assistant (NA)-D stated R1's skin could breakdown very easily if he was not repositioned every two hours. NA-D stated R1 was not able to make significant changes in his position on his own. During interview on 2/29/24 at 10:38 a.m., RN-B stated she had documented the skin assessment on 2/22/24, but stated she had not actually seen R1's skin. RN-B stated she had received the information from the hospice nurse to complete the documentation. R4's quarterly MDS dated [DATE], identified severe cognitive impairment and indicated she was dependent on staff for toileting, repositioning and transfers. R4's MDS identified a stage II pressure ulcer. R4's care plan dated 11/21/23, indicated potential for alteration in skin integrity due to limited mobility, pain, incontinence and diabetes. The care plan identified a history of pressure ulcers to R4's coccyx. The care plan directed staff to assist R4 to turn and reposition every two hours while sitting and while lying down. During continuous observation on 2/28/24, at 8:56 a.m. R4 was seated in the dining room in her wheelchair finishing breakfast. Underneath R4 in her chair was a mechanical lift sling. At 9:07 a.m. a staff member escorted R4 to her room and placed her in front of the television. At 9:52 a.m. a nurse entered the room to administer insulin then left. At 9:58 a.m. NA-A looked into the room but did not enter. At 11:26 a.m. R4 remained seated in her wheelchair in her room with no offers of repositioning. During interview and continuos observation at 11:31 a.m., NA-A stated R4 required total assistance from staff. NA-A stated R4 usually hung out in her wheelchair between breakfast and lunch then laid down after lunch. NA-A said R4 had a sore on her bottom and said her care plan indicated she should be repositioned every two hours. NA-A stated the last time R4 had been repositioned was around 8:00 a.m. At 11:37 a.m. NA-A and RN-A assisted R4 to lay down on the bed. RN-A removed an adhesive dressing from R4's buttocks performed a skin inspection which revealed a large area of scarring from previous ulcers and a scabbed over area approximately 1 cm x .5 cm. RN-A said R4 had a history of pressure ulcers that come and go. NA-A stated R4 should be repositioned every two hours. Facility Policy Pressure Ulcers dated 2/1/24,identified guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers and indicated the following information should be recorded in the resident ' s medical record: All assessment data (i.e., color, size, pain, drainage, etc.) when inspecting the wound.

Based on observation, interview and document review the facility failed to assess, develop and implement interventions to reduce the risk for falls for 1 of 3 residents (R2) who had repeated falls with fractures. This resulted in actual harm for R2 who sustained a fractured nasal bone, fractured vertebrae and fractured rib. In addition, the facility failed to ensure safe use of mechanical lift devices for 3 of 3 residents (R2, R4, R5) reviewed. This resulted in further harm to R2 who fell from a EZ Lift Stand and sustained a broken clavicle (collarbone). Findings include: R2's significant change Minimum Data Set (MDS) dated [DATE], identified intact cognition and indicated he was independent with transfers, toileting, and dressing. The MDS indicated he required moderate assistance for showers. R2's MDS further identified a fall with fracture prior to admission and indicated he had not had a fall since the prior assessment. R2's care plan dated 1/26/24, identified a potential for falls due to history of falls, medications, pain, weakness, heart and kidney disease. Interventions included: 12/15/23, keep wheelchair at bedside when not in use.,1/5/24, initiate and reinforce safety teaching, 1/5/24, walker, urinal at bedside. 1/26/22, frequent purposeful rounding. make sure resident has pendent call light. R2's medical record lacked evidence of a comprehensive assessment of his falls. Facility Healthcare Safety Zone (incident report) dated 12/14/23, indicated R2 called for staff assistance around 4:45 a.m R2 was seated on the floor next to his bed with his wheelchair behind him. There was a pool of blood next to R2, his nose was bleeding, he had a large skin tear by his left elbow and his right big toe was bleeding. R2 reported he had a nightmare, rolled over and woke up on the floor. Interventions placed prior to the fall included: personal items in reach, evaluate for environmental hazards, remind to call for assistance, personal alarm in bed and ensure wheel chair brakes are locked at all times. Interventions placed following the fall included bed/chair alarms and education. R2' facility Progress Note dated 12/14/23, indicated R2 returned from the emergency department (ED) around 6:30 p.m. R2 returned with a cervical thoracic orthosis (CTO) brace. (A neck brace that has an extension support to also protect the thoracic spine). Healthcare Safety Zone dated 12/19/23, indicated R2 slid off his shower bench to the shower floor. R2 called out for help and was found on the floor. R2 had old bruising under his eyes and a skin tear from his previous fall. The report did not include interventions following the fall. Healthcare Safety Zone dated 12/25/23, indicated R 2 was found on the floor in the bathroom at 5:30 a.m. It appeared his wheelchair brakes were not locked as chair was across the room. No injuries noted at the time. R2 did not have call light on and no gripper socks on his feet. The fall report did not include interventions following the fall. R2's Progress Note dated 12/26/23, indicated he slid off his bench in the shower. Nurse educated from now on staff needed to sit with R2 for safety purposes. Care plan lacked evidence interventions were implemented. R2's Event Report dated 1/19/24, identified a fall at 2:30 a.m. The report indicated R2 was found on the bathroom floor and complained of pain in his ribs on the left side. R2 was reminded to use his call light for assistance with transfers and toileting. R2's Progress Note dated 1/19/24, indicated he returned from the ED at approximately 2:20 p.m. R2 was diagnosed with a rib fracture. Encourage use of brace and to deep breath and cough every hour to prevent collapse of lungs and use pillow to help ease pain. R2's Progress Note dated 1/27/24, indicated he self-transferred to his bed and fell . R2 hit his call light and it got disconnected. Staff in next room responded and found R2 on the floor with his upper body leaning on the bed. R2's right toes were stuck under his wheel chair. R2 complained of pain in his knees which were red and swollen with an indent in the right knee. No intervention noted. During interview on 2/27/24 at 3:08 p.m., R2's falls were reviewed with the director of nursing (DON). The DON stated when a resident fell , the nurse in charge should place immediate interventions, then the interdisciplinary team (IDT) would review and update care plans and care sheets. The DON stated when R2 fell on [DATE], he sustained a fractured vertebrae and broke his nose. The DON said at that time they discussed therapy because R2 had become more weak and had been hospitalized multiple times. The DON stated the care plan was updated to include increased supervision and to have his wheel chair next to his bed. The DON stated on 12/19/23, R2 slid off his shower bench and staff were directed not to leave him alone in the shower. (Record lacked evidence this was care planned). The DON stated R2 was found on the floor in his bathroom on 12/25/23, and said his wheelchair brakes were not locked and he did not have non slip footwear on. The DON said they encouraged the use of non slip socks. The DON stated when R2 fell off the shower bench the second time on 12/26/23, there was no evidence the IDT had reviewed the fall. Following the fall on 1/19/24, the DON stated R2 was hospitalized for respiratory failure and COVID. The DON said R2 returned to the facility on [DATE], and said he was still able to move around the facility and was given a pendant style call light and reminders to use it. Following the fall on 1/27/24, the DON stated there was no evidence the fall was reviewed. The DON stated there was missing documentation in progress notes and the Health Safety Zone reports and confirmed a comprehensive assessment of R2's fall had not been completed. Fall from lift Healthcare Safety Zone dated 2/5/24, indicated staff was assisting R2 to the bathroom using a mechanical stand. R2 let go of the handles and began to slide out of the stand. Staff was able to guide R2 to the floor. R2 sustained a skin tear and complained of pain in his right shoulder. R2 was sent to the emergency department after dialysis. During observation and interview on 2/27/24 at 1:10 p.m., R2 was laying on his back in bed. R2 was asked how he was doing and replied terrible, I have a broken collarbone, and a broken rib. R2 stated when he broke his collar bone, they raised me up in the lift and it dropped. Not sure what happened, I probably slid out of it. R2 stated before he came to the facility he could walk with a walker and now he couldn't do anything. He sated he couldn't stand and used a machine to transfer. R2 said, If I break another bone they might as well shoot me. During interview on 2/27/24 at 2:23 p.m., trained medication aide (TMA)-A stated most of R2's falls had been on his dialysis days when staff were getting him up. TMA-A said the last one was from the mechanical stand and said he was not sure of the details but said that was how R2 got the broken clavicle. TMA-A said R2 now required a mechanical lift to transfer. TMA-A said prior to the fall from the stand they kept his wheel chair close, did frequent rounding and made sure his call light was in reach. TMA-A stated before R2 began falling he had been very independent. TMA-A said R2 had not been walking but was independent with transfers and toileting. During interview on 2/27/24 at 3:08 p.m., the DON stated when R2 fell from the mechanical stand on 2/5/24, it looked like he let go of the handles and staff guided him to the floor. The DON stated R2 sustained a skin tear and a broken collarbone. The DON stated an investigated into the details of the fall had not been completed. During interview on 2/27/24 at approximately 3:45 p.m., licensed practical nurse (LPN)-A stated normally R2 required assistance from one to two staff but had been having a hard time so on 2/5/24, she transferred him to the bathroom using the mechanical stand. LPN-A stated when she was bringing R2 to the bathroom his arms lifted and he fell through the lift. LPN-A said she had the harness secured around R2 but said it may have loosened when he was stood up. LPN-A stated she had not secured the calf strap when R2 was in the lift. LPN-A said no one from the facility had asked her about the details of the incident but said she did not feel the lift had malfunctioned in any way. LPN-A said R2 now required the use of a ceiling lift for transfers. R4's care plan dated 2/12/24, identified a self care deficit due to cerebral vascular accident with left sided weakness. The care plan directed staff to provide assist of one staff and [NAME] Stedy (a manual sit-to-stand transfer aid) or easy mover (mechanical stand aid) to transfer R4 to the toilet. An untitled facility care sheet dated 2/14/24, indicated R4 used a mechanical lift for transfers. The care sheet did not specify a sling size for R4. During observation and interview on 2/28/24 at 11:37 a.m., nursing assistant (NA)-A and registered nurse (RN)-A assisted R4 to transfer from wheelchair to bed using a mechanical lift. While lifting R4 up in the lift, the sling appeared too big. The sling was a split leg design but instead of bringing each strap under R4's legs and crossing them in the middle, each strap was brought under both of R4's legs and hooked to the lift. After R4 was laying on the bed NA-A and RN-A were asked about the sling size. NA-A looked at the sling and stated it was size large. NA-A stated the slings were based on weight and when asked if she knew if R4's sling was correct based on her weight she stated should would have to ask the nurse how much R4 weighed. When asked about the position of the leg straps, RN-A stated she would have to do some research. NA-A and RN-A then transferred R4 back to the chair the same way. During interview on 2/28/24 at 12:36 p.m., the facilities EZ- Lift representative stated if a fall occurred from a mechanical stand it could have been the straps were not properly attached. The representative said if the harness was still attached, likely the resident was not properly situated in the sling. The representative stated a resident should never slide out of the harness if it was the correct size and attached properly to the lift and the patient. In regard to the mechanical lift slings, the representative stated the slings should be used the way they were designed and said if they were not applied properly or not the correct size it could cause accidents. R5's care plan dated 2/14/24, identified a self care deficit due to dementia and directed staff to assist with transfer using one staff and a [NAME] Stedy. An untitled, undated facility care sheet, received on 2/28/24, indicated R5 used a mechanical lift for transfer. The sheet indicated make sure medium lift sling is used. During observation on 2/28/24 at 1:30 p.m., NA-B and NA-C transferred R5 from wheelchair to bed using a ceiling lift. R5 was using a mesh, split leg sling with blue straps. The label on the sling was missing. NA-B stated the sling was a large and said the medium slings had yellow straps. NA-B further stated he thought a medium sling would be good for R5 and said, this one is a little big. During interview on 2/28/24 at 1:52 p.m., RN-A stated the sling used to transfer R4 had been the wrong size and said the strap positioning was not done according to manufacturers instruction. An undated facility document titled EZ-Stand Transfer, directed staff to bring the lift as close to the patient as possible. Place the harness around the patient, fasten the safety harness, secure the strap and pull it tight to fit. Place feet on the foot plate and attach the shin strap. When lifting the patient up simultaneously tighten the safety strap fastened around the patients torso. A facility document titled kwikpoint Patient Lifts Safety Guide undated, indicated using the wrong sling or attaching the sling incorrectly may cause serious injury to the caregiver or patient. Facility policy Fall Prevention And Management dated 3/29/23, indicated if the fall involves a medical device secure the device and any parts or accessories for follow up investigation and report to the administrator.

