Every finding on record at River Valley Health and Rehabilitation Center LLC

Based on interview and document review, the facility failed to notify the medical provider with a change in condition for 1 of 1 resident (R33) reviewed for notification of change. Finding include:R33's face sheet provided on 3/24/26, included diagnosis of heart disease. R33's admission Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment, clear speech, could understand and be understood. R33 required supervision or partial assistance for most activities of daily living.R33's physician orders did not include an order for transfer to the hospital. Facility standing orders did not provide guidance for transfer to the hospital. R33's care plan did not include focus areas for heart disease or respiratory concerns.Progress notes indicated no documentation that a provider had been notified for three consecutive transports to the local emergency department (ED):--On 2/22/26 at 2:15 p.m., R33 was transported by ambulance to the ED for bilateral lung crackles, wheezing and shortness of breath. Family member (FM)-A had been in attendance at the facility. Registered nurse (RN)-A who was also the nurse manager, had been notified. At 5:58 p.m., staff at the hospital called the facility to report R33 would be returning.--On 2/23/26 at 7:20 p.m., R33 was transported by ambulance to the ED for hoarse voice, phlegm crackling in throat, hard time clearing throat, diminished lung sounds and wheezing. FM-A had been called and updated, as well as facility on-call nurse. At 10:00 p.m., R33 returned to the facility. --On 2/24/26 at 8:39 a.m., R33 was transported by ambulance to the ED due to audible crackles in lungs and low oxygen saturation. FM-A had been notified. At 10:21 a.m., the hospital called the facility to inform staff R33 would be admitted for acute respiratory failure. On 3/11/26 at 2:58 p.m., R33 returned to the facility. During an interview on 3/24/26 at 11:42 a.m., the director of nursing (DON) stated a provider would not necessarily be notified when a resident's condition changed requiring transfer to the ED. The DON stated R33 had frequent condition changes and his family had been notified. Requested change in condition policy, undated, which indicated facility staff made appropriate notification to the physician when there was a change in condition; changes in condition were reported to the physician. During an interview on 3/24/26 at 12:06 p.m., licensed practical nurse (LPN)-A stated when a resident's condition changed and needed to go to the hospital, nursing staff called the facility nurse on-call and/or DON, family member, and faxed the provider. In the fax, LPN-A stated the provider would be informed of what was going on with the resident and when the resident was sent to the hospital. LPN-A stated this was done all hours - days, evenings and nights. LPN-A stated she didn't know who received the fax or when it was reviewed. LPN-A stated nursing staff would not call a provider to notify them of a residents change in condition or to ask for guidance prior to sending to the hospital, adding, We just send them - we don't wait - so they get the care they need.During an interview on 3/24/26 at 12:29 p.m., the DON was asked what the facility policy on change in condition directed staff to do when a resident's condition changed. The DON stated the policy was to inform the provider and should be done real time, as the change was occurring. During an interview on 3/24/26 at 12:45 p.m., the DON reviewed the progress notes for the dates R33 had been transferred to the ED and stated a provider should have been contacted before anyone else had been notified. The DON acknowledged in some cases a provider who had knowledge of a resident might recommend medication or treatment first, and transport to the hospital might not be necessary. Facility Notification of Changes policy, undated, indicated it was the policy of the facility that changes in a resident's condition or treatment would be shared with the resident and/or resident representative according to their authority, and reported to the attending physician or delegate. Nurses and other care staff were educated to identify changes in a resident's status and define changes that require notification of the resident and/or their representative, and the resident's physician, to ensure the best outcomes of care for the resident. The objective of the policy was to ensure that facility staff made appropriate notification to the physician and notification to the resident and/or resident representative when there was a change in the resident's condition. The intent of the policy was to provide appropriate and timely information to the parties who will make decisions about care, treatment and preferences to address the changes.

Based on interview and document review, the facility failed to accurately code the presence of a pressure ulcer on the admission Minimum Data Set (MDS) assessment for 1 of 3 residents (R20) reviewed for pressure ulcers. Findings Include: R20's admission Minimum Data Set (MDS) dated [DATE], indicated R20 was admitted to the facility on [DATE], no cognitive impairment, required supervision with personal hygiene, and dependent with dressing, toileting, and transfers; diagnosis included pressure ulcer of sacral region unspecified stage, and Section M-Skin Conditions indicated R20 had no unhealed pressure ulcers/injuries. R20's Interim Payment Assessment MDS dated [DATE], indicated one or more unhealed pressure ulcers, and one stage 3 pressure ulcer. R20's care plan dated 1/19/26, indicated pressure injury to buttocks and interventions included; Monitor skin integrity daily during cares, .weekly skin inspection by nurse , treatment to open areas per order. R20's hospital summary report dated 1/15/26, indicated .sacral wound was identified as the likely source of infection and pressure injury of skin of sacral region. R20's Admission/Initial Data Collection assessment dated [DATE], indicated wound on coccyx area measuring 4.5 cm (centimeter) x 1 cm. On 3/23/2026 at 4:10 p.m. R20 stated she had a pressure ulcer upon admission from a previous facility located on her buttocks. On 3/24/2026 at 10:50 a.m., licensed practical nurse (LPN)-A stated she was the current MDS nurse but did not complete R20's 1/22/26 MDS. LPN-A stated registered nurse (RN)-B completed the assessment remotely and confirmed the admission MDS should have reflected a pressure ulcer. On 3/24/2026 at 1:00 p.m., during a telephone interview RN-B stated they were a MDS nurse and completed R20's MDS dated [DATE], section M and marked no for pressure ulcer but acknowledged this was an error. RN-B stated the skin assessment indicated a pressure ulcer but failed to correctly code it as a pressure ulcer on the MDS, impacting evaluation and treatment coding.On 3/24/2026 at 1:10 p.m., during a telephone interview RN-C stated they were the MDS specialist and assisted with MDS training and education and confirmed R20's wound should have been coded as a pressure ulcer and confirmed it was miscoded. RN-C stated that accurate coding is necessary to develop the care plan and guide treatments and that staff are expected to follow the RAI (Resident Assessment Instrument) Manual.On 3/24/2026 at 1:33 p.m., the director of nursing (DON) stated expectations were that MDS assessments are accurate. On 3/24/26 at 2:02 p.m., the administrator indicated in an email that the facility does not have a specific MDS policy and relies on compliance with the RAI Manual for coding and accuracy.

