Every finding on record at Oakland Park Communities, Inc.

Based on observation, interview and document review the facility failed to ensure the care plan was updated to accurately reflect transfer status for 1 of 3 residents (R1) reviewed for falls.Findings include:R1's Resident Face Sheet indicated R1's diagnoses included anxiety, failure to thrive and oxygen dependence.R1's admission Minimum data Set (MDS) dated [DATE], identified intact cognition and indicated she required partial to moderate assistance for toilet hygiene, sitting to standing and transfers.R1's Range of Motion (ROM)/Balance Transfer assessment dated [DATE], indicated she was unsteady but able to stabilize without staff assistance for: surface to surface transfers; walking; turning and facing the opposite direction when walking; and moving on and off the toilet.R1's Morse Fall Scale dated 5/20/26, indicated she was at high risk for falls. R1's quarterly MDS dated [DATE], identified intact cognition and indicated R1 required partial to moderate assistance with dressing and personal hygiene and was independent with bed mobility, transfers and ambulation.R1's care plan dated 2/17/26, identified a risk for falls related to oxygen use, forgetfulness and diagnosis of congestive heart failure. The care plan directed staff to anticipate her needs, indicated she used a wheelchair and was able to self-propel and indicated she required assistance from one staff and a walker to transfer and assistance from one staff for bed mobility. The care plan included verbal reminders not to ambulate/transfer without assistance. The care plan lacked direction for ambulation assistance. R1's fall risk care plan for wheelchair mobility, bed mobility, transfers and ambulation was not updated after completion of the 5/20/26 MDS.During interview on 8/27/26 at 11:23 a.m., nursing assistant (NA)-A stated prior to R1's fall on 8/13/26, R1 would get out of bed independently, walk around her room and took herself to the bathroom. R1 was independent and it was okay for her to ambulate independently in her room. On 8/13/26, prior to R1's fall, R1 had been up and back to bed by herself. NA-A stated when she walked down the hall, she observed R1 standing in her room by her closet. The fall occurred when R1 stumbled and fell.During interview on 8/28/26 at approximately 8:20 a.m., the director of nursing (DON) stated the mobility care plan was part of the NA care sheets but said it was a working document and they did not keep them, so the NA care sheet dated 8/13/26 was not available to review. The DON said if staff saw R1 self-transfer they were expected to assist her.During interview on 8/28/26 at 8:40 a.m., NA-C stated prior to R1's fall on 8/13/26, R1 had not used her call light very often. R1 transferred, great, staff assisted R1 with a gait belt with toilet hygiene. NA-A state after R1's husband passed away, staff were directed to assist R1 with transfers and if staff observed R1 up independently, they were to assist her due to occasional confusion.During interview on 8/28/26 at 8:46 a.m., Registered nurse (RN)-A stated R1 was independent but her care plan directed stand by assistance. RN-A said R1 was care planned to need assistance due to cognition but R1 was physically able to be independent. RN-A said she should have updated the care plan to independent for transfers after the mobility assessment was completed in May 2026, but had missed it. RN-A said R1 did not typically use her call light. If staff walked by R1's room in by R1 in the hallway and saw her up by herself, they were directed to assist her.Facility policy Care Plan Revision dated 5/2026. Indicated the care plan must be revised upon completion of MDS assessments.

Based on observation, interview and document review the facility failed to implement care planned interventions to reduce the risk for falls for 1 of 3 residents (R2) reviewed for falls.Findings include:R2's Resident Face Sheet indicated R2's diagnoses included Alzheimer's, dementia and malnutrition.R2's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment. R2 required substantial/maximal assistance for bed mobility and transfers. The MDS indicated R2 sustained one fall with injury, not major and two or more falls without injury since the last assessment period.R2's care plan dated 5/1/26, identified activities of daily living impairment and indicated R2 required assistance from one staff for bed mobility. R2's care plan directed staff to prompt R2 to void at least every two-to-three (2-3) hours and as needed. R2's care plan identified a high risk for falls. Fall interventions included toilet R2 per toileting care plan.R2's incident reports and correlating Fall documentation identified the following:7/3/26: incident report, R2 was found on the floor by her bed. R2 had been placed in bed and did not have shoes or gripper socks on. Care plan was updated with staff re-education to provide gripper socks when not wearing shoes.7/3/26: Fall Documentation, R2 was found on the floor on her buttocks. R2 did not have shoes or gripper socks on.7/14/26: Fall Documentation, R2 was found on the floor in her room seated upright. R2 had gripper socks and no shoes on.7/14/26: incident report, R2 was found on the floor in her room. R2 had gripper socks on and no shoes. Care plan updated to include R2 to rest in common area in the afternoon.7/18/26: incident report, R2 screamed and was found on the floor in common area. R2 sustained a skin tear to the outer left eyebrow. Care plan was reviewed with re-education to staff to anticipate R2's needs.7/18/26: Fall Documentation, Staff heard R2 scream. R2 was found lying on her back on the floor. R2 needs to be wearing gripper socks or shoes at all times. Intervention already in place8/26/26: incident report, R2 was found on the floor by her bed. R2 was wearing socks but no shoes.During continuous observation on 8/27/26 starting at 10:15 a.m.:10:15 a.m., R2 was seated in a wheelchair in the common area of the unit.11:01 a.m., staff escorted R2 to the activity room next to the common area.11:41 a.m., R2 was brought from the activity room directly to the dining room.12:49 p.m., R1 was brought back to the common area.12:59 p.m., staff escorted R2 into the activity room.1:46 pm., R2 was brought back to the common area.2:02 p.m., R2 was observed attempting to sit forward in her chair and fidgeting with her blanket. R2 movements appeared restless.During observation and interview on 8/27/26 at 2:04 p.m., nursing assistant (NA)-A and NA-B brought R4 to her room and assisted her to use the bathroom. NA-A stated she thought R2's care plan directed them to toilet her every 2-3 hours. NA-B stated she had not written down the last time R2 was assisted to the toilet and said, it was more of a routine. NA-B said staff did not have time to toilet R2 before current observation. R2's brief was wet and changed by the NA's.During interview on 8/28/26, at 10:47 a.m., the director of nursing stated if staff were not able to assist a resident with toileting as directed on the care plan, she would have expected them to ask for assistance. Facility policy regarding toileting assistance was requested but not received.

Based on observation, interview and document review, the facility failed to implement standards of practice to ensure an assessment was completed to safely use of a lift chair for 1 of 3 residents (R1) reviewed for accidents. This resulted in actual harm when R1 had an unwitnessed fall from the lift chair and sustained a trimalleolar fracture (a severe, unstable ankle injury involving fractures of three distinct bones: the lateral malleolus (fibula), medial malleolus (tibia), and posterior malleolus (back of the tibia)) with lateral subluxation of the talus (high-energy trauma (falls) forcing the foot into severe eversion.) R1 was sent to the emergency room (ER) via ambulance and required medical evaluation and treatment. The facility implemented corrective action, so the deficient practice was issued at past non-compliance.Findings include:R1's Hospital Discharge summary dated [DATE], identified discharge diagnoses left-side posterior cerebral artery (PCA) stroke territory infarct (affecting the left temporal-occipital lobe as well as thalamus area). She was found falling at home, having difficulty getting up, brought to the ER and evaluated extensively. She was found to have right upper extremity weakness as well as difficulties with coordination and was discharged from hospital to nursing home on 1/15/26 at 1:37 p.m.R1's admission Minimum Data Set (MDS) dated [DATE], identified she was admitted to the facility from an acute hospital on 1/15/26. R1 had slurred or mumbled words, responded adequately to simple, direct communication only, impaired vision, disorganized thinking, and severely impaired cognition. She had impairment of upper and lower extremities on one side and used a wheelchair for mobility. R1 was dependent upon staff for all cares including dressing, hygiene, transfers, and unable to walk. She had a medical history of stroke and urinary tract infection. She had one fall prior to admission to facility.R1's Morse Fall Scale (a tool used to assess risk for falling) dated 1/15/26, identified she had fallen previously, bedrest/wheelchair, nurse assist for mobility, and mental status identified overestimates or forgets limits regarding own ability to ambulate to bathroom. Fall risk score was 55 (low risk 0-24, moderate risk 25-44, and 45 or higher high risk) and indicated high risk for falling.R1's occupational therapy evaluation dated 1/15/26, identified she had no right sided control, unable to weight bear on right lower extremity and right knee tends to buckle, and required maximum assistance of two with standing. Trialed PAL (patient assist lift) lift and did not do well due to inability to control right upper extremity. Recommendation Hoyer lift for transfers. R1's physical therapy evaluation dated 1/19/26, identified Clinical Impressions: R1 demonstrated what appeared to be significant expressive and receptive aphasia (damage to parts of the brain causing impaired expression and understanding of language as well as reading and writing). She had weaknesses, especially the right knee buckled and right upper extremity, poor core control/leans to the right, poor safety awareness, and need for assistance for all transfers and mobility. R1 Current baseline: sit to stand transfers required moderate to maximum assistance and transfer from wheelchair/bed/wheelchair baseline was Hoyer lift.R1's care plan dated 1/16/26, identified she was at risk for falling and impaired mobility related to right side deficit related to stroke, osteoporosis, history of falls, weakness, osteoarthritis of both knees, and non-ambulatory. Staff were directed to follow therapy recommendations for ambulation and transfers, transfer with a Hoyer lift and assist of two, fall risk assessment completed upon admission, quarterly and as needed, and call light within reach always when in room. R1 was alert and oriented to person, had poor decision-making abilities, impaired safety awareness, impaired speech, unable to consistently communicate needs/unclear speech, impaired hearing and vision, and unable to remove self from a harmful situation. Staff were directed to re-orientate R1 as needed and anticipate needs.R1's progress noted from 1/21/26 through 1/24/26, identified: -On 1/21/26 at 10:18 a.m. alert and oriented to self, communicates with staff, needs anticipated, and transfers with Hoyer. -On 1/23/26 at 4:16 p.m. an outside worker notified director of nursing (DON) R1 was on the floor in her room around 1:40 p.m. DON and care coordinator registered nurse (RN)-A went to room and assessed. Upon entering, R1 was on the floor laying on her right side, lift chair was all the way up. R1 stated she had tried to get on hands and knees when asked what happened. She denied pain. Upon rolling her onto her back her right foot was noted to have eversion (a movement where the sole turns outward, away from the body's midline) with noticeable deformity at medial ankle and bruising. R1 had a deficit to entire right side of body related to recent cerebral vascular accident (CVA) (stroke) prior to admission. Nursing assistants (NA) reported she had just been placed in her recliner around 1:30 p.m., offered to be placed in bed, and stated she preferred to be in the recliner. R1 was placed in chair, reclined all the way back, covered with a blanket, and chair remote moved to the left side of the chair, and hung-over left arm of chair. Family was contacted as well as emergency medical system (EMS). R1 left facility via ambulance with necessary paperwork at 2:15 p.m.-On 1/24/26 at 10:03 p.m. Circulation, motor, and sensory (CMS) Assessment: Surrounding skin is dry/intact and warm to touch. Capillary refill less than two seconds. Petal [sic] pulses present and faint. Color and temperature appropriate. No sensation in limb due to stroke.R1's ER visit dated 1/23/26, identified [AGE] year-old with recent diagnosis of stroke and limited ability to communicate. She had an unwitnessed fall at nursing home, presented with an obvious deformity to right ankle, and no sensation to the right side of the body from her stroke. Clinical impressions: closed trimalleolar fracture of right ankle/unwitnessed fall. A closed reduction was completed, and a splint was applied. An external referral to orthopedics was placed for surgical repair. R1's x-ray of right ankle dated 1/23/26, identified fractures involving distal fibular metadiaphysis (the flared, neck-like portion of the lower fibula located just above the growth plate (physis) and the ankle joint usually resulting from ankle twisting or trauma), medical malleolus (bony bump on the inside of your ankle), and posterior malleolus of the distal tibia (critical for ankle stability). There is lateral subluxation of the talus relative to the distal tibia by 1.5 centimeters (cm) (A displacement of this magnitude (15 mm) is well beyond the typical threshold of 1-4 mm used to define significant instability, often requiring urgent evaluation and intervention). Calcaneal spurring is present. Soft tissue swelling is noted about the ankle. Impression: Trimalleolar fracture with lateral subluxation of the talus.Facility internal incident report dated 1/23/26, identified R1 was found on floor in her room, laid on right side, lift chair noted to be all the way up, and right foot to have eversion with noticeable deformity at medial ankle. R1 was unable to give description of incident. Immediate action taken, called 911, family contacted, transported to hospital for further evaluation. Internal investigation was completed. Chair was taken out of use immediately and removed later that day by family. Injuries observed at time of incident: suspected fracture of the right inner ankle. Mental Status: oriented to person only. Injuries report post incident: no injuries observed post incident. Predisposing environmental factors: None. Predisposing physiological factors: confused, gait imbalance, impaired memory, and other - in working lift chair, right side deficit to upper and lower extremities related to previous CVA.R1's Orthopedic Clinic Progress Note dated 1/28/26, identified pre-operative examination. She had a mechanical fall that resulted in a fracture dislocation (trimalleolar) of her right ankle. The fracture was reduced and placed in a splint. Unfortunately, she had a stroke two weeks ago and left her with significant hemiparesis on her right side. Under normal circumstances she would benefit from open reduction internal fixation but given her level of function and recent stroke that seemed to be a very risky way to go about managing this with little reward. The best option was to place her in a big bulky cast to protect the soft tissue to help fracture blisters recover and reassess her in two weeks' time. If she demonstrates recovery over time, we could potentially fix it in a delayed fashion or do a retrograde nail. If she demonstrates more skin breakdown, instability, and pain, she may benefit from an amputation. In the meantime, she was placed on strict non-weight bearing on the effected extremity.Facility five-day report dated 1/29/26 at 11:56 p.m., identified R1 was assisted into an electric recliner in her room that family had brought to the facility. She had not been assessed for use of the chair. Family indicated that the electric recliner was bought at a local store and delivered a day or two after she was admitted to the facility. Family had not explicitly told anyone they had got the chair, but staff knew about it because they had assisted her to sit in it prior to the day of the incident. R1 did not use a chair like this at home, and they believed the chair would be convenient for their mother. R1 was offered toileting and placed in the electric chair with feet elevated, covered in a blanket and remote draped over the left side of the arm rest to ensure it was not at risk for being sat on or wedged between the cushions. RCC had not been notified by family or staff of the chair being brought into the facility. RCC reported that when a resident had a lift chair, an assessment was completed by either therapy or an RN before a resident was allowed to use the chair to ensure safety. Upon admission on [DATE], R1's cognition was identified as severely impaired, high risk for falls, right sided paralysis/weakness and new cognitive deficits. Conclusion of the investigation identified the allegation was substantiated: R1 sustained a fall with injury while using an electric recliner brought into the facility without notification to administrative staff. Actions were taken because of the allegation: electric recliner was immediately removed from use and family removed the chair the evening of the incident. Care plan was updated to include resting in bed only when in her room. Audits of all rooms were completed on 1/23/26 to identify all electric recliners. All residents with functional electric chairs had completed assessments. A memo was placed out to staff: any new electric recliner must be reported immediately for proper assessment before use. A new form had been created for inclusion in the admission packets warning family/residents of potential dangers of electric equipment and instructions for notification to administration before bringing them to the facility. A designee will audit rooms once a week on an ongoing basis to ensure no new electric chairs have been brought to the facility without notification/assessment.Caregiver education dated 1/23/26, provided by therapy, identified transfers/bed mobility: Hoyer with assist of three. Ensure right lower extremity was fully supported. Do not use recliner. Be sure to avoid any weight bearing /twisting to the lower right extremity.Memo dated 1/26/26, Attention nursing staff: The only residents (5 listed) who are cleared to use electronic [sic] chairs/lift chairs. Any other lift chairs that are in the facility MUST remain unplugged. If you see a *new* chair, please be sure to pass that information on to DON or RCC immediately. We must assess before residents can use them for purposes of safety.New form added to admission packet titled Risks Associated with Power Recliner Chairs undated, identified cognitive impairment: individuals with cognitive decline may struggle to operate power recliner chairs safely. There have been documented cases where users activated the chair lift mechanism without understanding the consequences, leading to falls, and serious injuries, and including death. Unsupervised use: many users may operate these chairs without supervision, increasing the risk of accidents. Individuals may inadvertently push buttons on the remote control, causing the chair to tilt or rise unexpectedly which can lead to falls. Recommendation for Safety: Assessments by professionals - it is crucial for OT or RN assess the safety of power recliner chairs for individuals especially those with cognitive impairments. This includes evaluating the user's ability to operate the chair and understand the risks involved. Education and Training: Care givers and family members should be educated about the risks associated with power recliner chairs and trained in how to assist users safely. Supervision: Users, particularly those at higher risk, should not use power recliner chairs unsupervised. Caregivers should be present to assist with operations and to respond quickly in case of an emergency. Summary: power recliner chairs can provide significant benefits for mobility and comfort but can also carry risks that must be carefully managed to prevent serious injuries or fatalities, particularly among vulnerable adults. If family would like to bring a lift chair, please ensure you let social services/DON, or administrator know so that the resident can be properly assessed by therapy.During an interview on 2/18/26 at 12:14 p.m., care coordinator RN-A stated R1 was admitted on [DATE], post stroke, alert, oriented to self only, impaired cognition with periods of clarity, one minute aware of what was going on around her and the next minute quicky forgotten. R1 had no strength on entire right side of her body, unable to bear weight on right leg or stabilize self to stand, flailing right arm, and transferred with a Hoyer lift. Staff were expected to inform her, an RN or the DON when family brought in the lift chair and was not done. We were unaware R1 had a lift chair. R1's family informed us after the fall they brought in a lift chair on 1/16/26 or 1/17/26. Facility staff started using it right away for six to seven days without a lift chair assessment. The staff nurse would have been expected to know a lift chair assessment should have been completed prior to use to make sure the resident knew how to use the remote safely, did not get stuck, fall or injured especially with impaired cognition. RN-A stated on 1/23/26, she was made aware R1 was on the floor when DON came to her office. Together they went to R1's room and found her on the floor between the bed foot board and the lift chair, slightly rolled onto her right side, and right foot totally reversed. R1 was alert, confused, talked about how she wanted to see her friends, tried to get onto her knees, and unable to provide a clear report as to what happened. The lift chair footrest was down, and chair was upright all the way to the stand-up position. RN-A stated R1 would not have been safe using the lift chair independently due to her impaired cognition, inability to have removed herself from the chair safely without assistance. The fall was unwitnessed but most likely caused by when the lift chair was raised up to the standing position, unable to bear weight on right leg, could not stabilize herself, no Dycem (non-slip material), slid off chair and onto the floor. R1's fall could have been prevented if the lift chair was not in her room. R1 sustain fractures to the right ankle, sent to ER for assessment, a closed reduction completed, stabilizing brace placed, and referral made to Orthopedics.During an interview on 2/18/26 at 1:58 p.m., NA-C stated she worked with R1 often, was forgetful, never tried to get out of bed/chair by herself, unable to stand/walk, right side was paralyzed from a stroke, and transferred with a Hoyer and assist of two staff. She had transferred R1 to the lift chair at least three times days before her fall. The remote was placed on her left side in the chair pocket located on the side of the chair. She was unable to remember where it was located, very confused, out of it, and unable to make decisions for herself. NA-C stated was aware a lift chair assessment should have been completed prior to use to prevent falls/injuries, and unsure if had been.During an interview on 2/18/26 at 3:25 p.m., RN-B stated R1 had poor safety awareness, dependent upon staff for all cares and transfers with a Hoyer lift and assistance of two. She stated was unsure when R1 received the lift chair however, she had worked 1/18/26, for a couple of hours and assisted another RN with a Hoyer transfer from wheelchair to the lift chair. The remote was placed on the side of the chair so that she could not use it but could have possibly reached down and grabbed it. RN-B stated she did not think of looking to look if there was a lift chair assessment and thought since it was in her room they could use it. Best way to find out would have been to contact the care coordinator or DON and/or look in her electronic medical records under the assessments (lift chair). After R1 fell she realized a lift chair assessment had not been completed and should have been done prior to use by the DON or her and additionally, therapy on their end to ensure she was able to use the remote properly to prevent incidents/falls. R1's lift chair was found in the stand-up position; she slid out of the chair onto the floor and most likely would have not happened if the chair was not in there. R1 fractured her right ankle. She had received PT/OT in her room during the time the lift chair was being used. During an interview on 2/18/26 at 3:51 p.m., RN-C stated she was the MDS coordinator. R1's cognition was impaired, limited communication, unable to stand or walk and had a deficit to upper and lower right side post stroke. A chair assessment should have been completed by an RN prior to use to ensure she was safe to use the chair and would have helped prevent falls. The root cause analysis and interdisciplinary team (IDT) determined R1 was not safe to be in a lift chair, got a hold of the remote, pushed it, chair went up, fell out of chair, and fractured her right ankle in multiple spots. If the remote had been placed out of R1's reach she would have been safe, she was unable to get out of the chair by herself.During an interview on 2/18/26 at 4:30 p.m., NA-A stated R1 started using a lift chair right after she was admitted . R1 was confused, forgetful, and unable to stand or walk due to a stroke. The family requested she be placed in the lift chair to get more rest. She had transferred R1 many times during at least two shifts she worked with from the wheelchair or bed into the lift chair using a Hoyer lift and assist of two. NA-A stated R1's care plan and care sheet identified she was safe to be in the lift chair and if not, the nurse would have let us know. There was a staff nurse (unsure of her name) aware she had the lift chair, assisted with R1's transfer out of the lift chair days before her fall. NA-A stated on 1/23/26, at approximately 1:20 p.m. with assistance of NA-B, R1 was transferred with a Hoyer lift from wheelchair to bed, checked and changed, then transferred from bed to lift chair. R1's feet were lifted up with the lift chair remote, pillow placed under her right arm, covered with a blanket, call light positioned close by, and the lift chair remote was hung over the left arm rest, not secured to anything, so that she was able to reach the cord, pull it up to get to the remote, and usually how it was placed when she was in the lift chair. NA-A assisted another resident and not long after that R1 was seen on the floor, usure who found her or what caused the fall, and sent to ER. Looking back, R1's cognition was poor/impaired, and she would not have been safe using the remote to the lift chair alone. NA-A stated a chair lift assessment would be important to be completed prior to using the chair to ensure R1 was safe and understood how to use the chair.During an interview on 2/19/26 at 8:55 a.m., physical therapy assistant (PTA) stated he had assisted PT with the initial evaluation on 1/19/26, and R1's cognition was impaired, unable to follow cues without external support and poor memory. PTA completed three stands with R1 that lasted 18, 23, and 14 seconds, with maximum assistant, and identified R1 lacked trunk control and had severe leaning to the right side. He used a blocked technique to her right knee to decrease the risk of buckling, unable to stand or walk alone. R1 was a Hoyer lift transfer with assist of two staff. PTA stated the facility and therapy were unclear as to who should have completed the lift chair assessment. PTA indicated during the initial PT evaluation on 1/19/26, he was aware R1 was seated in a lift chair and used the remote to lower her feet down. Additionally, he saw her three times after that date: 1/20/26, she was seated in the lift chair, 1/21/26, and 1/22/26, she was in a wheelchair. PTA stated R1 would not have been safe in a lift chair and handling a remote independently due to her impaired cognition, confusion, poor memory, and right-side deficit of lateral control, right knee buckling and placed her at a higher risk for falls. The lift chair assessment should have been completed prior to use and if not, the lift chair should have been unplugged so that the lift part could not be used or removed from the room to help prevent falls.During an interview on 2/19/26 at 10:50 a.m., medical doctor radiologist (R) stated R1's right ankle x-ray completed on 1/23/26, identified Trimalleolar fracture (three areas) of her ankle. R1's fractures were new and mostly likely occurred from her fall on 1/23/26.During an interview on 2/19/26 at 10:52 a.m., primary provider medical doctor (MD) stated she completed the initial visit to see R1 on 1/20/26. R1 had a massive stroke unable to move anything on her right side/care for herself and unable to communicate or eat. It was sad to see her in that condition. R1 would not have been able to safely use the lift chair independently. The cause of her fall was 1/23/26, she was confused, tried to get up by herself and fell on the floor. Her fall could have been avoided. A fracture/fall can affect the mortality rate of an elderly person: over 50 % of the elderly people that have had a stroke will die from falling.During an interview on 2/19/26 at 12:44 p.m., physical therapist (PT) stated she completed R1's initial PT evaluation via telehealth on 1/19/26, with physical therapy assistant (PTA) in the room assisting. R1's cognition was impaired, unable to answer past medical history questions, and required tactile and verbal cues. R1 sat in the lift chair during the evaluation and the PTA used the remote to elevate her feet back up at the end of the assessment. PT stated she was unsure if R1 had access to the remote that day. According to OT documentation and email correspondence the initial assessment was completed by OT on the day of admission 1/15/26, the lift chair was not there, brought in after the admission date, and therefore did not trigger them to complete an assessment for a lift chair. PT stated was the first time she had seen R1 and did not complete a lift chair assessment. Generally, nursing would be expected to notify OT to complete a lift chair assessment prior to use, for safety reasons: make sure they know how to use and manage the remote control to avoid falls. R1 had right side weakness both upper and lower, instability in right knee, and poor core strength. She was unable to stand alone, sit alone on edge of chair/leaned backwards, and transferred with a Hoyer lift. R1 would not have been safe using a lift chair. PT stated she had impaired cognition and lacked knowledge to pick up the remote. Based on her assessment on 1/19/26, being in a lift chair placed R1 at a high risk for falls and injuries.During an interview on 2/19/26 at 1:30 p.m., family member (FM) stated R1 had never used a lift chair and was not familiar with it prior to when they brought the chair to her room on either 1/16/26 or 1/17/26, after her admission on [DATE]. FM stated the family thought R1 would be more comfortable in the recliner since she had slept in recliner (not a lift chair) at home. We were informed upon admission that any furniture could be brought in and did not think it was necessary to ask staff if a lift chair would be ok. Staff saw us deliver the lift chair and placed her in it right away with the Hoyer lift. FM stated when she visited on a day shift there was a nurse (unsure of name) noted the lift chair was moving and stated staff needed to make sure the remote was placed over the arm of the chair because when she slept accidentally pushed it when she moved, remote was located next to her body. FM stated after that day she noted during visits the remote hung over the left arm of the chair, never saw it in a pocket of the chair, was unaware there was a pocket. On the day of R1's fall she was called and informed your mom must have wanted to get up and fell. FM informed the caller her mother did not have the ability to get up and move. FM stated R1 was unable to reach the remote control, very tired/sleepy, and would not purposefully try to get up or able to use the remote to the lift chair.During an interview on 2/19/26 at 1:50 p.m., DON stated either an RN, floor manager, DON, or therapist would be expected to assess a resident prior to the use of a lift chair to make sure they are safe, appropriate for use, and care planned to prevent injuries. R1 was not assessed prior to the use of the electric lift chair because we were not aware the chair was here. R1 would not have been safe or cleared to use or the electric chair due to her stroke that left her with cognitive and physical deficits and no previous experience with a lift chair. DON stated she was not made aware R1 had a lift chair. On 1/23/26, staff NAs had placed R1 in the lift chair approximately five minutes before she was seen on the floor in her room by a vendor and then notified her. The fall was unwitnessed and R1 was unable to explain what happened. DON stated she thought R1 had started setting up the chair with the remote, most likely did not understand what happened and slid out of chair onto the floor. R1 sustained an injury, a trimalleolar fracture to the right ankle. During an interview on 2/19/26 at 2:40 p.m., NA-B stated R1 had impaired cognition and memory, and most likely unable to remember she could not stand independently. Most days it was hard to hold a conversation with her. R1 was transferred via Hoyer due to right side paralyzed due to stroke. On 1/23/26 at approximately 1:20 p.m. R1 requested to go into her lift recliner after lunch. NA-B stated NA-A assisted with a check and change and the transfer via Hoyer to the lift chair. NA-A used the remote to elevate her feet and recline her back in the lift chair. The remote was placed in the left side chair pocket out of reach by NA-A. R1's television turned on, covered with a blanket and call light placed within reach. Ten minutes later NA-B walked by R1's room and noted she was located on the floor with staff assisting her. R1's lift chair was positioned in the upright stand position. R1's cognition was not intact enough for her to use the lift chair remote, may have thought it was the TV remote instead and she would not have raised the chair up all the way to stand. Prior to R1's fall, unsure if a chair lift assessment should have been completed prior to use or if one was completed. The lift chair was placed in her room right after admission and she had used it at least seven times prior to fall. R1 was sent to ER and sustained a fractured ankle in three places. She had received education since fall and made aware of the importance of the lift assessment to be completed prior to use to prevent falls.Facility policy Fall Prevention and Reduction Program dated 1/2021, policy implemented to use a fall prevention and reduction program to provide prompt treatment and prevent further injury. A total score of 45 or greater on the fall risk assessment was considered high risk for potential falls and shall result in the implementation of appropriate fall prevention interventions related to cognitive status, medical condition, and identified in care plan. Fall Prevention Protocols may include but are not limited to: PT/OT safety or positioning screens, evaluations and/or treatment, rocking chair, Merri walker, ect., and other.Facility policy Electric Recliner dated 6/2021 and 2/2026, identified Policy: to keep the residents, other residents, and staff safe the resident's ability to properly operate and electric recliner will be evaluated by the therapy department, or a registered nurse and ongoing use will be observed for appropriateness by the facility staff. Purpose: to safely provide the residents with increased independence and mobility. Procedure: staff at the facility will observe the residents for any unsafe operation of the electric recliner. If a resident was found to be operating the electric recliner unsafely and putting themselves at risk, staff will fill [sic] report to the RCC or DON. Unsafe use will be discussed by the administrator, DON, RN's and department heads at morning meetings to determine what the proper action is. Resident maybe elevated by the therapy department or RN again at a time staff feel it is appropriate, or resident may not be safe to continue use.Corrective Action was implemented by 1/26/26, before survey entrance on 2/17/26, therefore the deficiency was issued at Past Noncompliance.

