Every finding on record at North Shore Health

Based on observation, interview, and document review, the facility failed to monitor and document the results of monitoring, for a resident with chronic lower extremity edema for 1 of 1 resident (R6) reviewed for quality of care.Findings include:R6's admission minimum data set (MDS) dated [DATE], identified moderately impaired cognition and diagnosis of chronic kidney disease, stage four (severe kidney damage and a significant loss of kidney function).R6's care plan dated 4/19/26 lacked a focus statement for edema management.R6's provider orders 5/7/26, identified to take R6's weight in the morning every Thursday, but didn't include monitoring for edema.A history and physical dated 4/14/26, identified R6 had a past medical history of chronic lower extremity edema, and had one-plus bilateral edema on exam.A Clinical admission assessment dated [DATE], identified R6's left and right lower extremities were extremely puffy with mild non-pitting edema in the calves, ankles and dorsum of feet.A monthly rounding provider note dated 5/19/26, identified two-plus pitting edema to the knees as stableA progress note dated 5/25/26, identified R6's provider was contacted, and nurse manager updated, due to an 18.1-pound weight gain since admission on [DATE]. A comprehensive skin assessment dated [DATE], identified R6 had mild bilateral, non-pitting edema in calves, ankles and dorsum of feet.During an observation and interview on 5/26/26 at 6:14 p.m., both of R6's lower extremities were very edematous and R6 stated that is how they have been and has had those tight socks in the past but not here.During an interview on 5/27/26 at 1:41 p.m., RN-A stated she had just noticed R6's weight gain this past weekend and notified the provider and the nurse manager. RN-A also stated R6 was admitted with the edema and they used to have edema monitoring on the treatment administration record (TAR) but the provider discontinued it and started a nebulizer. Today, RN-A stated R6 had diminished lung sounds and both lower legs were three-plus pitting edema, and she had been waiting to hear if they got any new orders and they did get one for Lasix (a diuretic medication), and RN-A felt his legs had been getting bigger and the risk for R6 could be skin breakdown and his legs to start weeping.During an interview on 5/27/26 at 2:39 p.m., the director of nursing (DON) stated would expect the nurses to assess the edema and listen to the lungs. Also, the DON stated she would expect the ongoing monitoring, documentation, and for it to be on the care plan. The DON added that even if the provider discontinued the edema monitoring, it was still within a nurse's scope to monitor edema.A policy, Assessment - Comprehensive Skin dated 3/7/24, identified its purpose was to develop a systematic assessment for all residents at risk for alterations in skin integrity. The policy further identified a comprehensive skin assessment included, but was not limited to, the skin color, temperature, edema, turgor, moisture and integrity.A policy, Care Plans - Comprehensive dated 1/3/26, identified its purpose was for a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident. Assessments of residents were ongoing and care plans were revised as information about the resident and the resident's conditions changed.

Based on interview and document review, the facility failed to develop and implement care planning for chronic health conditions for 2 of 2 residents (R3, R6) reviewed for care planning.Findings include:R3's significant change in status (SCSA) minimum data set (MDS) dated [DATE], identified impaired cognition and diagnoses of Alzheimer's dementia, and constipation. R3 was dependent on staff for assist with transferring and toileting.A care area assessment (CAA) dated 3/9/26, identified dehydration and fluid maintenance were triggered related in part to newly present constipation.R3's care plan dated 7/1/25, identified R3 was dependent on staff for toileting needs. The care plan didn't identify a focus statement for constipation.R3's provider orders included:-Bisacodyl suppository 10 milligrams (mg) as needed (PRN) for constipation, if no bowel movement (BM) in four days, give suppository and notify provider if no results.-Miralax 17 grams every 24 hours PRN constipation.-Senna-docusate 8.6/50 mg, give one tab every 24 hours for constipation once daily PRN.R3's electronic medical record (EMR) identified R3 hadn't had a recorded bowel movement from 4/6 to 4/9, 4/13 to 4/16, 5/15 to 5/18, and 5/23 to 5/27/26.During an interview on 5/27/26 at 2:46 p.m., the director of nurses (DON) stated she would expect constipation to be on the care plan.R6's admission minimum data set (MDS) dated [DATE], identified moderately impaired cognition and diagnosis of chronic kidney disease, stage four (severe kidney damage and a significant loss of kidney function).R6's care plan dated 4/19/26 lacked a focus statement for edema management.R6's provider orders 5/7/26, identified to take R6's weight in the morning every Thursday, but didn't include monitoring for edema.A progress note dated 5/25/26, identified R6's provider was contacted, and nurse manager updated, due to an 18.1-pound weight gain since admission on [DATE]. During an observation and interview on 5/26/26 at 6:14 p.m., both of R6's lower extremities were very edematous and R6 stated that is how they have been and has had those tight socks in the past but not here.During an interview on 5/27/26 at 1:41 p.m., RN-A stated she had just noticed R6's weight gain this past weekend and notified the provider and the nurse manager. RN-A also stated R6 was admitted with the edema and they used to have edema monitoring on the treatment administration record (TAR) but the provider discontinued it and started a nebulizer. Today, RN-A stated R6 had diminished lung sounds and both lower legs were three-plus pitting edema, and she had been waiting to hear if they got any new orders and they did get one for Lasix (a diuretic medication), and RN-A felt his legs had been getting bigger and the risk for R6 could be skin breakdown and his legs to start weeping.During an interview on 5/27/26 at 2:39 p.m., the director of nursing (DON) stated would expect the nurses to assess the edema and listen to the lungs. Also, the DON stated she would expect the ongoing monitoring, documentation, and for it to be on the care plan. The DON added that even if the provider discontinued the edema monitoring, it was still within a nurse's scope to monitor edema.A policy, Care Plans - Comprehensive dated 1/3/26, identified its purpose was for a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident. Assessments of residents were ongoing and care plans were revised as information about the resident and the resident's conditions changed.

Based on interview and document review, the facility failed to provide a written bed hold for 2 of 2 residents (R5, R30) reviewed for hospitalization. In addition, the facility failed to notify the Ombudsman of the transfers to the hospital.Findings include: R30 R30's quarterly Minimum Data Set (MDS) identified resident as cognitively intact with diagnoses of hemiplegia (paralysis affecting one side of the body) following cerebral infarction affecting left non-dominant side, chronic obstructive pulmonary disease (progressive lung disease that makes it difficult to breathe), depression, anxiety, anemia, dysuria (pain or discomfort during urination), obstructive and reflux uropathy (condition affecting the urinary tract and the flow of urine), and a personal history of prostate cancer. Progress note, dated 5/24/25, indicated it is evident that resident is not feeling well. T (temperature) 99.2 R (respirations) 40, P (pulse) 81 BP (blood pressure) 97/53. Update left with SMC MD who advised for resident to be seen in the ED. Resident transferred to the ED at approx. 1430. Sister received update on current status and ED visit- reports that she has provided update to son as well. Progress note lacked evidence of a bed hold being discussed with resident or representative at the time of transfer on 5/24/25 or during hospitalization. During review of R30's entire electronic medical record (EMR), the EMR lacked a completed bed hold form relating to resident's transfer to the emergency department on 5/24/25. Email received from administrator on 7/31/25 at 7:33 a.m., stated I wish I could give you the notice but I can't. The notification process to the resident/family got lost in personnel change. R5R5's quarterly MDS dated [DATE] identified resident as cognitively intact with diagnoses that included age related decline, cerebral infarction, repeated falls, anxiety, irritable bowel syndrome, diabetes, gout, and anemia.During interview on 7/28/25 at 3:25 p.m., R5 indicated she went to the emergency room on 7/27/25. R5 stated she is not sure if she had to sign anything but understood why she was going to the emergency room.During interview on 7/30/25 at 9:48 a.m., registered nurse (RN)-A stated when sending a resident to the hospital the nurse would call the primary provider to give an update on the situation. RN-A also stated the resident's family would be called as well. RN-A explained the business office would complete the bed hold when residents stay overnight in the hospital but not if they only go to the emergency room.During interview on 7/30/25 at 12:34 p.m., assistant director of nursing (ADON) stated her understanding was anytime a resident goes to the emergency room they should get a bed hold. ADON confirmed she did not ask R5 about a bed hold.During interview on 7/30/25 at 1:03 p.m., licensed practical nurse (LPN)-A stated when a resident was admitted to the hospital they would get a bed hold. LPN-A verified she did not obtain a bed hold for R5 on 7/27/25.During interview on 7/31/25 at 10:45 a.m., social worker (SW)-A stated it was her understanding that the facility should send the ombudsman a list of residents who were sent to the hospital monthly. SW-A explained she became aware of this requirement three weeks ago, and had sent a notice to the ombudsman on 7/18/25 for the previous 30 days. SW-A stated being unaware of requirement and the notices were not being sent before that time.During interview on 7/31/25 at 11:30 a.m., director of nursing (DON) stated the bed hold should be given when the resident leaves for the emergency room. DON indicated the bed hold was important to make sure the resident had a bed upon their return.Email received from administrator on 7/31/25 at 11:53 a.m., stated attached is the ombudsman notification for the last month [July 2025]. We do not have notification from previous months.Bed Hold Notice Policy last approved 8/20/2024, stated all nursing home residents must receive a bed hold notice and copy of the bed hold policy if they are placed on a bed hold, for either a planned absence or emergency event, a notice regarding that bed hold must be issued to the resident and/or the resident's representative prior to or at the time of departure.

Based on interview and document review, the facility failed to ensure 5 of 6 residents (R7, R10, R12, R15, R60) reviewed for immunizations were offered or received timely administration of pneumococcal vaccinations in accordance with the Center for Disease Control (CDC) recommendations. Findings include: The Centers for Disease (CDC) document Pneumococcal Vaccine Timing for Adults dated March 2025, included the following recommendations for adults 50 years or older: --PCV15 only at any age: administer PPSV23 on or after one year.--PCV15 & PPSV23 or PCV20 or PCV21 at any age: no additional administrations recommended.--PPSV23 only at any age: administer PCV20 or PCV21 at or after 1 year. OR administer PCV15 at or after 1 year.--PCV13 at any age: administer PCV20 or PCV21 at or after 1 year.--PCV13 at any age and PPSV23 at or before age [AGE]: administer PCV20 or PCV21 at or after one year.--Together with the patient providers may choose to administer PCV20 or PCV21 to adults 65 years or older who have already received PCV13 (but not PCV15, PCV20, or PCV21) at any age and PPSV23 at or after the age of [AGE] years old. The facility policy Pneumococcal Vaccination dated 1/16/25, directed vaccinations for the prevention of pneumococcal pneumonia were to be assessed and provide upon admission to those residents who had not previously had the vaccines. In addition, pneumococcal vaccine would be provided throughout the Calander year to residents based on their immunization status. Revaccination with pneumococcal vaccine will occur per CDC guidelines. The policy lacked evidence to support the most current CDC guidelines were being utilized for pneumococcal administration. R7 was admitted to the facility on [DATE]. R7's undated, Minnesota Immunization Information Connection (MIIC) report indicated R7 had received PCV13 on 7/16/15. Per CDC recommendations R10 qualified for shared decision making for an additional pneumococcal administration. R10 was admitted to the facility on [DATE]. The facility document titled Client information indicated R10 had last received the pneumococcal immunization PCV13 on 10/17/17. Per CDC recommendations R10 qualified for shared decision making for an additional pneumococcal administration. R12 was admitted to the facility on [DATE]. R12 received an unspecified pneumococcal immunization on 8/15/17, and a dose of PPSV23 on 11/5/08. CDC recommendations indicated R12 qualified for PCV20 or PCV21 at least one year after PPSV23. R15 was admitted to the facility on [DATE]. The facility provided document Client Information indicated R15 had received PCV13 on 10/2/13. CDC recommendations indicated R12 qualified for PCV20 or PCV21 administration. R60 was admitted to the facility on [DATE]. The facility document Client Information indicated R60 had received PCV13 on 1/30/18. Per CDC recommendations R60 qualified to receive PCV20 0r PCV21. During an interview on 7/30/25 at 2:23 p.m., the assistant director of nursing (ADON) stated the infection preventionist (IP) at the facility calculated when residents needed vaccinations such as pneumococcal and then documents for consent would go out to residents and or family. The ADON indicated a provider had informed them the CDC had decreased the screening age to 50 so they had been working to get the policy changed to 50 instead of 65. The ADON pulled up their policy and stated it currently didn't address screen residents between 50 and 64, but they policy was in process of being updated. During an interview on 7/31/25 at 8:59 a.m., the IP stated the infection prevention policies should reflect the most current and up to date CDC recommendations and confirmed their Pneumococcal Vaccination policy dated 1/16/25, did not reflect CDC recommendation changes made in October of 2024. The IP indicated the facility offered pneumococcal immunizations yearly and they were in the process of getting ready to offer pneumococcal immunizations to residents next month (August 2025). Nine residents had been identified. Once approved for administration, the facility would be sending out consents to residents/family. The IP indicated if there were a lot of residents that needed a pneumococcal vaccination at the end of the year they would not necessarily wait until August to administer the pneumococcal vaccine to those residents. They would try and do it sooner if four or more residents needed the vaccination. The IP provided a list of residents that had been identified for pneumococcal administration. In addition to R7, R10, R12, R15, and R60, R20 admitted on [DATE], R21 admitted on [DATE], and R26 admitted on [DATE], were also identified as needing pneumococcal administration. The facility guidelines for determining when to administer pneumococcal vaccinations to residents was requested but not received.

Based on interview and record review, the facility failed to incorporate provider orders as well as indications for use for aquathermia heating therapy pad (aqua-K pad) intervention in care plan for 1 of 3 residents (R19) reviewed for care planning.Findings include:R19's quarterly Minimum Data Set (MDS) dated [DATE], identified the resident was severely cognitively impaired with diagnoses that included Alzheimer's disease, depression, anxiety, varicose veins of lower extremity, hypocholesteremia, osteoarthritis, hypothyroidism, gastroesophageal reflux disease, and peripheral vascular disease.Review of R19's provider orders on 7/30/25, no order for use of aqua-K pad for back pain in resident's electronic medical record (EMR).During interview on 7/30/25 at 2:12 p.m., registered nurse (RN)-B stated R19 did use an aqua-K pad but was not sure how long the resident had been using it. RN-B identified the pump for the aqua-K pad was set to 100 degrees and on continuous mode, with an empty water reservoir. RN-B stated there was not an order for R19 to use the aqua-K pad. During joint interview on 7/30/25 at 3:03 p.m., director of nursing (DON) and assistant director of nursing (ADON) stated expectation that the provider would enter orders for the use of the aqua-k pad. DON and ADON explained the order would have the temperature settings, the frequency of use, and whether continuous use would have been allowed. DON and ADON stated being unsure if there was any danger in using the aqua-K pad without water or in using the pad continuously. DON and ADON confirmed that during the facility's switch from one EMR to another, the provider order for R19 to use the aqua-K pad did not transfer over. DON and ADON verified there was no order in the current EMR and staff did not have necessary directions on use and care of aqua-K pad.During interview on 7/31/25 at 1136, DON stated expectation of having a provider order for R19's use of aqua-K pad, and that information should have been in the resident's care plan.Aquathermia Pad policy, last revised on 1/27/2025, stated the use of an aquathermic pad is initiated by a physician's/advance practice provider's order that specifies duration and frequency. Policy continued on to state in preparation section review physician's/advance practice provider's order to determine treatment area, type of application, and temperature of treatment.

