Every finding on record at Presbyterian Homes of Arden Hills

Based on observation, interview, and document review, the facility failed to ensure reasonable accommodation of resident needs by not providing a call light within reach for 1 of 3 residents (R118) reviewed for call light accessibility. Finding include: R118's quarterly Minimum Data Set (MDS dated ) 8/12/26, indicated R118 had severe cognitive impairment. The MDS further indicated R118 was dependent on staff for all cares, bed mobility, transfers, and total body care. Diagnoses included Alzheimer's disease, dementia with behavioral disturbances, hemiplegia and hemiparesis (total or partial paralysis and muscle weakness on one side of the body) following unspecified cerebrovascular disease (CVA) affecting the right dominant side.R118's care plan dated 8/6/26, indicated the call light was required to be within reach of her left side due to right sided hemiplegia secondary to CVA.During an observation on 9/2/26 at 7:39 a.m., R118 was sitting in her room in a high back wheelchair facing the television. The call light was draped over a chair across the room, out of her reach. At 7:49 a.m., registered nurse (RN)-C entered the room and informed R118 she was going to obtain a blood glucose level; R118 was calm. RN C left the room at 7:52 a.m., and the call light remained draped over the chair. At 7:53 a.m., nursing assistant (NA) F entered the room and wheeled R118 to the dining room for breakfast. At 1:07 p.m., NA F brought R118 back into her room, placed her in front of the television, and left the room. The call light remained draped over the chair, out of R118's reach.During an interview on 9/2/26 at 1:17 p.m., NA C stated residents used their call lights to notify staff when they had a need. She stated the call light was required to be within reach at all times, whether the resident was in bed or in a wheelchair. NA F confirmed that R118 was unable to reach the call light and that it had been draped over a chair far away from her.During an interview on 9/2/26 at 2:46 p.m., RN B stated the expectation was when a resident was in their room, the call light must be within their reach at all times. She stated the call light was provided so the resident could notify staff of their needs.During an interview on 9/3/26 at 11:34 a.m., the Director of Nursing (DON) stated the expectation was a call light must be within a resident's reach at all times. She stated the call light was the method by which a resident requested assistance.A policy titled, Call Light Policy, modified 11/22, instructed staff to ensure the resident's room was equipped to allow the resident to call for staff assistance through a communication system that relayed the call directly to a staff member or centralized work area from each resident's bedside and toilet and bathing facilities. The policy instructed staff to position the call light conveniently for the resident to use and to ensure the call light was accessible based on the resident's accommodations within their room.

Based on observation, interview, and document review the facility failed to ensure provider notification was completed for 1 of 1 resident (R2) reviewed for edema and weight monitoring with parameters.Findings include:R2's quarterly minimum data set (MDS) dated [DATE], indicated R2 had moderately impaired cognition, was independent with mobility in wheelchair outside of room and walker within room, was independent with most ADLs, however required assist from nursing to apply ace wraps daily. R2's diagnoses included congestive heart failure (CHF), atrial fibrillation (irregular heartbeat), and high blood pressure. R2's care plan dated 7/20/26, indicated R2 had a potential nutritional problem related to CHF diagnosis with use of a therapeutic diet. R2's care plan directed nursing staff to weigh R2 per policy or medical doctor/nurse practitioner (MD/NP) order and to call provider if weight increased by 5 pounds (lbs) or more and to monitor for increased edema and shortness of breath.R2's physician orders included:- on 3/9/26, R2 required or needed to elevate legs when sitting or in bed for edema.- on 7/20/26, R2 required ace wraps daily, knee high for edema.- on 7/3/26, staff were required to monitor R2's weight on Monday, Wednesday, and Friday. For 5-pound difference from previous weight notify MD/NP.R2's electronic medical record (EMR) indicated R2 had the following weights:8/24/26 178.4lbs8/26/26 183.4lbs increase in 5lbs from previous weight8/28/26 183.4lbs8/31/26 188.0lbs increase in 5lbs from previous weightR2's medical record and progress notes were reviewed and lacked evidence to indicate the MD/NP had been updated regarding the increased weight per the provider order. During interview on 9/2/26 at 12:44 p.m., nursing assistant (NA)-A stated the nursing assistants were responsible for obtaining resident weights in the morning before breakfast. After weighing the resident, the nursing assistant documented the weight on a report sheet kept at the nursing station.During interview on 9/2/26 at 1:32 p.m., licensed practical nurse (LPN)-A stated the nurses were responsible for ensuring weights were completed and documented the resident weights in their medical record. LPN-A also stated the nurse who documented the weight should look at the previous weight and if the weight increased by 5lbs or more update the MD/NP if stated in the resident's order to do so. LPN-A stated the nurse was expected to document in a progress note in PCC when a provider is updated.During interview on 9/3/26 at 8:25 a.m., registered nurse (RN)-A, stated the floor nurses were responsible to update the MD/NP, if there was an order to do so, for a resident who is on regular weight monitoring for edema and their weight is outside of the parameters in the order. It is also expected the floor nurse document in a progress note to indicate the provider was updated and note any follow-up or new orders that resulted from the update. The facility may also receive a fax document to indicate acknowledgement of the communication by the provider. RN-A stated these faxed documents were uploaded and remained a part of the resident's medical record. RN-A also stated the registered dietician (RD) may also update the provider regarding concerns with a resident's weight, and they would also be expected to document that in a progress note. RN-A reviewed R2's EMR and verified there was no indication a provider had been updated regarding R2's weight increases.During interview on 9/3/26 at 9:30 a.m., director of nursing (DON) stated they would expect the MD/NP to be updated by the floor nurse if a resident had an order for regular weight monitoring related to edema and/or a diagnosis of CHF with parameters and to update the MD/NP if the resident's weight was outside of those parameters. DON stated they expected the provider notification to be documented in a progress note. DON stated the risks to this resident with increased weight due to fluid included; potential for fluid overload, risk for wounds due to the edema, exacerbation of CHF, and potentially hospitalization.A facility policy titled Communication and Notification - Staff, Practitioners, and Resident Representatives, with a date of 7/2024, directed staff to Document, in the resident's medical record, the time called, the person spoke with, what was reported and their response if any.

Based on observation, interview, and document review the facility failed to ensure beverages were provided in the appropriate consistency for 1 of 1 resident (R20) reviewed who required modified liquids.Findings include:R20's admission minimum data set (MDS) dated [DATE], indicated R20 had intact cognition, required supervision for intake, received mechanically altered diet of pureed texture food and mildly thickened liquids, and received speech therapy. R20's diagnoses included stroke, dysphagia (difficulty swallowing), coronary artery disease, high blood pressure, and risk for malnutrition related to therapeutic diet of altered consistency.R20's nutrition care area assessment (CAA) dated 8/8/26, indicated R20 required a mechanically altered diet and thickened liquids due to dysphagia with risk for choking and aspiration.R20's care plan dated 8/1/26, indicated R20 had potential for nutritional problems related to stroke and dysphagia and directed staff to serve diet as ordered. R20's care plan also indicated R20 had potential for dehydration or fluid deficit related to dysphagia and/or need for thickened liquids and staff were directed to encourage safe swallow strategies: no straws, alternate solids and liquids during meals, throat clear/double swallow, upright for 30 min after meals, and eat slowly.R20's order dated 8/24/26, indicated they were on a regular diet with an easy to chew texture for solids and mildly thick consistency for liquids.R20's speech therapy (ST) evaluation/updated plan of treatment dated 8/31/26, indicated R20 was on an altered diet and required liquids served to meet the international dysphagia diet standardization initiative (IDDSI) with mildly thick drinks (MT2).During interview and observation on 8/31/26 at 1:30 p.m., R20 was seated in a wheelchair next to their bed and overbed table. There was a sign posted on the wall across from R20's bed that listed strategies for safe swallowing. R20 stated they were on an altered diet with thick liquids. There was a beverage container with cover on R20's overbed table and within reach they indicated was regular water, and when inspected appeared to be a thin clear liquid. During interview on 8/31/26 at 1:38 p.m., RN-A verified R20 was on an altered diet with mildly thickened liquids and verified liquid in beverage container on R20's overbed table was thin water. RN-A removed the beverage container with thin water and stated they would return with the appropriate consistency water for R20.During interview on 9/2/26 at 10:45 a.m., speech language pathologist (SLP)-A expected all liquids served or given to a resident to be thickened if they were on an altered consistency liquid in their diet, even when water was passed to resident rooms. SLP-A stated R20 was on a thickened liquid diet related to a stroke and they admitted from the hospital on a modified diet. R20 required a follow up swallow study before a diet modification was implemented, even by a speech therapist, due to their silent aspiration (when liquid, saliva, or food enters the airway without triggering a protective reflex, such as coughing). SLP-A stated the risk for someone who is on thickened liquids to consume the wrong consistency of liquid would be aspiration pneumonia.During interview on 9/3/26 at 9:30 a.m., director of nursing (DON) expected residents on thickened liquids to have always received the appropriate consistency of liquid. DON stated the risk for someone who was on thickened liquids to consume the wrong consistency of liquid could be; choking, aspiration, pneumonia, and ultimately could die.A facility policy titled PHS Diet Policy dated 4/2026, indicated Residents who require foods of a defined texture or particle size must receive the appropriate IDDSI-designated diet level, in accordance with the IDDSI framework. The facility policy also stated that thickened liquids were for residents with swallowing difficulty to help decrease the risk of choking or coughing on liquids and that all liquids should be thickened to appropriate consistency before being served.

Based on observation, interview, and document review the facility failed to ensure proper personal protective equipment (PPE) was worn for 3 of 3 residents (R51, R118, R47) reviewed for enhanced barrier precautions (EBP). Findings include: R51 R51's quarterly MDS assessment dated [DATE], indicated R51 had severe cognitive impairment. The MDS further indicated R51 required moderate assistance of one person with toileting, bed mobility, transfers, and total body care. Diagnoses included Alzheimer's disease, major depressive disorder, insomnia, and retention of urine. R51's care plan dated 7/31/26, indicated EBP was required due to a multidrug-resistant organism (MDRO) of ESBL (extended-spectrum beta-lactamase), an enzyme produced by certain bacteria that makes them resistant to many common antibiotics. The care plan instructed staff to follow EBP in addition to standard precautions and to wear a gown and gloves during high-contact resident care. During an observation on 9/1/26 at 1:16 p.m., nursing assistant (NA)-B provided personal care to R51 without wearing the required gown. NA-B wore gloves while assisting R51 in the bathroom. During an interview on 9/1/26 at 1:47 p.m., NA-B stated she did not believe R51 was on EBP. She stated resident-specific care instructions were obtained from the care plan and documented on the care sheets. NA-B stated EBP was only used during wound care. After reading the posted EBP sign on R51's door, that instructed providers and staff to clean hands before entering and leaving room, wear gown and gloves for high-contact cares activities, including assisting resident with toileting. NA-B confirmed she did not have the proper PPE on when providing direct care to R51 and acknowledged a gown should have been worn. During an interview on 9/2/26 at 2:03 p.m., the registered nurse (RN)-B stated it was important for staff to follow the care plan because it provided specific care instructions and individualized information for each resident. RN-B stated adherence to the care plan helped reduce the risk of infection and injury while ensuring residents received the best possible care. RN-B further stated staff were expected to consistently don and doff all required PPE for residents on EBP to protect residents and reduce the risk of infection transmission. R118 R118's quarterly MDS dated [DATE] indicated R118 had severe cognitive impairment. The MDS further indicated R118 was dependent on staff for all care, bed mobility, transfers, and total body care. Diagnoses included Alzheimer's disease, dementia with behavioral disturbances, hemiplegia and hemiparesis (total or partial paralysis and muscle weakness on one side of the body) following unspecified cerebrovascular disease affecting the right dominant side. R118's care plan dated 8/6/26, indicated R118 required Enhanced Barrier Precautions (EBP)due to a wound on the left great toe. The care plan instructed staff to wear a gown and gloves during high-contact resident care activities, including dressing, providing hygiene care, and changing briefs. During an observation on 8/31/26 at 11:54 a.m., NA-C and NA-D provided personal care to R118 without wearing the required gown. Both staff members wore gloves while repositioning R118 with a mechanical lift. A EBP sign on R118's instructed providers and staff to clean hands before entering and leaving room, wear gown and gloves for high-contact cares activities, including assisting resident with transfers. NA-D confirmed R116 was on EBP precautions, and gown should have been worn. During an interview on 9/2/26 at 2:03 p.m., RN-B stated it was important for staff to follow the care plan because it provided specific care instructions and individualized information for each resident. RN-B stated adherence to the care plan helped reduce the risk of infection and injury while ensuring residents received the best possible care. RNC-B further stated staff were expected to consistently don and doff all required PPE for residents on EBP. During an interview on 9/2/26 at 3:54 p.m., NA-D stated R118 was on EBP for a wound. PPE was worn during direct contact with residents on EBP for infection prevention. NA-D further stated the information necessary to provide proper care for a resident came from the care plan and was listed on the care sheets. During an interview on 9/3/26 at 10:17 a.m., NA-D stated R118 was on EBP for a wound on her toe. She stated that when direct cares were performed, EBP, including gown and gloves plus handwashing, was required. The care sheet developed from the care plan provided information for each resident, and EBP was documented on the care sheet. She stated R118's door had a sign instructing staff when and how to don and doff the correct PPE. A bin with supplies and a garbage can were in her room for PPE disposal. During an interview on 9/3/26 at 10:43 a.m., IP-C stated staff were expected to consistently don and doff the required PPE in accordance with EBP signage and care plans. IP-C stated EBP was important to protect residents, the facility, and the community by reducing the risk of infection through potential portals of entry. IP-C further stated resident care plans were updated frequently and individualized to support each resident's highest practicable level of well-being. During an interview on 9/3/26 at 11:09 a.m., the DON stated the expectation of each staff member was to follow instructions in the care plan and the (Center of Disease Control) CDC signage with every direct-care encounter with residents on EBP. Supplies were kept in bins by each resident's door, and an additional garbage can was located in each resident's room for disposing of used PPE. The DON stated EBP was best practice to proactively provide a barrier that decreased the risk of transmission of microscopic disease-causing organisms. A policy titled, CC Enhanced Barrier Precautions Policy and Procedure, revised 4/24, instructed staff to use EBP when caring for residents with wounds or indwelling medical devices even if the resident was not known to be colonized or infected with an MDRO. The policy required an EBP sign to be placed on the resident's door and ensured adequate supplies of gowns, gloves, trash cans, and hand hygiene products were available in or near the resident's room. When performing high-contact resident care activities, staff were instructed to perform hand hygiene, don gloves and a gown, complete the activity, remove gloves and gown, dispose of them in a trash can in the resident's room or designated area, and perform hand hygiene again. R47 R47's significant change minimum data set (MDS) dated [DATE], indicated R47 was cognitively intact, dependent on staff for transfers, ambulation with a walker, and mobility in wheelchair. R47's diagnoses included stroke, high blood pressure, neurogenic bladder (interference with nerves that control bladder function) with indwelling catheter in place, severe weakness on one side of the body, depression, and colostomy status. R47's care plan dated 8/31/26, indicated R47 required EBP related to having an indwelling urinary catheter and directed staff to follow EBP in addition to standard precautions, which included wearing a gown and gloves during high-contact resident care activities. During observation on 9/2/26 at 7:55 a.m., nursing assistant (NA)-B entered R47's room to do morning cares. There was a sign on resident's door that indicated EBP required for close contact cares and inside room near door was a 3-drawer bin with PPE supplies. NA-B approached resident lying in bed and asked about preference for clothing. After arranging clothing, NA-B put on personal protective equipment (PPE), gown and gloves. NA-B approached R47 and emptied catheter collection bag into container, wiped catheter tubing with alcohol wipe, emptied urine into toilet, rinsed container with sink water, dumped into toilet, and flushed the toilet. NA-B removed gown and gloves and placed them in the waste basket, washed hands, and put new gloves on, however did not put a gown on. NA-B returned to R47 lying in bed, assisted with putting socks on and attaching leg strap of catheter collection bag over sock on right leg. NA-B then assisted R47 from a lying position to sitting on the edge of the bed, removed R47's night shirt, applied deodorant, and assisted with dressing R47 in a clean t-shirt followed by a button-down shirt. NA-B asked R47 if they want to walk to the bathroom?, R47 stated yes. NA-B placed gait belt around resident and assisted with transfer to a standing position. NA-B ambulated with R47, directing walker and pulling w/c behind, holding gait belt, to the bathroom. Once in bathroom, NA-B assisted R47 to sit in wheelchair and removed gait belt from around R47's waist. NA-B, with only gloves on still, wet a washcloth and assisted R47 with washing face and wiping eyes. NA-B removed gloves, washed hands and proceeded to take R47 to the dining room for breakfast. During interview on 9/2/26 at 10:32 a.m., NA-B stated they knew when a resident was on precautions because there would be a sign on the resident's door. NA-B stated if a resident was contagious, they would use all PPE; gown, gloves, and mask, otherwise gown and gloves for people with catheters or wounds. NA-B stated they should have worn a gown when they dressed and transferred R47 but forgot to put one back on when they took the other one off after emptying the catheter. During interview on 9/3/26 at 8:16 a.m., registered nurse (RN)-B stated there would be a sign on a resident's door that indicated if a resident was on precautions and what type of precautions. It would say on the poster or the sign what things you would need to wear. RN-B confirmed that for any dressing or transfer staff should be wearing gowns and gloves for EBP.