Based on interview and document review the facility failed to ensure 1 of 1 resident (R2) reviewed for medication errors was free of significant medication errors when orders for Potassium (electrolyte that carries an electrical charge to balance fluids in the cells, contacts muscles including the heart and transmits nerve signals to the brain) was not transcribed into the electronic medical record according to physician's orders and resulted in at least six missed doses of Potassium 10 milliequivalent (mEq).Findings include:R1's admission Minimum Data Set (MDS) dated [DATE], identified she was admitted to the facility from an acute hospital 1/15/26. R1 had slurred or mumbled words, responded adequately to simple, direct communication only, impaired vision, disorganized thinking, and severely impaired cognition. R1's medical included history of cerebral vascular accident (CVA) (stroke) and urinary tract infection (UTI).R1's care plan dated 1/16/26, identified she was at nutritional risk due to aphasia (a sudden neurological language disorder caused by brain damage) recent loss of independence, and mechanically altered diet. Staff were directed to provide assistance with eating and water pitcher be brought to her room twice daily to provide hydration and decrease risk for dehydration. R1 had a recent diagnosis of CVA. Staff were directed to administer medications as ordered and report abnormal labs and or vital signs to primary care provider. R1's Hospital Discharge summary dated [DATE], identified discharge diagnoses left-side posterior cerebral artery (PCA) stroke territory infarct (affecting the left temporal-occipital lobe as well as thalamus area), hyperlipidemia (high cholesterol levels), hypertension (HTN) (high blood pressure), arteriosclerotic disease, hypokalemia (low potassium), urinary tract infection (UTI), and deep vein thrombosis (DVT) prophylaxis. Hospital course: hypokalemia felt to be related to Lasix (diuretic) (removes excess fluid from the body). Patient will be on potassium supplements for approximately a month. Potassium could be discontinued if levels are normal. Medication list at discharge: potassium chloride 10 mEq oral two times a day. She was discharged from hospital to nursing home on 1/15/26 at 1:37 p.m.R1's Hospital labs completed from 1/11/16 through 1/15/26, identified:-On 1/11/26 Comprehensive Metabolic Panel (CMP) collected at 1:56 p.m.: Potassium 3.5 milliequivalent/liter (mEq/L) (reference range 3.5 to 5.1 mEq/L)-On 1/15/26 CMP collected at 7:02 a.m.: Potassium 3.1 mEq/L (low).Interagency Transfer Orders dated 1/15/26 at 10:10 a.m. R1's medication administration report from 1/13/26 through 1/15/26, identified: -Furosemide (Lasix) tablet 20 milligrams (mg) daily per mouth (po) start date 1/12/26. Administered on 1/13/26 at 10:08 a.m., 1/14/26 at 9:43 a.m., and 1/15/26 at 8:34 a.m.-Potassium Chloride 20 mEq (start 1/15/26at 8:15 a.m. and end 1/15/26 at 8:14 p.m.) 20 mEq every three hours' time four doses for potassium level 3.0 to 3.3. Administered 1/15/26 20 mEq po at 8:34 am. (three doses ordered were not given).-Stop taking these medications: Furosemide (Lasix), mirabegron (relaxes muscles of the bladder), omega-3 fatty acids, oxybutynin (decreases overactive bladder), ubiquinone-10 (antioxidant supplement used to treat congestive heart failure), valsartan-hydroCHLOROthiazide (used to treat HTN), and vitamin C (supplement).R1's hospital interagency handoff report dated 1/15/26 at 10:16 a.m. identified: lab results CMP collected at 7:02 a.m. and updated at 9:06 a.m. Potassium 3.1 mEq/L (low).E-prescription interface dated 1/15/26 at 10:27 a.m. provided the following information: identifying provider hospital MD. Pharmacy: local pharmacy listed. Associated diagnosis: Hypokalemia. Placing order: 1/15/26 at 10:27 a.m. Outpatient medication detail: Potassium 10 mEq CR tablet. Route: take one tablet by mouth two times a day orally. Sent to pharmacy as: potassium chloride 10 mEq CR tablet. Class: E-prescribing. Order: 1151425090. Date/Time Signed: 1/15/26 at 10:27 a.m. E-prescribing Status: receipt confirmed by pharmacy on 1/15/26 at 10:28 a.m.Pharmacy packing slip dated 1/15/26, time not indicated, identified potassium chloride 10 mEq extended release (ER) tablets (14) was delivered to facility. Trained medication assistant (TMA)-A's signature (unreadable and verified by DON) was located at bottom of document.R1's progress note dated 1/18/26, identified:-At 3:06 a.m. Communication: Order found in electronic medical chart - Potassium Chloride 10 mEq by mouth 2 times a day. Hypokalemia with a level of 3.1 mEq/L. Provider identified in note to continue for a month or so, until potassium level returns to normal.-At 3:06 a.m. Order Note: The order you have entered - Potassium chloride oral packet 10 mEq. Give 10 mEq by mouth two times a day for hypokalemia.R1's order summary report dated 2/18/26, identified: -Potassium chloride oral packet 10 mEq. Give by mouth two times a day for hypokalemia. Order date: 1/18/26. Start date: 1/18/26.R1's electronic medication record (EMAR) January 2026, identified:-Potassium chloride oral packet 10 mEq. Give 10 mEq by mouth two times a day for hypokalemia. Start date: 1/18/26. Administered morning and evening (twice a day from 1/18/26 through 1/28/26 (22 times). Potassium 10 mEq was administered in the morning only two days:1/23/26 (sent to ER) and1/29/26 (sent to ER/hospital).R1's primary provider initial visit at facility on 1/20/26, identified discharge summary and workup were reviewed. Medications prior to visit: potassium chloride 10 mEq one tablet (10 mEq) by mouth two times a day. Orders placed: complete blood count (CBC) with differential and glycated hemoglobin (average blood sugars over the past two to three months). Potassium level was not ordered.R1's ER visit dated 1/23/26, identified [AGE] year-old with recent diagnosis of stroke and limited ability to communicate. She had an unwitnessed fall at nursing home, presented with an obvious deformity to right ankle, and no sensation to the right side of the body from her stroke. Clinical impressions: closed trimalleolar fracture of right ankle/unwitnessed fall. Current outpatient medications on file: potassium chloride 10 mEq controlled release (CR) take one tablet by mouth two times a day. While in ER on [DATE] at 3:06 p.m. potassium level was checked, and result was 3.8 mEq/L.R1's Emergency Department (ED) Report dated 1/29/26, identified:-Active problems: hemiparesis and other later effects of CVA.-Fall at nursing home.-hyperkelemia (high potassium level)-Hypernatremia (high sodium level)-Acute Renal Failure-Severe DehydrationFamily reported R1 has not had anything to drink or eat over the past three days. Current outpatient medication on file prior to encounter: Potassium 10 mEq CR tablet one po two times a day. CMP lab results Potassium 7.2 mEq/L (high) (reference range 3.5 to 5.1).Facility Medication Error document identified: medication error date: 1/15/26 at 8:00 p.m. prepared by DON. Incident description: potential medication error from day of admission on [DATE] through 1/18/26. Order was not included on discharge orders (DC) listing; however, potassium was sent from pharmacy. This was possibly not reported right away to charge nurse, and resident potentially missed three doses on evening of 1/15/26, two doses on 1/16/26, two doses on 1/17/26. Medication started on 1/18/26. Potassium level completed at hospital on 1/23/26, was within normal limits (WNL). No injuries observed at time of incident or post incident. Agency/people notified: no notifications found. Remainder of document was left blank and date completed was not identified.During an interview on 2/18/26 at 12:14 p.m. care coordinator (CC) RN-A stated R1 was discharged from the hospital and admitted to the facility on [DATE]. R1's discharge orders dated 1/15/26 from the hospital did not include a potassium order but were included in the hospital notes. The hospitalist provider reviewed R1's labs and placed an order for potassium after discharge from the hospital (unsure of what date/time). Depending on the escribe date/time, the order should have gone through the pharmacy and usually the provider or the nurse would have contacted us. RN-A had no idea the provider added the order. On 1/17/26, RN-D was working night shift looked through provider notes and identified the order.During an follow-up interview on 2/19/25 at 11:57 a.m. RN-A stated the TMA would have been expected to communicate with the treatment nurse. She had not received a sticky note or notification from TMA-A (was the old way of doing things and working on changing that so it did not happen again), was unaware of R1's medication error until 1/18/26, when RN-A found the order.During an interview on 2/18/26 at 3:51 p.m. RN-C stated when a resident was admitted to the facility from a hospital the paper portfolio usually included a discharge summary and orders. It would be an expectation for the staff nurse to complete the admission to review those documents and any other ones sent from the hospital to get a full background on the resident, current problems/concerns, and discharge orders. When a medication was received from the pharmacy and no order was identified the nurse or TMA would be expected to have notified the charge nurse right away so that it could be investigated and medication errors are avoided.During an interview on 2/19/26 at 2:41 a.m. RN-D stated she usually worked the night shift starting at either 8:00 p.m. or 10:00 p.m. RN-D stated it was her job on the night shift to go through the medications in the cart and verify they were dated. She found R1's potassium medication card untouched and no medications removed from it in the medication cart. This was a red flag and investigated it. She searched for R1's hospital medical record only a few of the staff RN's have access to and was not easy to find. She knew there had to be an order for R1's potassium, pharmacy would not send it to the facility without one. She located a note written by the hospital MD which had written R1 should be placed on potassium, and an order. She printed the order, scanned it into R1's medical record, entered it into her facility orders and EMAR, and wrote a progress note. She verified the order was written and released on 1/15/26. When the pharmacy delivered medication and no order was found, it should have been looked into further right away. She followed the facility process, turned the information over to RCC. The CC would have notified the provider and investigated why this happened.During an interview on 2/19/26 at 10:15 a.m. pharmacy tech stated R1's releasing order information form was used as an e-prescription and placed in the system on 1/15/26, when ordered by the provider. She was unaware how that was received by the nursing home facility and verified R1's potassium 10 mEq tablets (16) were delivered on 1/15/26, unsure what time.During an interview on 2/19/26 at 10:52 a.m. primary provider medical doctor (MD) stated she was not aware of R1 missed doses of potassium. She had not initiated provider coverage with R1 until she completed her first visit on 1/20/26. The nurse should have followed the facilities protocol and would have been expected to notify either the prescribing provider or the provider on call if after hours. This would have been important because missed doses of potassium with lab value below normal range would affect the patient's health. R1 could have had cardiac issues such as arrythmias (irregular heartbeats), increased tiredness/confusion, and weakness. A follow up potassium level would be indicated depending on the symptoms they are having. MD stated when she saw her on 1/20/26, R1 was unable to speak but able to answer yes or no questions by nodding. That could have been used to determine if she was having symptoms and vitals were stable. During an interview on 2/19/26 at 11:31 a.m. TMA-A stated a TMA or nurse were able to verify and accept medications from the pharmacy. She received the medications delivered by pharmacy on 1/15/26, compared them to the delivery slip one by one, and signed the document. She administered R1's medications on the EMAR and noted the potassium (delivered that day) was not listed on there. She stated this happened frequently/multiple times and in the past, she placed the medication and a note on CC's desk, then reminded the mediations were to be kept locked up in medication room. She was instructed by CC to place the medication on the counter in the medication room with a note and CC followed up on them. On 1/15/26, she did not administer the potassium and placed it on the counter with a sticky note on it and RCC occasionally followed up with her. Unsure if that was done this time due to being off work for the next three days sick and then going on medical leave. TMA-A stated R1's missed doses of potassium from 1/15/26 through 1/17/26, would have been considered a medication error.During an interview on 2/19/26 at 1:50 p.m. DON stated she was unaware of what documents were received when R1 was admitted on [DATE], from the hospital. Staff would be expected to read and review the hospital summary notes and EMAR upon admission to verify that everything ordered/recommended on discharge has been implemented. The hospital summary usually was included in the hospital discharge paperwork on the day of admission but sometimes came days later. DON verified TMA-A had received and signed pharmacy slip on 1/15/26, potassium tablets were delivered to the facility. The TMA would be expected to have verified the medications received with the packing slip, placed the potassium tablets into the medication cart, and if there was not an order for the medication to communicate with the charge nurse working that evening, resident care coordinator (RCC) or DON. DON stated she preferred written or verbal communication and was informed a post it note was written and placed in the medication room along with the potassium delivered on 1/15/26. The medication remained in the medication room through many shifts. Many things went wrong: the order did not come from the provider, the next morning the pharmacy should have sent us the order, the potassium remained in the medication room on the counter left for the staff not to discover, discrepancy with the medication, and not placed in the eMAR. There should have been a follow up by nursing on 1/15/26 when the potassium arrived from the pharmacy without an order. Missed doses of potassium would be considered a medication error. DON stated she was made aware for the first time yesterday of the medication error by surveyor, completed a medication error report, and had not fully investigated the situation yet. DON stated on 1/17/26, during the night shift RN-D found the potassium on the counter in the medication room, looked on the interagency transfer orders received from the hospital, order for the medication was not on that list, logged into the hospital medical record system and found it in the medication record. The hospital provider or his nurse would have been expected to either call or fax the order to us and did not happen. That does not negate the issue on 1/15/26 and should have been followed up on 1/16/26 anyways. DON stated there was potential for harm, but no harm was identified, R1's potassium level within normal range on 1/23/26, when sent to ER to 3.8 mEq/L.Medication error policy was requested and not received.