Based on observation, interview, and record review the facility failed to ensure infection prevention measures were in place to ensure linen was properly handled and stored. These deficient practices had the potential to impact all residents who resided at the facility. In addition, the facility failed to ensure proper glucometer sanitization occurred. This deficient practice had the potential to impact all residents who received glucometer testing at the facility. Findings include:During a tour of the laundry area on 7/29/25 at 12:31 p.m., the lead housekeeping staff (HS-A) stated dirty laundry was brought to laundry in clear plastic bags from all areas. Their process was to remove the plastic bags and sort laundry in the dirty linen area of laundry. Staff were to always wear gloves when they sorted linen. Staff would also wear a gown or a jacket when they sorted linen that was obviously soiled. HS-A confirmed staff were not required to wear a gown/jacket over their clothing for routine linen sorting, it was their process to wear gloves for routine linen sorting and then gown up for laundry that was visibly soiled. During a tour of the clean linen storage area on 7/29/25 at 12:35 p.m., wooden shelves and metal carts lined the walls of the linen room. On the right wall, the bottom wooden shelves were less than an inch think and flush to the floor. The bottom shelves contained mattress pads and blankets, some directly touching the floor. During an interview on 7/29/25 at 12:49 p.m., HS-A stated laundry should not be stored so close to the floor because it could become contaminated. HS-A removed the linen from the bottom shelves and stated they would need to re-wash the linen before it could be used. During an interview on 7/30/25 1:50 p.m., the director of nursing (DON) stated they were not sure if it was an infection prevention requirement for staff to wear a gown and gloves or just gloves when sorting linen. They would have to look at the facility policy to know for sure. During an interview on 7/30/25 at 2:02 p.m., environmental services aide EVS-A stated they also got assigned to laundry. On laundry days they were responsible for sorting dirty linen, washing, drying, and folding linen. EVS-A stated they had to always wear gloves to sort dirty laundry. When they had yellow or red bags of linen that needed to be sorted, they also wore a gown or a jacket in addition to their gloves. EVS-A confirmed they were instructed they only needed to wear gloves to handle dirty linen unless it was from a yellow or red linen bag. During an interview on 7/31/25 at 9:51 a.m., the infection preventionist (IP) stated for infection prevention the laundry staff should be wearing gown and gloves at all times when sorting dirty laundry. The laundry policy should include direction to wear gown and glove at all times for laundry sorting. Gowning and gloving when sorting linen should be done to prevent cross contamination of the clean laundry. Laundry should not be stored where it can touch the floor and become contaminated. The facility policy Departmental (Environmental Services) - Laundry and Linen dated 11/2014, section: Sorting Linen, instructed employees sorting or washing linen must wear a gown and gloves. During an interview on 7/30/25 at 1:37 p.m., registered nurse (RN-B) stated blood sugars were normally done by the night staff at 5:30 a.m. so they hadn't had to clean the glucometer. RN-B picked up the oxiver wipes and stated if they had to clean the glucometer, they would wipe it down with oxiver wipes and make sure the glucometer remained wet for the dwell time of 1 minute. The ADON was present and stated they would use the oxiver wipes to sanitize the Accu-Chek inform II between residents. The ADON pulled the infection control manual to see how to clean the glucometer, then left, returned, and shared cleaning instructions for the Accu-check Inform (not the instructions for the current glucometer Accu-Chek Inform II) The instructions instructed not to use bleach.During an interview on 7/31/25 at 9:21 a.m., the IP stated they were not sure what the requirements were for cleaning the facility glucometer, as the nurse managers and the ADON did the glucometer training. The IP indicated the infection prevention program should include oversight of the training of staff to ensure staff were using the right products and processes to clean patient care for equipment for infection prevention and control. During an interview on 7/31/25 at 11:24 a.m. the DON stated the IP was responsible for setting the policies and procedures for equipment cleaning and then nursing was responsible for the training/teaching which took place in orientation. The DON indicated they would expect training to occur when new equipment was put into use, however they were not certain when the newer glucometer model was put into use. The DON stated they were not aware what wipes were being used by staff for the glucometer, but they would expect the IP would do periodic audits on equipment sanitization including the glucometer.The facility policy Cleaning of Non-Critical and Semi-Critical Reusable Resident Care Equipment in North Shore Living Care Center dated 8/23/24, identified the glucometer as equipment staff was to clean. The policy directed it was the responsibility of the person using the equipment to ensure it was properly cleaned before and after use. Alcohol wipes could be used on equipment with smooth, hard surfaces, and thermometers. Equipment should be left to air dry after wiped down. The facility policy Blood Glucose Testing dated 12/30/24, instructed blood glucometer meters should be cleaned and disinfected after every use. Attached manufacturer information recommended the use of Clorox Germicidal wipes. The attached document Maintenance and Care, how to clean and disinfect the ACCU-Check Inform II system, page 129, number 3, directed: use a Clorox Germicidal Wipe or a Super Sani-Cloth Germicidal Disposable Wipe to clean the meter.

Based on interview and document review the facility failed to perform passive range of motion (PROM) and a walking program as ordered, as well as document correctly for 1 of 1 resident (R27) reviewed for therapy. Findings include: R27's quarterly minimum data set (MDS) dated [DATE], identified R27 had no cognitive impairment. Diagnoses included hypertension and other orthopedic conditions. R27's provider orders date 2/27/24, indicated physical therapy (PT) to evaluate and treat if appropriate. R27's physical therapy orders to nursing undated, indicated PROM rehab program. Orders stated to complete PROM right knee extension 3 repetitions x30-60 second holds to end range and complete daily. R27's physical therapy orders to nursing also identified a walking program, which included the following: stand pivot and short distance ambulating with nursing staff daily. Document refusals for standing and short ambulation. R27's care plan dated 3/6/24, identified a functional mobility care plan with interventions including, PROM rehab program - complete PROM right knee extension. 3 repetitions x30-60 second holds to end range. Complete daily. The care plan lacked information about a walking program. R27's care guide sheet dated 7/27/24, identified R27 was on a PROM program and a walking program that was to be completed daily. R27's Nursing Rehabilitation PROM documentation was reviewed from 7/1/24 to 7/31/24, and lacked documentation PROM was completed on 7/7/24, 7/10/24, 7/16/24, 7/19/24, 7/22/24, 7/25/24, R27's walking program documentation was reviewed from 7/1/24 to 7/31/24, and lacked documentation walking was performed on the following dates: 7/1/24 to 7/3/24, 7/7/24, 7/10/24, 7/16/24, 7/19/24, 7/22/24. During an interview on 7/29/24 at 6:28 p.m., R27 stated she was on walking and a PROM programs that was set up by PT and was to be done by the staff every day. R27 stated the staff on day shift would walk her on some days but not every day and had never done any kind of range of motion on her knee. She could tell when she did not get to do the walking because the next time they walked her after missing a session, her knee was more stiff and sore. During an interview on 7/30/24 at 3:41 p.m., physical therapist (PT)-A stated a PROM and walking program had been set up in 3/24, on R27 and it was nursing's responsibility to make sure it was done every day. It was to ensure R27 would her mobility and her right leg would get stronger, with a goal of her to walk independently with a wheeled walker. During an interview on 7/31/24 at 10:31 a.m., nurse assistant (NA)-A stated R27 was on a walking program and a PROM program that was to be performed daily. NA-A stated They try to perform the walking program and PROM but do not always have time. If the walking program or PROM is not performed we will just leave it blank or document that it was not done. Staff would also pass on to the next shift the walking program and PROM was not completed on the last shift. During and interview on 8/1/24 at 10:01 a.m. the assistant director of nursing (ADON) stated anytime a resident is on a walking or a PROM program then it is up to the entire staff to make sure the actions are performed. If one person cannot get to it then the next shift would help out. The ADON reviewed R27's medical record and confirmed there were several days that had missing documentation, indicating that the walking and PROM programs were not completed. She also acknowledged several days were documented as not done with no explanation as to why. The ADON stated nurse orders that were daily needed to be completed daily, and if missed, documented with an explanation as to why it was missed. Facility Policy Nursing Rehab last revised 4/23/17, identified the nursing rehab program was provided to maximize each patient/resident's functional independence. Nursing would follow the program as built and ordered by therapy services and document daily. If a refusal was made by the resident the reason would be indicated.

Based on interview and document review, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to 2 of 2 residents (R8, R26) reviewed who remained in the facility after their Medicare part A covered services ended. Findings include: R8's Center for Medicare and Medicaid Services (CMS)-10123 signed as received on 2/1/24, identified a last covered day of 2/5/24, when R8's Medicare coverage would end. R8's Census Record dated 8/1/24, identified on 2/5/24, R8's payer source changed. The record further indicated R8 remained in the facility. R26's CMS-10123 signed as received on 2/29/24, identified a last covered day of 3/2/24, when R26's Medicare coverage would end. R26's Census Record dated 8/1/24, identified on 3/2/24, R8's payer source changed. The record further indicated R8 remained in the facility. R8's and R26's medical records were reviewed and lacked any evidence a SNFABN had been provided to explain the estimated cost per day or provide rationale or explanation of the extended care services or items to be furnished, reduced, or terminated. During interview on 7/30/24 at 1:32 p.m., administrator verified a SNFABN was not completed for R8 or R26. Administrator stated SNFABN's were not completed because they were not required. During interview on 7/31/24 at 1:59 p.m., business office accountant verified a SNFABN was not completed for R8 or R26. Explained it has never been the practice of the facility to provide a SNFABN to residents who remain in the facility when their Medicare part A covered services ended. A policy on beneficiary notices was requested and not received.

Based on observation, interview, and document review, the facility failed to ensure the facility's dishwasher temperatures were reaching the minimum temperature for the wash and rinse cycles. This deficient practice had the potential to affect all 27 residents who received meals from the facility's kitchen. Findings include: During an initial tour of the kitchen with cook (C)-A on 8/14/23 at 6:35 p.m., C-A stated the dishes were all washed for the day. C-A said the dishwasher was hot water sanitization. The dishwasher temperatures were filled in sporadically for August. The dishwasher had a label on the side of the machine [NAME] with wash temperature of 160 degrees Fahrenheit (F) and rinse temperature of 180 degrees F. The manufacturers' instructions for use dated 2/16, and the stamped label on the side of the dishwashing machine identified the temperatures needed to reach a wash temperature of 160 degrees F and a final rinse temperature of 180 degrees F, to ensure sanitation. On 8/17/23 at 9:22 a.m., in the main kitchen C-B ran a bin for dish collection through the dishwasher. The wash temperature on the Ecolab display was; wash 111 degrees F and rinse 183 degrees F. C-B ran a rack of cups through the dishwasher, the wash temperature on the Ecolab display was; wash 110 degrees F, rinse 170 degrees F. The Ecolab display with the temperature readings turned red. C-B stated they were not sure what to do about the dishwasher temperatures and the red warning display. C-B determined they should call the dietary manager. At approximately 9:36 a.m., the dietary manager (DM)-A entered and determined the dishwasher should not be used and staff would need to wash dishes in the kitchenettes on the Woods or Waves units. During an interview on 8/17/23 at 9:41 a.m., maintenance (M)-A stated they were having trouble with the dishwasher in the kitchen and parts were on order. During an interview on 8/17/23 at 9:52 a.m., the DM-A verified the dishwasher temperatures for the wash cycle needed to be at least 150 degrees F and the rinse cycle needed to be at least 180 degrees F. Staff were not recording temperatures in August and stated they really did not know if the dishwasher was getting to the proper temperatures. Not reaching the appropriate temperature could result in residents becoming ill. The dishwasher temperature logs were reviewed and identified the following out of range and missing temperatures: August 2023 8/1/23 a.m., rinse 158 F, p.m., wash 134 F, rinse 140 F 8/2/23, a.m., rinse 173 F 8/4/23, no recordings for a.m. 8/5/23, no recordings for a.m. 8/6/23, a.m. rinse 173 F, no recordings for p.m., or (at bedtime) HS 8/7/23, no recording for p.m. or HS 8/8/23, no recording for p.m. or HS 8/10/23, no recordings for a.m. 8/12/23, no recordings for a.m. or HS 8/13/23, no recordings for a.m. or HS 8/14/23, no recordings for a.m. 8/15/23, no recording for p.m. or HS 8/16/23, no recordings for a.m. or HS July 2023 7/1/23, p.m. wash 134 F, rinse 170 7/2/23, a.m. wash 139 F, rinse 171 7/4/23, a.m. wash 156 F 7/7/23, p.m. wash 152 F 7/11/23, p.m. wash 130 F, rinse 173 F 7/14/23, a.m. wash 155 F, rinse 178 7/16/23, p.m. wash 104 F 7/22/23, a.m. wash 153 F rinse 175, p.m. wash 158 F 7/25/23, p.m. wash 129 F During an interview on 8/17/23 at 4:53 p.m., the administrator expected staff to run the dishwasher probe per the policy to ensure the dishwasher was getting to the proper temperatures. The Dishmachine-Procedure for Operation dated 8/18/23, identified the dishwasher wash cycle needed to be at a minimum of 160 degrees F and the rinse cycle at a minimum of 180 degrees F.

Based on interview and document review, the facility failed to notify residents, representatives and families of confirmed cases of Coronavirus Disease 2019 (COVID-19), when one employee tested positive for COVID-19, per current federal guidelines. In addition, the facility failed to provide cumulative updates weekly to residents, their representatives and families of any subsequent positive cases or respiratory illnesses. This deficient practice had the potential to affect all 31 residents, families and representatives at the facility. Findings include: Center for Medicare & Medicaid Services (CMS) Center for Clinical Standards and Quality/Quality, Safety and Oversight Group (CMS QSO) memo 20-29 NH dated 5/6/20, required nursing homes to inform residents, their representatives, and families of those residing in facilities by 5 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other. The memo further directed facility's to provide cumulative updates at least weekly to residents, their representatives and families on any subsequent positive cases or respiratory illnesses. On 7/14/22, at 10:04 a.m. infection preventionist (IP) stated the last positive COVID-19 case in the facility was two months ago and it was a staff member. The IP stated the facility performed contact tracing to see if there were any staff considered a high risk exposure or any residents that were a close contact. The IP stated if staff or residents had been in one of the two classifications, those people would be notified they had an exposure. The IP stated he did not believe the facility notified all residents, resident representatives and family members when the facility had a confirmed positive COVID-19 case in the facility. The IP stated the facility did not have a policy that indicated resident, resident representative and family notifications processes. On 7/14/2022, at 3:44 p.m. the administrator stated the facility did not notify all residents, resident representatives and family members when the facility had a confirmed COVID-19 positive case. The administrator stated the facility would do contact tracing, and would only notify resident, resident representatives and family members of resident believed to be a high risk exposure. The administrator stated all residents, resident representatives and family members would not be notified unless contact tracing indicated a wide case of residents considered a high risk exposure. The facility COVID-19: Prevention Program policy dated 7/30/21, lacked any process or direction that residents, resident representatives and family members had to be notified by five p.m. the following day after a confirmed COVID-19 cased had occurred in the facility.