Based on interview and document review the facility failed to review and revise a care plan for 1 of 3 residents (R1) whose care plan was reviewed for revisions.Findings include: R1's annual Minimum Data Set (MDS) dated [DATE], indicated R1 was moderately cognitively impaired, dependent on staff for transfers from surface to surface, and had diagnoses included dementia. R1's care plan dated 1/23/26, indicated R1's family member (FM)-A gave verbal permission for R1 to continue to use the stand aid lift as long as the resident was able to do so and understood the risk of bruising and skin tears R1 may receive. R1's Resident Transfer assessment dated [DATE], indicated R1 was full weight bearing, was able to stand for 8 (eight) seconds safely while holding onto an assistive device, and was cooperative during transfers. The recommended mechanism for transfers from surface to surface was a two-person transfer with the stand assist lift. R1's progress note dated 6/11/26 at 10:40 a.m., indicated R1 may no longer be appropriate for the stand aid lift, and a Resident Transfer Assessment would be completed. R1's Resident Transfer assessment dated [DATE], indicated R1 was partial weight bearing, could not stand for 8 seconds safely while holding onto an assistive device, and was cooperative during transfers. The recommended mechanism for transfers from surface to surface was a two-person transfer will a full body lift. R1's care plan dated 6/11/26, indicated R1 required assistance of two staff with a full lift and medium sling. The care plan intervention to utilize the stand assist lift remained on the care plan without an end date. R1's progress notes dated 6/22/26 at 4:50 p.m., indicated R1 was transferred to the emergency department on 6/12/26 for a skin tear, and was changed from a stand assist lift to a full lift on 6/11/26. During an interview on 6/29/26 at 11:05 a.m., the FM-A stated that after R1 was injured using the stand assist lift on 6/12/26, the staff started to use a full lift. During an interview on 6/29/26 at 1:03 p.m., the registered nurse (RN)-A stated R1's ability to transfer using a stand assist lift was reassessed on 6/11/26 because staff were concerned about her ability to transfer safely. R1 was assessed and subsequently required a full body lift. The change was indicated on R1's care sheet utilized by the nursing assistants (NA) and on R1's care plan. The RN-A acknowledged when R1's care plan was updated to indicate use of the full body lift, the intervention to utilize the stand assist lift was not removed and an end date was not added. During an interview on 6/29/26 at 2:27 p.m., the licensed practical nurse (LPN)-A stated R1's transfer status was assessed on 6/11/26 and was changed from a stand aid lift to a full body lift because she was no longer able to stand for 8 seconds, had bruising on her lower extremities because she could not bear weight and had to lean heavily on the lift. The LPN-A stated he added the full body lift to R1's care plan and acknowledged he did not remove the stand aid lift from R1's care plan or add an end date, which could be confusing for staff. During an interview on 6/29/26 at 4:03 p.m., the nursing assistant (NA)-A stated if the correct lift was not utilized, accidents during transfers of residents could happen. During an interview on 6/29/26 at 4:32 p.m., the director of nursing (DON) stated any discrepancy in the care plan could be a problem for a resident and acknowledged the care plan was updated with new information for R1's transfers, but the information about the previous transfer status had not been removed and an end date was not added. The Care Plan Policy and Procedure dated 11/22, indicated changes to the care plan would be made as necessary resulting from significant changes in condition or needs and should be current at all times.

Based on observation, interview and document review the facility failed to ensure adequate supervision and scheduled toileting to reduce the risk for falls for 1 of 3 residents (R1) who had a history of falls. This resulted in actual harm for R1 who had an unwitnessed fall requiring emergency department (ED) services, sustained a laceration to the head, received five staples, and was admitted to the hospital for further observation. The facility implemented corrective action prior to the survey so the deficient practice was issued at past non-compliance. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], identified diagnoses of severely impaired cognition without behaviors and lower impairment of range of motion (ROM) on one side, repeated falls, hip fracture, weakness, and shortness of breath), Alzheimer's, and dementia. R1 required supervision/touching with oral and personal hygiene, frequently incontinent of bowel and bladder, and verbal cues or touching/steadying with ambulation up to 150 feet, partial/moderate assistance with toileting hygiene, shower/bathe, upper body dressing, bed mobility, and all transfers. R1 had increased risk of falls identified due to medication use, intracerebral hemorrhage, muscle weakness, and difficulty walking. R1's physical therapy Discharge summary dated [DATE], identified she required supervision or touching assistance to sit to stand, transfer from chair to bed, bed to chair and to toilet, and walked up to 150 feet. R1's care plan dated 6/5/25, identified the following fall interventions: -alert resident to changes to environment, 3/7/25 -place call light within reach, and answer promptly. 3/7/25 - keep in commons area, 3/12/25 -Night toileting between 10:00 and 11:00 p.m. 2:00 and 3:00 a.m., and 5:00 and 6:00 a.m. and as needed (PRN). 3/20/25 -place assistive device within reach, 3/20/25 -assure she had anti-rollbacks on wheel chair, 4/14/25 -place walker in closet with not in use, 4/14/25 -close blinds at night ( unless request to keep open), 4/17/25 -dementia clock within view, 5/2/25 room re-arranged bed next to wall, 5/2/25 -assist to toilet every morning, before meals and at bedtime (HS), 5/15/25 -reposition and toilet her with assistance of one every three hours during the day and as needed (PRN). 5/15/25 -make up bed upon rising, 5/21/25 -push fluids in between meals/aim for 49 ounces, 5/23/25 -use lavender patches for a calming effect if she became restless or tried to stand up, 5/30/25 -five pound weight blanket with sequins, 6/4/25 R1's toileting record for 5/18/25 identified only the following times: -at 4:51 a.m. toileted with extensive assistance. -at 9:29 p.m. toileted with limited assistance. R1's progress notes from 5/18/25 through 5/21/25, identified: -on 5/18/25 at 9:10 a.m., around 8:05 a.m. she was found on the floor in a sitting position beside her bed. She said, I'm making my bed. She was not capable of standing up on her own and was transferred safely with assistance of two staff with the use of a lift machine to her wheelchair without injury noted. Intervention based on root/cause analysis: She was aware that she was on the floor and said she just wanted to make her bed. Had tendencies of ending up on the floor because she wanted to do something. Had a history of falling multiple times without witness. Bring her to common area or nurse's station where she can be monitored most of the time to minimize her falls. -on 5/18/25 at 8:49 p.m., she was found in bathroom on the floor bleeding from her head, conscious and alert. She said she tried to use to the bathroom. She was transferred out of the bathroom into wheelchair. Received orders to send to local hospital. (progress note lacked information related to R1's continence status when found) -on 5/18/25 at 9:54 p.m., she was sent to local hospital via ambulance left at approximately 9:00 p.m. -on 5/19/25 at 4:14 p.m., she returned from hospital at 3:50 p.m. -on 5/21/25, at interdisciplinary team (IDT) met on 5/19/25 and reviewed fall she had on 5/18/25 at 8:40 p.m., where R1 was found in her bathroom with a laceration to her head. Intervention based on root cause analysis: she was assisted off the floor with a lift machine by staff. Neuros initiated, range of motion (ROM) and vitals done. She was sent to local hospital and came back with new order for antibiotic for diagnosis of cystitis (inflammation of the bladder usually caused by infection) without hematuria (blood in the urine). Care plan reviewed and remained appropriate. R1's camera footage for 5/18/25, and viewed by director of nursing (DON) identified: -at 4:24 p.m. at nurse's station and taken to her room. -at 4:32 p.m. she came out of her room and placed at nurse's station. -at 4:50 p.m. she was taken to the dining room. -at 6:20 p.m. staff brought her to the nurse's station from the dining room. -at 8:22 p.m. she went back to her room. -at 8:31 p.m. staff walked into her room and then left. -at 8:35 p.m. staff walked into her room again (most likely when she fell). -at 8:36 p.m. another staff walked into the room followed by another staff shortly after. -at 8:55 p.m. she was brought to nurse's station. -at 9:21 p.m. emergency medical services arrived (EMS). R1's ED provider note dated 5/18/25, identified [AGE] year-old female currently resides in the memory care unit with a history of notable major neurocognitive disorder due to multiple etiologies and multiple falls with head injuries including bilateral traumatic subdural hematoma (SDH). She presented today with an unwitnessed fall in the bathroom earlier tonight, found by a staff unaware how long she had been down but believed it to be less than two hours. She was unable to recall how or why she fell but did not believe she lost consciousness. She had a laceration to the back of the head and reported pain, some blood in her mouth but believed she had a bloody nose earlier on. Her family member noted that she usually walked with assistance but on occasion tried to walk on her own and frequently fell. Physical exam revealed a laceration that measured 4 centimeters (cm) by 3 cm located on the crown of her scalp. A local anesthetic, Lidocaine 1% with epinephrine (used to cause numbing or loss of feeling) was used prior to the application of five staples for skin repair and antibiotic ointment was applied. R1's hospital Discharge summary dated [DATE], identified she was admitted to hospital under observation for unwitnessed fall and work up related acute kidney injury. Her urinalysis was abnormal and treated with an antibiotic for a possible urinary tract infection (UTI). She was discharged back to the facility on 5/19/25 at 3:30 p.m. Facility investigation report summary submitted on 5/23/25 at 12:16 p.m., identified camera reviewed showed nursing assistant (NA) did not follow R1's plan of care. R1 was not taken to the bathroom after the initial toileting time of 4:30 p.m. NA reported was busy with two other residents, went back to nurse's station to check on R1, reading a book, assumed she was ok. She assisted another resident, came back and found R1 on the floor in the bathroom at 8:40 p.m., sent to ED, sustained a head laceration repaired with five staples, diagnosed with a possible UTI, and treated with antibiotics. (R1 left common area without redirection to return for supervision and was not toileted at 7:30 p.m.) R1's staff care sheet dated 6/3/25 identified toilet/reposition every three hours and PRN, every a.m., before meals, HS/night; 10:00 p.m. to 11:00 p.m. 2:00 p.m. to 3:00 p.m., and 5:00 p.m. to 6:00 p.m. and PRN. During an interview on 6/5/25 at 12:43 p.m., family member stated R1 was able to occasionally make her needs known, unable to use call light, and may have taken herself to bathroom rather than wait for help. She was unable to recall the day before events. R1 had received really good care at this facility and the only time she had concerns about her care was when she fell on 5/18/25, and had not been toileted after 4:30 p.m. She felt like there had been some problem solving difficulties and a plan of care where she required eyes on her and should have not been left alone in her room. She was not toileted in a timely manner, had to go to the bathroom, self-transferred, was most likely what caused the fall. During an interview on 6/5/25 at 4:00 p.m., registered nurse (RN)-A stated R1 was at risk for falls, was not the best historian, and unsure if it would have been sensical (logical). Staff were expected to follow her care plan: toilet every three hours and kept within site in common area. R1 refused occasionally; staff were expected to have reproached her at least twice within 15 minutes maximum. The care plan was not followed on 5/18/25 and R1 should have been toileted within a three-hour time period, had taken herself into the bathroom, self-transferred, fell and hit her head. RN-A indicated she attempted to assess R1's head injury but was unable to see wound, the entire back of her head continuously bled, and stuck to her head/hair. She held pressure to the wound, was sent to hospital for treatment, and received five staples to the laceration. R1 had factors of dementia and a UTI but basically the fall could have been prevented if the care plan would have been followed. During an interview on 6/5/25 at 4:20 p.m., NA-A stated R1 was a high risk for falls and unable to make her needs known. Staff were expected to anticipate her needs and follow her care plan to prevent falls. Her care plan indicated she was to be toileted every three hours. On 5/18/25, R1 was last taken to the toilet at 4:30 p.m., she assisted other residents and when finished was unable to find her at nurse's station so NA-A stated she went to her room and found R1 on the floor in the bathroom near the sink with a medium amount of blood on her head and clothing. R1 was responsive, had increased confusion, and told her she wanted to go to the toilet. NA-A indicated she had seen R1 last at 7:00 p.m. located by the nurse's station reading a book. She would have been expected to toilet her by 7:30 p.m., did not follow care plan, and could have avoided the fall if care plan would have been followed. NA-A added, R1 was injured, sent to ER, diagnosed with a UTI and received five staples to her head. She had received education the following day, communicate with nurse if unable to toilet a resident, always ask for help if needed, follow care plan, and carry the care sheets with her at all times. During an interview on 6/6/25 at 10:15 a.m. clinical coordinator RN-B stated R1 was at risk for falls, forgetful, and would attempt to self-transfer. Staff were expected to anticipate her needs so falls could be prevented. She most likely stood up, tried to self- toilet herself, and fell which resulted in a laceration with five staples. The care plan was not followed, R1 should have been toileted every three hours and was not within the appropriate time frame. She was impulsive and the fall may have been prevented if supervised in common area and toileted earlier. During interview on 6/6/25 at 11:20 a.m., DON stated R1 was at risk for falls and could make her needs known depending on the day. She reviewed R1's camera footage after her 5/18/25 fall in the evening and at 8:22 p.m., R1 was seen reading a book in her wheelchair located at the nurse's station. The nurse left the area and R1 had taken herself back to her room. DON added, part of her care plan is to keep her in common spaces but she independently wheeled back to her room. At 8:31 p.m. staff walked into her room and out again, unknown why, and at 8:35 p.m. staff entered her room here R1 was found on the floor in the bathroom. Staff would have been expected to have followed the care plan, toileted her, and placed her into bed. Because R1 was found in the bathroom, it is assumed she had tried to toilet herself but then fell. The fall could have prevented if she had been toileted per the care plan but with her history of falls, that is hard to say. R1 sustained a laceration to the head, was sent to the hospital via ambulance, received medical care, five staples to her head, diagnosed with acute cystitis/UTI and started on an antibiotic. She was notified that evening after the fall. The staff education was initiated on 5/22/25, presented via stand up (a daily meeting held on the floor by the managers) and the majority of the nursing staff on 4th floor had received fall prevention education by 5/23/25. The education document identified this was a recent incident in which a resident suffered an injury due to their care plan not being followed. All nursing staff were responsible for knowing and following the plan of care for the residents there were responsible for. Care sheet must be carried with nursing staff at all times. Facility policy Care Plan dated 11/2022, revealed the care plan identified needs for supervision, behavioral interventions, assistance with activities of daily living (ADLs) as necessary and individualized to meet the resident's needs. Facility policy Fall Prevention and Management Program dated 4/2021, identified the purpose of the policy was to assign responsibility and provide procedure for residents at risk for falls; to systematically assess fall risk factors; provide guidelines for fall and repeat fall preventive interventions; and outline procedures for documentation and communication. A fall was defined as an unintentional change in position coming to rest on the ground, floor, or onto the next lower surface and maybe witnessed, reported by the resident or an observer or identified when a resident was found on the floor or ground. The resident's care plan must be individualized and implement interventions according to resident specific risk factors by nursing staff to help prevent falls and provide a safe environment of care.

