Every finding on record at Pioneer Care Center

Based on observation, interview, and document review, the facility failed to ensure food stored in the refrigerators and freezers were labeled, dated and discarded properly. This deficient practice had the potential to affect all 89 residents who received food from the refrigerators, freezers and the kitchen.Findings include:On 8/4/25 at 9:44 a.m., during the kitchen tour with the cook the following concerns were identified.Walk in cooler-half container of sour cream without notation of an opened date and an expiration date of 6/20/25.Fridge in kitchen-1/4 container of mustard with an expiration date of 7/28/25.-1/2 bottle of barbeque sauce without notation of an opened date and no expiration date.During an interview on 8/4/25 at 10:20 a.m., cook verified the above findings during the kitchen tour. [NAME] stated her expectation was all opened food should have been dated and thrown away on or before the expiration date to prevent food-borne illness.During an interview on 8/4/25 at 10:30 a.m. dietary manager (DM) stated her expectation was all food should have been dated when it was opened and thrown away after the shelf life or the expiration date to prevent food-borne illness.Review of a facility policy titled Food Storage updated 3/23/25, identified leftover foods should be stored in covered containers or wrapped and clearly labeled, dated and monitored to assure that foods are consumed by their safe use by dates, or frozen.

Based on observation, interview and document review, the facility failed to ensure medications were labeled appropriately to include administration directions, insulin pens were dated and not expired and failed to dispose of expired eye drops per manufacturer recommendation's for 9 of 9 residents (R47, R69, R92, R36, R40, R73, R19, R10, R13) reviewed during medication storage and administration. Finding include: R47's medication review report signed [DATE], included orders for Thera Tears (for dry eyes) solution 0.25%, install one drop in both eyes four times a day for dry eyes. During an observation and interview on [DATE] at 3:31 p.m., a bottle of Thera Tears 0.25% eye drops was in R47's medication drawer. The bottle had no name, label, or date opened. The directions on the bottle from the manufacturing company indicated to install 1-2 drops in the affected eye as needed. Registered nurse (RN)-B indicated the box the eye drops came in was thrown after it was verified with the EMAR. RN-B checked the EMAR and indicated R47 receives Thera Tears four times a day, which was different than what was written on the bottle. RN-B indicated staff would follow the orders on the MAR and not on the bottle. During an observation and interview on [DATE] at 9:10 a.m., RN-C verified there was no name or directions on the R47 Thera Tears eye drop bottle. RN-C indicated the directions are on the EMAR and would follow the directions on the EMAR. RN-C indicated the family would bring R47's eye drops; that is why there is no name or label on the eye drop bottle. R69 R69's medication review report signed [DATE], included orders for latanoprost 0.005%, install one drop in both eyes one time a day for glaucoma. During an observation and interview on [DATE] at 3:34 p.m., R69 had a bottle of latanoprost (glaucoma) 0.005% eye drops in the medication drawer. There was no date of when the medication was opened, RN-B indicated the facility has a list of medications and when they expire on the medication cart from the pharmacy. RN-B verified the eye drops were open, and the EMAR indicated the eye drops expire 5/26. During an observation and interview on [DATE] 9:12 a.m., RN-C verified R69 latanoprost 0.005% eye drops had no date of when it was opened or when it expired on the eye drop bottle. RN-C indicated the process was to write on the eye drop when it was opened. RN-C indicated latanoprost normally expires in 28-40 days after being opened. RN-C indicated staff would write in the MAR when a medication expires. RN-C looked at the EMAR and showed the EMAR had the latanoprost expiring 5/26. During an interview on [DATE] at 9:23 a.m., clinical coordinator manager (CCM)-A indicated staff should date eye drops after opening. CCM-A was under the assumption that latanoprost eye drops expire 28 days after opening. CCM-A indicated staff should throw the eye drops if not dated when opened, and to order new eye drops from the pharmacy. CCM-A indicated it is important not to administer a medication when it has expired, to ensure the medication is working at its full strength. CCM-A checked with the pharmacy and confirmed the latanoprost eye drops were filled on [DATE], which indicates the medication had not expired. CCM-A indicated she would date the medication with the correct expiration date. CCM-A also provided a list of medications and expiration dates that the facility uses, and according to the list, latanoprost was good for six weeks after opening and being unrefrigerated. CCM-A also indicated the facility had labels with the resident names and room number for medications that were brought in by family and should have been applied to R47 eye drops. R92 R92’s Medication Review Report signed undated, revealed the following: - Artificial Tears Ophthalmic Solution1.4% instill one drop in both eyes as needed for dry eyes four times a day (QID). - Artificial Tears Ophthalmic Solution 1.4% instill one drop in both eyes three times a day for cataract evaluation until [DATE]. R92’s eMAR dated [DATE] to [DATE], revealed the following: - Ketorolac Tromethamine Ophthalmic Solution 0/5% instill one drop in both eyes one time a day for cataracts for 14 days starting [DATE]. - Ketorolac Tromethamine Ophthalmic Solution 0/5% instill one drop in both eyes one time a day for cataracts for 14 days starting [DATE]. - Prednisolone Acetate Ophthalmic Suspension 1% instill one drop in both eyes one time a day for cataract surgery for 21 days starting [DATE]. - Prednisolone Acetate Ophthalmic Suspension 1% instill one drop in both eyes one time a day for cataract surgery for 21 days starting [DATE]. - Refresh Tears Ophthalmic Solution (Carboxymethylcellulose Sodium) instill one drop in right eye three times a day for dry eyes starting [DATE]. - Refresh Tears Ophthalmic Solution (Carboxymethylcellulose Sodium) instill one drop in right eye as needed for dry eyes starting [DATE]. - Moxifloxacin HCL Ophthalmic Solution 0.5% instill one drop in both eyes four times a day for cataract surgery for seven days starting [DATE]. During an observation/interview on [DATE] at 3:45 p.m., RN-B opened R92’s locked medication drawer in R92’s room. Located in a cup in R92’s drawer revealed the following: - Refresh Tears Ophthalmic Solution (Carboxymethylcellulose Sodium) with R92’s name and prescription number (Rx). Eye drops lacked boxed packaging and instructions. - Moxifloxacin Ophthalmic Solution 0.5% with R92’s name and Rx number. Eye drops lacked boxed packaging and instructions. - Prednisolone Acetate Ophthalmic Suspension and lacked R92’s name, Rx number, boxed packaging, and instructions. RN-B confirmed the above findings and stated eye drops should be in the boxed packaging labeled with resident’s name, Rx number, and directions. R36 R36's Medication Review Report signed [DATE], included orders for Lantus Solo Star Subcutaneous solution Pen-injector 100 unit/ML (insulin Glargine) inject 8 units subcutaneously once a day for diabetes. R36's electronic medical record (eMAR) dated [DATE] to [DATE], identified R36 was currently receiving 8 units of Lantus insulin injection one time a day at bedtime. During an observation/interview on [DATE] at 3:33 p.m., trained medication aid (TMA)-C reviewed insulin pen with surveyor and confirmed the pen was not dated. TMA-C indicated TMA-C was aware pens were only good for 28 days after they were opened. TMA-C took the pen to registered nurse (RN)-F who confirmed the insulin pen was undated. RN-F discarded the insulin pen in the sharp’s container. R40 R40's Medication Review Report signed [DATE], included orders for Lantus Solo Star Subcutaneous solution Pen-injector 100 unit/ML(insulin Glargine) inject 14 units subcutaneously once a day for diabetes. R40's current medication administration record (MAR) identified R40 was currently receiving 14 units of Lantus insulin injection at bedtime daily. R73 R73's Medication Review Report signed [DATE], included orders for Latanoprost Solution 0.005% one drop to each eye once per day for glaucoma. R73's MAR identified R73 was currently receiving Latanoprost Solution 0.005% one drop to each eye once per day. During an observation and interview on [DATE] at 3:33 p.m., registered nurse (RN)-D confirmed R40's insulin pen in the locked drawer was not dated and R73's Latanoprost Solution 0.005% eye drops had an expiration date of [DATE]. RN removed the insulin pen from R40's locked medication drawer and the eye drops from R73's locked medication drawer and brought them to the medication room to be destroyed. RN-D verified Lantus insulin pen was good for 28 days and stated her expectation was R40's insulin pen would have been dated when it was opened. RN-A further stated her expectation was R73's eye drops were thrown away on or before the expiration date to ensure the medications were effective. R19 R19's Medication Review Report signed [DATE], included orders for Silicon Oil (Sil-Optho) prosthetic lubricant- one drop to left prosthetic eye twice a day for lubrication as needed. Artificial tear solution- instill one drop in right eye as needed for dry eye, and one drop in right eye five times a day for dry eye. Muro 128 ointment 5%- instill one application in right eye one time a day for corneal abrasion to right eye. During observation on [DATE] at 3:33 p.m., registered nurse (RN)-A confirmed R19 had a bottle of Sil-Optho not labeled, a bottle of Eye Relief not labeled, and a tube of Muro 5% not labeled. RN-A removed the medications from R19's medication locked drawer and brought to medication room, then indicated they would be destroyed. R10 R10's Medication Review Report signed [DATE], included order for Nitrogycerin Sublingual (below tongue) 0.4 milligram (MG)- give one tablet sublingually as needed for chest pain. Give one dose every five minutes for chest pain. Do not exceed three doses in 15 minutes. During observation on [DATE] at 3:44 p.m., RN-A confirmed R10 had two bottles of nitroglycerine, one with a label which included R10's name only and one not marked. RN-A stated they both should have R10's name and instructions attached. R13 R13's Medication Review Report signed [DATE], included orders for Breztri Aerosphere Inhalation Aerosol 160-9-4.8 microgram (MCG-ACT)- two puffs inhale orally two times a day for wheezing. Muro 128 ointment 5%- instill one drop in both eyes at bedtime for dry eye 1/4 strip in both eyes. During observation on [DATE] at 3:57 p.m., trained medication aide (TMA)-A indicated R13's two Brezti inhalers were not labeled. One was in her medication drawer, and one was on her bedside table. TMA-A stated there was a box for the inhaler with the label on it at one time, but it was not in R13's drawer anymore. R13 also had a Muro 5% eye ointment with no label. TMA-A indicated the Muro had a label, but it was not on it anymore. TMA-A also stated no expiration date was found on the Muro ointment. During a phone interview on [DATE] at 8:32 a.m., consultant pharmacist (CP)-A indicated all medications should have a pharmacy label with the resident's name and instructions. CP-A indicated if the medication was too small for a full label, she would expect the medication to be labeled with the resident's name and instructions to see electronic medication administration record (EMAR) for directions. CP-A stated if the medication was received in a box, the medication should be stored in the box which would contain the pharmacy label. CP-A stated it was important for medications to be labeled correctly to assure used correctly and for correct resident. CP-A indicated Xalatan/latanoprost eye drops expired 42 days or six weeks after opened. They should be labeled with date opened, and destroyed once expired. CP-A stated insulin pens should be dated when first used, and destroyed after manufactures recommended dates of how long the pens should be used, which was usually 28 days. CP-A indicated eye drops, and insulin pens should be dated when opened, and not used after expiration date per manufactures instructions. During interview on [DATE] at 9:14 a.m., director of nursing (DON) indicated her expectation was all medications would be labeled with resident's name, expiration date and directions for use. If the medication was not large enough for the full label, it should be kept in the box it came in. DON indicated the facility had labels they could use that had the resident's name and to refer to chart for direction of use. DON stated labels on medications were important to follow the rights of medication administration and safety. DON stated the facility had a shortened expiration date form, provided by pharmacy, which indicated which eye drops had shortened expiration dates after opened. DON stated her expectation was the eye drops were labeled when opened and disposed of when expired. DON stated insulin pens should also be dated when opened and disposed of when expired. DON indicated most insulin pens were to be disposed of after 28 days. DON stated it was important to dispose of medications after expiration as the medication may not be as effective after expired. The facility policy titled Medication Labeling And Storage revised 2/23, identified medications were stored in packaging, containers or other dispensing systems they were received. The policy identified medication labels included medication name, prescribed dose, strength, expiration date when applicable, resident's name, route of administration, and appropriate instructions and precautions. If medication containers had missing, incomplete, improper or incorrect labels, contact pharmacy for instructions regarding returning or destroying those items.

Based on observation, interview and document review, the facility failed to comprehensively assess the use of a low bed as a potential restraint for 1 of 1 resident (R32) reviewed for restraints.Findings include: R32's significant change Minimum Data Set (MDS) assessment dated [DATE], identified R32 had severe cognitive impairment and diagnosis of Parkinson's, hypertension (elevated blood pressure) and arthritis. R32 required extensive assistance for activities of daily living (ADL's) which included bed mobility, transfers, and toileting. R32 had no impairment of upper or lower extremities, had a history of falls, and required a wheelchair for mobility. MDS indicated R32 did not use any restraints. R32's significant change Care Area Assessment (CAA) dated 6/24/25, identified R32 had severe cognitive impairment and was a fall risk and R32 did not use any restraints. Review of R32's quarterly fall assessment dated [DATE], identified R32 had balance problems when walking and standing and was a moderate risk for falls. Assessment did not identify the use of any restraints. Review of R32's current physician orders signed 6/17/25, did not identify an order for a restraint. R32's medical record lacked any evidence a restraint assessment had been completed. R32's care plan revised 7/25/25, identified R32 had a self - care deficit and was at risk for falls related to confusion, impaired balance and limited mobility. Identified 32 had a fall on 7/25/25 and directed staff to ensure R32's bed is in the lowest position at night for safety. Identified R32 transferred using a stand-up lift. R32's progress note dated 7/28/25 at 10:55 a.m., identified on 7/25/25 R32 was found on the floor next to her bed. Identified R32 had attempted to self-transfer from bed. Identified a new intervention after fall was to have bed in lowest position when R32 was in bed. During an observation on 8/4/25 at 6:49 p.m., R32's bed was about 1 ft. off the ground and R32 was sitting at the edge of the bed leaning forward and was yelling I can't get up come help me. Nursing assistant (NA)-A and NA-B entered R32's room and assisted R32 to lie back down in bed and boosted R32 up in the bed. During a joint interview on 8/4/25 at 6:56 p.m., nursing assistant (NA)-A stated R32 attempts to get out of bed on her own and had fallen. NA-A stated the latest intervention was to put R32's bed in the lowest position to keep R32 from getting up and falling. NA-B stated the low bed makes it really hard for R32 to stand up on her own. NA-A and NA-B stated R32 was able to stand on her own even though it was not always safe. NA-A and NA-B stated they were unsure if R32's low bed was a potential restraint. During an interview on 8/5/25 at 8:26 a.m., licensed practical nurse (LPN)-A stated R32 's bed is in lowest position because R32 has had falls trying to self transfer out of bed. LPN-A verified R32 was able to stand up on her own. LPN-A stated she did not feel putting R32's bed in lowest position was a restraint because even though R32 was able to stand on her own it was not safe for R32 to stand on her own. LPN-A verified R32's low bed was not assessed as a potential restraint. During an interview on 8/5/25 at 8:33 a.m., physical therapy assistant (PTA) stated R32 was able to stand up on her own and she should wait for help to stand up. PTA stated R32's bed is in the lowest position so that if R32 attempts to stand up on her own and falls it won't be so far to fall. PTA stated she did not think of the low bed as a potential restraint for R32 because R32 was not aware of the potential of falls when she stood on her own. During an interview on 8/5/25 at 10:08 a.m., director of nursing (DON) verified R32's care plan revealed R32 had falls attempting to self- transfer and the latest intervention was for 32's bed to be placed in the lowest position. DON verified a restraint assessment had not been completed prior to placing R32's bed in the lowest position. DON stated she had not thought of the low bed as a restraint for R32 because even though R32 was able to self transfer she was not always safe during self- transfers. DON further stated she could see how R32's low bed could be a potential restraint. DON stated her expectation was that a restraint assessment would have been completed prior to placing R32's bed in the lowest position. Review of a facility policy titled Restraint Free Environment revised 2025, identified a physical restrain refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body such as placing a resident in a chair that prevents the resident from rising independently.

Based on observation, interview and document review, the facility failed to ensure recommended splint or alternative devices were utilized to help prevent further contractures and stiffness for 1 of 1 residents (R11) reviewed for range of motion (ROM). Findings include:R11's annual Minimum Data Set (MDS) assessment dated [DATE], identified R11 had severe cognitive impairment and had diagnoses of cerebral palsy (irregular brain development that affects movement and posture), seizure disorder, and malnutrition. Indicated R11 required extensive assistance of staff for activities of daily living (ADLs) including transfers and toileting. R11's care plan revised 7/26/23, identified R11 had limited physical mobility related to the disease process. Additionally, R11 had the potential for skin impairment related to decreased mobility. R11's care planned interventions included:- Apply small towel roll in between left elbow and shoulder and small roll in left palm web space.- Left Hand Contractures: Place foam roll in palm of left hand between thumb and palm to prevent skin breakdown. Remove and check skin every two hours and as needed. R11's treatment administration record (TAR) dated 7/1/25 to 8/5/25, identified R11 was to apply a small towel roll in between left elbow and shoulder and small roll in left palm web space Monday, Wednesday, and Friday.R11's Kardex dated 8/5/25 revealed the following:- Left Hand Contractures: Place small towel/washcloth as resident will tolerate in left palm between thumb and palm every two hours and as needed.- Place small towel/ washcloth as resident will tolerate between left elbow and shoulder. Notify nurse if noted skin alternation. During an observation on 8/4/25 at 12:18 p.m., R11 was lying in bed with eyes closed. R11 left hand was tightly closed with thumb pressed against palm of hand and four fingers placed over thumb. Additionally, R11's left arm was bent up at the elbow. R11 was able to move right hand open and closed. R11 is non-verbal and unable to answer any questions. R11 did not have a washcloth or foam roll placed in R11's left hand and left elbow.During an observation on 8/4/25 3:30 p.m., R11 remained in a similar position as noted above.During an observation on 8/4/25 at 7:02 p.m., R11 was resting in bed with music playing. R11 had a gown on and was covered with a thin blanket. R11 did not have a washcloth or foam roll placed in R11's left hand and left elbow.During an observation on 8/5/25 at 8:20 a.m., R11 was resting in bed covered with a blanket. R11 was listening to music with R11's eyes closed. R11 did not have a washcloth or foam roll placed in R11's left hand and left elbow.During an observation and interview on 8/5/25 to 9:47 a.m., registered nurse (RN)-E entered R11's room to provide medications. RN-E stated R11 did not have a brace for R11's left hand. RN-E further stated staff were to be doing range of motion (ROM) on R11's upper extremities to help reduce further contractures. RN-E provided ROM on R11 after completing medication administration. RN-E completed ROM, cleaned up supplies, left R11's room, and charted ROM in R11's TAR.During an interview and observation on 8/5/25 at 11:06 a.m., rehabilitation director (RD) revealed passive range of motion (PROM) of R11's upper extremities was an order from occupational therapy (OT). RD further revealed R11's left hand was contracted when R11 was admitted to the facility and R11 could not use a brace. RD indicated OT ordered the use of a washcloth in place of a brace. RD further indicated R11 had an order to place a washcloth in the left hand and left elbow Monday, Wednesday, and Friday. RD reviewed R11's care plan and stated another intervention was listed for staff to place a foam roll in R11's left hand and monitor every two hours. RD confirmed the correct order should have been to place a washcloth in R11's hand and elbow Monday, Wednesday, and Friday. RD entered R11's room to evaluate R11's left hand to see if contractors had gotten worse. RD stated there had not been much change in R11's left hand and left arm. RD indicated R11 would still benefit from having a washcloth placed in R11's hand and elbow as tolerated Monday, Wednesday, and Friday.During an interview on 8/5/25 at 11:22 a.m., registered nurse (RN)-F and RD reviewed R11's orders and care plan. RN-F confirmed the current orders and care plan interventions for R11 and indicated RN-F was unaware what exact orders staff should have been following. RN-F indicated RN-F would contact the clinical coordinator to confirm the correct orders for R11. During a follow-up interview on 8/5/25 at 2:13 p.m., RN-F indicated the clinical coordinator stated R11 should have had the foam roll intervention removed from the care plan. RN-F further indicated the correct order was currently listed on the TAR and staff should have been following the current order.During an interview on 8/5/25 at 2:33 p.m., director of nursing (DON) confirmed the above findings and stated she expected staff to follow the plan of care to ensure residents do not have a decline in care. DON further stated it is important residents continue to keep the highest level of ROM as possible. Facility policy titled restorative nursing services revised 7/17, resident will receive restorative nursing care as needed to help promote optimal safety and independence. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitation services. Restorative goals may include, but are not limited to supporting and assisting the resident in: participating in the development and implementation of his/her plan of care.

Based on interview, observation, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded to include the use of safety alarms for 1 of 1 residents (R17) reviewed for MDS. Findings include R17's significant change in status MDS dated [DATE], identified R17 had medically complex conditions, hypertension, anxiety, and depression. R17 needed extensive assistance with activities of daily living (ADLs). R17 did not use a bed alarm, chair alarm, floor mat alarm, or motion sensor alarm.R17's care plan was revised on 7/25/24, revealing R17 had audible wheelchair and silent bed and recliner alarms. R17's signed orders dated 6/17/25, revealed R17 had orders to monitor the placement and function of the bed and recliner alarm, and the audible wheelchair alarm every shift for fall intervention; the order start date was 2/6/24.During an observation on 8/4/25 at 6:48 p.m., R17 was in the living room area next to the dining room, with a chair alarm on the back of the wheelchair. During an observation on 8/5/25 at 8:05 a.m., R17 was lying down in bed, the bed was low to the floor with a floor mat and a bed alarm attached to the bed. During an observation on 8/5/25 at 12:10 p.m., R17 was not in the room, but the alarm strip was on the bed. R17 was in a wheelchair, sitting in front of the television with an alarm on the back of the wheelchair. During an observation on 8/6/25 at 7:10 a.m., R17 was in a low bed with a bed alarm attached to the bed. During an interview on 8/5/25 at 12:15 p.m., registered nurse (RN)-E, verified R17 has had a bed alarm and a chair alarm since RN-E started working at the facility about a year ago.During an interview on 8/5/25 at 2:17 p.m., MDS coordinator verified the MDS was not coded for a bed alarm or a chair alarm. The MDS coordinator viewed the Kardex and the care plan and verified R17 did have a bed alarm and chair alarm and should have been coded on the MDS. The MDS coordinator indicated the process was to review the assessments, care plan, and care conference notes when completing an MDS. The MDS coordinator indicated at times she would perform a visual assessment on a resident, but did not have a visual assessment when completing R17's MDS. During an interview on 8/5/25 at 2:52 p.m., RN-F viewed R17's care plan and Kardex and verified R17 had a bed alarm and chair alarm and should have been coded on the MDS. During an interview on 8/6/25 at 10:21 a.m., director of nursing (DON) expectation would be for the MDS coordinator to review the care plan. DON verified the bed alarm and chair alarm were located in R17's care plan. DON's expectation would be for the MDS to be coded correctly. Review of the facility policy titled Resident assessments dated October 2023, revealed information in the MDS assessment will consistently reflect information in the progress notes, plans of care, and resident observations/interviews.

Based on observation, interview, and document review, the facility failed to ensure proper implementation of the self-administration of medication (SAM) assessments for 2 of 2 residents (R36, R1), reviewed for medication administration. Findings include: R36's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R36 was cognitively intact and diagnoses of diabetes, heart failure, and arthritis and required the assistance of one staff with activities of daily living (ADL's) for transfers and toileting. R36's physician orders dated 8/4/25, revealed the following: - Lidocaine External Patch 4%, apply to back topically two times a day for pain. Apply at bedtime (HS) and remove at morning (AM). R36's electronic medical record (eMAR) dated 7/1/25 to 8/5/25, revealed nursing staff had applied and removed the lidocaine patch daily following physician’s orders. R36's self-administration of medication (SAM) assessment dated [DATE], indicated R36 was able to self-administer medications after the nurse set-up R36’s medications. During an observation on 8/05/25 at 3:45 p.m., trained medication aid (TMA)-C stated R36 was to have a lidocaine patch applied at HS. TMA-C confirmed R36's box of lidocaine patches were sitting out on R36's dresser in R36's room. TMA-C left the room after giving R36's medications, however, did not put R36’s box of lidocaine patches away in the locked medication drawer. During an observation on 8/06/25 at 8:09 a.m., R36 continued to have an open box of lidocaine patches, containing three unopen patches, sitting on top of R36’s dresser in R36’s room. During an observation and interview on 8/06/2025 at 8:52 a.m., R36's lidocaine patches remained in the same position. R36 indicated she had a patch put on at HS and R36 removed the lidocaine patch independently in the AM. During an interview on 8/06/25 at 8:32 a.m., pharmacy consultant (PC) stated R36 was to have one lidocaine patch on at a time and nursing staff should have only leave one patch out for R36 to apply. PC further stated it was important to follow the SAM assessments to ensure residents are appropriately using medications. During an interview on 8/06/2025 at 9:01 a.m., clinical coordinator (CC)-A confirmed R36's order for lidocaine patches. CC-A indicated R36 was not able to apply them independently but could remove them independently. CC-A revealed the lidocaine patches should have been put away in R36's drawer when they were not being used. CC-A entered R36's room and put the lidocaine patches away in R36's locked medication drawer. During an interview on 8/06/25 at 9:21 a.m., director of nursing (DON) confirmed the above findings and stated it was important for medication staff to put medications away in the appropriate location for safety reasons. DON further stated it was important for medication staff to return to the residents’ room to ensure medications were taken properly. R1's significant change minimum data set (MDS) dated [DATE], revealed R1 had a mild cognitive impairment. R1 had a diagnosis of having an indwelling urinary catheter, heart failure, and hypertension. R1 needed extensive assistance for activities of daily living (ADLs). R1's signed orders dated 6/17/25, had an order for Clotrimazole ointment 1% (antifungal) for cutaneous candidiasis (skin infection), apply to the penis head twice a day, and Miconazole powder (antifungal) to affected red areas topically as needed when the current supply of nystatin powder (antifungal) is exhausted. R1's care plan revised on 6/6/25, revealed R1 is not able to self-administer medications. R1's self-administration of medication assessment dated [DATE], revealed R1 was not able to self-administer medications. During an observation and interview on 8/4/25 at 1:07 p.m., a tube of Clotrimazole cream 1% and Nystatin powder was sitting on the nightstand. R1 indicated that staff would leave the cream and powder on the nightstand for staff to apply. R1 indicated that if the medications were not left out on the nightstand, staff would not apply the cream and powder, as only one person can get out the cream and powder and apply it when they are locked up. During an interview on 8/4/25 at 1:26 p.m., licensed practical nurse (LPN)-A verified R1 did not have an order to self-administer medication. LPN-A verified there was a tube of Clotrimazole cream 1% and Nystatin powder on R1 nightstand. LPN-A locked up the medications in the medication drawer. During an interview on 8:33 a.m., pharmacy consultant indicated Clotrimazole and Nystatin are both antifungal medications and should have a self-administered assessment done to ensure the resident knows how to correctly administer the medications. During an interview on 8/6/25 at 9:23 a.m., clinical coordinator manager (CCM)-A indicated medications applied by the nurse or trained medical assistant (TMA) should be in the medication drawer. CCM-A indicated that a self-administration assessment was important to ensure the resident understands how to administer a medication correctly. CCM-A indicated that locking a medication in a medication drawer is important to ensure the safety of residents and visitors. During an interview on 08/06/2025 at 10:23 a.m., director of nursing (DON) verified that creams and powders should be in a locked drawer unless the resident has a self-administration of medications order and was assessed to ensure they were safe to have the medications at bedside. Facility policy titled Self-Administration of Medications dated 2/21, the interdisciplinary team (IDT) assesses each resident’s cognitive ability and physical abilities to determine whether self-administering of medications is safe and appropriate. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party.