Based on observation, interview and document review, the facility failed to maintain acceptable infection control measures during personal cares for 1 of 1 resident (R20) who required an indwelling catheter and for 1 of 1 resident (R13) observed to receive lotion applied to legs. In addition, the facility failed to develop a tracking and trending system for monitoring infections not treated with antibiotic within the facility. This practice had the potential to affect all 31 residents, staff, and visitors to the facility. Findings include: R20's quarterly Minimum Data Set (MDS) dated [DATE], identified R20 with severe cognitive impairment and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS also indicated R20 required an indwelling bladder catheter. On 7/13/22, at 7:40 a.m. R20 was observed to receive assistance with morning cares. R20 was resting in bed with an indwelling bladder catheter drainage bag hanging from the side of the bed frame. At 7:45 a.m. nursing assistant (NA)-A donned gloves, gathered a wet washcloth and a urinal. NA-A placed the urinal directly onto the floor, opened the catheter drainage bag and released on the contents directly into the urinal on the floor. NA-A then closed the drainage port, wiped it off with the wet washcloth and picked up the urinal as she returned to R20's bathroom. NA-A was not observed to place a barrier between the floor and the urinal or to utilize alcohol wipes to clean the drainage bag port before or after emptying the bag contents. At 7:51 a.m. NA-A was observed to transfer R20 from the bed to a Geri chair (reclining wheelchair) via a standing mechanical lift. During the transfer, NA-A was observed to place the drainage bag directly on the foot rests of the lift. Once in the chair, NA-A hung the drainage bag on the side of the Geri chair and covered it with a towel. At 11:40 a.m. NA-A removed the drainage bag from the side of the Geri chair and tossed it onto the floor as NA-A positioned the lift in front of R20. Once R20 was positioned, NA-A picked up the drainage bag, placed it onto the foot rests of the standing lift, stood up R20 and transferred her to the toilet. The drainage bag remained on the lift foot rests until NA-A transferred R20 back into the Geri chair. NA-A stated the facility did not have enough staff to ensure all cares were done correctly as she was the only staff member caring for all of the residents in the Woods neighborhood. On 7/14/22, at 10:26 a.m. registered nurse (RN)-C stated the staff were to clean the catheter drainage bags with alcohol wipes and there was to be a barrier of some type between the floor and the graduate receptacle when emptying the drainage bag. -At 12:20 p.m. RN-A confirmed the facility practice was to ensure the drainage bags were kept off of the floor. During a transfer, the drainage bag was to hang on the side of the lift below the level of the resident's bladder and when the bag was emptied, a barrier was to be utilized between the graduate and the floor. In addition, the drainage bag port was to be sanitized with an alcohol wipe. The Urinary Catheter Care policy dated 7/15/21, directed the staff to sanitize the end of the drainage bag spout with an alcohol prep pad after draining the urine and prior to re-engaging the clamp and inserting the outlet tube into the hose. The policy did not direct the staff to keep the drainage bag off of the floor. R13's annual MDS dated [DATE], identified R13 with severe cognitive impairment and a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/13/22, at 12:53 p.m. NA-C was observed to transfer R13 from a Geri chair to bed with a full body mechanical lift. Once in bed, NA-C donned gloves and provided R13 with assistance with incontinence cares as she was incontinent of urine. NA-C applied a new incontinence product and pulled up R13's pants. NA-C was not observed to remove her gloves or wash her hands as she picked up a container of Eucerin (thick moisturizing lotion), open the container and dipped her gloved hand into the lotion, rubbed it on both gloves and applied it to R13's legs and feet. NA-C then removed her gloves and washed her hands. At 12:57 p.m. NA-C confirmed she had not removed her gloves or washed her hands between providing R13 with perineal cares and applying the lotion. NA-C stated she should have washed her hands. On 7/14/22, at 12:48 p.m. RN-A stated the staff should have removed gloves and washed hands after perineal cares and before applying lotion. The facility Handwashing Policy dated 6/23/21, directed the staff to perform hand hygiene after contact with blood, body fluids or excretions, [MEDICATION(S)] membranes, non-intact skin, or wound dressings even if gloves are worn. On 7/14/22, at 9:55 a.m. the infection preventionist (IP) tracking system and investigative system for infections not requiring antibiotic use was requested but not provided. On 7/14/22, at 10:04 a.m. the IP stated he had no tracking system for infections or symptom based illnesses that did not require antibiotics. The IP stated he would not have nursing staff notify him of residents with symptom based illnesses such as abdominal pain or diarrhea (symptoms related to gastrointestinal illness that may not require antibiotic usage) unless seen by the provider and the provider thought IP needed to be notified. The IP stated he would not worry or track gastrointestinal illnesses or other infections not requiring antibiotics unless seven or eight residents in the same area began having similar symptoms. Lastly, the IP stated the nursing staff and the providers would let him know if there were any concerns of infections they felt he needed to know about. On 7/14/22, at 2:00 p.m. the director of nursing (DON) stated the IP was in charge of monitoring all infections and also antibiotic usage. The DON stated that it was left up to the IP to monitor when there was a concern of infections in residents that could lead to widespread disease. Finally, the DON stated his expectation was staff would follow the policy and report infections as needed. Facility's Nosocomial Surveillance policy last approved 1/25/21, indicated the purpose of the policy was to assure North Shore Health had a plan in place to prevent and control the spread of infections, patients and residents that had infectious diseases would be treated promptly and lastly the nosocomial infection surveillance plan would monitor trends, clusters and outbreaks of infections. The policy procedure indicated nursing home staff would complete a report of infection form for residents that had suspected infections. The infection control coordinator would review the care center infection control log daily for surveillance that would identify any potentially communicable diseases.

Based on observation, interview, and document review, the facility failed to ensure controlled medications were stored, monitored, and readily reconciled to prevent diversion of controlled medications. Findings include: On 7/13/22, at 8:20 a.m. during a medication pass on The Waves nursing unit, the narcotic medication sign out book was noted to be a three ring binder. On 7/14/22, at 10:48 a.m. the director of nursing explained the process for signing in narcotic medications and signing narcotic medications out. The DON stated the pharmacy delivered the medications (narcotic and non-narcotic) and a nurse would go out to the car, they would verify the medications being delivered matched the delivery sheets. The controlled substances would arrive with a medication sheet and the medication card. The medication sheet would be placed in the three ring binder and the narcotic would be locked in a drawer inside a locked medication room; the delivery sheet would then be filed in a separate book. The system lacked an index page or other method to account for the controlled medications that were placed in the drawer. The DON verified, with the current system, the narcotic card and the medication sign out sheet could both be removed and no one would know the medication was missing. On 7/14/22, at 10:58 a.m. the DON stated he was not sure if the emergency narcotic kit was being accounted for at each shift change. A review of the narcotic sign off sheets was completed with the DON. The narcotic sign off sheets were calendars with no title, with two sets of initials in the date square. There was not an index to show what controlled substances should be in the drawer. -A review of May 2022, showed no counts done on the 1st, 23rd, and 30th. Only one set of initials (should be two) were on the 2nd, 7th, 8th, 13th, 14th, 15th, 16th, 18th, 20th, 21st, 22nd, 24th, 25th, 26th, 27th, 28th, 29th, and 31st. -A review of June 2022, showed no counts on the 6th, 8th, 11th, 17th, 20th, 23rd, 27th, 29th, and 30th. Only one set of initials were on the 5th, 9th, 10th, 12th, 13th, 14th, 16th, 21st, 22nd, 24th, 25th, and 26th. -A review of July 2022, showed no counts done on the 1st, 2nd, 3rd, 5th, and 6th. Only one set of initials were on the 4th, 12th, and 13th. The DON verified he would expect the on-coming and off-going shift to count the narcotics. On 7/14/22, at 1:44 p.m. the administrator stated the process for tracking controlled substances could be tightened up. It was her expectation that the on-coming and off-going staff would count the controlled substances daily. The facility policy Medications, Controlled dated 3/5/20, outlined the procedure as follows: -a pharmacist or designee brings a supply of the controlled medications to the Care Center -the charge nurse or the trained medication aid would enter the appropriate information on a Patient Narcotic Record Sheet after counting the controlled medication with another nurse -medications sent from the pharmacy would arrive with a completed Patient Narcotic Record Sheet. Narcotics were to be counted upon arrival -Schedule II and Schedule II-V medications were to be counted at the change of each shift by the off going and the on coming nurse and both were to sign the change of shift count record -if the count was incorrect, the supervisor was to be notified, after hours the on call administrator, the nurses were to remain on duty until the count was reconciled or the supervisor/administrator gave permission to leave

Based on observation, interview and document review, the facility failed to ensure dependent residents receive assistance with personal hygiene for 3 of 5 residents (R20, R13 and R29) who were dependent on staff for personal hygiene. In addition, the facility failed to provide timely assistance with incontinence cares for 1 of 2 residents (R13) identified as requiring total assistance with checking and changing of incontinence products. Findings include: R20's quarterly Minimum Data Set, dated dated dated [DATE], and annual MDS dated [DATE], identified R20 with severe cognitive impairment and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDSs indicated R20 required extensive assistance of one staff for all activities of daily living. R20's activities of daily living Care Area Assessment (CAA) did not trigger at the time of the annual MDS. R20's Urinary CAA dated 3/18/22, indicated R20 was dependent upon one staff for perineal cares. R20's care plan dated 6/7/22, indicated R20 required physical assistance of one staff for all cares. R20 had a permanent partial (partial false teeth) and will have very bad breath unless prompted to use special brushes for partial and regular teeth. The care plan also directed the staff to comb R20's hair and apply lipstick daily. On 7/13/22, at 7:40 a.m. nursing assistant (NA)-A entered R20's room to assist with morning cares. R20 was observed to be resting in bed. An indwelling foley catheter drainage bag was observed to be hanging on the side of the bed. NA-A obtained a wet washcloth from the bathroom sink. NA-A was not observed to utilize soap as she uncovered R20, performed perineal and catheter cares with the cloth and applied a fresh incontinence product. NA-A wash her hands. NA-A stated R20 never really lets me brush her teeth as she went to the closet to gather clothes. NA-A applied R20's pants and transferred R20 from the bed to a Geri chair (reclining wheelchair) via a standing mechanical lift. At 7:53 a.m. NA-A assisted R20 to don a shirt. NA-A stated, I cannot take the time to do everything, I just get them [the residents] up as best we can. NA-A asked R20 if she would like to brush her teeth now or later. R20 stated later. NA-A obtained a fresh wet washcloth from the bathroom and wiped off R20's face. NA-A was not observed to utilize soap. NA-A then combed R20's hair and wheeled her out of the room. At no time was NA-A observed to utilize soap, wash R20's upper body (under arms, under breast or back) or offer to assist R20 with applying lipstick. - At 11:40 a.m. NA-A stated she had not been able to offer R20 the opportunity to complete oral cares after breakfast. NA-A stated I didn't have time to do that. -At 11:51 a.m. registered nurse (RN)-C stated the NA staff were to complete partial baths with morning cares. This would include washing the face, under arms, under breasts, back and perineal cares. The staff were also to complete oral cares with morning and evening cares. On 7/14/22, at 12:20 p.m. RN-A stated the facility expectation would be for all residents to receive assistance with morning cares which would include washing the face, upper body, and perineal cares with soap. RN-A stated R20 required assistance with oral cares due to her partial and should be offered lipstick as wearing lipstick was a very important to R20 and her family. R13's annual MDS dated [DATE], identified R13 with severe cognitive impairment and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated R13 required extensive assistance of one staff for all activities of daily living, total assistance for transfers and total assistance with toileting as R13 was always incontinent of bowel and bladder. R13's Activities of Daily living CAA dated 5/4/22, indicated R13 was dependent upon one or two staff members for all activities of daily living. R13's Unrainy Incontinence CAA dated 5/4/22, indicated R13 required assistance to check and change incontinence products every 2- 2.5 hours. R13's Care Plan dated 6/25/22, identified R13 with a self-care deficit and directed the staff to provide extensive to total assistance with all activities of daily living. In addition, the care plan identified R13 as incontinent of bowel and bladder and directed the staff to assist with incontinence cares every 2- 2.5 hours. On 7/13/22, from 9:13 a.m. to 12:45 p.m. R13 was observed continuously. -At 9:13 a.m. NA-A checked R13's incontinence product and stated R13 was dry. NA-A was not observed to provide perineal cares as she donned R13's pants and positioned R13 into a full body mechanical lift. At 9:14 a.m. NA-A transferred R13 from the bed into a Geri chair via a full body mechanical lift. Once in the chair, NA-A removed R13's night shirt and donned a fresh shirt. NA-A was not observed to assist R13 with upper body washing. NA-A stated, I can only do so much today, otherwise it is way too much. NA-A then gathered a wet washcloth, wiped off R13's face, dampened a toothette (small piece of foam on a stick) and wiped out R13's mouth. She then combed R13's hair, assisted her with applying sun glasses. At no time was R13 observed to receive upper body or perineal cares with soap. -At 9:20 a.m. NA-A wheeled R13 out of her room and pushed R13 to the lounge area on the Woods neighborhood. -At 9:29 a.m. R13 was served breakfast and fed by RN-C. -At 10:09 a.m. R13 finished her meal and remained in the lounge area in front of the television. -At 10:57 a.m. NA-A moved R13's upper body (less than 2-3 inches) while seated in the Geri chair. R13 was not observed to assisted off of her buttocks. -At 11:30 a.m. NA-A stated R13 would be assisted with incontinence cares after lunch around 1:30 or so. -At 12:40 p.m. RN-C was informed R13 had not received assistance with incontinence cares. RN-C requested additional staff to come to the neighborhood to assist R13. -At 12:44 p.m. NA-B and RN-C wheeled R13 into her room. -At 12:45 p.m. NA-B transferred R13 into bed via a full body mechanical lift. NA-B was observed to check R13's incontinent product and was observed to be incontinent of urine. RN-C confirmed R13 had not received assistance with incontinence cares as directed by the plan of care as R13 had not received assistance for three hours and 30 minutes. On 7/14/22, at 12:55 p.m. RN-A stated R13 was to receive a partial bath with morning cares. In addition, R13 was to receive assistance with incontinence cares every 2-2.5 hours as directed by the plan of care. R29's significant change MDS dated [DATE], indicated R29 had severe cognitive impairment and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated required extensive assistance of one to two staff members for all activities of daily living and R29 had natural teeth. R29's activities of daily living CAA did not trigger at the time of the significant change MDS. R29's Fall CAA dated 6/25/22, indicated R29 had sustained a [CONDITION(S)] on 6/18/22, and required assist of one with all activities of daily living. R29's Care Plan dated 6/25/22, identified R29 with a self-care deficit related to dementia. The plan directed the staff to set up R29 with supplies and assist R29 with all activities of daily living. On 7/13/22, at 9:49 a.m. NA-A assisted R29 with morning cares. R29 was observed to be seated on the edge of the bed. NA-A transferred R29 from the bed to the toilet via a stand aide (non-electric standing device in which the resident stands on the device and a supportive seat holds the resident in a standing position while it while the device is wheeled to an alternative location.) NA-A wheeled R29 into the bathroom and assisted R29 onto the toilet. NA-A was observed to remove R29's shirt and washed R29's armpits with a wet washcloth. NA-A was not observed to utilize soap prior to donning R29's shirt. NA-A then brushed R29's hair. At 9:54 a.m. R29 was cued to stand with the stand aide. NA-A completed perineal cares with a wet wash cloth, however, soap was not observed to be utilized. NA-A applied an incontinence product, pulled up R29's pants and transferred R29 into the wheelchair. NA-A then washed R29's face with a wet washcloth (no soap) and asked R29 if she would like to brush her teeth. R29 stated she would brush her teeth later. At 9:59 a.m. R29 was wheeled out of the room to the dining room table. - At 11:40 a.m. NA-A stated she had not offered R29 the opportunity to complete oral cares as she didn't have time to do that. On 7/14/22, at 1:40 p.m. RN-A stated R29 required assistance to complete activities of daily living. The staff were expected to utilize soap during cares. In addition, R29 had natural teeth and was to be assisted with oral cares. On 7/14/22, at 3:45 p.m. the director of nursing (DON) confirmed the residents were to receive assistance with activities of daily living in accordance to their care plans. The Activities of Daily Living policy dated 4/26/17, directed the staff to meet each of the resident need of daily living as assessed by the registered nurse. The Oral Care Policy dated 5/2/17, directed the staff to ensure all resident receive appropriate oral care, including denture care, if applicable, twice a day. The Compressive Bowel and Bladder Assessment policy dated 3/2/17, directed the staff to complete a comprehensive assessment of the resident bowel and bladder function, implement interventions, develop a care plan for the resident and implement the care plan as directed.