Based on interview and record review, the facility failed to immediately consult with the resident's physician for a need to alter treatment significantly for one of one resident (R1) reviewed. This practice resulted in a delay of treatment to R1's pressure ulcers. Findings include: R1's face sheet indicated R1 was admitted to the facility on [DATE] with a primary diagnosis of unspecified atrial fibrillation. R1's additional diagnoses included chronic kidney disease stage 3 and spinal stenosis, sarcoidosis of other sites. R1's progress note dated 4/22/25 at 9:40 a.m. indicated medical director (MD)-A reviewed R1's sacral ulcer. Progress note indicated the pressure ulcer was red that extended out from the wound under four centimeters with moderate odor and drainage on the dressing. The progress note indicated the facility staff, or the MD would be calling nurse practitioner (NP)-A to arrange wound clinic visit or hospitalization for debridement soon. R1's progress note dated 4/22/25 at 9:49 a.m. indicated R1 was seen by MD that day for a pressure ulcer to his left glute/sacral area and the MD recommended R1 to be sent to the hospital for wound debridement. R1's progress note dated 4/22/25 at 9:54 a.m. indicated orders were requested from NP-A to send R1 to the hospital for wound debridement that was recommended by MD-A. The progress note indicated the facility staff was waiting for orders. R1's progress note dated 4/22/25 at 2:54 p.m. indicated NP-A had called the facility back and gave R1 a referral to the wound center. R1's provider visit note dated 4/23/25 indicated there had been a rapid deterioration of R1's pressure ulcer. NP-A noted R1 had an ulceration located on his left buttock that was no stageable. NP-A noted the pressure ulcer bed was covered with large eschar tissue, surrounding skin was inflamed, foul odor was noted, and small drainage was noted. NP-A recommended R1 to be sent to the hospital for debridement. R1's progress note dated 4/23/25 at 12:34 p.m. indicated R1 was sent to the hospital at 11:18 a.m. per NP-A's order due to the deterioration of R1's pressure ulcer on R1's buttocks. During an interview on 4/30/25 at 10:43 a.m., registered nurse (RN)-B stated MD-A recommended R1 to be transferred to the hospital but NP-A didn't want to send him to the hospital because NP-A was going to be at the facility on 4/23/25 and wanted to look at the pressure ulcer first. During an interview on 4/30/25 at 4:13 p.m., RN-C stated he worked with R1 and MD-A on 4/22/25. MD-A did not say R1's pressure ulcer was urgent. RN-C needed to inform NP-A about MD-A's recommendations so the facility could get orders from NP-A to send him to the hospital. RN-C stated it was protocol getting orders from NP-A to send R1 to the hospital even if MD-A gave orders to send R1 to the hospital. Attempts to interview NP-A on 5/1/25 at 8:39 a.m. but was not successful. During an interview on 5/1/25 at 8:54 a.m., MD-A stated clinical administrator (CA)-A asked if he could visit R1 due to R1's pressure ulcers. MD-A saw R1, and his pressure ulcer was large, soft slough, eschar, some odor, and surrounding erythema. MD-A stated he thought this wound was outside his expertise and had given the facility an order to send R1 to the hospital right away that same day. MD-A stated it was not appropriate to send R1 to the hospital over twenty-four hours after he gave the order. MD-A stated he was not informed by the facility that NP-A had disagreed with his recommendations of sending R1 to the hospital right away. MD-A stated he thought the facility had sent R1 to the hospital right after MD-A left the facility. During an interview on 5/1/25 at 9:30 a.m., CA-A stated MD-A wanted her to contact NP-A to get orders to send R1 to the hospital. The facility did not want to send R1 to the hospital because when residents usually go to the emergency room , they will always send them back with no treatment. CA-A stated she wanted R1 to be directly admitted to the hospital or directly to the wound clinic. Policy Communication and Notification- Staff, Practitioners, and Resident Representatives dated 7/2024 indicated staff would notify the practitioner any time there is a significant change in clinical condition including but not limited to a need to discontinue or change an existing form of treatment due to adverse consequences, or to initiate a new form of treatment and any other time there was a significant change in status from the plan of care.

Based on observation, interview and document review, the facility failed to use proper personal protective equipment (PPE) who are on enhanced barrier precautions (EBPs) for 1 of 3 (R1) residents reviewed for falls. Findings include: R1's Face Sheet dated 1/1/19, indicated R1 had retention of urine. R1's significant change Minimum Data Set (MDS) dated [DATE], indicated R1 had moderate cognitive impairment, had an indwelling catheter, and needed extensive assistance with all cares. R1's care plan dated 3/31/35, indicated R1 was on enhanced barrier precautions (EBPs) because R1 had an indwelling medical device the plan directed staff to wear gown and gloves during high-contact resident care activities. Enhanced Barrier Precautions signage on R1's door undated, indicated providers and staff would wear gloves and gown for the following High-Contact Resident Care Activities: dressing, bathing, transferring, changing linens, providing hygiene, changing briefs or assisting with toilet use, and when caring for wounds or device cares. During an observation on 4/16/25 at 8:22 a.m., nursing assistant (NA)-A, NA-B, and registered nurse (RN)-A applied gloves and entered R1's room to assist her with a transfer from bed to R1's wheelchair. NA-B stood on R1's right side of bed. NA-B turned R1 toward NA-B, NA-A and RN-A assisted R1 with pulling her pants up and her shirt down. RN-A placed R1's lift sheet under R1, NA-A assisted with placement of lift sheet. NA-A, NA-B, and RN-A assisted R1 by attaching the lift sheet straps to the full body mechanical lift. NA-A, NA-B and RN-A placed R1 in her wheelchair via full body mechanical lift, took off gloves, sanitized hands, and left the room. During an interview on 4/16/25 at 8:33 a.m., RN-A stated if a resident was on EBPs staff would be expected to wear gown and gloves with transfers and R1 was on EBPs. RN-A stated did assist R1 with a transfer and should have worn a gown but did not. On 4/16/25 at 8:37 a.m., NA-B stated R1 was on EBPs and NA-B should have worn a gown along with her gloves when transferring R1 but she forgot. On 4/16/25 at 9:22 a.m., NA-A stated R1 was on EBPs and he should have worn a gown when transferring R1 but he forgot to put the gown on. On 4/16/25 at 2:21 p.m., infection preventionist (IP)-A stated if a staff were to go into a residents room who was on EBPs they would need to gown and glove if they were going to transfer that resident. On 4/16/25 at 3:02 p.m., the director of nursing (DON) stated the staff were expected to gown and glove if they were going to provide high contact care with a resident on EBPs, this included when transferring a resident. The facility Enhanced Barrier Precautions policy and procedure revised 3/2025, indicated EBP (targeted gowns and gloves) would be used in conjunction with standard precautions and would be implemented during high contact resident care activities for residents who had indwelling medical devices. Indwelling medical devices included urinary catheters.

Based on observation, interview and document review the facility failed to ensure food was properly disposed of after their best by dates in 2 of 4 serving kitchens and failed to ensure food was properly stored in 2 of 4 of the serving kitchens reviewed. This had the potential to impact residents who reside on the unit the serving kitchen is located. Findings include: An observation on [DATE] at 1:21 p.m., the 3rd floor serving kitchen was reviewed. Server (S)-A was in the serving kitchen cleaning up after lunch. In the cupboard was a box containing 2 individual packets of instant cream of wheat. The top of the box was torn off. There was no use by date on the box. A second un-opened box of cream of wheat was next to the open box. The top of the box included best if used by date of [DATE]. An interview on [DATE] at 1:30, S-A verified there was no best by date on the opened box of cream of wheat and the April date on the unopened box. S-A further stated lead server (LS) who was responsible for checking the dates of food items daily. S-A further stated most of the items were served by the kitchen and the individual items were made for residents by the nursing staff. S-A stated she wasn't sure how it was determined if the opened box was any good and further stated both should have been removed. An observation on [DATE] at 1:43 p.m., the 2nd floor serving kitchen was reviewed. S-B was in the serving kitchen cleaning up after lunch. Upon review of the refrigerator, there were two half-gallon containers of [NAME] skim milk sitting next to each other. One milk container was approximately ,d+[DATE] full and had a best by date of [DATE]. The second milk container was less than ,d+[DATE] of milk left and had a best used by date of [DATE], 6 days prior this observation. The milk had just a small amount left. When interviewed on [DATE] at 1:50 p.m., S-B verified the milk had a best used by date of [DATE] and stated usually LS made rounds on the units to ensure items were stocked, labeled and to check if any food items needed to be removed. S-B further stated she was not sure which jug of milk was used as it was usually the nursing assistants who assist with the beverages. S-B stated everyone should be checking dates and acknowledged they had not as it was so busy and disposed of the milk. An observation on [DATE] at 2:18 p.m., S-C was in the 4 north serving kitchen. Inside the refrigerator was two large trays with multiple glasses of milk and apple juice. The juice and milk were not covered and not dated. When interviewed on [DATE] at 2:25 p.m., S-C verified the uncovered glasses and stated the juice and milk were prepped for evening shift a little while ago. S-C was not aware of the glasses needing to be covered. S-C then started to cover the beverages. When interviewed on [DATE] at 2:05 p.m., LS stated she has a process for ensuring items are stocked and when items expire and had a list of items for the main storage and the pantry kitchens (kitchenettes separate from the serving kitchen). Furthermore, LS stated she was responsible for the pantry kitchens on the units however, the servers who worked in the serving kitchens were responsible to review the food items and ensure proper storage. When interviewed on [DATE], the Assistant Dietary Director (ADD) expected those working in the serving kitchen to be checking food items daily to ensure they were used by the best-by dates. If no date was found the items should be thrown. ADD further stated staff were expected to date and cover all items stored or prepped for future use. When interviewed on [DATE] at 11:49 a.m., the administrator expected staff to follow the processes in place to ensure food is stored properly and removed if past the best by date. A facility policy titled Safe Food Storage Policy revised ,d+[DATE], directed staff to label, date and properly cover all food items upon opening of package. The policy directed staff to ensure food is rotated by placing new items behind older items in a first in, first out system, however did not indicate a method of checking dates to ensure food items had not expired.