Based on interviews and document review, the facility failed to contact the resident's physician of medication administration omissions for 1 of 3 resident (R1) reviewed who did not receive medications as ordered. Findings include:R1's admission Minimum Data Set (MDS) dated [DATE], identified she was admitted to the facility from an acute hospital 1/15/26. R1's care plan dated 1/16/26, identified she had a recent diagnosis of CVA. Staff were directed to administer medications as ordered and report abnormal labs and/or vital signs to primary care provider. R1's Hospital Discharge summary dated [DATE], identified discharge diagnoses left-side posterior cerebral artery (PCA) stroke territory infarct (affecting the left temporal-occipital lobe as well as thalamus area), hyperlipidemia (high cholesterol levels), hypertension (HTN) (high blood pressure), arteriosclerotic disease, hypokalemia (low potassium), urinary tract infection (UTI), and deep vein thrombosis (DVT) prophylaxis. Hospital course: hypokalemia felt to be related to Lasix (diuretic) (removes excess fluid from the body). Patient will be on potassium supplements for approximately a month. Potassium could be discontinued if levels are normal. Medication list at discharge: potassium chloride 10 milliequivalent/liter (mEq/L) oral two times a day. She was discharged from hospital to nursing home on 1/15/26 at 1:37 p.m.R1's Hospital labs completed from 1/11/16 through 1/15/26, identified: -On 1/11/26 Comprehensive Metabolic Panel (CMP) collected at 1:56 p.m.: Potassium 3.5 mEq/L (reference range 3.5 to 5.1 mEq/L)-On 1/15/26 CMP collected at 7:02 a.m.: Potassium 3.1 mEq/L (low).Interagency Transfer Orders dated 1/15/26 at 10:10 a.m., R1's medication administration report from 1/13/26 through 1/15/26, identified: -Potassium Chloride 20 mEq (start 1/15/26at 8:15 a.m. and end 1/15/26 at 8:14 p.m.) 20 mEq every three hours' times four doses for potassium level 3.0 to 3.3. Administered 1/15/26 20 mEq po at 8:34 am. (three doses ordered were not given). -Stop taking these medications: Furosemide (Lasix), mirabegron (relaxes muscles of the bladder), omega-3 fatty acids, oxybutynin (decreases overactive bladder), ubiquinone-10 (antioxidant supplement used to treat congestive heart failure), valsartan-hydroCHLOROthiazide (used to treat HTN), and vitamin C (supplement). R1's hospital interagency handoff report dated 1/15/26 at 10:16 a.m. identified: lab results CMP collected at 7:02 a.m. and updated at 9:06 a.m. Potassium 3.1 mEq/L (low).E-prescription interface dated 1/15/26 at 10:27 a.m. provided the following information: identifying provider hospital MD. Pharmacy: local pharmacy listed. Associated diagnosis: Hypokalemia. Placing order: 1/15/26 at 10:27 a.m. Outpatient medication detail: Potassium 10 mEq CR tablet. Route: take one tablet by mouth two times a day orally. Sent to pharmacy as: potassium chloride 10 mEq CR tablet. Class: E-prescribing. Order: 1151425090. Date/Time Signed: 1/15/26 at 10:27 a.m. E-prescribing Status: receipt confirmed by pharmacy on 1/15/26 at 10:28 a.m.Pharmacy packing slip dated 1/15/26, time not indicated, identified potassium chloride 10 mEq extended release (ER) tablets (14) was delivered to facility. Trained medication assistant (TMA)-A's signature (unreadable and verified by DON) was located at bottom of document. R1's progress note dated 1/18/26, identified:-At 3:06 a.m. Communication: Order found in electronic medical chart - Potassium Chloride 10 mEq by mouth 2 times a day. Hypokalemia with a level of 3.1 mEq/L. Provider identified in note to continue for a month or so, until potassium level returns to normal.-At 3:06 a.m. Order Note: The order you have entered - Potassium chloride oral packet 10 mEq. Give 10 mEq by mouth two times a day for hypokalemia.R1's order summary report dated 2/18/26, identified: -Potassium chloride oral packet 10 mEq. Give by mouth two times a day for hypokalemia. Order date: 1/18/26. Start date: 1/18/26. R1's electronic medication record (EMAR) January 2026, identified: Potassium chloride oral packet 10 mEq. Give 10 mEq by mouth two times a day for hypokalemia. Start date: 1/18/26. Administered morning and evening (twice a day from 1/18/26 through 1/28/26 (22 times). Potassium 10 mEq was administered in the morning only two days:1/23/26 (sent to ER) and1/29/26 (sent to ER/hospital).R1's primary provider initial visit at facility on 1/20/26, identified discharge summary and workup were reviewed. Medications prior to visit: potassium chloride 10 mEq one tablet (10 mEq) by mouth two times a day. Orders placed: complete blood count (CBC) with differential and glycated hemoglobin (average blood sugars over the past two to three months). Potassium level was not ordered.R1's ER visit dated 1/23/26, identified [AGE] year-old with recent diagnosis of stroke and limited ability to communicate. She had an unwitnessed fall at nursing home, presented with an obvious deformity to right ankle, and no sensation to the right side of the body from her stroke. Clinical impressions: closed trimalleolar fracture of right ankle/unwitnessed fall. Current outpatient medications on file: potassium chloride 10 mEq controlled release (CR) take one tablet by mouth two times a day. While in ER on [DATE] at 3:06 p.m. potassium level was checked, and result was 3.8 mEq/L.R1's Emergency Department (ED) Report dated 1/29/26, identified: -Active problems: hemiparesis and other later effects of CVA. -Fall at nursing home. -hyperkelemia (high potassium level) -Hypernatremia (high sodium level) -Acute Renal Failure -Severe Dehydration Family reported R1 has not had anything to drink or eat over the past three days. Current outpatient medication on file prior to encounter: Potassium 10 mEq CR tablet one po two times a day. CMP lab results Potassium 7.2 mEq/L (high) (reference range 3.5 to 5.1).Facility Medication Error document identified: medication error date: 1/15/26 at 8:00 p.m., prepared by DON. Incident description: potential medication error from day of admission on [DATE] through 1/18/26. Order was not included on discharge orders (DC) listing; however, potassium was sent from pharmacy. This was possibly not reported right away to charge nurse, and resident potentially missed three doses on evening of 1/15/26, two doses on 1/16/26, two doses on 1/17/26. Medication started on 1/18/26. Potassium level completed at hospital on 1/23/26, was within normal limits (WNL). No injuries observed at time of incident or post incident. Agency/people notified: no notifications found. Remainder of document was left blank and date completed was not identified.During an interview on 2/19/25 at 11:57 a.m. RN-A stated the TMA would have been expected to communicate with the treatment nurse as soon as the potassium was delivered from pharmacy and not listed on the EMAR. RN-A was unaware of R1's medication error until 1/18/26, when RN-A found the order during the night shift on 1/17/26 A provider was not contacted and should have been the following morning, it would have been important if R1 had side effects and/or re-check labs. R1's potassium level was below normal range at 3.1 mEq/L when admitted on [DATE], would be at the discretion of the primary provider to recheck labs.During an interview on 2/19/26 at 2:41 a.m. RN-D stated she usually worked the night shift starting at either 8:00 p.m. or 10:00 p.m. RN-D stated it was her job on the night shift to go through the medications in the cart and verify they were dated. She found R1's potassium medication card untouched and no medications removed from it in the medication cart. This was a red flag and investigated it. She searched for R1's hospital medical record only a few of the staff RN's have access to and was not easy to find. She knew there had to be an order for R1's potassium, pharmacy would not send it to the facility without one. She located a note written by the hospital MD which had written R1 should be placed on potassium with an order. She printed the order, scanned it into R1's medical record, entered it into her facility orders and EMAR, and wrote a progress note. She verified the order was written and released on 1/15/26. The provider was not notified due to it being in the middle of the night when discovered. When the pharmacy delivered medication and no order was found, it should have been looked into further right away. She followed the facility process, turned the information over to RCC and she would have notified the provider and investigated why this happened.During an interview on 2/19/26 at 10:52 a.m. primary provider medical doctor (MD) stated she was not aware of R1 missed doses of potassium. She had not initiated provider coverage with her until she completed her first visit on 1/20/26. The nurse should have followed the facility's protocol and would have been expected to notify either the prescribing provider or the provider on call if after hours. This would have been important because missed doses of potassium with lab value below normal range would affect the patient's health. R1 could have had cardiac issues such as arrythmias (irregular heartbeats), increased tiredness/confusion, and weakness. A follow up potassium level would be indicated depending on the symptoms they are having. MD stated when she saw her on 1/20/26, R1 was unable to speak but able to answer yes or no questions by nodding. That could have been used to determine if she was having symptoms and vitals were stable. During an interview on 2/19/26 at 11:31 a.m. TMA-A stated a TMA or nurse were able to verify and accept medications from the pharmacy. She received the medications delivered by pharmacy on 1/15/26, compared them to the delivery slip one by one, and signed the document. She administered R1's medications on the EMAR and noted the potassium (delivered that day) was not listed on there. She stated this happened frequently/multiple times and in the past, she placed the medication and a note on CC's desk, then reminded the mediations were to be kept locked up in medication room. She was instructed by CC to place the medication on the counter in the medication room with a note and CC followed up on them. On 1/15/26, she did not administer the potassium and placed it on the counter with a sticky note on it and CC occasionally followed up with her. Unsure if that was done this time due to being off work for the next three days sick and then going on medical leave. TMA-A stated R1's missed doses of potassium from 1/15/26 through 1/17/26, would have been considered a medication error.During an interview on 2/19/26 at 1:50 p.m. DON stated nursing would have been expected to have notified the provider on Monday morning and that was not done. It would be important so that the provider could have assessed the situation, changed things and/or order labs to be completed.Facility policy Notification of physician and family dated 10/2017, identified Physicians, responsible family members or legal representatives shall be notified, in a timely manner, of any changes in resident's condition. The following procedure will be used as a guideline for timely notification of changes in status, changes in treatment, incidents, accidents, and/or lab results. Definition of altering treatment: if a resident's treatment, medication or care plan is altered significantly due to adverse consequences, discontinuation or existing treatment or medication or beginning of a new treatment or medication. Altering treatment significantly: if the primary physician was not the source of the treatment change, they will be notified via phone message per clinic policy within 24 hours or the first business day following the change.

Based on interview and document review, the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN CMS10055) and the Notice of Medicare Non-Coverage (NOMNC CMS-10123) was provided to 1 of 3 residents (R17) reviewed for beneficiary notification. Findings include: R17's quarterly Minimum Data Set (MDS) dated [DATE], identified R17 was cognitively intact. R17 was admitted on [DATE], and there was functional range of motion in both upper and lower extremities and was not receiving therapy services. R17's medical record identified R17 started Medicare Part A services on 5/22/25, and last covered day of Medicare Part A services was 7/1/25. R17's medical record that a SNFABN or NOMNC was issued to the resident. The medical record lacked evidence R17 was made aware of the cost of continuing services or on how to appeal the ending of services. During an interview on 12/30/25 at 4:26 p.m., the administrator stated the notices were to be completed by the social services designee or the MDS coordinator. The forms would be presented to the resident a couple of days prior to the last covered day. When the forms were completed, it should have been documented and scanned into the medical record. During a follow up interview on 12/31/25 at 10:23 a.m., the administrator stated they could not find documentation the forms were completed and presented to the R17. This should have been completed. The policies related to the SNFABN and NOMNC were requested, but no policies were received.

Based on interview and document review, the facility failed to provide written bed hold notice to resident/resident's representative at the time of transfer to hospital for 1 of 1 resident (R12) reviewed for hospitalizations.Findings include: R12's discharge Minimum Data Set (MDS) dated [DATE], identified R12 had an unplanned discharge with return anticipated. Diagnoses included chronic obstructive pulmonary disease (COPD), diastolic heart failure (CHF), atrial fibrillation (irregular heartbeat) and myocardial infarction (heart attack). R12's progress note dated 12/9/25, identified R12 was admitted to the hospital for fever and shortness of breath with concern of a CHF exacerbation. R12's medical record lacked evidence a written notice for bed hold was provided, that specified the duration of the bed hold, the reserve bed payment policy and the nursing facility's policies regarding bed hold periods. During interview on 12/30/25, at 2:20 p.m. the unit manager (UM)-B stated when the facility received a call from the hospital that they were going to admit a resident, they would ask the family for a bed hold. The facility did not always get the call from the hospital or would get the call after hours and then it would be done the next day. Bed holds were usually done on the phone verbally and then would be documented and scanned into the resident's chart. UM-B was not sure why a bed hold notice had not been completed for R12. When interviewed on 12/30/25, at 3:53 p.m. the director of nursing (DON) stated she had been unable to find a signed or verbal bed hold completed for R12. A bed hold should be obtained when a resident was sent to the emergency room or hospital, and staff should have them sign one before they left the facility in case they were admitted to the hospital. If it was not obtained before a resident left the facility and the facility received notification the resident would be admitted to the hospital, the charge nurse was to call the family and obtain a verbal bed hold. A bed hold should have been obtained for R12; however, it had been missed. During telephone interview on 12/31/25, at 8:55 a.m. family member (FM)-C stated they had never discussed a bed hold or signed a bed hold when R12 was admitted to the hospital. R12 was able to return to the facility and her same room without any concerns or issues. The family knew R12's bed would be held at the facility because it was paid up for the month but had never been informed of the facility's bed hold policy. The facility's Bed Hold and Return for Hospital/Therapeutic Leave policy dated 7/2017, identified the facility would provide written information to the resident and/or representative about the facility's bed hold policy on admission and before a resident was transferred to the hospital or went on therapeutic leave. In case of an emergency transfer, the resident/representative would be provided with written bed hold notice within 24 hours after the transfer. The facility would hold a resident's bed for 18 consecutive days for a hospital leave. No charge would be made for those 18 days, regardless of payer source.

Based on observation, interview and document review, the facility failed to revise the resident's care plan to reflect accurate behaviors and interventions to mitigate behaviors for 1 of 1 resident (R18) reviewed for behavioral health.Findings include:R18's significant change Minimum Data Set (MDS) dated [DATE], identified R18 had moderately impaired cognition. R18 required maximum assistance with dressing and grooming, dependent with toileting and transfers and was unable to ambulate. R18 exhibited physical behavioral symptoms toward others such as hit, kick, push or grab one to three times per week and other behavioral symptoms not directed toward others such as rummaging, and/or verbal symptoms one to three days per week. R18 received antipsychotic and antidepressant medications on a routine basis. Diagnoses included Alzheimer's disease, dementia, restlessness and agitation, diabetes and depression. R18's nursing progress notes identified the following:11/19/25, Seen by physician on rounds with orders to attempt GDR with sertraline. Decrease sertraline from 100 milligrams (mg) to 75 mg every day. 11/20/25, Orders received for solumedrol (a steroid to reduce inflammation) dose pack, cough syrup and doxycycline (an antibiotic) for atelectasis (part of a lung collapse) in lung bases. 11/21/25, When R18 attempted to exit the activity room, his wheelchair came in close contact with R2, who was entering the room. R2 hollered at R18 to move and called him a profanity. R18 became agitated and yelled back. Both residents closed fists came in contact with the other's shoulders. Staff intervened and separated the two residents. 11/29/25, R18 was very rude to others. Attempted to hit two other residents as they were going past him. 11/30/25, R18 was calling staff and other residents names, using profanity. 12/2/25, R18 was fighting with his tablemate R2. When staff attempted to separate the residents, R18 swung his arm out and hit R2, making contact with the other residents back of head. Staff planned to discuss new seating arrangements for the two residents involved. R18 did not attempt to seek out R2 after the incident. 12/4/25, R18 attempted to give R6 a blanket. when R6 refused, R18 called R6 a stupid bitch. When staff attempted to bring R18 to another area, R18 reached out and hit R6 in the face. When assessed later, R6 did not have any physical injury or verbalize distress. R6 did not remember the incident. 12/5/25, order was received to increase R18's Zoloft back to 100 mg a day due to failed GDR attempt resulted in increased physical and verbal behaviors, agitation and restlessness. 12/7/25, R18 was observed ramming another resident's wheelchair. Redirection was effective. 12/11/25, R18 was agitated and calling other resident's names. 12/14/25, R18 was swearing at staff and residents and calling them names.R18's care plan with revision date 12/5/25, identified R18 had a diagnosis of depression, dementia with psychotic symptoms and Alzheimer's disease. R18 had a failed gradual dose reduction (GDR) attempt on Zoloft 12/2025. Goals were identified that R18 would not have undesirable side effects of his medications, would continue to participate in self-care, participate in activities and would not harm self or others. Interventions included to observe for side effects, sleep patterns, reorientate as needed and remove from stimulating environment if became agitated. Resident specific interventions included reading book or newspaper, looking at pictures, one to one visit, involve in activities, and wander guard for wandering. Target behaviors of sexual commentary, sticking tongue out, agitation, aggression, restlessness, depression, hollering out for help, exit seeking, wandering into other's rooms, kicking wheelchairs, spitting and resistive with care. However, the care plan failed to identify a potential for, and/or actual resident to resident altercations, including triggers, and interventions to prevent or intervene adverse altercations with other residents. R18's care plan failed to identify planned seating arrangements for meals in the dining room along with interventions to keep the environment calm. On 12/30/25, at 9:11 a.m. R18 was observed sitting in the general lobby area, visiting with another male resident. R18 would holler out to people walking past, asking for Christmas candy and making general comments such as she doesn't know anything. On 12/30/25, at 2:35 p.m. R18 was observed lying in bed with television on and door of room partially open. R18 would holler out at passerby, hey get in here, come back here. R18's voice became louder and angrier, until staff went into room to speak with him. On 12/30/25, at 5:00 p.m. R18 was observed seated at dining room table with another female resident seated, eating beside him. R18 reached out with his fork toward the other resident and asked if he could have her food. The unidentified female resident stated no, you ate all of yours. This is mine. R18 attempted to obtain some of her food with his fork but returned his fork to his plate and reached for his cup of liquid to drink. When interviewed on 12/30/25, at 5:50 p.m. the director of nursing (DON) stated R18 did not tolerate the Zoloft decrease very well and things escalated quickly. With in the two weeks, staff were seeing behaviors and attributed it to the GDR on his Zoloft as well as he had been started on a steroid. Right after the medication adjustments they had started to see an escalation of his behaviors. They discussed resident incidents, behaviors, changes of condition in their daily interdisciplinary team meetings and had also done an environmental analysis at the same time. The facility had noted they had a handful of residents that were exhibiting sundowning type of behaviors with increase agitation. Staff had reported it was difficult to control the dining room at supper time because of the sundowning behaviors some residents were exhibiting. IDT had implemented a few things that also improved R18's behaviors and aggression. Staff implemented a low stimulation environment in the common area between 2:00 and 4:00 p.m., housekeeping typically vacuumed the common area around 4:00 p.m. so they stopped that as well. We dimmed the lights, use of essential oils and tried to not have all the residents congregated in that one common area when waiting for supper. The facility had even turned the issue into a quality improvement project to track the interventions and progress with the escalation of resident behaviors in the evenings. During interview on 12/31/25, at 10:00 a.m. the DON stated she received an incident report on resident-to-resident incidents. The facility looked at if there were injury or mental anguish or changes in the victim to determine if an incident was reportable. The DON discussed the incident with the nurse working at the time it occurred and visit with the victim to assess for trauma. After every incident a new interventions was implemented. Usually the interventions were documented in the resident's care plan and are in the internal risk reports as well. Interventions were also put on the aide care sheets and as a memo in the nurse aide report and the nurse report book. New incidents and interventions were also passed on in shift report. The facility made it a practice to always do some kind of new intervention following an incident. They had put interventions in place for R18 for being around other residents, encouraging him to be active in activities. When R18 was having a bad day, staff were to bring him to his room or a quiet area, as well as the environmental changes they had done to help calm residents in the evenings. The DON thought R18's care plan had been revised on 12/5/25, but it did not include resident to resident altercations or the environmental interventions implemented. When R18 was like that, having a bad day, staff knew him well enough to know when he was building. Staff knew to move him to a different area when he was more agitated or restless. The staff also knew that R18 did not respond well to the younger girls assisting him with care, so they tried to pair him with older staff members for care. Was not specific in R18's plan of care but staff knew R18 and when he had escalating behaviors. A policy for care plans was requested, however was not received.

Based on interview and document review, the facility failed to ensure the facility antibiotic stewardship program was followed for antibiotic use for 1 of 1 resident (R23) reviewed for antibiotic use. Findings include:R23's quarterly Minimum Data Set (MDS) dated [DATE], identified R23 had significant cognitive impairment. R23 required total assistance with all activities of daily living (ADLs) and was incontinent of bowel and bladder. Diagnoses included Alzheimer's disease, anxiety, and urinary tract infection (UTI).R23's progress notes identified R23 was seen in the emergency room on [DATE] for possible seizure activity. R23 was diagnosed with a UTI and Keflex (an antibiotic) was ordered 500 milligrams (MG) two times per day for seven days. R23's medical record identified the following:12/15/25, a urine sample was obtained which identified many bacteria and was set up for culture. 12/16/25, a physician progress note identified R23 was seen on rounds. The physician noted R23 had been started on Keflex to treat a UTI. Results of R23's urine culture was not documented.R23's medical record lacked evidence of any established criteria (i.e. McGeer) being used to determine the presence of infection before an antibiotic was initiated. R23's medical record also lacked urine culture results to ensure the antibiotic ordered for R23's infection was appropriate and would be effective. When interviewed on 12/30/25, at 10:35 a.m. trained medical assistant (TMA)-A stated the unit manager followed up on ordered antibiotics and would review culture results to ensure the infection was sensitive to the antibiotic ordered. The medication nurse just followed the Medication Administration Record (MAR) and administered the antibiotic as ordered.During interview on 12/20/25, the unit manager (UM)-B stated she usually followed up on urine cultures to make sure the ordered antibiotic was appropriate. Once she knows a resident had a urine sample taken, she was on high alert and had access to the residents' charts at the hospital. She usually documented in the resident progress not that she had reviewed the culture and if it was sensitive to the ordered antibiotic or not. When a urine was done in the emergency room, they kind of watch and check for culture results after a day or so. UM-B reviewed R23's hospital one chart notes and verified a culture was done and identified an organism that was sensitive to the ordered antibiotic. UM-B stated she thought the culture results had been reviewed when R23's physician had rounded at the facility the following day. Review of the culture on file identified the culture had not been finalized until 12/17/25, the day after R23 was seen by her physician on rounds. When interviewed on 12/30/25, at 11:18 a.m. the director of nursing (DON) stated the unit managers were expected to follow up on urinalysis and culture results and ensure the appropriate antibiotics were ordered. The DON would have thought UM-B would have followed up on R23's urine culture as that was her expectation and if not sensitive to follow up with the resident's primary provider. The infection control nurse then collected the data and did a summary on the review of antibiotics. The facility's Antibiotic Stewardship policy with last review date 2/2025, identified the nurse would utilize the Loeb Minimum Criteria protocols to determine if it was necessary to treat with antibiotics or if adjustments in therapy needed to be made. Physicians would be notified of results of diagnostic tests to ensure residents were taking the appropriate antibiotic of if the antibiotic needed to be discontinued or changed.

Based on interview and document review, the facility failed to provide the most recent Centers for Disease Control (CDC) education regarding the potential risks and benefits for vaccinations being offered along with offering the most recent pneumococcal vaccine for 1 of 5 residents (R21) reviewed for immunizations.Findings include:R21's quarterly Minimum Data Set (MDS) dated [DATE], identified R21 was admitted to the facility on [DATE], was [AGE] years old, had moderate cognitive impairment, and had a diagnosis of heart failure. R21's immunization record dated 12/31/25, identified R1 had a historical record R1 had received the pneumovax vaccination on 10/23/02. However, R21's medical record failed to identify R21 or R21's representative was provided the most recent Centers for Disease Control (CDC) education regarding the potential risks and benefits of the pneumococcal.During an interview on 12/31/25 at 10:38 a.m., the interim director of nursing (IDON) stated a resident's immunization stated was reviewed upon admit and on a yearly basis. Documentation of is entered when immunizations were reviewed, education give, and if accepted or declined. There was no documentation in R21's medical that R21 or R21's representative had received education related to the pneumonia vaccine or if was offered.The facility's Pneumococcal Vaccine policy dated 11/2024, identified the facility would provide education related immunization and document administration or refusal of immunization.