Based on observation, interview, and document review, the facility failed to ensure residents identified at risk for pressure ulcers received the necessary care and treatment to prevent the development of pressure ulcers for 2 of 3 resident (R20 and R13) in the sample identified at risk for pressure ulcers. Findings include: R20's quarterly Minimum Data Set, dated dated dated [DATE], and annual MDS dated [DATE], identified R20 with severe cognitive impairment and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDSs indicated R20 required extensive assistance of two staff for bed mobility, extensive assistance of one staff for transfers, non ambulatory, and at high risk for the development of pressure ulcers. The quarterly MDS dated [DATE], identified R20 had one unstageable pressure ulcer with suspected deep tissue injury in evolution. R20's Pressure Ulcer Care Area Assessment (CAA) dated 3/15/22, indicated R20 was at moderate risk for pressure related breakdown due to diabetes, chronic incontinence and limited mobility. The assessment directed the staff to toilet R20 every two to two and a half hours to increase continence and reduce pressure. R20's progress note (nurses note) dated 5/12/22, at 12:49 p.m. indicated R20 had developed pressure areas on both heels. The right heel was noted to have a red blanchable areas that measured 3 centimeters (cm) by 2 cm. This is a result of pressure, but not yet categorized as a pressure injury. The left heel was noted to have a dark discolored tissue that was not blanchable surrounded by blanchable redness. The deep tissue injury was 1.8 cm by 0.8 cm. R20 utilized pressure reduction booties at all times. R20's progress note dated 5/12/22, at 2:45 p.m. included a comprehensives skin assessment. R20's Braden score identified R20 at high risk for the development of pressure sores. R20's mobility was identified as declined need total assist for almost all movement. R20 had a pressure reduction mattress on her bed, blue booties bilaterally to feet at all times, R20's heels were to be floated while in bed, and a pressure redistribution cushion on the Geri chair. R20's progress note dated 7/12/22, indicated the right heel area had resolved and the left heel discolored area measured 2 cm x 0.5 cm and the deep tissue injury measured 1.5 cm x .5 cm. R20's care plan dated 6/7/22, identified R20 high risk for the development of pressure ulcers. The care plan directed the staff to assist R20 to the toilet every 2-2.5 hours while awake to increase continence and reduce pressure, to keep heel booties on at all times except when transferring and to utilize pressure redistribution cushions on the bed and wheelchair. The care plan did not identify R20's deep tissue injury on the left heel. On 7/13/22, at 7:51 a.m. to 11:37 a.m. R20 was observed during continuous observations. -At 7:40 a.m. nursing assistant (NA)-A was observed to assist R20 with morning cares. R20's buttocks were observed to be pink without darkened areas. R20's feet were observed to be wrapped with gauze, covered with socks and wrapped in foam booties. -At 7:51 a.m. NA-A transferred R20 from the bed to a Geri chair (reclining wheelchair) via a full body standing lift. -At 7:58 a.m. R20 was wheeled into the main dining room. -At 8:16 a.m. registered nurse (RN)-C assist R20 with breakfast. -At 8:39 a.m. R20 was wheeled to the Woods neighborhood lounge area. -At 11:00 a.m. NA-A moved R20's upper body and placed a pillow behind her head. At no time did NA-A assist R20 off of her bottom. -At 11:03 a.m. R20's family member visited with R20 in the lounge area. -At 11:33 a.m. R20's family member wheeled R20 to the main dining room. -At 11:36 a.m. NA-A confirmed R20 had not been assisted with repositioning since she had assisted R20 out of bed at 7:51 a.m. (3 hours and 47 minutes earlier). -At 11:37 a.m. NA-A wheeled R20 to her room and assisted R20 from the Geri chair to the toilet via the mechanical standing lift. R20's buttocks/coccyx area was observed to be deep purple in color. NA-A stated R20 would occasionally have purple buttocks. R20's wheelchair was equipped with a pressure redistribution cushion. -At 11:53 a.m. RN-C observed R20's buttocks. RN-C confirmed R20's buttocks/coccyx area was deep purple. RN-C lightly pushed on R20's buttocks and stated the area was blanchable. RN-C stated R20 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-C stated R20 was to receive assistance with repositioning every two to two and a half hours. -At 1:35 p.m. RN-C added a progress note which indicated R20 was noted to have a blanchable purplish hue to her buttocks. R20 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R20 was not observed to have open areas noted on her buttocks. On 7/14/22, at 10:15 a.m. RN-C was observed to complete wound care on R20's heels. The right heel was observed to be intact without discoloration. The left heel was observed to have a dry blackened area approximately the size of a quarter. RN-C stated the heel deep tissue injury was improving. On 7/14/22, at 12:19 p.m. RN-A stated R20 was at risk for the development of pressure ulcers and was to receive assistance with repositioning every two to two and a half hours as directed by the plan of care. R13's annual MDS dated [DATE], identified R13 with severe cognitive impairments and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated R13 required extensive assistance of one staff for all activities of daily living, total assistance for transfers and R13 was non ambulatory. The MDS indicated R13 was at high risk for the development of pressure ulcers. R13's Pressure Ulcer CAA dated 5/4/22, indicated R13 had a [NAME] score reduced with change in mobility and incontinence: and was at increased risk for skin breakdown. The assessment directed the staff to reduce pressure on bony prominences by utilizing pressure reduction mattress pad, encourage mobility and ambulation if able, the staff were also to lift R13 verses sliding R13 across surfaces to reduce friction and to apply lotions. R13's Care Plan dated 6/25/22, identified R13 at risk for the development of pressure ulcers and directed the staff to provide R13 with pressure redistribution cushion, mattress and heel booties. The care plan also directed the staff to assist R13 with repositioning every two to two and a half hours. On 7/13/22, from 9:13 a.m. to 12:45 p.m. R13 was observed continuously. -At 9:13 a.m. R13 was observed to receive assistance with morning cares and was transferred from the bed to a Geri chair via a full body mechanical lift by NA-A. -At 9:20 a.m. NA-A wheeled R13 out of her room and pushed to the lounge area on the Woods neighborhood. -At 9:29 a.m. R13 was served breakfast and fed by RN-C. -At 10:09 a.m. R13 finished her meal and remained in the lounge area in front of the television. -At 10:57 a.m. NA-A moved R13's upper body (less than 2-3 inches) while seated in the Geri chair. R13 was not observed to assisted off of her buttocks. -At 11:30 a.m. NA-A stated R13 would be assisted with repositioning after lunch around 1:30 or so. -At 12:40 p.m. RN-C was informed R13 had not received assistance with repositioning. RN-C requested additional staff to come to the Woods neighborhood to assist R13 with repositing. -At 12:44 p.m. NA-B and RN-C wheeled R13 into her room. -At 12:45 p.m. NA-B transferred R13 into bed via a full body mechanical lift. R13's wheelchair was equipped with a pressure redistribution cushion. R13 had an intact foam dressing covering her coccyx. R13's skin was intact. RN-C stated R13 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The foam dressing was a preventative measure. RN-C confirmed R13 was to receive assistance with repositioning every two to two and a half hours; however, she had not received assistance with repositioning for three hours and thirty minutes. On 7/14/22, at 12:55 p.m. RN-A stated R13 was to be assisted with repositioning every hour due to her history of pressure ulcers; however the care plan directed the staff to assist with repositioning every two to two and a half hours. The Pressure Ulcer Prevention and Treatment policy dated 9/1/14, directed the staff to provide turning and repositioning the residents based on the residents individualized plan of care.

Based on interview and document review, the facility failed to report to the state agency (SA) resident to resident abuse (R4 towards R2) for 1 of 2 allegations of resident to resident allegations reviewed. Findings include: R4's Face Sheet undated, indicated R4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated R4 had severely impaired cognition, and was independent for activities of daily living (ADLs) with set up and cues. R4's Care Assessment Areas (CAA), undated, indicated [CONDITION(S)], cognitive loss/dementia, behavioral symptoms, falls and [CONDITION(S)] drug use as areas that would need to have care planned interventions and areas the facility would need to focus on for R4's care and safety. R4's care plan last revised 5/10/22, indicated she had behaviors that included wandering behaviors along with rummaging, pacing and wandering into other resident's rooms. Interventions included assess and document resident behavior, what triggered it, what was done, the results of any interventions attempted, and staff should notify IDT (interdisciplinary team) of changes. The care plan lacked any nonpharmacological interventions to attempt when R4 was exhibiting the listed behaviors. R4's progress notes dated 4/25/22, at 8:00 p.m. indicated R4 entered R2's room after supper. When R2 asked R4 to leave R4 kicked R2 in the thigh. The progress note indicated the primary care provider would be notified regarding the aggressive behaviors. The progress note lacked any documentation of notification of facility management, or the SA, related to the resident-on-resident altercation. On 7/14/22, at 1:53 p.m. the director of nursing (DON) stated if a resident-to-resident altercation occurred the staff needed to report the altercation to the primary care provider and facility administration right away so a report to the SA could be made right away if needed. The DON stated he was aware R4 kicking R2 on 4/25/22. The DON was unaware if anybody in administration had been notified right away when it happened and that he was notified the next morning in IDT meeting. The DON stated IDT discussed what occurred and agreed the resident-to-resident altercation did not need to be reported because even though they were done on purpose, R4 did not understand the ramifications of her actions. The DON stated the facility uses a grid to verify if a report needs to be made to the SA involving resident-to-resident altercations. On 7/14/22, at 2:57 p.m. RN-A provided during her interview, the Federal Long-Term Care Reportability for Abuse Under F225 Resident-To-Resident Altercations Grid. Step three of the grid indicated did the resident act willfully in the altercation? The grid indicated if yes and the actions resulted in injury and physical harm it would be reported to the SA immediately. Step three of the grid indicated even a resident with cognitive impairment may commit a willful act. On 7/14/22, at 3:28 p.m. RN-D stated she remembered the resident-to-resident altercation involving R4 and R2 that occurred on 4/25/22. RN-D stated that R2 did receive a bruise on the thigh that R4 kicked. RN-D stated she notified both resident's primary care providers and RN-A about the altercation after it happened. RN-D stated she did not believe it had to be reported to the SA because nursing staff have a binder with a check list regarding incidents that are reportable and what incidents are not. RN-D stated the grid provided in the binder indicated the altercation did not have to be reported. On 7/14/2022, 3:44 p.m. the administrator stated when any willful abuse occurred it would have to be reported to administration right away so the incident could be reported to the SA per facility policy. The administrator stated the incident on 4/25/22 was not reported because they could not be willful because R4 did not understand what she was doing during the actions of striking another resident. The administrator stated an expectation that all staff follow the policy and report any abuse that was willful. The facility Abuse Prevention Policy last revised 6/10/22, indicated residents had the right to be free from verbal, sexual, physical, and mental abuse, mistreatment, and neglect. The policy indicated residents must not be subjected to abuse or neglect by anyone including facility staff, other residents, consultants, volunteers, or family members. The policy defined resident to resident altercations as willful action between two or more residents that resulted in infliction of injury, unreasonable confinement, or intimidation with resulted physical harm, pain, or mental anguish. Abuse was defined as conduct would have reasonably caused physical pain, injury or emotional distress that included hitting, slapping, kicking, pinching, biting or corporal punishment of a vulnerable adult.

Based on observation, interview and document review, the facility failed to comprehensively assess and develop individualized interventions to address exhibited behaviors of dementia for 1 of 1 residents (R4) observed to wander and enter other resident rooms. Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated R4 had non-Alzheimer's dementia with resulting severely impaired cognition. R4's Care Assessment Areas (CAA), undated, indicated [CONDITION(S)] with documented tendencies of easy agitation, cognitive loss/dementia, behavioral symptoms, falls and [CONDITION(S)] drug use as areas that would need to have care planned interventions and areas the facility would need to focus on regard to R4's care and safety. R4's care plan last revised 5/10/22, indicated she had behaviors that included wandering along with rummaging, pacing, and wandering into other resident's rooms. Interventions included assess and document resident behavior, what triggered it, what was done, the results of any interventions attempted, and staff should notify the interdisciplinary care team (IDT) of changes. The care plan lacked any nonpharmacological interventions to attempt when R4 was exhibiting the listed behaviors. R4's activity care plan indicated activity staff would do small group, large group activities and 1 to 1 activities when R4 was unable to attend group activities. This care plan was initiated at time of admission. The care plan lacked any modifications based on altercations and changes in R4's status. R4's progress notes dated 4/25/22, at 8:00 p.m. indicated R4 entered R2's room after supper. When R2 asked R4 to leave R4 kicked R2 in the thigh. The progress note indicated the primary care provider would be notified regarding the aggressive behaviors. The progress note lacked any documentation of notification of facility management, or the SA related to the resident-on-resident altercation. The progress notes lacked any documentation of interventions placed after the altercation to protect R2. R4's progress notes dated 5/10/22, at 11:36 p.m. indicated R17 was in the dining hall with a clothing protector on and around R17's neck. R4 approached R17 and tried to pull the clothing protector over R17's head. When R4 was redirected R4 grabbed R17's glasses and bent them. The progress note lacked any documentation of notification of facility management, or the SA related to the resident-on-resident altercation. The progress notes lacked any documentation of interventions placed after the altercation to protect R17. On 7/11/22, at 7:17 p.m. R4 was observed in her room sitting in her recliner in pajamas watching the entryway to her room. Staff entered a room across the hall from R4 to assist that resident and R4 was observed leaving her room and attempting to enter that resident room. Staff was able to close the door to the other resident's room prior to R4 entering. R4 proceeded to wander up and down the hall without visualization by staff. - at 7:23 p.m. R4 attempted to enter R21's room but was stopped by the stop sign on R21's doorframe. R4 proceeded to push on the stop sign and tried to go under the stop sign to enter R21's room. R21 began calling for help. -at 7:26 p.m. nurse assistant (NA)-E approached R4 and redirected her down the hallway. After redirecting R4, NA-E proceeded to leave R4 wandering the hallway. On 7/13/22, at 10:02 a.m. R4 was observed in R27's room walking in circles and ovals, and pacing back and forth. R27 was sitting in his wheelchair in the hallway while R4 was wandering and pacing in his room. R27 never made an attempt to enter his room while R4 was in it. -at 10:07 a.m. NA-D approached R27 to see if he needed any assistance. R27 informed NA-D that R4 was in his room. NA-D assisted R4 out of R27's room and down the hall. R4 was left right away to wander the commons area while NA-D answered call lights. On 7/13/22, at 8:12 a.m. NA-D stated facility staff received dementia training annually as part of their computerized training. Part of training included resident specific plan of care and interventions that were appropriate for that resident. NA-D stated any resident specific interventions would be placed on the care plan along with the care cards so staff would be aware of what interventions were in place. NA-D stated R4 had to be redirected usually after an incident occurred and she was not aware of any interventions in place to stop occurrences of wandering, entering resident rooms, and potential resident altercations. NA-D reviewed the care cards and stated there were no documented interventions in place to address R4's care related to Dementia and Dementia type behaviors. On 7/14/22, at 1:53 p.m. the director of nursing (DON) stated all interventions were placed on the care plan and the care guides by the resident care manager when the changes occur. The DON stated changes in the care plan would occur because of a change in condition or related to behaviors a resident may have. Resident interventions were specific and built around specific resident needs. The DON stated it was his expectation all staff followed the plan of care and the care guide in relation to resident interventions for medical and behavioral concerns. On 7/14/22, at 2:57 p.m. registered nurse (RN)-A stated when there was a change in any resident care plan due to change of condition or change in situation she would make that change and would place the information on the care guide so staff would be aware of how to care for the resident. RN-A stated R4 was a challenging case and interventions tried in the past did not work. Activities would try to work with R4 but R4 did not like any of the activities the activity department offered R4. RN-A stated re-approach, re-approach, re-approach was the only thing staff could do to try to work with R4 because of staffing concerns. RN-A stated R4 should be under close observation or one on one but the facility was unable to perform these intervention due to staffing shortages. RN-A reviewed R4's care plan and stated there were no nonpharmacological interventions in place to address R4's behaviors and the activity interventions, small group activities, large group activities and one on one activities, had been in place since day of admission. No new interventions were in place since that time. A facility policy on dementia care and/or behavioral assessment was requested; however, none was received.