Based on observation, interview, and document review, the facility failed to ensure required nurse staffing information was consistently posted on a daily basis. This had the potential to affect all 90 residents, staff, and visitors who may wish to view the information. Findings include: On 8/4/25 at 11:19 a.m., the facility staff posting was sitting on a desk across from the elevator. The staff posting was dated 8/2/25 with a census of 88. During an interview on 8/4/25 at 11:24 a.m., director of nursing (DON) confirmed the date and census on the staff posting were incorrect. DON indicated the process was to update the nurse staff posting daily. The DON removed the Saturday staff posting, and behind was the Sunday staff posting. Monday's staff posting was located behind Sunday's. Monday was then placed on the counter, which was the current schedule, but had the incorrect census of 88. DON indicated the scheduler is responsible for creating the daily staff posting. The charge nurse was responsible for updating the staff posting with changes regarding resident census or staffing changes. During an interview on 8/4/25 at 12:00 p.m., the scheduler indicated the normal process is to create the nurse staff posting for the following day between 2:00 p.m. and 3:00 p.m. and post it behind the current staff posting. The scheduler indicated on Fridays, she would create the Saturday, Sunday, and Monday schedules and would post them behind Friday, as the scheduler does not work weekends. If there was an admission for the day, the scheduler would not put it on the current census, but would make changes for the following day's staff posting. The scheduler indicated the charge nurse would change the nurse staff posting on the weekends and make any updates regarding changes related to staffing or the census. A review of the facility policy, titled Posting Direct Care Daily Staffing Numbers, dated August 2022, revealed the facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents. The information recorded on the form shall include the name of the facility, current date, the resident census at the beginning of the shift for which the information is posted, twenty four hour shift schedule operated by the facility, the shift for which the information is posted, the type and category of nursing staff working during that shift who are paid by the facility, the actual time worked during that shift for each category and type of nursing staff and the total number of licenses and non-licenses nursing staff working for the posted shift.

Based on interview and document review the facility failed to assess and monitor bruises for 1 of 3 resident (R1) reviewed for injury of unknown origin. Findings include: R1's order dated 2/3/25 at 8:00 a.m. weekly bath day skin note. Monitor for changes, bruising, open areas. Notify nurse/general nurse practitioner (GNP) as needed. Every Monday for skin monitoring. Signed off as completed on 5/5/25, 5/12/25, and 5/19/25. R1's annual Minimum Date Set (MDS) on 4/24/25, identified R1 had severely impaired cognition, inattention (difficulty focusing, easily distractible, and difficulty keeping track of what was said), and disorganized thinking. Her medical diagnoses included Parkinson's (a movement disorder of the nervous system with symptoms that worsen over time such as tremors, slowed movements, rigid muscles, poor posture/balance, loss of blinking/smiling movements, speech changes, writing changes, nonmotor symptoms), dementia, and anxiety. She had impaired range of motion to bilateral lower extremities, unable to stand independently or walk. She required substantial to maximal assistance with personal hygiene, repositioning in bed, all transfers and dependent upon staff for toileting and oral hygiene, shower/bathe, dressing, and mobility in wheelchair. She was frequently incontinent of bladder and occasionally incontinent of bowel. Facility Resident Accident/Incident Report dated 5/17/25, completed by floor supervisor registered nurse (RN)-A identified date of incident 5/17/25 at 8:00 a.m. staff noted R1 had eight areas on greenish colored bruising, dime to nickel sized, on inner knee/thighs and appeared to be fingerprint in size. Notification to MD/GNP/PA and MD/GNP/PA was left blank and administrator and director of nursing (DON) were notified on 5/17/25. R1's progress note dated 5/17/25 at 10:27 a.m. identified she had bruising to upper/inner thighs and inner left knee. They were dark green in color. Bruises were fingerprint sized and did not appear to have cased pain when palpated. She was unable to answer when asked if she felt safe in facility, if anybody had hurt her or if she remembered how she got the bruises. Resource manager was notified. Appropriate actions were in place (actions not identified). Her granddaughter was contacted and informed of incident and had no questions/concerns at that time. Will continue to monitor and document as needed. R1's order dated 5/18/25, monitor bruising to inner bilateral thighs for healing. Discontinue when healed. No directions specified for order. No progress notes noted on 5/18/25. R1's progress note dated 5/19/25 at 1:34 p.m., identified skin assessment/observation of pubic area, buttocks, groin, and upper thighs: skin intact, warm, and dry. No new lesions, bruising or rashes noted. Chronic redness in groin, Nystatin applied. Healing bruises in inner thigh, almost gone. R1's progress note dated 5/20/25 at 10:42 a.m. Type: appointment return/physician visit/medication change. No changes to plan. Updated family member. R1's progress note date 5/22/25 at 11:49 a.m. Type: Skin/wound note. MD updated via fax. R1's progress note date 5/22/25 at 4:55 p.m. received a fax order from MD concerning the bruising found on the resident. Continue to monitor. R1's record lacked monitoring of bruises on 5/18/25, 5/20/25-5/22/25, or until resolved. During an interview on 5/23/25 at 11:00 a.m. registered nurse (RN)-A stated R1's progress notes written on 5/17/25, indicated appropriate actions were in place. The nurse providing cares and assigned to that unit would have been expected to monitor the bruising and document in the medical record/progress notes every shift. There was a nursing order to monitor the bruises but was unable to identify it had been placed in the TAR in electronic medical record. During an interview on 5/23/25 at 2:00 p.m., trained medication aide (TMA)-C stated he skin assessments usually would be identified and assigned through the resident's TAR (Treatment Administration Record) and he had not aware of anything for R1. During an interview on 5/23/25 at 2:10 p.m. RN-B stated she was not aware of R1's bruises were to be monitored and would confirmed that would have been important to monitor for any changes from the initial assessment on 5/17/25, such as more bruises, and whether they were healing or had a change in skin integrity. RN-B stated the order should have been to assess the bruises every shift, but the schedule (frequency) was not indicated in the order. She also verified the order was not located on the TAR and/or completed. Unless the nurse looked on every order they would have not known about the assessment and planned on adding it to the TAR. During an interview on 5/23/25 at 2:42 p.m. DON stated she would have expected the nurse to have placed the order into the TAR to ensure R1's bruises were getting monitored through healing. DON added, the nursing order was missing the routine/frequency was not entered and therefore had not shown up on the TAR. The monitoring of the R1's bruises were not signed off as completed and would have needed to follow up with staff if they were assessed every shift. During an interview on 5/27/25 at 8:32 a.m. with medical doctor/director (MD) stated had not been notified of R1's incident on 5/17/25 but would have directed the nurses as to how often they should have monitored the bruise, adding bruises do not really change every shift and most likely daily would have been sufficient. Monitoring is important to watch how the bruises evolve, look different from one day to another, if new bruises popped up, which may have triggered continued concern and/or a possible hematoma (a closed wound bleeding outside the blood vessels that resulted in a collection of blood) that may have required more medical care.

Based on interview and document review, the facility failed to notify a physician timely of a change in condition for 1 of 3 residents (R1) who had an injury of unknown origin related to bruising on her inner thigh. Findings include: R1's annual Minimum Date Set (MDS) on 4/24/25, identified R1 had severely impaired cognition, inattention (difficulty focusing, easily distractible, and difficulty keeping track of what was said), and disorganized thinking. Facility Resident Accident/Incident Report dated 5/17/25, completed by floor supervisor registered nurse (RN)-A identified date of incident 5/17/25, at 8:00 a.m. Staff noted R1 had eight areas of greenish colored bruising, dime to nickel sized, on inner knee/thighs which appeared to be fingerprint in size. Area on report labeled Was it necessary to notify MD/GNP/PA? was left blank, as was then name/date/time of MD/GNP/PA notified. Administrator and director of nursing (DON) notified on 5/17/25 at 9:45 a.m. R1's progress note dated 5/17/25 at 10:27 a.m., identified she had bruising to upper/inner thighs and inner left knee. The bruises were dark green in color, fingerprint sized and did not appear to cause pain when palpated. R1 was unable to indicate if she felt safe in the facility, if anybody had hurt her or if she remembered how she got the bruises. Progress note indicated resource manager was notified and appropriate actions were in place (those actions not described in progress note). Her granddaughter was contacted and informed of the incident and had no questions/concerns at this time. Will continue to monitor and document as needed. R1's progress note dated 5/19/25 at 1:34 p.m., Complete Skin Assessment: Healing bruises in inner thigh almost gone. No new concerns to report to provider. R1's routine visit follow up visit by medical doctor/director (MD) on 5/20/25 at 9:55 a.m., lacked any mention of skin/bruising. R1's progress note dated 5/22/25 at 11:49 a.m. Type: skin/wound note medical doctor (MD) updated via fax. (5 days later) During an interview on 5/23/25 at 11:10 a.m. RN-A stated the provider should have been notified immediately when the bruises were discovered on 5/17/25 so they could have chosen to evaluate her or send her in for evaluation. The provider was notified via fax yesterday, (5/22/25). During an interview on 5/23/25 at 2:42 p.m. DON stated the staff would be expected to have notified the provider right away after R1's bruises were found to see if he wanted a further medical evaluation completed and/or other interventions necessary depending on the situation. During an interview on 5/27/25 at 8:32 a.m. MD stated he was not familiar with R1's incident that occurred on 5/17/25, regarding bruises. MD stated he did not believe it was included on the rounding form he received from the nurse when he saw her on 5/20/35, and no mention of bruises were identified on his visit notes. He would have wanted to be notified so that R1 could have been examined, especially when there was a potential for alleged abuse. MD indicated the he would have completed the examination to verify if there were concerns for abuse. Certainty there would have been a possibility of sexual abuse especially if bruises were located close to the genital area, if not, rough handling and/or transfers with bruising would have been possible.

Based on observations, interviews and document review the facility failed to ensure an injury of unknown source was thoroughly investigated for 1 of 3 residents (R1) reviewed for abuse. Findings include: R1's annual Minimum Date Set (MDS) on 4/24/25, identified R1 had severely impaired cognition. Her medical diagnoses included Parkinson's (a movement disorder of the nervous system with symptoms that worsen over time such as tremors, slowed movements, rigid muscles, poor posture/balance, loss of blinking/smiling movements, speech changes, writing changes, nonmotor symptoms), dementia, and anxiety. She had impaired range of motion to bilateral lower extremities, unable to stand independently or walk. She required substantial to maximal assistance with personal hygiene, repositioning in bed, all transfers and dependent upon staff for toileting and oral hygiene, shower/bathe, dressing, and mobility in wheelchair. R1's care plan dated 5/19/25, identified impairment to skin integrity, activities of daily living (ADL) self-care deficit, and impaired communication. Staff were directed to anticipate and meet needs, use caution during transfers and bed mobility to prevent striking arms/legs/hands against any sharp or hard surfaces, assist of two staff for bed mobility and transfers with assist of one and PAL (patient assisted stand lift), monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, situations, and document. She was a vulnerable adult and staff were directed to monitor and report any suspected abuse or neglect following policy. R1's progress note dated 5/17/25 at 10:27 a.m., identified she had bruising to upper/inner thighs and inner left knee. The bruises were dark green in color, fingerprint sized and did not appear to cause pain when palpated. R1 was unable to indicate if she felt safe in the facility, if anybody had hurt her or if she remembered how she got the bruises. Progress note indicated resource manager was notified and appropriate actions were in place (those actions not described in progress note). Her granddaughter was contacted and informed of the incident and had no questions/concerns at this time. Will continue to monitor and document as needed. R1's progress note dated 5/19/25 at 1:34 p.m., indicated skin assessment/observation of pubic area, buttocks, groin, and upper thighs: skin intact, warm, and dry. No new lesions, bruising or rashes noted. Chronic redness in groin, Nystatin applied. Healing bruises in inner thigh, almost gone. The state agency (SA) facility report dated 5/17/25, at 11:30 a.m. indicated no incident was observed related to bruises. Nurse caring for resident today observed greenish discoloration which appeared as bruising to residents inner knees and thighs. Size ranged from dime to nickel size. There were four small bruises in a straight line to the right inner thigh and four small bruises reported to left upper knees extending to upper thigh. Questionable if that may be related to required assist of one staff for ADLs (activity of daily living) including bathing, dressing, toileting, and transfers with a PAL lift, possible check and changed every two hours and R1's incontinent product. Observation of R1 identified she had very sensitive skin (abdominal folds/under breasts/inner thigh/groin/buttocks). Appeared to be at baseline with no changes in behaviors, participation, cognition, or mood. She continues to required assistance with bed mobility and repositioning. Previous skin assessments did not reflect skin discolorations or bruising. Interviews with staff and investigation was ongoing. Review of the SA investigative report dated 5/23/25 at 4:05 p.m. no changes to her psychosocial wellbeing that would indicate abuse. Summary of interviews completed with staff identified no witnesses and those that worked with her reported increased difficulty with turning and repositioning, occasionally resistive to oral cares and adjustment to her pillow. She was not typically resistive when checked and changed, tried to help but was having more difficulty. Resident was checked and changed every two hours; bruising could have been related to process of changing her brief. No previous reports of bruising to her legs reported. Review of facility incident investigation staff interviews on 5/22/25, lacked evidence staff were asked questions related to observed or suspected abuse, concerns with aggressive cares, or other suspicious behavior by staff or residents. During an interview on 5/22/25 at 2:58 p.m. TMA-A stated R1 was not interview able, She became aware of the yellow/greenish bruises on R1, in the healing stages located and located on both her inner thighs on 5/17/25. TMA-s indicated she reported the bruises to the nurse and was present in the room while the nurse assessed her skin. She also stated R1 did not often resist or hold her legs together, she did become ridged at times but was then given time and space to relax. TMA-A confirmed she had not been interviewed by anyone related to the bruising or abuse. During an interview on 5/22/25 at 3:17 p.m. TMA-B stated she first became aware of R1's bruises on 5/17/25 when the nurse and NA showed her the bruises. R1 had three or four bruises on both sides of her inner thighs, one on the outside of the right thigh, and one underneath each of her thighs, that were darker purple about the size of a penny. The nurse, another NA and her all thought they looked like fingerprints. TMA-B confirmed she had not been interviewed by anyone about this incident. During an interview on 5/23/25 at 2:42 p.m. director of nursing (DON) stated the facility investigation interviews with the staff included a total of three questions: had they noted any skin changes/alternations prior to incident, any trouble moving/repositioning her in the bed, and any difficulty with cares. The staff were not asked any questions about abuse and should have been. That would have helped identify if there was any abused that occurred. No abuse was determined with interviews and only an increase with repositioning was consistently identified. During an interview on 5/27/25 at 8:32 a.m. medical director (MD) stated the facility would have been expected to complete interviews with the staff that included questions about abuse. We would have wanted to know if she was being abused. If he would have been notified about the incident, an examination would have been completed, identified if things looked suspicious, and helped direct the investigation. Facility policy Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property dated 2/26/19, identified injuries of unknown origin was defined as the source of the injury was not observed by any person, or source of the injury could not be explained by the resident; and the injury was suspicious because of the extent or locations of the injury (e.g., the injury was in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incident of injuries over time. The investigation will consist of an interview with the person or persons reporting the incident, any witnesses to the incident, staff members having contact with the resident during the relevant periods or shifts of the alleged incident.

Based on observation, interview, and document review, the facility failed to provide adequate supervision when a resident was brought outside onto the patio area and left there without supervision, and later became unresponsive for 1 of 1 resident (R1) reviewed for safety. Findings include: R1's St. Louis University Mental Status (SLUMS, screening test for dementia) examination dated 1/6/23, identified R1 had a mild neurocognitive disorder. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had verbal behaviors one to three times a week, and rejection of care. She was dependent upon staff for toileting hygiene, personal hygiene, sit to stand, chair/bed to chair transfers, toilet transfers, and was unable to ambulate. R1 was frequently incontinent of bladder and occasionally continent of bowel. Medical diagnoses included arthritis, depression, psychotic disorder, macular degeneration, and epilepsy (seizure disorder). R1's care plan dated 3/18/25, identified R1 had impaired balance, limited mobility, and behaviors, and directed staff to provide total assistance of two for transfers with a lift, and encourage the use of bell to call for assistance. R1 did not ambulate. R1 required staff assist with wheelchair for longs distances, and she was independent with short distances. She had dementia with ineffective coping skills and delusional disorder (a serious mental health illness where a person cannot tell what is real and from what is imaginary, paranoid). She had impaired cognitive function/thought process and decision making. Staff were directed to cue, reorient, and supervise as needed. She required supervision with all decision making. She was at risk for falls related to gait/balance problems, and the care plan directed staff to provide call light within each, encourage her to use it when assistance was needed. She needed prompt response to all requests for assistance. R1's Nursing assessment dated [DATE], identified she had periods of delusions and hallucinations, unsteady gait, poor balance, can stand and pivot only with help, and had moderate agitation (called out and used threatening language). R1's progress note dated 5/11/25 through 5/13/25 identified: - On 5/11/25 at 5:21 p.m. R1 was found outside at 4:30 p.m. unresponsive. R1 was assisted into the unit. Vital signs were as follows: blood pressure (BP) 168/89, pulse 116, respiration 22, temperature 99.8 degrees Fahrenheit (F), oxygen saturation (SaO2) 95% on room air. A cold washcloth was applied on her forehead and then she started mumbling. Placed call to 911 and requested for emergency medical service (EMS), family notified through her brother. Registered nurse (RN) charge nurse and RN care coordinator were notified as well. -On 5/11/25 at 9:43 p.m. R1 returned from the emergency department (ED). -On 5/12/25 at 4:28 p.m. Follow-up with staff working Sunday afternoon. R1 was assisted outside about 1:45 p.m. onto the short stay patio. Staff followed-up with resident two times from that time until 2:30 p.m. and offered her water. They also asked if she would like to come back inside, which she declined. Two staff offered to bring her in again about 4:00 p.m. and she declined at that time as well. She told them she did not want to come back in at that time. -On 5/13/25 at 1:30 p.m. R1 required intravenous (IV) fluids (in the ED): sodium chloride 0.9% bolus on 5/11/25 for additional fluids intake for hydration needs. The need for fluids was determined by physical exam and/or diagnostic testing which had indicated: abnormal fluid loss, unstable vital signs (increased temperature) and abnormal labs such as BUN/creatinine, glucose, and potassium. R1 also received treatment for abnormal fluid loss, heat exposure, head exhaustion and hyperkalemia. Rehydration was reasonable and necessary. R1's ED provider notes dated 5/11/25 at 6:34 p.m. indicated clinical impression: heat exposure, hyperkalemia (high potassium levels), heat exhaustion. She was found by staff at the nursing facility confused outside and quite confused upon EMS arrival. She was alert and oriented, though seemed to have some limited recall of recent events and may have some underlying dementia or other cognitive disorder. Her temperature was 100.1 orally, very warm to the touch with evidence of sunburn, suspected she was quite warmer earlier. Cooling measures were initiated prior to EMS arrival to facility, and mental status improved. She was given cool intravenous fluids and cooling packs were applied to the groin and axilla (under arms). Despite prolonged exposure she did not appear at this time to have suffered any untoward effects. Stable and discharged back to the nursing facility. During an interview/observation on 5/15/25 at 2:03 p.m. R1 sat in her wheelchair in her room well groomed, fully dressed in t-shirt, zip-up long-sleeved jacket, shorts, socks, and tennis shoes. She stated unsure how long she had lived at the facility, and stated she had been there since fall to winter to spring and now it's summer, I think. She went outside every day and activities staff took her out. She stated she was tired today. During an interview on 5/15/25 at 4:00 p.m. RN-A stated R1 pushed herself around the unit in the wheelchair with her feet. The resident patio area was fenced in, and staff entered a code on the pad located off to the left of the inside door. He had seen R1 outside both in front of the building, and in the patio area. R1's care planned did not identify interventions for her to go outside with or without anyone. Her cognition was affected at times, and she would not have been safe outside by herself when she was confused. She was unable to stand, walk, and/or transfer herself independently, and did not attempt to self-transfer. On 5/11/25, he administered medications to R1 between 8:00 a.m. and 9:00 a.m. while she was in her room. She ate breakfast in the dining room, and then went back to her room. At 12:00 p.m. until 12:45 p.m. she sat in dining room and ate lunch. He had gotten busy after that, took a break before 2:00 p.m. and returned to the floor. Nursing assistant (NA)-A had already given report to the oncoming NA-C. NA-B was scheduled for evening shift at 3:15 p.m. At 4:30 p.m. R1 was not in her room and was found out on the patio area by herself. He asked her, Should we go inside? She shook her head no. She was not responding appropriately and mumbled. When cued, she was unable to lift her feet. Foot pedals were placed on her wheelchair and she was pushed inside the building. Vital signs were taken at the nurse's station: blood pressure 165/89, heart rate was 115, temperature 99.8 degrees F., respirations 22, and SaO2 91%, and she was unable to respond. 911 was called. He placed a wet washcloth on her face and she started to wake up and talked a bit. EMS arrived, and once she was transferred to the gurney she woke up and became her normal self. He followed up with staff, and NA-C told him she had taken R1 out to the patio just before 2:00 p.m. and passed the information onto the evening shift NA-A. He expected staff to inform the nurse, and he was not told about R1 being outside. NA-B hadn't informed him until 3:20 p.m. NA-A requested assistance to get R1 back into the building and R1 had refused. R1 was unable to identify how to get back into the building, she sat outside in the patio area from 3:20 p.m. until 4:30 p.m. unsupervised, in 90-degree weather, without access to water, and was not safe by herself. During an observation on 5/15/25 at 4:20 p.m. the resident patio was in the short stay wing. A code pad was located inside on the left side of the door on the wall, at approximately eye level. The door had a large glass window with NO EXIT stamped on it. The door was unable to be opened without a code placed into the pad. There were four lawn chairs and a table against the inside of the metal white fencing, and a long wooden bench located up against the outside building wall. The patio could be visually seen from the main parking lot of the facility and from inside the building was a large window. No overhead protection from the sun was noted. During an interview on 5/16/25 at 10:00 a.m. NA-A stated R1 refused to come back into building on 5/11/25. Staff were expected to check on residents inside the building every two hours, and if they were outside, they should be checked on every 30 minutes to one hour. NA-D brought R1 outside in the patio area around 1:45 p.m., she checked on her before 2:00 p.m. to see if she wanted to come back in and offered water, and R1 declined. The temperature outside was at least 80 degrees out and partly cloudy. R1 wore shorts, and a t-shirt. R1 did not have on sunscreen, a hat or sunglasses. She also had no access to water. She was unsure why they didn't leave something for her to drink. At 2:00 p.m. NA-C was informed R1 was outside on the patio, and how long she had been there. Staff were expected to check on her, they could have seen her through the window from inside the building. There was not way for R1 to alert us if she needed anything other than pound on the glass window, wave her arms or knock on the door. A code was needed to open the door from the outside to get back into the building. She would be unable to have pushed the door open, was heavy. There was a buzzer outside on the wall, but she would have most likely been unable to reach it from her wheelchair. During an interview on 5/16/25 at 10:26 a.m. NA-C stated she had received report from NA-A and was made aware R1 was outside on the patio, but was not informed how long it had been. Usually upstairs in the dementia unit a resident was brought outside to the patio area and staff were expected to stay with them, and 15 minutes later the resident was brought back into the facility, and not left alone. R1 was forgetful and confused at times. She had been informed staff attempted earlier to her back into the building, and R1 did not want to go back inside. At 4:00 p.m. she checked on R1 and asked her to come into the building and she refused. The temperature outside was hot, 90 degrees and sunny, and R1 had no protection from the sun. She should have not been placed outside by herself. NA-A stated NA-B planned on updating the nurse about R1's refusal to come inside, but was unable to locate him, it was an extremely busy day with many visitors. At about 4:30 p.m., R1 was in the hallway in her wheelchair unable to talk. They placed ice towels on her prior to EMS arrival. None of this should have happened and could have been worse. During an interview on 5/16/25 at 12:00 p.m. RN-B stated staff would be expected to check with the nurse on duty prior to a taking a resident outside and left by themselves. R1 was confused at times, especially one day last week, and may have not been able to let herself back into the building. During an interview on 5/16/25 at 2:26 p.m. the director of nursing (DON) stated staff brought R1 out to the patio, checked back and offered water, and offered to bring her back inside. She refused to come back into the building. Staff would have been expected to have notified RN-A, and they did not follow the facility process. RN-A should have been informed R1 was taken outside especially at shift change. R1 had a mental health diagnoses and an altered through process related to delusions. Staff would have expected to check on R1 at least every 15 to 30 minutes and under the circumstances, felt they checked on her appropriately. During an interview on 5/19/25 at 12:22 p.m. NA-B stated he did not receive report when he arrived at work on 5/11/25 at 3:05 p.m. He passed ice water, and R1 was not located in her room. He was unaware of her being out on the patio. She should have not been left alone outside. After 4:00 p.m., NA-C approached him and requested assistance with R1. He put in the code and opened the patio door, and held the door open while NA-C informed R1 it was time to come in for supper. R1 replied no, she was ok, and refused to go in. She wanted to sit outside longer. He told her they would come back in a while. He was unaware how long she had been outside. She was left out on the patio, and they planned on checking back with her later, before supper. R1 sat alone in the wheelchair, with shorts and a t-shirt on, and without anything to drink. RN-A was unable to find R1 to administer medications, and then requested assistance with getting her into the building from the patio. A code was required to unlock the door to get back into facility, and he was unsure if R1 would have been able to reach the code pad since she was unable to stand up independently. The facility policy Safety and Supervision of Residents dated 7/2017, directed resident safety, supervision, and assistance to prevent accidents are facility-wide priorities. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessment needs and identified hazards in the environment. The type and frequency of resident supervision may vary among residents and over time for the same resident. Resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is a change in the resident's condition.