Based observation, interview and document review the facility failed to ensure staff transporting residents in a facility vehicle were trained on safe transport practices and had appropriate driver's license clearance for 3 of 3 (R1, R2, R3) residents reviewed for accidents. This resulted in an immediate jeopardy for R1 when he fell from his wheelchair to the floor of the van during transport after being improperly secured. Findings include: The immediate jeopardy (IJ) began on 7/2/25, at approximately 4:00 p.m., when nursing assistant (NA)-A was directed to transport R1 to the hospital, loaded him in the front passenger's seat of the van, securing only two out of the four required four-point tie downs, and no seat/lap belt. R1's wheelchair fell backwards onto the floor of the van during transport resulting in a skin tear on top of the left hand. Additionally, NA-A driver's license had not been cleared by the facility's insurance prior to this incident. The IJ was identified on 7/17/25, the administrator was notified of the IJ on 7/17/25, at 4:15 p.m. The IJ was removed on 7/2/25, and the deficient practice was corrected prior to the start of the survey and was therefore issued at past noncompliance. R1's admission Minimal data set dated [DATE], identified moderate cognitive impairment. R1's Morse Fall Scale (a tool used to assess fall risk) completed on 6/30/25 at 1:49 p.m. identified a history of falls, used a wheelchair for mobility, and impaired and weak gait. His fall risk score was 40 (low risk 0 to 24, moderate risk 25 to 44, high risk 45 or higher), and placed him at moderate risk for falls. R1's care plan dated 6/27/25, identified he had poor decision-making abilities and impaired safety awareness. R1's progress notes from 7/2/25 through 7/4/25, identified: -On 7/2/25 at 4:47 p.m., writer was alerted by daughter-in-law the new onset of confusion and worsening slurred speech. Upon assessment, resident was pale and noted to be having hard retention of fluid in abdomen, bilateral upper and lower extremities. He talked nonsense, had delayed responses to questions, confusion, and incomprehensible speech. He was sent to emergency department (ED) via facility van as he was unable to get into daughter-in-law's vehicle. He left facility at 4:16 p.m. with necessary paperwork. -On 7/2/25 at 6:30 p.m. local hospital called and indicated he was being admitted for pneumonia. -On 7/3/25 at 12:01 p.m., received nurse report from local hospital ambulance would bring him back to facility, scans clear, laceration to left hand covered with mepilex, left elbow skin covered with steri strip. Family discussed comfort care, oxygen 3 liters (L).-On 7/3/25 at 1:56 p.m., he returned to facility via ambulance at 12:50 p.m. minimally responsive. -On 7/3/25 at 3:25 p.m., fall assessment- In facility van on 7/2/25, via in route to ED for evaluation after change in condition. R1 was assisted to van with brake locks and tie downs being applied to front and rear. During transport he tipped backwards in wheelchair and sustained a skin tear to left hand. Staff present helped him back to seated position and continued to ED for evaluation. Unknown if he hit head, sustained back of left hand skin tear. Baseline mental status: oriented to person, place and time. Displayed poor safety awareness and long, short term memory loss, and recent decline in activities of daily living (ADL) abilities. -On 7/3/25 at 3:44 p.m. he returned on comfort cares; hospitalist prescribed comfort measures. Facility incident report identified on 7/2/25 at 4:00 p.m., R1 experienced a change in condition and was determined he should be seen in the emergency department (ED) for evaluation. R1 was assisted to load in his wheelchair into the facility van with an oxygen tank by staff who secured straps front and rear of wheelchair. When accelerating after stopping at a stop sign, R1's wheelchair came loose from the tie down and tipped backwards. He was assisted back to an upright position and driver proceeded to ED. Per staff report there was a red spot on his head, no bleeding and a skin tear to left hand. CT scan showed no other injuries. He was admitted to the hospital for treatment of pneumonia. ED triage notes dated 7/2/25 at 4:10 p.m., identified R1 arrived to ED via wheelchair with family with complaints of slurred speech, confusion and a fall on the way to ED. Family was told by nursing home (NH) staff that he was having mini strokes due to his noted slurred speech and confusion that had started today but had not given a timeframe of events to family or ED staff. On the way to the hospital, NH staff told family they did not have a front strap for his wheelchair and when staff hit the brakes, he proceeded to fall backwards while in the wheelchair and hit his head. No blood thinners on chart, no injury noted to back of head. Small skin tear to top of left hand, bleeding controlled. Slurred speech and confusion started prior to his fall. He was noted to have a delayed responses and incomprehensible words on arrival which had changed from his recent admission to this facility. Stroke code called on arrival at 4:08 p.m. and sent to have CT. ED provider note date of service 7/2/25 at 9:42 p.m., identified R1's computed tomography (CT) scan (imaging using x-ray techniques to create detailed images of bones, blood vessels, and soft tissues inside the body) and angiography combined a CT scan with the injection of dye (CTA) returned results indicated unclear if he had pneumonia or congestive heart failure (CHF), hospital treatment was needed. Review of the motor vehicle driving records (MVR) lacked evidence NA-A had been cleared before 7/2/25. (cleared on 7/3/25, after incident). During an interview on 7/15/25 at 1:40 p.m. family member (FM) stated R1 had a change in condition and facility staff suggested he be sent into ED. She was unable to transport him in her car due to the size of his oxygen tank, so the facility offered to transport him in the facility van. She left facility to meet them at the hospital, drove the long way around towards the hospital, after when she turned the corner saw the facility van pulled over on the side of the road and NA-A stood outside the van sobbing, and stated he fell over. She looked in the van and saw him positioned in the wheelchair on his back with his legs up in the air, head turned to the left side, located up against the back seat. He was awake and unaware of what had happened. She positioned herself at his feet by the front of the van and NA-A was positioned at his head. Together they pulled the wheelchair to an upright position. When asked what happened she stated she thought they did not strap in the front wheels. FM stated she encouraged her to calm down and breath, NA-A was distraught and scared. The skin located on the top of his left-hand was peeled back from the wrist to his knuckles and blood ran down his hand. She stated it was a freak accident and hoped the facility can figure out what happened so that it does not happen to someone else. During an interview on 7/16/25 at 10:48 a.m., nursing assistant (NA)-A stated she had not heard of a facility van orientation/education and or received any education regarding the safe transporting of a resident in the facility van. On 7/2/25, she transported two residents and to the best of her ability, used all straps provided to keep them safe. She transported a female resident (R3) earlier in the day on 7/2/25. R3 was positioned in the back of the van in a wheelchair with brakes on, all four tie down straps (two in front and back) and the seat/lap belt across her chest and abdomen area. She was randomly asked to transport the first resident to urgent care and then received a call to come back to facility to transport R1. When she arrived back at facility, RN-A pushed R1 out to the van in a wheelchair, placed him into the van and in the passenger spot. She locked his brakes and walked back into the facility. NA-A indicated she normally would place residents in the back of the van. She drove 10 miles an hour for about one block before pulling over to the side of the road where she reached over to R1 and pulled two straps on quickly, attached tie down straps located on the floor of the van, one in front and one in back to the wheelchair. She kept driving, then after the gravel road, turned left onto the highway to the hospital and in the middle of the turn he fell backwards in the wheelchair. The oxygen tank was heavy, located on the back of his wheelchair, and may have had something to do with the fall. He fell on top of the oxygen tank. She pulled over to the side of the road and waved down family member (FM) when she drove by. We lifted R1 in his wheelchair up to a sitting position. The front tie down had let loose. He had no bleeding on his head and had a skin tear on his left hand. During a follow-up interview/observation on 7/17/25 at 2:16 p.m., NA-A and surveyor went out to the facility van. NA-A stated the front passenger spot did not have the front connection for the seat beat located on the floor when she transported R1 to the hospital on 7/2/25. She pointed out an approximately 12-inch extension (seat/lap belt would have been attached to). Observation showed the extender was attached to the floor of the van was located up by the passenger spot on the left side of where the wheelchair would be placed. She stated one tie down was used in front and back of the wheelchair and should have tighten them, the one on the right front was not working and had been fixed since. He would have not fallen backwards if she would have had the right connection to the seat/lap belt and tightened the tie downs to the wheelchair. She was unaware of any special training/education, had seen other staff take the van and go, so she did not question it. During an interview on 7/15/25 at 3:37 p.m. activities director (AD) stated the van had a safety inspection completed by the department of transportation (DOT) on 7/11/25, prior to that she was unsure when it had been completed. She had provided van use education to approximately five staff for 2024 (unsure of date) and used the bus orientation check list. She physically demonstrated the tie downs and seat/lap belts in the bus. She was responsible to have provided the education/bus orientation check list to staff annually prior to driving the van to properly know how to secure a wheelchair and transport the resident safely. She was unsure if NA-A had completed the education. A motor vehicle driving record should have been checked annually on staff prior to driving the van and would have been expected to be completed by the administrator. She was unsure if NA-A driver's record was checked prior to 7/2/25. During a follow-up interview on 7/17/25 at 2:04 p.m., AD stated she had developed a more detailed safety check list for the van/bus and most likely will be completed by maintenance. The monthly safety checks had been completed by herself and used one form for both. She was unable to identified which vehicle was checked and if there had been an issue/concern due to only one check mark placed by each area looked at. She stated a separate safety check sheet for each vehicle would be used in the future. She had removed the floor extension belt (connected to the wall seat/lap belt) each time she placed a resident into the van or removed them. The floor extension belt connector was placed in the back of the van. During an interview on 7/17/25 at 9:29 a.m. interim DON/RN-A and corporate RN-E were both present. DON stated any staff driving the facility van or bus should have had a driving record checked and received the bus orientation prior to transporting a resident. DON stated NA-A was not included on the van driver list and transported two residents by facility van on 7/2/25. She was unsure if NA-A's driver's record report or education had been completed prior to 7/2/25. NA-A had reported to her she had not filled out the driver record check paperwork and would have been important to had made sure she had a valid driver's license and no tickets. NA-A had not received the bus orientation /education and should have. During an interview on 7/17/25 at 11:15 a.m. administrator stated the van was used to transport residents for outings, social events and appointments. On 7/2/25, The staff instructed NA-A to come back to the facility to get R1 and should have first verified NA-A had skills/knowledge to transport residents in a wheelchair in the van. It would have been critical to ensure we are transporting our residents safely. The nursing staff sent an unqualified driver without education to transfer residents in the van in the wheelchair and R1's accident could have been prevented. A second person could have confirmed the proper straps were attached as required and the fall could have been prevented. There were no safety checks completed by DOT on the van prior to 7/11/25. Monthly bus/van driver safety checks had been completed and verified seat belts were working and accessible. NA-A had transported R2 in the van in her wheelchair earlier in the day on 7/2/25, later in the day NA-A transported R1 in the van in his wheelchair. Both residents while being transported sat in the passenger spot, the four-point straps were there, available and in place it be used. NA-A only used two straps, one in the back and one in the front of the wheelchair. The seat/lap belt extender (should have been located on the floor of the van) was not placed and later found a brand new one in the back of the van still in the package. The proper use of the seat/lap belt and the four point tie downs could have prevented R1 from tipping backwards and hopefully forward, and the fall on 7/2/25. Without the bus orientation education, she would have not known to have looked in the van for the seat/lap belt extension. R1's situation was a medical emergency and should have been transported to the hospital in the ambulance. The charge nurse asked NA-A to transport R1 to the ED without asking the DON or administrator for verification. Van keys were kept in activity office and if an NA was told to go get them they would. NA-A had not completed the education or driving record checked prior to her transporting two residents in wheelchairs in the van on 7/2/25. The social worker designee (SWD) had transported residents in wheelchairs in the van, unsure as to how often, without receiving the required education and driving record checked since May 2025. All vehicles were removed from usage immediately following the incident. During an interview on 7/17/25 at 2:45 p.m. Q'Striant sales engineer representative (SEP) stated when a resident was transported in a van the four point die downs must be used to be kept safe. Without the use of the four tie downs, the resident would be placed at a higher risk for the wheelchair to tip over, flip backwards, and injury. The lap/seat belt was required to be used with all transfers and without the belt being applied placed the resident at risk for sliding and/or falling out of the wheelchair. Education and training for staff working with transporting a resident in a wheelchair in a van would help minimize many issues such as lack of knowledge that can create a lot of problems such as misuse of the system and help prevent injuries and accidents. Manufacturers Q'Straint user instructions undated, identified wheelchair must be placed facing forward in securement area, apply wheel locks/ turn power off. Attach tie-down anchorages and ensure they are locked in. Attach the four tie-down hooks to solid frame members or weldments, near seat level. Ensure tie-downs are fixed at approximately 45 degrees. Do not attach hooks to wheels, plastic, or removable parts of wheelchair. Ensure all tie-downs are locked and properly tensioned. If necessary, rock wheelchair back and forth or manually tension retractor knobs (if present) to take up additional webbing slack. Secure passenger: attach lab belts using integrated stiffeners (plastic end) to feed belts through openings between seat backs and bottoms, and/or armrests to ensure proper belt fit around occupant. On aisle side, attach belt with female buckle to rear tie down pin connector, ensuring buckle rests on passenger's hip. On the window-side attach belt with make tongue to rear tie-down pin connector and insert into female buckle. Attach shoulder belt- extend shoulder belt over passenger's shoulder and across upper torso and fasten pin connector onto lap belt. Note: combination lap/shoulder belts serve as both window-side lab belt and shoulder belt. Ensure belts are adjusted as firmly as possible but consistent with user comfort. Facility policy Use and Maintenance of Company Vehicles undated, identified for the business needs of the organization, there may be times when an employee is asked to operate a vehicle by the company. Employees are responsible to know that they are held to the state standards, rules, and regulations. The employees must have a valid and current driver's license to operate a company vehicle, or a personal vehicle with current auto insurance while on company business. Employees are expected to drive in a safe and responsible manner and to maintain a good driving record. Facility policy Facility Assisted Transportation 7/2025 identified it was the policy of this facility to ensure access to safe, non-emergency transportation to doctor's appointments, activity outings, and other trips deemed necessary. This may include use of local transportation, taxis, ambulance (for emergent or stretcher transfer) and/or facility van or bus when appropriate. The van will be well-maintained and equipped with proper safety features. This included wheelchair restraints which will be used according to manufacturer instructions. The van will also have required safety inspections with records being maintained by the facility administrator, or designee. All residents transported using the facility van/bus in a wheelchair will be properly secured using a 4-point harness and seatbelt to include shoulder harness and lap belt. Only staff who are authorized and listed on the facility insurance may drive/operate facility vehicles. Staff authorized to drive the van/bus will have training specific to Strain restraint system and be able to return demo proper restraint and seatbelt use. Staff authorized to drive the van/bus will have necessary training and licensure to operate the vehicle as well as knowledge of van safety features. Training records will be kept in the employee's file. Staff authorized to drive the bus will be aware of emergency procedures. If an emergency arises during transportation, the driver will pull over as soon as safe to do so and call 911 for assistance. This includes both medical and behavioral emergencies as well as any accidents. Travel liability in the facility van/bus will have details logged in binder in the vehicle to include miles, driver, safety checks, and date/time. The past noncompliance immediate jeopardy began on 7/2/25. The immediate jeopardy was removed 7/2/25, and the deficient practice corrected after the facility implemented a systemic plan that included the following actions: -Facility bus and van were immediately removed from use.-DOT inspection completed and passed for bus and van.-The lap belt extender was located and installed.-Two staff that have been trained on van/bus policies and procedures, completed online training/competency checked, and MVR checked will be allowed to hold the keys and/or transport residents.-Keys have been stored in locked box and can be unlocked by a 4-digit code known by only the facility administrator, cooperate RN, and DON. Keys must be checked out prior to vehicle use.-New policy was written Facility Assisted Transportation and facility policy Use and Maintenance of Company Vehicles was brought to the facility from the corporation.-Activities director and activities assistant received Q'Straint online training and return demo of knowledge.-A new MVR report and transportation log was created and will be used.-An all-staff meeting was scheduled for end of July 2025. R2's annual MDS dated [DATE], identified intact cognition. She required supervision/touching with transfers/walking with the use of a walker and required the use of a wheelchair for mobility. She required the use of oxygen. During an interview/observation on 7/16/25 at 11:34 a.m., R2 laid on top of her bed with oxygen on per nasal cannula (NC) at 3 L. When she left her room, her portable oxygen was placed in a small carrying case and positioned on the back of the wheelchair secured in a black bag. R2 indicated she required the use of the wheelchair when transported in the van or bus and walked with assistance. She usually sat in the passenger spot in the van and enjoyed that. She used the van once every couple weeks. Two weeks ago, she used the van and viewed in town showing of beautiful yards on the edge of town. The activities driver applied a strap to hold the front of the wheelchair, unsure if it was one or two straps, and she was unable to see how the back straps were attached. No seatbelt was applied in either the van (passenger spot or back of van) or bus when she was transported. She stated it seemed strange that she did not have a seat belt on and most likely should have. R3's quarterly MDS dated [DATE], identified intact cognition. Walks independently and used a manual wheelchair for mobility. During an interview on 7/16/25 at 10:00 a.m., R3 stated she used her wheelchair when she went out of building and utilized the van. A couple of weeks ago on 7/2/25, she was transferred to the clinic by NA-A. She was hooked up to four of those straps located on the floor of the van to the wheelchair and no seat belt was used. She was a very careful driver but thought it would be important to make sure she as safe with a seat belt. She does not go out much but when taken out in the bus and van by AD the wheelchair was strapped down and seatbelts were not used, for sure, every time she went for a ride. She indicated they had been unable to go out for activities lately though.

Based on observation, interview and document review, the facility failed to ensure manufacturer's instructions were followed for the use of a microwave heating of a gel pack, complete a comprehensive assessment of the burn and implement timely interventions to promote the healing of a burn for 1 of 1 resident (R15) reviewed for burns. This resulted in actual harm to R15 who sustained a 3rd degree burn (destroys your first three layers of skin and fatty tissue) from a gel pack. Findings include: R15's quarterly Minimum Data Set (MDS) dated [DATE], identified R15 had a moderate cognitive impairment and diagnoses that included weakness, type 2 diabetes, and chronic kidney disease. R15 required partial to moderate assistance to roll her body left and right and currently had no wounds. R15's care plan dated 10/16/24, identified R15 was at risk for pain related to spinal stenosis, osteoporosis, weakness, impaired mobility, shoulder pain, spondylolisthesis osteoarthritis, chronic gout, low back pain, and amputation of the second toe of the right foot. Non-pharmacological pain interventions may include rest, reposition, distraction, elevation and ice/warm pack. The care plan directed to update R15's physician with changes. R15's nursing progress notes identified the following: - 10/19/24 at 8:49 a.m., a voicemail was left for family member (FM)-A. R15 was complaining of right hip pain, would note rate pain. As needed (PRN) Tylenol and heat pack applied - 10/19/24 at 12:05 p.m., a nursing assistant (NA) noted a blister measuring 4-centimeter (cm) x 1.5 cm on R15's right hip related to heat pack being applied. Heat pack was not overly warm, but R15 did have fragile skin and did lay on the heat pack which may have contributed to blister occurring. R15 denied pain in hip or blister. Blister left open to air. FM-A informed and stated R15's skin was very thin and likely why it blistered easily. - 10/20/24 at 11:31 a.m., R15's blistered area was leaking clear fluid. The area was cleansed, and an ABD pad placed. The note failed to provide a description including measurements. - 10/23/24 at 11:42 a.m., R15's routine skin check performed this shift. No new skin concerns noted. Dressing to right hip/thigh changed. Scant amount of serous (clear to light yellow) fluid noted on old dressing. Cleansed and new dressing applied. Tolerated well. Area has no odor or signs/symptoms of infection. - 10/23/24 at 9:51 p.m., R15's dressing to right thigh changed due to previous dressing being soiled. Moderate amount of serous fluid noted on old dressing. No odor noted. Area cleansed with normal saline, and dressing changed per treatment record order. Tolerated well. - 10/26/24 at 3:00 p.m., Telfa (a non-absorbent and non-adhering dressing) and an ABD applied to right outer hip blister/wound. The outer edges of area were red in color and measure 7.5 cm x 4.5 cm, this was area on entire wound. Blister was intact and fluid filled. Resident had no complaints of pain within that area and tolerated dressing change well. - 11/4/24 at 3:27 p.m., R15's skin assessment was completed: 8 cm x 5.5 cm area to right hip that was previously a fluid filled blister in evolution. Skin remained intact. Peri wound was reddened. No warmth noted. Wound edges are smooth. Area was dry and flaky skin noted. Darken discoloration noted to right posterior and left anterior edges. Center of wound had pale color. No drainage to area. Area covered with Xeroform and ABD, secured with tape. R15 had no complaints of pain to area. Will change dressing to area daily. - 11/5/24 at 11:22 a.m., a new dressing applied to right thigh due to old dressing falling off. No drainage noted coming from area, no odor noted. Peri wound reddened; no warmth noted. Area where blister was dark in color. Dressing changed per orders. R14 tolerated well. - 11/7/24 at 7:56 a.m., a 7 cm x 5 cm area to right hip that was previously a fluid filled blister in evolution. Skin remains intact. Peri wound was reddened. No warmth noted. Wound edges were smooth. Area was dry and flaky skin noted. Darken discoloration noted to right posterior and left anterior edges. Center of wound had pale color. Slight brown drainage on previous dressing. Area covered with Xeroform and ABD, secured with tape. R14 had slight pain to area while cleansing and changing dressing. R15's physician updated. - 11/7/24 at 9:35 a.m., R15's physician ordered R15 to be evaluated in urgent care for R15's right hip wound. FM-A updated and in agreement. - 11/7/24 at 11:46 a.m., R15 was seen in urgent care due to wound to right hip. Orders as follows: Medi pore tape, Xeroform nonocclusive, ABD pad; if dressing starts to become saturated then increase dressing change to twice a day. Orders updated in Treatment Administration Record (TAR). Resident referred to wound clinic for further care of wound. R15's medical record lacked a comprehensive assessment for R15's burn along with interventions implemented. R15's MD/Nursing communication dated 11/7/24, identified a nursing concern related to a wound right hip 10/19/24. Hot pack. An order was received for Medi pore tape (hypoallergenic tape that is soft and breathable to reduce the risk for skin sensitivity), xeroform non-occlusive (a sterile, non-adhering permeable dressing consisting of absorbent, fine-mesh gauze impregnated with a water-in-oil emulsion blend), ABD pad (a large wound dressing). R15's physician progress note dated 11/8/24, identified R15's wound was a chronic Full Thickness Burn, thermal (3rd degree) acquired on 10/19/24 and had received a status of not healed. Initial wound encounter measurements were 4.18 centimeters (cm) length x 3.68 cm width x 0.01 cm depth. Necrotic adipose (a condition that occurs when fatty tissue is damaged, leading to the death of the fat cells) was exposed. No tunneling was noted. No sinus tract was noted. No undermining was noted. There was a moderate amount of serosanguineous (light pink, watery fluid) drainage noted which had a strong odor. R15 reported a wound pain of level 4/10. The wound margin was attached. Wound bed has no granulation (a sign of wound healing) (new connective tissue), no slough (dead tissue within the wound that can impede healing), no epithelialization (new cells) but had eschar (dead tissue that sheds or falls off from the skin). R15's Order Summary Report identified the following: -10/19/24, Nursing order to monitor 4 cm x 1 .5 cm blister to right hip two times a day. Use ice pack if causing discomfort. - 10/24/24, Nursing order to monitor 4 cm x 1 .5 cm blister to right hip. Change dressing every 3 days two times a day and as needed (PRN). Cleanse with saline and apply ABD (a large wound dressing) with tape - 11/7/24, Physician order to dressing to right hip - cleanse with saline, pat dry, apply Xeroform (a sterile, non-adhering permeable dressing consisting of absorbent, fine-mesh gauze impregnated with a water-in-oil emulsion blend) and cover with ABD, secure with Medi pore (soft cloth surgical tape, this is a breathable, gentle, conformable tape that comes in easy tear, perforated rolls) tape one time a day. R15's significant change Minimum Data Set (MDS) dated [DATE], identified R15 had a burn. R15's wound clinic notes dated 11/8/24 - 1/28/25, identified R15 had received consistent wound care since the referral and R15's wound was in the process of healing. During a telephone interview on 1/28/25 at 9:48 a.m., FM-A stated R15 had a fall back in October 2024 and received no injuries, but did receive a burn to R15's right hip from a hot pack. FM-A stated nursing did tell FM-A right away and said either the hot pack was faulty or they left it on too long. Nursing made it sound like it wasn't really a big deal and FM-A spoke with R15 every evening and R15 didn't say anything about it. Then, a few weeks later, FM-A was told R15 needed to be seen by a wound specialist. Nursing told FM-A they disposed of all the hot packs. FM-A stated she didn't know if nursing didn't think it was a big deal, but FM-A would have liked to be updated before being told about the wound specialist. Maybe we could have done something sooner and it wouldn't have gotten so bad. During a telephone interview on 1/28/25 at 10:43 a.m., registered nurse (RN)-C stated she was aware of the burn but was not working when it occurred. RN-C could not say what first aid was provided to R15, but R15 was being followed by wound care. RN-C stated she was told to not use the hot packs because they were unaware of the feature that would make gel packs so hot. RN-C believed the gel packs were discontinued. During a telephone interview on 1/28/25 at 1:30 p.m., RN-A stated she put the hot pack on R15. On 10/19/24, R15 fell during shift change. R15 was assisted back to bed but complained of right hip pain. RN-A had not been educated on the gel pack heating instructions nor had RN-A read the manufacturer's instructions on the back on the gel pack. RN-A heated a gel pack in the microwave for maybe 30 seconds, wrapped the gel pack in a hand towel, placed the gel pack on R15's right hip and positioned R15 on her right side so that R15 was lying on the gel pack. Later that morning, (approximately 30 minutes) R15 had a shower and RN-A performed a routine weekly skin assessment on R15 when RN-A discovered the reddened area that resulted in a burn on R15's right hip. RN-A did not apply ice or cool water and left R15's burn open to air. RN-A stated she was unaware of when R15's physician would have been rounding at the facility but did not seek medical attention for R15 because I thought it might go away. The undated Rester's Choice Gel Pack manufacturer's instructions directed the following: Clean microwave before use. Gel pack must be at room temperature before microwave use. Distribute gel evenly in pack and place in microwave. Before removing gel pack from microwave, check for leakage. If leakage occurred, wait for the gel pack to cool down and discard. Check for desired temperature (temperature will continue to rise slightly). If pack is too hot, let it cool until temperature is acceptable. If additional heat is desired, return to microwave and heat in 5 second increments. DO NOT overheat. Excessive heating might cause pack to rupture and leak. Place it in the provided pouch. Apply to affected area and use the strap as necessary to hold in place. Store at room temperature for future hot therapy use. Do not apply cold/hot therapy for more than 20 minutes. Microwave Heating Time: Since the power of microwave ovens may differ from one microwave to another, the best heating time should be tested when first used at each microwave: a.) Heat the gel pack for 30 seconds b.) Check temperature every 5 seconds When the desired temperature is reach and evenly distributed, that's the heating time that should be used at the current microwave oven. During an interview on 1/28/25 at 2:46 p.m., RN-B stated she was the acting director of nursing (DON) on 10/19/24, when R15 received a burn to R15's right hip. RN-B stated R15 had fallen, and staff applied a hot pack to R15's right hip for comfort. R15 was lying directly on the hot pack and R15's skin was burned. RN-B stated she was notified of the burn on 10/21/24, during the morning IDT meeting, but she did not notify R15's physician until 11/7/24, when there was concern about potential infection. RN-B stated she did not assess R15's wound until 11/7/24, because nursing staff had completed skin assessments. RN-B stated she did not evaluate nor analyze R15's burn to determine if the gel pack was used according to manufacturer's instructions and/or if any other diabetic residents had used the gel packs During an interview on 1/28/25 at 4:04 p.m., licensed practical nurse (LPN)-F stated R15's burn was caused by a hot pack, and LPN-F wasn't working when it happened. LPN-F stated she had used the hot packs many times. It's always a resident's choice if they want to use a hot or cold pack and LPN-F thought they could be left on for 30 minutes to an hour. If a burn happened when LPN-F was working, LPN-F would immediately try to cool off the burn with ice to try to lessen the burn; then would call the RN on-call for further direction. A joint interview was conducted with RN-D, who was the facility's corporate nurse, and director of nursing (DON) on 1/28/25 at 4:20 p.m. The DON and RN-D both stated they were not aware of the circumstances surrounding R15's burn. The DON stated she overheard nurses talking about microwaving gel packs. The DON stated she told the nurses microwaving gel packs was not advisable and ordered the [NAME] Hot Compresses on 12/19/24. However, the DON stated she did not question the nurses further and was unaware R15's wound was caused by a gel pack. We were talking about Best Practice. The DON stated she verbally educated the nurses regarding the [NAME] Hot Compress during report at shift changes but had done no formal education. The DON stated staff that worked casually would need to rely on other staff to tell them. DON stated staff were expected to assess, monitor, treat and document wounds to promote healing. RN-D stated the incident was a serious concern that showed lack of assessment and lack of follow through to prevent this from occurring again. During a telephone interview on 1/29/25 at 3:06 p.m., physician (DR)-A stated, typically for injuries, DR-A would expect to be notified in a day or two. For a burn, DR-A would more than likely have ordered a Silvadene dressing ((Silver sulfadiazine) is an antibiotic. It fights bacteria and yeast on the skin. Silvadene (for the skin) is used to treat or prevent serious infection on areas of skin with second- or third-degree burns) and instruct to continue to monitor the wound. R15's delay of evaluation and treatment did not ease the healing process; however, DR-A would not say if it worsened the wound because DR-A did not evaluate the wound prior to 11/7/24. During an interview on 1/30/25 at 8:49 a.m., the DON and RN-D stated R15's burn should have been thoroughly investigated to ensure equipment was used according to manufacturer's instructions, if staff were aware of how to use the gel pack and to determine which residents with circulatory problems or diabetes were involved to ensure no other residents were or could be harmed. A facility first aid policy was requested but not received. A facility wound monitoring policy was requested but not received A facility policy/procedure regarding the Rester's Choice gel pack was requested but not received. The American Burn Association's First Aid for Minor Burns direction dated 2020, identified the following: Stop the burning process: - cool with burn with running cool (not cold) water for at least 5 minutes. Sterile water not necessary. - Remove all jewelry, watches, rings, and clothing around the burned area as soon as possible. - Administer an over-the-counter pain reliver such as ibuprofen or acetaminophen for pain control. Follow the directions on the label. Consult a physician or health care provider if pain is not relieved. - Cover the burn with a sterile gauge bandage or clean cloth. Wrap the burned area loosely to avoid putting too much pressure on the burn tissue. - Minor burns will usually heal without further treatment. - For a small area burn (less than 1% or the size of the person's hand), apply soothing lotions that contain aloe vera to a burned area to help relieve the pain and discomfort. - Seek medical attention if there is a persistent fever not relieved by medication or redness that may extend beyond the border of the burn or pain is not controlled by ibuprofen or acetaminophen. - Drink plenty of fluids (electrolyte-containing solutions such as Gatorade) if the person appears to be dehydrated. Do not apply ice - this may further damage to the skin. Do not over cool! If victim starts to shiver, stop the cooling process. Do not use any butter, ointments, or other home remedies on the burn. Such substances may trap the heat in the tissue and makes the burn worse. Do not break any blisters - leave intact. Blisters may rupture over time - this is normal. Do not delay seeking medical attention if the burn is larger than the size of the victim's hand.