Based on observation, interview and document review, the facility failed to ensure sufficient staffing was available in order to implement provide timely assistance with personal cares according to the residents' assessed need and as directed by the care plan. This practice had the potential to affect one of two resident neighborhoods (Woods neighborhood) and all 14 resident who resided on the Woods neighborhood. In addition, the facility failed provide enough staffing to protect other residents during resident-to-resident altercations. This involved 1 of 1 resident (R4) who instigated resident to resident altercations with 2 of 16 (R2 and R16) who resided on the Waters neighborhood. Lastly, the facility failed to ensure 1 of 14 (R18) residents residing on the Woods neighborhood received care timely on the night shift. Findings include: See F677: The facility failed to ensure dependent residents receive assistance with personal hygiene for 3 of 5 residents (R20, R13 and R29) who were dependent on staff for personal hygiene. In addition, the facility failed to provide timely assistance with incontinence cares for 1 of 2 residents (R13) identified as requiring total assistance with checking and changing of incontinence products. See F686: The facility failed to ensure residents identified at risk for pressure ulcers received the necessary care and treatment to prevent the development of pressure ulcers for 2 of 3 resident (R20 and R13) in the sample identified at risk for pressure ulcers. See F688: The facility failed to provide range of motion services to prevent potential decrease in range of motion for 3 of 4 residents (R20, R13 and R11) reviewed whom required range of motion for restorative nursing exercises. R20 and R13 were not provided assistance with range of motion and were not reassessed upon the declines in range. See F809: The facility failed to ensure that breakfast was no later than 14 hours after the evening meal for 1 of 1 resident (R13) who was independent with eating after setting up and 1 of 2 residents (R29) reviewed that required assistance with eating. This practice had the potential to affect all 14 residents residing in the Woods neighborhood. R18's quarterly Minimum Data Set (MDS) dated [DATE], indicated R18 was alert and orientated and had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated R18 required extensive assist of one staff to use the toilet. R18's care plan dated 4/20/22, identified R18 as alert and pleasant with intact short and long-term memory. R18's care plan indicated R18 was incontinent of bowel and bladder and utilized incontinence products. R18 required more care than R18 wanted to accept. The plan directed the staff to assist R18 with incontinence cares as needed. On 7/12/22 at 2:21 p.m. R18, who resided on the Woods neighborhood, stated during the night shift on 7/12/22, she had put her call light on to use the bathroom round 3:00 a.m. The night staff did not answer the light, so she walked into the bathroom by herself but needed assistance to get off of the toilet. R18 stated she had put her bathroom call light on; however, the staff did not assist her until after 4:00 a.m. A Nursing Home Incident Report (NHIR) dated 7/12/22, at 6:14 p.m. indicated R18 had pushed her call light at 3:00 a.m., R18 ambulated into the bathroom independently at 3:10 a.m. and nursing assistant (NA)-C responded to the light at 4:10 a.m. The video cameras were viewed and indicated R18 was correct that she pushed the light at 3:00 a.m. The nursing assistant assigned to the Woods household responded to the light at 3:59 a.m. The video cameras also identified NA-C had been sleeping on the couch at the end of the household hallway. The unidentified NA working on the Waters household was walking around the other neighborhood; however, at 3:22 a.m. the charge nurse [registered nurse (RN)-D] also laid down on the couch and appeared to be sleeping. On 7/13/22, at 3:47 p.m. RN-F stated she did work the night shift on occasion. RN-F stated the night staff would take naps during their break times and was unaware of any of the staff oversleeping. RN-F stated R18 would occasionally complain of the staff not answering her call light timely; however, that was due to R18 not having a sense of time and wanting her call light to be answered immediately. On 7/14/22, at 7:08 a.m. NA-C stated the facility was staffed with three people at night. One NA in the Waters neighborhood, one NA in the Woods neighborhood, and a charge nurse. NA-C stated she had been working the night shift since 1988 and it was her routine to sit down and nap during her break times. If a call light went on during her break time, the nurse was to answer the light. At 9:13 a.m. the facility administrator stated she was aware the night staff routinely nap during their half hour break. The administrator stated the stated the facility was still in the process of investigating the incident involving R18, however, during the investigation, they had discovered the facility call system was not working properly. When a call light was pushed the system was to illuminate the light above the resident door and send an alert to the NA's walkie talkie on that wing. If the light was not answered in three minutes, the alert was to be forwarded to the NA in the opposite neighborhood. If the light was not answered in six minutes, the charge nurse's walkie talkie was to be alerted. The administrator stated for some reason, the lights were not functioning properly and were not being forwarded to the additional walkie talkies. The administrator also stated she had not yet talked to the staff members involved with the incident on 7/12/22, as the investigation was still spending. The maintenance staff members were working on the call system. At 10:28 a.m. the maintenance director stated the call system had malfunctioned on the evening of 7/10/22, and the maintenance staff members had been in the facility to adjust the system. He had been made aware of the malfunction a second time during the night of 7/12/22 and was alerted to the second malfunction on 7/12/22. At that time, it was discovered the call system was not forwarding to the additional staff member walkie talkies. The maintenance director stated he had been in contact with the manufacture company, and they were in the process of coordinating a time for the call system representative to come to the facility to repair the call system. The maintenance director stated the facility did not routinely check the call system to ensure the call forwarding system functioned properly. Review of the undated ARI call system manual did not instruct the users to check the call system on a routine basis. On 7/14/22, at 1:50 p.m. a call was placed to the Advanced Wireless Communication (sales rep company) to discuss call light system maintenance processes, a message for the facility representative was left, however, the company did not return a call to the State Agency. On 7/14/22, at 1:52 a.m. RN-A stated she had been made aware of R18's long call light and had reviewed the video camera which identified two of three-night staff appeared to be sleeping between 3-4 a.m. on 7/12/22. RN-A confirmed the facility had not completed their investigation. NA-C and RN-D had not been removed from the schedule while the investigation was pending and continued to work at the facility. RN-A stated she had not had an opportunity to interview the staff. RN-A stated R18's complaint of the staff not answering her call light between 3-4 a.m. on 7/12/22, was accurate and spot on. -At 2:29 p.m. the facility administrator stated R18's long call light was not abuse as R18 was not hurt. In addition, R18's long call light was not neglect of care, and she didn't feel the lack of call light response should have been reported to the State Agency. The administrator stated the only issues were the call light system was not functioning properly, and the maintenance department was working on the issues. The administrator stated the DON had visited with the night staff on 7/12/22, to provide coaching to the involved staff members. The administrator added the removal of the night staff while the facility continued their investigation would be neglectful as they didn't have the manpower/staff to cover the night shift without NA-C and RN-D. Review of NA-C and RN-D's personnel records lacked documentation related to coaching/education related to the NHIR reported on 7/12/22. -At 2:29 p.m. the DON stated he had spoken to both NA-D and RN-C regarding the incident on 7/12/22. He was aware the night shift napped during their breaks, however, call lights not being answered during the staff breaks was unacceptable. The DON confirmed the facility had found the call lights were malfunctioning related to the forwarding system from one walkie talkie to the next; however, the call light above the resident doors continued to illuminate properly. The DON confirmed having two of three-night staff member sleeping at the same time was also unacceptable as one household would not have alert staff members. The DON stated the facility did not have an enough spare staff members to cover the shifts if NA-C and RN-D had been removed from the schedule. He confirmed the investigation had not been completed but the facility was activity working on the investigation. -At 4:44 p.m. the facility administrator emailed a coaching session for NA-C and RN-D completed on 7/13/22, (no identified time) by the DON. RN-D indicated she was aware of R18's long call light and NA-C's walkie talkie was not functioning correctly. Both staff members were informed that it was unacceptable for call lights not to be answered in a timely manner. The staff were also directed to make sure the walkie talkies were functioning correctly at the start of their shifts. Resident concerns: On 7/12/22, at 8:20 a.m. R22 , alert resident, stated her call light during the night shift was not answered very quickly. R22 recalled accidently deficating her pants due to slow call light respone times. - At 2:41 p.m. R18, an alert resident, stated she had to wait an hour to have her call light answered during the night shift. Family Interview: On 7/12/22, at 9:10 a.m. family member (FM)-A stated she did not feel the facility had enough staff members. FM-A stated the facility only had one NA to work the 300-400 wing during the day and the resident would have to wait for assistance. Staff Interview: On 7/12/22, at 9:10 a.m. NA-F stated the facility did not have enough staff and at least once a week, the staffing was sad. NA-F stated the staff members come in early and stay late to assist the resident's with cares. She was not aware of any resident cares being omitted, but stated the staff members were streched to their limits. On 7/13/22, at 7:40 a.m. NA-A stated she was providing care to all 14 residents on the Woods Neighborhood. NA-A stated 14 people were too much for one person to care for. -At 9:14 a.m. NA-A stated she could only do so much for the residents therefor she had to skip some cares. NA-A stated I can only do so much. -At 11:05 a.m. RN-C stated some of the residents, such as R29, required additional supervsion and at times required 1-1 supervsion. Due to only having one nurse and one NA on the Woods neighborhood, providing a resident who required additional assistance was difficult. RN-A stated the normal staffing pattern was to only have three NA's assisting the residents. Two in the Water's neighborhood and one in woods. In order to assist residents with their weekly baths on the day shift, the night staff usually had to stay longer or the evening shift staff members would come in early. RN-C stated the residents recieve their weekly baths; however, the entire facility had to work together to make sure the residents recieved the baths. RN-C stated when only one NA was working the Woods neighborhood, they had trouble providing all of the cares. - At 11:30 a.m. NA-G stated she was assigned to the Woods Neighborhood. NA-G stated she had been working in another area of the facility campus; however, had ben reassigned to work on the Woods Neighborhood as directed by administation. -At 11:40 a.m. NA-A stated she did not have time to complete range of motion exercises for the resident as the facility did not have enough staff tto assist with extra cares. NA-A stated she did not have time to perform all cares for residents every day because they didn't have enough staff. NA-A stated she did not have to provide quality cares to all of the residents. - At 11:53 a.m. RN-C stated the facility did not have the enough staff to provide specific care such as range of motion to the residents. -At 1:55 p.m. NA-B stated the Waves neighborhood had residents who required more care; therefore, the facility routinely staffed two staff members on the Waves neighborhood and one on the Woods neighborhood. -At 2:14 p.m. NA-D stated the staff members have to choose what cares can be done for the residents. -At 3:00 p.m. the staff positing was observed hanging on a bullitin board where residents, staff and visitors entered the facility. The staff posting indicated the facility census was 31, the day shift included one RN, one LPN and three NAs. The evening shift included two RN's and three NA's and the night shift included one RN and two NAs. On 7/14/22, at 7:08 a.m. NA-C stated the facility had three staff members working in the entire building on the night shift. NA-C stated the facility had three NA's on the night shift in the past; however, the night staffing had been cut down to two NA's and a nurse. NA-C stated sometimes that worked okay, but other days it was very hard. - At 7:30 a.m. housekeeper (HSKP)-A stated the facility did not have enough staff. HSKP-A stated the residents would complain about having to wait a long time to have their needs met. The staff were trying their best and the facility was working on hiring more staff members. -At 1:45 p.m. RN-A stated when a neigbhood was having difficulty managing the workload for whatever reason, the nurse was to email the managment team and ask for assistance. The facility usually staff two nurses and three NA on the day and evening shift and one nurse and two NA's on the night shift. RN-A stated RN-C had emailed the managment team at 7:09 a.m. on the morning of 7/13/22, and requested assistance. An additional NA was assigned to assist on the Woods neighborhood; however, they were not able to get to the neighborhood until 11:30 a.m. RN-A stated she expected the staff to provide quality care to all of the residents. -At 2:30 p.m. the administator stated the facility had been working on recruiting more staff members; however, at this time they continued to be short staffed. The administator stated the facility was managing and was not aware of cares not being provided to the residents. -At 3:51 p.m. the director of nurses (DON) stated all staff members were pulling together to make sure there was enough staff at the facility to care for the residents. The DON stated the if a staff member was unable to work, they struggle to cover the shifts. The DON stated he was unware the residents had not received cares as directed by the plan of care. The facility staffing policy was requested but not provided. R4's Face Sheet undated, indicated R4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated R4 had severely impaired cognition, and was independent for activities of daily living (ADLs) with set up and cues. R4's Care Assessment Areas (CAA), undated, indicated [CONDITION(S)], cognitive loss/dementia, behavioral symptoms, falls and [CONDITION(S)] drug use as areas that would need to have care planned interventions and areas the facility would need to focus on regard to R4's care and safety. R4's care plan last revised 5/10/22, indicated she had behaviors that included wandering along with rummaging, pacing, and wandering into other resident's rooms. Interventions included assess and document resident behavior, what triggered it, what was done, the results of any interventions attempted, and staff should notify the interdisciplinary care team (IDT) of changes. The care plan lacked any nonpharmacological interventions to attempt when R4 was exhibiting the listed behaviors. R4's activity care plan indicated activity staff would do small group, large group activities and 1 to 1 activities when R4 was unable to attend group activities. This care plan was initiated at time of admission. The care plan lacked any modifications based on altercations and changes in R4's status. R4's progress notes dated 4/25/22, at 8:00 p.m. indicated R4 entered R2's room after supper. When R2 asked R4 to leave R4 kicked R2 in the thigh. The progress note indicated the primary care provider would be notified regarding the aggressive behaviors. The progress note lacked any documentation of notification of facility management, or the SA related to the resident-on-resident altercation. The progress notes lacked any documentation of interventions placed after the altercation to protect R2. R4's progress notes dated 5/10/22, at 11:36 p.m. indicated R17 was in the dining hall with a clothing protector on and around R17's neck. R4 approached R17 and tried to pull the clothing protector over R17's head. When R4 was redirected R4 grabbed R17's glasses and bent them. The progress note lacked any documentation of notification of facility management, or the SA related to the resident-on-resident altercation. The progress notes lacked any documentation of interventions placed after the altercation to protect R17. On 7/11/22, at 7:17 p.m. R4 was observed in her room sitting in her recliner in pajamas watching the entryway to her room. Staff entered a room across the hall from R4 to assist that resident and R4 was observed leaving her room and attempting to enter that resident room. Staff was able to close the door to the other resident's room prior to R4 entering. R4 proceeded to wander up and down the hall without visualization by staff. - at 7:23 p.m. R4 attempted to enter R21's room but was stopped by the stop sign on R21's doorframe. R4 proceeded to push on the stop sign and tried to go under the stop sign to enter R21's room. R21 began calling for help. -at 7:26 p.m. nurse assistant (NA)-E approached R4 and redirected her down the hallway. After redirecting R4, NA-E proceeded to leave R4 wandering the hallway. On 7/13/22, at 10:02 a.m. R4 was observed in R27's room walking in circles and ovals, and pacing back and forth. R27 was sitting in his wheelchair in the hallway while R4 was wandering and pacing in his room. R27 never made an attempt to enter his room while R4 was in it. -at 10:07 a.m. NA-D approached R27 to see if he needed any assistance. R27 informed NA-D that R4 was in his room. NA-D assisted R4 out of R27's room and down the hall. R4 was left right away to wander the commons area while NA-D answered call lights. On 7/14/22, at 8:56 a.m. R2 stated R4 came into his room about three months ago without being invited. R2 stated when he asked R4 to leave his room, R4 proceeded to kick him in his thigh and caused a bruise to form. When asked if he had pain or if R4 scared him, R2 did not answer and proceeded to look down at the floor. R2 stated that R4 still wandered in the facility so R2 kept his door shut so R4 cannot come in his room again. On 7/13/22, at 8:12 a.m. nurse assistant (NA)-D stated there were several days when cares would not get done because of staffing. NA-D stated the facility had not had restorative aides for about two years and the regular NA's would not do restorative cares because of staffing. On 7/14/22, at 1:53 p.m. the director of nursing (DON) stated after the altercation on 4/25/22, with R2 the provider did increase her [CONDITION(S)] medication from a lower dose back to a higher dose. the provider had just ordered a gradual dose reduction of that medication two weeks prior to the incident. The DON was unsure of any interventions performed after the altercation on 5/10/22. The DON stated that R4 really needed either close observation or one on one observation to protect R4 and other residents, but the facility did not have staffing to perform that intervention. On 7/14/22, at 2:57 p.m. registered nurse RN-A stated R4 was a challenging resident and the only thing that facility staff could do was reapproach, reapproach, reapproach when working with her. RN-A stated staff attempt to keep an eye on R4 so she would not wander into other residents or have another altercation with residents, but it was difficult to do. RN-A stated R4 needed close observation or one to one care to protect R4 and other residents but the facility did not have staff to perform that intervention. RN-A stated staffing was always a challenge. There was a nurse scheduled for the Waters neighborhood and a nurse scheduled for the Waves neighborhood. Two nursing assistants (NA) would be scheduled for Waves neighborhood and one for Waters neighborhood. We try to get more help for Waves, but staffing is short.