Based on observation, interview and document review, the facility failed to follow ordered wound care treatments, failed to ensure availability and use of ordered supplies, and failed to notify the provider when treatments were not completed for a pressure-related wound for 1 of 3 residents (R10) reviewed for pressure ulcers. Findings include: R10's discharge assessment - return anticipated Minimum Data Set (MDS) dated [DATE], indicated no cognitive impairment, required substantial/maximal assistance with personal hygiene, dependent on assistance with transfers, utilized a wheelchair, diagnoses included sepsis, burn of third degree on the buttock; unhealed pressure ulcers/injuries, one stage 3 pressure ulcer that was present upon admission/entry or reentry. R10's entry tracking MDS dated [DATE], indicated on 3/16/26, R10 was readmitted from a short-term general hospital. R10's care plan revision dated 3/17/26, indicated pressure ulceration to R (right) buttock and R dorsum foot and interventions included treatment to open areas per order. R10's inpatient hospital wound care note dated 3/11/26, nurse practitioner (NP)-C indicated new today is a wound present on the dorsum of his right foot. This appears to be related to pressure.R10's wound care follow up progress note dated 3/18/26, NP-C indicated ulceration on the right anterior foot after debridement measures 1 cm (centimeter) x 1.1 cm x 0.1 cm, 100% slough covered. To the ulceration present on the anterior right foot, lodosorb (used to clean wounds and promote healing of skin ulcers and wounds) was placed to the wound bed then Aquacel Ag Hydroftber (dressing absorbs fluid and bacteria from the wound and creates a moist environment that promotes healing) and protected with Mepilex silicone-based foam dressing. Change dressings every 3 days or if 50% saturated or greater, soiled or rolled edges that cannot be smoothed. Ulceration dorsum, right foot: 3. Wash hands, apply gloves, remove dressings, clean wound with 4 x 4 gauze soaked in wound cleanser 4. Apply lodosorb to the wound bed then cover with Aquacel Ag Hydrofiber 5. Cover with a Mepilex silicone-based foam dressing, can reinforce with tape as needed6. Change dressing every 3 days or if 50% saturated or greater, soiled or rolled edges that cannot be smoothed.R10's treatment administration record (TAR) dated 3/1/26-3/31/26, indicated start date 3/21/26, ulceration dorsum of R foot: 1) Gently cleanse w/ wound cleanser and gauze 2) Apply lodosorb to areas of slough and cover w/ Aquacel AG hydrofiber (calcium alginate) 3) Cover w/ adhesive foam dressing. every day shift every 3 day(s) for Ulceration Change PRN if greater than 50% saturated, edges rolled or missing. On 3/21/26, and 3/24/26, the TAR had a check mark with staff initials indicating the treatment was complete. On 3/23/26 at 1:32 p.m., R10 stated he had pressure areas on his foot, stated the area was improving, and confirmed staff were performing dressing changes and repositioning.On 3/24/26 at 8:27 a.m., licensed practical nurse (LPN)-A stated she had completed R10's dressing change on his foot that morning and the ordered lodosorb was unavailable. LPN-A stated she applied Aquacel and a foam dressing without the Iodosorb and had not notified the provider, wound care team, or registered nurse (RN)-A (facility nurse manager and wound care nurse) at that time. LPN-A stated the dressing change was ordered every three days and as needed. LPN-A further stated when R10 was readmitted to the facility after hospitalization, the right foot ulcer was present.On 3/24/26 at 2:31 p.m., LPN-A was observed entering the time clock room and stated she had completed her shift. LPN-A confirmed she had forgotten to contact the provider regarding unavailable supplies for R10's dressing change. LPN-A stated she would go back to contact the provider; however, she indicated the provider was not in the office and would be rounding the following day. LPN-A stated she planned to leave a note for the provider to address the dressing change but had not checked whether lodosorb had been ordered.On 3/24/26 at 3:11 p.m., the director of nursing (DON) stated staff are expected to follow physician orders, and if supplies are unavailable, an equivalent may be used, with documentation of what was completed and notification to the provider.On 3/24/26 at 3:55 p.m., RN-A, the facility wound care nurse, stated the facility utilizes an outside wound provider who evaluates residents approximately every two weeks. RN-A stated the provider assessed R10 on 3/18/26 and issued new wound care orders. RN-A further stated the wound care provider would have left necessary supplies, including lodosorb, at the facility for staff use. RN-A stated if lodosorb was not available, staff were expected to contact the pharmacy to reorder the product or contact the provider or wound clinic for an alternative treatment.On 3/24/26 at 4:05 p.m., observation of R10's room with RN-A revealed lodosorb was located in R10's room.On 3/24/26 at 4:26 p.m., during a telephone interview NP-C stated they had ongoing concerns and discrepancies between ordered and completed treatments of wounds at the facility. NP-C stated Iodosorb was necessary for debridement and prevention of further wound breakdown and infection. NP-C stated prior communication had occurred with the DON regarding concerns with wound care practices and that staff should notify the provider if treatments cannot be completed as ordered. NP-C stated they would have