Every finding on record at Ostrander Care and Rehab

Based on interview and document review, the facility failed to ensure the Notice of Medicare Non-Coverage (NOMNC CMS-10123) and the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN CMS10055) were provided to 1 of 3 residents (R30) reviewed for beneficiary notification.Findings Include: R30 was admitted on [DATE], Medicare part A identified as primary payer, Medicare part A skilled services ended on12/19/2025, and private pay started on 12/20/2025. Record review indicated R30's son as care and financial power of attorney (POA). R30's last day of Medicare part A skilled services was on12/19/2025. The Notice of Medicare Non-Coverage (NOMNC CMS-10123) provided by facility for review was not signed or dated by the resident or representative. An undated nor signed handwritten note on page 2, under the Additional Information title stated spoke with family member (FM)-A, sister. Family does not want to appeal. The facility director of nursing, (DON) confirmed, the unsigned and undated handwritten note was hers. Based on a phone interview on 04/15/2026 9:26 a.m., FM-A stated had visited more often than other family members but was not POA. FM -A did not recall any specific conversation with the facility DON in reference to the possibility of appeal and stated, we were just told therapy was going to stop. Facility was unable to provide a signed copy of the CMS-10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) for review. During an interview with on 04/15/2026 10:08 a.m., DON stated, had not presented R30's family a copy of the CMS-10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) for review and signature. A facility policy titled [NAME] care and Rehab Administration policy Rates and Charges/Medicare Policy reviewed on 2/2025 states,1. OCR must inform the resident or the resident agent/guardian before any changes in charges for services not covered under Medicare or Medicaid or by nursing home per diem rate. 5. Residents admitted under Medicare A will be informed within 48 hours of the need for denial of benefits pending change. 7. The Medicare denial will be explained to the resident or their responsible person and the reason of denial prior to obtaining the signature on the form.

Based on observation, interview, and record review, the facility failed to ensure proper personal protective equipment (PPE) was used during transfers and catheter care for 1 of 1 resident (R7) reviewed for enhanced barrier precautions (EBP). Findings include: R7's quarterly Minimum Data Set (MDS) dated [DATE] indicated R7 was cognitively intact and had an indwelling catheter. R7's provider orders included urinary catheter 18 french with/30 cc (cubic centimeter) balloon (size of catheter) related to open wounds and decreased mobility. May irrigated with 20-60 ml (milliliters) of NS (normal saline) prn (as needed) if sluggish or suspected blockage. R7's careplan indicated R7 had an indwelling catheter due to pressure ulcer and please follow EBP when emptying catheter. During an observation and interview on 2/18/25 at 3:34 p.m., an orange sign was noted on R7's door titled EBP indicated staff must wear gown and gloves for high contact resident cares including but not limited to transfers and catheter care. During the interview, R7 confirmed they had a catheter. A catheter bag was observed hanging on the side of R7's bed inside a dignity bag. During observation and interview on 02/19/25 at 10:46 a.m., licensed practical nurse (LPN)-A and nursing assistant (NA)-A entered R7's room to perform a dressing change. LPN-A and NA-A put on gloves and disposable yellow gown. After finishing the dressing change, LPN-A removed PPE, washed hands, and left the room. NA-A removed gown and gloves, washed hands, and applied new gloves. NA-B entered R7's room with mechanical lift. NA-B put on gloves. Without a gown, NA-A and NA-B rolled R7 from side to side to place lift sling under R7. NA-A raised R7 in the air with mechanical lift. NA-B held on to sling while R7 was moved to the broda chair (specialized wheelchair). R7 was lowered into the chair. NA-A and NA-B adjusted lift sling to make R7 more comfortable. NA-A removed gloves, washed hands, and returned with a paper towel and urinal to empty R7's catheter bag. Without a gown, NA-A placed the urinal on the paper towel on the floor. NA-A wiped the catheter bag valve with an alcohol wipe before and after emptying the bag into the urinal. NA-A then emptied the urinal in the toilet, rinsed it with water, and again emptied it in the toilet. NA-A removed gloves and washed hands. When interviewed, NA-A stated gowns are worn when assisting nurses with dressing changes only. NA-B stated hands are washed when entering a resident's room. Gowns and gloves are worn when assisting the nurse with dressing changes and when emptying Foley catheters and ostomy bags (a bag used to collect stool from an opening in the abdomen). During an interview on 2/20/25 at 10:50 a.m., the director of nursing/infection preventionist (DON/IP) stated proper PPE of gown and gloves is expected during peri care, dressing changes, bathing, activities of daily living, transferring, and emptying catheter bags. DON/IP confirmed staff should have worn a gown and gloves when R7 was transferred to their broda chair and when the catheter bag was emptied. A policy titled Enhanced Barrier Precautions (EBP) dated 5/1/24 indicated EBP is implemented for the prevention of transmission of multidrug-resistant organisms. EBP will be implemented for residents with chronic wounds such as pressure ulcers and/or indwelling medical devices including urinary catheters. PPE is necessary when performing high-contact care activities. High-contact resident care activities include dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, devices care or use including urinary catheters, and wound care requiring a dressing.

Based on interview and document review the facility failed to provide planning and coordination of services to facilitate a safe discharge to an assisted living facility (ALF) for 1 of 1 residents (R1) reviewed for misappropriation. Findings include: R1's Telephone Order dated 4/8/24, identified to start nocturnal oxygen at 1 liter per nasal canula for obstructive sleep apnea (OSA) and anxiety. R1's care plan dated 5/3/24, identified a focus that R1 required or requested assistance arranging medical appointments. Intervention dated 5/16/24, identified to notify family of appointments, schedule and arrange for transportation to medical appointments. An additional focus revised 9/26/24 identified R1 has agreed to go to an ALF due to inability to return home. R1's county worker was involved with discharge plans as well. Interventions dated 3/27/24 identified to coordinate, facilitate and communicate all plans for follow-up and future care needs and to perform medication reconciliation of all prescribed and non-prescribed medications. R1's care plan did not identify R1's diagnoses of sleep apnea nor did it identify the medical provider ordered intervention to receive oxygen therapy. Further did not identify interventions to assess and monitor for sleep apnea. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1's cognition to be intact and diagnoses of OSA (a sleep disorder characterized by repeated episodes of complete or partial blockage of the upper airway during sleep, leading to reduced or absent breathing which can result in low oxygen levels) and congestive heart failure (a chronic condition where the heart muscle weakens and cannot pump blood effectively which can lead to shortness of breath). Further identified oxygen was used. During an interview on 1/29/25 at 11:57 a.m., nursing assistant (NA)-A stated R1 would use her oxygen whenever she would sleep, she thought she used 2 liters at night. During an interview on 1/29/25 at 1:38 p.m., licensed practical nurse (LPN)-A stated R1 used her oxygen while she slept and would get very anxious about sleeping and quite hard to deal with if she didn't have her oxygen. During an interview on 1/29/25 at 1:46 p.m., NA-B stated R1 would use her oxygen anytime she was laying down in the bed, she did not like to lie down without it. R1's discharge summary dated 1/14/25, identified R1 had a planned discharge to the community. The discharge plan did not identify any set up for oxygen services. During a phone interview on 1/29/25 at 3:24 p.m., assisted living registered nurse (ALRN)-A stated on 1/14/25, R1 was admitted to the facility without oxygen services. ALRN-A stated R1 went without oxygen until 1/18/25, when R1 was not feeling well, was dizzy and was having a hard time breathing so the ambulance came and got her, and she was hospitalized until 1/21/25. ALRN-A stated R1 needs the oxygen at night while she sleeps. R1's Prehospital Care Report dated 1/18/25 at 3:17 p.m., identified an ambulance was dispatched to ALF for R1 who was complaining of difficulty breathing .facility staff report that R1 was transferred on 1/18/25, from another facility and still had not received R1's oxygen. R1 reported to staff experiencing a near syncopal (fainting) episode 20 minutes prior and still having a hard time breathing. R1's emergency department (ED) Provider note dated 1/18/25, identified R1 presented with a brief episode of lightheadedness and hypoxia .R1 was supposed to be on home oxygen but has been off it since her recent move. R1 was mildly hypoxic (inadequate supply of oxygen to the body's tissues) in the ED. We are unable to obtain home oxygen tonight and R1 was unable to be admitted to ED observation because of inability to independently safely ambulate. Will admit for further care. R1's hospital admission note dated 1/18/25 identified R1 presented to the ED via EMS due to a near syncopal episode along with feeling weak and lightheaded around 2:30 p.m. and had been on 1L nasal canula (NC) oxygen since 2016 and had moved facilities this past week and has not had been on the oxygen. R1's hospital discharge summary dated 1/18/25 to 1/21/25, identified R1 was supposed to be on oxygen via NC (1 L) at baseline however had not been able to obtain oxygen at her new assisted living facility, had not been using it for the past 4-5 days. R1 was evaluated by respiratory therapy (RT) colleagues for oxygen needs. R1 was found to be saturating above 88% at rest and ambulation, with no need for daytime oxygen. R1 also had nocturnal (night time) oxygen study done that revealed desaturations to 87%, requiring 2 liters/minute nasal canula. Follow up identified a prescription for overnight oxygen of 2 liters/minute nasal canula was sent with R1 for hypoxia due to chronic diastolic heart failure. During a phone interview on 1/29/25 at 10:41 a.m., emergency department social worker (EDSW)-A stated R1 was admitted to the hospital on 1/18/25, due to lightheadedness and hypoxia due to the facility not sending her oxygen to R1's ALF when she discharged and had been without oxygen for 4 days. During a phone interview on 1/29/25 at 11:04 a.m., R1 stated she has used her oxygen at night for years because she stopped breathing in the night. R1 stated when she was discharged from the facility on 1/14/25, to the ALF the facility never sent her oxygen with so she went without it for five nights and the one night she couldn't breathe. R1 stated she ended up in the hospital from not having her oxygen. During a phone interview on 1/29/25 at 9:10 a.m., family member (FM)-B stated R1 discharged from the facility to an ALF on 1/14/25 and her oxygen was not set up ahead of time with northwest respiratory services. FM-B stated R1 needed her oxygen at night for her sleep apnea and when R1 lays down her artificial heart valve doesn't work as well, due to that she had been on oxygen for years. FM-B identified she received a phone call from the hospital on 1/17/25, that R1 had been admitted because she had been without her oxygen for a few days because the prescription did not get written for her oxygen when she left the faciity on [DATE], to go to the ALF. During an interview on 1/29/25 at 10:18 a.m., medical director (MD)-A stated R1 discharged from the facility on 1/14/25, without a DME order for oxygen. MD-A further stated R1 used the oxygen at night while at the facility for sleep apnea. MD-A indicated without the use of oxygen at night, R1 had the potential for hypoxia and fatigue. . During an interview on 1/29/25 at 1:53 p.m., director of nursing (DON) stated R1 did not have R1's oxygen set up for her discharge from the facility on 1/14/25. DON indicated she received a phone call from a nurse at R1's ALF on 1/15/25, asking how to get R1's oxygen. DON indicated she had one of the providers send a prescription for oxygen to Northwest respiratory services (NRS). DON further indicated NRS had wanted her to send over R1's current nocturnal oxygen saturations levels and did not have the data for that so she did not send it as R1 was no longer a resident at their facility. DON indicated she thought R1's county case manager would set up R1's oxygen services and stated since she thought the oxygen was order was sent to NRS she didn't do any more follow up to ensure R1 would receive oxygen services. During an interview on 1/29/25 at 2:31 p.m., the administrator stated they did not have any oxygen orders for R1 sent with for discharge on 1/14/25. During a phone interview on 1/29/25 at 3:56 p.m., with (NRS) intake department trainer (IDT)-A stated R1 discharged from her facility on 1/14/25, and they did not receive an order for R1's oxygen until 1/15/25. IDT-A stated we did not have the information needed to submit to R1's insurance for her nocturnal oxygen use, so we were not able to establish care at R1's new facility. IDT-A stated typically we have a contract with long-term care (LTC) facilities and prior to a residents discharge the facility would contact us to go over necessary information needed for insurance verification to see if this is a service we can provide outside of the contracted nursing facility. On 1/16/25, we asked the facility for nocturnal oxygen saturations for R1, and we never received them. IDT-A stated we needed recent documentation that supports the continued need for oxygen in a home setting for insurance purposes. IDT-A stated we finally got everything we needed from the nurse at the ALF on 1/24/25, and R1's oxygen was then set up. Facility Policy, DISCHARGE PLANNING POLICY, revised 8/2018, identified a purpose that the interdisciplinary team shall prepare a comprehensive discharge care plan with the resident and resident representative to assist the resident to reach their discharge goal .4. Discharge a. If the resident is being discharged to a lower level of care within the facility, the facility will document the discharge plan and approaches as developed via the comprehensive care planning process (See Discharge Transfer Policy). b. If the resident desires returning to the community, document any referrals to Local Contact Agencies or other appropriate entities for the purpose of discharge (if applicable). c. Update the resident's comprehensive care plan and discharge plan (if applicable) with any information received form referrals to local contact agencies or other appropriate entities .7. Information for the Receiving Provider: The facility will share relevant information with the post-discharge care provider, including a. The resident's primary care physician and other consulting practitioners as well as their respective and contact information. a. The resident representative's contact information b. The resident's Advance Directives, c. All special instructions or precautions and for ongoing care as appropriate, d. The resident's comprehensive care plan goals, e. A copy of the discharge summary, and f. Any other necessary or relevant information or documentations to facilitate safe and effective transition of care. 8. Discharge Summary: a. A discharge summary will be completed upon discharge to include: a recapitulation of the residents stay in the facility (diagnoses, course of illness/treatment, therapy, lab, radiology and consultation reports, a final summary of resident status, medication reconciliation, a post-discharge plan of care developed with the resident and resident representative: Location/Agency/Facility where resident will reside, arrangements for care, medications and services post-discharge, arrangements for follow up communication post-discharge. 9. Discharge Follow Up Process: a. Upon discharge (internally or externally), social services or designee will complete follow up calls or visits with the resident, resident representative and receiving location (insert facility and state specific information here) for an appropriate transition of care, b. If areas of additional care coordination are needed, the facility representative and applicable team members will assist in the care coordination process. (insert transition of care policy information here) and c. documentation of discharge follow up will be completed per policy. (insert transition of care policy information here).

Based on interview and document review the facility failed to ensure comprehensive care plans were developed to implement care and services for oxygen therapy due to obstructive sleep apnea (OSA), for 1 of 1 residents (R1) reviewed for discharge. Findings include: R1's Telephone Order dated 4/8/24, identified to start nocturnal oxygen at 1 liter per nasal canula for OSA and anxiety. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1's cognition to be intact and diagnoses of obstructive sleep apnea (a sleep disorder characterized by repeated episodes of complete or partial blockage of the upper airway during sleep, leading to reduced or absent breathing which can result in low oxygen levels). Further identified R1 used oxygen while a resident. R1's care plan was reviewed and did not identify R1's diagnoses of sleep apnea nor did it identify the medical provider ordered intervention to receive oxygen therapy. Further did not identify interventions to to manage/treat the disorder with goals of care. During an interview on 1/29/25 at 11:57 a.m., nursing assistant (NA)-A stated R1 would use her oxygen whenever she would sleep, she thought she used 2 liters at night. During an interview on 1/29/25 at 1:38 p.m., licensed practical nurse (LPN)-A stated R1 used her oxygen while she slept, R1 would get very anxious about sleeping, and quite hard to deal with if she didn't have her oxygen. During an interview on 1/29/25 at 1:46 p.m., NA-B stated R1 would use her oxygen anytime she was laying down in the bed, she did not like to lie down without it. During an interview on 1/29/25 at 1:53 p.m., director of nursing (DON) stated R1's care plan was not updated to include R1's oxygen use, for obstructive sleep apnea after it was ordered on 4/8/24, and it should have been. During an interview on 1/29/25 at 2:26 p.m., the administrator stated It does not look like R1's care plan was updated to include her oxygen use for obstructive sleep apnea after it was ordered on 4/8/24, and it should have been. Facility policy, CARE & REHAB-[NAME] NURSING POLICY FORMULATION OF RESIDENT PLAN OF CARE, reviewed 7/2022, identified the Policy: [NAME] Care & Rehab will assess and provide guidelines for individualized resident plan of care. Rationale: The facility will establish a plan of care and create goals specified for the resident to reach and maintain the highest level of physical, mental and psychosocial function possible. Procedure: 1. Residents will be assessed upon admission and through nursing assessment the initial care plan will be developed. 2. The comprehensive care plan must be completed within 21 days of admission. 3. Care plans are updated quarterly, unless significant change is warranted. 4. Comprehensive plan of care which includes: resident-specific priority problems, short-term goals and measurable outcomes, interventions to meet the goals, Nursing summary response to interventions, nursing plan changes and recommendations, dietary, rehabilitation, discharge planning and others as applicable. 5. A care plan meeting will be held within 21 days of admission. The IDT will meet with the resident and/or advocate to discuss the formal determination of the residents plan of care as indicated by the MDS.

Based on observation, interview and document review, the facility failed to ensure dishmachine chemical sanitization solution was appropriately monitored to ensure dishes were properly sanitized. This had the potential to effect all 18 residents who resided in the facility. Findings include: During an observation and interview on 11/06/23 at 12:49 p.m., with dietary supervisor (DS)-C, observed the dishmachine in use. DS-C stated the dishmachine used low temperature heat and chemical to sanitize the dishes. While observing the dishmachine in use, dietary aide (DA)-A was asked to test the sanitizing solution. DA-A obtained a white Ecolab brand test strip from a container with expiration date of 5/1/24, and placed a strip in the water at the bottom of the dishmachine. When she removed the strip, it remained the same white color as when she inserted it into the water. DA-A tested it again with another strip and the color remained white. DS-C stated the test strip should turn dark purple to indicate the required 50 to 100 PPM (parts per million) to ensure proper disinfection of dishes. A paper log titled Dishwasher Temperature and PPM Levels had been on a clipboard hanging on the wall. The log indicated for every reading since 10/1/23 through 11/6/23, the PPM for testing the sanitizing solution was consistently 100 PPM, three times a day. DA-A admitted it was possible staff were writing the desired PPM on the log, but not actually getting those readings with the test strip. DS-C stated she would immediately contact the Ecolab representative. During an interview on 11/06/23 at 1:21 p.m., after speaking to the Ecolab representative, DS-C stated she became aware she had not primed the tubing when she replaced the 5 gallon bucket of Ecolab Ultra San (sanitizing solution) on about 10/31/23, and therefore sanitizing solution had not entered the dishmachine to sanitize dishes. With guidance over the phone from the Ecolab representative, DS-C stated after she primed the tubing, she tested the dishmachine water and the chemical strip indicated 100 PPM. DS-C presented this strip and it had been verified as reading 100 PPM. DS-C admitted that between at least 10/31/23 and 11/6/23, the PPM could not have tested at the required 50 to 100 PPM, yet the dietary staff had not informed her. DS-C admitted she had not monitored the PPM herself. DS-C acknowledged the staff were likely not testing the sanitizing solution, but yet filled in the log with the required PPM reading. During an interview and observation on 11/07/23 at 9:34 a.m., in the kitchen, DS-C was able to point out a priming button on the side of the dishmachine that was to be used to get air out of the line between the bucket of sanitizing solution and the dishmachine so that the sanitizing solution could reach the dishmachine. DS-C admitted she did not know about this button and this process until she spoke to the Ecolab representative. DS-C stated, I didn't know that .no one told me .I've been working here a year and had no clue. DS-C stated she understood the implication of improperly sanitized dishes causing illness in residents. DS-C stated she was not aware of the facility having an infectious outbreak and this was confirmed with the director of nursing (DON) who was also the infection preventionist. During a telephone interview on 11/07/23 at 11:09 a.m., the registered dietician (RD)-D stated she was at the facility once a month. RD-D stated she was unaware of the dishmachine sanitation solution being below the required PPM and thought the Ecolab representative should have been monitoring that. RD-D admitted not doing audits for regulatory compliance in the kitchen, but usually did a walk-through and could usually tell if there had been a problem, however had not observed verification of PPM for dishmachine sanitation solution. During an interview on 11/07/23 at 11:46 a.m., the administrator stated she would have expected dishmachine concerns to have been identified before now. The administrator stated the maintenance manager (MM)-A who used to be the dietary manager, told the administrator the sanitizer solution bucket needed to be changed before it ran out, then the tubing would not need to be primed. During an interview on 11/07/23 at 12:50 p.m., MM-A stated when she had been the dietary manager, she had not let a bucket of sanitizer solution go empty before adding a new bucket, then made sure to watch the solution to go up the tubing into the dishmachine. During a return call, telephone interview on 11/10/23 at 10:55 a.m., Ecolab representative (ER)-E stated when using the Ecolab Ultra San sanitizing solution in this application, the PPM should be between 50 and 100 PPM. ER-E stated there was no required dishmachine water temperature range for this product; just that it could not be a very high temperature. ER-E stated Ecolab had been at the facility quarterly for preventive maintenance checks on the dishmachine and before leaving, measured and verified the correct PPM. ER-E stated he had a scheduled inservice on the dishmachine at the facility on 11/13/23. The facility Cleaning Dishes/Dish Machine policy dated 2021, indicated prior to use, proper temperature and/or chemical concentrations and machine function should be verified. For low temperature dishwasher, 50 PPM hypochlorite.