Based on observation, interview and document review the facility failed to provide range of motion services to prevent potential decrease in range of motion for 3 of 4 residents (R20, R13 and R11) reviewed whom required range of motion exercises. R20 and R13 were not provided assistance with range of motion and were not reassessed upon the declines in range. Findings include: R20's quarterly Minimum Data Set (MDS) dated [DATE], and annual MDS dated [DATE], identified R20 with severe cognitive impairment and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDSs also indicated R20 required extensive assistance of one staff for all activities of daily living. R20 was non ambulatory and did not have any type of functional limitations in range of motion. R20's Activities of Daily Living Care Area Assessment (CAA) was not required to be completed at the time of the annual MDS on 3/15/22. R20's Progress Note (nurse's note) dated 6/8/22, at 3:30 p.m. indicated R20 did not have a restorative nursing program. R20's Care Plan dated 6/7/22, indicated R20 required physical assistance with mobility due to decondition related to diabetes and possible stroke. R20 was no longer able to ambulate. The care plan directed the staff to assist R20 with a NuStep machine (a compact semi-elliptical recumbent cross trainer which provides movement to the upper and lower extremities) daily in the early afternoon for 10-20-minute session. It also directed her to walk short distances in the hallway prior to the NuStep. In addition, R20 was to utilize a standing table and stand for 10 minutes per day. On 7/12/22, at 10:37 a.m. R20 was observed to be seated in a Geri chair. R20's right hand was closed in a fisted position. R20's left hand was noted to be covered by a blanket. On 7/13/22, at 7:40 a.m. nursing assistant (NA)-A was observed to assist R20 with morning cares. R20 was resting in bed. NA-A asked R20 to hold onto the one quarter side rail as she assisted R20 to roll over in bed. R20 was able to hold herself onto her side while perineal cares were completed. At 7:47 a.m. NA-A assisted R20 to don pants. R20 was not observed to participate and R20's legs were easily bent to put on the pants. At 7:48 a.m. R20 was transferred from the bed to a Geri chair via a mechanical standing lift. R20 was able to open her right hand and grab the lift independently. NA-A was observed to open R20's left hand and placed it on the standing lift handle. NA-A placed the mechanical lift harness on R20 and transferred her from the bed to the Geri chair. Once in the chair, NA-A assisted R20 to don a shirt. R20's shoulders were slightly moved by NA-A to don the shirt. NA-A was observed to direct R20 to open her hands to wash them. -At 8:25 a.m. R20 was observed to serve a breakfast meal. R20 did not attempt to reach for any of the meal items. Registered nurse (RN)-C fed R20 her meal. At 8:29 a.m. RN-C handed R20 an adaptive covered cup equipped with handles. R20 was able to hold the cup and drink from a straw independently. -At 11:40 a.m. NA-A stated the nursing assistants providing direct care did not have time to assist with residents with range of motion exercises. NA-A stated the facility had a nursing assistant assigned to assist with restorative exercises in the past; however, they had not had a restorative NA in the past two years. NA-A stated it was hard for the NA's to completed ROM. NA-A stated R20's shoulders and arms were stiff which made it harder to move R20 while dressing. -At 11:53 a.m. RN-C stated the facility did not have the staffing manpower to complete the restorative programs. RN-C stated the facility had not had a restorative program for the past two years. On 7/14/22, at 12:41 p.m. RN-A stated R20 had been ambulatory in the past and utilized a NuStep machine. However, R20 had not been able to walk for a couple of years. R20 was not on a restorative program at this time. However, RN-A was aware R20 tended to hold her arms close to her body and her hands in fist like positions. -At 2:09 p.m. RN-A was observed to complete ROM upper and lower extremities. R20 was not observed to have any type of limitation in her lower extremities. R20's arms were able to be raised to the elbow and shoulder were level with each other, however, the arms were not observed to be extended above R20's head. R20's elbows were stretched, however, R20's right elbow was not able to be fully extended. Both hands were able to put fully opened; however, once RN-A let go of the hands, R20 returned to a fisted position. RN-A stated R20's left elbow was stiffer than it when she had last assessed R20 during the MDS assessment period on 6/7/22. RN-A stated she was not aware there had been any type of changes to R20's ROM however R20's ROM had declined in her right elbow. RN-A stated R20 was in need of a therapy evaluation. R13's annual MDS dated [DATE], identified R13 with severe cognitive impairment and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated R13 extensive assistance of one staff for all activities of daily living, total assistance for transfers and R13 was non ambulatory. The MDS indicated R13 had no limitations in range of motion. R13's Activities of Daily Living CAA dated 5/4/22, indicated R13 required extensive assistance with all activities of daily living, she was non-weight bearing, did not walk, transferred with a fully body mechanical lift and received active range of motion with cares. R13's Care Plan dated 5/10/22, directed the staff to complete active range of motion with cares. On 7/12/22, at 9:40 a.m. R13 was observed seated in a Geri chair in her room with family member (FM)-A. R13's hands were noted to be in a fisted position close to her body. FM-A stated R13 was able to move her arms but she does not do that. FM-A stated the facility tries to assist with ROM, but often the staff did not have time to complete exercises. On 7/13/22, at 9:12 a.m. NA-A assisted R13 with morning cares. NA-A assisted R13 to don pants. R13's legs were observed to be straight. R13's right foot was observed to be straight with the toes pointed. NA-A was not observed to complete ROM exercises as she donned the pants. At 9:14 a.m. NA-A transferred R13 from the bed to a Geri chair via a full body mechanical lift. Once in the chair, NA-A assisted R13 to don a shirt. NA-A moved R13's arms to put the shirt on; however, R13's shoulders, elbows, wrists, and hands were not fully extended. NA-A was not observed to assist R13 with ROM exercises for the upper extremities. Review of R13's Restorative Nursing documentation revealed the following information: -April 2022, R13 participated in ROM 22 of 60 opportunities. -May 2022 R13 participated in ROM 23 of 60 opportunities. -June 2022, R13 participated in ROM 19 of 60 opportunities. -July 1, 2022- July 14, 2022, R13 participate in ROM 10 of 27 opportunities. Further review of the documentation directed the staff to record the amount of time R13 participated in the ROM exercises. 34 of the 72 the recorded documentation did not identify the amount of time R13 participated in the program. 35 of the 72 recorded documentation revealed R13 participated in the program for 30 seconds. Review of R13's Progress Notes (PN) revealed the following information: -PN dated 5/16/22, at 6:30 p.m. indicated R13 participated in active AROM twice a day. The documentation did not include a summary of how R13 tolerated the AROM program, nor it did not identify concerns. -PN dated 6/13/22, at 5:30 p.m. indicated R13 participated in AROM twice a day. The documentation lacked any additional information related to AROM. On 7/14/22, at 1:30 p.m. RN-A stated the facilities restorative aide position had not been filled for the past two years. The staff members were to complete AROM for R13 every day with cares. RN-A stated she reviewed the NA documentation; however, she had not identified the staff were recording ROM for 30 seconds. RN-A stated an exercise program for 30 seconds would not qualify as a participating in ROM. -At 1:58 p.m. RN-A completed AROM with R13. R13's arms were observed to be moved upward so the elbows were parallel with the shoulders. R13's arms were not able to extend above her head. R13's left had was able to be opened, however, the fingers remained at an approximate 90-degree bend at the third knuckle (knuckle between the finger and the palm of the hand). R13's left leg was observed to bend at the hip and knee, however R13's left leg was unable to fully extend. R13's right first finger (pointer finger) was observed to fully extend, however, the rest of the fingers and thumb were bent at a 90-degree angle and did not extend. R13's right leg and foot were observed to bend and fully extended. RN-A stated R13's shoulders were tighter than she had noticed in the past. The elbows, hands and legs remained the same since her last MDS. RN-A confirmed R13's shoulders had declined since the last assessment and R13 was in need of a therapy assessment. The Range of Motion, policy dated 5/19/21, indicated range of motion was to be provided to improve or maintain joint function, [MEDICATION(S)] effect of prolonged bed rest or immobilization, increase patient comfort, and improve blood flow. The policy did not direct the staff as to how often to provide the assistance, how to identify changes in ROM or the procedure required to refer residents to therapy for re-evaluation. R11's quarterly MDS dated [DATE], indicated R11's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R11's MDS indicated R11 was severely cognitively impaired and required extensive assistance with her activities of daily living (ADLs). R11's care plan dated 4/19/18, indicated she had a need for assistance with mobility related to severe [CONDITION(S)] joint disease, back pain, and carpal tunnel. Staff were directed to provide active and passive range of motion to shoulders bilaterally. R11's care plan did not address if or how to use a splint/palm protector. On 7/12/22, at 9:11 a.m. R11 was observed in her room her left hand was in a closed position, there was a splint/palm protector in her room but not in her hand. On 7/13/22, at 9:46 a.m. R11 was observed sitting in the dining area, she was not wearing any splint/palm protector in her left hand, her left hand was in the closed position, when asked how her hand felt, she stated it hurt. On 7/13/22, at 10:24 a.m. R11 was observed in her room seated in her recliner, her splint/palm protector was noted to be on a stand in her room not in her left hand. On 7/14/22, at 9:05 a.m. R11 was observed eating her breakfast in the dining room, she did not have a splint/palm protector in her left hand. On 7/13/22, at 1:57 p.m. NA-B stated R11 wore her hand splint at night but not during the day. NA-B stated R11 was able to open her hand to grab the bars on the Sara Stedy (a transfer device) during transfers. On 7/14/22, at 9:06 a.m. NA-I stated she would typically put the splint in R11's hand when she sits in her recliner. NA-I stated they were doing range of motion with her when they were dressing her. On 7/14/22, at 2:25 p.m. registered nurse (RN)-A was able to open R11's hand and gently stretch her hand to remove and replace R11's splint/palm protector in her left hand without any resistance or evidence of pain from R11. R11's skin was observed to have some redness between her thumb and first finger, blanchable, and no open areas. RN-A stated she would expect staff to put R11's splint in her left hand daily. On 7/14/22, at 3:25 p.m. the director of nursing stated he would expect staff to follow the care plan and use splints/palm protector for residents who need them. A policy on splints was requested but not provided.

Based on observation, interview and document review, the facility failed to ensure resident safety was maintained during transfers via a standing mechanical lift to a reclining wheelchair (Geri chair) for 1 of 1 resident (R20) observed to transfer via a standing mechanical lift. Findings include: R20's quarterly Minimum Data Set, dated dated dated [DATE], and annual MDS dated [DATE], identified R20 with severe cognitive impairment and diagnoses including Alzheimer's dementia, end stage [CONDITION(S)] and a history of bladder infections. The MDSs also indicated R20 required extensive assistance of two staff for bed mobility, extensive assistance of one staff for transfer and R20 was non ambulatory. R20 did not have a history of falls. R20's Fall Risk Care Area Assessment (CAA) dated 3/18/22, indicated R20 was at high risk of falls due to dementia and history of a stroke with weakness. R20 required extensive assist of one for safe transfer. R20's clinical record did not include a comprehensive transfer assessment or chair assessment. R20's care plan dated 6/7/22, identified R20 with impaired mobility due to status post stroke and some loss of physical mobility. The plan directed the staff to utilize a standing mechanical lift for all transfers. It also indicated R20 utilized a wheelchair for mobility but did not direct the staff to utilize a Geri chair. On 7/13/22, at 7:48 a.m. nursing assistant (NA)-A assisted R20 to sit on the edge of the bed. R20 was observed to hold onto the quarter side rail at the head of the bed with her left hand. NA-A then connected R20 to a standing mechanical lift and stood R20 in an upright position. NA-A maneuvered the lift so R20's back was facing the reclining Geri chair. NA-A locked the breaks of both the lift and the Geri Chair. NA-A then removed the lift controller connected by the lift via a telephone cord and walked behind the Geri chair. NA-A lifted/tilted the Geri chair onto the two front (approximate) 2-inch wheels, approximately 3-4 inches off the floor balanced the chair with NA's body as she maneuvered the Geri chair and R20 into a seated position. Once R20 was in the chair, NA-A removed the standing lift. At no time was NA-A observed to request assistance to transfer R20 from the bed to the chair. At 7:53 a.m. NA-A stated she was the only NA working in the Woods neighborhood and did the best as she could. At 11:51 a.m. NA-A transferred R1 from the toilet back into the Geri chair via the standing mechanical lift. NA-A was observed to lock the standing lift in front of the Geri chair. She removed the standing lift remote connected to the lift by the telephone cord and held it in her hand as she lifted the chair onto the front two wheels. NA-A held the chair approximately 3-4 inches off of the floor with her body as she lowered R20 into the Geri chair. NA-A was not observed to ask for assistance during the transfer. Review of R20's medical record did not include any type of documentation related to falls. On 7/14/22, at 12:25 p.m. registered nurse (RN)-A stated she and the DON had located the Geri chair for R20 about two months ago because R20 had been having difficulty sitting in a regular wheelchair. RN-A stated the facility did not complete any type of chair assessment prior to the initiation of the Geri chair. RN-A stated R20 just sat better in the Geri chair. RN-A stated the facility did not complete any type of formal transfer assessment, she confirmed R20 utilized a mechanical standing lift for all transfers. RN-A stated she had not observed R20 transferring from the lift into the Geri chair, however, the staff should not be lifting the chair off of the floor in order to position R20 into the chair. RN-A confirmed lifting the chair, balancing it off of the staff bodies in order to ensure proper placement puts R20 and the staff at risk for falling and potential injury. RN-A confirmed R20's transfers were in need of evaluation. At 3:33 p.m. the director of nurses (DON) confirmed R20 had not received a compressive chair or transfer assessment prior to the implementation of the Geri chair and standing lift combination. The DON stated he had not observed R20 during the transfer, however, a father evaluation was needed. The Positioning and Body Alignment policy dated 9/1/14, directed the staff to ensure residents who were partially or totally dependent on staff are positioned to maintain correct body alignment at all times. The policy did not address wheelchair assessments or transfer assessments.