Based on observation, interview and document review, the facility failed to comprehensively assess, monitor, develop and implement interventions to promote healing for 1 of 3 residents (R38) reviewed for a current, facility acquired, stage two pressure ulcer. Stage two pressure ulcer; partial-thickness skin loss with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Findings include: R38's significant change of status assessment (SCSA) Minimum Data Set (MDS) dated [DATE], identified R38 had diagnoses which included dementia, aphasia (loss or impairment to use or comprehend language), cerebral infarction (brain lesion in which a cluster of brain cells die when they don't get enough blood), congestive heart failure, chronic respiratory failure and dependence on supplemental oxygen. Indicated R38 had severe cognitive impairment and required extensive assistance with activities of daily living (ADL's) which included bed mobility, transfers, toileting, dressing, personal hygiene and bathing. Identified R38 was at risk for developing pressure ulcers. The MDS lacked documentation of R38 having a pressure ulcer. R38's SCSA care area assessment worksheet (CAA) dated 7/9/24, identified R38 required extensive assistance with bed mobility, had a pressure reducing mattress on his bed and no noted skin issues. Identified R38 demonstrated a steady decline over the past several months and spent more time in bed. R38's care plan revised 2/3/24, identified R38 had potential impairment of skin integrity. R38's care plan lacked documentation of a current pressure ulcer. Furthermore, R38's care plan indicated R38 had shortness of breath related to diagnosis of chronic respiratory failure and received oxygen via nasal cannula continuously. R38's care plan lacked documentation of interventions to prevent pressure ulcers related to oxygen tubing. R38's Braden scale (tool used to determine risk for pressure ulcer development) dated 7/16/24, identified R38 was at moderate risk for pressure ulcer development due to the following risk factors; slightly limited sensory perception, very moist skin, was chairfast, slightly limited mobility and very poor nutrition. In addition, friction and shearing were a potential problem for R38 who required moderate to maximum assistance with moving. R38's nursing respiratory assessment dated [DATE], identified R38 had oxygen continuously via nasal cannula and would not experience discomfort or altered quality of life related to respiratory status. R38's nursing assessment dated [DATE], identified R38 had no skin concerns. Skin remained intact. Cushion applicators present behind ears. R38's progress note weekly skin assessment dated [DATE], identified R38 continued to have skin breakdown behind left ear from nasal cannula tubing. Skin protector applicator was placed on nasal cannula tubing and a treatment to monitor R38's ear until healed was setup by nursing. The note lacked a description of the breakdown and the type of treatment initiated by nursing staff. R38's progress note weekly skin assessment dated [DATE], identified R38 had no skin alterations. R38's progress note weekly skin assessment dated [DATE], identified R38 had no skin alterations. R38's progress notes lacked assessment of the pressure ulcer including measurements, interventions implemented to promote healing and prevent further breakdown and weekly monitoring of the ulcer to determine if it was healing or worsening. R38's nursing assistant (NA) care guide/Kardex printed 7/24/24, indicated R38 had oxygen via nasal cannula continuously. The Kardex lacked documentation of the presence of a pressure ulcer. During an observation on 7/23/24 at 3:04 p.m., R38 was laying in bed with the nasal cannula on and foam protectors on oxygen tubing behind bilateral ears. A Band-Aid was observed to be on the back of R38's left ear. During an observation and interview on 7/23/24 at 3:25 p.m., registered nurse (RN)-B stated she was unaware R38 had a Band-Aid to the back of his ear and was unaware that R38 had a pressure ulcer present on the back of the left ear. RN-B removed the Band-Aid and stated the Band-Aid did not look new. RN-B stated the Band-Aid had dried blood on it, no odor, and no drainage noted to the area on back of the left ear. RN-B confirmed there had been no initial assessment of the pressure ulcer on the back of R38's left ear or any measurements of the pressure ulcer documented in the electronic medical record (EMR). At 4:04 p.m., RN-B measured the pressure ulcer of R38's left ear at 0.5 centimeters (cm) long by 0.5 cm wide and was round. RN-B verified the pressure ulcer was located in the middle of the back of R38's left ear and stated the first layer of the skin was gone. The wound bed was red and no drainage was observed. RN-B confirmed it was important to assess and measure a pressure ulcer to determine if the pressure ulcer was improving or worsening and to implement interventions to assist with healing. RN-B stated there was a wound checklist at the nurses' station for nurses to complete when a new pressure ulcer was identified on a resident. During an interview on 7/24/24 at 12:31 p.m., licensed practical nurse (LPN)-A verified the progress note on 7/23/24. LPN-A stated she did not observe a Band-Aid behind R38's left ear during the weekly skin assessment documented on 7/23/24 at 1:51 p.m. LPN-A stated R38 had some redness behind both ears however there were no open areas present. During an interview on 7/24/24 at 12:35 p.m., RN-A stated she was unaware of a skin concern behind R38's left ear prior to last evening on 7/23/24. RN-A confirmed R38 had developed a stage two pressure ulcer to the back of his left ear from the oxygen tubing. RN-A stated the expectation of nursing staff was to complete a wound checklist when a new pressure ulcer was identified and verified the following steps of the wound checklist: -measure wound and describe. -start initial treatment (barrier cream, dressing, monitoring schedule). -notify the following; resident, resident representative, dietary, therapy, doctor, care coordinator. -implement new interventions (start tissue tolerance, air mattress, heel boots, etc.). -update care plan. -document. -once completed turn wound assessment into care coordinator. RN-A confirmed the progress note on 7/9/24, should have had a wound checklist completed. RN-A verified it was important to complete the wound checklist sheet to determine objectively if the pressure ulcer on the back of R38's ear was healing or worsening and if the right treatment had been implemented. During an interview on 7/24/24 at 1:15 p.m., RN-C verified the progress note on 7/9/24. RN-C stated R38 had a scabbed area to the back of his left ear and RN-C stated the scab was not a new concern. During an interview on 7/24/24 at 12:46 p.m., R38's doctor verified he was not aware of R38 having a pressure ulcer prior to last evening on 7/23/24. R38's doctor confirmed he would expect the facility to update him timely when a pressure ulcer developed and stated it was important to provide the resident with treatment, prevent infection and promote proper healing. During an interview on 7/24/24 at 1:23 p.m., the director of nursing (DON) verified she was not aware R38 had a pressure ulcer prior to last evening on 7/23/24. The DON confirmed R38's care plan lacked documentation about the development of the pressure ulcer to his left ear. The DON stated the expectation of nursing staff was for them to complete a wound checklist whenever a pressure ulcer developed, complete weekly monitoring, updating the care plan, the doctor and provide interventions. The DON verified it was important to complete the wound checklist to ensure a resident's pressure ulcer was healing and not worsening and ensure the interventions in place were effective. Review of the facility policy titled Skin Assessment, undated, identified it was the policy of the facility to complete weekly skin checks and quarterly skin assessments. Indicated it was the facility's procedure once a pressure injury was identified, that assessment and treatments, which included pressure relieving and nutritional interventions, would be implemented, care planned and monitored to promote healing. Review of the facility policy titled Documentation of Wound Treatments, undated, identified a pressure ulcer would be assessed including response to treatment, change in condition and changes in treatment. Pressure ulcers would be monitored for progression of wound healing and care plans would be reviewed and modified as appropriate.

Based on observation, interview, and document review, the facility failed to ensure facial hair was removed for 1 of 2 residents (R75) who required assistance with hygiene, and was reviewed for activities of daily living (ADL). Findings Include: R75's quarterly Minimum Data Set (MDS) dated [DATE], identified R75 was severely cognitively impaired, with diagnoses which included dementia, coronary artery disease (CAD), and hypertension. Indicated R75 required substantial/maximal assistance with shower/bathing, and partial/moderate assistance with upper and lower body dressing. Identified R75 was independent with personal hygiene. R75's care plan revised 6/28/24, identified R75 had an ADL self-care performance deficit related to confusion, fatigue and impaired balance. R75 required assistance of one staff for dressing, bathing, and personal hygiene. R75's interventions identified R75 preferred no facial hair. During an observation and interview on 7/22/24 at 9:48 a.m., R75 was dressed in street clothes and seated in her recliner chair in her room. R75 had multiple white facial hairs approximately one quarter inch long across both cheeks, chin and around her mouth. R75 had a couple of approximately half inch long white facial hairs on her chin. R75 rubbed her chin and indicated she was unable to take them off by rubbing them. During an observation on 7/23/24 at 9:16 a.m., R75 was seated in her chair in her room and dressed in street clothes. R75 was looking for a pen to complete her word search puzzle book. R75 continued to have multiple white facial hairs approximately one quarter inch long across both cheeks, chin and around her mouth. R75 had a couple of approximately half inch long white facial hairs on her chin. During an interview on 7/23/24 at 9:18 a.m., nursing assistant (NA)-B stated she had not assisted R75 that morning with cares however, had noticed R75 had a large amount of facial hair present. NA-B indicated her usual practice when she observed R75 with facial hair, was to ask her if she could remove the hair and then remove it. NA-B stated it was important to assist R75 to remove facial hair to maintain her dignity. During an interview on 7/23/24 at 9:32 a.m., NA-C confirmed assisting R75 with ADL cares that morning and another day earlier that week. NA-C indicated the usual practice was to assist residents to remove facial hair when observed. NA-C had not looked closely at R75 that morning to check for facial hair however, should have done so. NA-C indicated it was important to assist residents with facial hair removal, as most of the female residents did not want any facial hair present. During an interview on 7/23/24 at 10:32 a.m., clinical manager registered nurse (RN)-A indicated the facility's usual practice was to ask residents or family members if the resident wished to have facial hair removed. RN-A stated if a resident wished to have facial hair removed, it was her expectation that staff checked for the presence of facial hair and asked them daily if they want it removed, as it was important to maintain dignity. During an interview on 7/23/24 at 10:39 a.m., director of nursing (DON) stated the facility's usual practice was for staff to offer to remove the resident's facial hair daily when present with morning cares. If a resident refused the offer, DON expected staff to document it. DON stated the resident's facial hair preference would have been identified on the resident's care plan. DON indicated it was important to assist residents to remove facial hair if they were unable to complete the task themselves to maintain dignity, to promote confidence and to have pride in their appearance. During a telephone interview on 7/23/24 at 10:48 a.m., family member (FM)-A stated R75 did not want to have any facial hair present and expected it to be removed. The facility policy titled Shaving The Resident revised 2/18, identified the purpose was to promote cleanliness and to provide skin care. The policy instructed to review the resident's care plan to assess for any special needs of the resident. The policy instructed to notify the supervisor if the resident refused the procedure.

Based on observation, interview and document review, the facility failed to ensure nebulizer medication was administered safely for 1 of 1 resident (R28) who was observed to self administer a nebulizer and had not been assessed as safe to self administer medications. Findings Include: R28's admission Minimum Data Set (MDS) dated [DATE], identified R28 was cognitively intact and had diagnoses which included: chronic obstructive pulmonary disease (COPD) (chronic inflammatory lung disease that causes obstructed airflow from the lungs), heart failure and anxiety disorder. Indicated R28 required partial/moderate assistance with upper body dressing, transfers, and hygiene. R28's care plan revised 6/27/24, identified R28 had activities of daily living (ADL) self-care performance deficit and required assistance for dressing, personal hygiene and transfers. R28 had potential for respiratory status/difficulty breathing related to COPD and interventions included administer medication/puffers as ordered. R28's care plan lacked self administration of medication interventions. R28's Medication Review Report signed 7/8/24, included orders for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) milligrams (MG)/3 milliliters (ML) (a bronchodiator medication that helps relax muscles in airway to increase air flow) one unit inhale orally four times a day for COPD. R28's Medication Review Report lacked an order to self-administer medication. R28's medical record lacked documentation of a self-administration medication (SAM) assessment completed. During an observation and interview on 7/23/24 at 8:36 a.m., trained medication aide (TMA)-A indicated R28 was probably done with her nebulizer medication, entered R28's room, unhooked the nebulizer mask and cup from the nebulizer machine, rinsed it in the sink and set it on a paper towel to dry. At 8:41 a.m., TMA-A indicated he planned to set up R28's nebulizer around lunch time and R28 would administer it herself after set up. During an observation and interview on 7/23/24 at 11:30 a.m., TMA-A entered R28's room, removed a vial of R28's Ipratropium-Albuterol Inhalation Solution from a locked medication drawer, opened the vial and poured it into the nebulizer cup. TMA attached the mask to the tubing on the nebulizer machine and handed the nebulizer to R28. TMA-A turned on the nebulizer machine, sanitized hands and exited R28's room. At 11:33 a.m., TMA-A was at the nursing desk. TMA-A indicated he thought R28 had been assessed to be safe to self administer medications. TMA-A reviewed R28's electronic medical record and verified it lacked a SAM for R28 to self-administer medications. TMA-A stated his usual practice was to set up R28's nebulizer, leave the room and R28 would administer the medication and shut it off when done. At 11:35 a.m., R28 continued to be self-administering her nebulizer in her room while no other staff member was present. During an interview on 7/23/24 at 3:34 p.m., unit manager registered nurse (RN)-A confirmed R28 did not have a SAM assessment, or an order for self administration of medications, which included the nebulizer. RN-A indicated the usual process was to complete a SAM assessment and if it was determined the resident was appropriate to self-administer medications, it should have been added to care plan. In addition, an order should have been obtained and it should have been identified on the resident's electronic health record banner. RN-A stated it was important to complete the SAM and obtain orders to assure medications were administered appropriately and would not cause harm. During an interview on 7/23/24 at 4:11 p.m., director of nursing (DON) indicated the facility's usual process was for licensed staff to complete a SAM and obtain an order for self-administration if the SAM determined the resident was safe to self- administer meds. DON expected staff to re-evaluate quarterly and when a significant change occurred. DON verified an order for self-administration of meds should have been obtained and should have been documented in the resident's care plan and electronic record banner. DON indicated it was important to complete the process to assure the resident received the medications as prescribed by their provider. During an interview on 7/23/24 at 5:03 p.m., R28 confirmed all nursing staff set up her nebulizer medications and did not remain with her while she self-administered the nebulized medication. R28 stated no one had discussed self-administering her nebulizer medication with her and she just automatically completed the task. During a telephone interview on 7/23/24 at 5:19 p.m., pharmacy consultant (PC)-A indicated it was her expectation the facility would have completed a SAM assessment and obtained an order for R28 to self administer her nebulizer medication. PC-A indicated for nebulized medication, the facility needed to assure the resident would keep the nebulizer mask in place and not remove it before the medication administration was completed. The facility policy titled Self-Administration Of Medications revised 2/21, identified residents had the right to self-administer medications if the interdisciplinary (IDT) team had determined that it was clinically appropriate and safe for the resident to do so. As part of the evaluation comprehensive assessment, the IDT team assessed each resident's cognitive and physical abilities to determine whether self-administration medications was safe and clinically appropriate for that resident. If deemed safe and appropriate for a resident to self-administer medications, this would have been documented in the medical record and the care plan.