Based on observation, interview and record review, the facility failed to ensure appropriate transmission-based precautions (TBP) were used for 3 of 3 residents (R69, R108, R4) who had COVID-19. Furthermore, the facility failed to ensure proper hand hygiene was used for 1 of 1 residents (R72) observed during personal care. Findings include: R69 significant change Minimum Data Set (MDS) dated [DATE], indicated R69 had severe cognitive impairment and diagnoses of dementia. R69's MDS further indicated R69 was dependent on staff for eating. R69's nursing progress note dated 9/1/24 at 5:07 p.m., indicated R69 had tested positive for COVID-19. R69's nursing order dated 9/1/24, indicated R69 required TBP because of an active infection of a highly transmissible pathogen that had been acquired by physical contact, airborne or droplet transmission. Staff were to assist resident to maintain strict isolation. R108's quarterly MDS dated [DATE], indicated R108 was cognitively intact and had diagnoses of cancer of the spine and diabetes. R108's nursing progress note dated 9/10/24 at 9:22 a.m., indicated R108 tested positive for COVID-19. R108's nursing order dated 9/10/24, indicated R108 required TBP because of an active infection of a highly transmissible pathogen that had been acquired by physical contact, airborne or droplet transmission. Staff were to assist resident to maintain strict isolation. R4's annual MDS dated [DATE], indicated R4 was cognitively intact and had diagnoses of chronic lung disease and diabetes. R4's nursing progress note dated 9/10/24 at 1:23 p.m., indicated R4 tested positive for COVID-19. R4's nursing order dated 9/1024, indicated R4 required TBP because of an active infection of a highly transmissible pathogen that had been acquired by physical contact, airborne or droplet transmission. Staff were to assist resident to maintain strict isolation. An observation on 9/11/24 at 8:25 a.m., R69's room door was closed. On the door was a pink sign directing staff droplet precautions was required. The sign directed staff to have gown, gloves, eye protection and a N-95 respirator on when entering. A white paper sign was also on the door and stated R69 was in quarantine from 9/1/24-9/11/24 and instructed staff a gown was required during all high contact cares such as personal cares and transfers. At 8:29 a.m., nursing assistant (NA)-A delivered breakfast to R69. Before entering R69's room, NA-A performed hand hygiene, removed their surgical mask, and donned a N-95 respirator and gloves. Without donning a gown or eye protection, NA-A entered R69's room and closed the door. Forty minutes later at 9:10 a.m., NA-A exited R69's room wearing an N-95 mask and carrying a bag of trash. NA-A went directly to the soiled utility room to dispose of trash, washed hands and had replaced the N-95 mask with a new surgical mask. When interviewed on 9/11/24 at 9:13, NA-A verified R69 was on TBP for COVID-19 and was assisting R69 with breakfast. R69 acknowledged they had not had a gown on and only had personal eyeglasses onto assist with breakfast. NA-A stated a gown was not needed to help with meals and was only required for close contact such as transferring and personal cares. NA-A stated their personal eyeglasses could be used as eye protection. An observation on 9/11/24 at 11:50 a.m., R108's room door was closed. On the door was a pink sign directing staff droplet precautions was required. The sign directed staff to have gown, gloves, eye protection and a N-95 respirator on when entering. A white paper sign was also on the door and stated R108 was in quarantine from 9/10/24-9/21/24, and instructed staff a gown was required during all high contact cares such as personal cares and transfers. At 11:54 a.m., NA-B delivered lunch to R108's room. Upon entering NA-B performed hand hygiene and donned a gown and gloves. Without donning an N-95 respirator or eye protection, NA-B entered R108's room and left the door open. NA-B talked with R108 as they set up lunch on R108's bedside table. At 11:59 a.m., NA-B removed the gown and gloves and performed hand hygiene upon exit of R108's room. At 12:00 p.m., R4's room door was closed. On the door was a pink sign directing staff droplet precautions was required. The sign directed staff to have gown, gloves, eye protection and a N-95 respirator on when entering. A white paper sign was also on the door and stated R4 was in quarantine from 9/10/24-9/21/24, and instructed staff a gown was required during all high contact cares such as personal cares and transfers. 12:01 p.m., NA-B continued to R4's room to deliver lunch. NA-B performed hand hygiene and donned a gown and gloves. Without donning a N-95 respirator or eye protection, NA-B entered R4's room leaving the door open. At 12:03 p.m., NA-B removed the gown and gloves, performed hand hygiene and exited R108's room. When interviewed on 9/11/24 at 12:15 p.m., NA-B verified R108 and R4 were on TBP due to COVID-19. NA-B acknowledged a N-95 respirator and eye protection was not in place as NA-B was just delivering trays. NA-B further stated eye protection and an N-95 respirator was needed during close contact cares such as helping to the bathroom. Hand Hygiene R46's quarterly MDS dated [DATE], indicated R46 was cognitively intact and had diagnoses of vascular disease and bladder dysfunction. Furthermore, R46 was always incontinent. R46's care plan revised 5/18/24, indicated R46 was incontinent and required assistance of one person for hygiene and incontinent cares. An observation on 9/11/24 at 12:06 p.m., NA-B entered R46's room to assist with incontinent cares. NA-B performed hand hygiene and donned gloves. NA-B unfastened R46's soiled brief and cleaned the front of R46 with wipes and then tucked the front side of the brief down and underneath R46. R46 was able to turn to the right side. NA-B then wiped R46's backside and removed the soiled brief and placed in the garbage. Without glove exchange or hand hygiene, NA-B took a clean brief and assisted R46 to turn and place the clean brief. NA-B then fastened the brief and removed the soiled gloves. Without hand hygiene NA-B assisted to pull down R46's dress and adjusted R46's sock. NA-A then bagged up the garbage and performed hand hygiene before leaving the room. When interviewed on 9/11/24 at 12:15 p.m., NA-B acknowledged they had not removed gloves or performed hand hygiene after removing R46's soiled brief and placing the new one. NA-B stated they should have performed hand hygiene and exchanged gloves after removing the soiled brief and before assisting with the clean brief and clothing. When interviewed on 9/12/24 at 10:36 a.m., the infection preventionist (IP) stated when a resident is positive for COVID-19, TBP for droplet with N-95 use was initiated right away. IP further stated the dates of quarantine were posted on the resident rooms along with the droplet isolation signs. IP acknowledged the quarantine signs indicated gowns with close contact cares and stated that could cause confusion. IP expected staff to have gowns, gloves, N-95 respirator, and eye protection on every time they enter a room of a resident with COVID-19. IP stated staff were expected to perform hand hygiene when moving from dirty or soiled items to clean items and after each glove removal. This will help minimize risk of spreading bacteria. When interviewed on 9/12/24 at 11:41 a.m., the Director of Nursing (DON) expected staff to perform hand hygiene and exchange gloves when moving from dirty or soiled items to clean items and after any glove removal. Staff were also expected to follow the signage on the doors and wear all the required personal protective equipment every time entering a room for residents on TBP. A facility policy titled COVID-19 revised 8/2023, directed staff to implement TBP when caring for a resident with COVID-19. Staff who enter the room should wear a N-95 mask, gown, gloves and eye protection that covers the front and sides of face. A facility policy titled Infection Control Hand Hygiene dated 2020, directed staff to perform hand hygiene after contact with visibly soiled items, and after removing gloves.

Based on interview and document review, the facility failed to report to the state agency (SA) allegations of potential neglect and verbal abuse for 2 of 3 residents (R30, R37). Findings include: R30's Optional State Assessment (OSA) dated 7/18/24, indicated R30 rarely made self understood, did not have behaviors or reject cares, required extensive assistance for all activities of daily living (ADLs), had aphasia (a language disorder that affects a person's ability to communicate), and hemiplegia or hemiparesis (paralysis or weakness on one side of the body). R30's annual Minimum Data Set (MDS) dated [DATE], indicated R30 had both a long-term and short-term memory problem, was always incontinent of bowel and bladder, was at risk for developing pressure ulcers. R30's care plan dated 8/2/24, indicated R30 had an ADL self-care performance deficit and interventions included, R30 required two staff participation to dress, one staff person assist with personal hygiene, and one assist with eating. R30's care plan dated 8/2/24, indicated R30 required one to two staff assist for bed mobility, and required two assist with a full mechanical lift for transfers. R30's care plan dated 8/2/24, indicated R30 was at risk for abuse and or neglect related to cognitive and functional deficits and interventions directed staff to follow the vulnerable adult policy, keep R30 safe at all times, and refer to resident services as needed. R37 R37's OSA dated 6/6/24, indicated R37 required extensive assistance with eating. R37's quarterly MDS dated [DATE], indicated a short-term and long-term memory problem, did not have behaviors, had a limitation in range of motion on one side of the upper and lower extremities, required setup or clean-up assistance with eating, had dementia, and hemiplegia or hemiparesis. R37's Medical Diagnosis form indicated R37 had unspecified dementia, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified side, anxiety disorder, major depressive disorder, muscle weakness, and dysphagia (difficulty swallowing). R37's care plan dated 9/10/24, indicated R37 had a self-care performance deficit related to dementia, history of stroke with right sided hemiparesis and right hand contracture and required assistance to perform most ADLs. R37's interventions identified R37 required supervision with eating in the dining room during meals with set-up. R37's care plan dated 9/10/24, indicated an alteration in mood or behaviors due to dementia and a history of delusions an unknown person from outside the facility was attempting to kill or harm R37 or R37's family and interventions indicated encouragement to participate in activities of interest, intervene as necessary to protect the rights and safety of others. Approach and speak in a calm manner, divert attention, remove from the situation and take to an alternate location as needed. R37's care plan dated 9/10/24, indicated R37 was at risk for abuse and neglect due to functional limitations and severe impaired cognition and dementia. Interventions directed staff to follow the vulnerable adult policy, keep R37 safe at all times, and refer to resident services specialist as needed. Nursing assistant's (NA)-F's Notice of Termination form indicated NA-F was overheard telling a resident to stop crying or NA-F would stop feeding them and a clinical coordinator informed NA-F they do not talk to residents like that and expected residents be treated with consideration, courtesy, and respect. Further, the form indicated on 8/14/24, NA-F forgot a resident in their room all morning and upon camera review, the resident was discovered at 11:04 a.m., still in bed and unattended to. NA-F took the resident to lunch at 12:10 p.m. The form indicated NA-F got busy and forgot and as a result the resident did not receive breakfast and did not receive morning cares. During interview on 9/12/24 at 9:44 a.m., the director of nursing stated the administrator had the video of the resident who was forgotten and further stated if there was confirmed abuse a staff person was terminated. During interview on 9/12/24 at 10:17 a.m., the administrator stated the resident who NA-F told to stop crying or she would stop feeding in the Notice of Termination form was R37 and further, the resident NA-F forgot was R30. The administrator further stated she spoke with registered nurse (RN)-A who told NA-F she could not do that and stayed with R37 until she was done and helped feed R37 the remainder of the meal. The administrator stated there was no written follow up completed for R30, but RN-A spoke to NA-F to make sure she reported to someone if she was unable to get a resident up in time. The administrator stated she viewed the footage and R30 was not up until about 11:00 a.m., and did not review cameras for R37. The administrator further stated she did not think they followed up with R30 and stated they dropped the ball on that one unless RN-A followed up. During interview on 9/12/24 between 10:35 a.m., and 10:59 a.m., RN-A stated she was standing by the health unit coordinator station completing paperwork and R37 sat at the table and NA-F was feeding R37. RN-A stated R37 was upset that day and was often upset and NA-F stated, if you don't stop, I'm going to stop feeding you. RN-A stated she was standing about 2 or 3 feet away from NA-F and immediately went to NA-F and told her she couldn't speak to R37 like that and went back to where she was standing and continued to do paperwork. RN-A stated she was appalled and stated R37 did not need help eating and stated she stayed with R37 the whole time and added R37 was ok and tended to have behaviors of crying and being agitated. RN-A stated she reported the encounter to NA-F's supervisor, CCHC-G. RN-A stated she felt it was abusive and added you don't talk to someone like that and stated she did not know whether CCHC-G reported the encounter to anyone other than human resources. RN-A stated R30 was non-verbal and stated they have an interdisciplinary team (IDT) meeting from 10:15 a.m., that ends about 11:00 a.m., and RN-A came upstairs and stated a staff person reported R30's food was in the kitchen and was thrown away because it was 11:00 a.m., and they forgot to feet R30. RN-A stated she asked NA-F what had happened and NA-F began to cry and told RN-A she got busy and missed R30. RN-A stated she contacted the director of nursing (DON) and the administrator right away along with CCHC-G and human resources and asked NA-F what she could do to make sure it didn't happen again. RN-A stated she contacted R30's daughter to explain staff forgot to give R30 breakfast and was not aware if any disciplinary action was completed. At 10:51 a.m., RN-A stated R30 did not have any pressure injuries and did not initiate a body audit because it did not make sense. RN-A stated R30 was incontinent and stated NA-F's shift started at 6:00 a.m. and R30 went about 5 hours by the time she got out of IDT R30 was up in the chair and thought it was around 10:30 a.m. RN-A further stated R30 was at risk of developing pressure ulcers and stated they were worried about R30's meal and did not look at the big picture about R30's skin. At 10:59 a.m., RN-A viewed R30's progress notes and verified there was no progress note indicating a skin assessment was completed for R30 on 8/14/24. During interview on 9/12/24 at 11:52 a.m., CCHC-G stated she was NA-F's supervisor and stated RN-A reported NA-F's statement to R37 on the same day it occurred and thought that incident occurred on 6/4/24. CCHC-G stated she had a log in for filing a vulnerable adult report, but stated their process was to call the administrator or DON who would direct staff how to proceed. CCHC-G further stated she started in her role as the CCHC on 6/3/24, but was an administrative intern at the facility prior. CCHC-G stated the administrator was out, but spoke to human resources about R37 if not the same day, the following day and the campus administrator was also involved. CCHC-G stated she received a report R30 did not receive breakfast and did not know if R30 did not get out of bed, but RN-A spoke to NA-F and handled the situation and stated the vulnerable adult report would be under the discretion of the administrator and the DON. During interview on 9/12/24 at 11:43 a.m., RN-A stated she did not notify R37's family and did not complete vulnerable adult reports and would contact the administrator or the DON and thought she notified both CCHC-G and the administrator regarding R37. During interview on 9/12/24 at 12:50 p.m., the administrator stated a vulnerable adult report was not completed for either resident and stated they should have been reported. A policy, Vulnerable Adult Abuse Prevention Plan, dated January 2023, indicated verbal abuse was the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability, neglect is the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish or emotional distress. Once abuse is suspected or identified, the facility will take all appropriate steps to stop the abuse and protect residents from additional abuse immediately. These steps include but are not limited to reporting the alleged violation and investigation within required timeframes, conducting a thorough investigation of the alleged violation, taking appropriate corrective action, revising the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse.