Based on interview and document review, the facility failed to ensure staff members responded to resident's requests or call lights in a timely, dignified manner for 3 of 3 residents (R18, R16 and R22) who expressed concerns related to staff members failing to assist residents to ensure the residents needs were met in a timely dignified manner. Findings include: R18's quarterly Minimum Data Set (MDS) dated [DATE], indicated R18 was alert and orientated and had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R18's care plan dated 4/20/22, identified R18 as alert and pleasant with intact short- and long-term memory. R18 had no mood or behavior issues. On 7/12/22, at 12:44 p.m. R18 stated registered nurse (RN)-E did not respond timely to her requests, she was rude and disrespectful. R18 stated while walking out of her bathroom with a (front wheeled) walker, she became entangled between the restroom door and the door to her room and required assistance to navigate the two doors. R18 saw RN-E walking in the hallway and called out to her to assist with the door. R18 stated RN-E instructed R18 to put on her call light and a nursing assistant would be in to assist her eventually. R18 stated this made her angry and she was able to navigate into her room on her own. R18 also stated she required medicated powder to be applied to her groin on a routine basis. R18 stated when RN-E was the staff in charge of passing medications, she would refuse to allow RN-E to apply the powder because RN-E has refused to assist with washing R18's groin area in the past and just wants to apply the powder. R18 stated when she had asked RN-E why she would not assist with washing prior to applying the powder, R18 stated RN-E had told her It was not her job to assist with washing. On 7/13/22, at 11:40 a.m. nursing assistant (NA)-A stated some of the nurses would assist with answering call lights and assisting the residents with needs. However, other nurses would answer the call lights and then direct the NA to assist the resident, even if it was only to get the resident a glass of water. NA-A stated when this happened, it took a little longer to respond to the resident requests. On 7/14/22, at 9:13 a.m. RN-C stated R18 did complain about staff members at times and R18 and RN-E had a personality conflict. RN-C stated R18 had made specific complaints about RN-E, however, she did not know what type of agreement had been reached to resolve the differences. RN-C was not aware of any new concerns from R18. At 9:38 a.m. the facility licensed social worker (LSW)-A stated she was aware R18 had expressed concerns about RN-E in the past and was holding a grudge against RN-E. R18 had unresolved feelings towards RN-E and had chronic complaints about staff members. When queried if LSW-A met with R18 on a regular basis to assist R18 in coping mechanisms or to do follow up with R18 to assist with any new personal conflicts, LSW-A stated she did not visit with R18 on a regular basis. LSW-A stated if a resident had any type of concern related to a nursing staff member, she referred those concerns to the director of nurses (DON). LSW-A reviewed R18's care plan and confirmed the care plan did not identify R18 as holding grudges against staff members and did not direct the staff members how to assist R18 with coping mechanisms. At 1:50 p.m. RN-A stated she was aware R18 expressed ongoing concerns about RN-E. The concerns brought forward to the administration and staff had been dealt with; however, R18 could not be informed what type of education or instruction RN-E had been given and this continued to frustrate R18. At 3:51 p.m. the DON stated he was aware of R18 and RN-E's personality conflict but an additional plan to manage the conflict to ensure R18 felt she was treated with dignity had not been established. R16's quarterly Minimum Data Set (MDS) dated [DATE], indicated R16's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R16's MDS indicated R16 was cognitively intact and required limited to extensive assistance with activities of daily living (ADLs). R16's care plan initiated 12/18/19, indicated R16 had a self-care deficit related to weakness and required assistance with ADLs. R16's care plan also indicated R16 had a mood problem and staff were directed to encourage her to express her feelings, establish a trusting relationship, listen attentively, use a calm approach, explain all procedures, acknowledge her feelings provide reassurance and comfort. On 7/12/22, at 10:36 a.m. R16 stated registered nurse (RN)-E was just mean in both her words and actions. R16 stated she had told RN-A about RN-E being mean but nothing changed. R16 stated RN-E was hateful, stating she would come in turn off the call light but wouldn't help her with what she requested. R16 stated RN-E would ask her what she needed but then not do it and would leave the room. On 7/14/22, at 9:22 a.m. R16 stated about a month ago RN-E wouldn't help her out of the bathroom and wouldn't get her any water; said she was too busy. R22's quarterly MDS dated [DATE], indicated R22 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R22's MDS indicated R22 was cognitively intact and required limited assistance with ADLs. R22's care plan initiated on 6/19/16, indicated she had a self-care deficit and required assistance with ADLs. In addition, R22's care plan indicated R22 was a vulnerable adult. Interventions included explain all cares, make sure call light was in each and encourage resident to ask for help. On 7/14/22, at 1:09 p.m. R22 stated she'd had some trouble with RN-E, stated she makes catty remarks, 'first you're hot then you're cold'. R22 went on to state RN-E was good at getting the NAs to do the work. R22 stated RN-E was a little better after RN-A talked to her. On 7/13/22, at 2:22 p.m. NA-D stated the residents tell her RN-E was mean and condescending. The residents have told her RN-E doesn't listen, would talk down to them, and would not help them to the bathroom. NA-D went on to state RN-E would come and find a NA to tell them when a resident wanted coffee, water, or needed to use the bathroom, and would not answer resident call lights. NA-D stated she has brought these concerns to the administrator. On 7/13/22, at 2:55 p.m. NA-E stated she had heard residents complain about RN-E, specifically R5 saying she just didn't like her. On 7/14/22, at 2:41 p.m. RN-A stated RN-E should be answering call lights and helping residents with their request(s). RN-A went on to state RN-E's behavior had been a consistent problem and RN-E had been offered the employee assistance program ([NAME]). On 7/14/22, at 3:11 p.m. the director of nursing (DON) stated he was aware of resident and staff complaints regarding RN-E. The DON stated he had talked with her about the complaints. RN-E told him she'd been really busy, but the DON stated she should take care of something easy like a request for water and not ask someone else to do it. The DON stated she had been offered [NAME] and went on to say RN-E had definite ideas about tasks and roles and what the RN does and what the nursing assistants (NAs) were supposed to do. The DON stated RN-E had previously been counseled and given a verbal warning regarding her behavior with residents. The DON stated RN-E had changed units to avoid a particular resident that she'd had bad interactions with. RN-E's employee file indicated she'd had counseling on 12/21/21, related to difficulty with co-workers and was assigned computer training modules on the Art and Science of Communication. RN-E's response was she thought her co-workers should have had to complete the same trainings. -On 1/21/20, RN-E received coaching related to being rude and abrupt. -On 11/13/19, RN-E received coaching on communication. The facility position description for an RN included providing quality, professional nursing care, maintaining a therapeutic environment that would nurture wellness of the whole person in mind, body, and spirit. In addition, the position description included performing duties with respect, including daily cares. The facility policy titled Dignity, Maintenance of Resident dated 9/1/14, directed staff to promote care for each resident in a manner and in an environment that maintains or enhances each resident's dignity and respect at all times. In addition, staff were directed to complete cares in a respectful manner and communicate with the residents during cares to maintain dignity for residents.

Based on interview and document review, the facility failed to ensure a mechanical lift sling was properly placed for 1 of 2 residents (R1) reviewed for accidents. This resulted in an immediate jeopardy (IJ) situation for R1, when she fell from a mechanical lift, resulting in a laceration to her head that required sutures, and rib fracture. R1 died the next morning. The deficient practice was identified as an IJ situation, however, the provider had already implemented corrective action prior to the investigation so the deficiency is issued as past noncompliance. The IJ began on [DATE], when the facility failed to correctly connect the mechanical lift sling loops to the mechanical lift. One of the sling loops came out of the hook, resulting in R1 sliding out of the mechanical lift, where she fell on the floor and hit her head. R1 was sent to the emergency department (ED) where a scalp laceration was sutured, and an x-ray was taken and indicated a fractured rib. R1 returned to the facility at 11:36 p.m. R1 died on [DATE], at 7:30 a.m. The administrator and director of nursing (DON) were informed of the IJ on [DATE], at 6:13 p.m. The facility had implemented corrective action to prevent recurrence by [DATE], so F689 was issued at past non-compliance. Findings include: R1's Diagnosis List undated, indicated R1's diagnoses included dementia, [CONDITION(S)] and [CONDITION(S)]. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had severely impaired cognition, and required assistance of staff with transfers. R1's care plan dated [DATE], indicated R1 had impaired mobility related to a past stroke, knee contractures and a repaired hip fracture. The care plan indicated R1 was non-weight bearing, and directed staff to transfer R1 with a mechanical lift. On [DATE], 11:32 p.m. a progress note indicated R1 was being transferred with the mechanical lift from the bed to the wheelchair at 4:30 p.m. when a mechanical lift sling strap came out of the hook, and R1 fell to the floor. The progress note indicated R1 did not lose consciousness, and she denied pain. The progress note indicated R1 received a laceration to the back of the head, and an abrasion to the right hip. R1 was transferred to the emergency department (ED) at 5:00 p.m. where she received three sutures to the laceration on the back of her head. A chest x-ray was completed, and indicated a fractured rib. R1 was noted to have shortness of breath, [CONDITION(S)] (rapid heart rate) and diaphoresis (excessive abnormal sweating). Orders for oxygen parameters and as needed [MEDICATION(S)] (a medication used to treat anxiety) were obtained. R1 was transferred back to the facility at 9:45 p.m. R1's ED visit note dated [DATE], indicated the computed tomography (CT) of R1's head and neck showed no intracranial bleeding and the cervical (neck) spine without any acute injury. R1's laceration to the head was cleansed and sutured. R1's oxygen needs were volatile while in the ED. A call was placed to the facility to assess weather R1 was at baseline. The facility reported R1 had been in times of oxygen desaturation but had not ever been air hungry of which R1 appeared while in the ED. R1 was not hospitalized and returned to the facility due to her do not resuscitate, do not intubate (DNR/DNI) status. R1 departed the ED to the facility in guarded condition. On [DATE], at 1208 a.m. a progress note indicated R1 continued to be short of breath and was using accessory muscles to breathe (a sign of abnormal or labored breathing). On [DATE], at 7:42 a.m. a progress note indicated the day shift nurse went into check on R1 at the beginning of her shift. R1 was noted to have had a medium sized emesis the color and consistency of coffee grounds. The emesis was checked for blood and was positive. R1 was clammy and had an abnormal breathing pattern. R1's family was notified and were on their way to the facility. R1 died at 7:30 a.m. A facility Incident Investigation Report Summary dated [DATE], indicated on the evening of [DATE], R1 was being transferred from the bed to the wheelchair by nursing assistant (NA)-A and the director of nursing (DON) using a mechanical lift. One of the lift sling straps came off of the lift, causing R1 to fall from the sling onto the floor. R1 received a laceration to the back right side of the head, an abrasion on the right hip and a skin tear on the left leg. R1 was sent to the ED where she had imaging of the head and neck, and the laceration to her head was cleaned and sutured. R1 was transferred back to the facility that evening. R1 died the next morning The Medical Examiners Preliminary Summary undated, indicated R1 died on [DATE]. The summary indicated a postmortem limited examination with radiographs was performed of which showed no evidence of life threatening trauma. Injuries included a laceration to the posterior scalp with surgical repair, and a fracture of the left rib without associate internal hemorrhage. The manner of R1's death was natural, and the cause of death was pending medical records. On [DATE], at 12:45 p.m. the administrator was interviewed and stated the facility recreated the fall, and felt the sling was placed correctly. The administrator stated they also interviewed staff. The administrator also stated maintenance checked all mechanical lifts following the fall, and they do this on a monthly basis. The administrator stated there were no concerns with any of their mechanical lifts. On [DATE], at 2:15 p.m. the DON was interviewed. The DON stated he was helping NA-A transfer R1 when she fell out of the mechanical lift. The DON stated he helped attach the sling to the mechanical lift, heard the sling click into place, but did not recall how many clicks he heard, so was unsure if all of the loops on the sling were attached. The DON stated R1 was being transferred from the bed to the wheelchair, and when she was close to the wheelchair, R1 fell and landed on the floor. The DON stated the strap under R1's right leg had come off of the mechanical lift. On [DATE], at 3:55 p.m. NA-A was interviewed. NA-A stated she and the DON were transferring R1. NA-A stated she heard the sling lift loops click into place. NA-A stated she had no idea how R1 fell out of the mechanical lift. On [DATE], at 10:00 a.m. The lift company (SMT Health Systems) representative was interviewed. The representative stated the facility informed him there was no damage or malfunction of the mechanical lift. The representative stated the only time he had seen something similar was when the operator didn't get the sling strap on the hook of the mechanical lift. The representative stated with the hook guards, the loop can't lift off of the lift, so the sling stays intact. The representative again stated he believed the fall from the lift was caused by operator error. On [DATE], at 2:33 p.m. R1's medical doctor (MD)-A was interviewed. MD-A stated the laceration to R1's head was caused by the fall from the mechanical lift. MD-A stated R1's rib fracture was probably caused by the fall from the lift, although R1 did have severe [CONDITION(S)], so it was difficult to tell. The facility's Mechanical Lift policy dated [DATE], indicated the mechanical lifts were used for safe transfer of non and partial weight bearing residents per their individual care plan. The IJ was removed on [DATE], when the facility conducted a root cause analysis of the fall, re-educated all nursing staff on the proper placement of mechanical lift slings and on use of the mechanical lifts, and on reporting any concerns with a mechanical lift. This was verified through observations and interviews.