Based on interview and document review, the facility failed to ensure residents were free of significant medication errors for 3 of 3 residents (R1, R2, R3) who had diagnosis of Diabetes and received long, and short acting insulin used for the treatment of elevated blood sugars. Findings include: R1's significant change Minimum Data Set (MDS) dated [DATE], identified R1 had serve cognitive impairment with disorganized thinking. R1's medical diagnoses included diabetes mellitus (DM), hypertension (HTN) (high blood pressure), malnutrition, and renal failure. R1 received insulin daily. R1's hospital discharge summary dated 11/22/23, identified R1 had marked elevation of blood sugars initially primarily secondary to steroid use. R1's blood sugars improved and came back to normal with some supplemental insulin. R1's renal failure has progressed. R1's blood sugars would need to be monitored closely. Insulin orders included: -NovoLog (Aspart) insulin 2 units subcutaneous (SQ) (injection between skin and muscle to allow medication to absorb slowly over long period of time) three times a day before meals if BS (blood sugar) > 400. -Detemir insulin 38 units SQ daily. R1's physician orders dated 12/19/23, identified: -2g Na (Sodium) diet regular texture. -BS TID (three times a day) related to type two diabetes mellitus. -Check blood glucose (BG) (history of low BG in AM's) one time a day for monitoring. Started on 11/29/23. -Offer bedtime snack to prevent low BS. Needs protein rich foods to stabilize sugars throughout the night, one time a day for diabetes. -Glucose oral gel 40% (dextrose/diabetic use). Give one application by mouth as needed for low BS. -Levemir (long-acting insulin used to lower BS over a 24-hour period) flex pen SQ solution pen injector 100 unit/ml (milliliter). Inject 38 units SQ one time a day for diabetes. Order started 11/22/23 and changed on 12/4/23. -Levemir flex pen SQ solution pen injector 100 unit/ml. Inject 34 units SQ one time a day for diabetes. Order started on 12/4/23. - NovoLog (fast acting insulin starts to work in 15 minutes, peaks in one hour, and works for up to two to four hours to lower blood sugars) flex pen SQ solution pen injector 100 unit/ml. Inject 2 units SQ three times a day for diabetes Hold if BS > 400. Order started on day of admission 11/22/23, and changed on 12/4/23, due transcription error. -NovoLog flex pen SQ solution pen injector 100 unit/ml. Inject as per sliding scale: if BS 0 to 400 =0 units; 401+ = 2 units, SQ three times a day for diabetes. For BS > 400. Order changed on 12/4/23, and current. R1's physician standing orders dated 11/22/23, and signed by primary physician identified: -Glucose 15g orally for BS levels below 50. Recheck BS in 15 minutes. May repeat Glucose times two. If BS stabilizes doctor maybe notified the next day. If the BS remains below 50 give Glucagon 1 mg (milligram) SQ or IM (intramuscularly) and notify doctor immediately. -Accu checks (blood sugar) as indicated for diabetic residents and symptoms of acute confusion, decreased alertness, diaphoresis, pallor, and/or meal refusal. Notify medical doctor (MD) of unconscious resident with BS lower than 50. For BS > 500, licensed nurse is to check BS level in two hours then notify MD if BS remains >500. -May hold medications times 24 hours as determined by RN (registered nurse). Medications refused or held after 24 hours required MD notification. R1's care plan dated 12/19/23, indicated R1 had diagnosis of diabetes mellitus and directed staff to administer diabetes medication as ordered by doctor and monitor/document for side effects and effectiveness. The care plan did not direct staff how to care for R1 if the blood sugars were critically high or low. R1's progress notes and electronic medication administration record (EMAR) confirmation from 11/28/23, through 12/18/23 identified: -11/28/23 at 2:02 p.m. Care conference summary: R1 felt confused this morning, noted low blood sugar today, did eat all breakfast, shaking hands, concerned he still had low BS and resident reported no one rechecked BS after the first time this morning. -12/1/23 7:00 a.m. Glucose oral gel 40% administered by mouth for low blood sugar. At 7:58 a.m. administration was effective. -12/2/23 at 7:55 a.m. BS 58 orange juice provided asymptomatic. At 8:14 a.m. BS 58, asymptomatic, glucose oral tablet chewable 4 gm given by mouth for low BS. At 11:59 a.m. (over three hours later) BS 150, administration was effective. -12/4/23 at 3:24 a.m. Glucose oral gel 40% administered by mouth for low blood sugar (documented under vitals in medical record at 3:23 a.m. BS 37 and at 3:58 a.m. BS 76). At 4:08 a.m. administration was effective. At 8:25 a.m. (documented under vitals in medical record at 8:25 a.m. BS 43). Glucose oral tablet chewable 4 gm given by mouth for low blood sugar. At 8:26 a.m. BS was 129, effective. (BS recorded to increase 86 mg/dl in one minute.) -12/4/23 at 8:42 p.m. Received phone call from a nurse indicated R1's daughter inquired about insulin parameters. Reviewed by primary physician and adjusted to hold NovoLog insulin if BS less than 250. Decreased Levemir insulin form 38 units to 34 units once daily. -12/5/23 at 2:02 p.m. Medication regimen review completed by consultant pharmacist (CP) no recommendations at this time. Very complex medical condition and medication regimen. Wide fluctuations in fasting blood sugars noted prior to admit to facility. Levemir insulin dose recently decreased and parameter of NovoLog insulin updated. Will continue to follow closely. (Pharmacist Review lacked evidence to identify concern related to held medications, physician notification or delayed follow up on low blood sugars.) -12/7/23 at 8:15 a.m. Administered Glucose oral gel 40% for low BS 56. At 9:42 a.m. (over one hour later) BS 369, effective. -12/7/23 at 2:09 p.m. received orders from nurse practitioner (NP), changed NovoLog two units three times a day for BS >400. To continue with Levemir insulin 34 unit daily upon discharge. -12/9/23 at 7:19 a.m. BS 57, glucose tab and orange juice provided. R1 asymptomatic. (Documentation in progress notes lacked evidence Levemir 34 units was held, or physician was notified. R1's EMAR identified Levemir insulin 34 units was held). At 7:26 a.m. BS remained at 57 orange juice and Glucose tab given. At 9:39 a.m. BS rechecked 396 (over two hours later), documented as effective. -12/14/23 at 3:41 a.m. Gave R1 orange juice with sugars and a boost for more stable carbohydrates (BS charted under vitals 66 and rechecked one hour later 148). -12/15/23 at 8:16 a.m. BS 62 this a.m. Levemir was held. At 12:32 p.m. R1 had taken medications without difficulty. Lunch BS 402; R1 reported he ate a good breakfast and a piece of cake at morning activity. (Record lacked evidence Provider was not notified.) -12/16/23 at 4:51 p.m. R1 was given 2 units of NovoLog insulin, blood glucose monitor read HI per manufactures, was above 600 (R1's vitals in medical record additional BS taken three more times indicated on 12/16/23 at 8:04 p.m., 12/17/23 at 2:22 a.m., and 6:02 a.m. BS remained above 600 four consecutive times and lacked evidence provider was notified). -12/17/23 at 8:52 a.m. Levemir insulin 34 units SQ was held due to resident feeling weak and state vision was blurry. BS 126. History of BS dropping quick, vital signs within normal limits, will continue to monitor and drinking orange juice presently. (Record lacked evidence physician was notified of resident experiencing possible diabetic symptoms or for holding medication.) -12/18/23 at 6:02 a.m. BS had been over 600 since 4:00 p.m. yesterday. No signs/symptoms of hyperglycemia. MD will be updated this morning. -12/18/23 at 12:59 p.m. R1 discharged back to Mill Street (assisted living). -12/18/23 at 5:35 p.m. R1 was discharged from facility. R1's E[DATE]/28/23, through 11/29/23, identified: -11/28/23, R1 received NovoLog insulin 2 units midday BS 144 and supper BS 268 (order transcribed/entered wrong, R1 should have not received NovoLog 2 units midday or supper unless BS was above 400). R1 also received Levemir insulin 38 units at bedtime (HS). R1's BS on 11/29/23 at 7:59 a.m. was 54. -11/29/23, R1 received Levemir insulin 38 units at HS and NovoLog insulin 2 units midday and p.m. (order transcribed wrong. R1 should not have received NovoLog midday with BS of 336). R1's E[DATE]/1/23, through 12/17/23, identified: -12/1/23, R1 received Levemir insulin 38 units at HS and NovoLog insulin 2 units midday and p.m. (order transcribed wrong. R1 should not have received NovoLog midday with BS of 219 and p.m. with BS of 393). On 12/2/23, at 7:00 a.m. and 7:18 a.m. BS was 50 and Glucose oral gel 40 % dextrose was given by mouth. R1's BS was not rechecked again until 11:49 a.m. BS of 219 (almost 4 hours later). -12/3/23, R1 received Levemir insulin 38 units and NovoLog 2 units at supper (order transcribed wrong. R1 should not have received NovoLog at supper time with BS of 375). On 12/4/23 at 3:23 a.m. BS was 37. R1 received Glucose oral gel 40% dextrose by mouth. R1's BS was rechecked at 3:58 a.m. BS 76. -12/4/23, R1 did not receive Levemir 38 units at 7:30 a.m. or NovoLog at supper as ordered. BS was 444 at 9:31 p.m. R1's blood sugar was rechecked at 2:16 a.m. and high at 366 (over 4 1/2 hours later). -12/9/23, R1 did not receive Levemir 34 units dose as ordered (order change on 12/5/23, decreased Levemir from 38 units to 34 units). R1's BS at 7:17 a.m., 7:22 a.m., and 7:26 a.m. 57. R1's BS rechecked at 11:40 a.m. read high at 342. -12/15/23, R1 did not receive Levemir 34 units dose as ordered. R1's BS at 8:17 a.m. 62. R1's blood sugar re-checked at 11:12 a.m. read high at 402. 12/17/23, R1 did not receive Levemir 34 units dose as ordered. R1's BS at 8:34 a.m. was 126. R1's blood sugar re-checked at 11:54 a.m. read high at 435. R1's BS continued to rise on 12/17/23 at 4:35 p.m. over 600, at 8:04 p.m. over 600, then on 12/18/23 at 2:22 a.m. over 600 and 6:02 a.m. Provider was not notified and R1 was discharged on [DATE] at 5:34 p.m. R1's healthcare visit completed by nurse practitioner (NP)-A on 11/30/23, identified R1 had DM with stage four chronic kidney disease with long term current use of insulin, peripheral neuropathy (nerve damage usually hands and feet) and diabetic retinopathy (complications of diabetes that can damage or destroy blood vessels in the retina) of both eyes both associated with DM. R1 has had a history of quite drastic blood sugar fluctuations and R1's blood sugars continued to fluctuate. R2's significant change MDS dated [DATE], identified R2 had severe impaired cognition and occasional behaviors directed towards others. R1's medical diagnoses included DM, HTN, peripheral vascular disease (PVD) (narrowed arteries with reduced blood flow to the arms or legs related to diabetes), cerebrovascular accident (CVA) (stroke), malnutrition, and dementia. R2's physician orders dated 1/10/24, identified: -Diabetic diet regular texture. -BG testing four times a day for diabetes management. -Check BG before breakfast one time a day. -Check BG at 2:00 a.m. (hypoglycemic episodes since increase of Lantus) one time a day for monitoring. -Offer/give HS snack before bed to prevent hypoglycemic over night at bedtime. -Glargine SQ solution pen-injector 100 unit/ml inject 24 units SQ one time a day for diabetes. -Metformin oral tablet 500 mg give two tabs by mouth two times a day for diabetes. -NovoLog insulin injection solution inject as per sliding scale: if 100-149 =1 unit; 150-200 = 2 units; 201-250= 4 units; 251 -300 = 6 units; 301-350 = 8 units; 351- 400 = 10 units; 401 plus = 12 units. If above 401, recheck BS in one hour. If still elevated contact physician. R2's standing orders signed and dated 11/1/23, identified: -Glucose 15 g orally for blood sugar levels below 50. Recheck BS 15 minutes. May repeat Glucose times two. If BS stabilizes doctor may be notified the next day. If the BS remains below 50 give Glucagon 1 mg SQ or IM (intermuscular) and notify doctor immediately. -Accu checks as indicated for diabetic residents and symptoms of acute confusion, decreased alertness diaphoresis, pallor and/or meal refusal. Notify MD of unconscious resident with BS lower than 50. For BS <500, licensed nurse is to check BS level in two hours and then notify MD if BS remains > 500. R2's hospital discharge summary dated 11/1/23, identified principal problem was diabetic ketoacidosis (DKA) (a serious complication of diabetes when the body cannot produce enough insulin caused by hyperglycemia (high blood sugars) associated with type 2 diabetes. Has had multiple episodes of DKA. Discharge instructions included: monitor blood sugars as patient has had episodes of hyperglycemia during hospital course. Blood sugar should be regularly monitored, and medications adjusted as necessary once discharged . R2's care plan dated 11/14/23, indicated a diagnosis of diabetes mellitus and staff were directed to monitor skin, administer diabetic medications as ordered by doctor and monitor for side effects. Monitor/document/report any signs and symptoms of hyperglycemia (high BS) and hypoglycemia (low BS). R2's progress notes and EMAR for 11/7/23, through 12/12/23 identified: -11/8/23 at 7:48 a.m. (EMAR) BS 578 rechecked at 10:23 a.m. BS 378 (over 2 1/2 hours later). -11/7/23 at 1:44 p.m. consultant pharmacist note identified medication regimen review complete. Fasting blood sugars and insulin dosing followed closely. -11/10/23 at 3:16 p.m. physician here and provided an order: increase Lantus to 28 units SQ daily. -11/11/23 at 12:40 p.m. (EMAR) BS 458, rechecked at 3:30 p.m. BS 113 (almost 3 hours later). -11/13/23, Metformin 500 mg give two tablets by mouth two times a day. (Dose was not administered at breakfast according to EMAR). At 8:54 p.m. Glargine insulin SQ inject 28 units one time a day for diabetes. Gave 26 units due to low blood sugars in the morning. -11/14/23 at 7:27 a.m. (EMAR) BS 487, rechecked at 11:00 a.m. BS 198 (3 1/2 hours later). At 3:57 p.m. BS 480, rechecked BS 207 at 2:08 a.m. on 11/15/23 (over 10 hours later). -11/14/23 at 3:14 p.m. Fax received back form physician with orders to decrease Lantus to 24 units daily. -11/16/23 at 2:33 a.m. snack administered for low BS. Will recheck and monitor. Record lacked evidence recheck was completed. -11/18/23 at 3:18 p.m. (EMAR) BS 474, rechecked at 7:34 p.m. BS 132 (over 4 hours later). Metformin tablet 500 mg give two tablets by mouth two times a day, dose held on 11/13/23, during breakfast. -11/19/23 at 2:15 a.m. (EMAR) check BS level at 2:00 a.m. snacks provided. -11/20/23 at 7:27 a.m. (EMAR) BS 409, rechecked at 11:59 a.m. BS 261 (4 1/2 hours later). -11/22/23 at 4:10 p.m. (EMAR) BS 498, rechecked at 7:28 p.m. BS 164 (over 3 hours later). -Glargine Insulin inject 28 units SQ was held on 11/28/23 (EMAR). -11/28/23 at 4:58 p.m. (EMAR) BS 521, rechecked at 8:32 p.m. BS 170 (3 1/2 hours later). -11/29/23 at 4:48 p.m. (EMAR) BS 438, rechecked at 9:10 p.m. BS 68 (over 4 hours later). -11/29/23 at 9:11 p.m. Glargine insulin was not administered according to EMAR. BS was 86. -12/4/23 at 5:17 p.m. (EMAR) BS 487, rechecked at 8:18 p.m. BS 322 (3 hours later). -12/6/23 at 6:00 p.m. consultant pharmacist note: medication regime completed. Fasting blood sugars followed closely. Glargine dosing recently adjusted. (Pharmacist Review lacked evidence to identify concern related to held medications, physician notification or delayed follow up on low blood sugars.) -12/7/23 at 2:14 a.m. administered orange juice, boost, peanut and butter jelly toast and banana. Will continue to monitor. -12/12/23 at 5:20 a.m. checked BS before breakfast 334. R2's EMAR dated 12/12/23, through 1/8/24, identified: -12/12/23 at 11:50 a.m. BS 472, rechecked at 4:40 p.m. BS 411 and another 12 unites of NovoLog was administered SQ. Rechecked at 7:57 p.m. (over 3 hours later). -12/15/23 at 3:45 p.m. BS 405, rechecked at 7:22 p.m. BS 174 (3 1/2 hours later). -12/19/23 at 4:24 p.m. BS 434, rechecked at 8:16 p.m. BS 471 (over 3 1/2 hours later BS remained above 400). -12/20/23 at 8:25 a.m. BS 422, rechecked at 11:50 a.m. BS 98 (over 3 hours later). -12/29/23 at 8:10 a.m. BS 512, rechecked at 11:54 a.m. BS 81 (over 3 1/2 hours later). -1/4/24 at 5:28 a.m. BS 499, rechecked at 7:43 a.m. BS 270 (over 2 hours later). -1/5/24 at 7:32 a.m. BS 405, rechecked at 11:49 a.m. BS 73 (over 4 hours later). At 4:54 p.m. BS was 405, rechecked at 7:47 p.m. BS 235 (over 2 1/2 hours later). R2's record lacked evidence low or elevated blood sugars were rechecked within one hour per order. MD was not notified when diabetic medication was held. R3's significant change MDS dated [DATE], identified R3 had moderately impaired cognition and occasional disorganized thinking. R1's medical diagnoses included HTN, heart failure, and DM. R3's physician orders dated 1/10/24, identified: -Assess blood sugar prior to receiving short acting insulin one time a day. -Assess blood sugars four times a day, times one week then continue to assess blood sugars twice a day. -Offer snack before bedtime to prevent low blood sugars one time a day for DM. -Insulin Aspart (NovoLog) SQ solution pen-injector 100 unit/ml inject 22 units SQ two times a day for diabetes. -Insulin Aspart (NovoLog) SQ solution pen-injector 100 unit/ml inject 24 units SQ one time a day for diabetes. -Insulin Glargine SQ solution pen-injector 300 units/ml inject 70 units SQ two times a day for diabetes. -Metformin ER (extended release) 24 hour 500 milligrams (mg) one tablet by mouth one time a day for diabetes. -Liraglutide SQ solution 18 mg/3 ml. Inject 1.8 mg SQ one time a day for diabetes. R3's standing orders dated and signed on 8/11/23, identified: -Glucose 15 g orally for blood sugar levels below 50. Recheck BS 15 minutes. May repeat Glucose times two. If BS stabilizes doctor may be notified the next day. If the BS remains below 50 give Glucagon 1 mg SQ or IM and notify doctor immediately. -Accu checks as indicated for diabetic residents and symptoms of acute confusion, decreased alertness diaphoresis, pallor and/or meal refusal. Notify MD of unconscious resident with BS lower than 50. For BS <500, licensed nurse is to check BS level in two hours and then notify MD if BS remains > 500. R3's care plan dated 12/20/23, identified R1 had diabetes and directed staff to monitor for signs and symptoms of hypoglycemia (low blood sugars), infection, and compliance with diet. R3's E[DATE]/24/23, through 11/27/23, identified: -11/24/23, 11/26/23, and 11/27/23, at HS (hour of sleep) Liraglutide SQ 1.8 mg one time a day for diabetes was held all three days. -11/23/23, at supper time Aspart insulin SQ 22 units two times a day for diabetes was held. -11/24/23 at 12:00 p.m. Insulin Aspart inject 24 units SQ one time a day was held. -11/24/23, at HS Glargine insulin 70 units SQ two times a day for diabetes was held. -11/26/23, Aspart insulin SQ 22 units two times a day for diabetes was held at breakfast time. Additionally, a.m. and HS doses of Glargine insulin 70 units were held. -11/27/23, at HS Glargine insulin 70 units was held. R3's E[DATE]/1/23, through 12/17/23, identified: -12/4/23, and 12/10/23 at HS Liraglutide 1.8. mg SQ one time a day was held. -12/13/23, and 12/16/23, at 12:00 p.m. Aspart insulin 24 units SQ was held. -12/1/23, 12/3/23, 12/5/23, 12/14/23, 12/15/23, 12/17/23, 12/27/23, 12/28/23, 12/29/23, 12/30/23, and 12/31/23, Aspart insulin 22 units SQ ordered two times a day was held in the a.m. and 12/4/23, 12/15/23, 12/21/23, and 12/29/23, supper doses were held. On 12/8/23, supper time and 12/22/23, a.m. R3 refused both times. -On 12/4/23 at HS and 12/17/23 a.m. Glargine 70 units SQ. R3's E[DATE]/1/24 through 1/7/24, identified: -On 1/1/24, 1/2/24, 1/3/24,1/4/24, 1/5/24, breakfast time Aspart insulin 22 units SQ was held. On 1/4/24, drug refused and 1/6/24, not given. -On 1/4/24, 1/5/24, 1/6/24, 1/7/24, a.m. Glargine insulin 70 SQ and 1/5/24 HS dose were all held. Provider was not notified when insulin and/or diabetic medications were held or declined by R3. R3's progress notes and EMAR from 12/4/23 through 1/8/24 identified: -12/4/23 at a.m. EMAR indicated Glargine 70 units was held. No documentation noted in the progress notes. -12/8/23 at 5:41 p.m. Resident declined insulin. BS 187. Record lacked evidence physician was not notified when Aspart insulin was held. - 12/10/23 at 8:46 p.m. R3's BS was 83. Glargine 70 units. Insulin dose was held. Record lacked evidence physician not notified. - 12/17/23 at 10:23 a.m. and 10:25 a.m. R3's BS 111, BS drops low, had big breakfast, and drank orange juice. EMAR lacked evidence insulins (Glargine and Aspart) were administered and progress note lacked evidence physician was notified. -12/26/23 at 11:58 a.m. BS 77, writer notified R3 of low reading. Insulin still given per resident request at the same time started eating lunch. -12/26/23 at 5:08 p.m. R3 had been running hypoglycemic today at lunch and supper and now symptomatic at supper stated she was not feeling well and husband stated she was not acting right. Resident appeared slightly lethargic but was awake, alert, oriented. Held supper dose of insulin. BS was 80 at original check, drank glass of orange juice, now 106. However, R3's BS was 77 at lunch, insulin was given and recheck was 158 about 1 hour and 30 minutes after lunch and back down to 80 for supper. Record lacked evidence Physician was notified of insulin being held. Onsite NP visit dated 1/2/24 identified blood sugars look good, asymptomatic. Continue current diabetic medications. Having increased neuropath/burning in feet. -1/4/24, 1/5/24, 1/6/24, noted on EMAR R3's Glargine 70 units were held every a.m. and at HS on 1/5/24. No additional documentation noted in progress notes. No evidence Physician was not notified. -1/7/24 at 7:50 a.m. R3 received scheduled NovoLog this a.m. Had history of dropping. Glargine insulin 70 units Held at this time. Record lacked physician was notified. -1/7/24, at 11:59 p.m. note left for NP in communication book regarding R3's Glargine being held 1/6/24, and 1/7/24. -1/8/24, at 2:53 p.m. consultant pharmacist note indicated medication regimen was reviewed and completed. No mention of insulin being held or recommendations. (Pharmacist Review lacked evidence to identify concern related to held medications, physician notification or delayed follow up on low blood sugars.) During an interview on 1/8/24 at 2:34 p.m., trained medical aide (TMA)-A stated she was responsible to process the admission orders when a resident was admitted to the facility. TMA-A also stated she had entered the insulin orders for R1 when he was admitted from the hospital on 11/22/23 and assumed the clinical coordinator had double checked them. TMA-A verified she was notified on 12/5/23, the insulin orders entered were incorrect and she had made a mistake and misunderstood the greater and less than sign (< and >), hit the wrong key, they were next to each other on the keyboard. TMA-A stated she had entered the order staff were to administer NovoLog insulin 2 units SQ three times a day if BS was below 400 and should have read above 400 which resulted in a medication errors. TMA-A confirmed she had been immediately retrained upon facility's recognition of this error and a new system was not in place for a second check upon transposition of orders. During an interview on 1/8/24 at 3:00 p.m., director of nursing (DON) stated standing orders for residents in facility indicated under registered nurse discretion any medication could have been held up to 24 hours without notification to physician. RN verified the standing orders did not identify which medications could be held. During a follow up interview on 1/9/24 at 4:00 p.m., DON verified R1's orders were reviewed and unable to identify any other orders from physician to be notified if BS were too high or too low other than the standing orders. DON stated the standing orders needed to be reviewed with the medical director and she was unaware insulin was being held without notification to physician. DON stated staff were expected to notify the physician when high risk medications were held such as insulin. DON also expected staff to monitor BS and if too low or two high, recheck the BS per standing order and if remained abnormal staff were expected to contact the physician for further orders. DON added, when long-acting insulin was held the resident's BS could become unstable and the resident could possibly end up with hypoglycemia/hyperglycemia which can have long standing effects on the entire body/multiple organs. Residents could end up with possible kidney issues, vision problems, increased falls, and much more. DON also stated those complications required to be addressed in a timely manner. DON indicated on 12/16/23, through 12/17/23, R1's blood sugars were extremely high over 600 multiple times, standing orders were not followed, and provider was not notified in a timely manner. During an interview on 1/9/24 at 10:30 a.m., RN-A stated licensed nurses are expected to recheck an elevated BS over 500 within a couple of hours and if remained elevated contact the provider for further direction. RN-A stated staff are also expected to recheck a low blood sugar especially after administration of glucagon within 15 minutes after the resident received it and if remained low further action would be required by following provider orders. RN-A verified standing orders allowed licensed staff to hold insulin without notification to provider up to 24 hours. RN-A indicated there was confusion with the standing orders and believed they had changed them recently. RN-A indicated she was told critical medications such as insulin, coumadin and considered night alert medications should not be held without notification to the provider. RN-A stated she would have notified the provider when a BS remained extremely high such as over 400 because it could have caused complications such as DKA. During an interview on 1/9/24 at 11:26 a.m., RN-B stated she had held long-acting insulin twice and standing orders indicted if more than 24 hours the provider needed to be contacted. RN-B verified a BS on the glucometer that read 600 usually indicated it was most likely over 600 and the provider should have been notified. RN-B stated the supervisor was informed on 1/18/24, when R1's BS was discovered to be over 600 consistently four times. RN-B indicated R1 informed her he had eaten a piece of cake and the BS had gone way up. RN-B stated the provider should have been contacted because R1 could have gone into DKA and was too long for a BS to be consistently extremely high. During a telephone interview on 1/9/24 at 1:12 p.m., pharmacist consultant (PC) stated R1 presented with a wide fluctuation in fasting blood sugars prior to admission to facility. PC stated long-acting insulin regulated R1's BS not necessarily the short acting. PC stated the NovoLog insulin order for R1 was unusual with such a brittle diabetic: give two units of NovoLog 2 units if BS was over 400. PC stated they had reviewed R1's BS prior to admission and he was one of those that had BS all over the board. PC indicated facility nursing staff lacked documentation especially on 12/15/23 when BS was 62 and Levemir was held. PC indicted nursing staff would most likely benefit from a refresher course and more education on how insulin worked. PC indicated she would have expected staff to have provided more documentation on that one. PC stated on 12/17/23 R1 was symptomatic, complained of blurry vision and felt weak. PC stated nursing judgement was indicated and error on side of precaution and could have the lack of the long-acting insulin that potentially increased his blood sugars the next day. PC also stated insulin was a high-risk medication, and the physician should have been notified when BS were over 500. PC stated long term management of diabetes and abnormal BS can result in many complications such as kidney issues and retinopathy (damage to blood vessels to the eye caused by diabetes). PC indicated R1 was not considered long term and there were many people that had not realized they had diabetes yet. PC stated on 11/29/23, R2's Glargine insulin (long acting) was held with BS 86 and as a rule that type of insulin should have not been held. PC stated R2 should have been offered a snack and insulin administered. PC R2's medical record lacked nursing documentation when that decision was made, should have identified why the medication was held and if symptomatic. PC stated on 1/7/24, R3's Glargine insulin 70 units was held when BS was 125. PC indicated the standing orders were very vague and therefore relied on nursing judgment call and they would have made the decision. During an interview on 1/9/24 at 3:05 p.m., clinical coordinator (RN)-C stated she had completed R1's admission on 11/22/23 and thought another nurse had checked the orders and it got missed. RN-C stated a new process was in place for two licensed staff to check off new admission orders and sign off. RN-C stated the standing orders were not clear and not sure staff would have known which medications could have been held. RN-C stated long-acting insulins should always be given otherwise BS levels would become unstable and uncontrolled. RN-C verified the long-acting insulin helped stabilize BS levels. RN-C stated BS could have gone high or low and concerned the resident would become hyperglycemic/hypoglycemic, become confused and increased risk for falls. RN-C stated the nursing staff would be expected to contact the provider for further orders. RN-C stated when R1's BS was over 500 or below 50 staff were expected to follow up and recheck in two hours and provider notified if BS remained high or low. RN-C stated between 12/16/23 and 12/17/23, when R1's BS read consistently 600 on the glucose machine most likely was over 600, R1 required more insulin, and a provider should have been notified. RN-C stated diabetes was a hard thing to manager and blood sugars go up and down, this could have referred R1's recovery time from his infection. RN-A stated the standing orders were not appropriate for R1 due to BS were difficult to control and he was a brittle diabetic. RN-C stated a licensed nurse did not have the authority to hold a critical medication without provider order and should have contacted the provider. RN-C stated on 12/17/23, R1 had blurry vision, was weak, low BS provider was not notified and should have been. RN-C also stated nursing staff were expected to recheck a low BS level below 50 within 15 minutes and contact provider if needed. During a telephone interview on 1/9/24 at 3:50 p.m., MD stated he expected to be made aware when long-acting insulin was being held and the reason why. MD indicated with resident's who are considered brittle diabetics it is very important to monitor them and update provider when they had a BS consistently over 600 and determine where to go from there. MD verified a standing order for insulin with a brittle diabetic would have not been appropriate, the BS required closer monitoring and management to help prevent complications such as hyperglycemia and DKA. Facility policy titled Insulin Administration dated 2014, identified guidelines provided for the safe administration of insulin to residents with diabetes. The insulin dosage requirements must be verified prior to administration to assure it corresponds with the order on the medication sheet and the physician's order. Nursing staff were expected to notify the supervisor if the resident refused the insulin injection. The policy identified types of in [TRUNCATED]

Based on interview and document review, the facility failed to conduct a care planning meeting for 1 of 1 residents (R23) reviewed for care plan. Findings include: R23's quarterly Minimum Data Set (MDS) dated [DATE], identified R23 had moderate cognitive impairment and had diagnosis which included anxiety disorder, depression, and seizure disorder. R 23's face sheet indicated he had been admitted to the facility on [DATE]. During an interview on 9/11/23 at 11:46 a.m., family member (FM)-A verified he was the representative for R23. FM-A stated he had not been invited to a care planning conference since R23 had been admitted to the facility. FM-A stated he would have considered attending if he had been invited. R23's electronic health record (EHR) identified an admission MDS was completed on 6/6/23, and a quarterly MDS was completed on 8/29/23. The EHR lacked documentation a care conference occurred which included R23 or his responsible representative. During an interview on 9/13/23 at 8:59 a.m., health information management (HIM) stated she was responsible for scheduling the care conferences. HIM confirmed R23's EHR lacked documentation care conferences had been completed. HIM was unsure why a care conference had not been scheduled for R23. During an interview on 9/13/23 at 9:17 a.m., social services designee (SSD) stated HIM scheduled the care conferences. SSD stated she could not recall having a care conference for R23. SSD confirmed R23's EHR lacked documentation of a care conference being held. SSD stated she was unsure why a care conference had not been completed for R23. SSD indicated care conferences were important to collaborate with R23 and his family in managing R23's care. During an interview on 9/13/23 at 11:46 a.m., clinical manager (CM)-A stated she did not recall having a care conference for R23 and verified the record lacked documentation of a care conference being held for R23. CM-A stated she was unsure why a care conference had not been held. CM indicated it was important to have care conferences, to invite R23 and his family to collaborate on R23's care. During an interview on 9/13/23 at 12:06 p.m., director of nursing (DON) confirmed R23's EHR lacked evidence of a care conference being held. DON stated she was unsure why a care conference had not been held. Indicated it was important to have care conferences to establish and to collaborate about resident's care. DON stated her expectation was all residents would have care conferences and all residents and family representatives would be invited to the care conferences. A facility policy titled Care Planning-Resident Participation undated. Indicated the facility supported the resident's right to be informed of, and participate in, his or her care planning treatment. Indicated the facility would encourage and assist the resident and/ or resident representative to participate in choosing care and treatment options.