Based on interview, observation, and document review, the facility failed to ensure R30 received a pillow for positioning for prevention of pressure ulcers and that aided in comfort associate with contractures. Findings include: R30's annual MDS dated [DATE], indicated R30 had severely impaired cognitive skills for daily decision making, had an impairment in range of motion to both upper and lower extremities, was dependent on staff for all activities of daily living, was at risk for pressure ulcers and had pressure relieving devices for the chair and bed. R30's Medical Diagnosis form indicated the following diagnoses: hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting the right dominant side, vascular dementia, contracture of the right and left hand, abnormal posture, and osteoarthritis of unspecified site, R30's care plan dated 8/2/24, indicated R30 had limited physical mobility related to impaired balance, range of motion, dementia, right and left hand contractures, osteoarthritis and interventions included: R30 had positioning signs located in her room, observe for changes in mobility, contractures forming or worsening. R30's care plan dated 8/2/24, indicated R30 was at risk for impaired skin integrity and interventions included to float elbow on the pillow while in bed, and float elbow on U pillow when in the chair see picture. R30's care sheet dated 9/6/24, indicated float elbow on a pillow while in bed and in the chair. During interview and observation on 9/9/24 between 1:48 p.m., and 1:57 p.m.,R30 was in her black reclining wheelchair and R30's elbow was contracted along with the left wrist and fingers on the left hand were curled shut. Signage was located above the bed that indicated R30 was always supposed to have a pillow under her left elbow, however, R30 did not have a pillow located under her left elbow. At 1:57 p.m., nursing assistant (NA)-E stated R30 had a pink pillow and placed it under R30's right elbow. When asked which elbow the pillow was supposed to go, NA-E placed the pillow under R30's left elbow. R30 did not decline to have the pillow. NA-E stated they liked the pillow put on in bed more than the chair but NA-E placed the pillow when R30 was in either location. During observation on 9/10/24 at 12:14 p.m., R30 was at the dining room table in her wheel chair and staff were assisting R30 with her meal. No pillow was located under R30's elbow. During observation on 9/10/24 at 12:42 p.m., an unidentified staff person brought R30 to her room. During observation on 9/10/24, between 12:43 p.m., and 12:55 p.m., NA-C and NA-D assisted R30 into bed with the full body lift. At 12:54 p.m., boots were applied to R30's feet and at 12:55 p.m., a bed pillow was placed under R30's right side and a leg positioning device was placed between R30's legs. NA-C did not apply the pillow under R30's left elbow and did not offer to apply the pillow. NA-C took R30's oxygen tubing out of the room. During interview on 9/10/24 at 1:04 p.m., registered nurse (RN)-B stated R30 was supposed to have a pillow under her elbow and would have expected the pillow to be in place in the chair and stated staff should have offered or placed the pillow under the elbow. RN-B verified after review of R30's care plan staff should have placed the pillow according to the care plan. During interview on 9/10/24 at 1:16 p.m., RN-A stated she thought R30 was supposed to have her elbows floated on any pillow because R30 had a history of pressure injuries and when agitated, tends to dig elbows in. During interview on 9/10/24 at 10:11 a.m., the director of nursing stated staff were not following the plan of care and further, it was important to have the pillows in order to prevent skin issues and the pillow could help with contractures and offloading because R30 had very fragile skin. A policy, Cares-AM and HS, dated September 2020, indicated every resident was to have daily a.m., and bedtime cares completed, being mindful of any resident preferences that may be care planned. The procedure directed staff to review the care plan, nursing assistant assignment sheet for the amount of assistance required to provide care and resident's ability to participate, and complete any other personal cares as requested by the resident or as indicated on the care plan (nursing assistant assignment sheet).

Based on observation, interview, and document review, the facility failed to ensure supplemental oxygen was properly maintained per professional standards for 1 of 1 resident (R30). Findings include: R30's Optional State Assessment (OSA) Minimum Data Set (MDS) dated [DATE], indicated R30 required extensive assist with bed mobility, transfers, eating, and toileting. R30's annual MDS dated [DATE], indicated R30 had severely impaired cognitive skills for daily decision making, did not identify whether R30 utilized oxygen therapy. R30's Medical Diagnoses form indicated the following diagnoses: chronic respiratory failure with hypoxia (low levels of oxygen in body tissues). R30's physician's orders indicated the following order: 1/8/24, Ok to keep oxygen at 1 to 4 liters via nasal cannula (NC) to keep oxygen saturations greater than 88%, change tubing every week. R30's care plan revised 8/2/24, indicated R30 had chronic respiratory failure with hypoxia and R30's goal was to receive oxygen per physician's orders and interventions included to follow facility protocol for care and maintenance of equipment, provide oxygen per nasal cannula see physician orders for liters per minute. During observation on 9/9/24, at 1:52 p.m., R30's oxygen tubing had a sticker that indicated 8/29/24 and the bubbler for the oxygen was dated 8/29/24. During interview and observation on 9/10/24 between 12:43 p.m., and 12:55 p.m., nursing assistant (NA)-C was getting ready to lay R30 down in the bed. R30's oxygen tubing was on the floor along with the cannula portion that goes into the nose and the oxygen was turned on at 2 liters. R30 also had portable oxygen with tubing on the back of the wheelchair, but was not in R30's nose and R30 was not using oxygen. At 12:55 p.m., NA-C picked up the oxygen tubing that was on the floor and placed the nasal cannula in R30's nose. NA-D stated the date on the humidifier and tubing was August 29th. NA-C stated she did not know the cannula was on the floor and stated she would call the nurse and took the oxygen tubing out of the room after being questioned whether the tubing should be placed on R30 after being on the floor. During interview on 9/10/24 at 1:04 p.m., registered nurse (RN)-B took off the bubbler and stated the humidifier was dated August 29th and added distilled water in the humidifier. RN-B stated oxygen tubing was changed every two weeks but would check to verify this and stated she did not expect staff to put the cannula in R30's nose after being on the floor. RN-B viewed the orders and verified the oxygen tubing should have been changed. During interview on 9/10/24 at 1:16 p.m., RN-A stated oxygen tubing was changed on a weekly basis and if it falls on the floor and stated if the tubing was dated August 29th, it should have been changed and stated staff should know if oxygen tubing was on the floor, the tubing should be thrown away. During interview on 9/12/24 at 10:11 a.m., the director of nursing (DON) stated she had someone that came weekly to change oxygen tubing, but that person was ill and there wasn't a back up plan. DON further stated they should not apply the cannula if it was on the floor because of infection control. A policy, Oxygen Equipment Care and Maintenance, modified October 2011, indicated tubing was not to touch the floor and tubing was changed and dated weekly. Additionally, the humidifier bottles would be changed and dated weekly.

Based on inteview and document review the facility failed to identify potential triggers and offer specialized services for 1 of 1 resident (R275) who had a history of trauma. Findings include: R275's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of major depressive and anxiety disorder. It further indicated R275 had a behavior of socially isolating herself, required substantial assistance with toileting and partial assistance with mobility. R275's Long Term Care (LTC) Psychosocial assessment dated [DATE], indicated R275 had a dignoses of major depressive disorder, anxiey, and had a history of trauma. It also indicated R75 had felt numb, detached from others, activities and/or surroundings as a result of that trauma. It lacked documentation that triggers were assessed to prevent re-traumatization. R275's Comprehensive Nursing Assessment Data Collection dated 8/22/24, indicated R275 preferred female caregiver only. It lacked documentation that triggers were assessed to prevent re-traumatization. R275's care plan dated 8/22/24, indicated I have a history of trauma. I was sexually abused for many years at a young age. I tend to isolate myself and can be quite shy due to this. It further indicated the following interventions: -I prefer females for personal cares -refer to resident services as needed -remind me that I am safe here R275's care plan lacked documentation of an assessment for triggers to prevent re-traumatization or other specialized services were offered or refused. R275's medical record lacked documentation ACP or other specialized services were offered or refused. R275's progress notes since admission lacked documentation of an assessment for triggers to prevent re-traumatization or specialized services were offered or refused. During interview on 9/9/24 at 5:35 p.m. R275 stated she had been a long time victim of child abuse and it was hard for her to have a male come in and change her brief, (especially at night) due to her past trauma. She understands they (the facility) may not have enough women (staff) but it seemed to be a problem during the overnight shift. R275 further stated she hadn't been assessed for triggers but her son told the facility about her past history of trauma when she was admitted . During a follow up interview on 9/10/24 at 10:23 a.m. R275 stated she hadn't been offered any specialized services (such as associated clinical physcology) to help her cope with past trauma. During interview on 9/11/24 at 12:24 p.m., household coordinator (HC)-A stated when a resident admits to the facility the household coordinators are responsible for completing an assessment titled Long-Term Care (LTC) Psychosocial assessment which included the questions regarding past trauma. The questions specifically assessed for triggers such as if the resident tends to isolate, detach from others and their surroundings, and if they had nightmares. The facility also offered ACP services and it should be documented if it was offered and if the resident accepted or declined it. HC-A further stated they spoke to R275 today, offered ACP services, and made a plan to check in on a quarterly basis to see how things were going. She also asked her about any triggers. HC-A stated ACP was offered at admission but hadn't been documented and added it today (9/11/24) to R275's care plan. During interview on 9/12/24 8:56 a.m., the director of nursing (DON) stated when a resident was admitted to the facility the household coordinators were responsible for completing all the paperwork and if something came up they would complete the assessment for trauma informed care. Once that was completed, it would be added to the residents care plan. The assessment used for trauma informed care was titled LTC Psychosocial assessment for any resident diagnosed with a behavioral health disorder or a history of trauma. The household coordinators should ask the residents about any triggers, unless asking about the trigger may be a trigger. They should be offering services such as ACP and documenting that services were offered and whether the resident accepted or refused the offer. The facility's policy on trauma informed care dated 12/2022, indicated Presbyterian Homes and Services will ensure we assess a resident who displays or is diagnosed with mental disorder or psychological adjustment difficulty, or who has a history of trauma and/or posttraumatic stress disorder and facilitate appropriate treatment and services to manage the assessed problem to attain the highest practicable mental and psychological well-being. The intent of this requirement is to ensure that the facility delivers care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally competent and account for experiences and preferences and address the needs of trauma survivors by minimizing triggers and/or re-traumatization.

Based on observation, interview, and record review the facility failed to provide medication as ordered by the provider for 1 of 3 residents (R72) observed during medication administration. Findings include: R72's quarterly Minimum Data Set (MDS) dated [DATE], indicated R72 had cognitive impairment and diagnoses of dementia and delusional disorder. R72's provider order dated 1/9/24, indicated R72 required Seroquel (antipsychotic medication used to help treat delusional disorders) 25 milligrams (mg) daily at bedtime. R72's September medication administration record (MAR) indicated R72 did not receive the ordered Seroquel on 9/9/24 as the dose was not available. R72's nursing progress note dated 9/9/24 at 6:52 p.m., indicated R25's Seroquel was not available and follow up with pharmacy was needed. A facility form titled Refill Reorder Form dated 9/1/24, indicated R72's Seroquel was requested to be refilled. A facility form titled Refill Reorder Form dated 9/8/24, indicated R72's Seroquel was requested to be refilled. A facility form titled Refill Reorder Form dated 9/10/24, indicated R72's Seroquel was requested to be refilled. A pharmacy comment on re-order form indicated to send 3 doses to facility and ok to bill to the facility. An observation on 9/9/24 at 6:48 p.m., trained medication assistant (TMA)-A prepared to administer R72 medications. R72's Seroquel was not available for administration. TMA-A had administered R72's other medications however was not able to administer the Seroquel. When interviewed on 9/9/24 at 7:00 p.m., TMA-A stated the last dose of Seroquel was administered yesterday. TMA-A stated they re-ordered it yesterday and it still had not arrived. If a medication was needing to be refilled, a fax was sent to the pharmacy. The latest time of arrival was between 8:00 and 9:00 p.m. TMA-A further explained if the Seroquel was not on that delivery, it would come tomorrow morning. When interviewed on 9/11/24 at 7:58 p.m., registered nurse (RN)-A stated medications should be re-ordered when there was about a week's worth left. The last row of the blister pack was red and should be reordered when taking from that row. Seroquel was not a medication in the emergency kit and if the medication was not available it would be missed. When interviewed on 9/12/24 at 11:41 p.m., the Director of Nursing (DON) stated when a medication was re-ordered, the hope was for it to be delivered the following day. DON further stated the facility had been working with pharmacy on this process and trying to ensure medications were received timely. When interviewed on 9/12/24 at 1:01 p.m., pharmacist-A stated R72's initial request was sent on 9/1/24, which was too soon to refill. Pharmacist-A stated insurance will not cover if the medication is refilled too soon. The facility was typically notified that the requested medication was too soon to fill via fax. The pharmacy then puts a notation in their system that will prompt pharmacy to fill when able. Pharmacist-A stated R72 had a 30-day supply of Seroquel last sent on 8/15/24 which should be good until 9/15/24. Pharmacist-A stated a refill request for the Seroquel was again sent on 9/8/24 and 9/10/4. On 9/10/24, the facility ok'd to pay for 3 days' worth until the refill could be completed. On 9/10/24, the pharmacy sent 3 days' worth of R72's Seroquel. A follow up interview on 9/12/24 at 1:25 p.m., the DON was asked if there was a process to track or understand why a medication would run out before the ability to refill. The DON stated they would need to look into that and get back however no further information was provided. A facility policy titled Medication ordering and receiving from pharmacy no date, directed staff to reorder medications when a 5-day supply remains to assure delivery can be timely.