Based on interview and document review, the facility failed to ensure that 1 of 3 residents (R1) was free of significant medication errors when staff failed to administer R1's [MEDICATION NAME] (a diuretic medication, used for removing excess sodium and water from the body) for seven days. R1 sustained harm, a decline in condition with wheezing and [MEDICAL CONDITION], and required hospitalization . Findings include: R1's Interagency Referral Form printed [DATE], indicated R1 had [DIAGNOSES REDACTED]. R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], also indicated R1 had a [DIAGNOSES REDACTED]. R1's physician orders [REDACTED]. R1's Medication Adminstration Record (MAR) indicated R1 was prescribed 20 mg of [MEDICATION NAME] to start on [DATE]. However, review of the resident's MAR indicated [REDACTED]. R1's care plan printed [DATE], identified a need for clinical monitoring of R1's hypertension while using [MEDICATION NAME] and [MEDICATION NAME] (a beta-blocking drug related to [MEDICATION NAME], used to treat hypertension and [MEDICAL CONDITION]). R1's hospital admission notes dated [DATE], indicated R1 had been readmitted to the facility on [DATE], with an order for [REDACTED]. R1's Hospital Discharge Summary dated [DATE], indicated R1 had returned to the nursing home from a previous hospitalization ([DATE] to [DATE]) more debilitated than his baseline. The discharge summary also indicated a medication error from the readmission to the nursing home [DATE], led to R1's [MEDICATION NAME] not being given for a week, which likely contributed to R1's decline. During interview on [DATE] at 1:50 p.m., registered nurse (RN)-B verified although R1 had orders for [MEDICATION NAME] 20 mg following hospitalization which was not administered following hospital return [DATE]. RN-B stated R1 was rehospitalized [DATE], and died on [DATE]. On [DATE] at 2:30 p.m., the director of nursing (DON) stated R1 became ill with a fever, chills, and a change in mentation on [DATE], and went to the emergency room (ER) at the local hospital. Lab work indicated R1 had an infection, and the family had requested it be treated locally. However during the ER visit, R1's condition deteriorated. R1's family decided to send R1 to a tertiary hospital in Duluth for one more chance at life. The DON stated R1 was readmitted to the nursing home on [DATE], but there had never been a definitive source of the infection identified. The DON also stated when R1 returned to the facility he was on oxygen, was short of breath, and was fatigued. The DON continued to state R1 was not feeling well during the early morning of [DATE], and had a low blood sugar that did not improve with food, and he had a slight wheeze. The DON stated a nurse's note indicated a little later that morning of [DATE], R1 had sounded wheezy and gurgly and all lung fields sounded very wet (fluid in lungs, a sign of respiratory distress). The DON stated R1 had not gotten relief from use of a nebulizer so his son was called, and he agreed to a local hospitalization at 6:45 a.m. Upon medication reconciliation at the time of the resident's [DATE] hospitalization , it was discovered the [MEDICATION NAME] had not been administered after R1's [DATE], readmission from the hospital. The DON stated R1 was given a dose of [MEDICATION NAME] and was [MEDICATION NAME] 1 liter (excessive urination indicated fluid leaving the body). The DON stated they had traced the origin of the medication error to the fact that R1's primary care physician (MD)-C entered R1's re-admission orders [REDACTED]. The computer system put all R1's medications on hold after the physician entered the orders. The DON indicated staff noticed within about 10 minutes that all R1's orders were put on hold. The pharmacist (P)-A immediately went in and manually re-entered all of R1's medication orders, including the [MEDICATION NAME] 20 mg. Next, P-A dispensed the medications, and delivered them to R1's locked pass through medication drawer. According to the DON, at some point after the manual re-entry of the [MEDICATION NAME] to the orders (which was the only order that was new/increased), it had continued to appear as on hold in the facility's electronic medical record system. The DON stated the evening nurse RN-A, had acknowledged R1's medications but had not noticed the [MEDICATION NAME] was in an on holdstatus. The DON further stated while RN-A had missed that the medication was documented as on hold, upon follow up with RN-A, RN-A was able to demonstrate the correct procedure for acknowledging medication orders. The DON also stated licensed practical nurse (LPN)-A had documented on [DATE], that R1's [MEDICATION NAME] was on hold in the computer system, and LPN-A had taken the medication out of R1's medication drawer and put it in the overflow bin. According to the DON, LPN-A had not questioned the hold, nor had she discussed it with anyone. The DON confirmed that R1 had not received any [MEDICATION NAME] while at the facility between ,[DATE] and [DATE] and stated immediately upon awareness of the medication error, the facility had worked to determine what had happened and how to prevent any re-occurrences. The DON stated they are re-instituting a system check where the overnight nurse checks medical orders to ensure accuracy. On [DATE], at 9:00 a.m. P-A stated she manually went in and edited, and resumed each and every medication order the physican had ordered for R1, about 30 medications. P-A stated she processed all of R1's medications, labeled them,and took them to R1's locked medication drawer. P-A stated after she re-entered all the medications by hand, there was another area that showed the [MEDICATION NAME] was on hold, but she didn't see that. P-A stated she had re-entered all medications so she had fixed the computer issue. P-A also stated the evening nurse incorrectly acknowledged the medication, which had the [MEDICATION NAME] listed as on hold. On [DATE], at 9:30 a.m. in a telephone interview, physician (MD)-A stated the [MEDICATION NAME] medication error was one of multiple factors affecting R1's re-hospitalization . MD-A stated R1 was already a very ill person, and was septic and near death when he'd first transferred to the hospital [DATE]. MD-A stated R1 certainly had a condition the [MEDICATION NAME] would have helped to treat. MD-A also stated R1 would have succumbed within a week or so regardless of the [MEDICATION NAME] due to multiple advancing health issues. On [DATE], at 11:00 a.m. LPN-A stated she had not questioned the [MEDICATION NAME] hold in R1's electronic medical record. However, stated she had later noticed the [MEDICATION NAME] in R1's medication drawer, and had personally removed it and put it in the overflow area of the medication room. LPN-A stated she done this based on past practice and the processes she had used in the past. LPN-A stated she did not question what she had done because the medication was listed on hold, so she'd removed it from the drawer. On [DATE], at 11:21 a.m. RN-A stated she got called in to fix the hold status, as she does computer work for the facility. RN-A stated the software functioned as it was designed; a resident was out on a bed hold, and so the medications that the physician entered were put on hold. However, when a resident was coming back to a long term care facility, it would be helpful to have orders entered before the resident came in the front door. RN-A stated the physician was doing his part in preparing for R1's return to the facility. RN-A stated facility staff noticed all the medications got put in hold status and had it fixed within the hour however, the [MEDICATION NAME] order had not responded the same way as it was a new order (20 mg instead of the 10 mg originally ordered). RN-A stated in (MONTH) 2019, the facility began a new process in their electronic medical record that puts a resident on a bed hold or leave of absence (LOA). This was done at other facilities that use this same computer system, but had not been done at this facility before. In the process, Step 1 was for the Admission Department to end the bed hold/LOA, and Step 2 was for the physician to review orders, restore ones that would continue, and begin new orders. RN-A stated since this new process began, two residents had returned from LO[NAME] The process went fine for the first resident, as the bed hold was removed prior to the physician entering orders. However for R1, the physican was entering orders prior to the removal of the bed hold, so the holds were put in place. RN-A again stated because the [MEDICATION NAME] was a new/increased order (not just a restored order), the computer system placed it on hold again, after the original catch and fix by the facility. On [DATE], at 3:30 p.m. in a telephone interview, RN-A stated acknowledging an order means to compare the printed medication list to the electronic medical record order. RN-A stated she was rather new and had been sick. RN-A stated she shouldn't have been at work and had not identified the order read hold. RN-A stated she was used to looking at the hard copy from the hospital, not a print out from the pharmacy, and she was not comfortable with the system used at this facility. The facility's Leave of Absence Process (for residents) dated [DATE], indicated the admission department was to end the bed hold, and notify the physician to review and update resident orders. The facility's Admission-Readmission policy updated [DATE], lacked direction about how to address orders that were on hold.

Based on document review and interview, the facility failed to provide adequate supervision for one of one resident (R1) reviewed when left alone in a standing lift that resulted in a fractured arm. Findings include: R1's medical record was reviewed. R1 had a [DIAGNOSES REDACTED]. R1's care plan dated 8/17/16, revealed R1 required the assistance of one staff with bed mobility to help with legs and to wear the leg strap on when transferring with EZ stand mechanical device. R1 had severe cognitive impairment with poor short-term memory. An incident report dated 11/4/16, at 4:00 p.m. indicated R1 was being transferred from the shower chair to wheelchair. Nursing assistant (NA)-A reported using the back strap and the waist clip, but not the lower seat sling strap as the care card directed. NA-A was about to begin lowering R1 to the wheelchair when R1 picked up her/his right foot off the stand and placed it on the floor behind her. NA-A put on the call light on for help, but no one came. NA-A left R1 alone to look for assistance. When NA-A and another staff returned to R1's room, R1 had slipped farther down in the back strap and R1 was hanging by his/her arms and R1 ' s legs were twisted. R1 was lowered to the floor. The report also indicated NA-A did not review the care card that directed staff to use lower seat sling strap, remind R1 to relax, and R1 must have the leg strap on. A practitioner's progress notes dated 11/4/16 and 11/7/16, indicted R1 had a bruise on the right shoulder and appeared to be in pain. The practitioner ordered an x-ray that indicated R1 sustained a proximal humerus fracture. R1 treatment for [REDACTED]. A nursing progress note dated 11/4/2016, at 8:00 a.m. indicated R1 lifted his/her foot off the machine while being transferred to the wheelchair, then attempted to move his/her arms out of the EZ stand mechanical device. A nursing progress note dated 11/4/16, at 10:31 a.m. indicated R1 complained of pain in the right arm and had a large bruise on the right upper arm. R1 would moan, frown, and voice pain when the right arm was moved. The pain notification form dated 11/13/16 to 11/25/16, indicated R1 was moaning and crying from the right arm pain. R1 was given hydrocodone 5/325 milligrams for pain and had good relief from it. An interview on 12/8/16, at 11:05 a.m. with nursing assistance (NA)-G indicated R1 was not able to hold onto the handles at all times when using EZ stand mechanical device. R1 was required to use the lower seat sling strap because R1 would sometimes attempt to sit down and needed extra support. An interview on 12/8/16, at 3:10 p.m. with NA-B indicated s/he provided training to NA-A. NA-B stated s/he did not instruct NA-A to read R1 ' s care card or use lower seat sling strap to provide R1 with additional support. An interview on 12/8/16 at 3:40 p.m. with Registered Nurse (RN)-C, RN-C indicated s/he responded to R1 ' s incident. When RN-C entered R1 ' s room, R1 lying on the floor. RN-C instructed staff to assist R1 off the floor with a mechanical lift and place R1 in bed. RN-C stated if a resident requires a change in the level of assistance to transfer the nursing assistants make the change on the resident care card. An interview on 12/9/16, at 7:55 a.m. with a maintenance staff (MT)-L indicated the facility had no maintenance records on any EZ stand mechanical devices. An interview on 12/9/16, at 8:15 a.m. with physical therapist (PT)-K indicated physical therapy does not do any assessment to determine a resident ' s ability to transfer with mechanical devices, unless a nurse requests one be done. PT-K stated R1 did not have a transfer assessment completed by physical therapy. An interview on 12/9/16, at 9:00 a.m. with RN-D indicated nursing assistants are trained by following another nursing assistant while performing tasks. RN-D stated there was no documentation of the training. RN-D stated R1 has been transferred using the EZ stand mechanical device since 2011 and R1 had not been reassessed for the use of the EZ stand since 2011. An interview on 12/9/16, at 11:45 a.m. with RN-H indicated the facility did not have an assessment to assure appropriateness of using an EZ stand mechanical device. Nursing assistant ' s update the care card if there is a change for the resident and let the nurse know. An interview on 12/9/16, at 2:00 p.m. with the administrator indicated s/he was not aware preventative maintenance was not done on the EZ stand mechanical devices. The facilities mechanical lift policy, undated, indicated the residents care card is used for transferring instructions and to notify the charge nurse if more assistance is needed than listed on the care card.

Based on observation, interview, and document review, the facility failed to provide appropriate care to prevent the development of pressure ulcers for 1 of 4 residents (R1) reviewed for pressure ulcers. The lack of assessment and the development of a stage 3 pressure ulcer constituted actual harm for R1. Findings include: R1's significant change Minimum Data Set ((MDS) dated [DATE], indicated [DIAGNOSES REDACTED]. The MDS further indicated R1 had severe cognitive impairment, required extensive assistance with bed mobility and transfers, and was totally dependent in bathing activities. The MDS also indicated R1 was at risk for pressure ulcers and had 1 stage 3 (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) and 2 unstageable pressure ulcers. The MDS indicated skin and ulcer treatments that included pressure reducing devices for the bed and chair, nutrition/hydration interventions, ulcer care and application of dressings to the feet. R1's Interdisciplinary Patient Progress Notes dated 6/5/14, indicated R1 was seen in the clinic on 6/4/14, with left mid-shin bruising and lower extremity [MEDICAL CONDITION] and no apparent trauma. The progress note further indicated R1 had a chronic malformation of the left foot with medial rotation and plantar flexion (toes pointed with rotation of the left foot to the center). The progress note indicated a slightly displaced bimalleolar fracture and was fitted with an air stirrup sport splint (a splint used to treat common sports injuries) to protect the fracture. physician's orders [REDACTED]. R1's care plan dated as reviewed 6/9/14, identified risk factors for pressure ulcer development that included limitation in self mobility, inability to ambulate and urinary incontinence. The care plan indicated R1 had no current pressure-related [MEDICAL CONDITION] with protective interventions of the splint in place, check with nurse for positioning of splint, nurse only should remove to check for pressure, cleansing and skin care. The care plan did not address frequency of cleansing and skin care. The weekly skin checks were part of the usual monitoring of all residents for potential skin problems. R1's electronic progress notes dated 6/29/14, indicated a stage 3 pressure ulcer discovered under the air cast. The ulcer on the medial aspect of the heel measured 2.5 cm by 1.5 cm by 1 cm in depth, with pale gray slough in the wound bed. R1's Weekly Skin assessment dated [DATE], indicated the air cast was not removed to view the skin after a bed bath. The Weekly Skin Assessments dated 6/21/14, and 6/28/14, indicated R1 had no discolorations over bony prominences; however, did not after pressure had been reduced. The documentation did not indicate the air splint was removed to observe the skin condition under the splint. R1's Interdisciplinary Patient Progress Notes dated 6/29/14, described several pressure ulcers under R1's air cast to include: 1. medial malleolus with stage 3 ulcer, straw colored/copious exudate, estimated size 2.5 inches by 1.5 inches; 2. lateral malleolus with unstageable ulcer, pressure point had non-blanching purpura colored area, non tender to palpation; and 3. edge of the left foot at the distal 5th metatarsal, bluish, non-blanching, non-tender. The progress note concluded the pressure ulcers developed under the air cast. On 8/13/14, at 9:39 a.m. licensed practical nurse (LPN)-A was observed to provide ulcer care to R1's left heel pressure ulcer. R1 was laying in the bed with a knee-high, white sheepskin lined boot to the left lower leg. The boot was removed and the left lower leg and foot were observed to be turned in with noticeable foot drop. LPN-A cut away the old dressings and removed all of the old dressing material. The dressings did not have visible drainage. There was a stage 3 ulcer observed on the lower aspect of the left inner heel just below the inner ankle bone. The ulcer was shaped like a crescent moon, dry and tan in color. LPN-A applied a clean, dry gauze dressing, wrapped R1's left foot, heel, and ankle with Kerlix gauze, and secured the dressing with paper tape. LPN-A reapplied R1's white sheepskin boot to R1's left lower leg. On 8/21/14, at 1:17 p.m. registered nurse (RN)-D stated R1's stage 3 pressure ulcer was discovered on 6/29/14, when the nursing assistants caring for her that day noticed fluid was leaking through the air splint. RN-D confirmed R1's weekly skin assessments dated 6/21/14, and 6/28/14, indicated no evidence of pressure ulcers. RN-A and RN-D both stated they would expect observation of all areas of the body, especially bony prominences, with the weekly skin assessments. LPN-C was interviewed by phone on 8/21/14, at 2:34 p.m. stated she did not open the air splint to observe R1's heel and ankle during the weekly skin assessment on 6/28/14. LPN-C stated she had been instructed to leave the air splint in place. In addition, R1's Nutritional assessment dated [DATE], indicated Ensure (high protein dietary supplement) one half cup twice daily would be administered to improve nutrition for healing ulcers. R1's Snack Fluids Intake forms for July and August, 2014, indicated R1 rarely consumed the supplement. During July 2014 R1 consumed the Ensure on 3 out of 30 opportunities. During August only 6 out of 34 opportunities. On 8/20/14, at 1:35 p.m. nursing assistant (NA)-F stated R1's supplements were provided at 10:00 a.m., 2:00 p.m., and at bed time. NA-F stated the amount taken was recorded for the dietary department to total. NA-F stated R1 refused the supplement earlier that day and sometimes would be asleep when the supplement was delivered. On 8/21/14, at 9:40 a.m. the dietary manager (DM) stated she was aware R1 was not taking the supplement very often. On 8/21/14, at approximately 3:30 pm the registered dietician (RD) stated she was not aware R1 had a pressure ulcer or R1 was not consistently receiving the Ensure supplement.