expected a phone call today when the dressing change could not be completed as ordered. On 3/24/26 at 4:31 p.m., the DON stated expectations were that physician orders should be followed but acknowledged prior instances of incorrect dressing application. The DON further stated NP-C had not raised concerns regarding incorrect supplies not being used, and the only concern previously discussed was a dressing was not fully secured and had shifted from the intended area of coverage. The DON confirmed some education had been provided to nursing staff regarding dressing changes but could not recall when or the specifics.On 3/24/26 at 6:16 p.m., RN-A was observed completing R10's dressing change to the right dorsum of the foot. Upon removal of the existing dressing, RN-A confirmed there was no evidence of Iodosorb present. RN-A stated the dressing would have appeared orange in color if the lodosorb was used. RN-A then completed the dressing change in accordance with NP-C's orders.The facility Skin Assessment & Wound Management Policy dated 2/25, indicatedOngoing Skin Issues- Follow ongoing treatments per provider order.- Update provider and resident/representative as needed.- Update care plan as needed

Based on interview and document review, the facility failed to administer a physician-ordered medication for 1 of 1 resident (R37), when lorazepam (used to treat anxiety) was not administered. The facility did not notify the provider or leadership, or implement an alternative intervention, resulting in a medication omission for several days. Findings include:R37's face sheet provided on 3/24/26, included diagnoses of congestive heart failure (when heart muscles cannot pump enough blood to meet the body's needs) and generalized anxiety. R37's annual Minimum Data Set (MDS) dated [DATE], indicated intact cognition, clear speech, could understand and be understood. R37 was either independent or needed partial assistance for most activities of daily living and was independent with walking. R37's handwritten physician order dated 12/12/25, (no time listed) indicated to start lorazepam 0.25 mg (milligram), 7:00 a.m. and 7:00 p.m. R37's care plan dated 11/10/24, indicated R37 was at risk for alteration in comfort and would have adequate pain relief. During record review, R37 had been experiencing anxiety for which lorazepam had been ordered on 12/12/25. Despite the order, R37 had not received the medication until 12/15/25. Progress note dated 12/12/25 at 2:48 p.m., indicated R37 has been seen by medical doctor (MD)-D. R37 had been more anxious due to shortness of breath and MD-D ordered to start lorazepam. Orders were faxed to pharmacy.Progress notes for the lorazepam subsequently indicated the following: -- Friday 12/12/25 at 2:48 p.m., orders faxed to pharmacy.-- Friday, 12/12/25 at 8:23 p.m., medication not available.-- Saturday, 12/13/25 at 11:15 p.m., pharmacy yet to deliver medication. -- Sunday, 12/14/25 at 12:13 p.m., medication will be delivered from pharmacy today.-- Sunday, 12/14/25 at 8:52 p.m., medication not available. -- Sunday 12/14/25, according to pharmacy, lorazepam had been delivered to the facility at 11:00 p.m.-- Monday, 12/15/25 at 8:09 a.m., registered nurse (RN)-A who was also the nurse manager indicated in a progress note, that written orders had been received from MD-D on 12/12/25, for lorazepam 0.25 mg, however the medication with instructions received from pharmacy indicated the dose to be lorazepam 0.5 mg. RN-A contacted pharmacy and was informed the reason was because the e-prescription from MD-D indicated a dosage of 0.5 mg. RN-A reached out to the clinic to obtain clarification of dosage from MD-D, but no response was received. -- Monday 12/15/25 at 9:34 a.m., still needing clarification on dose.-- Monday 12/15/25 at 11:23 a.m., progress note by RN-A indicated she attempted to reach MD-D, but when no answer, sent an urgent fax.-- Monday 12/15/25 at 2:44 p.m., progress note by licensed practical nurse (LPN)-A indicated family member (FM)-B and FM-C had questioned why R37 had not received lorazepam when it had been ordered on 12/12/25. LPN-A informed them the lorazepam order needed clarification on the dosage as the facility and pharmacy had different orders. FM-B questioned why that had not been handled on Friday or over the weekend. LPN-A explained to FM-B nursing was working on it. FM-B stated R37 should not have to ask for anything, should just get the lorazepam. R37 rated her pain 3/10 and denied needing additional pain medication. FM-C stated to LPN-A this should not have happened and R37 should have had her medication right away on Friday - She's [AGE] years old; she should be living her best life. FM-B told LPN-A she was told over the weekend that the medications would be handled and straightened out but I just keep getting lied too. LPN-A informed both FM-B and FM-C she would speak with the social worker and DON (director of nursing) regarding their complaints. -- Tuesday 12/16/25 at 4:01 p.m., progress note indicated MD-D's nurse was contacted about the continued discrepancy in doses for lorazepam (0.25 mg vs 0.5 mg). Requested MD-D's nurse to ask MD-D for an updated order regarding which dose to administer. -- Tuesday 12/16/25 at 7:00 p.m., per the medication administration record (MAR), the first dose of lorazepam was documented as being administered. During an interview on 3/24/26 at 4:29 p.m., RN-A recalled R37 and reviewed her progress notes in the electronic medical record from 12/12/25 to 