Based on interview and document review, the facility failed to submit accurate and/or complete data for staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data during 1 of 1 quarter reviewed (Quarter 3, 2023), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. Findings include: During an interview on 11/07/23 at 2:50 p.m., facility PBJ Staffing Data Report for quarter 3, 2023 (April 1 - June 30), was reviewed with the administrator. The specific metric titled: failed to have licensed nursing coverage 24 hours/day had been triggered for the following infraction dates: 5/20/23, 5/21/23, 5/30/23, 6/17/23, 6/26/23, 6/27/23, 6/30/23. The administrator stated the PBJ report was not accurate; that the facility had licensed nursing staff on duty on the infraction dates. Time cards and staff schedules were requested for the infraction dates identified on the PBJ report. Documents for the infraction dates were provided by the director of nursing (DON) and administrator and included: 1) Daily Nursing Staffing forms 2) agency invoices and 3) nurse timesheets. All three documents indicated there had been licensed nursing coverage 24 hours/day for each of the infraction dates. During an interview on 11/08/23 at 10:10 a.m., the administrator stated, I know what I did .I forgot to include agency nurse hours in the data submitted for the PBJ report. The administrator acknowledged that the data submitted for the PBJ report for the infraction dates had indeed been inaccurate due to excluding agency nurse hours. Facility Assessment with review date of 8/20/23, indicated there would be one RN or LPN for day and evening shifts, with no change related to the day of the week.

Based on observation and interview, the facility failed to ensure controlled substance medications were stored in a separately locked, permanently affixed compartment in refrigerator of storage room. In addition, the facility failed to ensure timely removal of expired stock medications of medication cart and storage room. Findings include: On 11/7/23 at 9:18 a.m., medications in medication cart were reviewed with licensed practical nurse (LPN)-A, noted several expired medications, including resident prescribed medications and stock medications. Expired medications included, 1. Stock over the counter (OTC) acetaminophen liquid pain relief 160mg/5ml, 473ml bottle, approximately 1/2 full, expiration date on bottle 10/23, medication remained in med cart for use. A tour of the medication storage room was conducted with LPN-A on 11/07/23 at 10:11 a.m. Door to medication storage room was locked upon entering, cupboards in storage room containing stock OTC medications were reviewed with LPN-A, noted several expired medications including 4 bottles of aspirin 81mg tablets, all unopened, exp. date on all bottles 10/23; 2 bottles of zinc 50mg all unopened, exp. date on all bottles 10/23; 2 bottles of melatonin 3mg, all unopened, exp. date on all bottles 10/23; 1 bottle of liquid pain relief acetaminophen 160mg/5ml- 473ml bottle unopened, exp. date on bottle 10/23. LPN-A stated stock OTC medications in cupboard of storage room were used for residents per physician standing orders/physician orders, confirmed stock OTC medications in cupboard in storage room were expired and should've been removed, stated would ensure all expired stock OTC medications were removed immediately. A portable (moveable) refrigerator, used for storing refrigerated medications was reviewed with LPN-A. LPN-A was observed to unlock portable refrigerator door, noted a small clear locked E-kit container. E-Kit container visualized and consisted of 1 small stock vial of injectable lorazepam (an anti-anxiety medication/controlled substance) on shelving rack, 3 bottles of lorazepam- 2mg/ml oral concentrate (30ml) prescribed to R14 noted in rack of portable refrigerator side door. Although, the medications were double locked, the refrigerator was not permanently affixed. During an interview, on 11/07/23 at 10:27 a.m., LPN-A indicated medication cart was gone through by any nursing staff able to administer medications daily to remove any expired stock and resident prescribed medications, stated medication storage room was gone through by nursing staff able to administer medications monthly to remove any expired stock and resident prescribed medications. LPN-A indicated any removal of controlled medications was completed with 2 licensed nursing staff. LPN-A reported awareness that controlled substance medications needed to be stored in an area providing 2 separately locked, one permanently affixed compartment, stated she was unsure why this hadn't been completed for the controlled substance medications stored in portable refrigerator. While interviewed on 11/07/23 at 11:31 a.m., the director of nursing (DON) stated staff were aware and it was her expectation for staff to check all medications in medication cart and medication storage room daily for expiration and non-use of and remove when indicated. The DON reported awareness that controlled substance medications needed to be stored in an area providing 2 separately locked compartments, stated was not aware controlled substance medications needed to be locked in a permanently affixed compartment. The DON indicated controlled substance medications to be refrigerated were kept in facility locked medication storage room, within a locked portable refrigerator, stated she thought process used for controlled medication substance storage was sufficient at time, would ensure process for controlled medication storage was corrected immediately. The facility Medication administration policy revised 5/23, indicated all medications require an order, all orders are valid for the specified number of days/doses ordered, Orders that do not specify the number of days/doses ordered are valid per physicians signed renewal of medications and treatments, Check labels for accuracy and expiration dates, All OTC medications are stored in medication carts or secured in locked cabinets, All new vials/inhalers/eye drops/nose sprays are marked with date they were opened. Safe handling, storage, & security of medication I. Schedule II-V controlled medications are to be stored in a separate area under double lock. (Does not indicate affixed compartment) M. Outdated, discontinued, contaminated, unwrapped, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of.

Based on observation, interview, and document review, the facility failed to provide a safe environment, ensuring residents who smoked had smoking products/devices used for smoking secured to prevent accidents for 1 of 2 (R15) reviewed for accidents/hazards. Findings include: R15's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R15 had intact cognition, displayed no behaviors, was independent of activities of daily living (ADLs), had impairment to left lower extremity, used a walker and wheelchair for mobility, and was a tobacco user. R15's face sheet printed on 11/8/23, included diagnoses of an unspecified brain disorder, chronic embolism and thrombosis of femoral vein (blood clot in leg), nicotine dependence, and weakness. R15's care plan printed on 11/8/23, indicated for staff to conduct smoking safety evaluation on admission and as needed (PRN) to ensure safe to smoke, educate resident/responsible party on facility's tobacco/smoking policy(s), and to orient resident to smoking times and procedures. Care plan lacked information provided to resident/staff on education for securing tobacco products/devices securely within facility. R15's smoking and safety assessment completed on 8/30/23, indicated R15 used tobacco products, had balance problems while sitting or standing, followed the facility's policy on location and time of smoking, and was deemed safe to smoke unsupervised. During an observation and interview on 11/06/23 at 1:59 p.m., R15 was noted to have a table with a lunch tray sitting on top in room. On the lunch tray observed a cigarette rolling machine, a bag of tobacco with loose tobacco spread all over tray, and cigarette filters. On a tray table next to bedside visualized a Marlboro menthol cigarette pack and a lighter. On bedside table observed a carton of Marlboro menthol cigarettes, 9 packs of unopened cigarette packs contained within carton. R15 reported was independent of smoking, denied any accidents/injuries when smoking, stated could smoke outside of facility on patio whenever he wanted to, placed extinguished cigarettes into a receptacle placed on patio. R15 reported able to keep tobacco products/devices used for smoking in room, was unaware if needed to keep tobacco products/devices secured in room, stated was never told per staff he needed to keep tobacco products/devices secured in room, indicated staff aware of tobacco products/devices left open in room. While interviewed on 11/07/23 at 3:26 p.m., LPN-A indicated residents were able to smoke while residing at facility, residents who smoked had to smoke outside of building in patio area, when finished smoking residents needed to discard cigarettes in receptacle located on patio prior to coming back into facility. LPN-A reported awareness of R15 being a smoker, unaware if R15 had a smoking safety assessment completed as DON completed all resident smoking safety assessments. LPN-A indicated awareness of R15 having tobacco products/devices used for smoking unsecured in room, reported unawareness if residents needed to keep tobacco products/devices used for smoking secured in room or secured in another area for supervision, stated she had not been informed resident's tobacco products/devices used for smoking needed to be secured. During an interview on 11/07/23 at 4:50 p.m., the director of nursing (DON) indicated was responsible to complete smoking safety assessments for all residents who smoked, stated assessments were completed upon admission, quarterly, significant change in conditions, or any time resident appeared unsafe while smoking. The DON indicated if residents were deemed independent with smoking, residents could keep tobacco products/devices used for smoking in room, stated residents needed to keep smoking products/devices in a secured location within room. The DON stated all residents independent of smoking were provided education on securing tobacco products/devices used for smoking at time of admission, education provided to residents was contained in resident admission packet, as well as in resident's care plan. The DON stated R15 was independent of smoking, was able to keep tobacco products/devices used for smoking in room, reported unawareness if R15's smoking products/devices were unsecured in room. The DON stated staff were aware of all residents who smoked, indicated staff were aware and expected to ensure residents who smoked were keeping tobacco products/devices used for smoking secured in room and if there were concerns to notify DON. While interviewed on 11/08/23 at 8:17 a.m., LPN-B indicated awareness R15 was independent with smoking and was aware R15 kept smoking products/devices unsecured in room. LPN-B reported unawareness of responsibility to ensure residents kept smoking products/devices secured in room, verified R15's care plan lacked any documentation for staff and/or residents to ensure smoking products/devices were kept secured in room. During an interview on 11/08/23 at 8:50 a.m., the DON indicated was responsible for initiating and updating care plans. The DON reviewed R15's care plan regarding securement of smoking products/devices, The DON confirmed lack of documentation provided for staff awareness. The DON verified potential risk for accidents/hazards and fire safety with not having R15's tobacco products/devices secured in room. The DON stated would update R15's care plan and educate staff to ensure all residents independent of smoking had smoking products/devices secured appropriately. The facility Rules and Regulations for [NAME] Care and Rehab procedure undated, indicated Smoking: Smoking within the facility is prohibited for visitors, employees, and residents. Residents may smoke outside. All smoking materials will be maintained at the nurse's station or concealed in your room and supervision will be provided by facility associates if deemed necessary by physician and/or nursing staff.

Based on interview and document review, the facility failed to ensure allegations of missing money/theft was reported to the state agency (SA) within 24 hours, in accordance with established policies and procedures, for 1 of 1 resident (R4) reviewed for personal property. Findings include: R4's face sheet printed on 11/8/23, indicated R4's diagnoses included anxiety, major depressive disorder (mood disorder), personality disorder, hoarding disorder, and insomnia (sleep disorder). R4's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R4 had intact cognition, required supervision of 1 staff for bed mobility and transfers, substantial/maximal assistance of 1 staff for ambulation in room and on unit, was independent of use of wheelchair in room and on unit. R4's care plan received on 11/9/23, indicated for staff to maintain R4's safety due to mood disorder. Review of facility investigation report indicated R4 informed licensed practical nurse (LPN)-A on 12/31/22 at 1:40 p.m. she was missing $200 (2- $100 bills) she had received from her mother on 12/29/22, LPN-A immediately notified director of nursing (DON) of R4's allegations of missing money, DON then notified the administrator of allegations. The DON contacted R4's family and confirmed $200 had been placed in a card within an envelope and delivered to facility. Report indicated R4's allegations of missing money was not reported per facility until 1/24/23, the DON contacted local law enforcement and filed a report with SA. Report indicated local law enforcement investigated incident, verified money had been received per R4 while at facility, unable to confirm allegation of staff theft. During an interview on 11/06/23 at 3:52 p.m., R4 indicated had $200 in cash sent to her in an envelope from her mother for Christmas, kept letter containing $200 in room, noticed money was no longer in envelope and was reported missing to staff. R4 stated she could not remember exact date money went missing and was reported to staff, reported incident occurred approximately end of 12/22. R4 indicated staff looked for missing money immediately after she reported money missing, stated staff could not locate missing money, reported she believed money was taken by a staff member, could not identify any staff when asked during interview. R4 indicated since incident, staff provided her a lockbox in room for safe keeping of money, reported only she had access to money in lockbox as she was only person aware of location for key to lockbox. While interviewed on 11/07/23 at 2:23 p.m., NA-A indicated awareness of incident with R4's $200 being reported missing. NA-A stated incident occurred approximately end of 12/22 and was reported right away to administrator and DON, indicated staff looked for R4's missing money for several weeks, money was unable to locate. NA-A reported R4 alleged a staff member took her money, stated she could not remember staff member R4 identified taking money. During an interview on 11/07/23 at 3:03 p.m., LPN-A indicated R4 initially reported to her $200 went missing from R4's room, stated when R4 reported incident to her she immediately contacted DON, staff searched R4's room and all over facility areas looking for missing money reported per R4, indicated staff looked for several weeks for missing money, unable to locate missing money. LPN-A indicated R4's report of missing money was reported to law enforcement, stated DON had reported, unaware when DON reported incident to law enforcement. LPN-A stated at time of admission, residents were offered personal trust account for money management, residents informed to not keep cash on hand to avoid losing and possible theft of, indicated following incident R4 had a lockbox implemented for securing money on hand. While interviewed on 11/07/23 at 4:48 p.m., the DON stated she was notified on 12/31/22 per LPN-A of R4's allegations of missing money, DON confirmed she had not reported allegations of missing money within 24 hours to local law enforcement, indicated allegations of missing money had not been reported to local law enforcement until 1/24/23. DON was asked why she reported allegations of missing money late, DON stated incident occurred awhile back and couldn't remember all the details, would review investigation report and follow-up with surveyor. During an interview with the DON and administrator on 11/08/23 at 8:38 a.m., the DON stated when R4 reported missing money on 12/31/22, thought to search for missing money first and forgot to report to SA. The administrator indicated R4 had a mental illness including history of fabrication (false claims), stated R4 was not always truthful and wanted evidence before filing report. The administrator indicated awareness of 24-hour reporting time frame for allegations of possible theft, confirmed R4's allegations of missing money should have been reported immediately upon learning of incident on 12/31/22. The facility Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property policy revised 2/23; indicated each covered individual shall report to the state agency and one or more law enforcement entities, any reasonable suspicion of a crime against any individual who is a resident of or is receiving care from the facility and each covered individual shall report immediately, but not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. Examples of situations that would likely be considered crimes include, but are not limited to: -Theft/Robbery

Based on observation, interview and document review the facility failed to ensure that medication was administered according to standard of practice when using an insulin pen for 3 of 3 administrations observed for 2 of 6 residents (R1 and R10) receiving insulin at the facility. This resulted in a greater than 5% error rate at 11% for the facility. Findings include: During an observation on 6/29/22, 7:20 a.m. a licensed practical nurse (LPN)-A checked the medication administration record (MAR) for R10 to determine the insulin he was to receive. LPN-A removed an insulin administration pen (a container pre-filled with insulin that can be used to directly administer insulin without having to draw the medication into another syringe) that matched the MAR. The MAR and the label on the pen indicated the medication belonged to R10 and contained NPH insulin and R10 was to receive 18 units subcutaneously. LPN-A was observed to clean the tip of the pen with an alcohol swab and apply a disposable needle under a cap. LPN-A then turned the dial on the pen to match the ordered dose of 18 units without removing the cap over the needle. LPN-A then went directly to R10's room where she applied a pair of gloves and notified R10 that she was going to administer his insulin. The two of them identified an appropriate site, LPN-A cleansed the area with alcohol, removed the cap from the insulin pen, pushed the needle into the fatty abdominal tissue, quickly injected the 18 units, held the pen in place for about 3 seconds and then removed it. LPN-A disposed of the needle and went to the MAR to document the insulin as having been given. During an observation on 6/29/22, 7:31 a.m. LPN-A checked the MAR for R1 and removed two insulin pens from the medication cart. LPN-A checked the labels against the MAR and determined that R1 was to receive 16 units of [MEDICATION(S)] insulin and 12 units of [MEDICATION(S)] insulin. LPN-A cleaned the tip of each pen, applied the needle and checking the MAR again, dialed the dose on the pen to match the ordered dose on the MAR. Using appropriate hand hygiene and gloves, LPN-A went to R1 in a private area, cleansed his skin on a site of his left abdomen. LPN-A removed the cap from the needle to the [MEDICATION(S)] insulin, inserted the needle in the clean site, rapidly administered the insulin into the fatty tissue and after a few seconds removed the needle. LPN-A then cleaned a site on R1's right abdomen and repeated these steps with the [MEDICATION(S)]. LPN-A then returned to the medication cart, disposed of the needles and returned both insulin pens to the cart, then documented the administrations as having been given. When interviewed on 6/29/22, 11:17 a.m. LPN-A stated the proper procedure for using an insulin pen was to alcohol the pen, attach a needle and then express two units, then dial up the dose. LPN-A stated she did not recall having removed the cap from the needle and did not recall that she had expressed two units to prime the needle. LPN-A stated the needle should be primed prior to giving the dose so the resident receives the correct dosage. When interviewed 6/30/22, 12:22 p.m. the facility director of nursing (DON) stated the proper procedure for the use of an insulin pen what to do the initial label check against the MAR, clean the pen with alcohol and apply the needle. Following the application of the needle, DON stated the needle should be primed with 2 units of insulin and then the dose dialed. Following this, the nurse should go to the resident, explain the procedure, locate and clean the site and administer the insulin into fatty tissue, holding the pen in place for a few seconds so all of the insulin goes into the tissue. DON was not able to state an action to take if no insulin was seen coming from the needle when primed, I don't know, as long as you use 2 units, you are pretty safe. The DON stated the needle must be primed to ensure the resident receives an accurate dose. DON stated not priming the needle could result in inaccurate dosing and blood sugar instability. A facility policy titled Use of Insulin Pens last revised June, 2022, indicated the proper procedure for the device was as follows: Attach a safety pen needle to the pen device. A 2-4-unit prime is performed before every insulin injection to ensure a small amount of fluid flows through then end of the needle. If necessary, repeat until this occurs. Correct insulin dosage should be dialed and rechecked against resident ' s prescription prior to administration. Maintain a 10 second wait following delivery of insulin before removing the needle from the skin to ensure full dose delivery and leakage from the site.