Based on observation, interview and document review the facility failed to ensure medication errors were prevented for 2 of 4 residents (R72, R109) observed during medication administration. This resulted in a medication error rate of 7.69%. Findings include: R72 R72's quarterly Minimum Data Set (MDS) dated [DATE], indicated R72 had cognitive impairment and diagnoses of dementia and delusional disorder. R72's provider order dated 1/9/24, indicated R72 required Seroquel (antipsychotic medication used to help treat delusional disorders) 25 milligrams (mg) daily at bedtime. R72's September medication administration record (MAR) indicated R72 did not receive the ordered Seroquel on 9/9/24 as the dose was not available. R72's nursing progress note dated 9/9/24 at 6:52 p.m., indicated R25's Seroquel was not available and follow up with pharmacy was needed. An observation on 9/9/24 at 6:48 p.m., trained medication assistant (TMA)-A prepared to administer R72 medications. R72's Seroquel was not available for administration. TMA-A had administered R72's other medications however was not able to administer the Seroquel. When interviewed on 9/9/24 at 7:00 p.m., TMA-A stated the last dose of Seroquel was administered yesterday. TMA-A stated they re-ordered it yesterday and it still had not arrived. If a medication was needing to be refilled, a fax was sent to the pharmacy. The latest time of arrival was between 8:00 and 9:00 p.m. TMA-A further explained if the Seroquel was not on that delivery, it would come tomorrow morning. R109 R109's admission MDS dated [DATE], indicated R109 was cognitively intact with diagnoses of Parkinson's disease, and hypothyroid (low thyroid hormone). R109's provider order dated 6/7/24, indicated R109 required levothyroxine 50 micrograms (MCG) daily for hypothyroidism. An observation on 9/10/24 at 8:40 p.m., TMA-B prepared R109's morning medications. R109's Synthroid medication pack was observed. There was a label placed that instructed the medication to be taken on an empty stomach. After R109's medications were prepared, TMA-B entered R109's room. R109 was up out of bed seated in a wheelchair finishing breakfast with the assistance of staff. TMA-B waited a few moments until R109 was done with breakfast and then administered R109's morning medications including Synthroid. When interviewed on 9/10/24 at 9:10 a.m., TMA-B acknowledged the Synthroid was given as R109 was finishing up with breakfast and the medication instructions from pharmacy to administer on an empty stomach. TMA-A stated they try to follow the directions; however, it was not always given before breakfast. TMA-B stated the medication was not scheduled at a specific time and was ordered as an 8:00 a.m. medication. Medications ordered at this time had a larger window of administration. TMA-B further stated if it was a priority to be given earlier due to the empty stomach instructions, the Synthroid would be scheduled for 7:00 a.m. When interviewed on 9/11/24 at 7:58 p.m., registered nurse (RN)-A stated medications should be re-ordered when there was about a week's worth left. The last row of the blister pack was red and should be reordered when taking from that row. Seroquel was not a medication in the emergency kit and if the medication was not available it would be missed. RN-A stated the medication order and the medication label on the packet or bottle should match up. If there were further administration instructions from pharmacy listed, they should be followed, and the medication order or schedule should reflect the medication administration instructions. When interviewed on 9/12/24 at 11:41 p.m., the Director of Nursing (DON) stated when a medication was re-ordered, the hope was for it to be delivered the following day. DON further stated the facility had been working with pharmacy on this process and trying to ensure medications were received timely. Furthermore, the DON expected staff to follow medication instructions listed from pharmacy on the medication card. When interviewed on 9/12/24 at 12:44 p.m., the consultant pharmacist (CP) stated Synthroid has a better absorption if given on an empty stomach and if given with meals, it may not be absorbed as well. A facility policy titled Medication Administration revised 5/2021, directed medications ordered to be given on an empty stomach will be administered at least 30 minutes prior to a meal.

Based on observation, interview, and document review, the facility failed to ensure foods were labeled, free from freezer burn, and the freezers were cleaned and maintained. Additionally, the facility failed to ensure use of hair restraints during food preparation and the refrigerators in the unit dining rooms were maintained. Findings include: During the initial kitchen tour with the nutrition and culinary supervisor (NCS) on 8/27/23 at 11:51 a.m., observed the following: Kitchen Freezer: 1 package of undated veggie burger patties NCS stated the patties would be tossed because they should have been dated 1 full box dated 6/19/23, contained ground hamburger patties that were open to air NCS stated the package should be closed and verified there were ice particles on the hamburger and the meet contained varied colors. Hot dogs in an undated plastic container, NCS stated she had no idea how long they had been in the freezer 1 bag of undated and opened to air corn with a best by date of 7/2025 1 package of pork cutlets NCS stated contained ice particles and was freezer burnt 1 opened and undated five pound bag of chick The back of the freezer contained a build up of icicles Dry Storage: 1 bottle of Canola with the cap unsecured and NCS stated the cap should be secured 1 plastic bottle of browning sauce with a build up on the opening NCS stated 3/27/22 was the date and the build up was dried sauce and the bottle would be tossed Basement Freezer: 1 bag of opened bananas with ice particles and three bags of bananas with torn bags NCS stated should be thrown away 3 packages of unlabeled and undated mashed bananas 7 packages of unlabeled brown frozen items NCS stated she did not know what was in the packages, but it looked like roast beef that was discolored with snow in the bags. The floor of the freezer contained dirty particles NCS stated she assumed was bananas. Main Kitchen: An unnamed male in the kitchen wore a hair net, but had a beard and was working next to food items with no coverage for the facial hair. During interview and observation on 8/29/23 at 7:40 a.m., the refrigerator in the north dining room contained a container of undated macaroni and cheese and a plastic container that was unlabeled and undated. The culinary director (CD) stated she would pull the items. Additionally, an undated container covered in tin foil contained mini donuts. A sign located on the refrigerator indicated the food was for residents and employee lunches and beverages were not to be stored in the refrigerator. The freezer contained a Dilly bar the CD stated was partially eaten and was stuck on the freezer surface and CD removed the item. During interview on 8/29/23 at 7:59 a.m., to 8:08 a.m., CD stated the bananas were disposed and stated the service representative came out on 8/28/23, and they updated him on the ice dam in the freezer and added it is something in the ceiling. CD stated expected food times to be labeled and dated. CD also stated they didn't require coverage for beards under food code. During interview and observation on 8/29/23 from 11:23 a.m. to 11:30 a.m., on the second floor refrigerator in the dining area, observed spots in the door on the second shelf from the bottom and the inside of the door hinges contained some dried spots that were caked on and NCS stated may have to put a work order in for the drippings in the refrigerator because it was caked on. During interview and observation on 8/29/23 at 11:40 a.m., on the third floor dining room refrigerator, a bottle of chocolate syrup with a brown substance located around the whole top of the container was located in the refrigerator and cook-(C)-A stated it was chocolate syrup on the lid and around the lid and would toss the item. A policy, Safe Food Storage Policy dated May 2019, indicated employees who received and stored food would maintain the storage areas including dry, refrigerated and frozen storage areas utilizing the following guidelines: make sure all goods are dated with received dates, label, date and properly cover all food items upon opening of package. A policy, Labeling and Dating Policy (Ready to Eat and /or Potentially Hazardous Food) dated August 2019, indicated label and date ready to eat and or potentially hazardous foods that are opened and or prepared with the following information: clearly indicate name of product if not in original container, mark food containers to show when food was opened/prepared, or when the food must be used or discarded based on facility procedure. Foods that are not marked will be discarded.

Based on observation, interview, and document review, the facility failed to provide air bed monitoring for safety and function for 1 or 1 resident (R6), reviewed for air bed safety. Findings include: R6's significant change Minimum Data Set (MDS) dated [DATE], indicated R6 was cognitively intact, and required extensive assist of one staff for bed mobility and transfers. R6's face sheet printed 8/30/23, indicated resident diagnosis included congestive heart failure (a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs), urinary tract infection, and atrial fibrillation (an abnormal heartbeat). R6's skin integrity care plan updated 7/28/23, indicated R6 had a pressure relieving mattress. R6's physician orders dated 8/8/23, indicated air mattress for skin integrity. During observation on 8/29/23 at 2:03 p.m., R6 air mattress control device had a continuos blinking red light. During interview on 8/29/23 at 2:28 p.m., engineer technician (ET)-B stated if an air bed was (was-use past tense) flashing red it was probably not good and indicated a malfunction which the maintenance department would have the air bed company come into the facility to replace the air mattress with a new one. ET-B also stated the housekeeping staff had been trained to check air mattresses when the weekly bedding change was completed, as well as, daily to monitor the air bed control units. and the house keeping staff knew when something was off to notify maintenance. During observation on 08/30/23 at 8:30 a.m., R6 air mattress control device had continued with a continuous blinking red light. During interview on 08/30/23 at 08:40 a.m., the environmental director (ED)-A stated a flashing red light on the air mattresses indicated the air bed control was not working or there had been a power outage prior. ED-A stated there were no scheduled maintenance monitoring logs of air mattresses in the facility, since housekeeping and nursing checked the air mattress device once a week and notified maintenance if issues were identified. ED-A verified R6's bed had a flashing red light and was not aware of any repair request for R6's air mattress from housekeeping or nursing staff and could not find or provide one. Housekeeping and nursing staff air mattress education with dates completed was requested and not received. A request for air bed repair from housekeeping or nursing for R6 was requested but not received. A maintenance monitoring and inspection documentation of air beds in the facility was requested and not received. The Facility Mattress, Bed Frame and Assistive Device Selection Policy updated 11/22/23, indicated beds, mattresses, and assistive devices must be inspected following the completion of a Physical Device Assessment recommending the initiation of a device. This will occur after informed consent and risk and benefit discussion has occurred. See Physical DeviceAssessment Policy. Engineering staff will be trained on the procedure for measuring the dimensions and zones in accordance with the FDA guidelines. All other staff will be educated on observations to report. Engineering will complete an annual inspection of all beds and devices. Annual inspections will be triggered through the Presbyterian Homes and Services Tels Work Order System.

Based on observation, interview, and document review, the facility failed to ensure dignity was maintained for 2 of 2 residents (R6, R8) reviewed for dignity. Findings include: R8's annual Minimum Data Set (MDS) dated [DATE], indicated R8 had severe cognitive impairment, did not reject care and it was somewhat important to choose what clothes to wear, was totally dependent on staff for personal hygiene to include shaving. R8's diagnoses included: non traumatic brain dysfunction, unspecified dementia, diabetes mellitus, depression, and hemiplegia or hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles). R8's care plan dated 6/27/23, indicated R8 wanted to be clean and well dressed daily. Further, R8 wore a wig that was to be on in the a.m., and off at bedtime, and required two staff participation with personal hygiene and oral care. Additionally, R8 had physical behaviors of striking out, hitting and scratching staff during cares due to dementia and depression with interventions included to allow R8 to make choices when possible about cares and activities, and document observed behavior and attempted interventions per policy. Further, indicated R8 had an alteration in blood glucose related to a diagnoses of diabetes and with an intervention of a nurse would provide nail care. The care plan lacked an intervention for shaving. R8's care sheet undated, indicated R8 wore a wig during the day and was removed at bedtime, received a bath on Monday a.m., was on bleeding and bruising precautions due to being on a blood thinning medication, and the nurse was to trim nails due to a diagnosis of diabetes. The care sheet lacked instruction for staff to remove R8's facial hair. R8's Target Behavior form from 8/1/23 to 8/30/23, indicated behaviors occurred on 8/7/23, 8/12/23, 8/13/23, and 8/26/23. The rest of the time frame indicated behaviors were documented as did not occur 55 times or not applicable 25 times. R8's Bath form from 8/1/23, to 8/30/23, indicated R8 received a bath on 8/14/23. No additional baths were documented during the time frame. Additionally, there were no documented refusals. R8's clinical physician orders dated 1/9/23, was reviewed and included an order to trim finger nails during shift every Monday and ask for nursing assistant (NA) assistance as needed. The Clinical Physician Orders form was reviewed and lacked any instruction for removing R8's facial hair. R8's medication administration record (MAR) and treatment administration record (TAR) for August 2023, was reviewed and lacked instruction for removing R8's facial hair. During observation on 8/27/23 at 3:45 p.m., R8 was observed to have a dark mustache on her upper lip and around her mouth. During observation on 8/29/23 at 7:16 a.m., R8 was up in her wheelchair and observed R8 to have a dark mustache. During observation on 8/30/23 at 8:31 a.m., R8 was at the dining room table and had a visible dark mustache noted and R8 was wearing her black colored wig. During interview 8/29/23 at 9:42 a.m., nursing assistant (NA)-B stated they looked at care sheets in order to know what kind of cares a resident required. During interview on 8/29/23 at 9:54 a.m., NA-B stated she did not shave R8 because a nurse needed to shave R8 because she could not risk cutting R8. During interview on 8/30/23 at 9:13 a.m., registered nurse (RN)-D stated she looked to the care plan to know what kind of cares a resident received and stated women were shaved on their bath day and added if a resident was diabetic, the nurse completed shaving. After asking about R8's bath day, RN-D stated it had been a while and if the resident had an electric razor, the NA could shave the resident and stated R8 had an electric razor and therefore the aide was responsible for shaving R8. LPN-A stated when someone refused cares, it was documented. During interview and observation on 8/30/23 at 9:26 a.m., RN-D verified there was no electric shaver in R8's room and at 9:30 a.m., verified R8 had facial hair and stated R8 should be shaved. During interview on 8/30/23 at 9:31 a.m., registered nurse (RN)-B stated R8 was diabetic and there was no specific assignment for shaving, but thought it was the nurse's responsibility and if R8 refused, expected documentation of refusals from all staff. RN-B verified there was no specific task for shaving on the care plan or care sheet, no bath documented since 8/14/23 for R8, no documentation the past three to four months regarding any refusals for shaving, and stated they should have a scheduled task for shaving because the task could get missed if it was not identified on the care plan and care sheet. RN-B added a female resident would not want facial hair. During interview on 8/30/23 at 9:47 a.m., the director of nursing (DON) stated the aide was responsible for shaving, but if a resident was diabetic, it was the nurse's responsibility. DON stated women should be shaved as needed and expected shaving be completed on bath days adding it was a dignity issue for a female to have facial hair. . 42580 R6's significant change Minimum Data Set (MDS), dated [DATE], indicated R6 was cognitively intact, and required extensive assist of one staff for toileting and personal hygiene. R6's face sheet printed 8/30/23, indicated resident diagnosis included congestive heart failure (CHF), urinary tract infection, and atrial fibrillation. R6's bladder care plan revised on 7/31/23, indicated R6 is occasionally incontinent of bowel and bladder, with goal that included would be free from skin breakdown due to incontinence and from brief use through review date. R6 catheter updated 8/27/23, indicated I have (SIC) catheter or urostomy with interventions that included position catheter bag and tubing below the level of the bladder. Catheter care per facility policy. R6's physician orders dated 8/4/23, included catheter care every shift and as needed. Document output in point of care (POC) record two times a day for catheter maintenance. Catheter bag and/or leg bag covered at all times. During observation and interview on 8/27/23 at 3:11 p.m., R6's catheter was attached to the side of her wheelchair (w/c) and not in a privacy bag. R6's catheter could be seen from the doorway. During interview, R6 stated, she would prefer the catheter bag be placed in a privacy bag. During observation on 8/29/23 at 1:09 p.m., R6's catheter was attached to the side of her W/C, hooked onto a bag attached to the top side rail attachment on W/C. R6's catheter tubing and catheter bag were at the level of her bladder; catheter bag was not in privacy bag. During interview on 8/30/23 at 10:50 a.m., nursing assistant (NA)-F verified catheter bag was not in privacy bag or below the bladder as should have been to allow urine to drain into the bag. During interview on 8/30/23 at 4:17 p.m., director of nursing (DON) stated, it was the expectation catheter bags were placed in privacy bags and placed below the bladder to prevent urine backing up into the bladder. A policy, Resident Care Policy dated February 2016, indicated every resident was to have morning and bedtime cares daily. The procedure included shaving female residents in the am and applying makeup as requested. A policy, Dignity dated September 2015, indicated residents were cared for in a manner and in an environment that promoted maintenance and or enhancement of each resident's quality of life Facility policy titled Catheter- Care of Indwelling Cath Policy modified on 6/2021, indicated catheter is placed in cloth bag when up in wheelchair and when in bed. Never raise a catheter bag above the level of the bladder. This could increase the chance of a bladder infection.