Based on interview and document review, the facility failed to ensure licensed nursing staff hours were submitted accurately on the payroll-based journal. This had the potential to affect all 32 residents residing in the facility. Findings include: The PBJ (payroll-based journal) Staffing Report CASPER Report 1705D FY [fiscal year] Quarter 4 2024 (July 1 - September 30) identified the facility had excessively low weekend staffing and failed to have licensed nursing coverage 24 hours/day on the following days: 7/23/24, 7/24/24, 7/25/24, 7/26/24, 7/27/24, 7/28/24, 7/29/24, 7/30/24, 7/31/24, 8/20/24, 8/21/24, 8/22/24, 8/23/24, 8/24/24, 8/25/24, 8/26/24, 8/27/24, 8/28/24, 8/29/24, 8/30/24, 8/31/24, 9/16/24, 9/17/24, 9/18/24, 9/19/24, 9/20/24, 9/21/24, 9/22/24, 9/23/24, 9/24/24, 9/25/24, 9/26/24, 9/27/24, 9/28/24, 9/29/24, and 9/30/24. The facility payroll and working scheduled were reviewed for 7/1/24 through 9/30/24 and there was a licensed nursing staff 24 hours/day consecutively on all 36 days identified on the PBJ report. During an interview on 1/29/25 at 8:49 a.m., registered nurse (RN)-B stated during quarter 4 2024, she was a salaried employee, and she did not use the timeclock even though she worked charge nurse shifts during that time. During an interview on 1/29/25 at 9:34 a.m., registered nurse (RN)-D, who was the corporate nurse, stated the administrator was responsible for submitting the PBJ for the facility, but the administrator was unavailable due to a family emergency. RN-D stated she was aware the administrator was having difficulty submitting the PBJ data and had to hand enter the information. The facility always had licensed staff in the building 24 hours/day, however, salaried employees were not using the timeclock system. A policy/procedure regarding PBJ data submission was requested but not provided.

Based on interview and document review, the facility failed to ensure the quality assurance (QA) committee held meetings with the required members on a, at minimum, quarterly basis. This had potential to affect all 32 residents residing in the facility at the time of the survey. Findings include: The Quality and Safety Meeting minutes dated 7/18/24, failed to identify the medical director was in attendance or had been provided the information for review and provide opportunity for feedback. The Quality and Safety Meeting dated 10/16/24, identified the director or nursing, consultant pharmacist and medical director were not in attendance or had been provided the information for review provide opportunity for feedback. During an interview on 1/30/25 at 2:13 p.m., with the director of nursing (DON) and registered nurse (RN)-D, RN-D stated the administrator was unavailable for interview. RN-D stated the information in the meeting minutes identified the required members did not attend; however, believed they were available by phone at any time needed. The facility policy Quality Assurance and Performance Improvement (QAPI) Program dated 6/2018, identified the objective of this requirement is the completion and implementation of the QAPI plan to identify the high risk, problem prone and high-volume areas to evaluate for improvement and identify, collect and use data relevant to the unique characteristic and needs of the residents. 1. The facility will develop, implement and maintain a QAPI program that is effective, data driven, comprehensive and will focus on indicators of the outcomes of care and quality of life. 2. The plan describes the process for identifying and correcting quality deficiencies and contains the necessary components such as: 3. Tracking and measure performance. 4. Establishing goals and thresholds for performance measurement. 5. Identifying and prioritizing quality deficiencies. 6. Systematically analyzing underlying causes of systemic quality deficiencies. 7. Developing and implementing corrective action or performance improvement activities; and 8. Monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed. 9. The facility maintains documentation and can demonstrate evidence that the program meets CMS requirements 10 . The facility presents evidence in the form of documentation to substantiate the ongoing implementation and QAPI program compliance with regulations to the State Survey Agency, Federal Surveyor or CMS if requested. 11. The Quality Assessment and Assurance Committee consists at a minimum of: a. The Director of Nursing. b. The Medical Director or his/her designee.

Based on observation, interview and document review, the facility failed to ensure enhanced barrier precautions (EBP) were followed for 2 of 2 residents (R14, R15) with wound care and failed to ensure personal protective equipment was used during the sorting of soiled laundry. Findings include: EBP: R14 R14's quarterly Minimum Data Set (MDS) dated [DATE], identified R14 had a severe cognitive impairment and diagnoses included dementia, anorexia, and chronic kidney disease. R14 was at risk for pressure ulcers but had no current pressure ulcers. R14's care plan revised 1/13/25, failed to identify R14's right great toe wound and/or the need for enhanced barrier precautions (EBP) to prevent infection. During an observation on 1/29/25 at 1:57 p.m., NA-A assisted with personal hygiene and pivot transfer from R14's bed to wheelchair. NA-A did wear gloves but failed to wear a gown during high contact activities. There was no signage, personal protective equipment (PPE) and/or cart in R14's room. During an observation on 1/29/25 at 3:16 p.m., nursing assistant (NA)-B assisted R14 to pivot transfer from R14's wheelchair to bed. NA-B did not don a gown or gloves. There was no signage, personal protective equipment (PPE) and/or cart in R14's room. During an observation on 1/29/25 at 4:22 p.m., registered nurse (RN)-B changed R14's dressing. There was no signage, personal protective equipment (PPE) and/or cart in R14's room. RN-B wore gloves but did not put on a gown. R14 had two open areas at the base of her right great toenail. The measurements for the first area were 0.5 cm x 0.4 cm and the second measured 0.3 cm x 0.1 cm. The areas were dry and scabbed. During an interview on 1/29/25 at 4:40 p.m., RN-B stated R14 should have been placed in enhanced barrier precautions (EBP) on 1/7/25 due to a chronic wound and was not. R15 R15's significant change Minimum Data Set (MDS) dated [DATE], identified R15 had a moderate cognitive impairment and diagnoses that included weakness, type 2 diabetes, and chronic kidney disease. R15 was at risk for pressure ulcers and R15 had a burn. R15's care plan revised 12/3/24, identified enhanced barrier precautions for R15 due to R15 was at risk for infection due to right hip wound. Staff were directed to use hand hygiene, gown and glove during care with expected exposure to blood, bodily fluids, skin breakdown, or mucus membranes. During an observation on 1/28/25 at 9:24 a.m., trained medication aide (TMA)-A assisted R15 to transfer from R15's wheelchair to R15's recliner using a full standing lift. TMA-A did not apply gown or gloves during the transfer. An EBP sign was hanging on the outside of the bathroom door with a plastic 3 tier bin inside R15's bathroom containing disposable gowns and gloves. During an interview on 1/29/25 at 9:13 a.m., TMA-A stated she did not wear a gown or gloves during R15's transfer because that was only if staff were doing cares, like toileting, or dressing changes. During an interview on 1/30/25 at 10:43 a.m., the director of nursing (DON) stated staff were expected to follow the facility's EBP policy to prevent infection. The facility policy Infection Prevention and Control Program revised 1/20/25, identified standard and transmission-based precautions were to be followed to prevent the spread of infections. However, the policy failed to identify EBP and/or when EBP would be used. Laundry During a tour of the laundry department on 1/29/25 at 8:28 a.m., a black fabric apron hung from a hook on the wall in the soiled laundry room. A 6-drawer plastic bin was on the floor underneath the hook, but no other aprons and/or disposable gowns were available. Laundry aide (LA)-A stated the staff wore the same black fabric apron throughout the day to sort soiled laundry because they only had the one because the ties broke on the other one. Each time soiled items needed to be sorted, the laundry staff would put the apron on and hang it back up on the hook when the sorting was done. The apron would be washed at the end of the day. LA-A stated there used to be a box of disposable gowns, however, those disappeared. LA-A stated it was yucky to put the apron on because you could see skin cells and stuff on the apron as the day went on and LA-A could see why the facility wanted laundry staff to wear an apron to protect their clothing. During an interview on 1/29/25 at 11:13 a.m., RN-D stated laundry staff were expected to wear a long sleeve, impermeable gown while sorting soiled laundry to prevent the contamination of their uniforms as well as preventing the contamination of clean laundry during folding. Staff should always wear a gown and gloves and, if a chance of splashing, a face mask/shield and eye protection. A facility policy regarding infection prevention and control during soiled laundry sorting was requested but not received.

Based on interview, and document review, the facility failed to develop, monitor, and evaluate their identified performance measures. This had the potential to affect all 46 residents residing in the facility. Findings include: The Facility assessment dated ,d+[DATE], identified the facility was a Medicare and Medicaid certified skilled nursing facility. The facility was licensed for 35 beds with an average daily census in the past year of around 34. The facility provided skilled nursing, unskilled nursing, short- and long-term care. Additional services offered are care for those with dementia or other cognitive deficits, end-of-life care, behavioral health, spiritual care, nutritional services, housekeeping, laundry, wound care, ostomy care, dialysis coordination, care of chronic and acute illnesses, oxygen therapy, physical/occupational/speech therapies, restorative and functional maintenance programs, care coordination with physicians, clinics and specialists. Facility Assessment and QAPI Information from the Facility Assessment was used to inform the Quality Assurance Performance Improvement (QAPI) process as indicated in the QAPI Plan. Improvement projects would focus on high-risk or problem-prone areas that the facility had identified through data collection of various sources as indicated in the facility policy and procedure for Quality Assurance and Performance Improvement. The description of care, services, and resources available at the facility provided both areas for monitoring processes and outcomes as well as information for investigation of root causes of adverse events and gaps in performance. The facility held QAPI meetings on a scheduled quarterly basis and more often, if indicated. The QAPI team consisted of representatives from each department along with open invitations to residents and direct care staff. The QAPI process was conducted according to industry standards. The Plan, Do, Study, Act process was used to review and implement and review effectiveness of improvement projects. The Quality and Safety Meeting dated 4/17/24, identified the following: Performance Improvement Projects: Fall Reduction: Have seen on-going root cause analysis, intervention review and education. - Walk to dine program - have increased walking for those who tolerate. Currently have ten, last quarter were eight participating. Four walking to all three meals, four walking to at least two meals, and two walking once daily - Restorative program - continuing to work towards getting up and going. Infection Control: focus on infection control rates, enhanced barrier precautions and audits. - Audits and training for EBP - Ensuring EBP rooms are fully stocked and staff knowledge - Training in new IP nurse The data failed to identify the facility developed and implemented action plans with measurable goals and/or identify actions taken. The Quality and Safety Meeting dated 7/18/24, identified the following: Performance Improvement Projects: Fall Reduction: Have seen on-going root cause analysis, intervention review and education. - Walk to dine program have increased walking for those who tolerate. Currently we have 8, last quarter was 1 participating. 4 walking to all three meals, 2 walking to at least two meals, and 2 walking once daily. - Restorative program - continuing to work towards getting up and going. A full-time therapy aide hired, starting July 22nd, will support restorative programs. Infection Control: focus on infection control rates, enhanced barrier precautions and audits. - Audits and training for EBP have been completed. - Continuing to ensure EBP rooms are fully stocked and staff knowledge. - Ongoing training in new IP nurse. The data failed to identify the facility developed and implemented action plans with measurable goals and/or identify actions taken. The Quality and Safety Meeting dated 10/16/24, identified the following: Performance Improvement Projects Fall Reduction: Have seen on-going root cause analysis, intervention review and education. - Walk to dine program -have increased walking for those who tolerate. Currently we have 8 participating. 4 walking to all three meals, 2 walking to at least two meals, and 2 walking once daily. - Restorative program -continuing to work towards getting up and going. Infection Control: Focus on infection control rates, enhanced barrier precautions and audits. - Audits and training for EBP have been completed. - Continuing to ensure EBP rooms are fully stocked and staff knowledge. - Ongoing training in new IP nurse. The data failed to identify the facility developed and implemented action plans with measurable goals and/or identify actions taken. The facility QAPI Meeting Minutes dated 1/15/25, identified the following: Performance Improvement Projects - Fall Reduction: Root cause analysis, interventions, and education ongoing. - Walk to dine program expanded. - Restoration program implemented. - Infection Control: Focus on rates, precautions, and audits. - QIPP Project - Nutrition: Snack survey completed, monthly dietician meetings. - Dining room: Audits conducted; access improved. - Weight loss/nutrition: Reports reviewed; bi-monthly weights implemented. The data failed to identify the facility developed and implemented action plans with measurable goals and/or identify actions taken. During an interview on 1/30/25 at 2:13 p.m., with the director of nursing (DON) and registered nurse (RN)-D, RN-D stated the administrator was unavailable for interview. RN-D stated the minutes did identify actions aimed at performance improvement, however, did not identify a measurement of success, and track performance to ensure that improvements were realized and sustained. The facility policy Quality Assurance and Performance Improvement (QAPI) Program dated 6/2018, identified the objective of this requirement is the completion and implementation of the QAPI plan to identify the high risk, problem prone and high volume areas to evaluate for improvement and identify, collect and use data relevant to the unique characteristic and needs of the residents. 1. The facility will develop, implement and maintain a QAPI program that is effective, data driven, comprehensive and will focus on indicators of the outcomes of care and quality of life. 2. The plan describes the process for identifying and correcting quality deficiencies and contains the necessary components such as: 3. Tracking and measure performance; 4. Establishing goals and thresholds for performance measurement; 5. Identifying and prioritizing quality deficiencies; 6. Systematically analyzing underlying causes of systemic quality deficiencies; 7. Developing and implementing corrective action or performance improvement activities; and 8. Monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed. 9. The facility maintains documentation and can demonstrate evidence that the program meets CMS requirements 10. The facility presents evidence in the form of documentation to substantiate the ongoing implementation and QAPI program compliance with regulations to the State Survey Agency, Federal Surveyor or CMS if requested. 11. The Quality Assessment and Assurance Committee consists at a minimum of: a. The Director of Nursing; b. The Medical Director or his/her designee; c At least three other members of the facility's staff, at least one of who must be the Administrator, owner, a board member or other individual in a leadership role; and d. The infection Preventionist - effective November 28, 2019. 6. The QAPI plan describes the methods to validate and update staff competencies at the time of hire and periodically. 7. The QAPI plan ensures that residents provide input to prioritize the areas to monitor and measure that reflect the resident's preferences, ethnic, cultural, and religious considerations. 8. Contract staff will contribute data and information and collaborate within the QAPI program. 9. QAA meetings will be held at least quarterly and with enough frequency to conduct required QAPI/QAA activities. 10. All facility staff, contracted staff, and volunteers will be educated about the QAPI plan and their role in development and implementation of interventions. 11. A plan will be in place to ensure that agency staff are educated on the facility QAPI plan. 12. The QAPI plan will be reviewed annually and with any significant change at the facility.

Based on interview and document review the facility failed to investigate a burn that resulted from the inappropriate use of a hot pack for 1 of 1 resident (R15) who was reviewed for wound care. Findings include: Rester's Choice Gel Pack manufacturer's instructions directed the following: Clean microwave before use. Gel pack must be at room temperature before microwave use. Distribute gel evenly in pack and place in microwave. Before removing gel pack from microwave, check for leakage. If leakage occurred, wait for the gel pack to cool down and discard. Check for desired temperature (temperature will continue to rise slightly). If pack is too hot, let it cool until temperature is acceptable. If additional heat is desired, return to microwave and heat in 5 second increments. DO NOT overheat. Excessive heating might cause pack to rupture and leak. Place it in the provided pouch. Apply to affected area and use the strap as necessary to hold in place. Store at room temperature for future hot therapy use. Do not apply cold/hot therapy for more than 20 minutes. Microwave Heating Time: Since the power of microwave ovens may differ from one microwave to another, the best heating time should be tested when first used at each microwave: a.) Heat the gel pack for 30 seconds b.) Check temperature every 5 seconds When the desired temperature is reached and evenly distributed, that's the heating time that should be used at the current microwave oven. - Caution/Warnings: Individuals with circulatory or diabetes issues should consult a physician before use. Do NOT lean or sit on pack. Unattended use of gel pack by elderly or incapacitated individuals is dangerous; monitor for insensitivities to product temperature. R15's quarterly Minimum Data Set (MDS) dated [DATE], identified R15 had a moderate cognitive impairment and diagnoses that included weakness, type 2 diabetes, and chronic kidney disease. R15 required partial to moderate assistance to roll her body left and right and was at risk for pressure ulcers. R15's nursing progress note dated 10/19/24 at 12:05 p.m., identified a nursing assistant identified a blister measuring 4 centimeters (cm) by 1.5 cm on R15's right hip related to heat pack being applied. Heat pack was not overly warm, but R15 did fragile skin and did lay on the heat pack which may have contributed to blister occurring. R15 denied pain in hip or blister. The blister was left open to air. Family member (FM)-A was informed and stated R15's skin was very thin and likely blistered easily. R15's physician progress note dated 11/8/24, identified R15's wound on R15's right hip was a chronic Full Thickness Burn (also called a third-degree burn. This type of burn involved all of the layers of skin and sometimes the fat and muscle tissue under the skin. Burned areas may be black, brown or white. The skin may look leathery. Third-degree burns can destroy nerves, so there may be little or no pain) that was acquired on 10/08/24 and had not healed. Initial wound encounter measurements are 4.18 cm length by 3.68cm width by 0.01 cm depth. Necrotic adipose (Fat necrosis is a condition that occurs when fatty tissue is damaged, leading to the death of fat cells (also known as adipose cells)) was exposed. No tunneling was noted. The patient reports a wound pain of level 4/10. The wound margin was attached, and the wound bed had no granulation (new connective tissue), slough (yellowish or tan colored material) or epithelization (wound closure) but did exhibit eschar (a hardened, dry, black or brown dead tissue, forms a scab-like covering over deep wounds, such as severe burns or ulcers). During a telephone interview on 1/28/25 at 1:30 p.m., registered nurse (RN)-A stated she put the hot pack on R15. On 10/19/24, R15 fell during shift change. R15 was assisted back to bed but complained of right hip pain. RN-A had not been educated on the gel pack heating instructions nor had RN-A read the manufacturer's instructions on the back on the gel pack. RN-A heated a gel pack in the microwave for maybe 30 seconds, wrapped the gel pack in a hand towel, placed the gel pack on R15's right hip and positioned R15 on her right side so that R15 was lying on the gel pack. Later that morning, (approximately 30 minutes) R15 had a shower and RN-A performed a routine weekly skin assessment on R15 when RN-A discovered the reddened area that resulted in a burn on R15's right hip. RN-A disposed of the gel packs because she believed R15's was caused by a defective gel pack; however, RN-A did not review the manufacturer's instructions to verify the gel pack had been used correctly. RN-A provided verbal direction to the other nursing staff; however, no documentation of that direction was done. Additionally, RN-A did not report the incident to RN-B (who was acting director of nursing at the time) until 10/21/24. During an interview on 1/28/25 at 2:46 p.m., RN-B stated she was the acting director of nursing on 10/19/24 when R15 received a burn to R15's right hip. RN-B stated R15 had fallen and staff had applied a hot pack to R15's right hip for comfort. R15 was laying directly on the hot pack and R15's skin was burned. RN-B stated she wasn't notified of the burn until 10/21/24. The burn was discussed in the morning interdisciplinary meeting (IDT) and it was decided the facility would obtain new gel packs because RN-A had thrown the gel packs away because RN-A believed the gel packs to be defective. RN-B stated no investigation to determine if the gel pack was used appropriately, if the gel pack should have been used for R15 who was a diabetic, if the nursing staff were aware of the gel pack heating instructions, and/or any other resident who had received a burn from the gel packs. RN-B stated a thorough investigation should have been conducted to prevent further harm to R15 or harm to any other resident. The facility's IDT (interdisciplinary team) minutes dated 10/22/24, identified Order new ice/hot pack but failed to identify and investigation into the causeative factors of R15's burn. The facility's IDT minutes dated 10/23/24, identified new hot packs/cold packs purchased but failed to identify R15's burn. The facility's purchasing order dated 10/22/24, identified microwavable heating pads were orders The facility's purchasing order dated 12/19/24, identified the purchase of 2 boxes of [NAME] Hot Compress. During an interview on 1/28/25 at 4:20 p.m., with the director of nursing (DON) and RN-D, the DON stated she started her role on 11/25/24 and was unaware of the circumstances of R15's right hip burn. A thorough investigation should have been conducted to ensure the safety of the residents. RN-D stated she was also unaware of the circumstances but R15's burn was a serious concern that showed lack of assessment and follow through to prevent a burn from happening again. The facility policy Abuse Prevention and Reporting revised 1/2025, identified at the administrator or his/her designee will then begin the investigation. As part of the investigation, the affected resident(s) will be interviewed, staff and other witnesses will be interviewed, circumstances leading up to the incident will be evaluated, employees/persons accused of abuse will be investigated, and policies and procedures will be reviewed.