Based on interviews and record reviews, facility failed to provide an opportunity for 2 of 2 residents (R10 & R12) to participate in a formal care conference to facilitate person centered care planning. Findings include: According to R10's Quarterly Minimum Data Set (MDS) assessment dated [DATE], R10 was cognitively intact and had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . When interviewed on 6/27/22, at 3:04 p.m. R10 stated he could not recall ever having been invited to a care conference (CC). He said he would go to resident council meetings, but had not been to a personal meeting regarding his care that he could recall. During the interview, R10 discussed various concerns about his medical care, his medications, the facility physician, his transplant team and coordination of care; as well as, his diet, the facility provided foods, activities, care of personal items and a wish to live in a different facility. R10 stated it was possible the facility had contacted his wife, but he had not received any notification that a CC was to be held and would like to have had. When interviewed on 6/29/22, at 10:03 a.m. the director of nursing (DON) stated she had a form that she filled out when any resident's quarterly MDS was due, and generally most of their CCs were a simple phone conversation going over that form. The DON stated the paper form was then scanned in to the resident's chart. When asked the DON was unable to locate documentation in R10's chart that a CC had occurred. DON was not able to say if R10 had been invited to a CC and did not know, without any record if a CC had been held for him since his admission approximately a year ago. DON stated this was not acceptable. According to R12's 5 day admission MDS dated [DATE] (a readmission after hospitalization ), R12 was cognitively intact and included diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . When interviewed on 6/28/22, at 11:11 a.m. R12 stated he was frustrated as he had not been feeling well. R12 said he felt like he was going backwards. R12 stated he was unsure what the facility was doing to help him with his health conditions. He expressed frustration that he was not receiving therapy, and he was unsure why that was. R12 stated he could not recall attending a care conference. When interviewed on 6/29/22, at 10:08 a.m. the DON stated she was not able to find evidence of any CC notes for R12 upon review of the chart. To prepare for CC, DON stated she gathered input from members of the interdisciplinary team (IDT), but a CC was generally completed by the DON alone. DON stated she was the social service designee for the facility. DON stated records of a CC should be accessible. A facility policy titled Care Planning, dated January 2013, indicated The Administrator is the Care Plan/ MDS Coordinator. She sets up the schedule in PCC [Point Click Care, the facility electronic health record platform] for both according to Federal Regulations. 2. The Director of Nursing shall provide a copy of the Care Planning schedule to the Dietary Manager and Activity Director and/or Social Worker (if available), who are members of the IDCT. 3. The Activity Director shall invite the resident and/or appropriate family member to the care conference via letter, phone, or in person. 4. The Activity Director will make an attempt to schedule care planning conferences at the best time of the day for residents and families. 5. At the Care Plan Conference residents and family member will be asked whether they have brought questions or concerns to the attention of facility staff. 6. The Activity Director shall maintain a record of who has been invited, who declines to attend, who fails to respond to the invitation, and who actually attends. 7.Family/resident attendance shall be documented on the Care Plan. 8. In the absence of the Activity Director, the Dietary Manager will schedule the Care Plan Conferences. And in the absence of the Dietary Manager the DON will issue the invites.

Based on observation, interview and document review, the facility failed to ensure resident right to personal privacy for 1 of 1 resident (R3) when staff enter residents room during provision of dressing change cares, fully exposing resident buttocks. Findings include: R3's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R3 had moderate impaired cognition and required extensive assistance from 2 staff with bed mobility, dressing, and personal hygiene. The MDS also indicated R3 had impairment of both upper and lower extremities. R3's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation, on 6/29/22 at 10:00 a.m., while staff were providing dressing changes to R3's lower back and buttocks; housekeeping (HSKP)-A, opened R3's door to room wide without knocking. HSKP-A asked staff present in R3's room to hand her R3's water pitcher for re-filling. At time of R3's opened room door, surveyor observed R3's neighboring resident looking towards R3's open doorway; R3 was lying on stomach in bed, buttocks fully exposed. During an interview, on 6/29/22 at 1:00 p.m., HSKP-A was asked about proper procedure when entering resident room doors, HSKP-A indicated proper procedure to include knocking on resident door and wait for response to come in. When HSKP-A was asked why she did not knock prior to entering R3's room, HSKP-A indicated she typically does knock on resident room doors prior to entering, was in a hurry to refill all resident room water-pitchers. HSKP-A did confirm that R3's privacy was compromised by opening room door wide and coming in unannounced. HSKP-A stated in future, would knock on door, wait for response to come in. When interviewed, on 6/30/22 at 11:21 a.m., licensed practical nurse (LPN)-A indicated awareness of 6/29/22 incident and R3's right to privacy being compromised. LPN-A stated while she was completing dressing changes to R3's buttocks; HSKP-A opened door to R3's room to get water-pitcher for refilling. LPN-A confirmed HSKP-A opened door wide to R3's, exposed buttocks. LPN-A stated all residents' rooms are private without privacy curtains, resident's privacy can be compromised if performing cares or procedures when opening resident doors. LPN-A indicated all staff should knock and wait for response before opening doors to enter resident rooms. During an interview, on 6/30/22 12:38 p.m., the director of nursing (DON), indicated awareness of 6/29/22 incident and R3's right to privacy being compromised. The DON indicated she was not sure of current plan in place to ensure resident privacy if resident room doors are opened and cares or procedures are being performed on resident at that time. The DON stated it was her expectation all staff should be knocking on resident room doors and waiting for response prior to entering. A facility policy, titled Combined Federal and State Bill of Rights, for Residents in Medicare/Medicaid Certified Skilled Nursing Facilities or Nursing Facilities; revised date 6/18/19, included a section identified as Privacy and Confidentiality and consisted of; the resident has a right to personal privacy and confidentiality, personal privacy includes personal care, facility staff shall respect the privacy of a resident's room by knocking on their door and seeking consent before entering except in an emergency or where clearly inadvisable.

Based on observation, interview, and record review the facility failed to implement and follow therapy intiated programs for 2 of 3 residents (R3, R12) who required range of motion, the use of a splint and walking programs maintain their activities of daily living. Findings include: R3's quarterly Minimum Data Set (MDS) assessment, dated 3/19/22; indicated R3 had moderately impaired cognition and functional limitations in activities of daily living (ADL). MDS also identified bilateral hand contractures, and required extensive assistance with bed mobility, transferring, dressing, personal hygiene, toileting, eating. R3 did not ambulate. The MDS further indicated diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Therapy Recommendations for Nursing Staff, dated 9/28/21; specified orthotic soft resting right-hand splint to be applied at night and removed in morning by nursing staff. R3's Therapy Recommendations for Nursing Staff, dated 9/30/21, updated 10/5/21; indicated nursing staff were to complete assisted AROM and PROM [active/passive range of motion] exercises to bilateral upper extremities to sites including shoulder, elbow, wrist, fingers. Nursing staff were to complete 10 repetitions to each site once daily. Therapy recommendations also indicated nursing staff were to complete PROM to BLE's to sites including ankle, knee, hips. Nursing staff were to complete 8-10 repetitions to each side once daily. Occupational therapy (OT) and physical therapy (PT) treatment encounter notes were requested and not received. On 6/27/22, at 6:34 p.m., R3 was observed sitting in her wheelchair in room. R3's bilateral fingers were visualized to appear tight, rigid, and curled inwards toward palm of hands. When R3 tried to extend her fingers of bilateral hand, fingers observed to straighten slightly, remaining mostly curled inwards to palm of hands. R3 was able to make a fist with left hand, although weak; unable to make a fist with right hand. R3 indicated she had worked in past with PT and OT, although had been several months ago. R3 stated she had not received bilateral upper/lower extremitiy (BUE or BLE) exercise therapy by staff, exercise therapy for BUE was completed independently occasionally, consisted of squeezing foam ball with bilateral fingers of hand. R3 indicated feeling contractures to right hand had worsened since last assessment by OT and PT. During an interview, on 6/30/22 at 10:04 a.m., nursing assistant (NA)-D indicated typically working night shift, was aware of R3's contractures to bilateral hands. NA-D stated R3's bilateral fingers of hand were stiffening, had weakness to bilateral hand, right hand worse than left hand. NA-D stated R3 was not receiving any restorative nursing therapy, was not aware of any exercise regimen to complete to BUE's or BLE's. NA-D indicated R3 had foam balls to use for strengthening of bilateral hand, completed strengthening exercises independently. NA-D stated was unaware of any brace or splint needing to be applied at night-time for contracture to R3's right hand. When interviewed, on 6/30/22 at 10:26 a.m., OT indicated was filling in for day, not regular staff, was not familiar with R3 or therapy needs. OT attempted to look for R3's therapy file, unable to locate. OT stated would check with PT to further assist in finding R3's therapy file. During an interview, on 6/30/22 at 11:00 a.m., licensed practical nurse (LPN)-A indicated awareness of R3's bilateral hand contracture, right side worse than left side. LPN-A stated R3 worked with PT and OT several months ago, had reached plateau and no longer needed services. LPN-A indicated since PT and OT discharge, R3 should have been receiving restorative nursing services. LPN-A stated when receiving orders from PT and OT for continued resident therapy; PT and OT staff communicate and provide resident orders directly to nursing staff, nursing staff then places resident therapy orders for all staff to review into a white binder labeled, Therapy sheets for Residents. LPN-A indicated nursing staff provides a copy of the resident's therapy order to the director of nursing (DON), DON then places the resident's therapy order into their care plan and NA assignments through the electronic medical record (EMR) system, which then triggers tasks for NAs to complete on their assignment sheet during their shift. LPN-A stated resident therapy orders are communicated to all staff during change of shift report as well. LPN-A indicated awareness of R3's exercise regimen, stated NAs were to perform range of motion (ROM) to BUE's; R3, independently, should be completing strengthening to bilateral hand by squeezing foam ball in hands. When interviewed, on 6/30/22 at 11:24 a.m., PT indicated R3 was evaluated and offered services, but never wanted to participate, just wanted to be left alone in bed in room. PT stated R3 had orders for continued AROM and PROM exercises to BUE's and BLE's, should be continued restoratively to prevent deconditioning to BUE's and BLE's. PT indicated since R3 would refuse to participate in therapy services, R3 reached plateau, discharge orders consisted of re-evaluation if deconditioning occurs or on an as needed (PRN) basis. During an interview, on 6/30/22 at 12:51 p.m., the director of nurses (DON) indicated unawareness of R3's therapy orders consisting of; soft splint to be applied at night and removed in morning, exercise regimen for AROM and PROM to be completed to BUE's and BLE's. The DON stated resident therapy orders are entered into their care plan and NA Kardex, assignments, through the EMR system by her or other nursing staff. The DON indicated when resident therapy orders are entered on NA Kardex, NAs can view tasks needing to be completed for resident during shift. The DON reviewed R3's care plan and NA assignments, confirming R3's care plan does contain AROM and PROM exercises to be completed to BUE and BLE daily, as well as soft resting right-hand splint to be applied at night and removed in morning. The DON indicated upon further review, R3's therapy order for soft resting right-hand splint application and exercise therapy to be completed to BUE's and BLE's was entered into EMR system incorrectly. The DON stated R3 should have received soft resting right-hand splint application and exercise therapy to BUE's and BLE's, and confirmed those services were not provided as ordered per therapy recommendations. On 6/30/22 at 3:59 p.m., PT re-evaluated R3's bilateral hand contractures and indicated continued stability with no new or worsening changes in condition. R12 When interviewed on 6/28/22, at 11:11 a.m. R12 stated he was frustrated as he had not been feeling well. R12 said he felt like he was going backwards. R12 stated he was unsure what the facility was doing to help him with his health conditions. He expressed frustration that he was not receiving therapy, and he was unsure why that was. Druing a follow up interview on 6/29/22, at 11:42 a.m. R12 was unable to state how frequently staff offered to walk him, but said sometimes he is in pain, or is not feeling strong enough, but he could not relate a frequency. R12 stated he was willing to go for a walk on 6/29/22, but it had not been offered. According to R12's 5 day admission MDS dated [DATE] (a readmission after hospitalization ), R12 was cognitively intact, had disgnosis including cancer, diabetes, heart failure, [CONDITION(S)] mental illness, renal issues and [CONDITION(S)] among other co-morbidities. According to a written physical therapy recommendation dated 5/18/22, R12 was to be walked at least 50 feet, 1-2 times per day with a four wheeled walker. According to R12's care plan, R12 has a focused problem area for activities of daily living dated 3/31/21 with an updated intervention added 3/15/22 that indicated R12 had a walking program and he was to be walked with a four wheeled walker 2-3 times daily by nursing for a distance of 50 feet with stand by assist. According to R12's electronic health record in the section titled tasks over the past 21 days, R12 was marked one time as being independent in ambulation, and the remainder of all entries, one per shift, documented the activity (ambulation) did not occur. When interviewed on 6/29/22, at 11:50 a.m. a licensed practical nurse (LPN)-A stated R12 was able to walk with a cane, but LPN-A did not know a frequency. LPN-A stated a belief that R12 didn't want to walk. When interviewed on 6/29/22, at 11:53 a.m. a nursing assistant (NA)-A stated R12 liked to walk but was unable to state a frequency with which R12 should be walked saying, we try to walk anyone who can walk. If we offer, and they refuse we chart that. When interviewed on 6/29/22, at 11:58 a.m. NA-B stated the only way she knew of who to walk in the facility was because she had learned it. NA-B stated R12, is not walking, he is in wheel chair. He just need some help. He can use wheel chair and can transfer himself. When interviewed on 6/30/22, at 10:03 a.m. an occupational therapist (OT) stated R12 had been receiving therapy, but had been discharged . OT stated therapy would write recommendations for the nursing staff to follow after discharge to maintain abilities. OT stated she believed the information was posted in a communication book for nursing assistants. When interviewed on 6/30/22, 11:14 a.m. a physical therapy aide (PTA) stated R12 had been receiving therapy to work on strengthening and ambulation. PTA stated recommendations had been provided to the nursing department to carry on the work after discharge from therapy services. PTA stated an expectation for nursing staff to follow the recommendations, or at least offer ambulation or exercise to the resident. PTA stated R12 may suffer a decline because he does not always like to do the exercise, but stated the nursing staff should offer regardless. PTA also stated any complaints from R12 about getting weaker should be reported to therapy so that he could be screened again to see if he might need therapy to be reinstated. PTA expressed concern that if R12 did not walk twice daily as recommended he would lose strength and would not be safe when he would next try to walk. PTA said the facility had a weekly meeting to go over caseloads and concerns, but could not recall anyone saying R12 was refusing to walk or that his condition had changed. When interviewed on 6/29/22, 12:16 p.m. director of nursing (DON) stated nursing staff should be able to access information about a resident's mobility on their electronic health record. DON stated an expectation for staff to follow therapy recommendations and if R12's chart said he was to be walked 1-2 times per day, they were to offer to walk him 1-2 times per day. DON said if documentation on the health record task list indicated activity did not occur it meant the staff had not walked the resident or had not completed the designated task. DON stated if a resident indicated they thought they were getting weaker, this should be reported to the charge nurse who should then try to figure out what was going on, including the involvement of the therapy department. DON also stated a resident's care plan should be updated as to why a resident is not walking or how they should be walked if that had changed. Facility policy and procedure titled, Range of Motion Screening, Voluntary Movement ROM Assessment, revised 10/17 and reviewed 3/14/19, consisted of; program description and rationale: to promote each resident's ability to maintain or regain the highest degree of independence as safely as possible, to promote wellness and debilitation, includes, but is not limited to programs in range of motion, splint or brace assistance. Policy: each resident will be screened for restorative nursing upon admission, annually, and with any significant change in function, appropriateness for a restorative program will be determined by the interdisciplinary team as needed and/or may be determined as a continuation of care following a course of physical, occupational, or speech therapy, licensed personnel supervise the restorative nursing programs, documentation of the interventions and the resident's response will be completed with each implementation, each resident's progress will be evaluated quarterly and with any change of condition, monthly nursing documentation should address resident functional status in relation to the plan of care. A facility policy for contractures was requested, but was not received. A facility policy last revised August of 2017 and titled Ambulation and Transfers policy, indicated Ambulation will be a part of every resident ' s daily routine as allowed by their status. Furthermore, the policy indicated nursing was to follow restorative programs that had been developed for residents.

Based on observation, interview and record review, the facility failed to follow intervention in place to prevent potential for injury for 1 of 1 resident's (R8) when the care plan was not followed when transferring a resident off the floor. In addition,, the facility failed to identify a potential hazard for 1 of 1 resident (R10) who was observed with a hot glue gun. Findings include: R8 According to R8's quarterly Minimum Data Set (MDS) assessment dated [DATE], R8 had severe cognitive impairment. R8 had a diagnosis of non-traumatic [CONDITION(S)] and Alzheimer's disease, history of stroke and [CONDITION(S)] (brittle/porous bones related to aging). The MDS indicated R8 required the extensive assistance of two persons to transfer, did not have steady balance and walking did not occur. Furthermore, the MDS indicated R8 had limited range of motion of both lower extremities. R8's care plan had a focused problem area dated 7/13/20 that indicated a problem with self-care and an intervention last updated 11/26/20 was listed as, TRANSFER: The resident requires assistance with transfer with 2 of care team members for assistance with transfers. May need to use EZ stand (mechanical lift) prn (as needed), Provide direction by using short, simple instructions. Provide resident with step-by-step guidance during transfer process, encouraging their participation as much as possible. On 6/27/22, at 4:32 p.m. R8 was observed crawling on the fall, coming out of the door to her room. R8 stated, I'm okay, I just want to talk to (my neighbor). R8's bed was noted to be lowered all the way to the floor, and a thick cushion was placed next to the bed. A tab alarm system was in place, but the alarm had been somewhat disassembled. When staff came to attend to R8, the director of nursing (DON) and a nursing assistant applied a gait belt, but had difficulty getting R8 to her feet and into a wheelchair. The DON said, (R8) is known to do this, she will turn off her fall alarm and get out of bed, that is why her bed in down to the floor with a fall mat next to it. R8 was not put back to bed at that time. On 6/29/22, 11:58 a.m. R8 had been sitting in a recliner in the living area of the facility watching television. Two nursing assistants, (NAs)-A&B approached R8 and informed her that it was time for lunch. The NAs placed a gait belt loosely around R8's waist. It drooped down near her buttocks as she was scooted to the edge of the chair. R8's wheelchair had been placed about three feet away. NA-A and NA-B leaned over R8, and each of them hooked an arms under her armpit area, grabbed the gait belt and prompted her to stand while they pulled under her arms and on the belt. The gait belt slid up R8s back and up into her armpit region as well. R8 did not bear any weight on her legs, but buckled at the knees and sagged, hanging by the belt and arms. R8's arms went up at the shoulder and her legs were bent under her. NA-A tried to reach the wheelchair, but could not quite reach it, and instructed NA-B to grab it. NA-B let go of the gait belt and grabbed at the chair and was able to drag it closer. R8 continued to sag and hang from their hooked arms and the gait belt under her arms, and NA-A and NA-B dragged her the last few feet to the wheelchair and turned to set her on the seat. NA-A then took R8 to the dining area. When interviewed immediately following the transfer, NA-B stated the only way she knew of how to transfer a resident was because she had learned it. NA-B stated the transfer had been done correctly because two persons and a gait belt had been used. NA-B did not think a mechanical lift had ever been used for R8. When interviewed on 6/29/22, 12:16 p.m. the DON stated the facility completed assessments to determine the best way to safely transfer any of the residents. DON stated, in general, a two person assist should be accomplished by, snuggly applying a gait belt, allowing only two finger widths of space between the belt at the resident's waist. The staff should then assist the resident to stand by grasping the gait belt in the back and pull on the belt and prompting the resident to stand. If the resident started to sag or the belt slip, DON stated they should be allowed to sit back down, and then the gait belt should be reapplied. DON also stated that if the resident was unable to safely support their weight with a two person assist and gait belt, the staff should get an EZ stand. DON stated underarm hooking and lifting a resident was not appropriate and stated the following concerns, dislocation could occur, the muscles could get over stretched; we don't chicken wing them. The DON stated all residents had a care sheet describing what type of cares to give and all nursing staff could access the information. When interviewed on 6/30/22, 11:14 a.m. a physical therapy aide (PTA) stated concerns when a gait belt is not sufficiently snug, and lifting under the arms was not safe transfer technique. PTA also stated, if a resident is slipping or sagging it would be easy for the resident or the staff to get their feet tangled and for a fall or injury to occur. PTA stated a person who does not bear weight when approached for a transfer could be left, and reapproached a bit later, or staff could offer the use of the EZ Stand. A policy titled Ambulation and Transfers and last updated August, 2017 indicated the procedure for transfers was to consult the care plan; to apply the gait belt around the resident's waist snugly to eliminate the possibility of sliding up on the ribs and to bring the resident to a standing position by grasping the belt with both hands while remaining upright, and creating a broad base of support by spreading feet. Finally, the procedure indicated to return the resident to a comfortable position in the wheelchair; however, did not provide information on how best to perform this. The procedure did not indicate what to do if the resident was unable to follow instructions. R12 According to R12's 5 day admission MDS dated [DATE] (a readmission after hospitalization ), R12 was cognitively intact, newly diagnosed cancer, diabetes, heart failure, renal issues and [CONDITION(S)]. The MDS also indicated the use of oxygen. According to R12's care plan, R12 has a focused problem area for acute/chronic pain related to diabetic [CONDITION(S)], last updated 5/11/22; however, the care plan did not address safety issues that might arise in relation to his [CONDITION(S)]. Hazards related to oxygen use were not included in R12's care plan. When interviewed on 6/28/22, 11:11 a.m. R12 stated he was frustrated as he had not been feeling well. R12 said he felt like he was going backwards. R12 stated he was unsure what the facility was doing to help him with his health conditions. R12 was observed to rub his left arm, and stated he had problems with pain and sensation in that limb. R12's room was observed to have a large table with craft items scattered about including paints, stickers, papers (flammable items), and a hot glue gun that was laying on its side on the vinyl table cloth, but was not plugged in. R12 was observed to utilize oxygen via nasal cannula at all times. During an observation and interview on 6/30/22, 8:51 a.m. R12 was observed seated at his craft table working on a project decorating garden trolls. His oxygen was in place and infusing. At that time, R12 expressed frustration that he was not able to use his hands as well as he used to due to his [CONDITION(S)]. R12 stated he was not as adept at handling things, and in fact, had dropped one of the gnomes the other day. The hot glue gun was within a few inches of where he was working, and laying on the flammable vinyl table cloth and near combustible items, but was not plugged in. R12 was unsure of when he had last used the hot glue gun. When interviewed on 6/30/22, 10:03 a.m. an occupational therapist (OT) stated R12 had received therapy services, and they had worked on strengthening, endurance and pain control. OT stated R12 was somewhat limited in his ability to use his left arm because of pain. OT was aware that R12 enjoyed doing craftwork, but was not aware he has been using a hot glue gun. OT expressed concern that R12 might drop the glue gun, or should he touch it and/or hot glue would land on his skin, with [CONDITION(S)] he might not be able to feel the heat and respond appropriately. When interviewed on 6/30/22, 12:01 p.m. DON stated she was aware that R12 had a hot glue gun in his room, but was not sure when it was last used. DON stated R12 has been known to use the hot glue gun, and he had decorated his cell phone with glued on gems. DON expressed concern that the hot glue gun was a potential source of heat that might be a fire hazard and when using oxygen, R12 would be at a higher risk for injury should a fire occur. DON also stated R12 had recently had increased problems with holding things, and had in fact, dropped his phone and broken it due to his [CONDITION(S)]. DON stated the facility did not have a policy for the use of hot glue guns, but planned to develop one.