12/15/25. RN-A stated there had been a discrepancy in the order for lorazepam dosages between what the facility received from the physician and what the pharmacy received from the physician. RN-A stated she had first been aware of the concern of R37 not receiving lorazepam over the weekend when she arrived to work on 12/15/25. RN-A didn't know if staff on duty over the weekend had attempted to contact a provider to clarify the order, or if they contacted leadership, such as the DON to assist with problem-solving.During an interview on 3/24/26 at 5:18 p.m., with the DON and administrator, both stated they had not been aware of the medication discrepancy and subsequent failure to administer a physician-ordered medication. The DON who was on-call that weekend, did not remember if he had received a call from nursing staff. The DON stated he would have expected staff to notify the provider and him, and acknowledged lorazepam was important to R37 who had just started on hospice and who experienced anxiety related to shortness of breath.During a telephone interview on 3/24/26 at 6:09 p.m., FM-C expressed concern about R37 not receiving lorazepam in a timely manner after it had been ordered by the physician. FM-C couldn't understand why staff were not able to resolve the problem with the order over the weekend (weekend of 12/12/25). FM-C stated once R37 did receive the lorazepam, it took the edge off the pain and anxiety, and she was able to die with dignity. On 3/24/26 at 6:15 p.m., and 6:35 p.m., attempted to reach nursing staff who had worked the weekend of 12/12/25, and who had documented progress notes about lorazepam not being available, but did not receive a return call as of 3/25/26.During an interview on 3/25/26 at 1:15 p.m., customer service representative at Polaris Pharmacy stated an original order from the facility had been received on 12/12/25, but was not a valid prescription because it did not include a provider signature, quantity of medication, or DEA (drug enforcement administration) number which were required for controlled medications. A blank e-script was then routed to the ordering provider, MD-D, to inform him. On 12/13/25, at 10 p.m., an e-prescription was received from MD-D for lorazepam 0.5 mg by mouth in the morning and one tablet 0.5 mg in the evening. Maximum daily dose 1 mg. Quantity 60 tablets. Since it was after delivery time, the medication had not been delivered. According to the representative, on 12/14/25 at 11:00 p.m., the lorazepam had been delivered to the facility for R37. Facility Medication and Treatment Orders policy dated 2/2024, indicated order for medications would be consistent with principles of safe and effective order writing. Orders must include name and strength of the drug; number of doses, start and stop date, and/or specific duration of therapy; dosage and frequency of administration; route of administration; clinical condition or symptoms for which the medication is prescribed. Only authorized personnel shall call in orders for prescribed medications to the pharmacy.

Based on interview and document review, the facility failed to ensure a registered nurse (RN) was on duty a minimum of eight consecutive hours per day for four of 30 days reviewed for RN coverage. This had the potential to affect all 35 residents residing at the facility. Findings include: Review of the nursing staff schedules from 4/13/25-5/13/25, identified there was no RN that worked for a minimum of eight hours per day. During an interview on 5/13/25 at 12:35 p.m., scheduling coordinator (SC)-A stated the facility was supposed to have an RN scheduled eight hours per day. It had been difficult lately, but she tried her best to fill the gaps utilizing facility staff, corporate agency staff, and outside staffing agencies. There had been gaps with RN coverage on the weekends recently. SC-A reviewed the schedules and identified there was no RN coverage for the facility on 4/27/25 (Sunday), 5/4/25 (Sunday), 5/10/25 (Saturday), and 5/11/25 (Sunday). SC-A stated the facility currently only had two RN's in-house, and had to rely on outside sources to fill the gaps in coverage, and sometimes the facility was only able to find licensed practical nurses (LPN)s that could fill the shifts. The gaps in coverage had occurred when the RN's who were scheduled called off for the shifts, and SC-A was unable to find a replacement. During an interview on 5/13/25 at 2:27 p.m., interim director of nursing (DON) stated the facility attempts to fill open RN shifts in-house, but if that is not feasible, the facility would reach out to the corporate agency staff and outside agencies with the open shifts. If there was not an RN available to work, he would cover the eight-hour gap. Weekends tended to be the hardest to find an RN to work the required eight-hour shifts. DON verified 4/27/25, 5/4/25, 5/10/25, and 5/11/25 had no RN coverage for eight hours each day. During an interview on 5/13/25 at 2:55 p.m., administrator acknowledged the facility had no RN coverage for eight hours each day on 4/27/25, 5/4/25, 5/10/25, and 5/11/25. It was his second day at the facility, and he had not been informed of the gaps in coverage. Moving forward, he would make sure the facility had an RN available eight consecutive hours each day. An email dated 5/13/25 at 4:06 p.m., identified the facility did not have a policy regarding RN coverage and followed the state guideline of eight hours of RN consecutive coverage and did not have a staff mandate policy.