Based on observation, interview, and document review, the facility failed to ensure 2 of 2 residents (R25, R98) had been assessed to safely self-administer medications. Findings include: R25's quarterly Minimum Data Set (MDS) dated [DATE], indicated R25 had mild cognitive impairment and diagnoses of stroke and chronic respiratory failure. Furthermore, R25's MDS indicated R25 required supplemental oxygen. R25's provider order dated 10/5/22, indicated R25 required Ipratropium-albuterol solution .5/2.5 milligrams (mg) per 3 milliters (ml) (medication to help open airways and improve breathing) via nebulizer (machine to administer inhaled medications) 4 times daily for shortness of breath. R25's provider orders lacked indication R25 was able to self-administer medications. R25's medical record lacked indication an assessment for R25 to self-administer nebulizer medications had been completed. An observation on 8/28/23 at 6:50 a.m., trained medication assistant (TMA)-A walked by R25's room stopped and opened the door slightly to peer inside before partially closing door and continuing down the hallway. An observation on 8/28/23 at 6:52 a.m., R25 was lying in bed with a nebulizer mask in place and running. The nebulizer appeared to be almost completed, however no staff were in room. At 6:57 a.m., TMA-A entered room. TMA-A waited in room until nebulizing medication was completed before removing mask from R25. An observation on 8/29/23 at 11:56 a.m., R25 was seated in the wheelchair in his room. The nebulizer mask was on and running. R25 stated can it come off it is done. Staff were not present in the room. At 12:02 p.m., TMA-B entered the room and removed the nebulizer mask and asked R25 if he was ready for lunch. When interviewed on 8/28/23 at 7:23 p.m., TMA-A stated residents who want to self-administer medications require an assessment and a provider order. TMA-A verified this was true for nebulizers as well. TMA-A thought R25 had one, but acknowledged there was no order or assessment completed. TMA-A further verified they had left R25's room when administering the nebulizer to document on the computer and was not present during administration of the nebulizer. When interviewed on 8/29/23 at 12:04 p.m., TMA-B stated an order would direct if the resident could self-administer medications. TMA-B further stated R25 was not able to self-administer any medications and was dependent on staff. TMA-B acknowledged they had not remained in the room with R25 for the duration of the nebulizer medication. When interviewed on 8/29/23 at 12:09 p.m., licensed practical nurse (LPN)-B stated there needs to be an order to self-administer medications and an assessment. LPN-B verified there was an assessment for inhaled medications that had been started on 8/28/23 but was not completed. When interviewed on 8/30/23 at 10:33 a.m., the director of nursing (DON) expected staff to remain in the room when administering all medications unless the resident had an order and an assessment. 42580 R98's annual Minimum Data Set (MDS) dated [DATE], lacked indication of R98's cognitive status with Care Area Assessment (CAA) triggered for cognitive loss, dementia and communication. R98's face sheet printed on 8/30/23, indicated R98 diagnoses included acute and chronic respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body or when you have too much carbon dioxide in your blood), acute onset chronic diastolic heart failure ( Heart failure that comes suddenly, often with sudden difficulty breathing and fatigue) and hereditary and idiopathic neuropathy unspecified (a group of inherited disorders that affect the nerves that branch out from the brain and spinal cord). R98's physician orders dated 6/2/22, indicated genteal tears solution 0.1-0.3 percent, instill one drop in both eyes as needed for dry eyes for times daily as needed (PRN); biofreeze external gel four percent topical analgesic. Apply to left shoulder topically as needed for chronic pain in shoulder. Apply thin layer daily prn until further notice. R98's care plan updated 7/15/23, indicated I am not able to self administer my own medications, set up and administer per orders. R98's care plan revised 7/18/23, indicated R98 has long-term and short-term memory impairment. Primary language is Cantonese and ability to participate in brief interview for mental status (BIMS) is dependent on availability of interpreter. Has communication problem with interventions that included use of communication board and provide interpreter as necessary. During observation and interview on 08/29/23 10:46 a.m., R98 had a tube of biofreeze cream which she pulled out of her wheelchair to show surveyor while talking in preferred language, with a few words of English stating pain hurt and pointing to shoulders and legs. There was a bottle of green liquid written in an unknown language sitting outside an opened box. There were two additional unopened boxes similar to the opened box, with unknown language written on the boxes. One bottle of genteal eye drops was also noted on top of wooden drawer near bed. During observation on 8/29/23 at 11:16 a.m., registered nurse (RN)-F entered R98's room to give medications. R98's room door was opened. The unknown contents were on top of the bed side table and the genteal eye drops were on top of the wooden drawer in room. RN-F completed giving resident R98 her medications and left room. There was no observation of RN-F removing the items one bottle with green content, two unopened bottles of unknown content), genteal eye drops; these were left in R98's room. These bottles of unknown content and the genteal eye drops could be seen on top of the table and wooded drawer in clear view from the door way. R98's record lacked documentation of a self-administration assessment. During interview on 8/29/2023 at 2:25 pm p.m., RN-F stated today was the first day observing unknown items (bottle of green liquid, two unopened boxes of unknown content, genteal eye drops) in R98's room on bed side table and on top of the wooden drawer but was not aware of a self-administration assessment for resident R98 and verified one should have been completed with eye drops and unknown items in R98's room. RN-F did not remove unknown items from R98's room. These items remained in R98's room until the end of the survey. When interviewed on 8/29/23 at 2:49 pm p.m., licensed practical nurse (LPN)-C stated R98 had pain cream used and kept by R98. LPN-C also stated had seen what appeared like homeopathic medication brought in by family for R98 to use for her pain for rubbing on her skin. LPN-C was aware of the boxes with unknown contents being in R98's room on an ongoing basis and was aware R98 used these items. LPN-C did not know if there was a self-administration assessment completed for R98. During interview on 8/29/23 at 3:05 p.m., registered nurse (RN)-A verified unknown items in R98's room and stated there should have been a self-administration assessment completed for R98 to have the unknown items including the genteal eye drops in her room. RN-A did not remove unknown items from R98's room. These unknown items remained in R98's room until the end of the survey. During interview on 08/30/23 12:41 p.m., family member (FM)-D stated the items on the table and drawer the family brings in. FM-D also stated these topical rubs were for R98's pain and FM-D also helped R98 to apply the ointments to R98's body with massage. During interview on 08/30/23 4:17 p.m., the director of nursing (DON) stated the facility did not have a self-administration assessment completed for R98 and it should have been completed for the items R98 had kept in her room including the genteal eye drops, two unopened boxes with unknown contents, the bottle of green liquid, and biofreeze cream observed in R98's room. A policy titled Self Administration of Medication Policy revised on 11/2016, directed staff to complete a self-administration of medication assessment on all residents upon admission, annually and with significant changes. Once the assessment was completed, the interdisciplinary team will review to determine the resident was able to safely self-administer medications.

Based on interview and document review, the facility failed to follow interventions implemented to reduce or prevent a fall for 1 of 1 resident (R1) reviewed for accidents. R1 was left unattended in bed with the head of the bed (HOB) elevated more than 30 degrees. R1 was found lying on the floor, was not breathing and was already blue around the mouth. Although noncompliance was present at the time of the event, the facility had implemented appropriate corrective action by 7/11/20, resulting in a finding of past noncompliance at G level harm for R1. Findings: R1's face sheet dated 7/14/20, indicated R1 had diagnoses of hypertension ([CONDITION(S)]), [CONDITION(S)] (MS), functional [CONDITION(S)], unspecified dementia without behavioral disturbance, and muscle weakness. R1's annual minimum data set (MDS) dated [DATE], indicated moderately impaired cognition, no behaviors, ADL: ate independent, all others extensive or total assist. No falls. R1's care plan dated 6/17/20, identified R1 was non-ambulatory, required assistance of two staff for repositioning in bed, and required the assistance of two staff with a full lift for transfers. It further indicated the HOB should not be raised above thirty degrees, as an intervention due to being a fall risk related to MS, impaired cognition, [CONDITION(S)], incontinence, weakness, and abnormal posture. When out of bed, R1 used a [NAME] chair, which is made for people with poor muscle/trunk control. The plan identified R1 could eat independently after set up. R1's nursing assistant care sheet dated 7/5/20, indicated the head of the bed (HOB) should not be raised above 30 degrees. Interview with R1's family member on 7/14/20, at approximately 11:00 a.m., identified R1 needed to be centerized in the bed, due to poor muscle control. On 7/14/20, at 1:01 p.m. during an interview with nursing assistant (NA)-A said she brought R1 his meal tray at approximately 5:30 p.m. She said R1 was laying in his bed, so she raised the head of the bed to forty five degrees so he could eat. NA-A also said she left R1 alone in his room and returned around 6:10 p.m. where she found him lying on the floor in his room next to his bed. R1's progress note dated 7/5/20, indicated R1 was on the floor in his room, not moving. He was unresponsive, his face was bluish, he wasn't breathing, and didn't have a pulse. R1's resident occurrence report dated 7/5/20, indicated R1 was found on the floor in his room at 6:10 p.m. and had fallen out of bed due to the HOB being elevated above 30 degrees. It further indicated the last time the resident was observed before the fall was at 5:30 p.m. when NA-A had brought him his meal tray. The Falls Follow Up Form indicated the resident may have tipped to the side while having dinner as one of the causal factors. It also stated that R1 had poor muscle control. On 7/14/20, at 1:01 p.m. during an interview with nursing assistant (NA)-A said she worked with R1 on a regular basis and was familiar with his cares. She also said she carries the nursing assistant care sheet with her and was aware that it indicated the HOB should not be raised above thirty degrees. NA-A further stated on several occasions she had previously given R1 his meal tray while he was in bed and had raised the head of the bed, so that he could eat. Review of interviews conducted by the facility as part of the investigation on 7/7/20, regarding how R1 is usually set up to eat meals, NA's (NA-B, NA-C) stated they assist R1 to the [NAME] chair to eat. Although the care plan did not direct staff to assist R1 to the chair for meals it did direct staff not to raise the head of the bed more than 30 degrees. On 7/14/20, at 1:26 p.m. during an interview with the Administrator confirmed NA-A was not following R1's care plan because she had raised the head of his bed above 30 degrees so he could eat. Although the facility failed to follow the care plan on 7/5/20, the facility was able to verify corrective action had occurred, including NA-A was placed on administrative leave on 7/6/20, she received further education on preventing falls (7/10/20) and residents rights (7/11/20), and the facility will be auditing her work performance. On 7/10/20, the facility also provided education to all staff on the importance of following the care plan and will complete random audits weekly and review them. The facility also completed an investigation timely. The corrective action was verified as completed 7/11/20, during the onsite survey 7/14/20. Therefore, this deficient practice is being cited at Past Noncompliance.

Based on observation, interview and document review, the facility failed to ensure toileting was provided to prevent falls for 1 of 3 residents (R1) reviewed for falls. This resulted in actual harm to R1, who fell and sustained a [MEDICAL CONDITION]. However, the facility implemented corrective action prior to the onsite investigation, so the deficiency is being issued at past non-compliance. Findings include: R1's Admission Record printed 1/15/20, indicated R1's [DIAGNOSES REDACTED]. R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R1 had severely impaired cognition. The MDS further indicated R1 was always incontinent of bowel, and occasionally incontinent of bladder. The MDS indicated R1 required extensive assistance of one staff with toileting and incontinence cares, and had experienced two or more falls with no injury since the last assessment. R1's Care Area Assessment (CAA) for Incontinence dated 12/30/19, identified R1 was experiencing urinary incontinence, was a fall risk, and had a visual field deficit. R1's Bowel, Bladder, and Skin Assessment completed on 10/25/19, indicated R1 required the assist of 1 staff, and was to be toileted every 3 hours and as needed during the day, and between 10-11 p.m. and 3-4 a.m. during night shift. R1's care plan initiated 1/15/19, identified R1 had a potential for falls related to impaired balance during transfers, frequent self-transfers, impaired safety judgment, incontinence with occasional urgency, medication side effects, and refusal of care from staff members. R1's goal was to remain free of serious injury. Interventions included toileting plan to be followed, and assist with ambulation and transfers. The care plan further identified R1 as being incontinent of bowel, and dependent on staff for management. R1's goal was to remain free from skin breakdown due to incontinence and brief use. Interventions included assist to the bathroom, and toileting schedule to be followed. The care plan lacked direction of when to toilet R1. R1's Care Sheet (nursing assistant care guide) dated [DATE], directed staff to assist R1 with toileting at the following times: Dayshift -every 3 hours and as needed, Night shift- between the hours of 10-11 p.m. and 3-4 a.m. On 9/13/19, a progress note indicated [REDACTED]. Two of the falls were at night related to R1 toileting herself independently. A fall in September was also related to R1 toileting herself independently. Interventions implemented included revision of R1's toileting times to every 3 hours, and as needed on the day shift and evening shift, again between 10 p.m. and 11 p.m., and then between 3-4 a.m. on the night shift. Review of R1's fall incident reports indicated the following: On 1/5/20, at 12:57 a.m. nursing assistant (NA)-A changed R1's incontinent brief while she was in bed, but did not offer to toilet her. At 4:30 a.m. NA-A entered R1's room and found her lying on the floor near her bedside. NA-A called for assistance, and R1 was evaluated by a registered nurse (RN). The incident report further indicated NA-A had not followed the care sheet which directed staff to toilet R1 between the hours of 10:00 p.m.-11:00 p.m. and 3:00 a.m.-4:00 a.m. On 1/5/20, at 11:01 a.m. a progress note indicated [REDACTED]. Staff also documented R1's leg appeared shorter and externally rotated to the left side. an order for [REDACTED]. On 1/8/20, a progress note indicated R1 was readmitted to facility on that day at 3:20 p.m. from the hospital. R1 was noted to have confusion and was disoriented. Further, the note indicated R1 had required left hip surgery and was now required assist of one for all activities of daily loving and transfers. On 1/15/20, at 2:14 p.m. NA-A was interviewed. NA-A stated he had been assigned to care for R1 on the night of the fall and resulting [MEDICAL CONDITION]. NA-A stated he had not worked on that particular unit before, and was unfamiliar with R1's cares. NA-A stated he had receive R1's care sheet which included instruction related to R1's cares. NA-A stated he believed R1 was to be toileted every 3 hours, and stated he only looked at the top/first part of the care guide which included directions for day shift. NA-A stated he did not look and read the instructions for the night shift which instructed staff to toilet R1 between the hours of 10:00 p.m.-11:00 p.m. and 3:00 a.m.-4:00 a.m. NA-A stated he changed R1's incontinent brief at 12:57 a.m. and she was sleeping. NA-A stated he did not check on R1 again until 4:30 a.m. NA-A stated he'd found R1 on her bedroom floor, and immediately called the nurse to get help. NA-A again stated he'd missed the night shift instructions to toilet R1 between the hours of 10:00 p.m.-11:00 p.m. and 3:00 a.m.-4:00 a.m. NA-A stated if he would have taken the time and read the instructions, he would have toileted R1, and perhaps she woundn't have fallen. On 1/16/20, at 3:51 p.m. the director of nursing (DON) was interviewed. The DON stated the purpose of the care sheets were to direct nursing assistant cares. The DON further stated R1's care sheet and care plan were not followed, which had resulted in a fall with injury. The DON stated it was her expectation that all staff would follow the individual resident's care sheets. The DON further stated all staff had been trained to follow the care plan and care sheets. The facility had implemented corrective action to prevent recurrence by [DATE], when it was verified NA-A was re-educated, education had been provided to all staff members regarding fall interventions and following the care plan/care sheets, and R1 had new fall interventions implemented. The implemented corrective actions were verified by interview with staff and policy review. The facility's 10/2017 Care Plan Policy and Procedure directed, The care plan will ensure the resident has the appropriate care required to maintain or attain the resident's highest practicable physical mental and psychosocial well-being. The facility's 9/2018 policy Fall Prevention and Management directed, The purpose of the policy is to assign responsibility and provide procedure for residents at risk for falls: to systematically assess fall risk factors: provide guidelines for fall and repeat fall preventative interventions; and outline procedures for documentation and communication.