Based on interview and document review, the facility failed to implement physician ordered interventions to prevent pressure ulcers for 1 of 1 residents (R1) reviewed for pressure ulcers. This resulted in actual harm for R1 who acquired three unstageable pressure ulcers that were caused by a device. Findings include: R1's entry Minimum Data Set (MDS) dated [DATE], indicated he did not have a pressure ulcer. A discharge MDS dated [DATE], identified three stage III (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed) pressure ulcers. However, the MDS was not coded correctly as the pressure ulcers were covered in slough (soft, moist avascular, devitatlized [dead] tissue) or eschar (thick leathery black or brown devitalized tissue). R1's care plan dated 8/4/21, identified a self care deficit and risk for pressure ulcers related to impaired mobility, below knee amputation and amputation of left toes. The care plan directed staff to monitor R1 for redness and breakdown daily. A facility Event Report dated 7/6/21, indicated R1 hit his foot on the bathroom door, said he heard a crack and had pain. An Emergency Department Visit note dated 7/12/21, indicated R1 was seen due to his leg injury following running into the door. The visit note identified a closed, non-displaced fracture of the left tibia. R1 had a splint applied to his leg. A [NAME] Bemidji Orthopedic and Sports Medicine progress note dated 7/14/21, indicated R1 was fit for a custom brace for his left leg. The note indicated, it is imperative to check the skin 3 times a day at the the care center and any problems return immediately. R1's Treatment Administration History dated 7/1/21 - 7/31/21, indicated weekly skin check, once daily on Friday. The treatment record lacked evidence R1's skin was monitored three times per day as ordered by the physician on 7/14/21. A Resident Progress Note dated 7/22/21, at 9:20 a.m. indicated during cares the nursing assistants (NA)s noted that R1 had a large indentation and open area on the back of his left leg and his left heel was black and green. The NAs noted when they removed R1's sock the area peeled off and a very strong odor was noted. A note dated 7/22/21, at 9:48 a.m. indicated a nurse assessed R1's leg and identified the following: R1's gripper sock was soaked with drainage and adhered to the back of his calf. R1's left heel was greenish in color, moist with wrinkled skin and a moldy odor. Staff were able to remove greenish matter with wound cleanser. Foot had a pressure area to back of heel, back of calf and a deep tissue injury on the heel. R1 stated, Oh, that hurts but was unable to rate pain. The note indicated R1 had been seen by the orthopedic physician and no skin concerns had been identified, however, R1's family member confirmed that the physician had not removed the brace to assess the skin during the visit. An untitled progress note written by the wound clinic registered nurse (RN) on 7/26/21, indicated R1 was referred back to the outpatient wound clinic for skin breakdown secondary to a brace that was issued on 7/14/21. The note indicated, It was clearly stated in the OT [occupational therapy] visit note that the skin should be assessed several times a day for skin breakdown. R1 stated the splint was on his leg for three days prior to it being removed and checked. R1 arrived for the visit with no sock and a foam dressing covering his foot/ankle. R1 had 3+ pitting [CONDITION(S)] and the brace was tight fitting due to the [CONDITION(S)]. The skin injuries were located on the left heel, left lateral ankle and left posterior calf that were clearly device related. R1 could not wear the brace as he would have continued breakdown due to known vascular compromise. R1's wounds were identified as: left lateral ankle - .2 cm x .2 cm, 100% eschar (dead tissue), left heel - .3 cm x .3 cm 100% yellow, dry slough (yellow devitalized tissue, that can be stringy or thick and adherent on the tissue bed), and left posterior calf - .2 cm x 3 cm 100% dry yellow slough. During interview on 8/16/21, at 2:19 p.m. RN-A who was the nurse manager on the unit, stated she had not seen R1's wounds but said it sounded like it looked green. RN-A stated when she had looked at R1's leg not long before he did not have any problems. RN-A stated after R1's appointment on 7/14/21, she had put the order in R1's treatment administration record for skin checks three times a day but when she looked for it she could not find it. RN-A said on 7/22/21, when she saw the note about the green, moldy skin she made an appointment for R1 to be seen at the wound care clinic. On 8/17/21, at 12:33 p.m. R1 was sitting up in bed eating lunch. When asked how he was and if he was being taken care of R1 said, you know, that's questionable. When asked about his wounds R1 stated staff had not been looking at his foot and said they didn't do nothing really. At 12:57 p.m. the director of nursing (DON) stated she asked one of the staff members that worked with R1 regularly and said R1 would not let staff look at his leg. The DON confirmed there was no documented evidence R1 refused to have his skin assessed. A policy related to implementation of physicians orders was requested but not received.

Based on observation, interview, and document review, the facility failed to comprehensively assess, monitor, and provide ongoing treatment including medical attention for 1 of 3 residents reviewed who had sustained a significant skin injury following a fall. This failure resulted in actual harm due to identification of the wound requiring sutures which could not be applied due to the delayed identification of the significance of the wound. Findings include: R3's undated face sheet indicated R3's [DIAGNOSES REDACTED]. R3's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R3 had moderate cognitive impairment and was independent with all activities of daily living (ADLs) with setup help from staff. The MDS indicated R3's skin was intact. R3's care plan dated 4/5/19, identified a self care deficit and directed the staff to supervise R3 with dressing and one staff to physically assist with bathing, pivot transfers, and ambulation with a wheeled walker. The care plan also indicated R3 had no skin issues. R3's Progress Note (PN) dated 6/5/20, at 4:01 a.m. indicated a V shaped skin tear was noted on R3's right elbow that measured 1.5 centimeters (cm). R3 stated he had fallen down onto the toilet hitting his elbow on the bar. The area was cleansed and covered with a 2 X 2 gauze and transparent dressing. However, R3's treatment record lacked information related to the skin injury and need for follow up/treatment. On 6/11/20, at 3:00 p.m. R3 was observed in his room, seated in the wheelchair with his right arm bent and resting on his lap. R3 lifted his right arm up with his left hand and stated he was not doing so good. It's my arm, I fell in the bathroom and hit it on the rail in there. R3 stated he wanted to go to the doctor, but the staff had taped it up, bandaged and wrapped his arm. R3 added, I think I need stitches. R3 stated the injury occurred about a week ago and verified that he did not ask for help with mobility into the bathroom because, I just go myself. If you are from the department of health, maybe you can look into it. On 6/12/20, at 8:15 a.m. R3 was observed seated in the wheelchair, in his bathroom facing the sink. -At 8:31 a.m. R3 was observed seated on his bathroom toilet. No staff entered the room. -At 8:35 a.m. staff entered the room and reminded R3 of the need to call for assistance in order to prevent falls. R3 refused assistance and remained sitting on the toilet. Staff exited the room. -At 8:37 a.m. staff entered R3's room and assisted him to finish toileting. -At 9:30 a.m. R3 stated, My elbow hurts, would you like to see it? and proceeded to remove the Kerlix wrap which was covering his right elbow wound. The wound appeared to have an open area that was approximately 2.0 cm in length and when R3 lifted up his elbow, the wound gaped open approximately 1.0 cm with an observable, undetermined depth. R3 stated he had asked the nurse for a new dressing, but she said he was not on her list of dressing changes to be completed that day. -At 9:35 a.m. the surveyor (SA) requested that RN-A notify the SA when she performed R3's right elbow dressing change so that the SA could observe it. -At 9:37 RN-B approached the SA and stated R3 did not have a dressing change ordered. When RN-B was informed R3 had an open area on his right elbow, RN-B stated there was no documented evidence of a dressing change order for R3's wound on the medication or treatment record. RN-B stated typically if a resident had an open area/wound, it would be identified on the treatment record and would include treatment orders. At this time, RN-B stated she was going to go look at R3's wound. Upon nearing R3's room, RN-A was observed exiting R3's room and stated to RN-B, yeah it is bad, it should have had stitches. I don't work here that often, so I was not aware of it. RN-A stated it was too late to send R3 into the clinic for stitches, therefore, RN-B directed RN-A to apply Steri-strips to the wound and to notify the physician for further orders. -At 9:44 a.m. a telemed visit was conducted with R3's primary physician who prescribed treatment orders, a wound program, and a follow up evaluation to be done in one week. R3's Physician Office Visit Note dated 6/12/20, indicated R3 had been evaluated for a skin tear on his right elbow following a fall in 6/5/20, and staff were wondering if the wound needed to be pulled together, but a week had past. The note indicated R3's elbow appeared to have a 2.0 cm length by a 0.5 cm width, triangular shaped skin tear directly over the olecranon prominence of the right elbow. The skin edges are withdrawn about a 1.0 to 1.5 cm and 0.5 cm depth at the worst midpoint of the triangle. There is no drainage. At this late juncture it is not worth placing sutures rather a Q-tip was to be used to lift the skin edge to try to approximate the tear a little better then to secure and place Steri-strips in an attempt to bring the wound edges together a little. Antibiotic ointment and a [MEDICATION NAME] (a transparent dressing) to be applied for one week at which time the physician would discuss proper removal of the [MEDICATION NAME] and replacement with the facility. On 6/12/20, at 1:30 p.m. a telephone interview was attempted with R3's unit manager, without success. On 6/12/20, at 3:30 p.m. during a telephone interview, the director of nursing (DON) stated she had only been in her position for four weeks, but had been aware of R3's right elbow skin wound as a result of a fall on 6/5/20. The DON stated the interdisciplinary team (IDT) had discussed the incident the next day and was told R3 had denied falling and would not allow staff to look at his arm. The DON stated she, herself had not visualized the wound as she had been told R3 would not allow the wound to be looked at. The DON acknowledged R3's documentation indicated the nurse had assessed and treated the skin injury as soon as it was identified, but had not noted the wound or treatment provided onto R3's treatment record in order to alert the staff that he had the wound and the need to continue monitoring it. In addition, the DON stated she would have expected there to have been more documentation related to R3's wound in his clinical record. The facility's Skin Risk Assessment Interventions policy revised on 4/25/19, indicated if a resident had a pressure injury or skin breakdown to complete the treatment as ordered, monitor area daily, conduct a weekly comprehensive assessment, document, and to monitor the wound for signs of infection.