Based on observation, interview, and document review, the facility failed to ensure appropriate catheter care was provided to prevent potential for urinary tract infection ([CONDITION(S)]) for 1 of 1 resident (R3) reviewed for catheter cares. Findings include: R3's quarterly Minimum Data Set (MDS) assessment, dated 3/19/22; indicated R3 had moderately impaired cognition and functional limitations in activities of daily living (ADL). R3's MDS identified bilateral hand contractures, required extensive assistance of 2 staff with toileting and personal hygiene. The MDS further indicated diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's face sheet, indicated diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's care plan, identified placement of indwelling catheter due to pressure ulcer to buttock area, also indicated to perform catheter care twice daily. R3's provider note, dated 6/15/22, indicated chronic indwelling catheter due to decubitus ulcers of buttocks and lower back. Provider's note did not mention any recent urinary infection. During an observation, on 6/29/22 at 10:18 a.m., while NA-A was visualized performing peri and catheter cares to R3, NA-A was observed to wear gloves while washing left upper inner thigh with plain water and clean washcloth. NA-A folded washcloth over to new portion of rag x4, washing only left upper inner thigh region, then dried with a clean towel. NA-A grabbed a new clean washcloth and began to cleanse right upper inner thigh. NA-A folded washcloth over to new portion of rag x4, washing only right upper inner thigh region, then dried with a clean towel. NA-A indicated during procedure, R3 does not like to be cleansed with soap while in bed, only will use soap when taken to shower or bath. When NA-A was asked why cleansing of labia, urethral meatus, and catheter had not been completed, only cleansing of bilateral upper inner thighs during cares; NA-A responded that she had cleansed sites. NA-A was observed to remove her gloves and changed into a new pair of clean gloves to perform urinary catheter drainage bag cares. With drainage bag attached to side of bed, NA-A cleansed end tip of drainage bag tubing with an alcohol wipe, released clamp for urine to drain into center of a graduated cylinder that another NA was holding for NA-A. R3's urine observed at time to appear amber in color with lots of sediment. NA-A was then visualized to re-clamp end tip of drainage bag, cleansed end tip of drainage bag with a new alcohol wipe, placed end tip into plastic holder of drainage bag. When interviewed, on 6/30/22 at 12:59 p.m., the director of nursing (DON) indicated all NAs had to complete a competency checklist upon hire, which included peri and catheter cares. The DON stated before an NA can perform resident cares independently, they had to have skills checked off by a veteran NA and DON to ensure competency. The DON indicated NAs were rechecked on their care competency skills in 3-6 months post hire to determine if any additional education was needed. The DON stated unawareness of concerns with NAs providing inappropriate peri and catheter cares, indicated all NAs working independently had been deemed competent in providing peri and catheter cares. The DON was informed while NA-A was observed per surveyor performing peri and catheter cares, NA-A was visualized to cleanse bilateral upper inner thigh, had not cleansed peri area or indwelling foley catheter. The DON stated NA-A was a newer employer, had only worked at facility for a few months. The DON confirmed cleansing of resident's bilateral upper inner thigh was not appropriate peri and catheter care. The DON indicated it was her expectation for all nursing staff to cleanse peri and catheter sites per standards of care taught, if questions or concerns about procedure, should seek further clarification from competent nursing staff or DON. A facility policy for peri care and catheter care were requested but was not received.

Based on observation, interview and document review, facility failed to evaluate sleep, mood and behavior to justify the use of a psychoactive medication and did not provide a routine for monitoring the effectiveness of new [CONDITION(S)] medications or provide non-pharmacological interventions for 1 of 4 residents (R10) reviewed for unnecessary medication. Findings include: During an interview on 6/27/22, at 2:52 p.m. R10 stated my mood affects my sleep, and I pick at my skin when I'm sleep. R10 had an old scar from his kidney transplant with areas of irritation where he had picked at it. R10 did not complain of his current mood and said he had plenty to keep him busy as he had all his electronic gadgets and had worked with computers for a living his entire life. His affect was pleasant, and animated. According to R10's Minimum Data Set (MDS) quarterly assessment dated [DATE], R10 was cognitively intact but suffering from multiple significant physical and emotional disabilities. The MDS did not indicate any episodes of [CONDITION(S)], hallucination, delusions or other behavioral manifestations including depression. R10's diagnosis list indicated R1's primary diagnoses for admission was type 2 diabetes mellitus . The list indicated R10 had multiple mental health diagnosis including anxiety, depression, post-traumatic stress disorder and a diagnosis for Asperger's syndrome. The list also indicated R10 suffered from [CONDITION(S)]. The list did not specify any associated problems of [CONDITION(S)] such as delusions or hallucinations. According to R10's sleep evaluation dated 5/17/22, R10 had indicated a satisfaction with his sleep, getting up only 1-2 times per night to urinate. The assessment indicated he did not feel fatigued during the day. No other information related to sleep was included in the sleep evaluation. A prior sleep evaluation dated 11/14/21 included the same information for R10 related to his sleep; however, it also indicated he had been taking 8 mg of [MEDICATION(S)] for sleep at that time. According to R10's physician orders R10 had orders for the following [CONDITION(S)] medications: [MEDICATION(S)] XL (an antidepressant) 37.5mg for depression (discontinued 6/7/22), [MEDICATION(S)] (an antidepressant) 200mg daily, [MEDICATION(S)] (an antidepressant) 50mg at bedtime for sleep, [MEDICATION(S)] (an antipsychotic) 2.5 mg for sleep/depression, started 6/8/22. In addition, R10 had an order for [MEDICATION(S)] (hormone for sleep regulation) 6mg for sleep, (increased to 9mg for sleep on 6/27/22) A review of R10's care plan indicated a focus problem area dated 7/9/21 for impaired coping. An associated intervention to evaluate sleep pattern was added on 7/9/21 without any further explanation. An additional focus problem area dated 9/2/21 indicated R10 was at risk for depression. This problem area included two interventions, one to assist with making appointments and to talk with R10 about his electronic devices because he enjoys that. No focus problem area was found addressing the use of an antipsychotic. Outside of the listed coping and depression, no other target behaviors were listed. Identification of any behavioral symptoms requiring the use of an antipsychotic were not uncovered in R10's facility medical record, and on-going monitoring of the effectiveness of an antipsychotic for sleep was not found in R10's facility medical record. Documentation of non-pharmacological interventions for sleep or other behavioral manifestations were not found in R10's record. When interviewed on 6/30/22, at 3:49 p.m. director of nursing (DON) stated R10 had a psychological history and had been to the psychiatrist. DON described R10 as having a diagnosis of anxiety and depression, and also of [CONDITION(S)] and Asperger's, describing behaviors of problems with social relationships at times. DON described occasions of unrealistic ideation such as becoming fixated on problems with the facility heating system, the internet or his medical care. DON described R10 as streaming everything all at once in his room with multiple electronic devices streaming television shows, videos, music etc. DON stated R10 had disliked the amount of internet available and had hacked in to the internet used for running their medical records, but had not accessed the records. The DON stated R10 had told her his psychiatrist was going to put him on [MEDICATION(S)] and [MEDICATION(S)], and this had actually occurred when he last had a visit approximately a month prior to this interview. DON stated the psychiatrist had listed the [MEDICATION(S)] for sleep, but DON said this was not a medication usually given for sleep. DON had reached out to the psychiatrist, but stated the return call was made by a colleague. When the psychiatrist eventually called back, DON stated the reason given by the psychiatrist for choosing [MEDICATION(S)] was R10 had said he had used it in the past and it had been effective. DON was unable to locate documentation in the facility records indicating the medication had been effective in treating sleep or other psychiatric concerns since the medication was originally started on 6/8/22. DON stated non-pharmacological interventions should be used prior to the use or in conjunction with the use of [CONDITION(S)] medication, but was unable to locate any documentation to indicate such interventions had been attempted for R10. A facility policy titled [CONDITION(S)] Drug Assessment last reviewed on September, 2013 did not apply to the use of psychotropics beyond indicating an assessment for abnormal involuntary movement assessments must be completed with the use of such medications.

Based on observation, interview and document review, the facility failed to ensure expired food were identified and removed, date opened containers of food stored in walk-in refrigerator and standup freezer, follow proper food handling practices to promote food safety. This had the potential to affect all 15 residents who were served food and beverages from the facility kitchen. Findings include: During interview and observation of kitchen on [DATE] at 2:35 p.m., with cook (C)-A, observed food items on shelves, in the walk-in refrigerator and standup freezer that were not dated or marked and/or were expired. C-A indicated all kitchen staff were responsible for checking food for opened dates and expiration dates, all refrigerators and freezers should be gone through daily to check for expired or damaged food. C-A indicated if any food or drink is not dated when opened, it should be removed immediately. C-A stated all left-over prepared food should be discarded in ,d+[DATE] days and beverages when marked are good for 7 days from date opened. The following items were observed during tour: Shelves: 1. 1 bag of hot dog buns; opened and dated [DATE]; exp date on bag [DATE] 2. 3 bags of hot dog buns; unopened; exp date [DATE] 3. 3 loaves of bread; unopened; dated on bag [DATE] Walk-in refrigerator: 1. 100% apple juice- 1.36L; approx. ¼ full; not marked/dated; exp date on container [DATE] 2. 100% grape juice- 1.36L; approx. ¾ full; not marked/dated; exp date on container [DATE] 3. 100% pineapple juice- 1.36 L; approx. ½ full; not marked/dated; exp date on container [DATE] 4. sliced honey ham in facility zip lock bag; opened [DATE]; use by date on by [DATE] 5. Ensure clear- apple flavor- 8 oz. bottles (32 bottles remaining); unopened; expiration date on each bottle [DATE] 6. Boost breeze- berry wild flavor- 8 oz. bottles (11 bottles remaining); unopened; expiration date on each bottle [DATE] 7. Boost- chocolate rich- 8 oz. bottles (9 bottles remaining); unopened; expiration date on each bottle [DATE] 8. Miracle whip light dressing- single packets; unopened; received in original box dated [DATE]; no expiration date 9. cut-up radishes in facility zip lock back from facility garden; not marked/dated 10. celery- leaves on stalks observed to be dried and turning brown; original box date [DATE] 11. La [NAME] thick and chunky salsa 8.5 lb; ¼ left; opened date ,d+[DATE]; unable to read expiration date on container 12. Broccoli in facility zip lock bag; observed to be brown in appearance; opened date on bag [DATE] 13. Shredded lettuce; ¼ left; not marked/dated; observed to have increased moisture and brown in discoloration Stand-up freezer: 1. 1 bag of freezer burned hot dog buns; unopened; exp date on bag [DATE] When interviewed during brief kitchen tour, on [DATE] at 3:00 p.m., C-A indicated when food and beverage items are delivered to facility, staff rearranged food items in kitchen storage areas, moved newer food items to back and older food items to front to be used up first. C-A stated when food items were opened, staff would write an open date on top, to indicate to staff when needed to discard items. C-A indicated that she and staff try to go through food inventory and remove anything unmarked/undated or expired frequently, did admit to having some food items that should have been removed due to being unmarked/undated and expired. During observation and interview of dinner meal on [DATE] at 12:18 p.m., dietary aide (DA)-A was visualized wearing hair net, walked over to employee sink, washed hands with soap/water, dried with paper towels, then applied clean gloves. DA-A walked over to counter in kitchen across from where steam table was set up, picked up resident meal tickets, placed on clean push-cart next to resident clean dishware. DA-A picked up resident meal ticket with gloved hands to read resident meal preference, set meal ticket on countertop across from steam table with gloved left hand, grabbed resident clean plate with gloved right hand, switched plate to glove left hand, picked up tongs with gloved right hand to place chicken [NAME] on plate, set plate back down on clean push-cart with left hand, grabbed a cutting knife with gloved right hand, while holding onto chicken [NAME] with left hand, would cut apart chicken [NAME] into pieces, set knife back down on clean push-cart with gloved right hand, picked apart chicken into smaller bite pieces with both gloved hands, picked plate back up with left hand, walked over to steam table, picked up spoon with gloved right hand and placed stuffing on plate, grabbed spoon for gravy with gloved right hand and poured gravy over stuffing, picked up spoon for green beans with gloved right hand and placed beans on plate, placed plate on resident tray and covered plate with covered top. DA-A was interviewed about process of food safety and cross-contamination with touching resident meal tickets, placing meal tickets on counter-top, touching meat when breaking it into smaller pieces. DA-A did not have a response other than she needed each resident meal ticket right in front of her to see what the resident's preferences and needs were, and still needed to be able to dish up, prepare meal accordingly. During an observation and interview, on [DATE] at 12:26 p.m., C-A took R9's dinner meal and placed on tray. C-A grabbed a thermometer from her scrub top pocket and placed thermometer on R9's napkin, covering slightly over silverware (knife), next to meal, on tray. Once entering R9's room, C-A set meal tray down in front of R9, took cover off meal plate, picked thermometer up off his meal tray, alcohol wiped end of thermometer, then temped R9's pork chop with gravy. Once exited from R9's room, C-A was asked about food safety and process of cross-contamination with placing thermometer from her pocket onto R9's meal tray/silverware. C-A indicated she shouldn't have taken thermometer from her scrub top pocket and place on resident meal tray/silverware, confirmed potential risk for foodborne illness due to unhygienic practice. Facility policy for food storage, food safety, and prevention of cross-contamination and foodborne illness were requested. Facility policy and procedure manual: Director of Food and Nutrition Services Responsibilities, dated 2021, consisted of; the director of food and nutrition services will be familiar with all local, state, and federal regulatory requirements related to food, food safety and sanitation, and assure all requirements are met; employees will be trained, assisted, and encouraged as needed; food will be prepared in a manner that prevents foodborne illness; staff will follow proper sanitation and food handling practices. Facility policy, Food Safety for Vegetable Gardens- Tips for Schools, Child Care and Long-Term Care Facilities, undated, indicated; poor personal hygiene is the cause of many foodborne outbreaks, surfaces used to prepare produce should be clean and sanitized. Facility policy, Long-Term Care Facility Garden Policy 2019, dated [DATE], consisted of; the facility should be following safe food handling practices once foods are harvested and brought to the kitchen for preparation, food safety requirements: the facility must procure food from sources approved or considered satisfactory by federal, state, or local authorities; nursing homes that have their own gardens such as, vegetable, fruit or herbs may be compliant with the food procurement requirements as long as the facility has and follows policies and procedures for maintaining and harvesting the gardens, including ensuring manufacturer's instructions are followed if any pesticides, fertilizer, or other topical or root-based plant preparations are applied.