Based on observation, interview and document review, the facility failed to implement consistent monitoring and evaluation of an open area on the coccyx to prevent further skin breakdown and failed to provide timely repositioning for 1 of 3 residents (R101) reviewed with pressure ulcers. The failure of the facility to monitor the open area on the coccyx resulted in the deterioration and identification of an unstageable deep tissue injury, which resulted in harm for R101, who was not provided timely repositioning and incontinent cares and experienced a newly acquired Stage 2 pressure ulcer. Findings include: R101 did not receive a position change on 2/12/18, for three hours and twenty-eight minutes (3 hrs, 28 min) and acquired a new Stage 2 open area, length 4.0 centimeter (cm) by width 1.4 cm size to the left mid buttock. An open slit in the coccyx was identified on 1/18/18; documentation was lacking to indicate the skin condition had been monitored and evaluated until 1/29/18, when an unstageable deep tissue injury was identified. R101 currently has an unstageable (Full thickness skin and tissue loss in which the extent of the tissue damage cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a stage 3 or stage 4 pressure ulcer/injury will be revealed.) deep tissue injury area measuring 6.5 cm, length 4.7 cm, width 1.7 cm, to the coccyx/right buttock area. Continuous observations were made of R101 on 2/12/18, from 12:00 p.m. until 3:28 p.m. and there was no offer of a position change. At 12:00 p.m. R101 was seated at the dining room table waiting for lunch. At 1:00 p.m. nursing assistant (NA)-A sat with R101 to feed food and fluids. At 1:30 p.m. R101 was wheeled in the specialty chair to the day room for music therapy group activity. There were no offers for a position change, R101 remained in the same position. At 2:00 p.m. R101 was wheeled in the specialty chair into the dining room for cookie baking group activity. There were no offers for a position change. At 3:00 p.m. R101 continued to sit at the cookie baking activity. At 3:12 p.m. R101 was transported to the day room to watch the Olympics on television. At 3:16 p.m. NA-B wheeled R101 to the bedroom for cares. NA-B was in and out of the bedroom to obtain supplies and the mechanical stand for the transfer. Registered nurse (RN)-C entered the room to assist with the transfer. At 3:28 p.m. the mechanical lift raised R101 off buttocks into a standing position. Observations continued on 2/12/18, and at 3:37 p.m. when NA-B and RN-C turned R101 onto the side to visualize the buttocks and posterior thighs. There was a four by three circular dressing with clear tape borders at the coccyx and right buttocks which extended to the left buttock. Under the clear tape dressing extending to the left buttocks was a new red moist open area that measured 4.0 cm length by 1.4 cm width. RN-C removed the dressing from the coccyx which revealed a unstageable pressure ulcer approximately 4 cm by 2 cm. There were multiple red creases/craters and wrinkling of the skin to the buttocks and posterior thigh areas on R101. At 3:55 p.m. RN-D came to the room with supplies and to assist with wound care and assessment. When interviewed on 2/12/18, at 3:00 p.m. RN-D verified she saw the left buttocks with a red area and confirmed it had not been open like it was at this time. RN-C verified applying the dressing to the wound in the a.m. on 2/12/18, and knew the dressing was too small to cover the entire area but it was all that was available. RN-C verified the tape from the dressing could have contributed to the Stage 2 pressure ulcer noted on the left buttock as well the failure to provide a position change every two hours according to the plan of care. When interviewed on 2/12/18, at 4:00 p.m. nursing assistant (NA)-B verified not knowing what time the day shift completed the repositioning care. Furthermore, NA-B verified R101 should have been in bed by 2:30 p.m. but the time got away from NA-B. R101's Resident Face Sheet, indicated [DIAGNOSES REDACTED]. Document review of the facility form titled Brief Interview for Mental Status (BIMS) revealed R101 was severely impaired and the Care Area Assessment (CAA) addressed impaired communication due to severely impaired cognition secondary to late onset [MEDICAL CONDITION]. The CAA form dated 7/6/17, included pressure ulcer risk due to total assist with all mobility, always incontinent, non ambulatory and a mechanical lift with all transfers. The skin assessment titled Skin Risk and Braden, dated 12/16/17, indicated R101 was at moderate risk to develop pressure ulcers and had an open wound to the right buttock and scar tissue on the left buttock. Repositioning was to occur every two to three hours. Document review of the progress notes dated 12/27/17, indicated the open area to the right buttock was [MEDICAL CONDITION] related. The left buttock area was closed. On 1/18/18, the progress notes indicated the open area in slit of buttock measuring 2 x 0.5 cm and 0.7 x 0.2 cm. Interventions included: applied barrier cream and offload per care plan. There are no progress notes from 1/18/18 until 1/29/19 related to measurements, evaluation and/or wound treatment. No ongoing monitoring of the skin condition was available for review. No mention of the open area was documented until the progress note dated 1/29/19, which read, Resident has a pressure injury. Deep Tissue Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Referring to the wound on the coccyx. The document titled, Skin and Wound dated 1/29/18, identified the wound measurements to the coccyx area as: 6.5 cm, length 4.7 cm, width 1.7 cm with slough, 30% of wound filled, eschar 40% of wound filled, surrounding tissue fragile skin that is at risk for breakdown. Review of the progress notes dated 2/12/18, at 4:57 p.m. documented by RN-C read, Resident has a pressure injury. Stage 2: Partial-thickness skin loss with exposed dermis. Practitioner notified. Resident/responsible party notified. Dietitian notified. The document titled, Skin and Wound-Wound Assessment, dated 2/12/18, indicated a new Stage 2 pressure ulcer acquired in house to the left buttock. Wound measurement area 3.9 cm, length 4.0 cm, width 1.4 cm, depth 0 cm. with surrounding tissue [DIAGNOSES REDACTED]: redness of the skin- may be intense bright red to dark red or purple. Document review of the plan of care dated 2/8/18, for skin integrity addressed recurring open area to buttocks related to moisture/incontinence pressure ulcer to coccyx and the intervention addressed wheel chair cushion, air mattress, and repositioning schedule every two hours and prn (whenever necessary). The untitled document staff refer to as the nursing assistant care sheet dated 2/12/18, for repositioning directed staff to reposition every two hours and to lay down in bed at 2:30 p.m. for a 45 minute to 1 hour nap. Document review of the nurse practitioner (NP) notes dated 1/17/18, titled Follow Up Visit, addressed skin as no rash, ulceration or suspicious lesion. A subsequent NP note dated 1/25/18, titled Follow Up Visit, addressed skin as no rash, ulceration or suspicious lesion. It was not until the 2/7/18, during a follow up visit that the NP addressed the coccyx wound and indicated it was reported on 1/29/18. On 2/7/18, the NP documented in the Follow Up Visit, Skin: has a Unstageable coccyx ulcer. New physician order [REDACTED]. When interviewed on 2/15/18, at 11:07 a.m. the NP verified she had not addressed the skin issues in the progress notes and stated, I thought the area was [MEDICAL CONDITION] related, which comes and goes. The NP verified being unaware of the actual open area to the coccyx until addressed on 1/18/18, as an open slit of buttock measuring 2 x 0.5 cm and 0.7 x 0.2 cm area. After completion of the wound assessment on 1/29/18 (11 days later), an unstageable deep tissue injury was identified. The NP verified the expectation would be that nursing staff provide weekly updates and typically would follow through every week but did not realize eleven days had elapsed without a wound assessment nor a physician notification. Furthermore, the NP verified she was unaware of the severity of the coccyx wound until 1/29/18, and did not address any skin issues nor examine the coccyx area on 1/17/18 nor 1/25/18, during follow up visits. Document review of the 1/2017 policy titled, Skin Integrity Management Policy, directed, Documentation on the wound using the Wound Assessment with a structured progress note generating from the assessment should be done at least weekly, or more frequently depending on the wound characteristics or type dressing used. When interviewed on 2/15/18, at 3:00 p.m. the director of nursing verified the facility expectation would be to evaluate the wounds weekly ensuring the physician was well informed and to follow the interventions especially for re-positioning in (R101) situation of every two hours.

Based on interview and record review, the facility failed to ensure the use of a standing lift was used to prevent an accident during a transfer for one of four residents, (R1), reviewed who required a standing lift for transfers, when R1 was transferred without a standing lift, fell , and broke a bone in his/her knee. Findings include: R1's medical record was reviewed. R1 [DIAGNOSES REDACTED]. R1's care plan dated 8/18/2016, indicated R1 required assistance of one staff with a standing lift for transfers. R1's brief interview of mental status dated 11/10/2016, with a score of 14 out of 15 indicated R1 was cognitively intact. R1's care guide sheet dated 12/30/2016, indicated R1 required the assistance of one staff with a standing lift for transfers, was unable to walk, and was at risk for falls. R1's nursing progress note dated 2/27/2017, indicated R1 was readmitted to the facility from the hospital at 4:45 p.m. R1 required the assistance of one staff with a standing lift for transfers. R1's nursing progress note dated 2/28/2017, indicated R1 fell on her knees in the bathroom during a transfer. The facility occurrence report dated 2/28/2017 at 10:30 a.m., indicated R1 was being assisted in the bathroom by nursing assistant (NA)-G at the time of the fall. The facility falls follow up form dated 2/28/2017, indicated R1 was assessed after the fall by RN-C, who took R1's vital signs, checked R1's skin for injury, completed range of motion, and asked R1 about pain. R1 denied any pain at the time. R1 was lifted from the floor with a mechanical lift and three staff and placed into bed. R1's nursing progress note dated 3/1/2017, indicated at 5:13 a.m. R1 complained of pain in the right hip, knee, and heel. Nursing staff provided Tramadol 25 milligrams (mg) for pain. R1's nursing progress note dated 3/1/2017, indicated at 6:32 a.m. R1 received a warm pack to the effected area (unknown site). R1's nursing progress note dated 3/1/2017, indicated at 6:41 a.m. R1's medication and warm pack interventions were ineffective. R1's nursing progress note dated 3/1/2017, indicated at 9:37 a.m. Family member (FM)-E requested the facility send R1 to the hospital. Orders were received from the nurse practitioner. R1's emergency room progress note dated 3/1/2017, indicated R1 was given oxycodone 5 mg for pain and an x-ray was taken of R1's knee, which revealed a fracture of the tibia of the right knee. R1 was not a candidate for surgery, R1 was given a knee immobilizer and additional prescription for oxycodone. R1's nursing progress note dated 3/1/2017, indicated R1 returned from the hospital at 7:00 p.m. with a knee immobilizer on her right leg, due to a broken bone. R1 was given Tramadol 25 mg. The facility internal investigation document dated 2/28/2017, indicated after the fall occurrence registered nurse (RN)-A interviewed R1, who stated nursing assistant (NA)-G did not use the standing lift to transfer R1. An interview was conducted with RN-A at 1:25 p.m. on 3/20/2017. RN-A stated R1 reported to him/her on 2/28/2017 that NA-G did not use the standing lift to help R1 in the bathroom. An interview was conducted with licensed practical nurse (LPN)-D at 3:23 p.m. on 5/11/2017. LPN-D stated she went to R1's room to give R1 medication. LPN-D stated she witnessed NA-G holding on to R1 from behind in the bathroom with his hands holding R1's pants at the waist. LPN-D stated NA-G did not use a transfer belt or the standing lift with R1. LPN-D stated she witnessed R1 fall to the floor landing on her knees. The facility position description for nursing assistants dated 5/2016, indicated the nursing assistant is responsible for the provision of care and services to the residents in assisting residents with transfers, walking and positioning. The nursing assistant supports the resident's choices, follows regulations, and best practices. The nursing assistant works under the supervision of a registered nurse. The facility position description for registered nurses dated 11/2010, indicated the registered nurse will manage the performance of the assigned staff under his/her supervision. The facility policy for resident transfer assessment dated ,[DATE], indicated all residents will be assessed for transfer needs. If a resident requires a standing lift it will be documented in the care plan and the nursing assistant care sheet.