Based on observation, interview and document review, the facility failed to provide assistance with personal hygiene for 2 of 5 residents (R23 and R 63) reviewed for activities of daily living (ADL)'s. Findings include: R23 R23's quarterly Minimum Data Set (MDS) dated [DATE], identified R23 had moderate cognitive impairment and had diagnosis which included anxiety disorder, depression, and seizure disorder. Indicated R23 required extensive assistance with bed mobility and toileting. Identified R23 required limited assistance from staff with transfers and personal hygiene. R23's current care plan dated 5/31/23, indicated R23 had deficits with ADL's related to activity intolerance. R23 required staff assistance with personal hygiene. R23's comprehensive Care Area Assessment (CAA) dated 6/11/23, identified R23 required assistance with ADL's. Indicated R23 had an activity intolerance. During an observation on 9/11/23 at 10:59 a.m., R23 was seated in a recliner in his room and had several dark long facial hair present on his chin, above his lips and on his cheeks which were approximately 1/4 inch or longer. During an interview on 9/11/23, at 1:45 p.m., family member (FM)-A stated R23 preferred to be shaved daily. During an observation on 9/11/23 at 6:06 p.m., R23 was seated on the edge of his bed and continued to have several long facial hair 1/4 inch or longer on his chin, above his lips and on his cheeks. During an observation on 9/12/23 at 8:43 a.m., R23 was seated at the dining room table eating breakfast and continued to have several facial hair 1/4 inch or longer on his chin, above his lips and on his cheeks. During an interview on 9/12/23 at 10:00 a.m., nursing assistant (NA)-A stated R23 required set up assistance from staff to shave. NA-A stated she had not assisted him with shaving recently. NA-A indicated she was unsure of when the last time R23 had been shaved and indicated the long dark facial hair on R23's face appeared to be more than a few days growth. During an interview on 9/12/23 at 10:05 a.m., NA-B stated staff were required to assist with set up for R23 to shave when facial hair became visible. NA-B stated he had not assisted NA-B with shaving recently. NA-B indicated the long facial hair on R23's face appeared to be more than a few days growth. During an interview on 9/12/23 at 11:34 a.m., licensed practical nurse (LPN-A) stated R23 required set up assistance from staff to shave. LPN-A verified R23 had long facial hair and was uncertain when the last time R23 had been shaved. LPN-A stated her expectation was R23 would have been shaved daily. During an interview on 9/12/23 at 3:55 p.m., director of nursing (DON) indicated R23 required staff assistance with shaving. DON stated her expectation was R23 would have been shaved daily or when facial hair was present. 48583 R63 R63's recent significant Minimum Data Set (MDS) dated [DATE], identified R63 had moderate cognitive impairment and had diagnosis which included cancer, dementia, and heart failure. Indicated R63 required total assistance of staff for all ADL's. R63's care plan, revised 9/11/23, indicated R63 had deficits with ADL's and required total staff assistance with all cares. R63's comprehensive Care Area Assessment (CAA) dated 7/20/23, identified R63 required total assistance from staff with all ADL's. Indicated R63 was on hospice and unable to perform ADL cares independently. During an observation on 9/13/23, at 7:05 a.m R63 was laying in bed on her back with her head slightly elevated, glasses on and blanket pulled up to her chest. Room lights were shut off and television was shut off. Resident yelled out from her room. - 9/13/23, 7:25 a.m. R63 was awake and looking around the room. R63 remained on her back with head slightly elevated. Glasses were on and call light was within reach. - 9/13/23, 7:51 a.m. R63 continued the same as above. - 9/13/23 8:03 a.m. NA-D and NA-E entered R63's room to provide daily ADL's for R63. NA-D asked R63 if her and NA-E could get her ready for the day. NA-D asked R63 to change her shirt and provided two shirt options. R63 chose a shirt, NA-D and NA-E removed R63's shirt and placed the new shirt on. NA-D placed gloves on and pulled R63's blankets down. NA-D provided directions to R63 to turn and roll and removed soiled brief. NA-D used contents from tube in drawer, placed on wipe and wiped R63's peri area and bottom. NA-D removed gloves and applied new brief under R63. NA-D applied new gloves and instructed R63 to roll to side to get brief pulled up and secured. NA-D removed gloves, pulled blankets up and applied hand sanitizer. NA-D applied gloves, obtained wet wash cloth from the bathroom sink, brought to R63's bedside and washed R63's face with the wet washcloth. NA-D removed gloves. NA-D asked if R63 would like her whiskers removed and R63 replied yes. NA-D stated she would find something to remove whiskers and then asked R63 what she would like for breakfast. NA-D then stated she would get R63 something to eat and drink, sanitized hands and left the room. NA-D or NA-E were not observed to provide oral cares. During an interview on 9/13/23, at 9:48 a.m. NA-D stated R63 required full assistance from staff with ADL's. NA-D confirmed R63 had not received oral cares during am cares. During an interview on 9/13/23, at 11:56 a.m. RN-B indicated R63 required full assistance from staff with ADL's. RN-B indicated his expectations were for staff to provide R63 with assistance of all ADL's which included oral cares. During an interview on 9/13/23, at 1:05 p.m. director of nursing (DON) stated R63 required staff assistance from staff with ADL's and was incontinent of both bladder and bowel. DON indicated the expectations were each resident receive ADL cares daily including oral cares. DON stated if R63 refused her expectations would be staff would attempt to provide cares at a later time. If R63 continued to refuse, DON would expect staff to inform the RN and the refusal would be documented. Review of a facility policy titled Activities of Daily Living (ADL's) Supporting dated 2001, revised 3/2018, revealed appropriate care and services would be provided for residents who were unable to carry out ADL's independently including: hygiene ( bathing, dressing, grooming, and oral care).

Based on observation, interview, and document review, the facility failed to ensure residents were assessed for the ability to self administer medications for 2 of 2 residents (R57, R34) observed for medication administration. Findings include: R57 R57's Diagnosis Report dated 9/13/23, indicated R57 had diagnoses which included hemiplegia and hemiparesis (paralysis and/or weakness on one side of the body) following cerebral infarction (stroke) of right dominant side, low back pain, and depression. R57's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R57 was cognitively intact. R57's Active Orders as of 9/13/23, included: -acetaminophen 650 milligrams (mg) two times a day for pain. -cyclobenzaprine five mg every eight hours as needed for pain related to muscle spasms. R57's electronic health record (EHR) lacked a medication self-administration assessment. During an observation on 9/11/23 at 6:40 p.m., registered nurse (RN)-A provided R57 with the two medications listed above and R57 stated she did not want to take the medication yet. RN-A stated R57 was approved for self-administration of medications and left the medications at R57's bedside in a paper medication cup for R57 to take at a later time independently. -at 7:25 p.m., the medications remained at the resident's bedside in the medication cup. During an interview on 9/12/23 at 11:51 a.m., clinical manager (CM)-A reviewed R57's EHR and was unable to find an assessment for self-administration of medications or a physician order for self-administration of medications. CM-A stated the medications should not have been left at R57's bedside. R34 R34's Diagnosis Report dated 9/13/23, indicated R34 had diagnoses which included bilateral primary open-angle glaucoma (chronic, progressive, and irreversible optic neuropathy with progressive loss of peripheral vision), depression, anxiety, and dependence on supplemental oxygen. R34's significant change MDS assessment dated [DATE], indicated R34 was cognitively intact. R34's Active Orders as of 9/13/23, included: -albuterol sulfate HFA aerosol solution 108 (90 Base) micrograms (mcg) per inhalation, one puff inhale every four hours as needed for shortness of breath, wheezing, or cough related to asthma -artificial tears one percent instill two drops in both eyes two times a day for dry eyes and as needed -Atrovent HFA aerosol solution 17 mcg per inhalation, two puffs inhale orally four times a day for shortness of breath related to asthma -ProAir HFA aerosol solution 108 (90 Base) mcg per inhalation, one puff every four hours as needed for shortness of breath -Symbicort aerosol 80-4.5 mcg per inhalation, two puffs two times a day for shortness of breath related to asthma. R34's EHR lacked a medication self-administration assessment. During an observation and interview on 9/11/23 at 2:24 p.m., in R34's room, her inhalers and eye drops were located in a box in her room. R34 said they were there so she could use them independently as needed. During an interview on 9/12/23 at 3:51 p.m., the director of nursing (DON) stated residents were able to self administer medications after they had been assessed to safely self administer their medications and a physician's order had been obtained. During an interview on 9/13/23 at 10:12 a.m., the consultant pharmacist stated the facility should follow their protocol/procedure to ensure the resident was safe to self-administer medications. When a resident was determined to be safe to administer medications, the facility should have obtained an order from the physician as well. The facility policy titled Self-Administration of Medications dated 2/2021, indicated the interdisciplinary team (IDT)would assess each resident's cognitive and physical abilities to determine whether self-administering medications was safe and clinically appropriate for the resident. If the IDT determined it was safe and appropriate for the resident to self-administer their medications, it would be documented in the medical record and in the care plan.

Based on observation, interview, and document review, the facility failed to ensure 1 of 1 residents(R78) received appropriate ongoing catheter cares reviewed for urinary catheter care. Findings include: R78's Diagnosis Report dated 9/13/23, indicated R78 had diagnoses which included malignant neoplasm of prostate. R78's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R78 was cognitively intact and had an indwelling foley (urinary) catheter. R78's significant change Care Area Assessment (CAA) dated 6/30/23, indicated R78 had a foley catheter in place related to a diagnosis of prostate cancer. The CAA identified proceed to care plan to avoid risk and complications related to the indwelling foley catheter. R78's care plan dated 6/21/23, indicated R78 had a self-care deficit, had a foley catheter and had a goal to remain free from catheter-related trauma. Interventions included positioning the catheter bag and tubing below the level of the bladder and away from the entrance room door, monitor and document intake and output, monitor for pain and discomfort due to catheter, and monitor for signs and symptoms of infection (pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color and increased pulse and temperature). The care plan lacked information on how to care for the indwelling foley catheter. R78's Order Summary Report current as of 9/13/23, directed staff to obtain urinary output (foley catheter) every shift. The report lacked information about catheter cares. During an observation on 9/12/23 at 10:47 a.m., nursing assistant (NA)-C entered R78's room to assist him out of bed and to get ready for the day. NA-C performed hand hygiene, donned gloves, placed a gait belt on R78 and walked with him into the bathroom. NA-C assisted R78 to sit on the toilet and removed his brief. NA-C reminded R78 to use the call light when he was done. -at 10:56 a.m., R78 put on his call light, NA-C answered the call light, performed hand hygiene, put on gloves, threaded R78's foley catheter bag through his brief, assisted him to stand, pulled up his brief after wiping his rectal area, walked him to the sink and stood by while R78 washed his hands at the sink. NA-C assisted R78 to walk to his recliner, settled him into his chair, placed a blanket on his lap and exited the room with the garbage. During an interview on 9/11/23 at 10:36 a.m., R78 said he believed he had the catheter in place for about two months. R78 stated staff did not cleanse around the catheter tube daily. During an interview on 9/12/23 at 11:03 a.m., NA-C stated she did not complete catheter cares and believed the nurses performed R78's catheter cares. NA-C confirmed she had never completed any catheter cares for R78. During an interview on 9/12/23 at 11:07 a.m., trained medication aide (TMA)-A stated R78 received catheter cares at bedtime and he would get a bath on Tuesdays and occasionally on Saturdays. TMA-A stated catheter cares had not been completed by her on 9/12/23. TMA-A reviewed R78's electronic health record (EHR) and was not able to locate where catheter cares had been documented as completed. During a follow-up interview on 9/12/23 at 11:14 a.m., R78 stated staff had never washed around his catheter or his perineal area. R78 stated he received a tub bath twice a week. During an interview on 9/12/23 at 11:45 a.m., clinical manager (CM)-A stated the standard of care for an indwelling foley catheter would be for staff to complete catheter and perineal cares at least once daily and to document the cares. CM-A stated catheter care was expected to be completed by the NAs. CM-A reviewed R78's care plan and verified the care plan lacked interventions for catheter cares. During an interview on 9/13/23 at 11:38 a.m., the director on nursing (DON) stated the standard of care for residents who had catheters would be for staff to complete catheter care twice daily and as needed to prevent infections. The policy Catheter Care, Urinary dated 8/2022, indicated the purpose of catheter care was to prevent urinary catheter-associated complications, including urinary tract infections. The policy indicated perineal care should have been completed daily.

Based on observation, interview and document review, the facility failed to provide a summary of the baseline care plan to the resident representative, for 1 of 1 (R3) resident reviewed for care planning. Findings include: R23's quarterly Minimum Data Set (MDS) dated [DATE], identified R23 had moderate cognitive impairment and had diagnosis which included anxiety disorder, depression, and seizure disorder. Indicated R23 required extensive assistance with bed mobility and toileting. Identified R23 required limited assistance from staff with transfers and personal hygiene. R23's base line care plan dated 5/31/23, identified R23 required staff assistance with personal hygiene and ambulation and was independent with eating after setup. Identified R23 was at risk for falls and directed staff to ensure R23 was wearing proper footwear, and was signed by the clinical manager (CM)-B. R 23's face sheet indicated he had been admitted to the facility on [DATE]. During an interview on 9/11/23 at 11:46 a.m., family member (FM)-A stated he had not received a summary of R23's baseline care plan. During an interview on 9/13/23 at 11:50 a.m., clinical manager (CM)-B stated she completed R23's baseline care plan and was not able to recall providing R23's representative a summary of the baseline care plan. During an interview on 9/13/23 at 12:06 p.m., director of nursing (DON) stated she was unsure why a summary of the baseline care plan was not provided to R23's representative. DON indicated her expectation was a summary of the baseline care plan would have been provided to R23's representative. A facility policy titled Care Plan - Baseline dated 2001, revised 3/22, indicated the baseline care plan includes instructions needed to provide effective, person- centered care of the resident. Identified the resident and/ or representative were provided a written summary of the baseline care plan.

Based on observation, interview and record review the facility failed to ensure residents were free from accident hazards when a resident was transferred without following the plan of care for 1 of 3 residents (R1) who used a front wheeled walker for transfers. R1 fell during the staff assisted transfer without the use of her walker and sustained an acute left maxillary sinus fracture (a sinus located near the nose) and an acute left orbital floor (eye socket) fracture that resulted in harm. The facility had implemented corrective action so the deficient practice is being issued at past non-compliance. Findings include: R1's quarterly Minimum Data Set ((MDS) dated [DATE], identified R1 had moderate cognitive impairment and had [DIAGNOSES REDACTED]. R1's MDS further identified she required extensive assistance with transfers, walking, bed mobility and toileting. R1's MDS identified her balance was not steady, only able to stabilize with human assistance with surface to surface transfers and from seated to standing. The MDS identified R1 had two or more falls since last assessment, and one of the falls R1 sustained a minor injury. R1's significant change of status assessment (SCSA) MDS dated [DATE], identified R1 had two or more falls since the last assessment and she acquired one major injury. R1's SCSA Care Area Assessment (CAA) dated 4/10/19, identified R1 had balance problems and had three falls in the last quarter of which she obtained a wrist fracture. R1's CAA identified fall interventions were in place, and she was at risk of falls related to her balance problems. Falls would be addressed in R1's care plan to maintain current level of functioning and to minimize risks. R1's care plan revised 3/5/20, identified R1 was at risk of falls, required assistance of 1 for bathing, dressing, personal hygiene and toilet use and listed various interventions which included: nursing staff to assist of 1 with FWW (front wheeled walker) for transfers. R1's care plan also directed use of chair and bed alarms, dycem and autolock breaks to wheelchair. Review of the facility incident report dated 2/28/20, identified R1 was being transferred without the use of a walker, from recliner to wheelchair when R1 lost balance and tipped forward onto the floor. R1's care plan instructed staff to transfer R1 with assistance of one with front wheeled walker, and walker was not used. The facility investigation identified nursing assistant (NA)-B was interviewed, provided education on care plan adherence regardless of familiarity and frequency of working with R1, then NA-B was sent home. R1 was sent to emergency department, and had follow up eye examination appointments on 3/2/20, 3/3/20, and 3/4/20. R1 sustained a laceration above her left eye, carpet burn to her left cheek and fracture of her left ocular cheek bone. R1's care plan was updated to include transfer assitance of 2 staff with front wheeled walker. Facility wide education was put in place for care plan adherence and safe patient handling. R1's Emergency Department Visit report dated 2/28/20, identified R1 obtained an acute left maxillary sinus fracture, an acute left orbital floor fracture and laceration related to a fall. R1 had orders for [MEDICATION NAME] (antibiotic) 500 mg orally three times a day for 5 days for [MEDICATION NAME] (preventive treatment) for sinus fracture. On 3/9/20, at 9:30 a.m. R1 was in her recliner with feet elevated, covered with a blanket, in her room, bedside table next to her, while she talked on the phone. At 11:01 a.m. R1 remained seated in recliner, feet on floor with one shoe on and one shoe off. At that time, registered nurse care coordinator (RNCC)-A entered room, briefly talked with R1 and proceeded to open her armoire, reviewed the care plan attached to the inside of the armoire door, then returned to assist R1 out of the recliner. RNCC-A placed R1's front wheeled walker in front of her, instructed her to push off the recliner's arm rests. R1 placed her hands on the walker, and while RNCC-A held onto R1's transfer belt, R1 stood, pivoted and then sat in wheelchair. Dycem (non-skid sheeting) was observed on the seat of the recliner, as well as an alarm pad. R1's care plan, was observed taped on the inside of R1's armoire, and instructed staff to use 1 assist with front wheeled walker for transfers. Review of R1's facility incident reports from 12/1/19, to 3/9/20, identified the following: -12/9/19, at 7:45 p.m. R1 found sitting on floor by bed, R1's roommate informed staff R1 had transferred self from wheelchair to bed, then slid down from the bed to the floor. R1 was reminded to call for help. -12/21/19, at 4:45 p.m. R1's bed alarm sounding, staff found R1 sitting on floor by bed. R1 informed staff she was trying to go to the bathroom, and refused to ask for assistance. R1 had been toileted twice prior that shift. -12/30/19, at 4:00 p.m. R1's roommate alerted staff, who found R1 sitting on floor. R1 had self transferred herself. R1's chair alarm was found not to be properly placed. -2/28/20, at 1:29 p.m. R1 was assisted by staff with transfer from recliner to wheelchair. R1 sustained a laceration to face and had left shoulder/clavicle pain. R1's front wheeled walker was not in front of her for transfer. R1's primary care provider (PCP) was notified, and order received to send to emergency department. On 3/9/20, at 9:20 a.m. NA-C indicated the usual facility practice was to place individual resident care plans inside their closets. NA-C indicated if things changed, such as how a resident transfer, then RNCC-A would print off a new one. NA-C indicated she had just received training two days ago regarding care plans and to check them every day you walk into residents' rooms. On 3/9/20, at 10:06 a.m. trained medication aide (TMA)-A indicated she had attended training last week on care plans. TMA-A indicated staff are to make sure they check the resident's care plans in their armoires before doing anything with the residents. TMA-A indicated the nurses made changes, and we should check the dates of the care plans and if we have issues or concerns we ask the nurse. On 3/9/20, at 1:06 p.m. voice message was left for NA-B who returned the call on 3/11/20, at 3:31 p.m. NA-B indicated she had transferred R1 on 2/28/20, when she had her fall NA-B indicated she had not used the walker, and R1 tipped forward. NA-B indicated she had training on residents cares prior. NA-B indicated she was not aware R1 used a walker for transfers. NA-B indicated R1 wanted her to rush and get her up. NA-B indicated she was aware all residents had care plans in their closets, but had not looked before she transferred R1. NA-B indicated she had received education after the incident which included to check care plans, even if residents were in a hurry, to tell them to wait a minute while you check the care plan. On 3/9/20, at 1:32 p.m. NA-E indicated all residents had care plans inside their wardrobes in their rooms and she reviewed the individual resident care plans for specific instructions on how to care for the individual resident. NA-E indicated she was scheduled to attend training on care plans within the next week. On 3/9/20, at 1:38 p.m. NA-F indicated he had received education on how to take care of the residents. NA-F indicated he just completed care plan training again, which included [MEDICATION NAME] checking care plans to make sure you don't miss something. On 3/9/20, at 1:45 p.m. NA-G indicated he knew how to take care of residents based of their care plans in their closets. NA-G indicated he was aware R1 had a fall, and there was a change with her transfers. NA-G indicated when he looked at her care plan that morning, she was an assist of one staff with her walker. NA-G indicated for awhile they used two staff. NA-G was unaware if he had education or training scheduled coming up. On 3/9/20, at 1:49 p.m. NA-A indicated she checked residents care plans, which were taped to the inside of their closet doors to know how to provide cares to residents. NA-A indicated she also could check with her co-workers if had questions. NA-A indicated there was mandatory education for all nursing staff, today or tomorrow and it goes until 3/19/20. NA-A pointed to a sign for Mandatory Education for All Nursing Staff which included scheduled dates, posted on the cupboard above the nurses desk. On 3/9/20, at 1:53 p.m. RN-A confirmed mandatory education had been initiated after R1's fall and indicated the mandatory in-service included a simulation regarding care plan compliance, review of abbreviations used, and a pre and post test. During the simulation sessions, RN-A indicated she observed staff and completed any additional education needed at that time. R RN-A indicated 26 nursing staff had compelted the education so far, and identified she thought there were 60 licensed and unlicensed staff who needed to complete the mandatory re-training. RN-A indicated if all staff had not completed it, the facility planned to schedule a make up day. RN-A indicated if a staff member did not complete it by then, they would be taken off the schedule until they reviewed it. RN-A indicated an announcement for the training was also texted to all staff. On 3/9/20, at 2:17 p.m. RNCC-A reviewed R1's electronic health record with surveyor. RNCC-A reviewed R1's history of falls, assessments of the falls and interventions put in place after the falls. RNCC-A identified R1 had five falls since 12/1/19 and indicated R1 had sustained an ocular cheek bone fracture on 2/28/20 when she fell while being assisted by a NA-B to transfer from her chair to her wheelchair. RNCC-A confirmed R1's care plan was not followed and NA-B did not use the walker with the transfer. RNCC-A indicated NA-B received individual education and the facility was in the process of completing facility wide education for all licensed and unlicensed nursing staff. On 3/9/20, at 2:48 p.m. licensed practical nurse (LPN)-A indicated she was scheduled to attend the mandatory training on Thursday regarding care plans. LPN-A indicated she was not aware of R1's current cares, but indicated she would need to refer to her care plan. LPN-A indicated residents' care plans were printed and placed on the inside door or resident's armoires. LPN-A indicated if there were any changes a new care plan would be put up on the inside of the resident's armoire door. On 3/9/20, at 3:46 p.m. in a follow up interview, RNCC-A indicated R1 had been an assist of one staff with the walker for transfers prior to her fall. RNCC-A indicated the facility had increased her to two staff with walker after the fall for a few days, then reassessed her, and returned her to assist of one staff with the walker for transfers. RNCC-A indicated they had begun to complete audits and continued to have a few going on at that time to regarding following resident care plans. RNCC-A indicated they initially completed audits with NA-B and other specific staff who had an issue with following the care plan. After that, random audits were completed on day and evening shift facility wide. RNCC-A indicated they had planned on completing a few more audits, including another one with NA-B. RNCC-A indicated if a resident had a change in their care plan, they would watch to assure staff were checking the resident's care plan. On 3/9/20, at 4:02 p.m. during a phone interview with family member (FM)-A, FM-A indicated she was notified the staff member transferred R1 from her chair to her wheelchair on 2/28/20, but did not have the walker in front of her, and R1's legs are not stable and that is how she fell . FM-A indicated R1 had been seen by the eye doctor and an ophthalmologist who examined her to assure her orbital muscle was still intact, and decided no surgery was needed. FM-A indicated she just wanted to be sure when staff helped R1, that they look in the armoire to read the list on how to care for R1. FM-A indicated staff should just remember to check R1's care plan in case something changed, and felt the staff should read it on a daily basis. On 3/9/20, at 4:07 p.m. during a follow up interview, RN-A indicated when R1 fell , R1 had blood on her hands and the carpet with staff sitting with her. RN-A indicated they got R1 up with a mechanical lift, then applied ice to her shoulder. RN-A indicated R1 had a laceration on her eyebrow and a carpet burn to her cheek. RN-A indicated R1's eye looked blood shot, but no pooling of blood in the eye was noted. RN-A indicated she contacted FM-A, then interviewed NA-B. RN-A indicated NA-B stated she forgot to check R1's care plan to see how to transfer her. RN-A indicated they completed immediate education with NA-B, and then completed audits over the weekend. On 3/9/20, at 4:43 p.m. during a telephone interview with R1's primary care physician (PCP)-A nurse stated the PCP would return a call tomorrow. On 3/11/20, at 8:45 a.m. PCP-A left a voice message which he indicated he would call back later that day. No further calls or messages were received. On 3/9/20, at 4:24 p.m. director of nursing (DON) confirmed he was aware R1's care plan was not followed as expected during a transfer and he was aware R1 had received a serious injury. The facility posting titled Mandatory Education undated, identified dates and times listed: 3/5/20, 3/12/20, or 3/19/20, at 7 a. m., 10 a.m., 2 p.m., and 4 p.m. and on 3/6/20, and 3/13/20, at 7 a.m. or 10 a.m. The form identified that one session must be attended and was a mandatory re-training session on care plans, care plan updates and transfers for all licensed nurses, trained medication aides and nursing assistants. Review of the facility Mandatory re-training session on care plans, care plan updates and transfers for all licensed nurses, trained medication aides and nursing assistants was completed. The education included a posting at all nurses stations, a written test titled Care Plan Education and Review and a simulated care plan. The signature form of those attended identified 26 licensed and unlicensed nursing staff of the 60 staff identified by the facility who required re-education, had attended through 3/6/20. Review of the facility audit forms titled Transfer Per Care Plan identified staff members were observed to determine if resident care plans were checked then followed during transfers. Seven audits had been completed by 3/9/20. On spot education or resident reassessments were completed as needed. The facility policy titled Using The Care Plan revised August 2006, identified care plans were placed in the resident's chart, and care kardex were placed in the resident's closet. The policy further identified staff were responsible to provide care as directed on the resident care plan. The facility policy titled Assessing Falls And Their Causes revised October 2010, identified the purpose of this procedure is to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. The policy included areas to follow which included; after the fall, defining details of the fall, identifying causes of a fall or fall risk, documentation and reporting. The past non-compliance that began on 2/28/20, was verified during the 3/9/20, onsite visit and was corrected by the facility on 3/6/20. The facility immediately re-educated NA-B, other staff on that shift who worked with R1 and initiated mandatory retraining sessions for all licensed and unlicensed staff regarding care plans, care plan updates and transfers. The facility began audits to assure care plans were being followed for nursing staff through out the building. Verification of corrective action was confirmed by interview with a variety of nursing staff and documentation of chart audits that verified resident's care plans were being followed while nursing staff provided their cares. There was a plan in place for all licensed and unlicensed nursing staff to be re-educated to care plans, care plan updates and transfers. The education was reinforced by random audits still in place to ensure resident's care plans were being followed while nursing staff provided their cares.