Based on interview and document review, the facility failed to inform the physician of a burn for 1 of 1 resident (R15) reviewed for burns; and failed to inform the physician of a resident fall with significant bruising 1 of 1 resident (R29) reviewed for falls. Findings include: R15: R15's quarterly Minimum Data Set (MDS) dated [DATE], identified R15 had a moderate cognitive impairment and diagnoses that included weakness, type 2 diabetes, and chronic kidney disease. R15 required partial to moderate asssistance to roll her body left and right and was at risk for pressure ulcers. R15's care plan dated 10/16/24, identified R15 was at risk for pain related to spinal stenosis, osteoporosis, weakness, impaired mobility, shoulder pain, spondylolisthesis osteoarthritis, chronic gout, low back pain, and amputation of the second toe of the right foot. Non-pharmacological pain interventions may include: rest, reposition, distraction, elevation and ice/warm pack. The care plan directed to update R15's physician with changes. R15's nursing progress notes identified the following: - 10/19/24 at 8:49 a.m., a voicemail was left for family member (FM)-A. R15 was complaining of right hip pain, would note rate pain. As needed (PRN) Tylenol and heat pack applied. - 10/19/24 at 12:05 p.m., a (nursing assistant) NA noted a blister measuring 4 centimeter (cm) x 1.5 cm on R15's right hip related to heat pack being applied. Heat pack was not overly warm, but R15 did have fragile skin and did lay on the heat pack which may have contributed to blister occurring. R15 denied pain in hip or blister. Blister left open to air. FM-A informed and stated R15's skin was very thin and likely why it blistered easily. The note failed to identify if R15's physician had been notified. - 10/20/24 at 11:31 a.m., R15's blistered area was leaking clear fluid. The area was cleansed, and an ABD pad placed. The note failed to provide a description including measurements or if R15's physician had been notified. -10/23/24 at 11:42 a.m., R15's routine skin check performed this shift. No new skin concerns noted. Dressing to right hip/thigh changed. Scant amount of serous fluid noted on old dressing. Cleansed and new dressing applied. Tolerated well. Area has no odor or signs/symptoms of infection. The note failed to identify if R15's physician was notified. - 10/23/24 at 9:51 p.m., R15's dressing to right thigh changed due to previous dressing being soiled. Moderate amount of serous fluid noted on old dressing. No odor noted. Area cleansed with normal saline, and dressing changed per treatment record order. Tolerated well. The note failed to identify if R15's physician was notified. - 10/26/24 at 3:00 p.m., R15 had a bath. Telfa (a non-absorbent and non-adhering dressing) and an ABD applied to right outer hip blister/wound. The outer edges of area were red in color and measure 7.5 cm x 4.5 cm, this was area on entire wound. Blister was intact and fluid filled. Resident had no complaints of pain within that area and tolerated dressing change well. However, the note failed to identify if R15's physician was notified. - 11/4/24 at 3:27 p.m., R15's skin assessment was completed: 8 cm x 5.5 cm area to right hip that was previously a fluid filled blister in evolution. Skin remained intact. Peri wound was reddened. No warmth noted. Wound edges are smooth. Area was dry and flaky skin noted. Darken discoloration noted to right posterior and left anterior edges. Center of wound had pale color. No drainage to area. Area covered with xeroform and ABD, secured with tape. R15 had no complaints of pain to area. Will change dressing to area daily. - 11/5/24 at 11:22 a.m., a new dressing was applied to right thigh due to old dressing falling off. No drainage noted coming from area, no odor noted. Peri wound reddened; no warmth noted. Area where blister was dark in color. Dressing changed per orders. Resident tolerated well. However, the note failed to identify if R15's physician was notified. - 11/7/24 at 7:56 a.m., a 7 cm x 5 cm area to right hip that was previously a fluid filled blister in evolution. Skin remains intact. Peri wound was reddened. No warmth noted. Wound edges were smooth. Area was dry and flaky skin noted. Darken discoloration noted to right posterior and left anterior edges. Center of wound had pale color. Slight brown drainage on previous dressing. Area covered with xeroform and ABD, secured with tape. Resident had slight pain to area while cleansing and changing dressing. R15's physician updated. - 11/7/24 at 9:35 a.m., R15's physician ordered R15 to be evaluated in urgent care for R15's right hip wound. FM-A updated and in agreement. R15's MD/Nursing communication dated 11/7/24, identified a nursing concern related to a wound right hip 10/19/24. Hot pack. An order was received for Medi pore tape (hypoallergenic tape that is soft and breathable to reduce the risk for skin sensitivity), xeroform non-occlusive (a sterile, non-adhering permeable dressing consisting of absorbent, fine-mesh gauze impregnated with a water-in-oil emulsion blend), ABD pad (a large wound dressing). R15's nursing progress note dated 11/7/24 at 11:46 a.m., identified R15 seen in urgent care due to wound to right hip. Orders as follows: Medi pore tape, xeroform nonocclusive, ABD pad; if dressing starts to become saturated then increase dressing change to twice a day. Orders updated in Treatment Administration Record (TAR). Resident referred to wound clinic for further care of wound. R15's physician progress note dated 11/8/24, identified R15's Wound #1 Right Hip was a chronic Full Thickness Burn, thermal (3rd degree) acquired on 10/19/2024 and had received a status of Not Healed. Initial wound encounter measurements are 4.18 cm length x 3.68cm width x 0.01 cm depth. Necrotic adipose (a condition that occurs when fatty tissue is damaged, leading to the death of the fat cells) was exposed. No tunneling has been noted. No sinus tract was noted. No undermining was noted. There was a moderate amount of serosanguineous drainage noted which had a Strong odor. R15 reported a wound pain of level 4/10. The wound margin was attached Wound bed has no granulation (a sign of wound healing) (new connective tissue), no slough (dead tissue within the wound that can impede healing), no epithelialization (new cells) but had eschar (dead tissue that sheds or falls off from the skin). During a telephone interview on 1/28/25 at 1:30 p.m., registered nurse (RN)-A stated she notified R15's physician by making a note in the rounding book. However, RN-A stated she was unaware of when R15's physician would have been rounding at the facility. During an interview on 1/28/25 at 2:46 p.m., RN-B stated she was the acting director of nursing (DON) on 10/19/24 when R15 received a burn to R15's right hip. RN-B was notified of the burn on 10/21/24, but she did not notify R15's physician until 11/7/24 when there was concern about a potential infection. A joint interview was conducted with the DON and RN-D on 1/28/25 at 4:20 p.m. The DON and RN-D stated R15's physician should have been notified immediately to ensure appropriate care and treatment of the burn to prevent worsening and to promote healing. During a telephone interview on 1/29/25 at 3:06 p.m., physician (DR)-A stated, typically for injuries, DR-A would expect to be notified in a day or two. For a burn, DR-A would more than likely have ordered a Silvadene (Silver sulfadiazine is an antibiotic. It fights bacteria and yeast on the skin. Silvadene (for the skin) is used to treat or prevent serious infection on areas of skin with second- or third-degree burns.) dressing and instruct to continue to monitor the wound. R15's delay of evaluation and treatment did not ease the healing process; however, DR-A would not say if it worsened the wound because DR-A did not evaluate the wound prior to 11/7/24. 41575 R29: R29's quarterly MDS dated [DATE], identified R29 had intact cognition. R29 required moderate assistance to dress lower body and with grooming. R29 was independent with transfer and ambulation. R29 had experienced one fall with injury since her last assessement period. Diagnoses included fibromyalgia, chronic pain syndrome, age related osteoporosis, moderate stage rheumatoid arthritis of multiple sites, and intervertebral disc degeneration, lumbar region with back pain. R29's care plan with revision date 11/6/24, identified R29 was at risk for falls related to weakness, and impaired mobility. R29 was independent with ambulation with a walker. R29 receivied anticoagualant therapy with a goal to be free from discomfort or adverse reactions related to anticoagulant use. R29's progress notes were reviewed and identified the following: - 11/29/24, R29 fell when trying to hang up a shirt in her closet. Her walker started to roll away and she became weak and fell , hitting her right side of her body on the floor. A physical assessment was completed, and family was notified. However, failed to identify if the physician was notified. -11/30/24, a large, swollen area and bruise 25 cm by 28 cm was noted on R29's right hip as a result of her fall the previous day. Ice packs were applied. - 12/2/24, R29 complained of not feeling well and questioned if she had a sinus infection. R29 agreed to be seen in urgent care the following day. R29 also complained of pain in right hip and was given an ice pack -12/3/24, R29 returned from urgent care. R29 had been assessed for complaints of respiratory illness. A hip X-ray had also been completed which was negative. A Office Visit report dated 12/3/24, identified R29 was seen in clinic for symptoms of cough, nasal congestions and sinus pressure. R29 reported a fall 11/29/24, in which she landed on her right side. R29 complained of pain and reported a large lump on her right hip. On assessment the right hip had large swelling and a large hematoma with pain over the lateral hip. R29 was able to bear weight. A hip Xray was completed with negative findings. R29 was to use heat or ice in 20-minute intervals and return if symptoms worsened. When interviewed on 1/29/25, at 10:44 a.m. R29 stated she had fallen on around the beginning of December in front of her closet. R29 was reaching up for something in the closet and fell . R29 had a bruise that went from her hip to her bruise and still had the lump over the right hip. Pointed to a small, elevated area over her right hip, visible through her pants and stated it still hurt in her groin area. She went to the clinic because she had not been feeling well and they had noticed the bruise and took and Xray which turned out to be ok. When interviewed on 1/30/25, at 3:16 p.m. DON stated she was unable to find an investigation related to the fall with injury. R29's bruise and injury had been monitored on the treatment administration record and/or on her care plan, however, R29's physician had not been notified of the incident, nor was R29 evaluated by the provider. The DON stated it was the facility's general practice to notify the provider of all resident falls. The DON was unable to find documentation R29's primary provider had been notified of her fall with injury on 11/29/24. The facility policy Incidents and Accidents dated 1/2025, identified it was the facility's policy to utilize point click care to report, investigate and review any accidents or incidents that occurred. The nurse would contact the resident's provider to inform them of the incident/accident and report any injuries or other findings, and obtain orders, if indicated.

Based on interview and document review the facility failed to report a burn that resulted from the inappropriate use of a hot pack to the state agency (SA) for 1 of 1 resident (R15) reviewed for wound care. Findings include: The Rester's Choice Gel Pack undated manufacturer's instructions directed the following: Clean microwave before use. Gel pack must be at room temperature before microwave use. Distribute gel evenly in pack and place in microwave. Before removing gel pack from microwave, check for leakage. If leakage occurred, wait for the gel pack to cool down and discard. Check for desired temperature (temperature will continue to rise slightly). If pack is too hot, let it cool until temperature is acceptable. If additional heat is desired, return to microwave and heat in 5 second increments. DO NOT overheat. Excessive heating might cause pack to rupture and leak. Place it in the provided pouch. Apply to affected area and use the strap as necessary to hold in place. Store at room temperature for future hot therapy use. Do not apply cold/hot therapy for more than 20 minutes. Microwave Heating Time: Since the power of microwave ovens may differ from one microwave to another, the best heating time should be tested when first used at each microwave: a.) Heat the gel pack for 30 seconds b.) Check temperature every 5 seconds When the desired temperature is reached and evenly distributed, that's the heating time that should be used at the current microwave oven. - Caution/Warnings: Individuals with circulatory or diabetes issues should consult a physician before use. Do NOT lean or sit on pack. Unattended use of gel pack by elderly or incapacitated individuals is dangerous; monitor for insensitivities to product temperature. R15's quarterly Minimum Data Set (MDS) dated [DATE], identified R15 had a moderate cognitive impairment and diagnoses that included weakness, type 2 diabetes, and chronic kidney disease. R15 required partial to moderate assistance to roll her body left and right and was at risk for pressure ulcers. R15's nursing progress note dated 10/19/24 at 12:05 p.m., identified a nursing assistant (NA) noted a blister measuring 4 centimeters (cm) by 1.5 cm on R15's right hip related to heat pack being applied. Heat pack was not overly warm, but R15 did fragile skin and did lay on the heat pack which may have contributed to blister occurring. R15 denied pain in hip or blister. The blister was left open to air. Family member (FM)-A was informed and stated R15's skin was very thin and likely blistered easily. R15's physician progress note dated 11/8/24, identified R15's wound on R15's right hip was a chronic Full Thickness Burn (also called a third-degree burn. This type of burn involved all of the layers of skin and sometimes the fat and muscle tissue under the skin. Burned areas may be black, brown or white. The skin may look leathery. Third-degree burns can destroy nerves, so there may be little or no pain) that was acquired on 10/19/24 and had not healed. Initial wound encounter measurements are 4.18 cm length by 3.68cm width by 0.01 cm depth. Necrotic adipose (Fat necrosis is a condition that occurs when fatty tissue is damaged, leading to the death of fat cells (also known as adipose cells)) was exposed. No tunneling was noted. The patient reports a wound pain of level 4/10. The wound margin was attached, and the wound bed had no granulation (new connective tissue), slough (yellowish or tan colored material) or epithelization (wound closure) but did exhibit eschar (a hardened, dry, black or brown dead tissue, forms a scab-like covering over deep wounds, such as severe burns or ulcers). An investigation into causative factors and analysis of R15's burn was requested and was not received. During a telephone interview on 1/28/25 at 1:30 p.m., registered nurse (RN)-A stated she put the hot pack on R15. On 10/19/24, R15 fell during shift change. R15 was assisted back to bed but complained of right hip pain. RN-A had not been educated on the gel pack heating instructions nor had RN-A read the manufacturer's instructions on the back on the gel pack. RN-A heated a gel pack in the microwave for maybe 30 seconds, wrapped the gel pack in a hand towel, placed the gel pack on R15's right hip and positioned R15 on her right side so that R15 was lying on the gel pack. Later that morning, (approximately 30 minutes) R15 had a shower and RN-A performed a routine weekly skin assessment on R15 when RN-A discovered the reddened area that resulted in a burn on R15's right hip. However, RN-A stated she did not report the burn to the state agency (SA) because she wasn't sure if the reddened area wouldn't go away. During an interview on 1/28/25 at 2:46 p.m., RN-B stated she was informed of R15's burn on 10/21/24, however, a report to the SA was not discussed nor completed. I just didn't think of it. During an interview on 1/28/25 at 4:20 p.m., with the director of nursing (DON) and the RN-D, the DON stated she started her role on 11/25/24 and was unaware of the circumstances of R15's right hip burn. The report to the SA should have been filed. RN-D stated she was also unaware of the circumstances of R15's burn was a serious concern that showed lack of assessment and follow through to prevent a burn from happening again. The facility policy Abuse Prevention and Reporting revised 1/2025, identified all cases of suspected abuse/neglect/exploitation must be reported to authorities immediately, after forming a suspicion if cause of suspicion did not result in serious bodily injury, to the Administrator, Department Manager, or the Administrator's designee. The definition of immediately, means as soon as possible, but no later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or results in serious bodily injury, or not later than 24 hours. A person (including an employee, volunteer or other person) associated with the facility, who reasonably believes or who knows of information that would cause a person to believe that the health or welfare of a resident of the facility has been, is or will be adversely affected by abuse or neglect by any person shall, as soon as possible, report the information supporting the belief to the Minnesota Department of Health, or the appropriate healthcare regulatory agency, by telephone, in writing, or by personal visit. Reports of abuse, neglect, misappropriation of property, and exploitation should be made immediately to the Administrator or his/her designee. During normal business hours, notify the Administrator or Director of Nursing. During non-normal business hours, notify the on-call RN (responsible to submit reports to MDH during non-normal business hours) and notify the administrator and director of nursing (this may be done by phone, answering machine, voicemail, or text message).

Based on observation, interview and document review, the facility failed to ensure the medications section of the Minimum Data Set (MDS) was accurately coded for 1 of 1 resident (R15) reviewed for MDS accuracy. Findings include: R15's significant change Minimum Data Set (MDS) dated [DATE], identified R15 had a moderate cognitive impairment and diagnoses that included Type 2 Diabetes. R15 received an insulin injection weekly. R15's Order Summary Report dated 6/20/23, identified R15 received Trulicity (an antihyperglycemic - glucagon-like peptide-1 (GLP-1) receptor agonists) (used with a proper diet and exercise program to control high blood sugar in people with type 2 diabetes) subcutaneous solution pen-injector 3 milligram (mg)/0.5 milliliter (ml). Inject 3 mg subcutaneously in the morning every Thursday related to type 2 diabetes. During an interview with the registered nurse (RN)-D on 1/29/25 at 11:32 a.m., RN-D stated she was assisting with completing resident MDS while the facility's MDS nurse was out of the facility on medical leave. RN-D stated Trulicity was not an insulin but a GLP-1 medication to assist in the treatment of type 2 diabetes and, because of that, should be identified as an insulin on the MDS. RN-D stated the MDS was a tool to assist in the resident's individualized plan of care and R15 received an injectable mediation to treat type 2 diabetes once a week. Because of this, RN-D stated R15's MDS was coded correctly. The facility policy Resident Assessment (Minimum Data Set (MDS)) revised 1/2025, identified it was the policy of the facility to conduct initial and periodic standardized assessments of each resident's functional capacity. This will include assessment and evaluation of a resident's needs, strengths, goals, life history, and preferences using the resident assessment instrument (RAI) as specified by CMS. Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated 10/2024, identified the steps for assessment included: 1. Review the resident's medication administration records for the 7-day look-back period (or since admission/entry or reentry if less than 7 days). 2. Determine if the resident received insulin injections during the look-back period. 3. Determine if the physician (or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) changed the resident's insulin orders during the look-back period. 4. Count the number of days insulin injections were received and/or insulin orders changed.

Based on observation, interview, and document review, the facility failed to provide ambulation services to prevent a decline in function for 1 of 1 resident (R40) in the sample who had a decline in ambulation. This practice caused actual harm for R40 related to the loss of the ability to ambulate. Findings include: R40 was admitted [DATE], with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE], identified R40's severe cognitive and memory problems. The MDS indicated R40 did not ambulate, and required staff assistance for bed mobility, transfers, and used a wheelchair (w/c). The Falls Care Area Assessment (CAA) dated 8/16/11, identified R40 required extensive assistance with mobility and activities of daily living, and used a w/c for mobility. Occupational therapy (OT) and physical therapy (PT) documentation indicated R40 received both OT/PT skilled services upon admit, and restorative nursing programs were initiated 8/18/11. The rehab program developed by PT indicated R40 would be ambulated with a walker and assist of 1 staff three times a week, distances as able, to promote mobility. The physical therapist's discharge summary on the Inpatient Plan of Treatment form dated 8/19/11, directed a re-evaluation by PT if a change in status occurred. The current care plan dated 2/1/12, directed that R40 receive "rehab program as ordered by OT/PT. See rehab section of the chart for program details." The date the entry had been initiated was 8/17/11. On 4/11/12, at 9:10 a.m. nursing assistant (NA)-B and the director of nursing (DON) assisted R40 with toileting. R40 required a mechanical stand-up lift to transfer from the w/c to the toilet. At 9:23 a.m. R40 was observed while NA-B and NA-C assisted the resident from the w/c onto the bed. R40 required verbal prompts with positioning hands on the lift handles and physical assistance with foot placement on the lift during both transfers. R40's knees bent appropriately and R40 was able to straighten them to stand upright throughout the transfers. At approximately 9:30 a.m. NA-B and NA-C stated R40 does not walk. NA-C stated R40 had never walked with the floor staff, but used to walk with the rehab aide. On 4/12/12, at 11:50 a.m. rehab aide (RA)-A stated R40 did start out walking, but not consistently. RA-A explained R40 walked "only on good days" and explained some days the resident would walk all the way down the hall, other days R40 could not stand. RA-A stated around Christmas, the DON had observed her struggle when attempting to walk R40. She added the DON directed her to stop ambulating the resident and to start using the mechanical lift at that time. RA-A stated she could not get to all the residents' restorative programs as directed because she had 20 residents to work with and only had 4 hours in the afternoon to do rehab. Rehab Charting Sheets dated October 2011, identified R40 had ambulated up to 200 feet. The sheet from November indicated the last ambulation entry was made on 11/10/11, when R40 ambulated 75 feet. On 11/17/11, a circled "R" (which indicated refusal) was recorded, however, documentation to explain the refusal was lacking. The Rehab Charting Sheets from the remainder of November through April were reviewed and no further ambulation was recorded. Comments on the back of the Rehab Charting Sheets identified on 10/28/11, "Res (resident) had hard time amb. (ambulating) r (right) foot didn't want to move." No additional notes were made until 1/5/12, and 1/30/12, which again identified R40's difficulty taking steps. Further documentation related to R40's decline in ambulation status was lacking in the medical record. A PT evaluation was completed 1/17/12, due to R40's difficulty walking and lack of coordination after the resident experienced a fall. R40 received PT services from 1/17-2/15/12. The physical therapist's discharge summary on the Inpatient Treatment form dated 2/9/12, identified R40 was not able to perform ambulation secondary to a decline in status and indicated R40 should be transferred with a mechanical standing lift for increased patient and staff safety. On 4/12/12, at 2:50 p.m. physical therapist (PT)-A was interviewed by phone. PT-A stated in August R40 was ambulatory, and in February R40 was non-ambulatory due to a decline in function. PT-A stated since August, R40 went from walking to a huge decline in status. PT-A stated therapy should have been informed of the resident's difficulty with ambulation in November in order to get therapy involved then. PT-A questioned, "Did something happen in November?" and added, "That's why we want to get in and do another assessment to determine that." She stated maybe PT needed to pick R40 up three times a week to see if R40's abilities could be improved. PT-A added by the time she had worked with R40, the resident could no longer walk. PT-A stated someone with [MEDICAL CONDITION] needed to keep walking or they would not be able to. PT-A stated, "They need that or they will stiffen up." PT-A also stated the ambulation program should have been done as directed. PT-A stated if R40 was only able to walk 5 feet or something, that would even be different, but if the resident went from walking 75 feet one day, to one refusal, and then nothing else was documented, the physical therapy department should have been notified of the resident's change in status as she directed in her initial discharge summary. On 4/13/12, at 10:10 a.m. the DON reviewed the Rehab Charting Sheets and stated they should have done the physical therapy referral sooner. She added there was no reason why it was not done. She stated the norm is if residents are not walking anymore, they should be re-evaluated by PT. When asked why R40 was not walking anymore, the DON stated she could not tell without guessing. She then verified documentation to address R40's inability to ambulate was lacking. The DON stated she was responsible for monitoring the restorative nursing program and added she was able to check the sheets once a month. She stated she was not aware R40 was not walking until she looked at the Rehab sheets the end of January. She indicated staff were aware they should tell her if there are changes or difficulty in residents' abilities. The DON stated R40 should have been getting the restorative nursing programs when not receiving skilled therapy. The Ambulation Policy and Procedure dated 12/94, indicated residents who will benefit or require ambulation will be provided with ambulation, and the therapeutic benefit will be assessed by physical therapist or DON. The policy identified an initial evaluation and reassessments would be done by the physical therapist or rehab coordinator.