Based on interview and document review, the facility failed to comprehensively assess and/or develop and implement fall interventions in order to minimize the risk for falls and injury for 2 of 3 residents (R1, R3) identified at risk for falls. This failure resulted in actual harm when R1 was not provided timely toileting assistance and her wheelchair had not been positioned by the bed, as directed, resulting in a fall and subsequent sacral fracture. This failure also resulted in actual harm when R3 did not receive comprehensive assessments and implementations of new fall interventions following each falls per the facility fall policy resulting in a significant skin injury which would have required the application of sutures. Findings include: R1's admission Minimum Data Set ((MDS) dated [DATE], indicated R1's [DIAGNOSES REDACTED]. The MDS also indicated R1 required limited assistance with transfers, dressing, and personal hygiene and extensive assistance with bed mobility and toileting. R1 had not ambulated and required assistance with mobility in her wheelchair. R1 had a history of [REDACTED]. R1's Activities of Daily Living (ADL) Functional Status Care Area Assessment (CAA) dated 5/26/20, indicated R1 had fallen at home and sustained a left [MEDICAL CONDITION] with surgical repair. R1's nurses noted reflected forgetfulness and confusion at times and indicated R1 required ADL assistance. R1's Fall CAA dated 5/26/20, indicated R1 was at risk for falls related to her history of falls, medications, slight cognitive impairment, incontinence and pain. The undated, personal care sheet, a pocket care plan utilized by the nursing assistant's, indicated R1 had a left [MEDICAL CONDITION] with surgical repair and was partial weight bearing to left leg, had bouts of confusion, was at risk for falls, and directed the staff to provide every 30 minutes rounding checks, assist of one to transfer with a walker and gait belt, a low bed, pendant call light, hip protectors to be worn, wheelchair to be at bedside, signage in room to remind to call for assistance, and to toilet every two hours and at 4:00 a.m. and 6:00 a.m. R1's comprehensive care plan created 5/26/20, indicated R1 had mild cognitive impairment, had a potential for falls due to a history of falls, medication use, limited mobility, incontinence, and cognitive deficit. The care plan directed the staff to keep assistive devices and call light within reach, hip protectors on when awake, 30 minute rounding (visual checks), frequent reminders to use call light, signage for reminders to call for assistance, offer toileting every two hours and at 4:00 a.m. and 6:00 a.m., assist of one with a front wheeled walker and gait belt for transfers, low bed, bed to be at transfer height for all transfers, pendant call light, and to initiate and reinforce safety teaching. The care plan also indicated R1 was at risk for potential complications related to anticoagulant (blood thinner) therapy and directed the staff to protect R1 from injury/trauma. R1's Fall Risk Assessment, dated 6/2/20, identified R1 was at risk for falls. R1's clinical record lacked any previous fall risk assessments. R1's 5/30/20, incident report submitted to the State Agency (SA) indicated on 5/30/20, R1 was found on the floor, in her room. R1 stated she was trying to ambulate to the bathroom when she fell . R1's Nurse Progress Note (PN) dated 5/28/20, indicated R1 was alert and orientated with confusion at times. She was able to use the call light appropriately most times, was continent of bowel and bladder, and required assistance of one with ADL's and to pivot transfer. R1's PN dated 5/29/20, indicated R1 required extensive assistance of one for wheelchair locomotion on the unit. R1's PN dated 5/30/20, at 12:06 a.m. indicated staff had heard R1 yelling for help. R1 was found seated on the floor, in her room. Staff assessed R1 and with the assistance of three staff and a gait belt, assisted R1 up off the floor. Upon rising, R1 immediately complained of pain in her left and was assisted to sit in her wheelchair then pivot transferred to her bed. Upon transfer, R1 again complained of increased pain in her left leg. Staff assessed R1's left hip area and noted deformity to the upper left leg and swelling. The on call provider was contacted. R1's PN dated 5/30/20, at 12:42 a.m. indicated an ambulance was called to transfer R1 to the emergency room . A subsequent PN at 3:51 a.m. indicated the emergency room staff called and notified the facility that R1 had re-fractured her left hip and world be admitted to the hospital for further care. R1's 6/5/20, 5 day investigation report submitted to the SA indicated R1 had sustained a fall with significant injury due to staff not following R1's care plan, as directed. The report indicated the care plan directed the staff to keep R1's wheelchair at bedside and to toilet R1 every two hours. The investigation revealed R1's wheelchair was not positioned at her bedside rather was positioned across the room, and R1 had not been toileted every two hours as directed. The facility re-educated the staff on the importance of following care plan directives and were directed to review the personal care attendant (PCA) sheets (pocket care plans which identified each resident care needs) at the start of every shift. The report also indicated R1 had not sustained a hip re-fracture, but did sustained a sacral fracture as a result of the fall. On 6/12/20, at 3:30 p.m. the director of nursing (DON) stated R1's care plan indicated a fall prevention program was in place which would refer the reader to the PCA for the individualized interventions implemented. The DON stated during the investigation of R1's fall, it was discovered that the staff did not follow R1's care plan regarding placing the wheelchair by the bed and toileting R1 every two hours as R1 had not been assisted with toileting since 8:00 p.m. the previous evening (approximately four hours prior to the fall). R3's undated face sheet indicated R3's [DIAGNOSES REDACTED]. R3's quarterly MDS dated [DATE], indicated R3 had moderate cognitive impairment and was independent with all ADLs with setup help from staff. The MDS also indicated R3 was occasionally incontinent of bowel and bladder and had experienced two or more falls since his last assessment. R3's care plan dated 4/5/19, identified a self care deficit and directed the staff to supervise R3 with dressing and one staff to physically assist with bathing, pivot transfers, and ambulation with a wheeled walker. The care plan indicated R3 often transferred himself and did not ask for help. The care plan also indicated R3 had occasional incontinence and directed the staff to offer toileting every two hours when awake to help avoid self transfers. The care plan indicated R3 was at risk for falls and directed the staff to place R3 on a fall prevention plan, provide a walker, encourage R3 to sit while praying, to not give R3 powder, to encourage use of gripper socks at all times, encourage to call staff for assist, conduct frequent and purposeful rounding, offer and assist as he would allow with showers, provide a longer phone cord and a one way glide and anti roll back on wheelchair. Review of R3's PN revealed the following: -On 2/21/20, at 3:20 a.m. R3 was found sitting on the bathroom floor. His brief and pants were lying on the floor next to him with the wheelchair nearby with the brakes engaged. No injuries were noted. R3's clinical record lacked evidence of a root cause analysis and interventions implemented. -On 3/15/20, at 6:31 a.m. R3 was found on the shower floor. He stated he purposely got down on the floor and was wiping up excess water but could not get himself back up. R3's clinical record lacked evidence of a root cause analysis and interventions implemented to prevent future occurrences. The record also indicated R3 would independently take a shower in his bathroom shower. -On 3/29/20, R3 rang his call light and was found sitting on the bathroom floor. R3 stated he had lost his footing on the slippery bathroom floor and went down, landing on his buttocks. R3 had had a bowel movement which was noted on the floor, R3's shoes, and on the toilet seat and bowl. R3's clinical record lacked evidence of a root cause analysis and interventions implemented. -On 4/1/20, at 9:17 a.m. indicated R3's care plan was reviewed. A subsequent note dated 4/2/20, at 9:02 a.m. indicated care plan review directed staff to increase scheduled toileting, to offer toileting every two hours while awake with a goal of one or less incontinent voids per week. However, the note did not identify the effectiveness of the current fall interventions nor any new fall interventions implemented. -On 6/5/20, at 4:01 a.m. a V shaped skin tear was noted on R3's right elbow that measured 1.5 centimeters (cm). R3 stated he had fallen down onto the toilet hitting his elbow on the bar. The area was cleansed and covered with a 2 X 2 gauze and transparent dressing. An incident report was completed, however, did not include a root cause analysis or evaluation of the bathroom to ascertain how R3 obtained the injury. -On 6/12/20, at 9:50 a.m. staff entered R3's room to assist R3 as he had transferred himself to the toilet. R3 was very resistive with staff. R3 was reminded to use call light to ask for assistance. R3 stated he did not need help. R3 was reminded of his previous falls and was asked to use his call light in order to prevent future falls. Writer indicated this conversation with R3 would be discussed with the nurse manager on her return. R3's clinical record lacked evidence of a comprehensive assessment of the aforementioned fall incidents which would have included a root cause analysis. The record also lacked an assessment on how R3 sustained a skin tear on his right elbow from the toilet grab bars following a fall. On 6/11/20, at 3:00 p.m. R3 was observed in his room, seated in the wheelchair with his right arm bent and resting on his lap. R3 lifted his right arm up with his left hand and stated he was not doing so good. It's my arm, I fell in the bathroom and hit it on the rail in there.At this time, two U-shaped metal bars were observed bolted to floor on both sides of the toilet. The bars had a smooth surface with no sharp edges noted. R3 stated he wanted to go to the doctor, but the staff had taped it up, bandaged and wrapped his arm. R3 added, I think I need stitches. R3 stated the injury occurred about a week ago and verified that he did not ask for help with mobility into the bathroom because, I just go myself. If you are from the department of health, maybe you can look into it. On 6/12/20, at 8:15 a.m. R3 was observed seated in the wheelchair, in his bathroom facing the sink. -At 8:31 a.m. R3 was observed seated on his bathroom toilet. No staff have entered the room. -At 8:35 a.m. staff entered the room and reminded R3 of the need to call for assistance in order to prevent falls. R3 refused assistance and remained sitting on the toilet. Staff exited the room. -At 8:37 a.m. staff entered R3's room and assisted him to finish toileting. -At 9:30 a.m. R3 stated, My elbow hurts, would you like to see it? and proceeded to remove the Kerlix wrap which was covering his right elbow wound. The wound appeared to have an open area that was approximately 2.0 cm in length and when R3 lifted up his elbow, the wound gaped open approximately 1.0 cm with an observable, undetermined depth. R3 stated he had asked the nurse for a new dressing, but she said he was not on her list of dressing changes to complete that day. -At 9:35 a.m. the SA requested that RN-A notify the SA when she performed R3's right elbow dressing change so that the SA could observe it. -At 9:37 RN-B approached the SA and stated R3 did not have a dressing change ordered. When RN-B was informed R3 had an open area on his right elbow, RN-B stated there was no documented evidence of a dressing change order for R3's wound on the medication or treatment record. RN-B stated typically if a resident had an open area/wound, it would be identified on the treatment record and include dressing change orders. At this time, RN-B stated she was going to go look at R3's wound, however, upon nearing R3's room, RN-A was observed exiting R3's room and stated to RN-B yeah it is bad, it should have had stitches. I don't work here that often, so I was not aware of it. RN-A stated it was too late to send R3 into the clinic for stitches therefore RN-B directed RN-A to apply Steri strips to the wound and notify the physician for further orders. -At 9:44 a.m. a telemed visit was conducted with R3's primary physician who described and prescribed orders for a wound program, with a follow up evaluation to be done in one week. R3's Physician Office Visit note dated 6/12/20, indicated R3 had been evaluated for a skin tear on his right elbow following a fall in 6/5/20, and staff were wondering if the wound needed to be pulled together, but noted a week had already past. The note indicated R3's elbow appeared to have a 2.0 cm by 0.5 cm triangular shaped skin tear directly over the olecranon prominence. The skin edges are withdrawn about a 1.0 cm to 1.5 cm and 0.5 cm depth at the worst midpoint of the triangle. There is no drainage. At this late juncture, it is not worth placing sutures and directed the staff to use a Q-tip to lift the skin edge to try to approximate the tear a little better then to secure and place Steri-strips in an attempt to bring the wound edges together a little. Antibiotic ointment and a [MEDICATION NAME] (a transparent dressing) to be applied for one week at which time the physician would discuss proper removal of the [MEDICATION NAME] and replacement with the facility. On 6/12/20, at 1:00 p.m. RN-B stated she was not aware that the facility's fall policy directed RN or physical therapist (PT) to observe a resident transfer following each fall and confirmed this evaluation had not been completed. RN-B verified the staff were not completing fall risk assessments and developing and implementing new interventions after each fall, rather would complete a fall risk assessment only if something had changed with the resident. In addition, RN-B stated she would have expected the nurse to have assessed the bathroom to investigate how R3 had cut his elbow on the toilet grab bar and document that assessment in R3's PN's. RN-B stated there would have been plenty of other interventions to implement in an attempt to minimize falls and/or injury. On 6/12/20, at 1:30 p.m. a telephone interview was attempted with R3's unit manager, without success. On 6/12/20, at 1:38 p.m. occupational therapist (OT)-A stated the head therapist attended the facility's interdisciplinary meetings meetings (IDT), but she did not think on a daily basis. OT-A stated the occupational therapy department would receive referrals for evaluations following a resident's fall and verified a referral had not been received following R3's falls. On 6/12/20, at 3:30 p.m. during a telephone interview, the director of nursing (DON) stated she had only been in her position for four weeks therefore was not familiar with R3's March 2020, falls. However, the DON stated she had been aware of R3's right elbow skin tear wound as a result of landing on the toilet hard on 6/5/20. The DON stated the IDT had discussed the incident the next day and was told R3 had denied falling and would not allow staff to look at his arm. The DON verified R3's falls had not been comprehensively assessed which would have included the identification and potential elimination of the cause of the elbow injury, and a RN or physical therapist evaluation of R3's transfer abilities in order to identify a need for therapy and/or new interventions to be implemented. The DON stated the IDT as well as nursing staff should have attempted to identify and implement alternative interventions for safe transferring techniques for R3. The facility's Fall Management Program policy and procedure revised 12/10/18, indicated after each fall, staff were to implement immediate interventions to prevent another fall and identify possible or likely causes. Staff were to evaluate the chain of events or circumstances preceding a fall and continue to collect and evaluate information until they either identified the root cause of the fall, or determined the cause could not be found. The policy also directed the staff to complete a post fall evaluation which consisted of a nurse or physical therapist observation of the resident transferring and if had difficulty transferring, an additional evaluation may be initiated. The policy directed the staff to ensure the post fall assessment and interventions implemented were documented.