Based on observation, interview and document review, the facility failed to ensure a mechanical sit to stand lift sling was applied according to manufacturer's guidelines for 1 of 1 resident (R8) who experienced a fall during a transfer. This deficient practice resulted in actual harm for R8 who required hospitalization for fractures of the right humerus, and left knee and was no longer able to bear weight to stand and required adaptive devices for eating. Findings include: R8's quarterly Minimum Data Set (MDS), dated [DATE], indicated R8 had [DIAGNOSES REDACTED]. The MDS indicated R8 was cognitively intact, and required extensive assistance of 1 staff person with transfers, bed mobility, dressing, toilet use, and personal hygiene. In addition, the MDS indicated R8 was independent with feeding herself after set up was provided. R8's significant change Care Area Assessment (CAA), dated 10/31/18, indicated R8 was cognitively intact, was non weight bearing, and required total assistance with most of her activities of daily living (ADL)'s related to fractures to her arm and knee after her fall. In addition, the CAA indicated R8 had mobility impairment related to arm and knee fractures secondary to a fall and required a full body Hoyer lift (mechanical lift) for all transfers. R8's care plan, revised 1/22/19, indicated R8 had a self-care deficit with ADL's related to recent fractures of her right humerus, and left knee on 10/18/18. R8's care plan listed R8 was non-weight bearing, did not ambulate, and directed staff to use a full body lift, with 2 staff assist, for transfers and toileting. Further, R8's care plan directed assistance of one with feedings, and use of a curved utensil for eating and a plate guard for self feeding as able. On 1/29/19, at 8:39 a.m. R8 was seated in an electric wheelchair at a table in the dining room, silverware, and a mug was on the table in front of her. R8 wore a black sling on her right arm, and was dressed in street clothes. A dietary aide was present in kitchen area, preparing food items. The dietary aide approached R8's table, placed a plate of breakfast food items in front of her, and immediately exited the area. R8 looked down at her plate, and stated, Hey, you forgot my crooked fork. The dietary aide returned to R8's table with an adaptive spoon and placed the spoon at her place setting. R8 began to slowly start to eat her breakfast. Review of R8's Resident Accident/Incident Report, dated 10/18/18 at 4:30 p.m., revealed R8 had been transferred with the use of a sit to stand lift and a nursing assistant (NA), when the stand had been pushed over the threshold of the bathroom, the left side of the harness became suddenly disconnected from the lift, with R8 hanging from the right side of the lift. The NA stated she believed the strap holding R8 on the left side had snapped as it was a loud and abrupt motion when released. The NA indicated R8 had not fallen from the stand but the loop on the sling had become disconnected from the stand on the left side. She indicated she may not have had the loop securely latched in the stand. Initial inspection noted the strap was not broken, a small fray was noted in the edge of the left side. R8 complained of severe pain in arms, legs and neck. An ambulance had been called, and R8 transferred to the hospital at that time. The report indicated the lift had been inspected by nursing and maintenance and found to be in working order. A small bit of fraying was noted on the loop of the sling for the lift, however, the loop was intact and appeared to come off of the area it should have connected to on the stand. The report also indicated random lift audits had been performed on numerous staff for use of sit to stand lifts and full body lifts. Review of R8's physican progress noted from 11/1/18 to 1/29/19, revealed : -11/1/18, R8 had been transferred with a lift about 2 weeks prior and the lift had became disconnected causing her to fall. She was found to have a periprosthetic [MEDICAL CONDITION] femur and right proximal humerus fracture. The notes indicated the provider had discussed her fractures and potential treatment options. The provider noted R8 would likely not be able to bear weight on her leg again given the nature of the fracture and she may need long-term bracing of knee without further intervention and R8 declined surgical intervention. - 11/28/18, on examination, R8's left knee demonstrated significant flexion contracture and inversion contracture to the left foot. X-ray of the right shoulder demonstrated impaction of the humeral head neck fracture with interval callus formation. - 12/26/18, with therapy, R8 had made good progress with her elbow, hand and wrist range of motion and seemed to have more functional with use of her right hand. R8 still could not feed herself with her right arm. R8 was to continue therapy to her right upper extremity, and discussion for therapy to her left lower extremity. Given the nature of her fracture and deformity at the fracture site, it is unlikely she will ever be able to bear weight on her left leg. R8 declined therapy to left lower leg at that time. On 1/29/19, at 2:36 p.m., R8 stated she had experienced a fall several months ago which resulted in her right arm and left knee being fractured. R8 stated the lift sling loop slipped off the lift when the NA pushed her into the bathroom, and indicated as result of her injuries she now used a full body Hoyer lift for transfers. She stated, It has made me pretty handicapped. On 1/31/19, at 9:40 a.m., nursing assistant (NA)-D indicated in the past R8 had used a sit to stand PAL lift for transfers, but now transferred with the use of a full body lift and had used the full body lift for a while. On 1/31/19, at 10:14 a.m., registered nurse (RN)-A confirmed R8 had fallen from a PAL lift a couple of months ago, had used to bear weight and stand using the PAL lift, but now required the use of a full body lift. RN-A stated at present, R8 was able to feed herself with the use of adaptive silverware. On 1/31/19, at 12:10 p.m., registered nurse clinical coordinator (RNCC)-A stated she was aware of the incident that had occurred when R8 had fallen from the sit to stand lift, and stated the NA had hooked R8 up to the PAL lift without making sure the loops were fully behind the black rubber hooks. She indicated R8's lift sling disconnected from the lift, causing a fracture of her right arm and left knee. RNCC-A stated she had inspected the sling used to transfer R8 when she fell from the PAL lift, and described one loop had been damaged and was torn partially through. RNCC-A indicated since the fall, R8 required adaptations of bent silverware and a lipped plate to feed herself. RNCC-A stated R8 was no longer able to bear weight to transfer with the PAL lift, and required the use of full body Hoyer lift for all transfers. Review of the EZ [MEDICATION NAME] Stand operators manual, dated 5/98, instructed before operating the unit, insure that the harness is not ripped or frayed. Attach the harness to the hooks at the end of the EZ Stand arm using the loops provided, make sure the same loop is attached on each side. Be sure to check the sling attachments each time the sling is removed and replaced, to ensure that it is properly attached before the patient is removed from a stationary object (bed, chair or commode.) Further, the manual directed, before lifting a patient from a stationary object ( wheelchair, commode or bed), slightly raise the patient off the stationary object and check that all sling attachments are secure. If any attachment is not correct, lower the patient and correct the problem, then raise the patient and check again. DO NOT move the patient if the patient sling is not properly connected to the attachment points on the patient lift. Check that the patient sling is properly connected to the attachment points BEFORE lifting the patient. On 1/29/19, at 2:03 p.m. maintenance supervisor (MS) indicated there was a mechanical lift representative from EZ way lifts at the facility about 2 months ago and provided a training where safe transfer information was reviewed, what to look for, and how to avoid injuries. MS indicated department heads from nursing, maintenance, and administration attended the training and indicated it was open to available staff to attend as well. MS verified the EZway training was not a mandatory staff training, and all nursing staff did not attend. On 1/31/19 at 12:35 p.m., the director of nurses (DON) stated during a transfer with the sit to stand lift to the bathroom, the NA moved R8's lift over the threshold into the bathroom, and PAL lift loop of the sling unhooked from the lift. The DON stated the NA had not put the loop on fully over the lift hook safety latch, and indicated the sling loop had been slightly frayed. The DON stated the investigation of the incident with R8 revealed the NA had not ensured the lift sling loop was fully over the PAL lift hook, and stated, it was human error. The DON stated the facility had completed random lift audits and competencies on random staff throughout the entire facility over the last couple of months. The DON stated the facility had 105 nursing staff in the building and verified not all staff had completed competency on use of mechanical lifts after R8's fall. The DON verified nursing was not required to attend the EZ way training that had been provided at the facility, and indicated a few available staff attended. Requested a list of staff who attended the EZway training, none was provided. The DON provided competency forms for current staff retrained on the use of the mechanical lifts. The review revealed 48 of the 105 current nursing staff had completed competency training on the mechanical lifts after R8's fall. DON confirmed the findings after the review. Review of the policy titled, Safe Lifting and Movement of Residents, indicated staff would be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures for use of equipment and safe lifting techniques.

Based on observation, interview, and document review, the facility failed to provide the necessary care and services for 1 of 3 residents (R79) who required the use of an indwelling catheter. This deficient practice resulted in harm for R79 who required hospitalization and surgical procedures for removal of a foreign body in the urinary bladder. Finding include: R79's admission Minimum Data Set (MDS) dated , 1/7/19, indicated R79 was moderately cognitively impaired and had [DIAGNOSES REDACTED]. The MDS indicated R79 required extensive assistance of two staff with activities of daily living and had a indwelling Foley catheter. Review of R79's care plan, revised 1/23/19, indicated R79 had a indwelling Foley catheter related to bladder outlet obstruction and [MEDICAL CONDITION]. The care plan listed several interventions which included staff were to monitor/record/report to medical doctor for signs and symptoms of UTI, pain burning, blood tinged urine, cloudiness, no output, depending urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills altered mental status, and check for kinks each shift. Review of R79's nursing assistant sheet dated 1/31/19, indicated staff were to check tubing for kinks each shift and monitor/document for pain/discomfort due to catheter. Further, R79's care plan directed to monitor/record/report to medical doctor for signs and symptoms of UTI, pain burning, blood tinged urine, cloudiness, no output, depending urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills or altered mental status. On 1/29/19 at 8:37 a.m., R79 was seated in his wheelchair at the dining room table, waiting for the breakfast meal, visiting with other residents at the table. R79 wore a clear, plastic catheter leg bag attached to his right lower leg and had a small amount of amber yellow urine in the leg bag. On 1/31/19 at 9:27 a.m. R79 was seated in his wheelchair at the dining room table eating breakfast, reading a paper and drinking coffee. R79 had a catheter leg bag attached to his right lower leg and had a small amount of amber yellow urine in the leg bag. Review of R79's Progress Notes from 12/31/18 to 1/31/19 revealed the following: On 1/12/19 at 6:25 a.m., blood tinged urine in Foley bag and had complaints of bladder feeling full and needed to go to the bathroom. A post-void residual (PVR) (test done to see how much urine left in the bladder) 880 millimeters (ml), repositioned R79 unsuccessful and reported to oncoming nurse. - at 7:24 a.m. R79 had very little output on the night shift, PVR done 800 ml, R79 complaining of pain in lower abdomen, called placed to charge nurse on-call and was advised to replace the catheter. Catheter removed, the tubing was dark red in color, new catheter inserted and was unable to get urine return. Call placed to hospital to get order to send R79 over to the emergency room . - at 2:05 p.m. R79 returned from the emergency department with the following orders: [MEDICATION NAME] (antibiotic) 500 milligrams (mg) every day times 7 days, irrigate catheter every 4 hours times 24 hours and as needed for clogged catheter. Progress note from emergency department indicated R79 had a hematuria plugged catheter, UTI, and pneumonia. On 1/20/19 at 11:30 a.m. R79 attempted to remove catheter and self ambulated to the bathroom stating, because I had to go. The licensed practical nurse (LPN)-C was notified by the NA R79's Foley catheter was out and needed to be replaced. LPN-C, per order, attempted to replace Foley catheter and R79 had complaints of pain when the balloon was inflated on the Foley catheter. LPN-C attempted to deflate the balloon with no success. The NA then notified LPN-C the tip of the catheter she had inserted did not look the same as the one in the garbage. LPN-C proceeded to observe the Foley catheter that was in the garbage and verified the tip of the Foley catheter was not intact. LPN-C contacted charge nurse on-call and was directed to send R79 to the emergency room . LPN-C obtained order to send to emergency room , paper work sent and old Foley catheter to determine how much was in the bladder. At 2:31 p.m., spokesperson from hospital notified facility and stated R79 was in route to Fargo. On 1/21/19 at 11:22 a.m. spoke with R79's daughter and indicated R79 would be having procedure tomorrow to remove the catheter piece that broke off inside R79. On 1/24/19 at 4:45 p.m. R79 returned from recent hospitalization for cystoscopy ( thin tube, with a camera and light at the end, inserted through the urethra (the tube that carries urine out of the bladder) and into the bladder to visualize the inside of the bladder) to remove a foreign object from the bladder. (R79 had pulled out Foley and broke off, leaving some of the catheter in his bladder). R79 had 16 french Foley catheter replaced and noted to be draining dark yellow urine. R79's Emergency Department Visit, dated 1/20/19, indicated R79 presented from the nursing home with Foley catheter issue. R79 had pulled out his catheter and staff thought the catheter had been pulled completely out. Staff attempted to place a new catheter which was met with resistance, inflated the balloon and had no urine drainage. Staff attempted to remove the second catheter placed but was unable to deflate the balloon and sent R79 to the emergency room . R79 reported some discomfort in his penis/supra pubic area and denied any acute symptoms. On exam R79 had blood at the meatus (a passage or opening leading to the interior of the body) of the penis and radiology reported foreign body which was presumably the end of the Foley catheter was seen within the bladder. The nurses were able to aspirate the fluid from the balloon within the penis of the second catheter and remove it with minimal amount of blood. Discussed R79's condition with radiologist and would most likely not be safe procedure that he could do. The radiologist indicated R79 would mostly likely need cystoscopy performed and was transferred to Fargo, ND for [MEDICATION NAME] radiology or urology intervention. R79's Radiologist Report, abdomen single view, dated 1/20/19, indicated abdomen demonstrated part of the Foley catheter that was broken off was seen in the lower pelvis. R79's Discharge Summary, dated 1/24/18, indicated R79 had [MEDICAL CONDITION], dementia and hypertension who was transferred from Fergus Falls, MN on 1/20/19 after he pulled on his Foley catheter, broke it and retained foreign body in bladder. R79 had been hospitalized a month prior for [MEDICAL CONDITION], acute [MEDICAL CONDITION] secondary to lower urinary tract symptoms (LUTS) from [MEDICAL CONDITION] and Foley had been placed at that time. Ultrasound at the outside facility showed retained portion of the catheter in the bladder so he was transferred to Fargo, ND. R79 was seen in the emergency room by urology and underwent cystoscopy but they were unable to remove the catheter fragment. R79 underwent a cystoscopy again on 1/22/19, which was successful to recover the broken part of the Foley catheter. R79 was treated with intravenous [MEDICATION NAME] (antibiotic) which was switched to [MEDICATION NAME] dose of Keflex (antibiotic) 500 milligrams (mg) daily until another urological procedure on (MONTH) 15th per urology recommendations and to maintain Foley catheter until surgery. R79's hospital Admission History and Physical, dated 1/20/19, indicated R79 had retained Foley catheter and was not clear but the catheter originally was pulled or tugged on and part of it came out. Report was that once they realized that part of it was still retained, staff had a second attempt to place a catheter, which went in but did not go in all the way and 10 ml had been put in the balloon of the catheter, the balloon would not deflate and catheter would not dislodge. R79 was sent to Fargo, ND on ultrasound one was able to see the foreign body in the bladder and the bladder was very full with 500 ml or more and leaking urine out of the urethra at this point. The urologist recommended flexible cystoscopy, there was no bleeding, no trauma, bladder full, quite trabeculated (bladder outlet obstruction) and could see the catheter with balloon deflated. The urologist could see at least 6 to 8 inches and the end of the catheter was transected. Took some time attempting to remove foreign body with the eyelet and with our flexible alligator grasper was unsuccessful. The urologist attempted flexible scope to be able to line up the severed end and grasp the one in the grasper which was unsuccessful. R79 had 16 french coude catheter placed with clear urine return. R79 was started on antibiotics, lab work obtained and plan was to attempt cystoscopy again with an anesthetic in the next several days and try to remove foreign body with alligator if possible. R79's Hospital Operative Report, dated 1/22/19, indicated R79 had cystoscope performed and noted some [DIAGNOSES REDACTED] having catheter tubing in. The urologist could see a piece of Foley catheter about 8 inches long and could not be removed with alligator clips and used large foreign body forceps that would be used for bladder stones and was able to grab the end of the catheter and brought it out in it's entirety. The cystoscope was again inserted, looked for more foreign body and none noted. R79 had some minor excoriation of the prostatic urethra and bladder, Foley catheter placed and clear urine returned. On 1/29/19 at 12:13 p.m. nursing assistant (NA)-E confirmed R79 had a Foley catheter and needed staff assistance with the care of his catheter. NA-E indicated R79 had gone to the hospital because he pulled his catheter out. On 1/29/19 at 11:49 a.m. licensed practical nurse (LPN)-C confirmed R79 had a Foley catheter in place and a NA had reported to her that R79 had pulled his Foley catheter out and it needed to be replaced. LPN-C indicated she gathered her supplies, inserted a new Foley catheter with no resistance, put 10 ml water in the balloon and R79 asked if it was supposed to be painful while he bent over in pain. LPN-C indicated she tried to deflate the balloon by removing the 10 ml of water and the water would not come out. LPN-C indicated the NA stated that tip of the catheter she had just placed did not look like the catheter in the garbage. LPN-C then observed R79's old catheter and noted it was not intact. She stated she knew at that moment R79 had pulled his catheter apart and tore it out. LPN-C indicated she thought the piece of the catheter must still be inside of R79. LPN-C indicated she stopped everything, called the nurse in charge and was directed to send R79 to the emergency room . LPN-C indicated R79 was seen in the emergency department in Fergus Falls, MN and transported to Fargo, ND to surgically remove the piece of the catheter that had broken off inside of R79. LPN-C indicated she tried to get the second catheter out but was unable to. LPN-C stated she did not know when she inserted the second catheter that R79 had ripped it out until the NA brought it to her attention. LPN-C indicated CC-B had talked to her about making sure she looked at the catheter tip to make sure the catheter was intact, before inserting a new catheter at that time. On 1/29/19 at 12:01 p.m., clinical coordinator(CC)-B confirmed R79 currently had a Foley catheter in place and required staff assistance to help care for the Foley catheter. CC-B indicated R79 had complaints of discomfort with the Foley catheter and had been seen the week prior for a UTI. The CC-B indicated she had gotten a call over the weekend in regards to R79 pulling out his catheter and placed it in the garbage. The CC-B indicated LPN-C was working, had not checked the catheter to make sure the tip was intact, and inserted a new Foley catheter into R79. CC-B indicated R79 had complaints of abdominal pain and when LPN-C tried to remove the second catheter, she was unsuccessful. CC-B indicated LPN-C then checked the old catheter that was in the garbage and that's when she realized the catheter tip had broken off. CC-B indicated she directed LPN-C to send R79 to the emergency room for further evaluation. CC-B indicated she had followed up with LPN-C to make sure she always checked for a foreign body before insertion of a new catheter. On 1/29/19 at 3:19 p.m. during a telephone interview, physician (P)-A confirmed R79 had a Foley catheter and was seen at the emergency room in Fergus Falls, MN. P-A indicated R79 had some how pulled out his Foley catheter and reported a piece of the Foley catheter was transected/cut. P-A indicated staff had tried to put another catheter in R79 when the other catheter came out and did not realize R79 still had a piece of the Foley catheter in him. P-A indicated he had a hard time getting the piece of Foley catheter out of R79 because it had migrated back into the bladder after the second catheter was inserted. P-A indicated they scoped R79 and found a piece of the catheter in the bladder and they got it out. P-A indicated staff should of looked at the catheter when it came out and they would have known a piece of the catheter was gone. P-A indicated he thought if staff would of not placed the second catheter, the other piece of the catheter would have stayed in the urethra. P-A indicated he would have not put another Foley catheter in R79, indicated he was concerned staff was not documenting the catheter was out and making sure the whole catheter was intact before inserting a new catheter. On 1/31/19 at 1:06 p.m. director of nursing (DON) confirmed R79 had a Foley catheter and needed staff assistance with the care of his catheter. The DON indicated a NA reported to LPN-C that R79 had pulled out his catheter and transferred himself to the toilet. LPN-C attempted to re-insert a new catheter when the NA noted the new catheter did not look like the old catheter. The DON indicated that's when LPN-C realized the catheter tip was still in the R79, after she had already inserted a second catheter. The DON indicated LPN-C called CC-B and was instructed to call the emergency room and send R79 for evaluation. The DON indicated R79 was seen in the emergency room in Fergus Falls, MN and then transported the Fargo, ND. The DON indicated they attempted to remove the broken off catheter tip from R79 in the emergency room , but was not successful. The DON indicated R79 had a cystoscopy in Fargo which was successful and was readmitted to the facility. The DON indicated he had a conversation with LPN-C, reviewed her competencies and indicated he felt she was competent with catheter care. The DON indicated he gave LPN-C verbal education about assessing the catheter when removing it and prior to insertion of a new one. The DON indicated he would expect staff to follow the facility policy as written. Review of facility policy titled, Foley Catheter Insertion, Male Resident, revised 10/2010, directed staff to notify the physician of any abnormalities (bleeding, obstruction) and report other information in accordance with facility policy and professional standards of practice. Review of facility policy tilted Catheter Care, Urinary, revised 9/2014, indicated to notify the physician or supervisor in the event of bleeding or if the catheter was accidentally removed. Review of facility policy titled, Using the Care Plan, revised 8/2006, indicated the care plan shall be used in developing the residents daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident.