Based on interview and record review, the facility failed to ensure a registered nurse (RN) was on duty a minimum of 8 consecutive hours per day for 5 of 7 days reviewed. This had the potential to affect all 32 residents living in the facility. Findings include: Review of the nursing staff schedules and time punches for 8/29/24, 9/8/24, 9/28/24, 9/29/24 and 1/11/25 identified there was no evidence an RN had worked for a minimum of 8 hours per day. Interview on 2/5/25 at 11:23 a.m., with RN-B identified the facility was short on RN coverage and either she or the director of nursing (DON) would attempt to cover those shifts as charge nurse or floor nurse, however some days no replacements could be assigned. She confirmed for the above dates, there was no RN working. Interview and document review on 2/5/25 at 12:38 p.m., with the administrator confirmed the facility failed to provide consecutive 8 hours per day of RN coverage on the above mentioned dates due to the lack of available RN staff. The facility had been attempting to recruit staff, and they also had staff hired who then quit. The administrator confirmed the facility attempted to staff according to their facility assessment, and attempted to fill those vacancies when able. A policy addressing RN coverage or staffing was requested but not provided by the end of the survey.

Based on interview and document review, the facility failed to submit accurate staffing data based on payroll and other verifiable, auditable data during 1 of 1 quarter reviewed (Quarter 4), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. This had the potential to affect all 32 residents living in the facility. Findings include: Review of the July 2024, Electronic Staffing Data Submission Payroll-Based Journal (PBJ) Frequently Asked Questions, located at https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/nursinghomequalityinits/downloads/pbj-policy-manual-faq-11-19-2018.pdf, identified reporting shall be based on the employee ' s primary role. It is understood that most roles have a variety of non-primary duties that are conducted throughout the day (e.g., helping out when needed). Facilities shall still report just the total hours of that employee based on their primary role. However, CMS recognizes that staff may completely shift their primary role in a given day. For example, a nurse who spends the first four hours of a shift as the unit manager, and the last four hours of a shift as a floor nurse. In these cases, facilities can change the designated job title and report four hours as a nurse with administrative duties, and four hours as a nurse (without administrative duties). Review of staffing schedules and timecard verifications identified the DON was noted having been on duty from 6:00 a.m. - 6:00 p.m., (12 consecutive hours) working as a staff RN on 8/4/24. Her name had been handwritten on the schedule as an active nurse, and review of her timecard identified she was clocked in during that time. However, it was noted she was not logged into the correct identified role. The DON's active nursing shift on 8/4/24 had not been included on the submitted PBJ report resulting in an inaccuracy. Interview on 2/5/25 at 8:15 a.m., with the administrator identified the director of nursing (DON) and Minimum Data Set (MDS) coordinator both covered to fill RN hours. The DON did not log hours differently or potentially notify the business office unless she was actively working as a fill for the RN position. This resulted in lack of documented RN coverage when she was not appropriately coded in their payroll based journal. The Administrator confirmed the PBJ was inaccurate for 8/4/24 and provided the schedule and timecard of the DON who had been on duty for 12 consecutive hours filling that role of the required RN Coverage. Interview on 2/5/25 at 8:49 a.m., with the human resources (HR) director identified she submitted the employee hours (time clock hours) after receiving them from the corporate office. She logged into PBJ, uploaded the files, and printed the CASPER (Certification and Survey Provider Enhanced Reporting) (A quality measure report that provides information about a skilled nursing facility's performance) report to confirm her submission had been accepted. She also reviewed an individual staff hours report for accuracy of timecards. She reported she was not aware of an error in reporting until the end of the quarter when a report was run. Review of the current, undated PBJ policy identified staffing data was generated and submitted from their electronic timekeeping system and submitted to the centers for Medicare and Medicaid Services (CMS) according to the guidelines provided.