Based on observation, interview, and document review, the facility failed to comprehensively assess and reassess pressure ulcers to prevent the development and the worsening of pressure ulcers, and consistently monitor pressure ulcers for 1 of 4 residents (R18) reviewed for pressure ulcers. This resulted in harm for R18 who developed a deep tissue injury on the left heel, an unstageable pressure ulcer to the right hip that worsened, and multiple Stage 2 pressure areas to the coccyx and buttocks that worsened. Findings include: Pressure ulcer stages from the National Pressure Ulcer Advisory Panel (NPUAP): Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Stage 2: 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 serum-filled blister. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling. Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. R18's Face Sheet printed 9/19/18, identified [DIAGNOSES REDACTED]. R18's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R18 had severe cognitive impairment, and required extensive assistance of staff with bed mobility, transfers, toileting, personal hygiene, and eating. The MDS also identified R18 was at risk for the development of pressure ulcers, and currently had two Stage 2 pressure ulcers and one Unstageable pressure ulcer, neither of which was present or were at a lower stage on the prior assessment dated [DATE]. The MDS also indicated R18 had a pressure reduction device in the bed and the chair, and was on a turning and repositioning program. R18's Care Area Assessment (CAA) for falls dated 4/9/18, was a checklist that included extrinsic risk factors, [MEDICATION NAME] risk factors, medications that increase risk for pressure ulcer development, [DIAGNOSES REDACTED]. All of these areas were left blank. The second half of the CAA included the analysis of findings; document the description of the problem, causes and contributing factors related to the care area listed. This part of the CAA had a note which indicated Stage 1 pressure ulcer on buttocks per nurse notes/nursing interdisciplinary team (IDT) observation, is at risk for further pressure ulcer due to limited mobility, poor nutrition, bowel incontinence, terminal condition on hospice, medications. Has open area on ball of foot and abrasions on legs. Crawled on floor at home. The decision was made to care plan. R18's care plan dated 4/10/18, indicated R18 had a potential for alteration in skin integrity due to limited mobility, bowel incontinence, medications, terminal condition, and cognitive deficit. The care planned interventions directed 1-2 staff to turn and reposition every 1-2 hours, monitor skin for redness/breakdown daily, pressure guard mattress and cushion in wheelchair, and Prevalon boots on both feet at all times. On 8/8/18, a pressure ulcer problem was added to the care plan. The care plan indicated R18 had a pressure ulcer on his right hip, and Stage 2 pressure ulcers on his coccyx. The intervention directed to monitor for signs and symptoms of infection. R18's nursing assistant care guide sheet directed a pressure reduction mattress, reposition R18 every 2 hours, float heels when in bed, and Prevalon boots (reduce pressure on the heel) when not in bed. On 9/17/18, at 6:30 p.m. R18 was observed with an alternating pressure mattress to the bed, a cushion on the wheelchair, and Prevalon boots in place. On 9/19/18, at 8:30 a.m. R18 was observed being repositioned in a timely manner. At 9:00 a.m. R19 was observed to have an alternating pressure mattress to the bed, a cushion on the wheelchair, and Prevalon boots in place. On 9/17/18, at 6:16 p.m. family member (FM)-A was interviewed. FM-A stated R18 developed a pressure ulcer on his left heel sometime around the beginning of June. FM-A stated R18 was trying to get out of bed, and his heel ended up resting on the floor. No staff came to check on him for a long time, and R18 developed a deep tissue injury. FM-A stated staff told her he liked to keep his heel hanging off the bed and resting on the floor, but FM-A stated this wasn't true. FM-A also stated R18 had a pressure ulcer on his right hip. On 9/19/18, at 1:00 p.m. the pressure ulcer on R18's right hip was observed with licensed practical nurse (LPN)-B and registered nurse (RN)-F. RN-F stated half of the pressure ulcer was a Stage 3, and the other half of the pressure ulcer was unstageable. RN-F stated the pressure ulcer measured 7 centimeters (cm) x 4.3 cm, and had slough (dead tissue) and scabbed areas. RN-F stated R18's heel pressure ulcer would not be available to be observed, as the dressing change was every 3-5 days, and she had changed it yesterday. R18's Skin Risk Assessment with Braden Scale (used to help determine a person's risk for developing pressure ulcers) dated 4/2/18, indicated R18 was at risk of developing a pressure ulcer, and listed interventions that included pressure ulcer device in chair and bed, turning and repositioning program, and pressure ulcer care. Skin Risk Assessment with Braden Scales were completed on 4/5/18, 4/12/18, 4/19/18, 4/26/18, and all indicated R18 was at risk of developing a pressure ulcer. A Skin Risk Assessment with Braden Scale was last completed on 7/9/18, and this also indicated R18 was at risk of developing a pressure ulcer. The facility did not do skin assessments following the development of the pressure ulcer to the left heel on 6/3/18, the development of the pressure ulcer to the left buttocks on 7/30/18, the development of the pressure ulcer to the right hip on 8/5/18, the development of the pressure ulcers to the coccyx on 8/7/18, and the development of the pressure ulcer to the right buttock on 8/16/18. Review of R18's medical record indicated the following: On 4/2/18, a progress note identified as initial skin assessment indicated R18's heels, buttocks, and front and back torso were unremarkable. On 4/9/18, a progress note identified a Stage 1 pressure ulcer on R18's buttocks. On 4/23/18, a progress note indicated no new open areas, but lacked description of the Stage 1 pressure ulcer on R18's buttocks. A note by the Hospice nurse indicated nurses reported wounds were healing. On 6/3/18, a progress note indicated R18 was found with his left heel on the floor, and when straightening him in bed, it was noted he had a 10 cm fluid filled blister on the heel pad of his left foot. R18's heel was purple and very boggy (soft). The area was considered a Deep Tissue Injury (DTI)in evolution. A Mepiplex (foam) dressing was applied. On 6/6/18, a progress note indicated a home care nurse saw R18 to assess his heel and his skin. The note indicated the left heel pressure ulcer was a suspected DTI from a combination of sheer, friction and pressure. The pressure ulcer was not measured. The note also identified a small, sheer area on R18's coccyx, no further information was identified. On 6/6/18, a wound consult was completed. The nurse documented family reported left heel ulcer to staff over the weekend. Resident had Prevalon boots, however, staff reported the boots were worn inconsistently. A 6 cm x 6 cm pressure ulcer was noted, with a mostly resolved blister. The nurse documented R18 was at high risk for worsening and new pressure ulcers due to [MEDICAL CONDITION], immobility and most likely vascular disease due to diabetes. The left heel ulcer appeared related to pressure, friction and shear, and was suspicious for DTI due to the purplish center. Orders were given for Prevalon boots at all times in and out of bed, and foam heel dressing every three days and as needed. The nurse further recommended to monitor for changes, and to notify Hospice staff if the pressure ulcer opened and was draining. The nurse also recommended R18 might benefit from added gel and/or [MEDICATION NAME] if changes are noted, and directed staff to continue with daily skin inspection and pressure reduction interventions. On 6/21/18, a progress note indicated the left heel pressure ulcer was unstageable, and deep purple in color. The pressure ulcer was not measured. On 6/25/18, a progress note indicated R18's left heel had a black scab on it. The pressure ulcer was not measured. On 7/2/18, a progress note indicated R8's heel pressure ulcer was black in color and intact, with a small amount of dark red drainage on the old dressing. The pressure ulcer was not measured. On 7/5/18, a progress note indicated R18's heel pressure ulcer measured 7 cm x 6 cm, and was black in color. On 7/9/18, a progress note indicated R18's heel pressure ulcer was a dark brown and yellow loose scab. The scab came off during the dressing change, and the skin underneath had good blood return, and was close to being healed. There were three areas on the heel that were open, and they measured 3 cm x 1 cm with no depth, 1 cm x 0.3 cm with yellow slough (was unstageable), and 4 cm by 0.2 cm. On 7/17/18, a progress note indicated R18's left heel DTI continued to have small black eschar at back of heel. The pressure ulcer was not measured. On 7/21/18, a progress note indicated R18's left heel pressure ulcer was approximately 2 cm x 2 cm unstageable area. On 7/24/18, a progress note indicated R18's left heel pressure ulcer measured approximately 2 cm round, and was unstageable. On 7/28/18, a progress note indicated R18's left heel pressure ulcer measured 2 cm by 2 cm, and was unstageable. On 7/30/18, a progress note indicated R18's heel pressure ulcer measured 2 cm x 1.5 cm, had eschar and slough, and was unstageable. The note also indicated R18 had a new Stage 2 pressure ulcer to his left buttocks that measured 2.5 cm x 0.5 cm. The facility did not reassess following the development of the left buttocks pressure ulcer. A Mepiplex dressing was applied. On 8/2/18, a progress note indicated R18's heel pressure ulcer had small amounts of drainage and slough. The pressure ulcer was not measured or staged. The facility continued with the Mepiplex dressing. On 8/5/18, a progress note indicated R18's right lateral hip shear was reddened, and he would be kept off his right hip to allow for better healing. The pressure ulcer was not measured or staged. The facility did not reassess following the development of the right hip pressure ulcer. On 8/6/18, a progress note indicated R18 had a warm, red, hard, swollen area measuring 18.2 cm x 13.5 cm to his right hip. The pressure ulcer was not staged. A Mepiplex dressing was applied. On 8/7/18, a progress note indicated R18 had a Stage 1 pressure ulcer to his coccyx that measured 8 cm x 8 cm, and within that area there were further pressure ulcers. On the left coccyx, there was an unstageable pressure ulcer measuring 0.5 cm x 1 cm, and a second pressure ulcer was a Stage 2 measuring 0.2 cm x 0.2 cm. Medial to that pressure ulcer was a Stage 2 pressure ulcer measuring 0.3 cm x 0.3 cm. Above the gluteal crease was a Stage 2 pressure ulcer measuring 0.8 cm x 0.5 cm. A Mepiplex dressing was applied. The pressure ulcer on R18's hip measured 6 cm x 4 cm, and was not staged. The facility did not reassess following the development of the pressure ulcers on the coccyx. On 8/8/18, a progress note indicated R18's left heel pressure ulcer measured 1.1 cm x 1.3 cm, was unstageable, with macerated edges and eschar to the center of the pressure ulcer. On 8/16/18, a progress note indicated R18 had an unstageable pressure ulcer on his right buttock that was black in color and draining. The pressure ulcer was not measured. The note lacked indication of what type of treatment was done for this pressure ulcer. It was also noted the left heel pressure ulcer had a new dressing in place. The heel pressure ulcer was not staged or measured. The progress note indicated no other skin issues were noted. On 8/23/18, a progress note indicted R18's unstageable pressure ulcer on the right buttock was large, had drainage, and was black in color. The pressure ulcer was not measured. The note lacked indication of what type of treatment was done for this pressure ulcer. The heel pressure ulcer had a new dressing in place, but the heel pressure ulcer was not measured or staged. On 8/30/18, a progress note indicated R18 sacral dressing was changed. The pressure ulcers on R18's coccyx were not described in the note. The note also indicated R18 had [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA, a type of staph infection that is resistant to many antibiotics) in his right hip he was uncomfortable, so the pressure ulcer was not measured. The note further indicated the left heel pressure ulcer had an intact foam dressing. On 8/31/18, a progress note indicated R18 had an unstageable pressure ulcer to his coccyx that measured approximately 1.4 cm x 1 cm. The pressure ulcer on R18's right hip measured 8 cm x 4.5 cm, and was not staged. On 9/11/18, a progress note indicated the pressure ulcer on R18's right hip measured 7.7 cm x 4.8 cm. The pressure ulcer was not staged. The pressure ulcer to R18's coccyx measured 0.5 cm in diameter, and was unstageable. The pressure ulcer to R18's left heel was a DTI that was now an open area that measured 1.5 cm x 2.0 cm with a depth of 0.4 cm. On 