Based on observation, interview, and document review, the facility failed to provide appropriate assessment, monitoring, and implement appropriate interventions to try prevent the development of pressure ulcers for 2 of 3 residents (R28, R48) in the sample who had developed pressure ulcers. The facility's failure to adequately complete ongoing assessment and monitoring of skin impairments and risk factors related to pressure ulcers resulted in actual harm for R28. Findings include: R28 had a history of [REDACTED]. The facility failed to complete a comprehensive skin assessment and ongoing monitoring to prevent to reoccurrence of a PU. R28 was diagnosed with [REDACTED]. The Skin Assessment Report dated 8/5/11, identified multiple skin blisters on the left inner buttocks, thigh, and six other unidentified sites. The undated Checklist of Skin Risk Factors and Interventions indicated risk factors for skin breakdown included R28 requiring assistance with activities of daily living (ADLs) and had signs and symptoms of [MEDICAL CONDITION]. Interventions indicated a Foley catheter to prevent maceration, turn and reposition every 2 hours, encourage mobility and ambulation, elevate heels off the bed, monitor labs, weight, and/or intake, lift do not slide the resident to decrease friction, and moisturize dry skin. R28 did not currently have a Foley catheter. The significant change Minimum Data Set ((MDS) dated [DATE], indicated R28 had no cognitive impairment and required extensive assistance from staff with mobility. The MDS indicated R28 was not at risk for pressure ulcers (PU) determined through clinical and formal assessments and had no current or healed PUs. The Pressure Ulcer Care Area Assessment (CAA) dated 9/12/11, indicated R28 was not at risk for PU development, but did have issues with scratching at his bottom and developing blisters from time to time. R28 was noted to be continent of bowel and bladder, had returned from the hospital with some skin issues, and required extensive assistance with mobility. The CAA lacked review of all risk factors such as friction and sheer, chairfast status, pertinent [DIAGNOSES REDACTED]. Review of the record indicated: On 9/3/11, nursing notes indicated R28 returned from a hospitalization with 2 open areas on buttock and coccyx and 2 fluid filled blisters (location unidentified). On 9/18/11, nursing notes indicated R28's coccyx area had multiple areas of discoloration due to old wounds. The left side of buttock crease had an area of scabby/scaling skin with no open areas. The right crease/buttock are had a reddened circular area with a 0.25 cm dark, intact scab. Areas of excoriation were noted by the rectal area. Staff were directed to continue to provide good pericares, repositioning every 2 hours and apply barrier cream. No further assessment or monitoring was noted for this area. The Admit and Re-Admit Comprehensive Nursing assessment dated [DATE], identified "Darkened areas where old open areas were" on R28's buttocks (coccyx). On 12/1/11, the physician progress notes [REDACTED]. On 12/1/11, the Physician order [REDACTED]. On 12/1/11, the Nurses Notes indicated R28 had a stage 2 PU over his sacrum. More frequent off loading of his backside, a recommended 2 hour turning schedule and/or a specialty mattress was advised. No skin assessment, monitor of the PU, or follow up of the physician orders [REDACTED]. The Nurses' Notes dated 2/7/12, identified a "small open area on his bottom" and the note dated 2/8/12, identified a "small open area on buttocks." The notes dated 2/9/12, 2/10/12, and 2/12/12, identified an open area to R28's left buttock. Staff indicated the open areas were related to "scratching." The Operative Report dated 2/8/12, from DPM (doctor of podiatric medicine)-A identified R28 was treated for [REDACTED]. The area was noted as 2 cm x 1.5 cm x 0.1 cm composed of "necrotic, devitalized, hyperkeratotic, and fibrous debris in the presence of inflammation and serous to serosanguinous drainage." The area was debrided and a dressing was applied. Staff were directed to "continue local wound care and "regularly monitor shoewear or pressure reducing devices, and transfer appliances such as wheel chairs, for signs of wear and increased pressure to bony prominences." In addition the note directed, "The facility could consider accommodative shoewear, or pressure reducing devices..." The nursing notes from 2/8/12, did not identify the right heel ulcer and treatment by the DPM. The record lacked any further documentation of treatment, monitoring and assessment of R28's right heel until a nursing note dated 3/26/12. The Braden Scale (a tool for predicting pressure sore risk) dated 2/12/12, indicated R28 was at mild risk for pressure sores. However, the Braden tool identified potential problems with friction and sheer, very limited mobility, and chairfast activity levels from 10/1/11 through 2/12/12. The Nurses' Note dated 2/12/12, identified R28 had a healing open area on the left buttocks/coccyx. A dressing was applied to be changed every 5-7 days and as needed. R28 was also identified to have a history of open areas related to boils and scratching at buttocks/coccyx area. The quarterly MDS dated [DATE], indicated R28 had no cognitive impairment and required extensive assistance from staff with mobility. The MDS indicated R28 was at risk for PUs by clinical and formal assessments and had no current or healed PUs despite the 2/8/12, treatment of [REDACTED]. The plan of care (POC) dated 2/15/12, indicated R28 was at risk for PU development, with a mild risk for skin breakdown related to slightly limited sensory perception, decreased mobility and activity, potential for friction and shearing. The POC did not identify the right heel ulcer noted on the Operative Report dated 2/8/12. On 3/9/12, the Skin Grid-Pressure/[MEDICAL CONDITION] Ulcer/Other form indicated R28 had a PU to the right buttock measuring 2 cm x 2 cm. The area was described as a darkened area with no drainage. The Nurses' Notes dated 3/26/12, indicated R28 was found with right heel "broken down, it does have a scab on it." The note indicated a moon boot would be applied if R28 would comply. On 3/27/12, the Nursing Notes indicated R28's right heel was noted to have a 4 cm dry/callused are with a 1 cm x 1.4 cm dry, red irregular shapes center with the skin gone. A compression sock was placed and a request for new shoes was placed with social services. It was further noted the resident continued to refuse to wear moon boots and refused to try an "APP Mattress" (for pressure relief). Benefits had been explained to R28 but he continued to refuse. At no other time, was R28's refusal for turning and repositioning or the moon boots documented in the clinical record. On 3/27/12, the Skin Grid-Pressure/[MEDICAL CONDITION] Ulcer/Other form indicated R28 right heel had a 4 cm in diameter calloused area with a peeling center/blood blister 1 cm x 1.4 cm with 0.1 cm in depth. On 3/27/12, the POC was revised to indicate R28 had a right heel calloused area and a darkened area on buttock with no open area. The nutritional area of the POC indicated R28 also had an open area on left buttock. The interventions included [MEDICATION NAME] (a high protein supplement used for wound healing) twice a day, assist with 2 staff and an EZ stand (a lift used to assist a resident to stand), turn and reposition every 2-3 hours and document refusals to turn and reposition. On 3/27/12, the POC was revised to direct staff to offer moon boots and document refusals. On 4/3/12, the Skin Grid-Pressure/[MEDICAL CONDITION] Ulcer/Other form indicated the area to the right buttock was noted to be healed. The stage was not determined on the documentation. On 4/10/12, the Skin Grid-Pressure/[MEDICAL CONDITION] Ulcer/Other form indicated R28 had a stage 2 PU on the right bottom heel with a 1.5 cm x 1.5 cm area with 0.2 cm of depth, pink in color. The 4/11/12, Operative Report and Nurses' Notes indicated R28's right heel was derided with an order for [REDACTED]. On 4/12/12, at 9:22 a.m. R28 was observed while assisted with toileting. An open area was observed to the left of the coccyx. The area was observed to be approximately 1 cm in diameter with the skin sheered away. Registered nurse (RN)-A stated this area was from a skin condition R28 had. At 10:18 a.m. one heel protector and gel cushion were noted in R28's room. At 11:32 a.m. licensed practical nurse (LPN)-A was observed to change R28's dressing to his right heel. The wound was 0.8 cm x 1 cm with approximately 0.3 cm depth. The PU appeared to be a stage 2 wound with partial thickness loss of the dermis with a shallow open ulcer. On 4/12/12, at 9:30 a.m. nursing assistant (NA)-B and NA-C stated R28 is repositioned about once a shift when he needs to go to the bathroom. The NAs could not state any other time R28 should be repositioned with staff assistance. NA-B stated R28 will refused to reposition often but he just repositions himself in his chair. The NAs stated R28 refuses repositioning often and has been educated about the need to reposition. At 9:35 a.m. R28 stated he thinks when the air comes out of his cushion in his chair it causes pressure on his bottom. R28 stated he tries to move himself in his chair but but he was not aware that he should get up out of the chair throughout the day. At 10:44 a.m. the director of nursing (DON) stated no assessment of R28's repositioning needs could be found. The DON stated she had looked though his whole chart and it should have been done. The DON stated the assessment should have been completed with the significant change MDS in September 2011. At 11:41 a.m. LPN-A stated R28 had a PU to the heel. She stated she did not know where the PU came from, but added R28 propels himself with that foot in the wheelchair. She also stated R28 had moon boots while in bed but does refuse to wear them and has a wool afghan at the foot of his bed. LPN-A stated R28 should be repositioned every 2 hours when in bed and in the chair. LPN-A stated they should be documenting when R28 refuses repositioning. LPN-A stated R28 likes to lay flat in bed and refuses repositioning about 50% of the time. LPN-A stated R28 did have a PU to the left of his coccyx in the past, she felt was from pressure or shearing. At 2:01 p.m. LPN-B stated he thinks R28's PU is from his shoe rubbing on the heel. LPN-B could not state R28's repositioning schedule when asked. He stated R28 likes to lay on his back at night and when they put a cushion in under him, he often removes it. LPN-B stated R28 is a hard sleeper and it is hard to wake him up to reposition him at night. At 2:54 p.m. RN-A stated R28's PU was due to his contracted feet. She stated R28 crosses his legs at night and this puts pressure on his heel. RN-A stated R28 should be repositioned every 1.5 to 2 hours. RN-A stated no individualized repositioning assessment had been determined because R28 had a Braden of 15 (mild risk of pressure sore development). RN-A stated the facility's consultant told them they did not have to do a pressure tolerance assessment if the Braden score was 15. RN-A stated R28 can shift himself but he would not be able to offload for an adequate amount of time. RN-A stated this assessment should have been completed last fall with the significant change assessment. She stated that was when R28's positioning needs really changed. RN-A stated R28 had a history of [REDACTED]. On 4/13/12, 9:47 a.m. the DON stated R28 had a history of [REDACTED]. The DON stated R28 lacked a comprehensive skin assessment. The DON stated she felt R28 might have gotten the current PU from his shoes. She stated for a while they were really good at putting the boots on him at night and getting him to lie down occasionally. The DON stated R28 has a specialty mattress and thought they had tried another mattress, but was unsure of when this was. R48 lacked appropriate ongoing assessment, monitoring and implementation of interventions related to a pressure ulcer identified on admission. R48's [DIAGNOSES REDACTED]. R48 was admitted [DATE], and discharged on [DATE]. On 11/30/11, the Discharge Form from the discharging hospital indicated R48 had no skin related issues upon discharge. On 11/30/11, the Admit and Re-admit Comprehensive Nursing Assessment indicated no redness or open areas were noted on R48's skin. The Skin Grid-Pressure/[MEDICAL CONDITION] Ulcer/Other document dated 11/30/11, indicated R48 had a 3.5 cm dark purple area to the right heel that was identified as a PU. The PU was noted to be black in color. No drainage or depth was noted to the PU. No staging of the PU was identified. The Braden Scale dated 11/30/11, indicated R48 was at risk for skin breakdown. The facility's Tissue Tolerance Testing dated 12/8/11, indicated R48 could tolerate 2 hours laying without redness over bony prominence. The admission Minimum Data Set ((MDS) dated [DATE], indicated R48 had moderate cognitive impairment and required extensive assistance from staff with mobility. The MDS indicated R48 was at risk for a PU as determined by clinical and formal assessment. The Pressure Ulcer CAA dated 12/7/11, indicated R48 was at risk for skin breakdown, required extensive assist with activities of daily living (ADLs), was unable to move self without assist, and had no pressure related skin issues upon admission. The Tissue Tolerance Test dated 12/8/11, indicated R48's skin was pink/red after 2 and 3 hours of sitting and could not tolerate 2 hours of sitting. No further assessment was completed to determine how long R48 could tolerate sitting without redness developing on his bony prominence. The POC dated 12/8/11, indicated R48 required assistance from 2 staff with bed mobility, repositioning every 2-3 hours and as needed and was at high risk for the development of a PU. The POC lacked any direction to staff related to heel PU or pressure relieving devices or interventions for R48's heels. On 12/19/11, the Skin Grid-Pressure/[MEDICAL CONDITION] Ulcer/Other document indicated R48 continued to have a 3.5 cm PU, black in color. No drainage or depth was noted to the PU. No staging of the PU was identified. On 12/23/11, the Skin Grid-Pressure/[MEDICAL CONDITION] Ulcer/Other document indicated the area was a 2 cm x 2 cm PU, red in color and had an Allevyn dressing placed on the wound. No staging of the PU was identified. On 1/2/12, the Skin Grid-Pressure/[MEDICAL CONDITION] Ulcer/Other document indicated the PU was 3 cm x 2 cm with serosangious drainage and red in color. No staging of the PU was identified. On 1/14/12, the Skin Grid-Pressure/[MEDICAL CONDITION] Ulcer/Other document indicated the PU was 2 cm x 2 cm, black in color, was healing and was painful to touch. No staging of the PU was identified. On 1/14/12, the Skin Grid-Pressure/[MEDICAL CONDITION] Ulcer/Other document indicated R48 sustained a wound to the left heel measuring 0.5 cm x 1 cm and was red in color. No staging of the PU was identified. A review of the the Therapy Treatment Notes (TTN) indicated: On 12/2/11, the certified occupational therapy assistant (COTA)-A identified R48 had indentations from socks and nursing was notified. Wheelchair positions for lower extremities were discussed with nursing and high blue heel protectors were placed to lower extremities. The COTA instructed to staff to place the boots when in the wheelchair and while laying down. On 12/7/11, While inspecting skin for [MEDICAL CONDITION] therapy, R48's skin looked good. On 12/8/11, R48's right leg was leaning on the leg rest causing an indentation on his skin. Boots were placed on his legs. On 12/21/11, The COTA-A indicated she had discussed with nursing to observe the right heel. On 12/23/11, R48 was observed to not have the moon boots on to protect R48 from pressure. The right heel was noted to have a reddened/purplish area with a red middle. Instructions were: boots on at while in bed, no gripper socks were recommended and to use a heel lift to prevent shearing when assisting R48 off the bed. COTA-A documented she did not feel the night aides had received education regarding the intervention. The nursing staff was reeducated at this time. On 12/26/11, Occupational therapist (OT)-A documented she recommended the nursing staff monitor for the use of the heel boots while in bed at night. On 12/30/11, Certified occupational therapy assistant (COTA)-A documented R48's right heel area increased in size. On 1/17/12, COTA-A documented the heel boots were not on overnight and discussed this concern with nursing related to the heel PU. On 1/17/12, COTA-A documented the wound was not healing and the right heel was 1.5 cm with 1/16th of depth. The discharge MDS dated [DATE], indicated R48 had one stage 1 PU (intact skin with non-blanchable redness of a localized area usually over a bony prominence) upon discharge on 1/17/12. On 4/12/12, at 11:54 a.m. OT-A stated R48 was very ill when he came in. OT-A stated R48's legs were weeping from so much [MEDICAL CONDITION] and he was very compromised. She stated they gave him, or he came with, the pressure relieving or "moon" boots when he was admitted . OT-A stated R48 did not have any PUs when he was admitted . She stated they were doing [MEDICAL CONDITION] therapy so they would see R48's legs regularly. She stated she did recall COTA-A observing R48 without the boots on at night. They did talk to the DON about this. OT-A stated they have brought concerns to the DON in the past related to residents in general, regarding not having devices in place that therapy recommended. At 2:14 p.m. LPN-A stated she recalled R48 having a PU to the left and right heel. She stated R48 should have had heel or moon boots in place. LPN-A stated staff needed reminding about placing the boots. She recalled COTA-A voicing concerns about the use of the boots and remembered passing it on to the next shift. LPN-A stated the boots were not noted on the POC. She stated communication with therapy and their interventions could be improved. LPN-A reviewed R48's Tissue Tolerance Testing and stated a thorough assessment was not completed. On 4/13/12, at 8:20 a.m. COTA-A stated she had observed R48 without the pressure reliving boots on at night at times and had discussed her concerns with nursing staff. She stated R48 did not have PUs when he was admitted . COTA-A stated she was concerned about placement of booties and shearing when transferring and had talked with staff about this too. COTA-A stated R48 developed a PU to the right heel which did not open and then shortly before discharge, had developed a PU to the left heel. She added R48 also had an area of concern on his calf from pressure as well. COTA-A stated she had referred to a nurse in another facility to get the appropriate treatment for [REDACTED]. At 9:38 a.m. the DON stated the Tissue Tolerance Testing was incorrect and no care planning was completed regarding R48's PU interventions. The DON stated she could not recall R48's PUs adequately enough to speak about the stage of the PUs. The policy Pressure Ulcer Risk assessment dated ,[DATE], directed staff to identify and evaluate all areas of risk of constant pressure, implement individualized interventions in attempt to stabilize, reduce or remove underlying risk factors and modify interventions as appropriate.

Based on observation, staff interview, record review, and policy review, the facility failed to provide the necessary care and services to ensure the effective management of significant pain for 1 of 1 resident (R35) in the sample identified with pain which resulted in actual harm to R35. Findings include: R35 had a history of [REDACTED]. However, her current symptoms of pain, of which staff were aware, lacked adequate assessment and interventions to manage the pain. R35 was [AGE] years old and weighed 76 pounds on 5/18/11, with [DIAGNOSES REDACTED]. The hospital return pain assessment completed on 1/28/11, identified the resident as stating she had a backache and that it hurt when she moved. The change of status Minimum Data Set ((MDS) dated [DATE], indicated the resident had short term memory problems and poor decision making skills, required extensive assistance for all activities of daily living, and had no pain. However, the record lacked an updated comprehensive pain assessment. The change of status MDS dated 5/6/11, indicated the resident had short term memory problems and poor decision making skills, required extensive assistance for all activities of daily living, and had no pain. The Care Area Assessment (CAA) for cognitive loss dated 5/11/11, indicated R35 had short term memory loss, made poor decisions, and had increased dependencies. The CAA for communication dated 5/11/11, identified risk factors for communication was unmet needs and difficulty communicating. However, the record lacked an updated comprehensive pain assessment. The plan of care dated 2/9/11, indicated the resident required extensive assistance with transfers, ambulation, dressing, and grooming and was mentally unable to remove self from danger. The plan of care also noted resident had a recent fall on 1/22/11, with complaints of back pain and would have Tylenol as ordered. A review of the January 2011 medication administration record (MAR) indicated R35 received Tylenol 650 mg. every night and every four hours as needed for pain. However, when R35 returned from the hospital on [DATE], with a new [DIAGNOSES REDACTED]. every night was not on the physician's order. The physician's orders [REDACTED]. every 4-6 hours as needed. The nurse's note dated 1/28/11, indicated the resident reported back pain increased with any movement, and that when R35 was positioned she would moan and ask staff to stop. The noted indicated staff educated the resident to ask for a pain medication (Tylenol) as needed and to take it before the pain got worse. The MAR lacked any documentation the resident received a pain medication. The February MAR indicated R35 had mild pain every evening. However, the MAR indicated the resident had only received pain medication on two different days, 2/7/11, and 2/20/11. The nurse's note dated 3/7/11, at 7:30 a.m. indicated R35 had a fall in the bathroom in the presence of a nursing assistant (NA) and received a " golf-ball side protrusion " and 2 cm laceration to side of head. The resident was transported to the emergency department for evaluation and returned at 12:15 p.m. with no change in physician orders. The MAR indicated the resident did not receive any pain medication at all in March 2011. The nurse's notes dated 4/15/11, at 7:30 p.m. indicated R35 fell and was transported to the emergency department where she had staples applied to a wound on the back of her head. R35's pain was monitored on every shift with a scale that indicated: 0 was no pain, 2 was mild pain, 3 was distressing, 4 was horrible, and 5 was excruciating. A summary of the pain scale documented in the April 2011, MAR and the administration of pain medication was as follows. 4/15/11, 0 for pain on all three shifts (night, day, evening).Tylenol 650 mg. given at 11:30 p.m. 4/16/11, 3 for pain during the night shift, 0 pain during day, and 3 for pain during the evening shift, Tylenol 650 mg. given at 11:00 p.m. 4/17/11, 3 for pain during the night shift, 3 for pain during the night shift, 0 for pain during the day shift, and 3 for pain during the evening shift. No pain medication administered on 4/17. 4/18/11, 0 for pain during the night shift, 2 for pain during day, and 3 for pain during the evening shift, Tylenol 650 mg. given at 12:00 p.m. 4/19/11, 0 for pain during the night shift, 3 pain during day, and 2 for pain during the evening shift, Tylenol 650 mg. given at 11:00 p.m. Tylenol 650 mg. given at 11:30 a.m. 4/20/11, 0 for pain during the night shift, 0 for pain during day, and 4 for pain during the evening shift. No pain medication administered on 4/20/11. 4/21/11, 4 for pain during the night shift, 5 pain during day, and 1 for pain during the evening shift, Tylenol 650 mg. given at 4:25 a.m. Tylenol 650 mg. given at 3:30 p.m. 4/22/11, 5 for pain during the night shift, 5 pain during day, and 4 for pain during the evening shift, Tylenol 650 mg. given at 5:15 a.m.. The nurse's note dated 4/19/11, at 11:30 a.m. documented "resident was grimacing, moaning, groaning and guarding left side. Rated pain 5/5. Tylenol 650 mg. given. Informed charge nurse of patients severe pain. Pain was in lumbar region with pain radiating to ribs and left hip area." The nurse's note contained documentation from a RN on 4/20/11, (next day) at 3:00 p.m. which noted the physician was faxed regarding resident's pain and requested [MEDICATION NAME] Patch. On 4/20/11 at 5:00 p.m. an order was received for [MEDICATION NAME] 12 hours on and 12 hours off. The MAR documented the first patch was applied at 5:00 a.m. on 4/21/11. However, the nurse's note on 4/21/11, noted [MEDICATION NAME] to be discontinued due to insurance would not cover it. At that time, an order was received to administer [MEDICATION NAME] 50 mg. ? tab PRN (as needed) every 6 hours. During the time period from 4/23/11 until 4/29/11, [MEDICATION NAME] 50 mg. ? tab was administered at least once a day and on one day it was given 3 times during the day. The MAR indicated the resident's pain was monitored every shift and pain medication was given when pain was reported except on 4/30/11 when the resident was identified as having a 2 for pain during the evening shift. The record lacked documentation R35 received pain medication. A review of the May 2011, MAR identified the nurse continued to monitor for pain every shift. A summary of the pain scale documented in the MAR and the administration of a pain medication was as follows: 5/1/11, 1 for pain during the evening shift, 0 for pain during the day and 0 for pain during the evening shift. [MEDICATION NAME] 25 mg given at 12:00 a.m. 5/2/11, 0 for pain during the evening shift, 0 for pain during the day and 2 for pain during the evening shift. [MEDICATION NAME] 25 mg given at 4:00 p.m. 5/3/22, 0 for pain during the evening shift, 0 for pain during the day and 2 for pain during the evening shift. No pain medication administered on 5/3/11 at all. 5/4/11, 0 for pain during the evening shift, 1 for pain during the day and 1 for pain during the evening shift. No pain medication administered on 5/4/11 at all. This pattern continued through the remainder of the month of May. However; R35 was identified as being in pain on May, 6, 8, 11, 13, 17, 18, 19, 21, and 22 without receiving any type of pain medication at all according to the MAR records. On 5/23/11, the facility received a fax from the physician with a new [DIAGNOSES REDACTED]. The medical record included a progress note from R35's physician during a routine exam at the nursing home on 5/13/11. The physician assessment included, [MEDICAL CONDITION], dementia, and multiple "compression of [MEDICATION NAME] spine, stable, though she has significant pain. She can put on [MEDICATION NAME]." However, the physician did not order the [MEDICATION NAME] (pain patch) and the facility failed to contact the physician to order the patch so the pain medication could be implemented. On 5/24/11, at 11:30 a.m. the facility received a verbal order from the physician to discontinue all of R35's oral medications due to end stage condition. On 5/25/11, at 6:15 a.m. LPN-D stated R35 always says "No" when asked if she has pain. LPN-D added she believed the resident had pain and is "old-fashioned" and does not want to complain. LPN-D also stated R35 was in pain at that time, but could not have a pain medication because all of the oral medications were discontinued. The LPN added there was a Tylenol order which could be given rectally. On 5/25/11, at 7:20 a.m. NA-D and NA-E was observed to transfer R35 to the wheelchair and then wheeled in to the bathroom. When R35 was transferred to the toilet she moaned quietly and was grimacing. R35 was then wheeled to the tub room for a shower. At 7:45 a.m. NA-D was interviewed regarding R35's pain. She stated R35 yelled out when she was put on the shower chair, but was not sure if it was from pain or surprise from sitting in a cold chair. On 5/25/11, at 11:00 a.m. LPN-B stated R35 always denied pain when asked. On 5/25/11, at 3:45 p.m. LPN-C stated she thought R35 does have pain but it was difficult to assess. NA-F stated on 5/25/11, at 3:50 p.m. R35 will yell out when they transfer her and will say, "Ouch, ouch, my back hurts." during transfers. NA-F added she thinks R35's head still hurts where it was cut and she had the staples because she does not like it when her hair is brushed. On 5/25/11, at approximately 2:30 p.m. the assistant administrator was interviewed related to R35's pain symptoms and the lack of interventions. The assistant administrator was informed about the lack of a scheduled pain medication and the physician's progress note when the doctor documented on 5/13/11, the "resident had significant pain" and could have a [MEDICATION NAME]. When the assistant administrator was informed the pain medication was never ordered she commented the resident should have and could have been receiving that pain medication all this time. She stated she was very concerned about the resident's care. The director of nursing (DON) was interviewed on 5/26/11, at 9:15 a.m. related to R35's pain. The DON was not aware the resident did not have a regular scheduled dose of pain medication. She stated there should have been a new pain assessment with the significant change of status on 5/6/11. The DON stated one of the nurses should have reviewed the physician's note on 5/13/11, regarding initiating a [MEDICATION NAME] and contacted the physician for an order. The DON then stated the facility had faxed the physician on 5/25/11, asking for an order for [REDACTED]. The undated Pain Management and Assessment Policy indicated when the RN is informed of any problems with pain control or the physician changes pain medication, the RN is responsible to complete a pain assessment weekly until pain management is achieved. The policy also noted pain assessments will done when there is a change in the resident's condition.