Based on observation, interview, and document review the facility failed to monitor and evaluate signs/symptoms of [CONDITION(S)] (skin infection) and fluid volume status and [CONDITION(S)] (swelling) for 1 or 2 residents (R4). The facility's failure to monitor and evaluate worsening skin conditions for timely treatment resulted in harm when R4 was hospitalized for [CONDITION(S)]. Findings include: R4's facility face sheet, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R4 did not have a cognitive impairment and did not have behaviors. The MDS indicated R4 was independent with activities of daily living with exception of personal hygiene which R4 required physical assistance from one staff. The MDS indicated R4 was administered a diuretic medication. R4's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -Fluid restriction 1.5L (liters) daily related to congestive heart failure (start date 1/13/20) -2 gram restricted sodium diet (start date 9/16/19) -[MEDICATION(S)] (diuretic medication) 2.5 mg (milligrams) every Saturday (start date 2/27/21) -[MEDICATION(S)] (diuretic medication) 100 mg daily (start date 1/22/21) -Elevate legs in bed 1-2 hours twice a day. Complete leg [CONDITION(S)] exercises 15 times every day. Butte squeezes, hip marches, knee kicks, ankle pump. Assist with lower extremity compression on in the morning/remove at bedtime. Artiflex (soft) cotton wraps B[bilateral] foot to knees, spiral wrap high stretch wraps foot to knee. [MEDICATION(S)] B knee to groin. Monitor skin integrity and manage right thigh posterior wound (old) twice per day for [CONDITION(S)] (start date 2/1/21.) -Daily weight if a weight gain of 2-3 pounds (lbs.) or more per day, over a 2- day period or 5 pounds in a one week, notify the physician (start date 3/4/20) R4's electrolyte imbalance care plan dated 7/6/20, indicated the imbalance was due to diuretics used to treat congestive heart failure, pulmonary hypertension, and kidney disease. Associated interventions directed staff to obtain daily weights and report to the nurse of an increase of 3 pounds, labs monitored by physician and medication adjustments as necessary to monitor kidney disease. R4's nutritional care plan dated 1/19/20 indicated R4 was non-compliant with her fluid restriction and low sodium diet. The associated interventions included: -1.5 liter fluid restriction; R4 requested she will self-monitor (1/13/20). -Identified the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . -Give medications as ordered and observe for side effects and effectiveness. -Observe and notify the nurse of increased [CONDITION(S)]. R4's cardiovascular care plan dated 10/4/20, included the following interventions; -Encourage resident to elevate legs in bed 1-2 hours twice per day, complete leg [CONDITION(S)] exercises (start 2/1/21) - Assist with LE compression on in am/off at bedtime apply Artiflex (soft) cotton wraps to Bilateral feet to knees, spiral wrap high stretch wraps foot to knees. Apply Turbigrip to bilateral knee to groin. -Monitor for any signs/symptoms of heart failure: dependent [CONDITION(S)] of legs and feet, Shortness of breath with activity, cool/dry skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation of the lungs, increased heart rate, lethargy and/or disorientation. - [CONDITION(S)] Pump Instructions: Set up Lymph Machine/Plug In; Have [R4] lay down in bed; elevate the head of the bed and bilateral LE with pillows; check blood pressure. Greater than 100 systolic BP required in order to pump; Don B cotton stockinet; Don Blue [CONDITION(S)] sleeve on each LE and zip up; Turn on the machine (red button) and start the timer; [R4] MUST CHECK BP EVERY 5 MIN THROUGHOUT THE ENTIRE SESSION; Can pump up to 45 min if R4's systolic BP remains 85 or greater; Shut off the pump if systolic BP is less than 85 or if diastolic continues to decrease (start date 01/02/20) - Observe for and report to the nurse any adverse reactions to diuretic therapy: complaints of dizziness, complaints of feeling lightheaded or dizzy when standing up after sitting or lying down (postural hypotension), extreme tiredness (fatigue), and an increased risk for falls. - Observe for and report to the nurse any changes with respiratory status, [CONDITION(S)] (lower extremities) and changes in weight -Observe for and report to the nurse any [CONDITION(S)] or increase in [CONDITION(S)] (lower extremities) to licensed nurse. - When assisting resident, observe for and report to the nurse any of the following on legs (lower extremities): excessive [CONDITION(S)], redness, blistering, itching, burning, bruises, cuts, excessive warmth, open areas and/or discoloration or drainage. During an observation and interview on 4/6/21, at 10:08 a.m. R4 was in her room sitting in her wheelchair, both of R4's legs were edematous, and she was not wearing any type of compression wraps. Above R4's knees, both inner legs were very red with pustules, and clear fluid was actively draining. R4 stated she used to be a registered nurse, had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R4 stated it started off on the right leg, stated she had to tell the nurse about it, and that it was not caught soon enough. R4 stated she didn't immediately start on an antibiotic and kept getting worse. R4 stated the right leg improved, then the left leg started to get red, stated the left foot was twice the size and painful. R4's record identified amount of fluid consumed for each meal; the record lacked evidence of 24-hour fluid intake amounts and if they were evaluated for compliance with the fluid restriction. R4's progress note dated 1/14/21, at 6:28 p.m. included, Resident told staff that she might be developing [CONDITION(S)] above right foot. Action: Author felt site, which was not warmth [sic]- to touch. Her vital signs when checked were: 98.3, 78, 20, 132/74 and 95% [temp/pulse/respirations/blood pressure/blood oxygen saturations on room air] with little SOB [shortness of breath] at rest. Primary provider was contacted who gave order take resident's temperature every shift and to mark site with a permanent marker to monitor site for any changes and update her as needed. Response: Resident was updated about step taken. Site will be monitored and primary provider to be updated as ordered. R4's progress note dated 1/14/21, at 9:39 p.m. indicated R4 felt anxious and was having difficulty breathing; oxygen saturations were 93-96% on room air with normal vital signs. R4's progress note dated 1/17/21, at 5:55 p.m. Included, Patient reported increased [CONDITION(S)] and wanted her doctor to be updated about it. Writer left a voice message to her doctor. R4's weight record indicated: 1/8/21 weight was 360 lbs. 1/9/21 weight was 366.4 lbs. Physician was not notified of weight increase. 1/10/21 weight was 362.4 lbs. 1/11/21 weight was 364.8 lbs. 1/12/21 weight was 357.6 lbs. - no reweight for verification of the 7 lb. weight loss without intervention 1/13/21 no weight recorded 1/14/21 weight was 359.0 lbs. 1/15/21 weight was 358.6 lbs. 1/16/21 no weight recorded 1/17/21 weight was 360.8 lbs. R4's weight change note dated 1/18/21, at 2:07 p.m. included Wt [weight gain of 4.5 lbs. last 3 days, Notified [physician]. Will give extra 20 mg of [MEDICATION(S)] today and increase Dose to 120mg qd [every day] x 5days. Check labs next week and [physician] will see this week on rounds. Resident informed, also re-educated on fluid and salt restrictions. R4's weight on 1/19/21, was 365.2 lbs. R4's record identified R4 was not evaluated by a physician for 6 days after the onset of symptoms of [CONDITION(S)]. Physician visit dated 1/20/21, included, She also has issues related to [CONDITION(S)] and marked [CONDITION(S)] of her lower legs. Cardiovascular: Positive for leg swelling. She has marked increase in her leg size. she does complain of her legs being worse as well as the girth of her legs increasing and pustules that have been forming. She is obviously scratched at some of them on my visit today. Both legs are quite large and her lower legs are somewhat edematous today. She got nodular areas on the anterior and posterior calves as well as up towards her thigh that her chronic in nature, however there is some areas now that almost look blistering and pustular-like, she is leaking some clear fluid. There is some [CONDITION(S)] noted on the posterior aspects of both legs that is suspicious for early [CONDITION(S)]. 7. Marked [CONDITION(S)]. She was doing lymphatic pumping but cannot do now currently due to open areas. Again encouraged her to follow dietary restriction as well as fluid restriction. The note indicated the physician ordered [MEDICATION(S)] (antibiotic) for 5 days. R4's weight at the time of the visit was 365 pounds. R4's progress note dated 1/20/21, at 7:25 p.m. included, Resident acting different, dozes off at times in the middle of a sentence, spacey and confused. Suspected to be drunk however no evidence of the same, resident was given simple verbal test and performed dismally, vital signs WNL [within normal limits] and afebrile, Neuro checks completed. Resident was started on [MEDICATION(S)] 500mg TID [antibiotic three times a day] for [CONDITION(S)] and has received only one dose and it's not suspected to be reason for altered mental status, resident states she's that way because she has not been sleeping okay for few days now, will monitor as needed and update primary MD as needed. R4's progress note dated 1/21/21, at 10:40 p.m. indicated R4 had increased complaints of pain and skin to left leg and foot were red and warm, with a fever of 100.0 degrees. Note indicated the physician was notified, gave order to send to emergency room for further evaluation, however, R4 refused to be transferred, the physician ordered was informed and gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's progress note dated 1/22/21, at 7:16 p.m. indicated R4 had an unwitnessed fall from self-transfer that resulted in injury; Resident was found on the floor by her bed with her head toward the foot of the bed while her feet toward the head of the bed Upon entering room resident's floor was noted to be having larger amount of urine with no gripper socks or foot wear on resident's feet .During head to toe assessment, resident was noted to had sustained abrasion/rug burn of 58cm x 1.5cm from her upper back to her right buttocks area and a 12cm x 1cm abrasion/rug burn the back of her left forearm. R4's progress note dated 1/22/21, at 10:30 p.m. indicated R4 complained of severe left lower extremity, lower back to mid back pain, skin to extremity red. Physician was updated of increased pain and swelling to extremity; physician gave order to send R4 to emergency room . Although there was a weight gain with an increase in diuretic the record continued to lack evidence of [CONDITION(S)] monitoring and evaluation and continued to lack monitoring/evaluation of lower extremities for signs and symptoms of [CONDITION(S)]. R4's hospital discharge summary dated 1/28/2021, indicated R4 was admitted to the hospital on 1/23/21 for [CONDITION(S)] of the left leg and was discharged back to the facility on [DATE]. The summary indicated R4 presented with progressive left lower extremity [CONDITION(S)] despite an outpatient antibiotic regimen for [CONDITION(S)]. Summary indicated R4 was started on intravenous antibiotics then transitioned to oral antibiotics. We did emphasize the importance of adhering to compression stockings for management of her [CONDITION(S)] in effort to reduce the risk of recurrent [CONDITION(S)]. The summary included the following orders for antibiotics: [MEDICATION(S)] 500 mg (2 capsules) twice per day for soft tissues infection until 2/3/2021, and [MEDICATION(S)] 100 mg twice a day for soft tissue infection until 2/3/2021. Upon hospital return on 1/29/21 R4's weight record identified more than a 25 lb. weight loss while hospitalized ; weight was 336.00. R4's physician visit dated 2/3/21, identified R4 had been hospitalized for [CONDITION(S)]. She says her left foot is still somewhat swollen but not nearly as painful. Also of note she had lost quite a bit of weight due to diuresis while in the hospital and also she says she was not eating much . The note indicated R4 had [CONDITION(S)] to both legs that was improved. R4's weight at the time of visit was 25 pounds less than the physician visit on 1/20/21; weight was 340.0 pounds. R4's progress note dated 3/26/21, included I'm concerned my wt [weight] is increasing, I am more short of breath and the [CONDITION(S)] in my legs is getting worse I think I need more diuretics Wt up 2.2 lbs overnight, and 4 lbs in 4 days. Resident did eat pizza and beer last night, does not follow diet or fluid restrictions. Notified [physician] who ordered and extra dose of [MEDICATION(S)] today. R4's progress note dated 3/31/20, included Resident states R [right] thigh [CONDITION(S)] is larger than L [left] thigh, measured 4.5cm R>L, also has red patchy area bilateral inner thighs to knees. The note also included, continue to observe [CONDITION(S)] and rash. The plan was continue to monitor. R4's physician communication note dated 4/1/, indicated R4 had been seen on physician rounds on 3/31/2021, physician ordered [MEDICATION(S)] (antifungal/[MEDICATION(S)] medication) for possible [MEDICATION(S)] to the inner groin and increased [MEDICATION(S)] 2.5 mg every Wednesday and Saturday. During an observation and interview on 4/7/21, at 12:30 a.m. R4 sat in her wheelchair in her room. Lower extremities continued to remain edematous; R4 had gripper socks on with no compression wraps on. Upper legs remained edematous and very red with blisters (pustules) that were actively dripping. R4 stated the blisters/legs were not getting any better, thinks they started draining in January. R4 stated the development of blisters makes her at risk for [CONDITION(S)]. R4 stated legs have not gotten better or worse. R4 stated she used to use the [CONDITION(S)] pumps however stopped using them because the sleeves no longer fit and was not as compliant in using them as she should have been. R4 stated she had stopped using the pumps shortly before going to the hospital. R4 stated she has not been seen by the [CONDITION(S)] clinic but the physician gave a referral to be seen again; [CONDITION(S)] was not her expertise and wished she would have gotten a referral earlier. R4 stated she had not been getting any therapy for her [CONDITION(S)] and was not utilizing the wraps at all currently because of discomfort, staff were busy, and staff had not offered to put them on. Stated she would not refuse them if she was offered. R4 stated when she was in the hospital the [CONDITION(S)]/[CONDITION(S)] was being managed by wraps twice to three times a day which was effective. R4 stated the circumference of her legs was not being measured by nursing staff, however used to be. R4 indicated that the increase in circumference since coming back from the hospital has made it more difficult to transfer and ambulate. During an observation on 4/8/21, at 1:00 p.m. R4 was laid in bed. Licensed practical nurse (LPN)-B explained to R4 she was going to change the dressings to upper thighs. Both of R4's legs from the buttock down to her knees was very red with blisters/pustules actively draining. R4 had 4 small areas of moisture associated skin damage. During an interview on 4/7/21, at 1:48 p.m. medical doctor (MD) stated R4 had mental illness and would make multiple health complaints, she also had self-abusive behaviors. MD stated R4 historically was non-complaint with wraps and [CONDITION(S)] pump. At one time she had been using pumps for up to 45 minutes. MD stated that she had just put in a [CONDITION(S)] clinic referral a couple of weeks ago. MD stated the [CONDITION(S)] started off on the right leg, confirmed antibiotic was not started until 1/20/21, stated [CONDITION(S)] on the right leg seemed to have gotten better but then the left leg started showing signs of [CONDITION(S)]. MD indicated the top of the left foot was very swollen when she had looked at during visit. MD stated she offered to send R4 to the hospital she declined. MD stated an expectation staff monitor symptoms of [CONDITION(S)] and [CONDITION(S)] and document findings. During an interview on 4/7/21, at 3:21 p.m. LPN-B stated R4 has not been using the wraps or the pumps all the time because of left knee pain, she had fallen on her left knee and the pumps hurt too much. LPN-B stated the rash and weeping comes and goes in severity. LPN-B stated petroleum based ointment was put on her legs and didn't know if R4 had been referred to dermatology and/or the [CONDITION(S)] clinic for management. LPN-B stated fluid intakes were not documented and not evaluated. LPN-B stated R4's [CONDITION(S)]/[CONDITION(S)] was not being measured, but had been at one time by measuring the circumference. LPN-B stated when there was a noted increase in [CONDITION(S)] it was documented in a progress note. During an interview on 4/7/2021, nursing assistant (NA)-B stated R4's legs have been like that forever and a day. NA-B indicated R4 was supposed to have ace wraps on her legs, and that R4 would allow wraps to be on. NA-B stated most of the time R4's legs were hurting her. NA-B indicated R4 was not walking herself to destinations like she is supposed to be. During an interview with the director of nursing (DON) and administrator on 4/7/21, at 6:16 p.m. the DON said the nurses were supposed to evaluating fluid intakes and the administrator stated the facility did not have a current system in place for fluid intake monitoring/evaluation. DON stated the [CONDITION(S)] pumps no longer fit around R4's legs and had ordered new sleeves to fit. DON indicated R4 was not always compliant with her pumps and refusals should be documented. DON and administrator indicated R4 was not compliant with her restriction. DON stated [CONDITION(S)]/[CONDITION(S)] was supposed to be monitored and documented. DON stated an expectation physician was notified of weight gain per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . DON indicated R4 was just given a referral to the [CONDITION(S)] clinic recently.