9/20/18, at 9:01 a.m. RN-A was interviewed. RN-A stated R18's right hip pressure ulcer started out as a shearing, and quickly developed into a pressure ulcer. RN-A stated the pressure ulcers on his coccyx and buttocks have waxed and waned. RN-A stated R18's heel pressure ulcer started out when he placed his heel on the floor, and the facility did not determine how long it had been on the floor. RN-A further stated they complete a skin risk assessment when residents are admitted , and again every quarter. RN-A stated documentation on pressure ulcers was done weekly and as needed (however, review of R18's medical record indicated weekly documentation did not occur). On 9/20/18, at 10:57 a.m. nursing assistant (NA)-D was interviewed and stated they make sure they reposition R18 every 2 hours. On 9/20/18, at 12:58 p.m. RN-A was interviewed again. RN-A stated R18 developed a Stage 1 pressure ulcer a few days after he was admitted . RN-A stated R18 was at moderate risk for pressure ulcers according to his skin risk assessment. RN-A stated she placed R18 on an every two hour repositioning program when he was admitted . RN-A stated the facility did not reassess R18 following the development of the pressure ulcers. On 9/20/18, at 1:40 p.m. the director of nursing (DON) was interviewed. The DON stated staff was assessing and reassessing R18's pressure ulcers, and they did this on the Skin Risk Assessment with Braden Scale. The DON was unable to provide documentation of reassessment following the development of R18's pressure ulcers to the hip, coccyx, and buttocks. The facility policy Pressure Ulcer Risk assessment dated ,[DATE], indicated the purpose of the policy was to provide guidelines for the assessment and identification of residents at risk of developing pressure ulcers. The policy directed a comprehensive skin risk assessment and Braden Scale would be completed upon admission, with each additional assessment, quarterly, annually, and with significant changes. The policy further directed skin would be assessed for the presence of developing pressure ulcers on a weekly basis, or more frequently if indicated. The policy also directed nurses would conduct skin assessments at least weekly to identify changes. The facility policy Pressure Ulcer Treatment dated 12/17, indicated the purpose of the policy was to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers. The policy directed the pressure ulcer treatment program should focus on the following strategies, which included assessing the resident and the pressure ulcer(s), managing tissue loads, and pressure ulcer care. The policy further directed pressure ulcer treatment required a comprehensive approach, including determining the cause of pressure and relieve, redistributing pressure, implementing pressure relieving devices, and initiating a skin grid and care plan.

Based on observation, interview, and document review, the facility failed to ensure 1 of 3 residents reviewed, R1, was free from abuse. R1 installed a video camera in her room on 2/1/2017 to feel safe. The staff were directed by administration to ask the resident the same question about the camera every time they entered the room to provide care. The staff were also directed to tell the resident that if they were not able to turn the camera off they would take the resident to another room to provide care. R1 was tearful on multiple occasions due to staff constantly asking the resident about turning off the video camera as the resident wanted the camera left on. The resident stated the staff's interactions with her significantly decreased after the installation of the camera. Staff treatment of [REDACTED]. Findings include: R1's care plan dated 2/4/17, indicated R1 required total staff assistance with all activities of daily living (ADL's) and assist of one staff with eating. R1 required a total body mechanical lift for all transfers. During observation on 2/14/16, at 6:30 p.m. R1 was in her room laying in bed. On the wall there was a notarized document signed by R1 and family member (FM)-D titled, Consent To Electronic Monitoring. The consent indicated R1 had given consent to placement of the video camera in her room, and indicated, I ask that staff members respect my consent to placement of the device and not talk to me about the device, tamper with the device, remove the device, or pressure me to turn off the device. The device is being used to better understand my care and to prevent maltreatment of [REDACTED]. During observation of R1's room, there was a small plastic daisy sitting on a small end table in front of the residents bed which contained a video camera in the center of the flower. R1's Progress Notes indicated on 2/1/17, at 3:50 p.m. staff had spoken with FM-D who stated a video camera was put into R1's room to protect the resident. R1 had signed a notarized consent for the video camera and the paper was hanging in R1's room. R1's Progress Note dated 2/4/17, at 10:30 a.m. indicated R1, Was very tearful. RN (registered nurse) wiped tears with cool cloth and asked why she was so upset. Resident stated that she felt staff were upset with her because of the camera. RN assured her this was not the case. Staff are concerned for her and feel uncomfortable performing cares with a video recording. No one is angry with the resident. Resident feels interactions have lessened because of the video camera. The progress note also indicated the resident, Said this is her home and the camera has changed how it feels here. She began to cry again. RN explained that if the time comes that she is too distressed about the camera, staff RN may ask permission, on camera, to permanently disable it. Unplug it, remove batteries. R1's Progress Note dated 2/7/17, at 11:12 a.m. indicated the nurse was completing a mood and mental evaluation on R1 and the resident started crying and stated, People treat her differently because of the camera in her room. R1's Progress Note dated 2/8/17, at 1:30 p.m. indicated FM-D called the facility and requested staff put a tissue over the video camera instead of turning the camera because when staff turn the camera it is not always turned back in the right position. The Progress Note indicated the nurse called the director of nursing (DON) regarding FM-D's request to put a tissue over the camera, and the DON instructed, The lawyer said to turn the camera so we need to stick to what they say. R1's Progress Note dated 2/14/17, at 8:31 p.m. indicated, Prior to HS (hour of sleep) cares and assessment, staff asked resident if she wanted the camera covered and she stated yes 'no peeking.' Camera covered with red hanky while resident was exposed. R1's current Nursing Assistant care sheet (what the nursing assistants use to know specific cares on residents) dated 2/10/17, indicated R1 Loves to visit with staff. During observation on 2/14/17, at 7:00 p.m. four handwritten pieces of paper were hung up behind the nurses station on R1's unit. The handwritten paper directed staff when going into R1's room to ask the following questions. May I turn the camera off while I work with you as it makes me uncomfortable? If the resident said yes staff were directed to turn the camera off. If the resident responded no, staff were directed to respond, Then I would like to do your cares in another area. Staff were directed to, Document EVERY time you ask this question and what you get for a response. The other papers were titled R1's data collection for the camera, and contained boxes which were titled, quote what you asked R1, time, what was R1's response to what you ask, and action taken. Some of the data collection included: 2/1/17, at 4:45 p.m.- Staff stated to R1, I don't consent to the camera you might have consented to the camera but I don't. I stated I can't turn it off (the camera) because of the papers in her room (the consent). The resident response was documented as, She stated then turn it off. 2/2/17, at 3:30 p.m.- Asked to turn off camera. Refused and said we were the first people to ask to turn it off. The next entry was made at 4:12 p.m. on 2/2/17, which indicated, Resident didn't want the camera off or to go to another room but agreed to turn the camera. The resident response was, Agreed to have RN (registered nurse) in the room and could turn camera around. 2/6/17, at 5:55 p.m.- Staff asked the resident if they could cover the camera up. R1's response was documented as, You're the only one who asks that you know. If you don't like it open your own place. That's what they tell you to say. The action taken was staff responding to R1, Well, it makes me uncomfortable. Staff proceeded to do cares with the camera covered. 2/9/17, at 4:30 p.m.- Is it okay if I turn the camera, I feel uncomfortable. The resident requested staff use the red handkerchief to cover the camera. A hospital progress note dated 2/6/17, indicated R1 was ill in November 2016, December 2016, and early January 2017, with a chronic infection. At that time she was unable to make any medical or legal decisions, however, she was now alert and orientated and it appeared the confusion and [MEDICAL CONDITION] had resolved. When interviewed on 2/14/17, at 6:45 p.m. FM-D stated since R1 had the video camera in her room, staff treated the resident differently. FM-D stated R1 liked to joke and laugh with the staff, however, since placement of the video camera staff only focused on the camera in the room, and avoid conversation and entering R1's room. FM-D stated R1 was upset about being treated differently and did not like being questioned about the camera every time staff came into her room. FM-D stated R1 had signed a notarized consent and talked to multiple staff and told them she agrees with the video camera in her room but staff would not stop asking. FM-D stated she had requested the facility not turn the camera to the side, or shut it off, because it is not put back in the correct position after cares are complete. FM-D brought in a red handkerchief to cover the camera when staff are providing cares to R1 to ensure the residents privacy, however, most of the time staff just turn the camera and will not use the handkerchief. When interviewed on 2/14/17, at 7:05 p.m. licensed practical nurse (LPN)-M stated the video camera was discovered hidden in R1's room about a month ago. About a week after the camera was found, the daisy video camera was placed by family on R1's end table in her room. LPN-M stated staff were initially instructed to turn the video camera off while in R1's room, and then a few weeks ago it changed to just turning the camera away from the resident and point it towards the wall. LPN-D stated FM-D had requested staff to just cover the camera instead of moving it or turning it off, but staff were directed by administration to turn the camera or shut if off. LPN-M stated she was aware R1 was upset and the resident had cried about the video camera. LPN-M stated R1, Was in a difficult spot; we (staff) want it off; (FM-D) wants it on- the resident is in between. Administration told staff they had a right not to be videotaped, and LPN-M stated staff were confused because they didn't know if they should be turning the camera, shutting it off, or covering it up. When interviewed on 2/14/17, at 7:30 p.m. Nursing assistant (NA)-E stated she was directed about two weeks ago to cover the camera when providing cares to R1. NA-E stated R1 gets annoyed with staff when they ask about the camera and often responds, Yes! You know you can cover it! NA-E stated when she goes into R1's room she says to the resident, Can I cover it (video camera) because we don't want to be taped during cares. NA-E stated this was the instruction provided by administration to staff. During interview on 2/14/17, at 7:45 a.m. NA-F stated the video camera in R1's room was, Causing a lot of commotion. NA-F stated there were NA's in the facility who did not want to provide cares to R1 and steer clear of R1's room. NA-F stated she tells R1 she is uncomfortable doing cares with the video camera and turns it towards the wall as she had been directed by administration. NA-F stated R1 was cognitively intact and, This is too hard on the resident; we tell her every time we do cares we are uncomfortable with the camera. During interview on 2/15/17, at 8:50 a.m. director of nursing stated the facility policy did not allow any videotaping and staff had the right not to be videotaped. DON stated for staff protection they had been instructed to ask the resident about turning off the video camera every time they do cares. DON stated she was aware R1 felt staff didn't come around as much to talk with her since the video camera was in place. DON stated staff were directed to ask the resident to turn the video camera off, and if resident refused, they would take the resident to another room to provide cares. DON stated administration was aware of the notarized consent for the video camera signed by R1, however, the facility is currently having it reviewed to ensure it is a legal document. DON stated R1 was Caught in the middle, between having the video