Based on observation, record review, interview, and policy review, the facility failed to complete timely and comprehensive assessments of falls to ensure appropriate interventions were implemented to try to minimize further falls/accidents for 2 of 5 residents (R35, R30) reviewed and identified with falls. Findings include: R35 lacked adequate assessment of risk for falls and implement effective interventions to reduce the risk for falls. The resident sustained [REDACTED]. R35 was admitted with [DIAGNOSES REDACTED]. R35 had a history of [REDACTED]. On 5/25/11, at 7:20 a.m. nursing assistant (NA)-D and NA-E were observed to transfer R35 to the wheelchair. The resident did not bear weight, she was then wheeled in to the bathroom and transferred to the toilet by two staff. She was observed to have a transparent dressing on her left arm covering a laceration she received on 5/11/11. She was observed to be fragile and very thin. The significant change of status MDS dated [DATE], indicated the resident had short term memory problems and poor decision making skills, required extensive assistance of all activities of daily living and extensive assist of two staff for transfers and ambulation. The significant change of status MDS dated [DATE], indicated the resident had short term memory problems and poor decision making skills, required extensive assistance for all activities of daily living and extensive assist of one staff for all transfers and ambulation. The MDS also indicated the resident had a fall with an injury since the prior assessment period. The CAA for cognitive loss dated 5/11/11, indicated R35 had short term memory loss, continued to make poor decisions, and had increased dependencies. The CAA for communication dated 5/11/11, identified risk factors for communication was unmet needs and difficulty communicating. The CAA for falls dated 5/11/11, noted R36 was "at high risk for falls" with the last fall on 4/15/11, when resident was "walking in room and must have turned around too fast and fell ." The plan of care dated 2/9/11, indicated the resident required extensive assistance with transfers, ambulation, dressing, and grooming and was mentally unable to remove self from danger. The plan of care identified R35 as a high risk for falls related to intermittent confusion, poor vision, gait/balance issues. The interventions included provide assist of one staff with ambulation with front wheeled walker (FWW), remind resident to use call light as needed for assistance, then wait for assist, re-orient to move slower, tends to do everything quickly. R35 received skilled PT services on 1/23/11 through 2/10/11, with no ambulation recommended except with "Rehab nursing" and assist with all transfers. On 3/31/11, R35 was re-evaluated by PT and the assessment noted the resident desired to ambulate independently. The PT notes indicated R35 was able to ambulate up to 200 feet with stand by assistance of one staff. On 4/18/11, R35 was discontinued from PT services with the recommendation to walk the resident to meals with assist of one staff. A review of the nurses notes indicated R35 had the following falls: -On 1/22/11, at 7:30 p.m. resident was found on floor in room by bedside, stated she bent down to pick something up and got dizzy. -On 3/7/11, at 7:35 a.m. resident slipped off toilet when reaching for an item a nursing assistant was present in the bathroom but could not reach her. -On 4/15/11, at 7:30 p.m. an incident/accident report indicated R35 was found on floor by the bed. The RN post incident assessment completed on 4/16/11, indicated the resident fell when walking in her room. The nurse's notes dated 4/15/11, at 7:30 p.m. indicated R35 fell and was transported to the emergency department where she had staples applied to a wound on the back of her head. The assessment noted the resident stated she was walking in her room, must have turned around too fast, and fell . The new or different safety measure implemented was to have staff walk with resident at that time and remind resident to slow down and not move so fast/quick. However, on 4/18/11, (three days after the resident fell ) the resident's walker was removed from her room to discourage her from walking independently. A review of the therapy treatment noted indicated on 4/18/11, the FWW was removed the resident's room due to the resident was walking and fell in her room. - On 5/11/11, at 8:30 p.m. the nurses' notes indicated the resident was lying on floor in bathroom with head next to toilet and extremities under sink and received a 3 cm. x 1 cm. open area to left elbow. The incident report dated 5/11/11, noted there was no chair alarm and the call light was not on. The report noted the resident stated she had finished using the toilet and was trying to wash hands, standing up, slipped, hung on to the sink, and went down. The resident was quoted in the incident report, " I took myself to bathroom because I could not wait anymore. " It was also noted the resident had been in the wheelchair. The facility did not complete a RN post incident assessment until 5/15/11, (four days later) to evaluate contributing factors or implement new or different safety measures to minimize the resident's risk of falling again. On 5/18/11, the RN noted NAs are to offer assistance with toileting and reminded not to leave alone in the bathroom, will post sign in bathroom. The physical therapy assistant (PTA) stated on 5/26/11, at 9:00 a.m. therapy removed R35's walker on a Monday, due to the resident's fall that happened on the weekend, 4/15/11 which was a Friday evening. The PTA stated they did not feel she was safe enough to ambulate alone due to impulsiveness The DON was interviewed on 5/24/11, at 1:15 p.m. and when asked why a post incident assessment was not completed until five days after the fall she stated, " good question " and said she had not been at work that week and added it should have been completed the same day. The DON was also asked about the chair alarm and if the resident was supposed to have it because it had not been identified in the plan of care or on the nursing assignment sheets. The DON stated at that time she implemented the chair alarm the day she reviewed the fall and just forgot to document it. On 5/25/11, at approximately 2:40 p.m. the assistant administrator was informed about the above falls with R35 and a registered nurse who failed to complete a post incident assessment timely to determine if other interventions were appropriate. The administrator was also informed about the location of the resident's room, how isolated she was because staff could not visualize the resident from the hallway because the privacy curtain was always closed around her bed. The administrator stated she understood and agreed with the concerns. The DON did not notice the progress note or did not follow up on the doctor's suggestion. Review of the September 2007, Fall Prevention and Reduction Program Policy stated a Registered Nurse must complete a post-incident assessment following a resident fall or incident, preferable on the shift the fall occurred or on the next available shift that a RN was present. R30 lacked a comprehensive assessment of causal factors related to falls to ensure appropriate interventions had been implemented to minimize further falls. R30's [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE], identified R30 with some memory loss and as requiring assistance with transfers and toileting. The significant change MDS dated [DATE], continued to identify R30 with memory loss and requiring assistance with transfers and toileting. The Falls Care Area Assessment (CAA) dated 3/14/11, indicated R30 was at high risk for falls due to her [DIAGNOSES REDACTED]. The Fall Risk Assessment form dated 12/16/10, indicated R30 was at high risk for falls. The nursing admission progress note dated 12/15/10, indicated R30 was at high fall risk due to current [DIAGNOSES REDACTED]. The current plan of care dated 3/16/10, included the use of bed and wheelchair alarms, and a hi/low bed. The plan of care also directed staff to remind the resident to use the call light to ask for assistance and to place the resident in a supervised area while up in wheelchair. A review of R30's falls according to the incident/post fall reports (IR) indicated: On 12/20/10, at 7:15 p.m. R30 was found sitting on the floor at the end of her bed. R30 had stated that she got up to go to the bathroom. R30 had reported hip pain and was transferred and hospitalized until 12/22/10. No new injury or fractures were identified. Safety measure in place at the time of the incident was to have the call light in reach. The post fall evaluation indicated that the resident did not put on the call light to ask for assistance. New interventions implemented were use of a bed alarm, chair alarm, and a high/low bed. On 12/25/10, at 7:00 p.m. R30 was found lying on her right side in front of her wheelchair by the foot of her bed. The IR indicated R30 had attempted to self transfer to bed from the wheelchair. The brakes were not on and the resident had not asked for assistance. The IR identified a chair alarm was not in the wheelchair at the time of the incident. The new intervention added was to not leave the resident alone in her room while in the wheelchair and to have the resident in a supervised area when up in the wheelchair. The wheelchair alarm was to be re-applied. On 1/15/11, at 2:20 a.m. R30 was found on the floor by the bathroom door. After the fall, R30 reported right hip pain, but no injury was indicated by the facility. R30 incurred three skin tears to the right upper arm measuring 2 centimeters (cm) X 2 cm, 1 1/2 X 2.2 cm, and 2.2 cm X 2 cm. The IR indicated R30 had not put on the call light to ask for assistance and had probably needed to use the bathroom. The bed alarm had not gone off to notify staff of the self transfer as it had been positioned too low in the bed. The assessment also indicated that the "noodle" did not prevent the resident from the self transfer. The use of a foam noodle had not been indicated as a previous intervention or identified on a care plan to direct staff on use. New interventions implemented included moving the resident's bed against the wall and to place the bed alarm in the appropriate place. Staff were reminded to check the bed alarm placement before putting the resident in bed. On 1/23/11, at 8:20 p.m. R30 was witnessed to stand up out of a lobby chair and attempt to sit in a chair next to it. The IR indicated R30 got her foot caught on the leg of the chair and fell to floor on her left side. The NA had reported that it looked like R30 had hit her head. The chair alarm was on and it was sounding but the staff were not able to get to R30 fast enough to prevent the fall. New interventions implemented at that time were to keep the resident in her wheelchair or lounge chair with the clip alarm attached in the TV room as long as staff was present to supervise. A urinalysis was to be obtained. The resident had been reported as confused and restless prior to the fall. The IR also indicated the doctor would be contacted for a medication to be used for restlessness. No injury was identified. On 2/3/11, at 11:10 p.m. R30 was found on her knees in her room. The resident was reported to be agitated and restless prior to that incident and had tried transferring herself two times before the actual fall. The staff had been in to check the resident approximately one minute prior to the incident to answer an alarm. The form indicated the bed alarm had sounded and the resident was in a low bed. New measures to be implemented were to have staff talk to the resident's daughter about a room change to a closer room to the nurse's station and that a noodle would be placed on the bed. No injury was identified. R30 was moved to a room closer to the nurses station on 2/5/11. On 2/7/11, at 8:30 p.m. the IR indicated R30 had attempted to transfer self from the recliner in the lobby to her wheelchair and fell striking her head on a coffee table. The chair alarm was ringing. R30 reported a headache after the fall and sustained a 3 cm X 1 cm skin tear on the left shoulder that was steri-stripped. New interventions added were to have physical therapy/occupational therapy (PT/OT) evaluate and that the facility would make sure there was someone to supervise the resident while in the recliner. These notes also indicated that the doctor had ordered PT/OT to evaluate the resident, to stop the Norvasc (blood pressure medication) and start Namenda (medication for treatment of [REDACTED]. A CT scan (an X-ray machine that makes detailed pictures of structures inside the body) was ordered for 2/9/11, if R30's headache continued but was not required with no complaints of headache 2/9/11. On 4/23/11, at 8:10 p.m. R30 was reported to have been in bed for the night but with straightening her covers she fell with the bed alarm sounding. The report included an assessment that the resident possibly could have slipped if she had socks on. New interventions implemented were making sure sheets and covers were without wrinkles, to put on non-slip booties/socks as the resident allowed, and to place strips (non-skid) on the floor next to bed. The post fall evaluation form indicated that the use of a mat at the side of the bed was discussed with the director of nurses (DON) and another registered nurse (RN), but staff felt a mat might increase the risk of a fall as it may slip out from underneath the resident. The use of a foam noodle was declined as the resident would not be detoured and would fall a greater distance. Although the IRs identified some new interventions following R30's falls, a comprehensive assessment, including causal factors and risk factors, had not been completed to ensure possible appropriate interventions had been implemented. Occupational and physical therapy (OT/PT) treatment notes dated 1/8/11, indicated R30 was to be seen five times weekly by each service as of 12/22/10. They recommended assistance of two with transfers. OT/PT notes dated 1/9/11, indicated R30 would be seen three times a week and that the bed and chair alarms seemed appropriate. They indicated a Hoyer (mechanical lift) transfer to be used. OT/PT treatment notes dated 1/9/11, indicated that as of 12/29/10, R30's services were discontinued due to resident's refusal to participate in therapy services. OT/PT treatment notes dated 2/10/11, indicated PT would see R30 for two-three times/week for thirty days. Treatment notes dated 2/21/11, identified that services were discontinued on 2/23/11. A OT referral form dated 2/3/11, indicated that R30 was able to transfer with assist of one when alert. That same form indicated that assistance of two needed if or when R30 demonstrated decreased alertness or ability to follow directions. A restorative activities form dated 2/23/11, indicated R30 was able to ambulate up to 250 feet with assist of one. On 5/24/11, at 1:41 p.m. NA-B stated she thought the resident could be re-evaluated for ambulation. NA-B stated that if R30 got ambulated more often that may help prevent her falls and that she was not sure why R30 was in her wheelchair all the time. On 5/24/11, at 1:55 p.m. NA-G stated that they have been walking R30 more to help her be less fidgety. NA-G stated that walking really seemed to lessen that and that they had brought that up to the RN's over the week-end but does not know if they have had a chance to look at that. On 5/24/11, at 2:15 p.m. NA-A stated that when R30 gets agitated she gets her up and takes her for a walk and to the bathroom as this might be why she was agitated. On 5/24/11, at 2:49 p.m. RN-B verified that R30 was assessed at high risk for falls on admission and continued to be high risk. RN-B stated one reason the resident may be falling was that she was trying to go to the bathroom. RN-B stated they had not tried a toileting plan but "it wouldn't have been a bad idea." RN-B stated that the intervention with R30 being supervised while she was in the wheelchair would not be met in the cases with the falls at 8:10 p.m. and 8:30 p.m. because there was not staff at the nurses station continuously at these times. RN-B stated that walking does decrease R30's agitation and that it kept her mind busy so she was not thinking of getting up but this was not an intervention at that time. On 5/25/11, at 2:10 p.m. the DON verified R30 was at high risk for falls. The DON stated that they do a cause analysis with some cases and when asked if it was done with R30 she stated she could not honestly say yes but it might help with R30.

Based on observation, record review, policy review, and interview, the facility failed to ensure the plan of care was followed for assistance with transfers for 1 of 1 (#1) residents in the sample that was not assisted with a transfer as directed by the plan of care, fell and sustained a fracture that caused actual harm for the resident; and failed to implement and/or care plan adequate fall interventions following falls for 1 of 3 (#2) residents in the sample who had experienced falls. Findings include: Resident #1 who required the assistance of two staff and the use of a transfer belt for transfers, was assisted by one staff to sit on the edge of the bed. The staff did not have a transfer belt, had turned away from the resident to obtain the belt, the resident stood on her own and fell hitting the wheelchair. As a result of the fall, Resident #1 experienced a facial hematoma (blood filled bruise) of the left cheek, a non-displaced pubic ramus (pelvic bone) fracture, and a contusion of the left knee. Resident #1 was admitted to the facility on [DATE]. Resident #1's [DIAGNOSES REDACTED]. On 9/27/10, at 1:03 p.m. Resident #1 was observed being assisted to transfer from her wheelchair to her bed. Two Nursing Assistants/NA's were observed assisting the resident with a transfer belt around Resident #1's waist. A large hematoma was observed on Resident #1's left cheek with purple bruising of the resident's neck and left eye. Resident #1 was wheeled to the bedside, the wheelchair brakes were applied by the NA and the resident was transferred by the two NA's with the assistance of the transfer belt. Review of Resident #1's quarterly Minimum Data Set ((MDS) dated [DATE], indicated the resident was moderately cognitively impaired with poor decision making and required extensive physical assistance from two staff for transfers and toilet use. The MDS revealed Resident #1 had experience falls in the past 31 to 180 days. Review of Resident #1's Resident Assessment Protocol Summary (RAPS) dated 4/30/10, stated, "Falls...high risk for falls. Has had falls in the past 3 months. Last fall on 4-16-10 during a transfer from bed to wheelchair. Her knee gave out and she was lowered to the floor by the NA...Does need assistance with transfers..." Review of Resident #1's plan of care with an update on 8/5/10, stated "Transfers with assist of 2 staff...Transfer belt around resident waist at all times per her request...assist of 2 staff/gait belt with transfers..." Review of the facility's Rehab Notes dated, 8/23/10, stated, "From 8/4/10 PT (physical therapy) to DC (discontinued) 8/6/10. From 8/5/10 AO2 (assist of 2) for transfers." Review of the facility's Resident Abuse Report Form dated 9/7/10, stated, "...pt. (patient) fell and sustained L (left) cheek hematoma, L superior proximal non-displaced pubic ramus fracture, and L knee contusion when attempting self transfer. Pt. sent to ER...(NA) states he was getting (Resident #1) up to go to the B/R (bathroom) he sat her up on the edge of the bed...(Resident) was not waiting for him to transfer...and he was trying to quickly get the gait belt but when he turned around she was already standing up (with) her hands on the w/c (wheelchair). Her elbow buckled and she fell and hit her face on the w/c...Fall with injury seems to be (secondary) to pt. attempt to self transfer as well as contributing factor of NAR (Nursing Assistant Registered) not having assist x 2 (two staff) for transfer..." Review of the emergency room discharge instructions dated 9/7/10, stated, "L cheek hematoma, L superior non displaced pubic ramus fracture, L knee contusion, Weight bearing as tolerated...Oxycontin (opioid analgesic) dose same as current (20 milligrams) increase to four times a day..." Review of the facilities Medication Administration Record for September 2010, revealed Resident #1 required the increased analgesic from 9/7/10 until 9/16/10 when the Oxycontin was decreased to two times a day (ordered prior to fall at two times a day). Review of the facility's policy and procedure titled Transfer Policy reviewed 8/06, stated, "Objective: To transfer resident the safest way possible for both the resident and the Caregiver...2. Resident's individual transfer plan is on the resident's care plan...Rules for Transfers: 1. Transfer belts are required for any transfer that requires physically supporting the resident's weight...Transfers:...2. Two person pivot transfer...Have staff one on each side holding unto belt..." An interview with the Director of Nursing (DON) on 9/27/10, at 2:26 p.m. confirmed staff are trained to have the transfer belt ready prior to assisting a resident to sit on the edge of the bed. In addition, the DON revealed the NA had failed to follow Resident #1's plan of care that directed staff to transfer the resident with the assistance of two staff and a transfer belt. Resident #2 had experienced several falls without adequate interventions implemented after each fall to prevent future falls. In addition, Resident #2's care plan was not developed to include new fall interventions initiated by the facility. Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #2's admission MDS dated [DATE], indicated the resident was cognitively modified independent with difficulty making decisions in new situations only and had limited short term memory. The MDS revealed Resident #2 required extensive physical assistance from one staff for transfers and toilet use. Review of Resident #2's RAPS assessment dated [DATE], stated, "...Falls...high risk for falls...Risk for severe injury if fall should occur..." Review of the facility's Fall Risk Assessment form dated 2/18/10, scored Resident #2 at 13 and dated 5/14/10, and 8/1/10, scored the resident at 15, both scores assessed the resident at high risk for falls. Review of Resident #2's plan of care with an estimated completion date of 11/2/10, stated, "...At high risk for falls...Remind resident to ask for assistance, Call light in reach at all times, Transfers with assist of 1..." Review of the facility's RN Post Incident Assessment form dated 3/30/10, revealed Resident #2 was found on the floor next to her bed and indicated she was trying to go to bed. The assessment indicated Resident #2 was alert and oriented however had periods of confusion. The intervention for that fall was to remind Resident #2 to use the call light and wait for staff assistance. Review of the RN Post Incident Assessment form dated 5/1/10, at 4:20 a.m. indicated Resident #2 was found sitting on the floor next to her bed. Resident #2 reported to staff she was attempting to go to the bathroom and fell . Resident #2's roommate put on the call light. The intervention for that fall was to "...enforce call light usage and waiting for assistance...If res (resident) has another self-transfer-may need bed/chair alarm..." The facility failed to implement new fall interventions after the second fall. Review of the RN Post Incident Assessment form dated 6/2/10, revealed on 6/1/10, at 3:05 p.m. staff responded to Resident #2's roommate hollering for help and Resident #2 was found on the floor. Resident #2 denied hitting her head however, later staff felt a "bump" on the resident's head. The intervention for that fall was to remind the resident to use the call light to request help. Again the facility failed to implement new fall interventions in order to prevent future falls. Review of the RN Post Incident Assessment form dated 7/18/10, revealed on 7/17/10, at 1:15 a.m. Resident #2 was found sitting on the floor next to her bed with a skin tear to the right elbow. The intervention was to continue to monitor and add a "noodle" to the bed. That intervention was not care planned for a fall prevention for Resident #2. Review of nursing documentation indicated on 8/12/10, Resident #2 was observed by staff standing next to her bed. Resident #2 did not fall but the note indicated a bed and chair alarm were added at that time for fall prevention measures. Review of Resident #2's care plan did not list the alarms as a fall prevention measure. Review of the facility's policy and procedure titled Fall Prevention and Reduction Program revised August 2010, stated, "It is the policy...to implement and use a Fall Prevention and Reduction Program to provide prompt treatment and prevent further injury...3. RN Post Incident Assessment:...completed by RN on the shift incident occurred or the next available shift...includes...protocols in place and what new or different protocols will be implemented...Process:...4. The RN Charge Nurse and/or MDS Coordinator will document all fall prevention protocols and update the resident's care plan as needed..." When interviewed on 9/30/10, at 1:17 p.m. the Director of Nursing confirmed no new fall interventions had been put into place after each fall for Resident #2 and should have been. On 10/1/10, at 10:25 a.m. the DON was contacted and confirmed all interventions for fall prevention were required to be care planned.