Based on interview and record review the facility failed to conduct a thorough analysis of resident's falls in a timely manner, review of appropriate patient-centered interventions, evaluate the effectiveness of current interventions to prevent and/or reduce the likelihood of future falls and complete incident reports when a resident is found on the floor for 2 of 4 residents (R13 and R9) reviewed for accidents. The facilities failure resulted in harm when R13 had 8 falls with the 12/12/21 having resulted in a hospitalization with diagnosis of fractures and continued to have falls after readmission to the facility. Findings include R13's face sheet identified R13 admitted to the facility on [DATE], with diagnoses that included history of falling, diabetes type 2, [CONDITION(S)], muscle weakness, generalized [CONDITION(S)], [CONDITION(S)] [CONDITION(S)], and [CONDITION(S)] of left non-dominant side following stroke. R13's admission Minimum Data Set (MDS) assessment, dated 12/2/2020 indicated R13 did not have cognitive impairment however, had signs and symptoms of [CONDITION(S)]. The MDS also indicated R13 did not have rejection of care behaviors, did have other behavioral symptoms and verbal behavioral symptoms directed at others. The MDS indicated R13 had falls without fracture six months prior to admission to the facility. The MDS also identified R13 required extensive assistance from two or more staff for bed mobility, transfers, dressing, and toilet use. The MDS indicated R13 was frequently incontinent of bladder and bowel. R13's Fall Care Area Assessment (CAA) dated 12/8/2020 included, had multiple falls prior to admission. He has multiple health issues contributing to his high risk for falls ie CVA [cerebral vascular accident-stroke] with weakness. He desires to be independent and attempts to stand on his own and he needs ext [extensive] assist of 2 staff. His balance is poor and needs assist with transfers. R13's is working with therapy to regain strength and endurance R13's care plan dated 11/25/2020, identified R13 was at risk for falls related to balance problems and impaired mobility. The associated fall interventions included; - Provide resident with safe environment: clutter free; support/assistive devices are available and in good repair; the bed in low position at night; personal items and call device call light within reach; non-glare soft lighting at night (start date 11/25/2020) -Remind resident to use call device, call light for assistance as needed (start date 11/25/2020) -Encourage, remind and assist resident with using the bathroom at more frequent intervals. Up with 2 assist, gait belt, and 4 wheeled walker, must have shoes on and left lower extremity orthotic (revision date) 11/26/2020) -Ensure resident is wearing appropriate- fitting clothing and footwear that fits well when ambulating or mobilizing in wheelchair (revision date 11/26/2020). -Inform the resident/caregivers about safety reminders and what to do if a fall occurs (start date 12/4/2020) -Bed alarm on bed, check for function every and shift, fall mat in place, high-low bed (start date 12/4/2020) -Every 15 minute visual checks (originally initiated on 12/12/20) R13's record revealed the following falls: Fall 1- 12/2/2020, at 6:22 a.m. included Staff heard short hall door alarm going off; f/u [follow-up] found resident attempting to open the door hence alarm went off. Resident was in bed and did not get assistance from staff to get out of bed, when asked how he was able to get out of bed independently resident stated there were two guys in the room and they kept telling him to get up and leave so he did that, staff checked and no one was in the room. Bed alarm and chair alarm was initiated for safety. Fall 2-12/3/2020, at 5:22 a.m. included Resident attempted multiple self-transfers throughout the night hence setting off bed sensor, difficult to determine if resident understands simple verbal commands/redirection d/t resident flat effect and doesn't respond to questions. Resident high risk of falls, DON [director of nursing] to review safety measures. Fall 3-12/3/2020, indicated R13 had an unwitnessed fall resulting in an abrasion to his left knee at 8:00 p.m.; R13 was found on the floor with clothes and incontinent brief next to him indicating he must have removed them. The report indicated R13 had attempted self-transfer. The immediate action taken indicated staff assessed for injuries and range of motion performed with no concerns. The report also included, Resident has been attempting self-transfers and also found opening exit door to short hall. The report did not identify root cause of the fall and did not identify immediate interventions to prevent and/or reduce the risk of re-occurrence. Fall 4-12/4/2020, at 7:26 a.m. included Resident self-transferred from bed, was found on the floor in room [alert and orientated x 3] Bed/chair alarm inplance [sic] and functioning, assisted to bed. No injuries noted, denies hitting head. Action: assist to bed. Bed alarm on and functioning. Increase visual checks. Will obtain hi/low bed and floor mat. Fall 5-12/10/2020, at 6:13 p.m. indicated R13 had an unwitnessed fall without injury. The progress note included Resident found laying on the floor in front of wheelchair on his left/front. Chair alarm is sounding, call light in reach attached to his wheel chair. The note indicated range of motion was within normal limits and R13 was transferred into bed. On 12/12/21 R13 had 4 additional falls Fall 6- At 7:06 a.m. included, Resident found on floor, Bed exit alarm sounding, found on floor mat. Oriented to self. No injuries. Action: assist to bed with Hoyer lift, all safety measures in place. Bed/chair alarm, hi/lo bed. floor mat, will increase visual checks The note and/or medical record did not specify and/or define how frequently R13 was supposed to have safety checks completed and continued to lack evidence the care plan was revised to reflect that intervention. Fall 7- At 4:33 p.m. included, Writer was notified by house keeping staff That the resident is on the floor. Immediately went to the room found the resident laying on the floor mat on the left side. Denied pain , no injuries noted, Able to move both extremities. Was trying go to the bathroom. Assessed the resident vitals taken , BP 121/94 , P 94, O2 93 R,18, [blood pressure/pulse/oxygen saturation/respirations] With assist of 3 staff use of Hoyer lift resident assisted from the floor back to bed, Bed alarm in place, call light within reach. Reminded to call when he needs help, Staff to make frequent checks, Both parties notified. Fall 8- At 6:49 p.m. included, Writer heard an alarm going off from resident room and went to find out why it's alarming, writer found resident laying on the floor mat on his right side, no injury or bruising noted. Transferred from the floor with 3 staff via mechanical lift and put back to bed after assessment. DON and POA [power of attorney] notified placed on 15 Minutes check for safety, will continue to monitor. R13's progress note dated 12/13/2020, at 3:13 p.m. indicated at 9:00 a.m. R13 wheezed heavily with oxygen saturation of 87% on room air, R13 was restless, looked week and had elevated pulse at 126. The note indicated the physician gave an order to send R13 to the hospital for further evaluation. At 10:20 a.m. R13 was transferred to the emergency room . R13's late entry progress note entered on 12/18/2020, at 6:38 p.m. for 12/13/2020 at 6:34 p.m. included, Resident had 3 unwitnessed falls 12/12/20, denies injuries, alert to self and intermittently to environment. neuro's intact slight hypotensive 95/55 HR 130 known afib. The note indicated interventions included assist to bed. floor mat, hi/low bed in place, bed/chair alarms on and functioning, start q 15 min visual checks. R13's late entry Post Fall Evaluation note entered on 12/18/2020, at 6:33 p.m. for 12/14/2020, at 8:20 a.m. The note indicated safety evaluation and education as provided on 12/10/2020, did not result in hospitalization and/or injury. The fall details included, resident with dementia, alert x 1, chair alarm on and functioning, q 15 minute visual checks per staff, floor mat in use, has working bed alarm The note also indicated R13 was not using cane/walker as instructed, was not wearing prescribed oxygen at the time of the fall, call light was not on, was hypotensive, and had an active infection. The note indicated that there was no contributing environmental factors, however R13's medication condition contributed to the fall. The evaluation did not include new interventions. R13's progress note dated 12/16/2020, indicated a bolster mattress had been ordered (mattress that has raised sides that could decrease ability to roll and/or get out of bed). R13's record lacked evidence of care plan revision for mattress. R13's hospital After Visit Summary (AVS) dated 12/22/2020, indicated R13 was admitted to the hospital on 12/13 and discharged back to the facility on [DATE]. The summary identified R13 had multiple risk factors for falls including history of stroke, [CONDITION(S)], [CONDITION(S)] [CONDITION(S)], and [CONDITION(S)] secondary to diabetic ketoacidosis. The summary indicated R13 was found to have a large left acute retoperitoneal hematoma (blood loss due to the injury). In addition, R13 had sustained fractures of his left ribs. After hospitalization Fall 9- R13's Fall note dated 1/24/ , at 2:16 p.m. indicated R13 had an unwitnessed fall; he was found on the floor in his room lying by his wheel chair on his back with his head towards the door and feet towards wheelchair. R13 denied hitting his head, and did not have any visible injuries. The note indicated vital signs were normal and R13 was assisted back to bed. Intervention included, Resident will continued to be monitored for further changes related to fall with primary provider updated. Response included; Continued to be alert and functioning with in his normal limit with no s/s of pain, new skin issue or injury noted related to fall. Fall 10-R13's progress note dated 3/17/2021, at 6:54 p.m. included, Therapy went into resident's room and found him on the floor. Resident said, I took my walker and went to my closet to change my pants. Because this pants are not good. My knees gave up, and I fell to the floor. I did not hit my head, I fell and sat on my butt. resident's pants were not wet. He had his shoes on his feet. He was assessed for any injuries, he was able to move his extremities without pain. He was assisted off the floor with gait belt and assist times three. He was encouraged to always [NAME] for help and his call light was placed within reach. Will continue to assess for any changes R13's post fall evaluation dated 3/17/ , at 6:32 p.m. indicated R13 attempted to walk himself in his room and the reason for fall was evident; loss of balance with no assistance from staff, unlocked wheelchair, not wearing prescribed oxygen at the time, call light was not on, and was not using cane/walker. The report indicated a pattern in the falls was related to self-transfers. During an interview on 4/7/2021, at 3:08 p.m. medical doctor (MD) stated the retroperitoneal bleed could have been caused by multiple falls because of R13 being on anticoagulants [blood thinners]. During an interview on 4/7/2021, at 3:20 p.m. licensed practical nurse (LPN)-B stated she remembered R13, and was working at the time of one of his falls. LPN-B stated he had been sitting in his wheel chair and tried to stand up, LPN-B stated she took vital signs, performed range of motion, and assisted R13 back to bed. LPN-B indicated she wasn't aware if the safety alarms had been implemented before or after that fall. LPN-B indicated she would put immediate interventions in place to prevent reoccurrence. During an interview on 4/7/2021, at 3:43 p.m. nursing assistant (NA)-B stated she remembered R13, when he first was admitted he was really confused and non-compliant. NA-B stated she had remembered that R13 fell a few times and then was admitted to the hospital; when R13 came back he was easier to work with and more compliant. NA-B stated she remembered having to check on R13 frequently. NA-B stated R13 was a fall risk and it was communicated verbally and was on the care plan if residents were at risk for falls. During an interview on 4/7/2021, at 3:50 p.m. director of nursing (DON) reviewed R13's incident reports in combination with the medical record. DON stated after the fall on 12/3, the care plan was revised to include interventions of the fall mat and high/low bed; however the record lacked identification of root cause of the fall. DON stated for the fall on 12/10, there was insufficient documentation to determine root cause, but stated because it was after supper he probably had to go to the bathroom. DON confirmed and stated there was no new appropriate fall interventions added to the care plan. DON stated for the first fall on 12/12, the report was not completed, there was insufficient documentation to determine root cause, and lacked evidence of immediate intervention. DON stated for the second fall, there was not enough information, frequent monitoring was implemented; stated defined as every 30 minute safety checks. DON indicated analysis for root cause was not completed. DON confirmed the record lacked evidence 30 minute checks were completed. DON stated after the 3rd fall every 15 minute checks were initiated, however the record lacked evidence the checks were completed. DON indicated the record lacked analysis and identification of root cause. DON confirmed after review of the falls from 1/24 and 3/17, and confirmed the record lacked evidence of analysis, and no new interventions had been implemented. DON stated the fall report should include enough information to ascertain a potential root cause. DON indicated based on the analysis appropriate interventions needed to be care planned and implemented. R9 R9 admission record indicated admitted [DATE]. R9 admitted to hospice 11/19/20. R9 admission record included diagnoses: chronic respiratory failure with [CONDITION(S)], chronic congestive heart failure, history of falling, dependence on supplemental oxygen, pneumonia, chronic kidney disease, coronary artery disease, muscle weakness, abnormalities of gait and mobility, left femur fracture, benign neoplasm of colon, type 2 diabetes, moderate protein calorie malnutrition, sleep apnea, [CONDITION(S)], shortness of breath, malignant neoplasm of prostate. R9 minimum data set (MDS) quarterly assessment dated [DATE] indicated intact cognition, no behaviors, assist of 1 assist for activities of daily living, uses walker and wheelchair, always incontinent of urine, and occasionally incontinent of bowels, 2 or more falls with no injury, on continuous oxygen, and on hospice. R9 care plan dated 10/18/20 included resident has activities of daily living (ADL) self-care performance deficit related to balance issues, fatigue, limited mobility, status post fracture and will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, and fall related injury. It included at each review, evaluate and document the continued need for each assistive device(s) used by the resident. It included resident can turn self in bed; encourage to use call light to request assistance and provide reminders as needed; ensure call light is within reach; and assist of 2 with gait belt and walker for mobility. R9 care plan also indicated resident has had an actual fall with serious injury related to left hip fracture. Interventions included bed alarm; bolster mattress; check on resident at frequent intervals to see if any assistance is needed and to offer reassurance to resident; check placement of floor matt when resident in bed; evaluate and monitor resident for three days after the day the fall occurred and report any changes with vital signs, changes with condition or status such as: pain, skin discolorations, swelling, difficulty moving an extremity, or change in mental status; evaluate the environment at the time and location of the fall and attempt to identify any factors that may have contributed to the fall, such as uneven surfaces, bed not in lowest position, poor lighting, resident not wearing footwear with non-skid soles, resident not using/wearing assistive device (sensory - glasses, hearing aid; function - walker, cane, etc.), frequently used items not within easy reach of resident, etc. and report findings to supervisor; obtain and record vital signs after fall event and as ordered by physician; provide first aid if indicated and obtain emergency assistance (911) if appropriate; remind resident not to get up out of bed/chair with assistance; remind resident to use call device call light for assistance as needed. R9 progress note dated 2/27/2021 at 10:09 p.m. indicated at 9:40 p.m., R9 was observed on his knees and appeared to be trying to change out of his pad which was wet; R9 denied falling; R9 was assisted with new pad and back to laying position in bed with 2 assist; vital signs taken; neurological checks baseline; and will continue to monitor. No incident report or investigation provided for this event. R9 progress note dated 3/1/2021 at 02:45 a.m., included writer went into R9 room to do vitals and observed R9 on his knees, resting on the bed in a praying position; R9 could not say what he was doing; this was the third time this weekend he has demonstrated this behavior; R9 denied any discomfort; vital signs taken; resident pad checked and changed and assisted back to bed; resident then fell asleep; will continue to monitor. No incident report or investigation provided for this incident. R9 progress note dated 3/9/2021 at 02:51 a.m., included following rounds and changing R9 pad, R9 bed alarm sounded and R9 was observed on his knees resting on his bed; R9 denied falling and stated was repositioning self; R9 was assisted back to bed and will continue to monitor. No incident report or investigation completed for this incident. During an interview on 04/07/21 at 03:22 p.m., physician (MD)-A stated she reviews falls and R9 has not had any recent falls. During an interview on 04/08/21 at 01:54 p.m., director of nursing (DON) stated staff are encouraged to update the care plan with any new interventions following a fall. DON verified no new interventions were added to care plan with recent falls. DON verified no incident report was filed for some of the falls noted in progress notes. DON stated staff are to notify the physician and family of falls. DON stated there is no notes from interdisciplinary (IDT) meetings. Facility Fall Management Policy dated 12/20 included the following: if a fall occurs, the charge nurse will complete the incident report and fall investigation worksheet, notify responsible party and physician; notification, via telephone, the physician of the resident's condition and follow any orders; notification must be done immediately; If any orders, they will be processed; the charge nurse will record fall on the 24-hour sheet, a fall prevention strategies and intervention will be placed on care plan; Interventions must be put into place and documented in nurses' notes to prevent further incidents; the incident report and the falls investigation worksheet are forwarded to the Director of Nursing; All incidents are reviewed after each occurrence with the interdisciplinary (IDT) care team.

Based on interviews and document review, the facility failed to intervene timely for 1 of 1 residents (R)3 with a known history or urinary tract infections, stones and [CONDITION(S)] [critical infection if not treated results in death] who required immediate medical interventions for lack of urine output. This resulted in harm when R3 was hospitalized with [CONDITION(S)] and kidney stones. Findings include: R3 admission record indicated readmitted [DATE]. R3 admitted to hospice on 3/25/21. R3 discharge date of [DATE]. R3 annual minimum data set (MDS) assessment dated [DATE] indicated impaired condition no rejection of cares , extensive assist of 1-2 with mobility and transfers with use of walker or wheelchair, indwelling catheter, bowel incontinence, history of fall no injury, and weight loss. R3 admission record included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3 order summary report indicated orders for: change nephrostomy bag weekly; irrigate nephrostomy tube with 10 ml sterile water as needed; measure urinary output from catheter every shift; record nephrostomy output every shift; catheter irrigation with 60 ml sterile water as needed; change indwelling foley catheter monthly; [MEDICATION(S)] [ used to treat certain bladder and urinary conditions]2.5 mg twice daily related to urethral spasms; trospium chloride [used to treat overactive bladder] 20 mg every 12 hours as needed for bladder spasms. R3 care plan included he has indwelling catheter for obstructive [CONDITION(S)] [when your urine can't flow]. Use of [MEDICATION(S)] Tamsulosin, and tropism for bladder spasms. Also has bilateral internal [CONDITION(S)] stents. Goal is R3 will show no signs and symptoms of urinary infection related to catheter use. Interventions include the following: assist resident as needed with maintaining personal cleanliness; 16 french 30 milliliter foley catheter. Position catheter bag and tubing below the level of the bladder. Change to leg bag during the day for dignity issues; offer and encourage fluid intake at meals, with activities and with medication administration; R3 has catheter changes by charge nurse every month on the 1st of each month; secure catheter tubing to leg to minimize trauma to the insertion site and make sure that the tubing is free of kinks and urine is present in the tube; check the tubing to ensure that there is urine present and collecting in the catheter bag. Empty the catheter drainage bag every shift and as needed. Notify the nurse if there is only a small amount of urine or none is present in the drainage bag. Report to the nurse if urine in the tubing/catheter drainage bag appears cloudy or appears dark yellow/brown; promptly report to nurse if resident complains of any pain/discomfort, or if there is any redness, odor or drainage on or around the catheter dressing site; observe for and report any of the following to the nurse: pain, burning, blood tinged urine, foul smelling urine, change mental status, change in behavior, such as confusion, increased restlessness or wandering. R3 progress note (PN)dated 2/11/2021 at 06:13 a.m. indicated R3 refused incontinent and catheter cares at 4am, staff attempted to redirect without success. R3 PN dated 2/13/2021 at 04:47 a.m. indicated indwelling foley catheter and nephrostomy tube intact, patent and on positive placement, urine dark amber in color with moderate sediment, output 400ml and 200ml respectively. R3 PN dated 2/17/21 at 3:47 a.m. indicated R3 refused foley catheter change and will attempt tomorrow. R3 PN dated 2/18/2021 at 00:01 a.m., indicated R3 foley catheter scheduled to be changed, small blood clot noted upon change then clear urine. - was it changed? R3 PN dated 2/20/2021 at 04:54 a.m., indicated indwelling foley Catheter and Nephrostomy intact, patent and on positive placement, draining well, urine dark amber in color with moderate sediment, encouraging fluids and will continue to monitor. R3 PN dated 2/21/2021 at 05:42 a.m., indicated R3 slept through the night, no hallucinations reported this shift. Indwelling foley catheter and nephrostomy intact, patent and on positive placement, draining well, urine dark amber in color with small sediment, output 150 ml from catheter and 150 ml from nephrostomy, encouraging fluids and will continue to monitor. R3 PN dated 2/24/2021 at 05:37 a.m., indicated indwelling foley catheter and nephrostomy intact and on positive placement, draining well; nephrostomy output ruby red in color, resident denies abdominal pain/discomfort, encouraging fluids, will monitor and update primary physician as needed. R3 PN dated 2/24/2021 at 22:10 p.m., indicated physician updated on resident continued ruby red output with low grade temperature of 99.1, orders given to collect urine specimen for urine analysis and urine culture. R3 PN dated 2/26/2021 at 04:38 a.m., indicated indwelling foley catheter and nephrostomy intact, patent and on positive placement, draining well, urine dark amber with moderate sediment. Encouraging fluids, Urine specimen collected. R3 PN dated 2/26/2021 at 6:46 p.m., indicated urine analysis from 2/26/21 showed 2+Bacteria; MDnotified; VSS 104/84-75-18-98.7; [blood pressure, pulse, respirations, temperature]. R3 denies bladder or left flank pain; urine dark not concentrated or with sediment. Physician stated to wait until urine cultures results are back before treatment. R3 stated I feel fine. Will continue to monitor. No documentation of urine analysis or culture results found in chart. R3 PNdated 2/28/2021 at 05:47 a.m., indicated nephrostomy had no output, flushed tube with normal saline and there was no resistance. Continue to monitor for output. R3 PNdated 3/1/2021 at 00:19 a.m., indicated nephrostomy bag appeared clogged, not draining well. A new bag was applied to site. Continue to monitor R3 PN dated 3/1/2021 at 00:20 a.m. indicated R3 appeared more congested once lying in bed, noted a wetness when R3 coughed. Lung sounds diminished. Staff reported that when R3 was upright in wheelchair there had been no issues. Vital signs (VS): Temperature 98.9, oxygen saturation 92% room air, respirations 24, pulse 72, blood pressure 123/87. R3 would not participate in Aerobika exercises this evening. R3 received scheduled nebulizer treatment and inhaler. R3 also repositioned higher up in bed to open up chest region more. Will ask day nurse to touch base with physician about possible chest x-ray. R3 PN dated 3/1/2021 at 04:36 a.m., indicated during last night rounds R3 had displayed two concerns: 1) R3 speech was more garbled than usual. He was alert but staff were not able to understand what R3 was trying to say. He did not appear to be upset. 2) R3 soaker pad was noticeably wet. Continued to encourage R3 to drink more fluids. Nephrostomy tubing was flushed with normal saline easily-no resistance. Foley catheter tubing flushed with normal saline easily, no resistance. Foley balloon was rechecked-drew out 30 ml and put back in 30 ml. Will continue to monitor. R3 PNdated 3/1/2021 at 2:03 p.m., R3 was sent to St. Mary's emergency department for evaluation due to increased lethargy, decreased intake, catheter and nephrostomy tube patent with dark urine. MD and daughter notified. R3 PN dated 3/1/2021 at 3:35 p.m., R3 was noted to be very lethargic since the beginning of this shift. His initial vital signs when checked at 0700 were: 98.7, 79, 14, 104/70 and 92% room air with no shortness of breath. Lung sound were clear auscultation. Author was able to administer R3 morning and noon medications with an ensure supplement. However, his vital signs when checked again at about 1300 due to further increased lethargy were: 98.9, 85, 16, 111/59, and 92% room air. It was then primary provider was updated who gave order to send resident to the emergency room . R3 was sent to the emergency room at 1:30 p.m R3 PN dated 3/1/2021 at 11:32 p.m., indicated talked with a nurse at St Mary's who called to review resident medications and also resident baseline prior to transfer, the nurse reported that resident was diagnosed with kidney stone and also awaiting further tests. R3 hospital discharge summary dated 3/8/21 indicated R3 principal diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Palliative cystourethroscopy [prostate cancer]with placement of [CONDITION(S)] stents on 3/1/21 and placed on oral [MEDICATION(S)] and [MEDICATION(S)] antibiotics to facilitate transfer back to facility. R3 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R3 PN dated 3/9/2021 at 00:23 a.m., indicated foley catheter patent and temperature of 99.1. R3 PN dated 3/9/2021 at 3:57 p.m. indicated R3 continues with [MEDICATION(S)] for UTI. He tolerated medication well. There was no adverse effect noted during this shift. R3 continues to be assist of one with cares and transfers. He was able to stay in his room as asked by staff. He was able to communicate his needs to staff. About 1:30 p.m. R3 reported he had some bladder spasm, then later stated he felt better and the bladder spasm had stopped. VS: blood pressure 101/63, pulse 80, respirations 18, temperature 98.7, oxygen saturation 96% room air. 300ml of urine in his foley. Urine is clear, no bleeding and no cloudiness observed. Staff continue to encourage R3 to drink fluid. Will continue to assess for any changes in health status. R3 PN dated 3/10/2021 at 00:12 a.m., indicated R3 was polite and appeared much more comfortable then day before upon return from hospital. He was alert when making requests. R3 denied any discomfort. VS: temperature 98.9, blood pressure 75/59, pulse 76, respirations 30, oxygen saturation 96% room air. R3 adjusting better to nectar thick liquids this evening and not swearing at the texture as previous evening. R3 PN dated 3/10/2021 at 4:00 p.m. indicated R3 on [MEDICATION(S)] 300 mg daily for [CONDITION(S)] with no adverse reaction or side effect and remained afebrile. R3 PN dated 3/11/2021 at 3:34 p.m. indicated R3 continued on [MEDICATION(S)] 300 mg daily for [CONDITION(S)] with no adverse reaction or side effect and remained afebrile. R3 PN dated 3/11/2021 at 3:36 p.m. indicated R3 was noted to be alert and oriented to self, communicating with staff in making his needs known, at times appeared to be confused. He was able to use the call light in calling for staff assist. His vital signs when checked were: temperature 98.9, pulse 83, respirations 18, blood pressure 136/86 and oxygen saturation 95% room air with no shortness of breath (SOB) at rest. He remained to be incontinent of bowel and have permanent catheter in place with output of 500 mL during this shift. Resident remained to be assist of two staff with all transfers. He is currently receiving therapy during days shift on weekdays. Resident takes medications whole with no swallowing difficulties and mostly independent with meal after set up. R3 PN dated 3/12/2021 at 6:31 p.m. indicated R3 did not eat much of his meals. He is total assist with cares, transfers, and independent with eating after tray setup. R3 is incontinent of bowel and has a foley catheter. He is still on his antibiotics. There was no adverse reaction noted during this shift. VS: blood pressure 112/72, respirations 20, temperature 98.3, oxygen saturation 96% room air. Will continue to assess for any changes in health status. R3 PN dated 3/13/2021 at 3:45 p.m. included R3 is alert and oriented to self and staff. However, he did not eat any of his meals. He would drink a glass of fluid when nurse offered to him. Urine is clear yellow. He continuous with the antibiotics. No adverse reaction observed during this shift. Resident denied pain or discomfort during this shift. Vital signs: blood pressure 111/78, pulse 83, respirations 20, temperature 98.5, oxygen saturation 98% room air. Will continue to monitor. R3 PN dated 3/14/2021 at 03:27 a.m. indicated R3 did not eat supper but writer was able to encourage R3 to eat a pudding with meds, and a pudding and half a Glucerna drink after first rounds. R3 urine is also very cloudy as R3 isn't drinking enough. Will continue to encourage more healthy snacks and fluids. Continue to monitor. R3PN note dated 3/15/2021 at 03:51 a.m. indicated R3 continues not to eat/drink very wellR3 also continues to have wet sounding nonproductive cough, afebrile, oxygen saturations running mid 90's on room air, diminished lung sounds, urine continues to be cloudy and have odor. Continue to encourage fluids, solids, healthy stacks. Continue to monitor. R3 PN dated 3/17/2021 at 4:02 p.m. indicated, R3 was alert and oriented to staff. However, He did not eat his breakfast and lunch during this shift. He also refused his morning meds. He told staff to leave him alone. He was fed some magic cup. He had about half of cup and he did not want the rest. He was encouraged to drink more fluid. staff assisted him with fluid. He had couple of sips. He did not have any urine in his catheter. Vital Signs: blood pressure 96/56, Temperature 98.3, respirations 18, pulse 71, oxygen saturation 90% room air. Will continue to monitor. physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . It indicated R3 has not made much progress since return and he is very fatigued and not eating much. R3 PN dated 3/18/2021 at 3:43 p.m. indicated R3 is alert and oriented to staff and self. R3 continues to refuse medications, food, and fluid. R3 speaks nonsensically. R3 stated there was [NAME] behind the staff and staff should watch out. He is assist of one with activities of daily living (ADL), transfer with two assist. He has a foley catheter, and he is incontinent of bowel. Staff continue to encourage fluids and food, but he continues to refuse. However, he took half a glass of Ensure. VS: blood pressure 86/58, pulse 89, respirations 20, temperature 98.7, oxygen saturation 93% room air. Will continue to assess. R3 PN dated 3/19/2021 at 09:43 a.m. indicated R3 refused medications, to eat or drink fluids that are offered, aide attempted to feed. Refusing to get out of bed. R3 stated I just want to die. MD-A notified, attempted to call daughter but unable to leave voice message. R3 PN dated 3/19/2021 at 5:24 p.m. indicated R3 still refusing food/fluid, and medications. Input 300 ml, Output 300 ml dark. VS: blood pressure 80/57, pulse 76, respirations 20, oxygen saturation 91%, temperature 98.9; updated MD-A, have not been able to reach daughter. Found phone number in resident's room called and it is his sister-in-law who will make some calls to find number for son and get ahold of daughter to call facility. R3 PN dated 3/22/2021 at 6:43 p.m. indicated a care conference at 2:00 p.m. regarding R3 decline in condition. Family asked that Hospice be involved. Informed MD-A at 4:00 p.m., Faxed referral at 6:30 p.m. to St Croix Hospice and gave report to intake nurse. R3 passed away 4/7/21. During an interview on 04/07/21at 02:36 p.m., director of nursing (DON) stated that R3 started to decline and give up back in February and that he had begun to not eat much. DON stated they tried to give him any food and drink he would take. DON stated staff should be monitoring and documenting any behaviors and urine characteristics and reporting any changes to physician. During an interview on 04/07/21 at 03:16 p.m., MD-A stated R3 started to decline more in February 2021. MD-A stated this was expected with his advanced chronic obstructive pulmonary disease (COPD) and dementia. MD-A stated R3 had stents and a nephrostomy tube and he was hospitalized twice and each time he returned and had more decline and did not fully recover. MD-A stated he would have had the stents replaced every 3 months and seemed to not make it that long and would get an infection. MD-A stated he liked his coffee and candies and since he did not have teeth it would take him longer to eat and would lose his appetite before finishing. MD-A stated after his last hospitalization in February he had stated he was ready to die. During an interview on 04/08/21 at 01:54 p.m., DON stated staff are to notify the physician of signs and symptoms of urinary tract infection such as change in urine color or odor, falls, change in condition, abnormal blood sugar level, new confusion, changes in skin, blood pressure changes, new cough or fever, etc. DON stated the physician should have been notified when R3 started to have change in urine color. DON stated there is not a record of the urine analysis and culture that was completed on 2/26/21. DON stated she was not aware of R3 returning from hospital on two antibiotics thus not in the infection log. DON stated daily shift monitoring for effectiveness of the antibiotic should have been documented every shift for R3. Facility identification and follow up of infections procedure indicated when a resident exhibits signs/symptoms of suspected infection, the unit nurse or charge nurse will complete the infection report form; follow routine procedure for notifying the attending physician and family and begin close monitoring of vital signs and input and output; document in the nurse notes every shift the presence or absence of symptoms and continue this documentation until 48 hours after symptoms have subsided or until 48 hours after the last dose of antibiotics; the infection prevention nurse will gather further data for infection tracking and reporting and provide consultation and education as needed; date from the completed infection control reports will be presented at quarterly infection control/Quality assurance meetings and will be given to nursing department managers to make available to all staff. Facility policy antibiotic stewardship program dated revised 2/2019 included that nursing staff will complete the appropriate McGeer Criteria form with resident signs/symptoms to see if symptoms meet criteria for treatment prior to notification of physician; chart information including whether the physician chose to treat or not treat the symptoms. It included if an antibiotic is ordered or if resident is on antibiotic upon admission nursing will address any signs/symptoms and response to treatment and tolerance ot the antibiotic will be recorded as appropriate.