camera in her room, and staff not wanting the video camera in the room. During interview on 2/15/17, at 9:50 a.m. R1 stated she has told everyone she is fine with the video camera in her room. R1 stated when staff ask her about the video camera she tells them to do what they want, I am sick of it- I don't want to keep being asked! R1 stated staff treat her differently because of the video camera and they are, Cold; staff ignore me; they don't like the camera. R1 stated staff don't stay in her room and joke and talk with her anymore, and before staff were even all the way in her room and knew what she wanted, they were asking to turn the video camera off. R1 stated the video camera made her feel safe. R1 stated a couple weeks ago one of the nurses was, In my face all morning long about the damn camera. R1 stated she finally responded to the nurse to either turn the camera off or get rid of it. R1 stated she talks and talks about the camera and says it is okay, however, staff continue to ask about it all day, everyday. R1 stated, It pisses me off, when staff constantly talked about the camera because, They (staff) know the routine! During a follow up interview on 2/15/17, at 10:40 a.m. DON stated she had just spoke with R1 and the resident wanted the video camera in her room, and staff would now just tell R1 they would be turning the camera off when doing cares instead of asking the resident every time. DON stated they were going to make this change so staff don't have to ask R1 about the camera constantly, but she will still have a chance to give input. During interview on 2/15/17, at 11:00 a.m. NA-G stated she had been directed by administration to ask R1 to turn the camera off because she was uncomfortable with it on, and if the resident refused staff should take her to another room and provide cares. NA-G stated R1 was teary and told her she was sad because she felt staff treat her differently when they go into her room. NA-G stated she was aware some of the newer staff were nervous about going into R1's room with the video camera. When interviewed on 2/15/17, at 11:15 a.m. NA-H stated when she goes into R1's room she asks the resident to turn the camera and, Turns it no matter what. When interviewed on 2/15/17, at 11:30 a.m. NA-I stated when she provided cares to R1 she tells the resident she is not comfortable providing cares with the video camera on and she turns the camera towards the wall. NA-I stated when R1 asked her to cover the camera with the handkerchief instead of turning it towards the wall she told the resident she was directed by administration to turn the camera and not cover it. NA-I stated R1 told her in the past she didn't want to deal with talking about the camera everyday. When interviewed on 2/15/17, at 11:50 a.m. LPN-J stated staff were directed by administration that staff had a right to not be videotaped and were directed to tell the resident staff were uncomfortable with the camera on and they would be turning it towards the wall. LPN-J stated R1 told her she feels she was treated differently by staff because of the video camera in her room as staff does not joke and play around with her like they used to. LPN-J stated she can see staff treating the resident differently because they all have to watch what they say when the video camera is on. LPN-J stated she asked the DON if staff could cover the video camera with the handkerchief but was directed administration wanted the video camera turned towards the wall. When interviewed on 2/15/17, at 12:15 p.m. unit manager (UM)-K stated staff were directed to ask R1 if they could turn the camera for their privacy, and if R1 said no staff would tell the resident they will do cares in another room. UM-K stated she felt the issues with the video camera made R1 more confused and guarded, and, We have lost our joking relationship. UM-K stated staff get nervous with the camera in the room so they do treat the resident different. UM-K stated the video camera made staff uncomfortable, and she was aware she didn't go into R1's room as much as she did prior to the video camera. UM-K stated all the direction staff had been given regarding the camera was directed by administration. When interviewed on 2/15/17, at 1:00 p.m. RN-L stated administration had directed staff to tell R1 they would be turning the video camera while doing cares, and if the resident did not want the video camera turned, staff would need to take the resident to another room to do cares privately. RN-L stated a few weeks ago R1 had refused to have the camera turned and would not go to another room to have cares provided. RN-L stated she spoke with R1 and the resident agreed to allow the camera to be turned if RN-L would stay in the room when the aides were providing cares. When interviewed on 2/16/17, at 9:30 a.m. social worker (SW)-N stated staff were directed to tell R1 they were not comfortable providing cares with the video camera on and ask if they may turn it towards the wall. If the resident refused, staff would bring the resident to another room to provide R1's cares. SW-N stated after the video camera was discovered, the resident had a change in behavior. SW-N was not sure if the change was because of the actual video camera or because of the effects of the camera. SW-N stated recently R1 had refused to talk with her, so the DON was assessing the resident and changes in behavior. SW-N stated the resident had agreed to the camera since the camera had been installed, and she felt the resident was, Unfairly put in the middle. SW-N stated the R1 still goes out to the dining room and activities, but, She is being treated differently in her room. SW-N stated staff feel threatened because of the video camera and the facility needed to respect the staff rights to not be videotaped while providing cares. When interviewed on 2/16/16, at 10:40 a.m. the administrator stated administration directed staff to alert the resident she was on camera and possible audio and staff would be turning the video camera towards the wall. However, the administrator stated the previous day staff were directed to turn the video camera off when providing cares instead of asking the resident. The administrator stated this change was made because she was not aware until the previous day the residents life was being affected by staff constantly asking the resident about the camera. The administrator stated staff were originally directed to ask the resident if they could turn the camera when doing cares because they were uncomfortable being on camera. The administrator stated she was aware R1 had signed a notarized consent to the video camera, however, that was currently being reviewed by the facility's legal team because the residents cognition varied at times and they wanted to ensure the resident understood the consent and that it was an actual legal document. The administrator stated a few weeks ago staff had discussed the consent to electronic monitoring with the resident and she understood at that time. The administrator stated the situation with the video camera had been assessed on a daily basis by multiple staff, however, she was unsure why no one had brought to her attention the effect staff treatment was having on the resident until the previous day, 2/15/17, approximately three weeks after the video camera had been in place. The facility policy titled, Photography and Video Imagining, Patient, Visitor, Workforce Member- Enterprise, revised on 2/3/17, indicated Video monitoring by family/ friends in a patients room must be approved by the bedside nurse. Family/ friends should be informed that the camera or monitor must be focused only on the patient and cannot be placed in a position that captures staff or other patients or activities in the room. Staff may ask the individual to stop taking pictures or recording at any time. The facility policy does not state how the resident's rights will be protected.

Based on observation, interview, and document review, the facility failed to ensure that 1 of 3 residents reviewed, R1, could exercise her rights as a resident of the facility when she installed a video camera in her private room on 2/1/2017 in order to feel safe. R1 stated after the facility found out about the camera she felt staff treated her differently. As a result of the camera the facility administration directed all staff upon entering the resident's room to state, May I turn the camera off while I work with you as it makes me feel uncomfortable. The staff were also directed to tell the resident that if they were not able to turn the camera off they would take the resident to another room to provide care. This resulted in actual harm for R1 who experienced psychosocial harm related to staff constantly questioning the resident about her right to have a camera in her room. Findings include: R1's care plan dated 2/4/17, indicated R1 required total staff assistance with all activities of daily living (ADL's) and assist of one staff with eating. R1 required a total body mechanical lift for all transfers. During observation on 2/14/16, at 6:30 p.m. R1 was in her room laying in bed. On the wall there was a notarized document signed by R1 and family member (FM)-D titled, Consent To Electronic Monitoring. The consent indicated R1 had given consent to placement of the video camera in her room, and indicated, I ask that staff members respect my consent to placement of the device and not talk to me about the device, tamper with the device, remove the device, or pressure me to turn off the device. The device is being used to better understand my care and to prevent maltreatment of [REDACTED]. During observation of R1's room, there was a small plastic daisy sitting on a small end table in front of the residents bed which contained a video camera in the center of the flower. R1's Progress Notes indicated on 2/1/17, at 3:50 p.m. staff had spoken with FM-D who stated a video camera was put into R1's room to protect the resident. R1 had signed a notarized consent for the video camera and the paper was hanging in R1's room. R1's Progress Note dated 2/4/17, at 10:30 a.m. indicated R1, Was very tearful. RN (registered nurse) wiped tears with cool cloth and asked why she was so upset. Resident stated that she felt staff were upset with her because of the camera. RN assured her this was not the case. Staff are concerned for her and feel uncomfortable performing cares with a video recording. No one is angry with the resident. Resident feels interactions have lessened because of the video camera. The progress note also indicated the resident, Said this is her home and the camera has changed how it feels here. She began to cry again. RN explained that if the time comes that she is too distressed about the camera, staff RN may ask permission, on camera, to permanently disable it. Unplug it, remove batteries. R1's Progress Note dated 2/7/17, at 11:12 a.m. indicated the nurse was completing a mood and mental evaluation on R1 and the resident started crying and stated, People treat her differently because of the camera in her room. R1's Progress Note dated 2/8/17, at 1:30 p.m. indicated FM-D called the facility and requested staff put a tissue over the video camera instead of turning the camera because when staff turn the camera it is not always turned back in the right position. The Progress Note indicated the nurse called the director of nursing (DON) regarding FM-D's request to put a tissue over the camera, and the DON instructed, The lawyer said to turn the camera so we need to stick to what they say. R1's Progress Note dated 2/14/17, at 8:31 p.m. indicated, Prior to HS (hour of sleep) cares and assessment, staff asked resident if she wanted the camera covered and she stated yes 'no peeking.' Camera covered with red hanky while resident was exposed. R1's current Nursing Assistant care sheet (what the nursing assistants use to know specific cares on residents) dated 2/10/17, indicated R1 Loves to visit with staff. During observation on 2/14/17, at 7:00 p.m. four handwritten pieces of paper were hung up behind the nurses station on R1's unit. The handwritten paper directed staff when going into R1's room to ask the following questions. May I turn the camera off while I work with you as it makes me uncomfortable? If the resident said yes staff were directed to turn the camera off. If the resident responded no, staff were directed to respond, Then I would like to do your cares in another area. Staff were directed to, Document EVERY time you ask this question and what you get for a response. The other papers were titled R1's data collection for the camera, and contained boxes which were titled, quote what you asked R1, time, what was R1's response to what you ask, and action taken. Some of the data collection included: 2/1/17, at 4:45 p.m.- Staff stated to R1, I don't consent to the camera you might have consented to the camera but I don't. I stated I can't turn it off (the camera) because of the papers in her room (the consent). The resident response was documented as, She stated then turn it off. 2/2/17, at 3:30 p.m.