Based on observation, interview and document review, the facility failed to timely notify the physician of new onset pressure ulcers for 1 of 1 resident (R7). Findings include: R7's 11/15/24, annual Minimum Data Set (MDS) identified R7 was cognitively intact and had a diagnosis of dementia, anxiety, depression, psychotic disorder (impaired relationship with reality, confusion, hallucinations and delusions) and malnutrition. R7 was at risk for pressure ulcer development and no pressure ulcers at the time of the assessment. R7 required supervision or touching assistance with bed mobility, transfers, and toileting. R7 had an indwelling catheter during the look back period. R7's current, undated, care plan identified on 8/9/24, he was noted to be at risk for alteration in mobility related to weakness and dementia. At that time, R7 was independent with bed mobility, had grabs bars to assist with bed mobility, could safely enter and exit his bed, and was independent with locomotion in his wheelchair. R7's 11/14/24, Target Behavior Form identified R7's wife had passed recently, and he was noted to have appeared to be sad. R7 displayed anxiety related to his wife's funeral service. R7 appeared helpless and dependent on staff for his care needs. R7's 11/14/24, [NAME] Scale for Predicting Pressure Ulcer Risk assessment score was 19, which indicated average risk (lowest level risk which is not abnormal compared to healthy individuals). Review of 12/18/24, faxed notification to the physician (2 days after discovery) identified R7 had open areas to the left hip, measures 1.5 centimeters (cm) X 0.2 cm x 0.1 cm and the right hip, measures 2.4 centimeters (cm) x 1.5 cm x 0.1 cm depth with slough (yellowish white material of dead cells and debris) of the wound bed, serosanguineous (bloody clear) drainage to dressing, and erythema (redness) to site. Recommendations by staff to the MD for treatment were to remove the old dressing, cleanse site with wound cleanser and gauze, apply Medi-honey to the wound bed, cover with non-adhesive foam dressing and change every 3 days or as needed until resolved. Staff proposed to refer to wound care for evaluation and R7 was to take liquid protein 30 milliliter (ml) twice a day. The physician response to the fax identified he agreed with the facilities plan as above. The corresponding nurses note from 12/18/24 showed staff also added liquid protein (increases healing) and notified the MD and family of the open wound areas. Interview on 2/04/25 at 1:11 p.m., with medical director (MD)-A identified he routinely received notifications from the facility by phone and fax. MD-A identified the facility had not notified him, initially, of R7's wound. Observation and interview on 02/05/25 at 09:33 a.m., with wound care nurse and nurse practitioner (NP) had removed the foam dressing on R7's right hip. R7's wound appeared red around the area the size of a dime. The surrounding skin and edges were intact had no drainage from the wound. NP obtained measurements and applied a non-adhesive foam dressing and stated R7'S right hip was healed. The NP and wound care nurse had repositioned R7 to his left side. NP had removed the foam dressing on his left hip. The wound appeared as a quarter sized shape. The wound had a small slit in the wound bed with a small amount of blood draining from the wound. The edges of the wound were intact. The NP cleansed the wound, obtained measurements and applied a non-adhesive foam dressing to R7's left thigh. NP and the wound nurse discarded their supplies in the trash bin and had removed their PPE. NP and wound care nurse had sanitized their hands after leaving R7's room. NP identified R7's left hip wound was a stage 3 pressure ulcer and had improved significantly with R7's current wound treatments and wound care visits. She identified R7's left hip was to heal approximately in 1 month. NP identified R7 had cognitive deficits and appeared to lie in his bed more often since his wife had passed. She confirmed the addition of the air mattress (implemented on 12/27/24) had helped alleviate the pressures of his bilateral hips as R7 favored side lying position in bed. Interview on 2/05/25 at 3:28 p.m., with administrator identified she would expect nursing staff to follow facility policy and to notify the provider of a new onset wound needed to be assessed immediately to prevent further skin breakdown. Review of March 2024 Skin Assessment & Wound Management policy identified nursing staff were to notify the provider for treatment orders.

Based on observation, interview and document review, the facility failed to ensure ventilator equipment supply water was not expired for 1 of 1 (R18). Findings include: R18's [DATE], annual Minimum Data Set (MDS) identified R18 had a diagnoses of respiratory failure and chronic obstructive pulmonary disease (COPD) and was cognitively intact. R18 had used a non-invasive mechanical ventilation system, along with 02 therapy. R18's current, undated care plan identified R18 used a ventilator for her COPD. The nursing staff were directed to replace the tubing and 02 chamber, clean and inspect the tubing, and notify the respiratory company of any damage to the machine or if there staff had any concerns. Observation and interview on [DATE] at 12:19 p.m., with licensed practical nurse (LPN)-A while in R18's room and later in the storage room, identified R18 had a ventilator (a non-invasive ventilator with a mask used to assist COPD patients with easier breathing) which sat on the table next to R18's bed. The ventilator had tubing attached to a bag of sterile water. The water had an expiration date of [DATE]. LPN-A identified the water bag was changed every few months. She was not aware the water had expired 4 months ago. R18 had an extra water in the storage room to replace the expired bag currently hung in R18's room. LPN-A walked to the storage room, opened a cardboard box that had 1 water left that also had an expiration date of [DATE]. She confirmed the facility should be checking for expiration dates and should not use expired sterile water. R18's active orders, identified the nursing staff was to order supplies (to include water) every 2 months, inspect and clean the ventilator weekly or sooner as needed, change the oxygen (O2) tubing and clean the filter weekly, and place a date and time on the water bag to note when it was put into use. Interview on [DATE] at 1:14 p.m.,with R18 had used the ventilator to assist her with her breathing as she had difficulty while sleeping at night. She would apply the face mask and the nursing staff would turn on the machine when she went to bed approximately at 9:30 p.m She recalled the water having been changed a few days ago by a staff. Interview on [DATE] at 6:08 p.m., with registered nurse (RN)-A identified she was informed by LPN-A that R18's water had expired. R18 had a scheduled delivery of water to arrive the next day. R18 had nursing orders that reminded nurses to change the water on the Treatment Administration Record (TAR). R18's [DATE], [DATE], and [DATE], TAR identified nursing staff were to check the water every shift. Staff were to hang a new water bag if low and input a Y or N if a new water had been placed. The log identified staff had last placed a new water on R18's ventilator on [DATE]. There was no indication the TAR included for staff to check the expiration on water. Interview on [DATE] at 9:37 a.m., with the ventilator company identified he was not informed by the facility of the expired sterile water. R18 had been a customer since [DATE] and had received a box of sterile water every 6 months. The ventilator required staff to use sterile water for the closed system and staff were to to change the bag once the contents were empty or if it was expired. Observation and interview on [DATE] at 10:12 a.m., with the administrator in R18's room identified the sterile water was expired as of [DATE]. She was not made aware of the situation and would have expected to be notified the ventilator company and order replacement water. She agreed it was not an acceptable practice of using expired products for residents. A policy for the ventilator machine and requested but none was provided.