Based on observation, interview and document review, the facility failed to ensure adequate supervision and accident prevention by facility staff when a stove top was left on and unattended for 4 of 21 residents (R1, R2, R3 and R4) who had severe cognitive impairment and were independent in mobility on the Deerwood unit and at risk for burn from the hot stove top. The deficient practice had the potential to affect all the cognitively impaired residents who were independent with mobility. This resulted in an immediate jeopardy (IJ) situation for R1, R2, R3, and R4. Findings include: The IJ began on 6/18/18, at 9:25 a.m. when upon entrance on the Deerwood neighborhoods kitchen, the stove top front right burner was observed to be turned on and left unattended posing a risk for serious injury for a burn. On 6/18/18, at 1:32 p.m. the facility administrator and the dietician were notified of the IJ for the identified residents at risk for possible injury R1, R2, R3,and R4. The IJ was removed on 6/19/18, at 1:09 p.m., however, non-compliance remained at a isolated score and severity which indicated no actual harm with potential for more than minimal harm (Level D.) On 6/18/18, at 9:25 a.m. upon entrance to the Deerwood unit kitchen, a flat top stove and oven and four burners (a large burner in the front on the right and in the back on the left, two small burners, one on the left front and one in the back on the left) was present on the back wall of the kitchen adjacent to a steam table on the left side and a counter top on the right side. At that time the stove top right front burner was observed to be on as indicated by a red light on the right side of the stove top. The kitchen had two entrances, on either side of the kitchen area, yellow plastic chains were observed to be hanging from the walls on on both sides of the entrances, neither chain was across the entrances to the kitchen. No staff were present in the area, continuous observations began at that time. Residents were observed seated in wheelchairs in the dining room seated at the tables, the hallway of the unit and in the activity area behind the dining room. -At 9:28 a.m. the kitchen stove top, right front burner remained on, with no staff observed in the kitchen or dining area of the Deerwood neighborhood. The surveyor placed a hand over the right front burner, approximately 4 inches from the surface and heat could be felt radiating from the stove top. At that time R6 was observed seated in a wheelchair in the dining room, she wheeled herself towards the unchained kitchen entrance and stated she had been waiting for her breakfast. R6 propelled herself back to a table in front of the counter of the kitchen area. Residents were observed seated in wheelchairs in the dining room seated at the tables, the hallway of the unit and in the activity area behind the dining room. -At 9:31 a m. the stove top burner remained on, with no staff observed in the kitchen or dining are of the Deerwood unit, and R6 remained seated in her wheelchair at the dining room table. Residents remained in various areas of the unit, including the dining room, seating area near adjacent to the kitchen and in the hallways. -At 9:35 a.m. a staff member entered the kitchen from the hall adjacent to the outside of the neighborhood and held an english muffin in his gloved hand. He stated he was the homemaker (HM)-A for the Deerwood neighborhood, had left the Deerwood neighborhood and walked to the Cherrywood neighborhood for an english muffin. HM-A confirmed the front right burner of the stove was left on unattended and stated he thought he had only been gone a few seconds. He immediately shut the burner off and confirmed the burner was hot. HM-A stated he did not usually work on the Deerwood unit and was not aware of how many english muffins were needed, and had run out. He stated he usually would not leave the stove top on unattended and indicated he should have applied the yellow chains across both entrances to the kitchen area before leaving the kitchen. On 6/18/18, from 9:25 a.m. to 9:35 a.m. the front right burner of the Deerwood neighborhoods stove top was observed to be on, unattended and hot for a total of ten minutes unsupervised by staff. No staff were observed to walk out or in the neighborhood during the entire ten minute duration. The hot stove top would have been accessible to residents on the unit posing a safety hazard, including cognitively impaired residents. On 6/18/18, at 9:58 a.m. a tour of the Deerwood unit was conducted, one resident, R7 was observed lying in bed. No other residents were observed to be lying in bed. Residents were observed seated in wheelchairs in their rooms, seated in recliners in the common area and in the dining room seated at the tables. observed in various areas of the unit, seated in recliners in the seating area adjacent to the kitchen. On 6/18/18, at 10:00 a.m. during a follow up interview, HM-A stated he did not usually work on the Deerwood unit and stated he had not aware of any residents attempting to enter the kitchen. He indicated he thought several residents had dementia and were cognitively impaired and indicated he was unaware of any residents that wandered. On 6/18/18, at 10:07 a.m. licensed practical nurse (LPN)-A indicated she was the nurse on the Deerwood unit at that time. LPN-A stated most of the residents on the unit had [DIAGNOSES REDACTED]. LPN-A stated she been unaware the HM had left the stovetop on and unattended. She stated she had not been asked to supervise the kitchen area prior to the interview. On 6/18/18, at 10:10 a.m. HM-B stated her usual practice would be to not leave the kitchen area during a meal service. She stated if she had to leave, she would shut the stove off, chain off the entrances of the kitchen with the two plastic yellow chains and she would let a staff member know she was leaving the area. HM-B indicated she would never leave a burner on and walk away. On 6/18/18, at 10:15 a.m. registered nurse manager (NM)-A for the Deerwood unit stated the current census on the unit was 21. NM-A stated two residents on the Deerwood unit wore wanderguards on their persons, due to a history of wandering. A list of residents which resided on the Deerwood unit was requested with the following information: resident name, cognition, mobility status and history of wandering. At that time, NM-A stated the stove top should never be left unattended when it was on. NM-A confirmed it was a safety concern for residents. Review of R1's Significant Change of Status Assessment (SCSA) Minimum Data Set ((MDS) dated [DATE], identified R1 had severe cognitive impairment and had [DIAGNOSES REDACTED]. The MDS identified R1 did not use a mobility device and indicated staff had supervised R1 during ambulation and locomotion during the assessment period. R1's SCSA Care Area assessment dated [DATE], identified R1 had cognitive impairment with periods of inattention, was hard of hearing and was able to stabilize himself during transition from a sitting to standing position. R1's CAAs lacked indication of R1's safety awareness and judgement. R1's current care plan revised 5/31/18, revealed R1 had impaired cognition and decision making, was independent with transfers and ambulation without an assistive device. The care plan revealed R1 was at high risk for wandering as he had left the unit and had a wanderguard on his left ankle. Further, R1's care plan revealed he was dependent on staff to maintain his safety. R1's nursing assistant (NA) care guide printed on 6/18/18, revealed R1 was at high risk for wandering, had a wanderguard on his left ankle and was independent with transfers and ambulation. R2's SCSA MDS dated [DATE], identified R2 had severe cognitive impairment and had [DIAGNOSES REDACTED]. The MDS identified R2 had required extensive assistance with activities of daily living (ADL's) in areas of transfers, locomotion and limited assistance with ambulation. The MDS identified R2 had used a wheelchair and a walker. R2's SCSA CAA dated 5/3/18, identified R2 had disorganized thinking and had cognitive impairment. The CAA revealed R2 received extensive assistance with ADL's including transfers, locomotion and required limited assistance with ambulation. Further, the CAA identified R2 was at risk for falls due to impaired cognition. R2's CAAs lacked indication of R2's safety awareness and judgement. R2's current care plan revised 5/3/18, revealed R2 had impaired cognition and thought processes. R2's care plan revealed she required assistance of one staff with ambulation with a walker, transfers and locomotion with a wheelchair. R2's care plan revealed she would self transfer, was at a high risk for falls and required staff to anticipate her needs and maintain R2's safety. R2's NA care guide printed 6/18/18, revealed R2 was at high risk for falls, self transferred and required assistance with transfers, ambulation and locomotion. R3's quarterly MDS dated [DATE], identified R3 had severe cognitive impairment and had [DIAGNOSES REDACTED]. The MDS identified R3 had verbal behaviors, and identified R3 had required extensive assistance with transfers, walking and locomotion, and used a walker and a wheelchair for mobility devices. R3's annual CAA dated 11/24/17, identified R3 had disorganized thinking, inattention and cognitive loss. The CAA identified R3 had impaired memory, was impulsive and was at risk for falls. R3's care plan revised 5/29/18, revealed R3 had impaired cognition and communication related to [DIAGNOSES REDACTED] and [MEDICAL CONDITION]. R3's care plan revealed he required assistance with transfers, ambulation with a walker and locomotion with a wheelchair. The care plan revealed R3 was able to propel himself in a wheelchair with his feet around the household. R3's care plan revealed he was at high risk for falls and had various interventions in place, including bed and chair alarms, not to be left unattended in his room when restless or anxious, directed staff to use recliner in the day room, fall mat and staff notification when family leaves the household. Further, R3's care plan directed facility staff to maintain his safety. R3's NA care guide printed 6/18/18, revealed R3 was at high risk for falls, listed the aforementioned fall interventions and required assistance with transfers, ambulation with a walker and locomotion with a wheelchair. The care guide revealed R3 was able to propel himself in a wheelchair with his feet around the household. R4's quarterly MDS dated [DATE], identified R4 had moderate cognitive impairment and had [DIAGNOSES REDACTED]. The MDS identified R4 had required extensive assistance with bed mobility, transfers and locomotion during the assessment period. The MDS identified R4 had received assistance with ambulation on two occasions during the assessment. R4's annual CAA dated 10/13/17, identified R4 had memory impairment, needed cues, reminders and supervision daily. The CAA identified R4 had highly impaired vision, was hard of hearing, had impaired cognition and required assistance with ADL's of bed mobility, ambulation, transfers and locomotion. The CAA further revealed R4's confusion would worsen when she was fatigued. R4's CAA lacked indication of R4's safety awareness and judgement. R4's care plan revised 4/11/18, revealed R4 had impaired thought processes, impaired vision and hearing and required staff assistance with transfers, bed mobility, ambulation with a walker, locomotion with a wheelchair. R4's care plan revealed staff were to maintain her safety. R4's NA care guide printed 6/18/18, revealed R4's required assistance with transfers, ambulation and locomotion. On 6/18/18, at 10:20 a.m. HM-C stated she would never leave the kitchen area during a meal service, or when a cooking surface was hot. She stated if she had to leave she would shut the stove off, chain off the entrances of the kitchen with the two plastic yellow chains and she would let a staff member know she was leaving. On 6/18/18, at 10:23 a.m. HM-D stated she used the kitchenette stove daily when preparing residents breakfast meals. She stated the stove had a locking mechanism which was to be locked with a key when the stove was not in use. HM-D stated she would never leave the stovetop burner on, unattended and indicated when staff were not present in the kitchen a plastic yellow chain would be applied across both entrances to the kitchen to detour wandering residents. On 6/18/18, at 10:28 a.m. HM-E stated her usual process when leaving the kitchen area of a neighborhood was to shut off the stove, lock the stove with the key to ensure residents could not turn the stove back on. She stated she would also apply the yellow chains across both entrances to the kitchen area. On 6/18/18, at 10:34 a.m. HM-F stated her usual process when preparing resident meals would be to remain in the near the cooking surfaces and indicated she would not leave the stove unattended. She stated if she needed an item outside of the neighborhood, she would ask another staff member to get it for her or she would have another staff member supervise the kitchen area while she obtained the item. Further, she stated if no staff were available, she would shut off the stovetop, lock the stove with a key and place the yellow plastic chains across both entrances to the kitchen to detour residents from entering. On 6/18/18, at 10:40 a.m. nursing assistant (NA)-A stated she felt most of the residents on the Deerwood unit were cognitively impaired and she felt no residents currently wandered off of the unit. She stated most of the cognitively impaired residents needed staff assistance with mobility, however, she indicated a few residents were able to freely move around the unit, such as R4, when she was in a wheelchair and R1 when he utilized a walker. NA-A stated she was unaware of any resident entering the kitchen area or attempting to enter the kitchen area in her memory. She indicated when the kitchen was not in use, plastic yellow chains were to be affixed across the entrances of the kitchen to detour residents from entering. Further, NA-A stated she had not been asked to supervise the kitchen area prior to interview and was unaware the stove had been left on without staff supervision. On 6/18/18, at 11:25 a.m. during a follow up interview, the Deerwood residents care guides were reviewed with NM-[NAME] NM-A confirmed nine residents had [DIAGNOSES REDACTED]. NM-A confirmed the following: R1 had a [DIAGNOSES REDACTED]. R2 had a [DIAGNOSES REDACTED]. R3 had a [DIAGNOSES REDACTED]. R4 had daily periods of confusion and was able independently move about the unit once she was in a wheelchair. On 6/18/18, at 11:55 a.m. registered dietician (RD)-A stated she expected stove surfaces to be off when the HM was not present. RD-A confirmed staff were expected to be present when the stove was in use in order to supervise residents. She stated dietary and HM staff had received orientation upon hire and annually on safe practices in neighborhood kitchens. RD-A stated if the HM assigned to the neighborhood needed to leave the stove or kitchen for any reason, the stove should be shut off and another staff member should supervise the area until the HM returned. Further, she indicated she would expect the yellow chains to be applied across both entrances to the kitchen to prevent residents from entering and indicated she would not necessarily expect staff to lock the stoves with the key if they were going to return. On 6/18/18, at 12:06 p.m. the facility administrator stated he expected the neighborhood stove tops to be shut off when staff were not present in order to ensure residents were safe. The administrator stated if a staff member needed to leave the kitchen area during meal service, then another staff member needed to be informed in order to monitor the kitchen area. Further, the administrator confirmed some of the residents on the Deerwood unit were cognitively impaired. On 6/18/18, at 2:48 p.m. during a group interview with the facility administrator and vice president, both confirmed they expected the kitchenette stove top to be shut off when staff were not present. The administrator and vice president confirmed multiple residents which resided on the Deerwood unit were cognitively impaired and required staff supervision. They both confirmed the hot burner left on and unattended was a significant safety concern and indicated they did not feel it was a continued immediate safety risk once the stove was turned off. Further, the administrator and vice president indicated they felt the issue was resolved when the HM shut the stove top off and indicated they did not feel residents on the unit would wander into the kitchen area. The IJ that began on 6/18/18, was removed on 6/19/18, at 1:09 p.m. when the facility completed the following: -policy and procedure for Safe Practives in the Household Kitchen was updated to reflect resident safety. -education was provided to staff on the updated policy and procedure and safety measures used in the neighborhood units to ensure resident safety. -auditing is in place for monitoring safe use of cooking services and resident safety. A facility policy titled, Safe Practices in the Household Kitchen, approved 1/2011, identified it was the facility's policy to have homemakers and team members who prepare food in the kitchen would follow safety precautions to protect staff and residents. The policy listed various procedures staff were to implement to ensure resident safety which included, to turn off all appliances when not in use, when leaving kitchen disconnect stovetop and unplug small appliances. Further the policy directed staff when a steam table was in use, the kitchen should not be unattended.

Based on observation, interview and document review, the facility failed to ensure adequate supervision and accident prevention by facility staff when a stove top was left on and unattended for 4 of 21 residents (R1, R2, R3 and R4) who had severe cognitive impairment and were independent in mobility on the Deerwood unit and at risk for burn from the hot stove top. The deficient practice had the potential to affect all the cognitively impaired residents who were independent with mobility. This resulted in an immediate jeopardy (IJ) situation for R1, R2, R3, and R4. Findings include: The IJ began on 6/18/18, at 9:25 a.m. when upon entrance on the Deerwood neighborhoods kitchen, the stove top front right burner was observed to be turned on and left unattended posing a risk for serious injury for a burn. On 6/18/18, at 1:32 p.m. the facility administrator and the dietician were notified of the IJ for the identified residents at risk for possible injury R1, R2, R3,and R4. The IJ was removed on 6/19/18, at 1:09 p.m., however, non-compliance remained at a isolated score and severity which indicated no actual harm with potential for more than minimal harm (Level D.) On 6/18/18, at 9:25 a.m. upon entrance to the Deerwood unit kitchen, a flat top stove and oven and four burners (a large burner in the front on the right and in the back on the left, two small burners, one on the left front and one in the back on the left) was present on the back wall of the kitchen adjacent to a steam table on the left side and a counter top on the right side. At that time the stove top right front burner was observed to be on as indicated by a red light on the right side of the stove top. The kitchen had two entrances, on either side of the kitchen area, yellow plastic chains were observed to be hanging from the walls on on both sides of the entrances, neither chain was across the entrances to the kitchen. No staff were present in the area, continuous observations began at that time. Residents were observed seated in wheelchairs in the dining room seated at the tables, the hallway of the unit and in the activity area behind the dining room. -At 9:28 a.m. the kitchen stove top, right front burner remained on, with no staff observed in the kitchen or dining area of the Deerwood neighborhood. The surveyor placed a hand over the right front burner, approximately 4 inches from the surface and heat could be felt radiating from the stove top. At that time R6 was observed seated in a wheelchair in the dining room, she wheeled herself towards the unchained kitchen entrance and stated she had been waiting for her breakfast. R6 propelled herself back to a table in front of the counter of the kitchen area. Residents were observed seated in wheelchairs in the dining room seated at the tables, the hallway of the unit and in the activity area behind the dining room. -At 9:31 a m. the stove top burner remained on, with no staff observed in the kitchen or dining are of the Deerwood unit, and R6 remained seated in her wheelchair at the dining room table. Residents remained in various areas of the unit, including the dining room, seating area near adjacent to the kitchen and in the hallways. -At 9:35 a.m. a staff member entered the kitchen from the hall adjacent to the outside of the neighborhood and held an english muffin in his gloved hand. He stated he was the homemaker (HM)-A for the Deerwood neighborhood, had left the Deerwood neighborhood and walked to the Cherrywood neighborhood for an english muffin. HM-A confirmed the front right burner of the stove was left on unattended and stated he thought he had only been gone a few seconds. He immediately shut the burner off and confirmed the burner was hot. HM-A stated he did not usually work on the Deerwood unit and was not aware of how many english muffins were needed, and had run out. He stated he usually would not leave the stove top on unattended and indicated he should have applied the yellow chains across both entrances to the kitchen area before leaving the kitchen. On 6/18/18, from 9:25 a.m. to 9:35 a.m. the front right burner of the Deerwood neighborhoods stove top was observed to be on, unattended and hot for a total of ten minutes unsupervised by staff. No staff were observed to walk out or in the neighborhood during the entire ten minute duration. The hot stove top would have been accessible to residents on the unit posing a safety hazard, including cognitively impaired residents. On 6/18/18, at 9:58 a.m. a tour of the Deerwood unit was conducted, one resident, R7 was observed lying in bed. No other residents were observed to be lying in bed. Residents were observed seated in wheelchairs in their rooms, seated in recliners in the common area and in the dining room seated at the tables. observed in various areas of the unit, seated in recliners in the seating area adjacent to the kitchen. On 6/18/18, at 10:00 a.m. during a follow up interview, HM-A stated he did not usually work on the Deerwood unit and stated he had not aware of any residents attempting to enter the kitchen. He indicated he thought several residents had dementia and were cognitively impaired and indicated he was unaware of any residents that wandered. On 6/18/18, at 10:07 a.m. licensed practical nurse (LPN)-A indicated she was the nurse on the Deerwood unit at that time. LPN-A stated most of the residents on the unit had [DIAGNOSES REDACTED]. LPN-A stated she been unaware the HM had left the stovetop on and unattended. She stated she had not been asked to supervise the kitchen area prior to the interview. On 6/18/18, at 10:10 a.m. HM-B stated her usual practice would be to not leave the kitchen area during a meal service. She stated if she had to leave, she would shut the stove off, chain off the entrances of the kitchen with the two plastic yellow chains and she would let a staff member know she was leaving the area. HM-B indicated she would never leave a burner on and walk away. On 6/18/18, at 10:15 a.m. registered nurse manager (NM)-A for the Deerwood unit stated the current census on the unit was 21. NM-A stated two residents on the Deerwood unit wore wanderguards on their persons, due to a history of wandering. A list of residents which resided on the Deerwood unit was requested with the following information: resident name, cognition, mobility status and history of wandering. At that time, NM-A stated the stove top should never be left unattended when it was on. NM-A confirmed it was a safety concern for residents. Review of R1's Significant Change of Status Assessment (SCSA) Minimum Data Set ((MDS) dated [DATE], identified R1 had severe cognitive impairment and had [DIAGNOSES REDACTED]. The MDS identified R1 did not use a mobility device and indicated staff had supervised R1 during ambulation and locomotion during the assessment period. R1's SCSA Care Area assessment dated [DATE], identified R1 had cognitive impairment with periods of inattention, was hard of hearing and was able to stabilize himself during transition from a sitting to standing position. R1's CAAs lacked indication of R1's safety awareness and judgement. R1's current care plan revised 5/31/18, revealed R1 had impaired cognition and decision making, was independent with transfers and ambulation without an assistive device. The care plan revealed R1 was at high risk for wandering as he had left the unit and had a wanderguard on his left ankle. Further, R1's care plan revealed he was dependent on staff to maintain his safety. R1's nursing assistant (NA) care guide printed on 6/18/18, revealed R1 was at high risk for wandering, had a wanderguard on his left ankle and was independent with transfers and ambulation. R2's SCSA MDS dated [DATE], identified R2 had severe cognitive impairment and had [DIAGNOSES REDACTED]. The MDS identified R2 had required extensive assistance with activities of daily living (ADL's) in areas of transfers, locomotion and limited assistance with ambulation. The MDS identified R2 had used a wheelchair and a walker. R2's SCSA CAA dated 5/3/18, identified R2 had disorganized thinking and had cognitive impairment. The CAA revealed R2 received extensive assistance with ADL's including transfers, locomotion and required limited assistance with ambulation. Further, the CAA identified R2 was at risk for falls due to impaired cognition. R2's CAAs lacked indication of R2's safety awareness and judgement. R2's current care plan revised 5/3/18, revealed R2 had impaired cognition and thought processes. R2's care plan revealed she required assistance of one staff with ambulation with a walker, transfers and locomotion with a wheelchair. R2's care plan revealed she would self transfer, was at a high risk for falls and required staff to anticipate her needs and maintain R2's safety. R2's NA care guide printed 6/18/18, revealed R2 was at high risk for falls, self transferred and required assistance with transfers, ambulation and locomotion. R3's quarterly MDS dated [DATE], identified R3 had severe cognitive impairment and had [DIAGNOSES REDACTED]. The MDS identified R3 had verbal behaviors, and identified R3 had required extensive assistance with transfers, walking and locomotion, and used a walker and a wheelchair for mobility devices. R3's annual CAA dated 11/24/17, identified R3 had disorganized thinking, inattention and cognitive loss. The CAA identified R3 had impaired memory, was impulsive and was at risk for falls. R3's care plan revised 5/29/18, revealed R3 had impaired cognition and communication related to [DIAGNOSES REDACTED] and [MEDICAL CONDITION]. R3's care plan revealed he required assistance with transfers, ambulation with a walker and locomotion with a wheelchair. The care plan revealed R3 was able to propel himself in a wheelchair with his feet around the household. R3's care plan revealed he was at high risk for falls and had various interventions in place, including bed and chair alarms, not to be left unattended in his room when restless or anxious, directed staff to use recliner in the day room, fall mat and staff notification when family leaves the household. Further, R3's care plan directed facility staff to maintain his safety. R3's NA care guide printed 6/18/18, revealed R3 was at high risk for falls, listed the aforementioned fall interventions and required assistance with transfers, ambulation with a walker and locomotion with a wheelchair. The care guide revealed R3 was able to propel himself in a wheelchair with his feet around the household. R4's quarterly MDS dated [DATE], identified R4 had moderate cognitive impairment and had [DIAGNOSES REDACTED]. The MDS identified R4 had required extensive assistance with bed mobility, transfers and locomotion during the assessment period. The MDS identified R4 had received assistance with ambulation on two occasions during the assessment. R4's annual CAA dated 10/13/17, identified R4 had memory impairment, needed cues, reminders and supervision daily. The CAA identified R4 had highly impaired vision, was hard of hearing, had impaired cognition and required assistance with ADL's of bed mobility, ambulation, transfers and locomotion. The CAA further revealed R4's confusion would worsen when she was fatigued. R4's CAA lacked indication of R4's safety awareness and judgement. R4's care plan revised 4/11/18, revealed R4 had impaired thought processes, impaired vision and hearing and required staff assistance with transfers, bed mobility, ambulation with a walker, locomotion with a wheelchair. R4's care plan revealed staff were to maintain her safety. R4's NA care guide printed 6/18/18, revealed R4's required assistance with transfers, ambulation and locomotion. On 6/18/18, at 10:20 a.m. HM-C stated she would never leave the kitchen area during a meal service, or when a cooking surface was hot. She stated if she had to leave she would shut the stove off, chain off the entrances of the kitchen with the two plastic yellow chains and she would let a staff member know she was leaving. On 6/18/18, at 10:23 a.m. HM-D stated she used the kitchenette stove daily when preparing residents breakfast meals. She stated the stove had a locking mechanism which was to be locked with a key when the stove was not in use. HM-D stated she would never leave the stovetop burner on, unattended and indicated when staff were not present in the kitchen a plastic yellow chain would be applied across both entrances to the kitchen to detour wandering residents. On 6/18/18, at 10:28 a.m. HM-E stated her usual process when leaving the kitchen area of a neighborhood was to shut off the stove, lock the stove with the key to ensure residents could not turn the stove back on. She stated she would also apply the yellow chains across both entrances to the kitchen area. On 6/18/18, at 10:34 a.m. HM-F stated her usual process when preparing resident meals would be to remain in the near the cooking surfaces and indicated she would not leave the stove unattended. She stated if she needed an item outside of the neighborhood, she would ask another staff member to get it for her or she would have another staff member supervise the kitchen area while she obtained the item. Further, she stated if no staff were available, she would shut off the stovetop, lock the stove with a key and place the yellow plastic chains across both entrances to the kitchen to detour residents from entering. On 6/18/18, at 10:40 a.m. nursing assistant (NA)-A stated she felt most of the residents on the Deerwood unit were cognitively impaired and she felt no residents currently wandered off of the unit. She stated most of the cognitively impaired residents needed staff assistance with mobility, however, she indicated a few residents were able to freely move around the unit, such as R4, when she was in a wheelchair and R1 when he utilized a walker. NA-A stated she was unaware of any resident entering the kitchen area or attempting to enter the kitchen area in her memory. She indicated when the kitchen was not in use, plastic yellow chains were to be affixed across the entrances of the kitchen to detour residents from entering. Further, NA-A stated she had not been asked to supervise the kitchen area prior to interview and was unaware the stove had been left on without staff supervision. On 6/18/18, at 11:25 a.m. during a follow up interview, the Deerwood residents care guides were reviewed with NM-A. NM-A confirmed nine residents had [DIAGNOSES REDACTED]. NM-A confirmed the following: R1 had a [DIAGNOSES REDACTED]. R2 had a [DIAGNOSES REDACTED]. R3 had a [DIAGNOSES REDACTED]. R4 had daily periods of confusion and was able independently move about the unit once she was in a wheelchair. On 6/18/18, at 11:55 a.m. registered dietician (RD)-A stated she expected stove surfaces to be off when the HM was not present. RD-A confirmed staff were expected to be present when the stove was in use in order to supervise residents. She stated dietary and HM staff had received orientation upon hire and annually on safe practices in neighborhood kitchens. RD-A stated if the HM assigned to the neighborhood needed to leave the stove or kitchen for any reason, the stove should be shut off and another staff member should supervise the area until the HM returned. Further, she indicated she would expect the yellow chains to be applied across both entrances to the kitchen to prevent residents from entering and indicated she would not necessarily expect staff to lock the stoves with the key if they were going to return. On 6/18/18, at 12:06 p.m. the facility administrator stated he expected the neighborhood stove tops to be shut off when staff were not present in order to ensure residents were safe. The administrator stated if a staff member needed to leave the kitchen area during meal service, then another staff member needed to be informed in order to monitor the kitchen area. Further, the administrator confirmed some of the residents on the Deerwood unit were cognitively impaired. On 6/18/18, at 2:48 p.m. during a group interview with the facility administrator and vice president, both confirmed they expected the kitchenette stove top to be shut off when staff were not present. The administrator and vice president confirmed multiple residents which resided on the Deerwood unit were cognitively impaired and required staff supervision. They both confirmed the hot burner left on and unattended was a significant safety concern and indicated they did not feel it was a continued immediate safety risk once the stove was turned off. Further, the administrator and vice president indicated they felt the issue was resolved when the HM shut the stove top off and indicated they did not feel residents on the unit would wander into the kitchen area. The IJ that began on 6/18/18, was removed on 6/19/18, at 1:09 p.m. when the facility completed the following: -policy and procedure for Safe Practives in the Household Kitchen was updated to reflect resident safety. -education was provided to staff on the updated policy and procedure and safety measures used in the neighborhood units to ensure resident safety. -auditing is in place for monitoring safe use of cooking services and resident safety. A facility policy titled, Safe Practices in the Household Kitchen, approved 1/2011, identified it was the facility's policy to have homemakers and team members who prepare food in the kitchen would follow safety precautions to protect staff and residents. The policy listed various procedures staff were to implement to ensure resident safety which included, to turn off all appliances when not in use, when leaving kitchen disconnect stovetop and unplug small appliances. Further the policy directed staff when a steam table was in use, the kitchen should not be unattended.