- Asked to turn off camera. Refused and said we were the first people to ask to turn it off. The next entry was made at 4:12 p.m. on 2/2/17, which indicated, Resident didn't want the camera off or to go to another room but agreed to turn the camera. The resident response was, Agreed to have RN (registered nurse) in the room and could turn camera around. 2/6/17, at 5:55 p.m.- Staff asked the resident if they could cover the camera up. R1's response was documented as, You're the only one who asks that you know. If you don't like it open your own place. That's what they tell you to say. The action taken was staff responding to R1, Well, it makes me uncomfortable. Staff proceeded to do cares with the camera covered. 2/9/17, at 4:30 p.m.- Is it okay if I turn the camera, I feel uncomfortable. The resident requested staff use the red handkerchief to cover the camera. A hospital progress note dated 2/6/17, indicated R1 was ill in November 2016, December 2016, and early January 2017, with a chronic infection. At that time she was unable to make any medical or legal decisions, however, she was now alert and orientated and it appeared the confusion and [MEDICAL CONDITION] had resolved. When interviewed on 2/14/17, at 6:45 p.m. FM-D stated since R1 had the video camera in her room, staff treated the resident differently. FM-D stated R1 liked to joke and laugh with the staff, however, since placement of the video camera staff only focused on the camera in the room, and avoid conversation and entering R1's room. FM-D stated R1 was upset about being treated differently and did not like being questioned about the camera every time staff came into her room. FM-D stated R1 had signed a notarized consent and talked to multiple staff and told them she agrees with the video camera in her room but staff would not stop asking. FM-D stated she had requested the facility not turn the camera to the side, or shut it off, because it is not put back in the correct position after cares are complete. FM-D brought in a red handkerchief to cover the camera when staff are providing cares to R1 to ensure the residents privacy, however, most of the time staff just turn the camera and will not use the handkerchief. When interviewed on 2/14/17, at 7:05 p.m. licensed practical nurse (LPN)-M stated the video camera was discovered hidden in R1's room about a month ago. About a week after the camera was found, the daisy video camera was placed by family on R1's end table in her room. LPN-M stated staff were initially instructed to turn the video camera off while in R1's room, and then a few weeks ago it changed to just turning the camera away from the resident and point it towards the wall. LPN-D stated FM-D had requested staff to just cover the camera instead of moving it or turning it off, but staff were directed by administration to turn the camera or shut if off. LPN-M stated she was aware R1 was upset and the resident had cried about the video camera. LPN-M stated R1, Was in a difficult spot; we (staff) want it off; (FM-D) wants it on- the resident is in between. Administration told staff they had a right not to be videotaped, and LPN-M stated staff were confused because they didn't know if they should be turning the camera, shutting it off, or covering it up. When interviewed on 2/14/17, at 7:30 p.m. Nursing assistant (NA)-E stated she was directed about two weeks ago to cover the camera when providing cares to R1. NA-E stated R1 gets annoyed with staff when they ask about the camera and often responds, Yes! You know you can cover it! NA-E stated when she goes into R1's room she says to the resident, Can I cover it (video camera) because we don't want to be taped during cares. NA-E stated this was the instruction provided by administration to staff. During interview on 2/14/17, at 7:45 a.m. NA-F stated the video camera in R1's room was, Causing a lot of commotion. NA-F stated there were NA's in the facility who did not want to provide cares to R1 and steer clear of R1's room. NA-F stated she tells R1 she is uncomfortable doing cares with the video camera and turns it towards the wall as she had been directed by administration. NA-F stated R1 was cognitively intact and, This is too hard on the resident; we tell her every time we do cares we are uncomfortable with the camera. During interview on 2/15/17, at 8:50 a.m. director of nursing stated the facility policy did not allow any videotaping and staff had the right not to be videotaped. DON stated for staff protection they had been instructed to ask the resident about turning off the video camera every time they do cares. DON stated she was aware R1 felt staff didn't come around as much to talk with her since the video camera was in place. DON stated staff were directed to ask the resident to turn the video camera off, and if resident refused, they would take the resident to another room to provide cares. DON stated administration was aware of the notarized consent for the video camera signed by R1, however, the facility is currently having it reviewed to ensure it is a legal document. DON stated R1 was Caught in the middle, between having the video camera in her room, and staff not wanting the video camera in the room. During interview on 2/15/17, at 9:50 a.m. R1 stated she has told everyone she is fine with the video camera in her room. R1 stated when staff ask her about the video camera she tells them to do what they want, I am sick of it- I don't want to keep being asked! R1 stated staff treat her differently because of the video camera and they are, Cold; staff ignore me; they don't like the camera. R1 stated staff don't stay in her room and joke and talk with her anymore, and before staff were even all the way in her room and knew what she wanted, they were asking to turn the video camera off. R1 stated the video camera made her feel safe. R1 stated a couple weeks ago one of the nurses was, In my face all morning long about the damn camera. R1 stated she finally responded to the nurse to either turn the camera off or get rid of it. R1 stated she talks and talks about the camera and says it is okay, however, staff continue to ask about it all day, everyday. R1 stated, It pisses me off, when staff constantly talked about the camera because, They (staff) know the routine! During a follow up interview on 2/15/17, at 10:40 a.m. DON stated she had just spoke with R1 and the resident wanted the video camera in her room, and staff would now just tell R1 they would be turning the camera off when doing cares instead of asking the resident every time. DON stated they were going to make this change so staff don't have to ask R1 about the camera constantly, but she will still have a chance to give input. During interview on 2/15/17, at 11:00 a.m. NA-G stated she had been directed by administration to ask R1 to turn the camera off because she was uncomfortable with it on, and if the resident refused staff should take her to another room and provide cares. NA-G stated R1 was teary and told her she was sad because she felt staff treat her differently when they go into her room. NA-G stated she was aware some of the newer staff were nervous about going into R1's room with the video camera. When interviewed on 2/15/17, at 11:15 a.m. NA-H stated when she goes into R1's room she asks the resident to turn the camera and, Turns it no matter what. When interviewed on 2/15/17, at 11:30 a.m. NA-I stated when she provided cares to R1 she tells the resident she is not comfortable providing cares with the video camera on and she turns the camera towards the wall. NA-I stated when R1 asked her to cover the camera with the handkerchief instead of turning it towards the wall she told the resident she was directed by administration to turn the camera and not cover it. NA-I stated R1 told her in the past she didn't want to deal with talking about the camera everyday. When interviewed on 2/15/17, at 11:50 a.m. LPN-J stated staff were directed by administration that staff had a right to not be videotaped and were directed to tell the resident staff were uncomfortable with the camera on and they would be turning it towards the wall. LPN-J stated R1 told her she feels she was treated differently by staff because of the video camera in her room as staff does not joke and play around with her like they used to. LPN-J stated she can see staff treating the resident differently because they all have to watch what they say when the video camera is on. LPN-J stated she asked the DON if staff could cover the video camera with the handkerchief but was directed administration wanted the video camera turned towards the wall. When interviewed on 2/15/17, at 12:15 p.m. unit manager (UM)-K stated staff were directed to ask R1 if they could turn the camera for their privacy, and if R1 said no staff would tell the resident they will do cares in another room. UM-K stated she felt the issues with the video camera made R1 more confused and guarded, and, We have lost our joking relationship. UM-K stated staff get nervous with the camera in the room so they do treat the resident different. UM-K stated the video camera made staff uncomfortable, and she was aware she didn't go into R1's room as much as she did prior to the video camera. UM-K stated all the direction staff had been given regarding the camera was directed by administration. When interviewed on 2/15/17, at 1:00 p.m. RN-L stated administration had directed staff to tell R1 they would be turning the video camera while doing cares, and if the resident did not want the video camera turned, staff would need to take the resident to another room to do cares privately. RN-L stated a few weeks ago R1 had refused to have the camera turned and would not go to another room to have cares provided. RN-L stated she spoke with R1 and the resident agreed to allow the camera to be turned if RN-L would stay in the room when the aides were providing cares. When interviewed on 2/16/17, at 9:30 a.m. social worker (SW)-N stated staff were directed to tell R1 they were not comfortable providing cares with the video camera on and ask if they may turn it towards the wall. If the resident refused, staff would bring the resident to another room to provide R1's cares. SW-N stated after the video camera was discovered, the resident had a change in behavior. SW-N was not sure if the change was because of the actual video camera or because of the effects of the camera. SW-N stated recently R1 had refused to talk with her, so the DON was assessing the resident and changes in behavior. SW-N stated the resident had agreed to the camera since the camera had been installed, and she felt the resident was, Unfairly put in the middle. SW-N stated the R1 still goes out to the dining room and activities, but, She is being treated differently in her room. SW-N stated staff feel threatened because of the video camera and the facility needed to respect the staff rights to not be videotaped while providing cares. When interviewed on 2/16/16, at 10:40 a.m. the administrator stated administration directed staff to alert the resident she was on camera and possible audio and staff would be turning the video camera towards the wall. However, the administrator stated the previous day staff were directed to turn the video camera off when providing cares instead of asking the resident. The administrator stated this change was made because she was not aware until the previous day the residents life was being affected by staff constantly asking the resident about the camera. The administrator stated staff were originally directed to ask the resident if they could turn the camera when doing cares because they were uncomfortable being on camera. The administrator stated she was aware R1 had signed a notarized consent to the video camera, however, that was currently being reviewed by the facility's legal team because the residents cognition varied at times and they wanted to ensure the resident understood the consent and that it was an actual legal document. The administrator stated a few weeks ago staff had discussed the consent to electronic monitoring with the resident and she understood at that time. The administrator stated the situation with the video camera had been assessed on a daily basis by multiple staff, however, she was unsure why no one had brought to her attention the effect staff treatment was having on the resident until the previous day, 2/15/17, approximately three weeks after the video camera had been in place. The facility policy titled, Photography and Video Imagining, Patient, Visitor, Workforce Member- Enterprise, revised on 2/3/17, indicated Video monitoring by family/ friends in a patients room must be approved by the bedside nurse. Family/ friends should be informed that the camera or monitor must be focused only on the patient and cannot be placed in a position that captures staff or other patients or activities in the room. Staff may ask the individual to stop taking pictures or recording at any time. The facility policy does not state how the resident's rights will be protected.