Based on observation, interview and document review, the facility failed to protect residents from verbal/mental, physical and sexual abuse, for 4 of 5 residents (R1, R2, R3 and R4) reviewed for allegations of abuse. The facility's failure to protect residents resulted in an immediate jeopardy situation. The immediate jeopardy began on 4/24/19, when the facility failed to report, protect, and investigate allegations of verbal/emotional abuse for R1, R2, R3, and R4. The IJ was identified on 4/30/19, the director of nursing, administrator, facility owner, and business office manager were notified at 1:59 p.m. The immediate jeopardy was removed on 5/1/19, at 4:56 p.m. after it could be verified the facility had implemented an acceptable removal plan however, noncompliance remained at the lower scope and severity level of G, isolated with actual harm for R1, R3 and R4 who experienced humiliation and or fear of NA-A. Findings include: A report to the State Agency (SA) dated 4/23/19, at 6:44 p.m. indicated the reporter had multiple concerns about treatment of [REDACTED]. Allegations included physical and emotional abuse by AP1 (nursing assistant (NA)-A) to unidentified residents. The report alleged a resident had stated AP1 was physically aggressive during cares describing her as, 'a mean [***] ,' and when she changed him she ripped his pants off in an aggressive manner, and complained about how he was 'always covered in[***] and she was tired of cleaning the resident up. According to the report that resident had told the reporter AP-1 would often put him on the toilet 'hard,' and was generally rough with cares and AP-1 once left resident only partially dressed on his bed with no blanket on and the door wide open. The report indicated during another incident, a resident had became combative and attempted to hit AP1, AP1 was observed grabbing the resident's hand and saying, 'If you ever hit me, it will be the last time you hit anyone.' Further, the report alleged AP 1 was generally rough getting residents out of bed, and ignores resident complaints or requests to be left in bed and indicated AP1 frequently gossips about other staff or residents with residents. AP1 once remarked to a staff member, 'If you know how to feed a baby, you can feed these damn idiots. It's not hard.' According to the report, the reporter had informed the administrator and director of nursing of the concerns pertaining to NA-A's behavior however, nothing had been done. During an entrance conference on 4/26/19, at 2:02 p.m. all vulnerable adult reports reported to the SA, incidents, and grievances were requested for the last three months. The facility provided a binder of information however, there were no documents indicating any alleged physical, verbal/mental, or sexual abuse. During an interview with licensed practical nurse (LPN)-A on 4/26/19 at 2:15 p.m., LPN-A stated she had reported to the director of nursing (DON) that NA-A had physically abused R1 by being rough during cares, and had subsequently mentally abused R1 by yelling and shaming him for being incontinent of stool. LPN-A stated this happened between 4/15 and 4/24/19. LPN-A further stated NA-A had a history of [REDACTED]. During an interview with resident (R)-1 on 4/26/19 at 2:28 p.m., R1 stated NA-A was rough and routinely yelled at him when she assisted him to the bathroom. R1 angrily and loudly stated, Every time (NA-A) works with me, I get pushed around like a goddamn kid. I'm [AGE] years old and I do the best I can. I don't like (NA-A). (NA-A) treats me like crap, she treats me rough and is mean. When R1 was asked whether he had reported the incidents to anyone, R1 stated he'd told LPN-A adding, What good does that do? The more you report people here the more I get bruises. During an interview with the DON and administrator on 4/26/19 at 3:34 p.m., the DON and administrator stated LPN-A had made a report to them on 4/24/19 alleging NA-A was rude and short to R1. The DON and administrator confirmed the allegations had not reported to the SA and verified they had no documentation of the report. The DON stated NA-A was their go to aide and was the lead NA, and stated she had never received reports of concerns pertaining to NA-A prior to LPN-A's report 4/24/19. The administrator and DON confirmed the allegations had not been reported to the SA because they felt the allegations were because of a personality conflict between LPN-A and NA-A. In addition, the administrator and DON stated they thought an investigation was supposed to be completed prior to reporting allegations to the SA. The DON stated their investigation included interviewing the dietary manager, one nurse, and R1. The DON and administrator confirmed NA-A was not interviewed, and no other residents had been interviewed. The DON also confirmed the interviews conducted as part of the investigation were not documented. In addition, the DON stated NA-A had been observed during cares on the evening of 4/24/19, and during the day shift 4/25/19. The DON confirmed there was also no documentation to verify NA-A had been observed providing care, or of any decision as to whether they had considered ongoing supervision. The administrator and DON stated NA-A had not been removed from the schedule at any time, but had continued to work unsupervised during the facility's investigation. They also stated they had only been made aware of allegations of verbal/mental abuse by NA-A towards R1, and stated they were unaware of any other residents involved. R1's annual Minimum Data Set (MDS) assessment dated [DATE], included [DIAGNOSES REDACTED]. The MDS also indicated R1 had moderate cognitive impairment and did not have any verbal, physical, or rejection of care behaviors. The MDS further indicated R1 required extensive assistance from one staff for transfers and toileting. R1's vulnerable adult care plan dated 10/4/17, indicated: Resident at risk of being abused by other vulnerable adult, related to cognitive impairment, impaired mobility, age, nursing home placement, past behaviors of yelling/swearing at staff. The care plan directed all staff to report episodes of abuse/maltreatment immediately. The care plan also indicated R1 had cognitive impairment and was occasionally incontinent of bowel. The care plan also indicated R1 was able to alert staff when he needed to have a bowel movement, required help transferring on/off the toilet, adjusting clothing, performing peri care, and changing incontinent products. In addition, a problem area for behaviors dated 10/4/17, indicated R1 had disruptive verbal outburst behaviors and yelled at staff when staff tried to take cigarettes away. The care plan directed staff to record and identify patterns of behaviors and patterns for underlying causes. During an interview on 4/27/19, at 10:13 a.m. anonymous employee (AE)-2 stated, Within the last two weeks (R1) reported (NA-A) had yelled at him for being incontinent of stool and treated him roughly. AE-2 stated they did not observe the incidents, did not know the date of occurrences, and did not report to administration because they thought the incidents had already been reported per other staff members. AE-2 indicated prior to R1's allegation, AE-2 had reported similar concerns to the DON within the last month (dates and method of reporting intentionally omitted to protect the employee who wished to remain anonymous) of NA-A's aggressive rough treatment of [REDACTED]. During an interview on 4/27/19, at 4:59 p.m. AE-4 alleged having reported concerns with NA-A's inappropriate comments directed towards residents. AE-4 stated having observed NA-A aggressively transfer residents, and stated NA-A was not careful, and made fun of multiple residents, which included R1, on a daily basis over the course of at least a month. During an interview on 4/29/19, at 11:48 a.m. AE-7 stated R1 had reported to her multiple times over the last month that R1 did not like NA-A because she yelled at him for being incontinent of stool and treated him roughly during transfers. AE-7 acknowledged not reporting this in fear of retaliation from NA-A, and because AE-7 thought administration had already been made aware of NA-A's behaviors. R2's quarterly MDS assessment dated [DATE], included [DIAGNOSES REDACTED]. The MDS indicated R2 exhibited verbal behaviors directed towards others on 4 to 6 days during the assessment period, and rejection of care behaviors on 1 to 3 days during the assessment period. In addition, the MDS indicated R2 required extensive assistance from one staff member for bed mobility, hygiene, dressing, and toileting, and required extensive assistance from two or more staff members for transfers. R2's behavior care plan dated 8/30/18, indicated R2 had disruptive behaviors; verbal outbursts, swearing, irritability, agitation, and refusal of cares. The care plan directed staff to administer medications, identify patterns of behavior, identify triggers and/or underlying cause of behavior, maintain safety of resident and others. The care plan also directed staff to encourage reminiscence, present tasks one at a time, use consistent approach. During an interview on 4/26/19, at 7:11 p.m. AE-1 reported having witnessed NA-A rubbing her breast all over R2's head within the last couple of weeks. AE-1 stated when NA-A was asked why she did that, NA-A had stated it was to cheer him up and he liked it. AE-1 confirmed this had not been reported to the DON, administrator or State Agency. AE-1 also stated on a daily basis NA-A was rough when providing care to R2, and that NA-A teased and mocked R2 by repeating what R2 said. AE-1 said this would upset R2 and made him very agitated. AE-1 stated NA-A had done this for at least the last two months. AE-1 also stated when R2 would refuse cares NA-A would ignore the refusals and continue to provide care for R2. AE-1 stated R2 would demonstrate increased verbal and physical behaviors because of NA-A's treatment adding, she would get him screaming. AE-1 stated concerns of how NA-A treated residents had been brought to the attention of the DON within the last month (dates and method of reporting intentionally omitted to protect the reporter). R2's physician visit note dated 4/10/19, indicated R2 was being seen for ongoing issues related to dementia with behavioral dyscontrol. The note included, has been getting progressively more agitated with each catheterization, refusing and being physically and verbally aggressive with staff putting him at risk. I witnessed this this morning while staff were trying to get him up for breakfast. They do try to let him sleep in and be on his own schedule. R2's record lacked documentation of behaviors or behavioral analysis. R2's record reviewed from 3/1 through 4/29/19, included one progress note dated 3/24/19, pertaining to R2's physically and verbally combative behaviors during care. During an observation on 4/27/19, at 10:53 a.m. R2 was observed seated on a commode in the middle of his room. NA-A and NA-D were assisting R2 with morning cares. NA-A asked R2 if he wanted to be shaved, R2 responded, whatever. NA-A was heard to mimic R2 stating, whatever. When R2 did not respond, NA-A stated, we are in a whatever mood today, aren't we? R2 did not respond. R2 was cooperative during care. During an interview on 4/27/19, at 10:13 a.m. AE-2 stated having reported concerns to the DON within the last month (date and methods of reporting intentionally omitted to protect the reporter) of NA-A's aggressive rough treatment of [REDACTED]. During an interview on 4/27/19, at 1:05 p.m. the surveyor reported to the DON and administrator the allegations of NA-A's sexual misconduct toward R2. The DON and administrator stated they had been unaware of any allegation of sexual misconduct. During an interview on 4/27/19, at 3:38 p.m. AE-3 stated having witnessed NA-A being rough with R2, when standing him or sitting him down in his chair, but could not recall specific dates. AE-3 stated when R2 was in the dining room during meals NA-A had been observed antagonizing R2 by repeating what he said, or making fun of him. AE-3 stated NA-A intentionally ruffled feathers to get a negative reaction from him such as yelling out. AE-3 acknowledged not reporting to the administration and/or the SA because they thought administration was well aware of NA-A's behaviors since other staff had told AE-3 they'd reported to the director of nursing. During an interview on 4/27/19, at 4:59 p.m. AE-4 reported concerns with NA-A's inappropriate comments directed towards residents (contents of the report, dates, and method of reporting intentionally omitted to protect the reporter). AE-4 acknowledged having seen NA-A aggressively transferring residents, not being careful, and making fun of multiple residents which included R2, on a daily basis over the course of at least a month. On 4/29/19, at 7:58 a.m. AE-6 stated having witnessed NA-A being rough to R2 during cares on a daily basis by forcing him to get daily cares done despite R2 refusing. AE-6 stated R2 would start hitting and kicking during cares, NA-A would get aggressive with R2, would not stop providing cares and/or would not allow R2 to refuse cares. AE-6 stated having witnessed NA-A's roughness with R2 since (MONTH) of (YEAR). AE-6 reported sometimes walking out of R2's room during cares because of R2's refusals, and NA-A would continue to provide care even though R2 was yelling at her to stop. AE-6 stated NA-A would cause R2 to have verbal and physical behaviors by repeating what R2 said. AE-6 acknowledged not having reported NA-A to administration, in fear of retaliation from administration, but mostly in fear of retaliation from NA-A. AE-6 then indicated an unawareness an independent report could be made to the State Agency without going through facility administration. During an observation on 4/29/19, at 9:23 a.m. R2 laid in bed. NA-A and NA-B prepared R2 for morning cares. NA-A handed R2 a wash cloth and prompted R2 to wash his face. When R2 was done, NA-A told R2 she was going to remove his incontinent brief. NA-A started to remove R2's brief and R2 began to resist. NA-A grabbed and held R2's right wrist so he could not move. R2 screamed loudly, LEAVE ME ALONE! LET GO OF MY WRIST! THAT'S ENOUGH OF THAT! R2 then grabbed NA-A's wrist, NA-A directed R2 to let go of her wrist and removed her wrist from R2's grip. NA-A then directed NA-B grab his wrist so I can do this (peri care). NA-B gently put her hands on top of R2's hands without restraining hand movements and provided reassurance while NA-A completed peri care. R2's hands/wrists were observed to be discolored. During an interview on 4/29/19, at 11:48 a.m. AE-7 reported having witnessed NA-A being aggressive and rough while providing daily cares to R2 daily over the course of months. AE-7 further stated even though R2 screamed for her to stop, and tried to kick and hit NA-A, NA-A would continue to provide cares. AE-7 also reported when R2 would say something to NA-A she would repeat it back to him in a cynical sarcastic tone which would further aggravate and upset R2. AE-7 stated NA-A should not do that, but should have walked away. AE-7 reported not walking away when NA-A would refuse to accept R2's refusals for fear of what would happen to R2, and feared retaliation if she were to leave the room. AE-7 acknowledged not reporting NA-A's behavior to administration because other staff had warned about retaliation from administration, and also because AE-7 had a fear of retaliation from NA-A. On 4/30/19, at 12:10 p.m. R2 laid in bed, R2 was observed to have dark purple bruising on both hands/wrists and forearms. R2's left inner forearm had a large purple bruise about 5-6 centimeters (cm), top of right hand had purple bruise about 0.5 cm by 1.0 cm. During an interview on 4/30/19, at 12:14 p.m. the director of nursing stated R2 typically had discoloration on his hands, and was at risk for bruising related to medication use (other than a blood thinner). The DON also stated R2 self propelled his wheelchair which could cause bruising, and stated R2 refused to wear protective sleeves. The DON confirmed R2's record lacked identification of any other skin impairments. R2's skin note dated 5/1/19, indicated R2 had bruises of unknown origin found on his arms. The skin note further included: No open areas noted, does have various bruising noted, left inner forearm bruise 5 cm (centimeters) x 3 cm, purple in color; right dorsal bruise base of hand 0.5 cm x 0.7 cm, purple in color; outer right lower arm discoloration, varied in color yellow/purple 4 cm x 1.5 cm; outer right forearm bruise noted 2 cm x 2 cm, purple with yellow markings, C shaped bruise outer right forearm 2 cm X 1 cm, purple to light brown. R3's MDS assessment dated [DATE], indicated R3 was cognitively intact, and did not exhibit verbal, physical, or rejection of care behaviors. The MDS indicated R3 required extensive assistance from one staff for bed mobility, dressing and hygiene, and required extensive assistance from two or more staff for toilet use. R3's [DIAGNOSES REDACTED]. R3's vulnerable adult care plan dated 2/13/19, included: Resident is at risk of being abused by other vulnerable adults. The care plan directed staff to, Report any concerns of potential abusive situation to the DON/ADM (administrator) upon report by resident. Provide reassurance. Ensure safety of resident as able. The care plan also included, (R3) will focus her anger against staff who do not do as she desires. The care plan further indicated R3 had identified certain staff as her friends and would spend time sitting in front of the nurses' station. During an interview on 4/26/19, at 2:37 p.m. R3 stated she thought NA-A was mean to her because she mocked her. R3 stated she had a medical condition that sometimes caused her to vomit. R3 stated just the other day, NA-A had walked behind her and made fake vomiting noises. R3 stated this happened in the day room and in the dining room where other residents and staff were present. R3 stated she had not reported the incident to administration because there had been staff who witnessed NA-A treating her like that, so she thought staff should have reported it. R3 stated she had historically reported NA-A's behavior to the facility staff, but couldn't identify any specific dates. R3 stated she had a fear of reporting due to potential retaliation from NA-A and administration. R3 then stated, Just this past week, I was sitting by the nurses' station and (NA-A) stuck her breast in my face and shook them back in forth. There were staff who witnessed the incident. R3 stated NA-A had done that to her on more than one occasion, stating it had happened multiple times over the last several months. During a follow-up interview on 4/29/19, 8:16 a.m. R3 stated NA-A's actions of publicly rubbing her breast in her face was very embarrassing and was confusing to her. R3 said she had asked NA-A to stop doing that, to which NA-A stated, you know you like it and NA-A would just blow it off and did it all the more. During the conversation R3 had her head down, spoke quietly, and fidgeted with her necklace. During an interview on 4/26/19, at 7:11 p.m. anonymous employee (AE)-1 confirmed witnessing NA-A during the last week (week of 4/22/19) putting her chest in R3's face and shaking her breast as R3 sat in her wheelchair in the day room. AE-1 stated she had not reported the incident to anyone because she had gotten busy and forgot. During an interview on 4/27/19, at 1:05 p.m. the surveyor reported to the DON and administrator the allegations of NA-A's sexual misconduct toward R3. The DON and administrator stated they had not previously been aware of the allegation. At that time, the DON stated R3 disliked two aides because they would not have a friendship with her other than a professional relationship, and stated one of the aides R3 disliked was NA-A. During an interview on 4/27/19, at 3:38 p.m. (AE)-3 stated on 4/23/19 or 4/24/19, R3 had reported to her that NA-A had gotten into her bed, played with her hair, and was motor boating (sticking face between cleavage and blowing hard) on R3. AE-3 verified she had not reported the allegation to administration or the State Agency. During an interview on 4/28/19, at 9:34 a.m. AE-5 stated R3 had reported NA-A would jump into bed with her and put her boobs in (R3's) face. AE-5 said R3 did not like it. AE-5 could not remember when and/or how often R3 had reported NA-A's behaviors. AE-5 stated NA-A's behavior was not appropriate, but confirmed she had not reported R3's allegations to administration or the State Agency. During an interview on 4/29/19, at 7:58 a.m. AE-6 seen NA-A putting her breast in R3's face by the nurses' station within the last month or so. AE-6 also indicated they had heard from other staff members NA-A had done that. AE-6 stated had not reported to the administration in fear of retaliation from administration but mostly feared retaliation from NA-A. AE-6 then indicated an unawareness an independent report could be made to the State Agency without going through facility administration. During an interview on 4/30/19, at 7:50 a.m. R3 stated when she was coming in from outside on 4/29/19, at 6:30 a.m. NA-A had assisted her through the door and when she got inside, NA-A sat in her lap and rubbed her bottom up against her lap. R3 stated LPN-A witnessed the incident. During an interview on 4/30/19, at 7:50 a.m. LPN-A confirmed witnessing NA-A assisting R3 through the door, sitting on her lap, and moving her bottom around on R3's lap. R4's quarterly MDS assessment dated [DATE], indicated R4 had moderate cognitive impairment. The MDS also indicated R4 did not have rejection of care behaviors. The MDS indicated R4 required limited assistance of one staff for transfers, was independent with dressing, and required physical help limited to transfers for bathing. R4's facility [DIAGNOSES REDACTED]. R4's care plan dated 12/9/18, indicated R4 had a [DIAGNOSES REDACTED]. The care plan also included, irritability, numerous vocal complaints after she requests things a certain way and is not happy with her decision. Makes up situations that do not occur. Hears children running. The care plan interventions included: identify behavior patterns and triggers and/or underlying causes of behavior. During an interview on 4/27/19, R4 stated she did not like NA-A because she was so rough and mean and doesn't allow for choices. R4 stated, it was either her (NA-A) way or the highway. R4 stated when NA-A assisted her to get undressed she yanks my nightgown off over my head, and NA-A would set her down hard on the shower chair describing it as, she's rough. R4 stated staff were aware she did not want NA-A in her room or helping her. R4 stated she had not reported the issue to administration because she wasn't going to cause any problems. R4 stated, She (NA-A) can do that on her own (cause problems) if she keeps it up. R4 stated she feared retaliation from NA-A. Although R4's physician visit note dated 4/10/19, indicated R4 had had behavioral dyscontrol with primary anxiety that was worsening, and that R4 would get almost paranoid at times with staff as well as other residents, R4's record lacked evidence of documented behavioral patterns of rejection of care. In addition, R4's record lacked evidence of documentation of any worsening of anxiety symptoms, or of assessment and evaluation of symptoms if they were displayed. Progress notes reviewed from 2/1 through 4/26/19, included mention of only one documented behavior when R4 had been irritable for most of a shift, would not disclose what was wrong, and expressed being upset because dogs were in the dining room during coffee hour. On 4/26/19, at 7:11 p.m. AE-1 stated R4 did not want NA-A to provide showers or baths. AE-1 said she had not observed NA-A providing care to R4 however, knew R4 did not like the NA-A provided care to her. AE-1 indicated she thought administration was aware of this, and stated she had not reported it. On 4/27/19, at 10:20 a.m. AE-2, indicated R4 had historically told staff NA-A was not to provide care to her. AE-2 stated R4 refused NA-A because R4 was scared of her and feared retaliation. AE-2 stated the other day (date not specified), AE-2 had noticed R4 seemed down after NA-A had answered her call light. AE-2 attempted to talk to R4 and R4 would not say anything. AE-2 had not reported this to anyone, for them to intervene with R4 to determine the cause of her being down. On 4/29/19, at 7:58 a.m. AE-6 stated R4 would not allow NA-A to provide her care. AE-6 stated R4 was scared of NA-A and R4 would tell AE-6 she did not want NA-A to provide care. AE-6 then stated R4 acted differently (could not describe differently) when NA-A was around. AE-6 confirmed she had not brought R4's concerns/refusal to have NA-A provide cares, to administration. On 4/29/19, at 11:48 a.m. AE-7 stated R4 had told her NA-A was rough with her, and never wanted NA-A to provide care. AE-7 was not aware what NA-A had done that was considered rough by R4, and said she had not previously reported R4's concerns to administration. During an interview on 4/29/19, at 1:06 p.m. NA-A was observed to be visibly sweating when asked questions. NA-A's voice was noted to be elevated and she responded with a rapid speech pattern. NA-A stated, I know I'm rough because I'm quick, and I know that there are residents that I am too rough with and sometimes I hurt people, but I apologize. NA-A stated working with residents was so repetitious, she was used to doing it, and was usually in a hurry to get things done. NA-A stated she had been working a lot of hours and had told administration she didn't want to work so many hours. NA-A then stated, I've had the same personality for [AGE] years, I'm not about to change it now! NA-A further stated newer staff try to tell her what to do, they don't know the residents, I know the residents! I'm not going to listen to them, because I know them better! During an interview with the DON and administrator on 4/29/19 at 1:51 p.m., the DON and administrator were asked whether the concerns LPN-A had reported 4/24/19, and the surveyor had subsequent inquired about 4/26/19, had been submitted to the SA. The administrator stated a report had not been submitted to the SA because they felt the allegations were customer service related and were a result of a conflict of personality between NA-A and LPN-A. They described the additional investigation they had initiated. They stated on 4/26/19, 3 residents and one nurse had been interviewed. The DON stated the residents interviewed had denied any kind of mistreatment by NA-A. In addition, the administrator stated NA-A had been provided education regarding the facility's code of conduct and respecting residents on the evening of 4/26/19. The DON and administrator confirmed there had been no other changes of supervision for NA-A, and NA-A had remained on the schedule from 4/26-4/29/19. The administrator stated NA-A had been suspended at about 1:30 p.m. that day pending further investigation after an NA had reported allegations of physical abuse having occurred during cares that morning. The DON and administrator confirmed they had not made a report to the SA regarding the allegation of NA-A's sexual misconduct even after the surveyor had made them aware of this 4/27/19. The DON and administrator stated two staff members were interviewed about the sexual misconduct allegations. However, they verified NA-A had not been interviewed, was not removed from the schedule during the investigation, and NA-A continued to provide care to residents unsupervised. The administrator acknowledged the facility's policy indicated to Report sexual misconduct to the State Agency, protect residents, and complete a thorough investigation, and verified the policy was not followed. Investigative documentation was provided by the facility on 4/29/19 at approximately 2:00 p.m. Documentation dated 4/27/19, included the interview times of one nurse and one NA. According to the documentation, the staff members were asked if they had seen or heard of any staff behaviors where the staff inappropriately put their body parts towards a resident. Documentation indicated both staff members had said no. During a follow up interview with the administrator on 4/29/19 at 3:34 p.m., the administrator stated she had interviewed R3 about the sexual misconduct incidents. The administrator said R3 had confirmed NA-A had inappropriately put her boobs in her face and shook them around. The administrator also stated R3 had reported to her that this morning NA-A had helped her in from outside, sat in her lap, and wiggled her bottom around on R3's lap. The administrator verified the incident may have been avoided if R3 had been interviewed sooner, because NA-A would have been removed from the schedule as a result of the investigation. The administrator stated R3 was at high risk for abuse related to her behaviors so when she reported allegations they should be thoroughly investigated. The undated facility Abuse Policy included: It is the policy of Care & Rehab-Ostrander that each resident will be free from abuse. Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment or involuntary seclusion. The resident will also be free from physical or chemical restraints for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. Additionally, the resident will be protected from abuse, neglect, and harm while they are a resident at the facility. No abuse or harm of any type will be tolerated and residents and staff will be monitored for protection. The IJ was removed on 5/1/19, at 4:56 p.m. when implementation of an acceptable removal plan could be verified: NA-A was terminated from the facility; The director of nursing and administrator received 1:1 re-education on the facility's abuse policy, and were found to be competent in abuse procedures; All staff were re-educated on abuse reporting procedures and found to be competent; All residents in the facility were interviewed and/or assessed in order to ascertain impact and extent of harm from NA-A's emotional/physical/ and sexual misconduct.