Based on observation, interview, and document review, the facility failed to assess and meet the needs of 1 of 1 (R7) resident reviewed for the provision of medically related social services, who was grieving the death of a significant other. Findings include: R7's 11/15/24, annual Minimum Data Set (MDS) identified R7 was cognitively intact and had a diagnoses of dementia, anxiety, depression, psychotic (impaired relationship with reality, confusion, hallucinations and delusions) disorder and malnutrition. R7 had little interest or pleasure in doing things and had trouble falling or staying asleep or sleeping too much 12 to 14 days. R7 had felt down, depressed, hopeless, had a poor appetite, felt bad about himself, or have let himself or his family down, had trouble concentrating on things, moving or speaking slowly that other people would not have notice, and thoughts that R7 would be better off dead or wanting to hurt himself in some way never to 1 day. R7's current, undated care plan identified R7 was at risk for alteration of mood and behavior. Staff were to provide redirection, validate R7's feelings with regards to his wife's passing, monitor side effects related to medication management, be aware of mood and behavior changes, monitor and respond to unmet needs and contact R7's family with concerns. There was no mention staff had appropriatly monitored R7's behaviors or mood for his ability to cope with his wife's death. R7's 11/14/24, Target Behavior Form identified R7's wife had passed recently and appeared sad. R7 displayed anxiety related to his wife's funeral service. R7 appeared helpless and dependent on staff for his care needs. R7's 11/14/24, Patient Health Questionnaire (PHQ-9) identified he was mildly depressed. R7's 11/15/24 at 1:53 p.m., progress note identified R7 was informed by the social services designee (SSD) and R7's stepson that his wife had passed. R7 wanted to be left alone and declined SSD to sit with him. There were no further notes from social services for any visits. R7's 11/22/24, progress note by physician (MD)-A identified due to R7's dementia, he may not be able to comprehend his wife had passed. R7 had behaviors and hallucinations and was to continue on his current medication management. There was no mention MD-A advised staff to frequently check his coping with his wife's passing as that may require enhanced monitoring of R7's psychosocial needs. R7's activities log identified on: 1) November 2024, R7 had refused to participate in activities 18 times, lower than normal. 2) December 2024 had refused to participate in activities 19 times, lower than normal. 3) January 2025 had refused to participate in activities 9 times but was beginning to improve with participation. Observation on 2/03/25 at 7:11 p.m., identified R7 was asleep in bed. Interview on 2/03/25 at 7:31 p.m., with trained medication aide (TMA)-A wife had passed last November. R7 and his wife had been married for [AGE] years. The facility had a memorial service for her with R7 in attendance. She identified R7 appeared withdrawn and did not attend daily activities he normally would and ate his meals in his room. Interview on 2/04/25 at 1:11 p.m., with medical director (MD)-A identified he would see R7 on physician rounds. Often R7 would often be asleep. MD-A noted R7 appeared sad and withdrawn after his wife's death and agreed staff should monitor R7 for his psychosocial needs and potential withdrawl and provide medically related social services. Interview on 2/04/25 at 4:42 p.m., with social services designee (SSD) identified R7 had used telehealth services in 2023 for his mental health. She was present in R7's room along with R7's family when they had informed R7 that his wife has passed. SSD identified she frequently checked in on R7, but noted she had not documented any visit. She noted she had not reviewed R7 psychosocial or behavioral needs after R7's wife had passed and residents coping with the loss of a loved one should be monitored for negative effects on thier well-being. Interview on 2/05/25 at 3:07 p.m., with licensed practical nurse (LPN)-C identified R7 was self-isolating in his room. R7 was aware his wife had passed but at the time it occurred, it appeared to have no effect on him. She identified a referral for mental health services was discussed at team meetings but they determined those would not be appropriate for R7 and stated it would not make a difference due to his dementia and his past medical history of electro-shock therapy. Review of Social Service Director job description identified the designee was to provide 1:1 visit with residents to assess psychosocial needs and to provide reassurance, support of resident/families grieving, encourage family involvement and support, communicate to appropriate facility staff psychosocial needs and problems to each resident and make referrals to the community, individuals or agencies to meet residents' psychosocial needs. Interview on 2/05/25 at 3:28 p.m., with administrator had no policy related to bereavement services. She identified staff had not received direction on how to assist R7 with his grieving.