Based on observation, interview, and document review, the facility administration directed all staff to treat 1 of 3 residents reviewed, R1, in such a manner that caused mental anguish to R1. This treatment of [REDACTED]. Findings include: R1's care plan dated 2/4/17, indicated R1 required total staff assistance with all activities of daily living (ADL's) and assist of one staff with eating. R1 required a total body mechanical lift for all transfers. During observation on 2/14/16, at 6:30 p.m. R1 was in her room laying in bed. On the wall there was a notarized document signed by R1 and family member (FM)-D titled, Consent To Electronic Monitoring. The consent indicated R1 had given consent to placement of the video camera in her room, and indicated, I ask that staff members respect my consent to placement of the device and not talk to me about the device, tamper with the device, remove the device, or pressure me to turn off the device. The device is being used to better understand my care and to prevent maltreatment of [REDACTED]. During observation of R1's room, there was a small plastic daisy sitting on a small end table in front of the residents bed which contained a video camera in the center of the flower. R1's Progress Notes indicated on 2/1/17, at 3:50 p.m. staff had spoken with FM-D who stated a video camera was put into R1's room to protect the resident. R1 had signed a notarized consent for the video camera and the paper was hanging in R1's room. R1's Progress Note dated 2/4/17, at 10:30 a.m. indicated R1, Was very tearful. RN (registered nurse) wiped tears with cool cloth and asked why she was so upset. Resident stated that she felt staff were upset with her because of the camera. RN assured her this was not the case. Staff are concerned for her and feel uncomfortable performing cares with a video recording. No one is angry with the resident. Resident feels interactions have lessened because of the video camera. The progress note also indicated the resident, Said this is her home and the camera has changed how it feels here. She began to cry again. RN explained that if the time comes that she is too distressed about the camera, staff RN may ask permission, on camera, to permanently disable it. Unplug it, remove batteries. R1's Progress Note dated 2/7/17, at 11:12 a.m. indicated the nurse was completing a mood and mental evaluation on R1 and the resident started crying and stated, People treat her differently because of the camera in her room. R1's Progress Note dated 2/8/17, at 1:30 p.m. indicated FM-D called the facility and requested staff put a tissue over the video camera instead of turning the camera because when staff turn the camera it is not always turned back in the right position. The Progress Note indicated the nurse called the director of nursing (DON) regarding FM-D's request to put a tissue over the camera, and the DON instructed, The lawyer said to turn the camera so we need to stick to what they say. R1's Progress Note dated 2/14/17, at 8:31 p.m. indicated, Prior to HS (hour of sleep) cares and assessment, staff asked resident if she wanted the camera covered and she stated yes 'no peeking.' Camera covered with red hanky while resident was exposed. R1's current Nursing Assistant care sheet (what the nursing assistants use to know specific cares on residents) dated 2/10/17, indicated R1 Loves to visit with staff. During observation on 2/14/17, at 7:00 p.m. four handwritten pieces of paper were hung up behind the nurses station on R1's unit. The handwritten paper directed staff when going into R1's room to ask the following questions. May I turn the camera off while I work with you as it makes me uncomfortable? If the resident said yes staff were directed to turn the camera off. If the resident responded no, staff were directed to respond, Then I would like to do your cares in another area. Staff were directed to, Document EVERY time you ask this question and what you get for a response. The other papers were titled R1's data collection for the camera, and contained boxes which were titled, quote what you asked R1, time, what was R1's response to what you ask, and action taken. Some of the data collection included: 2/1/17, at 4:45 p.m.- Staff stated to R1, I don't consent to the camera you might have consented to the camera but I don't. I stated I can't turn it off (the camera) because of the papers in her room (the consent). The resident response was documented as, She stated then turn it off. 2/2/17, at 3:30 p.m.- Asked to turn off camera. Refused and said we were the first people to ask to turn it off. The next entry was made at 4:12 p.m. on 2/2/17, which indicated, Resident didn't want the camera off or to go to another room but agreed to turn the camera. The resident response was, Agreed to have RN (registered nurse) in the room and could turn camera around. 2/6/17, at 5:55 p.m.- Staff asked the resident if they could cover the camera up. R1's response was documented as, You're the only one who asks that you know. If you don't like it open your own place. That's what they tell you to say. The action taken was staff responding to R1, Well, it makes me uncomfortable. Staff proceeded to do cares with the camera covered. 2/9/17, at 4:30 p.m.- Is it okay if I turn the camera, I feel uncomfortable. The resident requested staff use the red handkerchief to cover the camera. A hospital progress note dated 2/6/17, indicated R1 was ill in November 2016, December 2016, and early January 2017, with a chronic infection. At that time she was unable to make any medical or legal decisions, however, she was now alert and orientated and it appeared the confusion and [MEDICAL CONDITION] had resolved. When interviewed on 2/14/17, at 6:45 p.m. FM-D stated since R1 had the video camera in her room, staff treated the resident differently. FM-D stated R1 liked to joke and laugh with the staff, however, since placement of the video camera staff only focused on the camera in the room, and avoid conversation and entering R1's room. FM-D stated R1 was upset about being treated differently and did not like being questioned about the camera every time staff came into her room. FM-D stated R1 had signed a notarized consent and talked to multiple staff and told them she agrees with the video camera in her room but staff would not stop asking. FM-D stated she had requested the facility not turn the camera to the side, or shut it off, because it is not put back in the correct position after cares are complete. FM-D brought in a red handkerchief to cover the camera when staff are providing cares to R1 to ensure the residents privacy, however, most of the time staff just turn the camera and will not use the handkerchief. When interviewed on 2/14/17, at 7:05 p.m. licensed practical nurse (LPN)-M stated the video camera was discovered hidden in R1's room about a month ago. About a week after the camera was found, the daisy video camera was placed by family on R1's end table in her room. LPN-M stated staff were initially instructed to turn the video camera off while in R1's room, and then a few weeks ago it changed to just turning the camera away from the resident and point it towards the wall. LPN-D stated FM-D had requested staff to just cover the camera instead of moving it or turning it off, but staff were directed by administration to turn the camera or shut if off. LPN-M stated she was aware R1 was upset and the resident had cried about the video camera. LPN-M stated R1, Was in a difficult spot; we (staff) want it off; (FM-D) wants it on- the resident is in between. Administration told staff they had a right not to be videotaped, and LPN-M stated staff were confused because they didn't know if they should be turning the camera, shutting it off, or covering it up. When interviewed on 2/14/17, at 7:30 p.m. Nursing assistant (NA)-E stated she was directed about two weeks ago to cover the camera when providing cares to R1. NA-E stated R1 gets annoyed with staff when they ask about the camera and often responds, Yes! You know you can cover it! NA-E stated when she goes into R1's room she says to the resident, Can I cover it (video camera) because we don't want to be taped during cares. NA-E stated this was the instruction provided by administration to staff. During interview on 2/14/17, at 7:45 a.m. NA-F stated the video camera in R1's room was, Causing a lot of commotion. NA-F stated there were NA's in the facility who did not want to provide cares to R1 and steer clear of R1's room. NA-F stated she tells R1 she is uncomfortable doing cares with the video camera and turns it towards the wall as she had been directed by administration. NA-F stated R1 was cognitively intact and, This is too hard on the resident; we tell her every time we do cares we are uncomfortable with the camera. During interview on 2/15/17, at 8:50 a.m. director of nursing stated the facility policy did not allow any videotaping and staff had the right not to be videotaped. DON stated for staff protection they had been instructed to ask the resident about turning off the video camera every time they do cares. DON stated she was aware R1 felt staff didn't come around as much to talk with her since the video camera was in place. DON stated staff were directed to ask the resident to turn the video camera off, and if resident refused, they would take the resident to another room to provide cares. DON stated administration was aware of the notarized consent for the video camera signed by R1, however, the facility is currently having it reviewed to ensure it is a legal document. DON stated R1 was Caught in the middle, between having the video camera in her room, and staff not wanting the video camera in the room. During interview on 2/15/17, at 9:50 a.m. R1 stated she has told everyone she is fine with the video camera in her room. R1 stated when staff ask her about the video camera she tells them to do what they want, I am sick of it- I don't want to keep being asked! R1 stated staff treat her differently because of the video camera and they are, Cold; staff ignore me; they don't like the camera. R1 stated staff don't stay in her room and joke and talk with her anymore, and before staff were even all the way in her room and knew what she wanted, they were asking to turn the video camera off. R1 stated the video camera made her feel safe. R1 stated a couple weeks ago one of the nurses was, In my face all morning long about the damn camera. R1 stated she finally responded to the nurse to either turn the camera off or get rid of it. R1 stated she talks and talks about the camera and says it is okay, however, staff continue to ask about it all day, everyday. R1 stated, It pisses me off, when staff constantly talked about the camera because, They (staff) know the routine! During a follow up interview on 2/15/17, at 10:40 a.m. DON stated she had just spoke with R1 and the resident wanted the video camera in her room, and staff would now just tell R1 they would be turning the camera off when doing cares instead of asking the resident every time. DON stated they were going to make this change so staff don't have to ask R1 about the camera constantly, but she will still have a chance to give input. During interview on 2/15/17, at 11:00 a.m. NA-G stated she had been directed by administration to ask R1 to turn the camera off because she was uncomfortable with it on, and if the resident refused staff should take her to another room and provide cares. NA-G stated R1 was teary and told her she was sad because she felt staff treat her differently when they go into her room. NA-G stated she was aware some of the newer staff were nervous about going into R1's room with the video camera. When interviewed on 2/15/17, at 11:15 a.m. NA-H stated when she goes into R1's room she asks the resident to turn the camera and, Turns it no matter what. When interviewed on 2/15/17, at 11:30 a.m. NA-I stated when she provided cares to R1 she tells the resident she is not comfortable providing cares with the video camera on and she turns the camera towards the wall. NA-I stated when R1 asked her to cover the camera with the handkerchief instead of turning it towards the wall she told the resident she was directed by administration to turn the camera and not cover it. NA-I stated R1 told her in the past she didn't want to deal with talking about the camera everyday. When interviewed on 2/15/17, at 11:50 a.m. LPN-J stated staff were directed by administration that staff had a right to not be videotaped and were directed to tell the resident staff were uncomfortable with the camera on and they would be turning it towards the wall. LPN-J stated R1 told her she feels she was treated differently by staff because of the video camera in her room as staff does not joke and play around with her like they used to. LPN-J stated she can see staff treating the resident differently because they all have to watch what they say when the video camera is on. LPN-J stated she asked the DON if staff could cover the video camera with the handkerchief but was directed administration wanted the video camera turned towards the wall. When interviewed on 2/15/17, at 12:15 p.m. unit manager (UM)-K stated staff were directed to ask R1 if they could turn the camera for their privacy, and if R1 said no staff would tell the resident they will do cares in another room. UM-K stated she felt the issues with the video camera made R1 more confused and guarded, and, We have lost our joking relationship. UM-K stated staff get nervous with the camera in the room so they do treat the resident different. UM-K stated the video camera made staff uncomfortable, and she was aware she didn't go into R1's room as much as she did prior to the video camera. UM-K stated all the direction staff had been given regarding the camera was directed by administration. When interviewed on 2/15/17, at 1:00 p.m. RN-L stated administration had directed staff to tell R1 they would be turning the video camera while doing cares, and if the resident did not want the video camera turned, staff would need to take the resident to another room to do cares privately. RN-L stated a few weeks ago R1 had refused to have the camera turned and would not go to another room to have cares provided. RN-L stated she spoke with R1 and the resident agreed to allow the camera to be turned if RN-L would stay in the room when the aides were providing cares. When interviewed on 2/16/17, at 9:30 a.m. social worker (SW)-N stated staff were directed to tell R1 they were not comfortable providing cares with the video camera on and ask if they may turn it towards the wall. If the resident refused, staff would bring the resident to another room to provide R1's cares. SW-N stated after the video camera was discovered, the resident had a change in behavior. SW-N was not sure if the change was because of the actual video camera or because of the effects of the camera. SW-N stated recently R1 had refused to talk with her, so the DON was assessing the resident and changes in behavior. SW-N stated the resident had agreed to the camera since the camera had been installed, and she felt the resident was, Unfairly put in the middle. SW-N stated the R1 still goes out to the dining room and activities, but, She is being treated differently in her room. SW-N stated staff feel threatened because of the video camera and the facility needed to respect the staff rights to not be videotaped while providing cares. When interviewed on 2/16/16, at 10:40 a.m. the administrator stated administration directed staff to alert the resident she was on camera and possible audio and staff would be turning the video camera towards the wall. However, the administrator stated the previous day staff were directed to turn the video camera off when providing cares instead of asking the resident. The administrator stated this change was made because she was not aware until the previous day the residents life was being affected by staff constantly asking the resident about the camera. The administrator stated staff were originally directed to ask the resident if they could turn the camera when doing cares because they were uncomfortable being on camera. The administrator stated she was aware R1 had signed a notarized consent to the video camera, however, that was currently being reviewed by the facility's legal team because the residents cognition varied at times and they wanted to ensure the resident understood the consent and that it was an actual legal document. The administrator stated a few weeks ago staff had discussed the consent to electronic monitoring with the resident and she understood at that time. The administrator stated the situation with the video camera had been assessed on a daily basis by multiple staff, however, she was unsure why no one had brought to her attention the effect staff treatment was having on the resident until the previous day, 2/15/17, approximately three weeks after the video camera had been in place. The facility policy titled, Photography and Video Imagining, Patient, Visitor, Workforce Member- Enterprise, revised on 2/3/17, indicated Video monitoring by family/ friends in a patients room must be approved by the bedside nurse. Family/ friends should be informed that the camera or monitor must be focused only on the patient and cannot be placed in a position that captures staff or other patients or activities in the room. Staff may ask the individual to stop taking pictures or recording at any time. The facility policy does not state how the resident's rights will be protected.