Based on observation, interview and document review, the facility failed to provide skin care in accordance with physician orders, to promote healing and prevent further pressure ulcers from developing for 1 of 2 residents (R3) reviewed for pressure ulcers. As a result of the facility's failure to assess and provide care, R3 sustained harm when she developed additional pressure ulcers. Findings include: R3's face sheet indicated secondary [DIAGNOSES REDACTED]. Also included on physician visit notes dated 11/23/16, was that R3 had been losing weight due to not eating, had a fungal infection on her buttocks in November 2016, refused to be repositioned, refused to turn to side while in bed, experienced incontinence of both bladder and bowel and on that R3 was receiving hospice services. In light of these comorbidities, the facility did not promote assessment and care to prevent further pressure ulcer development. R3's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R3 was receiving hospice services, and required extensive assistance (two persons for physical assist) to complete transfers, bed mobility, dressing, toileting, personal hygiene. In addition, the significant change MDS indicated R3 had moisture associated skin damage (incontinence associated [MEDICAL CONDITION], perspiration, drainage). R3s care plan included a problem initiated 10/1/14, which indicated: potential for impaired skin integrity, with a goal to provide skin treatment to improve breakdown areas, and further identified interventions for nurses to complete included skin assessment per policy, weekly skin assessment, reduce pressure and friction, and to conduct close observation on bony prominences such as coccyx and heels. R3's Nursing Assistant (NA) assignment card (includes specific care plan interventions the NA should implement for R3) printed 1/4/17, indicated R3 had potential for impaired skin integrity. The care card indicated the NAs should assist with hygiene and general skin care, avoid using hot water for cleansing, minimize pressure on bony prominences, offer fluids with position changes, report changes to nurse, use moisturizer with cares, keep skin clean and dry, use incontinence pads, barrier cream to peri area as needed, and to keep linens clean, dry and wrinkle free. A Toileting and Repositioning Worksheet for R3 dated 1/5/17, instructed staff to check and change R3 every 2 hours. Physician order [REDACTED]. Pat dry. Apply skin prep and let dry. Apply Alginate Ag (a type of dressing with silver which acts as an antimicrobial agent) to wound bed. Apply 6 x 6 or 6 x 11 adhesive superabsorbent dressing and change twice a day AM (morning), PM (evening) until resolved, and to cleanse wound and periwound tissue on left lower buttock. Pat dry. Apply barrier paste to wound edges. Apply silver collagen to wound bed. Apply adhesive foam x 12 days AM (each morning) until resolved. The previous physician's orders [REDACTED]. R3's progress notes were reviewed in regards to pressure ulcer development: A note dated 11/17/16 indicated weekly skin assessment: buttocks are red with a small open area (pressure ulcer #1), offload pressure from her butt, skin intact. A note dated 12/1/16 indicated weekly skin assessment: buttocks red and skin is thin, small open area on left butt (pressure ulcer #1). A note dated 12/5/16 identified: skin problem open area, left mid buttock (PU#2), right mid buttock (PU#3), right lower buttock (PU#4), left lower buttock (PU#1). A note dated 12/9/16 included: [MEDICATION NAME] dressing replaced to coccyx wound. Wound clean and dry. A note dated 12/15/16 indicated weekly skin assessment: continues to have area on left buttock (PU#1) covered. Small open area. Resident's skin is thin and fragile and resident refuses to turn side to side. A note dated 12/26/16 included: area is still open (PU#1), very fragile. Resident was turned and repositioned. New dressing applied. A note dated 12/29/16 included: pressure ulcer unstageable (new PU#5) area on sacrum size 2 centimeters (cm) x 2 cm, no tunneling, no under minding present, moderate amount of [MEDICAL CONDITION] exudate noted. Area two left lower buttock (PU#1) size 1 cm x 1.5 cm x 0.2 cm no tunneling, no undermining present, moderate amount of serous exudate present. Review of R3's Wound Care Skin Integrity Evaluation page 1 of 2, dated 12/21/16, included: Wound One, Sacrum, date of onset 11/21/16, indicates pressure ulcer/ Unstageable, size 2 x 2 (L x W cm) Page 2 of 2 dated 12/21/16 included: Wound Two date of onset 11/21/16, indicates Moisture associated Skin Damage 1 x 1.5 length x width centimeters (L x W cm) with a 0.2 cm depth, both wound dressing changes are to be completed twice a day. During an observation on 1/4/17 at 8:28 a.m., R3 was observed lying in bed propped on the left side of her body. R3 was observed continuously until 10:37 a.m. to be in the same position. At 10:37 a.m., staff went into R3's room to provide care. During the care, nursing assistant (NA)-C was interviewed and stated R3 had been put to bed at 8:00 a.m. NA-C stated R3 is supposed to be repositioned every two hours. NA-C confirmed R3 had been in the same position since 8:00 a.m. (2 hours and 33 minutes). At 10:37 a.m., NA-C and NA-D were observed to reposition and change R3. During the observation it was noted the coccyx dressing had been soiled with a brownish colored matter (appeared to be feces) and there was a gel like substance coming from a tear in the dressing. After cleaning the peri-area, the nursing assistants were in the process of putting a new incontinent brief on R33, right over the obviously soiled dressing. At that time, the surveyor intervened and asked the nursing assistants what they were supposed to do when the observed a soiled dressing, both NA-C and NA-D stated they would go get the nurse. Licensed practical nurse (LPN)-A was observed to conduct wound care and a dressing change for R3 at 11:03 a.m. on 1/4/17. LPN-A stated, There is a pressure ulcer on coccyx and a new one starting under here, as she pointed to another area on R3's lower coccyx. During the observation, the surveyor asked LPN-A what substance was oozing out of the dressing. LPN-A said, It's alginate (from the dressing) coming out of the wound. When asked when the dressing had last been changed and the wound assessed for size, drainage, signs of infection, etc., LPN-A stated it had been changed last night (1/3/17) and that measurements were done weekly. During the dressing change, R3 complained the application of the new dressing 'burned'. Upon hearing this, LPN-A removed the new dressing and stated she would call the wound nurse to see if something else could be ordered. During observation of the dressing change 1/5/17 at 10:49 a.m., RN-A and LPN-A were assisted by NA-A. RN-A measured R3's four ulcers (two additional were identified from the day prior). The ulcers were identified to measure: Coccyx ulcer one 2 cm x 3.1 cm x 0.4 cm; wound two 0.6 cm x 0.7 cm; wound three 1.1 cm x 0.6 cm; wound four 0.8 cm x 0.4 cm, length x width x depth (L x W x D in cm). RN-A stated she was applying a silver alginate dressing cut to size, and covering it with an absorbent dressing to the coccyx, which was to be done twice a day. Review of the facility's Task/Treatments Summary Report for December 2016 and January 2017, revealed R3's physician had prescribed dressing treatments to both pressure ulcers twice daily. There was no documentation to identify whether or not the treatments had been completed on December 30 or 31, 2016 or January 1, 2, 3, 4 and 5, 2017. LPN-A was interviewed on 1/5/17 at 2:51 p.m., regarding facility expectations for assessment of pressure ulcers especially related to the development of R3's second, third and fourth open wounds. No additional assessment information was provided when requested. However, LPN-A verified there were now four open wounds as had been measured earlier that day. LPN-A also stated the areas were reddened at the end of November 2016, but had gotten worse. During interview with the facility's acting director of nursing (DON) at 4:15 p.m. on 1/5/17, the DON stated she would expect staff to conduct weekly skin assessments and measurements for all skin ulcers. The surveyor attempted to contact R3's medical doctor twice on 1/5/17 with no success and no return call. The facility's policy for pressure ulcer care/services was requested but was not received.