Based on observation, interview and document review, the facility failed to comprehensively reassess, develop and implement interventions to promote healing, prevent the worsening of pressure ulcers for 1 of 3 residents (R96) reviewed for pressure ulcers. This deficient practice resulted in actual harm for R96 who developed worsening pressure ulcers. In addition,the facility failed to implement interventions to prevent the development of pressure ulcers for 1 of 5 residents (R99) identified at risk for the development of pressure ulcers. Findings include: Review of R96's admission Minimum Data Set ((MDS) dated [DATE], identified R96 had severe cognitive impairment and had [DIAGNOSES REDACTED]. The MDS identified R96 was totally dependent on staff for all activities of daily living (ADL's.) The MDS identified R96 had two stage 1 pressure ulcers (observable pressure related alteration of intact skin whose indicators compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: skin temp, tissue consistency, sensation, and or a defined area of persistent redness,) and two stage 2 pressure ulcers (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured blister,) which were present upon admission. The MDS further listed a pressure ulcer intervention of a pressure relieving device for the bed and chair for R96. The MDS did not include a turn and repositioning program for R96. Review of R96's pressure ulcer Care Area Assessment (CAA) dated 12/15/15, identified R96 had two stage 1 pressure ulcers to the buttocks, two stage 2 pressure ulcers, one on each heel and received treatments to the pressure ulcers. The CAA identified R96 was at risk for development of further pressure ulcers and required staff assistance with bed mobility. The CAA further identified R96 required staff assistance with repositioning every 2 hours and as needed (prn.) R96's clinical record lacked documentation of a comprehensive analysis of R96's skin status on admission. Review of R96's current care plan dated 12/8/15, identified R96 had an actual skin impairment to heels and buttocks. R96's care plan identified R96 required assistance of 2 staff to turn and reposition in bed. However, R96's care plan failed to identify a turn and repositioning schedule. R96's care plan listed various interventions of checking and changing every 2 hours, pressure reducing mattress, apply booties to both feet when in bed and to keep R96's skin clean and dry. On 1/27/16, at 4:30 p.m. registered nurse (RN)-B stated she felt R96's two stage 2 pressure ulcers had significantly worsened within the last week. RN-B stated she had set up an appointment for R96 to be seen at a wound clinic almost two weeks ago when R96's buttocks pressure ulcer had developed eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound,) tissue on the ulcer. RN-B indicated R96 was seen at the wound clinic on 1/21/16, and R96's buttocks ulcer had been debrided (removal of dead or devitalized tissue) at that time. RN-B confirmed R96 had been diagnosed with [REDACTED]. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling,) to the sacrum. RN-B stated R96 needed staff assistance with repositioning every 2 hours to aid in pressure relief of the sacrum. RN-B stated the only treatment to R96's bilateral heel pressure ulcers were to wear pressure relieving boots. On 1/28/16, during continuous observations from 7:59 a.m. to 10:58 a.m., R96 was observed lying in bed on her back without being offered, or assisted to, reposition during the entire observation. - At 7:59 a.m. R96 was observed lying in bed on her back, eyes closed, with a blanket covering up to her neck. R96's bilateral bottom of both feet were uncovered, and black padded boots were observed on both feet. - At 8:52 a.m. R96 remained lying in bed in the same position, on her back with a blanket covering up to her neck. No staff had been observed to enter R96's room. - At 9:10 a.m. R96 remained lying in bed in the same position, on her back with a blanket covering. - At 9:45 a.m. R96 remained lying in the same position, on her back, in bed with her eyes open and a blanket covering her. R96 was observed to make no changes in her position independently. No staff had been observed to enter R96's room. - At 10:17 a.m. R96 continued to lay in bed on her back, eyes open, a blanket covering up to her chin. Nursing assistant (NA)-A was observed walking down the hall outside of R96's room. NA-A looked at R96's room as she walked past, however, did not stop or enter R96's room. NA-A was not observed to offer R96 assistance. - At 10:19 a.m. the certified nurse practitioner (CNP) entered R96's room and approached R96's bed. The CNP briefly spoke with R96 and immediately exited the room. R96 remained in the same position, lying on her back in bed. - At 10:46 a.m. R96 remained lying in the same position, on her back, in bed, eyes open, a blanket was covering up to her chin. - At 10:58 a.m. R96 remained on her back in bed. NA-A and NA-E entered R96's room to provide assistance with personal cares. NA-E removed the blanket covering R96 and proceeded to pull down her slacks and checked the front of R96's brief. NA-A assisted to turn R96 onto her left side towards NA-E. NA-E assisted to hold R96 onto her left side while NA-A pulled the back of R96's slacks to expose the brief. NA-A proceeded to remove R96's brief and a moderate amount of brown drainage was on the brief. Upon removal of the brief, a 4 inch (in) by 8 in absorbent dressing was observed covering R96's sacral area. The dressing had a moderate amount of brown, pungent, foul smelling drainage which had seeped through R96's dressing and onto her brief. - At 11:01 a.m. licensed practical nurse (LPN)-A and RN-A entered R96's room. LPN-A removed the 4 in x 8 in absorbent dressing which covered R96's sacrum. A moderate amount of brown, pungent, foul smelling drainage was observed on the dressing. LPN-A proceeded to remove packing gauze from the inside of the pressure ulcer. The gauze was saturated with brown, pungent, foul smelling drainage. RN-A confirmed R96 had a current stage 4 pressure ulcer on the sacrum and confirmed the odor and drainage. RN-A stated he had not observed R96's stage 4 pressure ulcer since it had been debrided at the wound clinic. RN-A observed and confirmed R96's pressure ulcer which revealed measurements of 4 centimeters (cm) long x 3.5 cm wide x 2 cm deep. RN-A stated R96's pressure ulcer had tunneling present under the edges of the entire ulcer which measured 1.4 cm to 1.8 cm. He stated R96 had necrotic tissue of the surrounding skin on the left side extending out form the opening of the the ulcer. RN-A stated R96's stage 4 pressure ulcer had not been open at the time of the last assessment, nor was necrotic tissue noted at the that time. LPN-A proceeded to place fresh packing gauze into R96's sacral pressure ulcer with two gauze pads soaked with normal saline and covered R96's ulcer with an absorbent pad and taped the dressing in place. RN-A removed the pressure relieving black boots from R96's feet. R96's right heel was observed to have a flat, hard, blister which measured 1.5 cm x 1.6 cm with no depth. RN-A stated he felt R96 had a healing stage 2 pressure ulcer on her right heel. R96's left heel was observed to have hard, eschar tissue, surrounded in pink skin, which measured 2.5 cm x 3.0 cm, depth obscured by the eschar tissue. RN-A stated R96 had an unstagable (related to slough or eschar: wound bed cannot be visualized due to the presence of slough or eschar,) ulcer on her left heel. RN-A confirmed R96 left heel had a previous stage 2 pressure ulcer that had worsened to an unstagable ulcer. RN-A confirmed R96's current stage 4 sacral pressure ulcer had also worsened from a stage 1 to a stage 4 pressure ulcer. On 1/28/16, at 11:01 a.m. NA-E stated she had assisted R96 to get dressed that morning at 6:45 a.m. and confirmed she had not repositioned R96 since that time. NA-E stated R96 was unable to reposition herself and required staff assistance for repositioning every 2-3 hours. On 1/28/16, at 11:03 a.m. LPN- A stated she was aware R96 had black eschar on R96's sacrum on 1/24/16, and a slight odor was also present at that time. LPN-A stated she felt the previous treatment of [REDACTED]. ulcers. LPN-A stated she was unaware of what R96's care plan directed for repositioning, but felt R96 should be repositioned at least every 2 hours to relieve pressure on her sacrum. On 1/28/16, at 11:04 a.m. NA-A stated she had not repositioned R96 since the beginning of her shift (7:00 a.m.,) and was unsure of when R96 was last repositioned. NA-A stated she thought R96 should be repositioned every 2-3 hours. R96 had not been repositioned from 6:45 a.m. to 10:58 a.m. a total of 4 hours and 13 minutes. Review of R96's weekly wound assessments from 12/8/15, to 1/21/16, revealed the following; -On 12/8/15, identified R96 had been admitted with stage 1 pressure ulcers, one on each buttocks and stage 2 pressure ulcers described as fluid filled blisters, one on each heel. The assessment revealed R96's right buttocks pressure ulcer measured 2.0 cm x 6.0 cm x 0.0, the left buttocks pressure ulcer measured, 2.4 cm x 6.0 cm x 0.0, right heel pressure ulcer measured 1.5 x 1.5 cm x 0.0 and the left heel pressure ulcer measured 5.0 cm x 3.5 cm x 0.0 cm The assessment identified a current intervention of air mattress, cushion to chair and booties. The assessment did not identify R96 was on a turning and repositioning plan. -On 12/17/15, revealed R96 pressure ulcers were unchanged. The assessment identified R96 had a stage 2 pressure ulcer on the right heel, described as an intact blister with irregular, light brown edges and measured 1.5 cm x 1.6 cm x 0.0 cm. The assessment identified R96 had a stage 2 pressure ulcer on the left heel, described as an irregular, intact fluid filled blister and measured 5.0 cm x 4.0 cm x 0.0 cm. The assessment revealed R96's skin surrounding both heel ulcers was intact and normal The assessment did not identify R96 was on a turn and repositioning routine. -On 12/18/15, revealed R96's pressure ulcers were unchanged. The assessment identified R96's right heel stage 2 pressure ulcer was a fluid filled blister and measured 1.5 cm x 1.5 cm x 0.0 cm The assessment identified R96's left heel stage 2 pressure ulcer was a fluid filled blister and measured 5.0 cm x 3.5 cm 0.0 cm. The assessment identified R96's right buttocks stage 1 pressure ulcer measured 2.0 cm x 6.0 cm x 0.0 cm R96's left buttocks stage 1 pressure ulcer measured 2.4 cm by 6.0 cm x 0.0 cm. The assessment lacked surrounding skin characteristics and coloring. The assessment did not identify R96 was on a turn and repositioning routine. -On 12/23/15, identified R96's right heel stage 2 pressure ulcer was a fluid filled blister and measured 1.5 cm x 1.5 cm x 0.0 cm The assessment identified R96's left heel stage 2 pressure ulcer was a fluid filled blister and measured 5.0 cm x 3.5 cm 0.0 cm. The assessment identified R96's right buttocks stage 1 pressure ulcer measured 2.0 cm x 6.0 cm x 0.0 cm R96's left buttocks stage 1 pressure ulcer measured 2.4 cm by 6.0 cm x 0.0 cm. The assessment revealed R96's pressure ulcers had no drainage, no odor and areas were improving;. The assessment did not identify R96 was on a turn and repositioning routine. -On 1/5/16, identified R96's buttocks pressure ulcers had worsened from a stage 1 to stage 2. The assessment identified R96's right buttocks pressure ulcer was a stage 2, measured 2.0 cm x 4.0 cm x 0.0 cm. R96's left buttocks pressure ulcer was a stage 2, measured 2.4 cm x 3.0 cm x 0.0 cm. The assessment revealed R96's stage 2 heel ulcers were fluid filled blisters and measured; right heel 1.5 cm x 1.5 cm x 0.0 cm, left heel measured 5.0 cm x 3.5 cm x 0.0 cm. The assessment indicated the pressure ulcers were healing. (The assessment indicated the pressure ulcers were healing, however, the progress notes indicated R96's pressure ulcers were worsening. )The assessment also revealed R96 had interventions in place of an air mattress and booties in bed. The assessment did not identify R96 was on a turn and repositioning routine. -On 1/14/16, identified R96's right buttocks stage 2 pressure ulcer measured 2.0 cm x 3.5 cm x 0.0 cm, left buttocks stage 2 pressure ulcer measured 2.4 cm x 3.0 cm x 0.0 cm. The assessment identified R96's right heel stage 2 pressure ulcer was a fluid filled blister and measured 1.5 cm x 1.5 cm x 0.0 cm. R96's left heel stage 2 pressure ulcer was a fluid filled blister and measured 5.0 cm x 3.5 cm x 0.0 cm. The assessment indicated R96's pressure ulcers were improving and revealed interventions had been in place that included air mattress, off loading boots on when in bed and udder balm to areas on bottom. The assessment listed a referral to a wound clinic would be done if no improvement in 2 weeks. The assessment did not identify R96 was on a turn and repositioning routine. -On 1/21/16, identified R96's right buttocks stage 2 pressure ulcer measured 2.0 cm x 3.5 cm x 0.0 cm, left buttocks stage 2 pressure ulcer measured 2.4 cm x 3.0 cm x 0.0 cm. The assessment identified R96's right heel stage 2 pressure ulcer was a fluid filled blister and measured 1.5 cm x 1.5 cm x 0.0 cm. R96's left heel stage 2 pressure ulcer was a fluid filled blister and measured 5.0 cm x 3.5 cm x 0.0 cm. The assessment revealed a referral was made to the wound clinic. The assessment did not identify tissue type, surrounding skin and did not reflect the presence of the eschar tissue. Review of R96's nursing progress notes from 12/8/15, to 1/25/16, revealed the following; -On 12/8/15, identified R96 had an air mattress and heel protectors in place for identified skin issues. -On 12/10/15, revealed staff had noted some skin breakdown on R96's left butt cheek proximal to the coccyx area and a cream was applied. The progress note also revealed redness on R96's right heel and a heel protector was in place. -On 12/11/15, revealed R96 continued to have skin breakdown on the left butt cheek proximal to the coccyx, cream was applied. The progress note also revealed redness on R96's heel, a heel protector was in place. -On 12/15/15, revealed R96 continued to have blisters on both heels. The note indicated R96 had booties on both feet and an air mattress. -On 12/22/15, revealed R96's pressure ulcers on the buttocks were open with dark pink surrounding skin with scant amount of bleeding. The note revealed an Allevyn dressing was applied to R96's coccyx ulcer which measured 2 cm x 1.7 cm. The note indicated the unit coordinator was informed and treatment was set up to monitor R96's ulcer and to change the dressing every 3 days and as needed. A further note revealed R96 was to wear pillow boots at all times. -On 1/4/16, revealed R96's dressing was changed to the open areas on the coccyx and noted serous drainage on the old dressing. -On 1/5/16, revealed R96's dressing was changed to the open areas on the coccyx with serous drainage on the old dressing. The note identified R96's ulcer to the inner coccyx area and right buttocks was dark, had a foul odor and the surrounding skin was dark pink and moist. -On 1/7/16, identified R96 was seen by the physician with a new order to apply Udder Balm to the coccyx wound as needed and to refer to a wound clinic in 1-2 weeks. -On 1/17/16, identified R96's coccyx pressure ulcer had black necrotic (eschar) tissue which covered the wound which measured 1.0 cm x 1.5 cm and surrounding skin was pinkish to red in color. The note further indicated other wounds on R96's buttocks had healed except for the coccyx ulcer. The note revealed R96 had a referral on 1/7/16, for the wound clinic in 1-2 weeks if the wound did not improve with Udder Balm cream. A note was placed in a physicians communication book. The note did not indicate if a referral had been made. R96's clinical record lacked a comprehensive skin reassessment when R96's pressure ulcers worsened. -On 1/20/16, identified R96's coccyx pressure ulcer was not healing and an appointment had been made with the would clinic. -On 1/23/16, identified R96's coccyx pressure ulcer had a scant amount of bloody drainage, wound bed was dark black in color and the surrounding skin was firm with redness and swelling. The note revealed R96 exhibited pain with the dressing change. -On 1/25/16, revealed R96 had returned from the wound clinic with a diagnosed stage 4 sacral pressure ulcer. The note revealed R96 was to receive the following treatment to the sacral pressure ulcer; start saline moistened 4 x 4's into wound, change every eight hours, wet to dry and cover with gauze. R96 was to have a ROHO type wheelchair pad, mattress pad and to continue to wear heel boots at all times. The note further revealed R96 had another appointment with the wound clinic for further care. Review of R96's Braden ( a tool used to identify risk for skin breakdown/pressure ulcers) scale assessments dated 12/9/15, 12/15/15, 12/22/15 and 12/29/15, identified R96 was at moderate risk for skin breakdown. Review of R96's tissue tolerance test (TTT-tool used to determine skin's ability to withstand pressure and determine appropriate turning and repositioning schedules) dated 12/8/15, identified R96's skin was normal on the buttocks after 2 hours of lying. The TTT while sitting entry was dated 12/12/15, identified R96 had no redness on the buttocks at 2 hours. The TTT revealed a third entry dated 12/25/15, identified R96's skin was normal on the buttocks after 2 hours of lying. A fourth entry undated, identified R96's skin was pink/red after lying for 3 hours. The TTT did not identify an analysis of R96's TTT results and did not identify R96's repositioning needs. The form also indicated R96's care plan had not been updated to include a routine repositioning schedule. Review of R96's physician correspondences from 12/18/15 to 1/20/16 revealed the following; -A resident fax condition report to physician dated 12/18/15, revealed R96's physician had been notified of stage 2 pressure ulcers on both heels. The fax lacked notification of R96's buttocks pressure ulcers. -A podiatry clinic referral dated 12/22/15, identified R 96 had decubitus ulcers of the heels with the left ulcer greater then right ulcer, the left ulcer measured 3.5 cm x 4.0 cm and the right ulcer measured 1.6 cm x 1.9 cm. The note indicted R96 was to wear pressure relieving boots at all times. -A physician progress notes [REDACTED]. The note revealed R96's heels were improving and R96's coccyx was worsening. The note revealed R96's coccyx ulcer was to be treated with Udder Balm cream as needed and a referral for the wound clinic in 1-2 weeks if no improvement with the udder balm. -A wound physician progress notes [REDACTED]. The progress note further revealed R96's sacral pressure ulcer measured 4.0 cm x 4.0 cm x 2.0 cm and had a moderate amount of odorous, green drainage. The progress note revealed R96 was to receive wet to dry dressing changes every 8 hours and R96 was to return in one week for further debridement. On 1/28/16, at 11:24 a.m. RN-A verified R96's sacral pressure ulcer had worsened since R96's admission. RN-A identified R96's stage 1 pressure ulcer on the sacrum had worsened to a stage 4 pressure ulcer and R96's stage 2 pressure ulcer on the left heel had worsened to unstagable pressure ulcer. RN-A stated the floor nurses who completed the daily treatment for [REDACTED]. RN-A confirmed he had completed weekly wound assessments on R96's pressure ulcers since admission. RN-A confirmed the last wound assessment he had completed for R96 was on 1/21/16. RN-A indicated he had observed R96's pressure ulcers at the time of the weekly assessments. RN-A confirmed R96's care plan did not include a repositioning plan for R96 and confirmed R96 was not on a current repositioning schedule. RN-A stated R96 was unable to independently reposition herself and indicated he usually waited for staff nurses to complete a TTT, then he would determine the repositioning program/schedule. RN-A stated he had just received the results of R96's TTT results that day. RN-A stated the results of the TTT had indicated R96 required assistance with repositioning every 2 hours. RN-A confirmed no new pressure relieving interventions had been put into place for R96 since the pressure ulcers had worsened. RN-A listed various tasks he was responsible for which included, admissions(30 admissions in the last year), assessments and care planning. RN-A did not provide an explanation for the discrepancies of R96's pressure ulcers found in R96's weekly wound assessments and R96's progress notes. On 1/28/16, at 11:36 a.m. the director of nursing (DON) stated she felt it was unacceptable for R96 to lay on her back for over 3 hours with a stage 4 sacral pressure ulcer. The DON stated she expected staff to implement new interventions when R96's pressure ulcers had worsened. The DON confirmed she was aware R96's sacral pressure ulcer had worsened from a stage 1 to a stage 4 and stated she was unaware R96 did not have a repositioning schedule in place. The DON stated she expected R96's pressure ulcers to have been reassessed when they worsened and that the nurse manager should be notified of any and all changes with R96's pressure ulcers. On 1/28/16, at 2:01 p.m. a phone interview was conducted with R96's wound physician (MD.) The MD stated he had last evaluated R96 on 1/25/16, when she had presented at the clinic with a sacral unstagable pressure ulcer. The MD stated R96's stage 4 sacral pressure ulcer had liquefaction necrosis (the soft tissue surrounding R96's sacral bone had liquefied,) underneath a rib of eschar tissue which had covered the pressure ulcer. The MD stated he had opened and debrided the ulcer. The MD stated he felt R96's would have opened sooner or later due to the liquefaction of the soft tissue. The MD stated R96's pressure ulcer depth was down to the sacral bone, required future debridment's and routine wet to dry packing's. The MD stated R96's sacral ulcer was caused by pressure which caused the soft tissue around the sacrum to liquefy. The MD also stated with continued unrelieved pressure, R96's sacrum soft tissue would continue to liquefy. The MD stated he felt R96 should be routinely repositioned to prevent pressure on her sacrum. Review of facility policy titled, Pressure Ulcer treatment revised 2/2014, revealed a purpose of the procedure was to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers. The policy directed staff to review the residents care plan to assess for any special needs. The policy revealed the pressure ulcers treatment program included, assessing resident and current status of pressure ulcers, current support surfaces, education and quality improvement. The policy revealed a definitions and descriptions of the types of pressure ulcers including, stage 1, stage 2, stage 4 and unstagable. The policy revealed a protocol for individual pressure ulcer stages. The policy directed staff to implement the following interventions for stage 1 pressure ulcers, relieve and redistribute pressure, turn schedule, reduction of friction, shear and incontinence. The policy directs facility staff to notify the physician of a wound did not improve in 2-3 weeks, to re-evaluate nutritional support, off-loading/redistribution devices and wound care products. Review of a facility policy titled, Pressure ulcers/skin breakdown revised 2/2014, directed facility nursing staff to complete a thorough assessment which was to include; the location, stage, length, width and depth, presence of exudates or necrotic tissue, pain presence, residents mobility status, current treatment and interventions and active diagnoses. Review of a facility policy titled, Repositioning revised 5/2013, revealed a purpose of the procedure was to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort, prevent skin breakdown, promote circulation and provide pressure relief. The policy revealed repositioning was critical for residents who were immobile or dependent on staff for repositioning. The policy directed staff to evaluate residents skin condition, develop and implement repositioning plans for residents at risk for breakdown, who were immobile and residents with pressure ulcers. The policy directed facility staff to avoid positioning of a resident on an existing pressure ulcer as additional pressure may impede healing. The policy directed staff to reposition residents who were in bed should be on at least every 2 hour repositioning schedule. The policy directed staff to document, monitor and evaluate resident repositioning plans. R99 who was identified at risk for pressure ulcers did not receive timely repositioning. R99's significant change MDS dated [DATE], indicated R99 had [DIAGNOSES REDACTED]. The MDS identified R99 was severely cognitively impaired and required extensive assistance of two staff for transfers, bed mobility, toilet use, limited assistance of one staff for ambulation and extensive assist of one staff for dressing, personal hygiene. The MDS identified R99 was at risk for the development of pressure ulcers and listed various treatments which included pressure reducing device on bed and on chair. Further, the MDS indicated R99 was frequently incontinent of bowel and bladder. R99's CAA dated 11/20/15, indicated R99 needed extensive assistance with bed mobility and Braden Score indicated R99 was at risk for development of pressure ulcers. The CAA also indicated R99 needed extensive assistance with toileting and was frequently incontinent of bowel/bladder, and was offered toileting every two hours and as needed. R99's Braden Scale for Predicting Pressure Sore Risk form, dated 11/19/15, identified R99 was at risk for the development of pressure ulcers, skin was very moist, spent majority of shift in bed or chair, had a problem of friction and shearing and nutrition was probably inadequate. R99's current care plan dated 7/2/15, identified R99 had impairment to skin integrity related to cyst to buttocks, occasional incontinence, falls and refusal of cares. The care plan directed staff to keep skin clean and dry. The care plan listed various interventions which included to clean peri area with each incontinent episode and R99 was able to tolerate repositioning every two hours with no alterations in skin. Review of R99's current nursing assistant care plan, provided by the facility, directed staff to monitor, document and report any changes in skin breakdown, assist with one staff to turn and reposition in bed, to use disposable briefs, change as needed, clean peri area after each incontinent episode. During observation on 1/27/16 at 1:17 p.m. R99 was observed seated in a red tilt and space wheelchair at the dining room table, when nursing assistant (NA)-H and NA-J wheeled R99 back to his room and proceeded to assist R99 from the wheelchair to his bed via total mechanical lift. NA-H checked R99 to see if he was incontinent of bowel and bladder and NA-H stated he was dry. NA-H asked R99 how he would like to lay and he did not respond to her. NA-H and NA-J proceeded by positioning R99 on his back laying on a white cloth pad underneath him, then placed a pillow on his upper right side of his body and upper left side, head of bed slightly elevated approximately 30 degrees, bed in low position, call light placed, bed alarm functioning, covered with a blanket which came up to his mid chest area, and video monitor in place, at 1:23 p.m. NA-H and NA-J exited the room. At 1:52 p.m. NA-H and NA-J entered R99 room due to call light going off, NA-H turned call light off and NA-H stated bed alarm was going off, we adjusted the bed alarm then exited the room, R99 continued to lay on his back, with a pillow positioned on his upper right side of his body and upper left side, head of bed slightly elevated approximately 30 degrees, bed in low position, call light placed, bed alarm functioning, covered with a blanket which came up to his mid chest area. NA-H and NA-J did not offer to reposition or assist with toileting for R99. At 2:33 p.m. licensed practical nurse (LPN)-C and another staff member entered R99's room and proceeded to count the narcotics in R99's medication drawer and left the room at 2:34 p.m. R99 continued to lay in the same position on his back, with a pillow positioned on his upper right side of his body and upper left side, head of bed slightly elevated approximately 30 degrees, bed in low position, call light placed, bed alarm functioning, covered with a blanket which came up to his mid chest area. LPN-C and other staff member did not offer to reposition or assist with toileting for R99. At 3:03 p.m. R99's call light was going off, NA-K entered the room and noted R99's elbow rested on the call light pad. NA-K shut call light off and repositioned the call light. R99 continued to lay on his back, with a pillow positioned on his upper right side of his body and upper left side, head of bed slightly elevated approximately 30 degrees, bed in low position, call light placed, bed alarm functioning, covered with a blanket which came up to his mid chest area. NA-K exited the room, and did not offer to reposition or assist with toileting for R99. At 4:14 p.m. R99 had his right leg slightly hanging off the edge of the bed and continued to lay on his back, with a pillow positioned on his upper right side of his body and upper left side, head of bed slightly elevated approximately 30 degrees, bed in low position, call light placed, bed alarm functioning, covered with a blanket which came up to his mid chest area. LPN-C entered R99's room and stated he is on the move. NA-K and NA-I also entered R99's room while LPN-C was asking R99 if he was having any pain and he stated yes on my butt. LPN-C then asked R99 his level of pain by saying is it crying pain, R99 responded by saying yes. NA-K and NA-I applied disposable gloves to both hands, removed R99's blanket, then the pillows from the right and left side of his upper body, then pulled his pants down to his knees. NA-K and NA-I indicated R99's incontinent product was wet with urine and soiled with stool and proceeded to change his incontinent product. At 4:18 p.m. NA-K provided peri cares to R99's scrotal area which was bright red and shiny in color. At 4:20 p.m. NA-K and NA-I rolled R99 to his left side and NA-I proceeded by cleaning up R99 rectal/buttocks which had soft brown stool all over it which extended up underneath R99 dressing that he had on his right upper buttocks area. During the observation R99's buttocks was noted to be slightly red around the rectal area which extended to the outer edges of his buttock crease with no open areas noted. At 4:31 p.m. NA-I brought in mechanical lift and got R99's red tilt and space wheelchair from bathroom with chair alarm in place to R99's bed. NA-K and NA-I rolled R99 side to side