Based on observation, interview and document review the facility failed to ensure appropriate personal protective equipment (PPE) was used during a sterile dressing change for 1 of 1 resident (R85). Findings include: R85 was admitted on [DATE] for orthopedic aftercare with diagnoses of infection in his left hip following an arthroplasty, ( a surgical procedure to replace a joint with an artificial one), absence of his left hip joint, rheumatoid arthritis, and local infection of his skin and subcutaneous tissue. 85's admission orders identified staff were to follow Enhanced Barrier Protections ((EBP), infection control (IP) control practices that use PPE to reduce the spread of multi-resistant organisms (MDROs)), while caring for IV lines and during performance of high contact personal cares. R85 had a peripherally inserted central catheter ((PICC), a flexible tube inserted into a vein in the upper arm and threaded into a large vein near the heart). through which his antibiotic medication was administered. The sterile dressing on his left upper arm, PICC line dressing was to be changed weekly with documentation placed in the progress notes. Review of R85's current, undated care plan identified he was on EBPs, due to a surgical wound on his left hip, and a PICC in his left upper arm. Interventions directed staff to wear PPE according to EBP and administer the IV medication (Ceftriaxone 2 grams (GM) every 24 hours), through 3/7/25. Staff were to monitor the PICC insertion site and report any signs of infection, discomfort, or adverse reactions Observation on 2/3/25 at 5:11 p.m., with registered nurse (RN)-B as she performed a sterile dressing change to R85's PICC site. A sign was posted on the outside of R85's door identifying EBP and listing the PPE to be worn for any close contact procedures. PPE to be worn included a mask, gown and gloves. The supplies were located on a cart outside the resident room. RN-B gathered supplies to perform the sterile dressing change, entered R85's room and explained the dressing change procedure. RN-B was wearing a mask upon entering the room, washed her hands and applied gloves, but no gown. She then cleansed the surface of the bedside table with Sanicloth wipes prior to placing the dressing change items on the surface. RN-B had R85 also mask, changed gloves and performed hand hygiene appropriately. She changed the dressing and performed the indicated measurements using sterile technique. RN-B finished the procedure by flushing a new end cap, applying it to the PICC line and flushing the line with sterile saline, then dated and initialed the dressing and cleaned up her supplies. Interview on 2/3/25 at 5:45 p.m., with RN-B identified R85 was on EBP due to his surgical hip wound and PICC line. She reported EBP PPE would include a gown, gloves and mask to be worn when providing any personal care especially if there was a change for body fluid contact. RN-B identified she had not worn a gown when performing the PICC dressing change, and she was not certain why, but stated she should have. She identified she was nervous at being observed and had not though about it. Interview on 2/4/25 at 9:16 a.m., with trained medication aid (TMA)-A identified if a resident had been placed on EBP, PPE required would include a mask, gown, and gloves and that would be for any task requiring personal contact with the resident. Interview on 2/4/25 at 11:11 a.m., with TMA-B identified R85 was on EBP due to having a PICC line and any care provided requiring contact would require use of a gown, mask and gloves. She identified there was also a sign posted on the outside of the door when a resident was on EBP and PPE was located outside the door. she reported the sign was bright colored and visible when approaching the room, because he liked to have his door closed. Interview on 2/4/25 at 11:28 a.m., with licensed practical nurse (LPN)-A identified R85 was on EBP due to a surgical wound on his left hip and he had a PICC line for administration of IV antibiotics. LPN-A reported the dressings were checked every day, but the hip dressing was not removed and the PICC line dressing was changed by the RN. Interview on 2/4/25 at 3:00 p.m., with the infection preventionist (IP) identified R85 was on EBP due to his hip infection and having a PICC line in place for antibiotic administration. She identified he had a return appointment with the infection prevention MD on Friday 2/7/25 and they would be receiving additional information following that visit. The IP identified if a resident was placed on EBP staff were to wear a gown, gloves and mask with any procedure or care requiring close contact. If there was a potential for splashing, goggles/face shield were to be added. She reported her expectation for staff to wear appropriate PPE even if they were not working specifically with the PICC line, but gave the example of assisting with bathing, transferring, or any high contact activity. Review of the current, undated Enhanced Barrier Precautions policy identified to avoid transmission of multi-drug-resistant organisms. All staff have received training on EBP at the time of hire and it is repeated annually. Signage was to be posted on either the door or wall outside a resident's room to identify the type of precautions, what PPE was indicated, and the high-contact activities that required the use of PPE. The IP was to complete periodic monitoring to ensure compliance and provide additional training if indicated. EBP were to remain in place for the duration of the resident's stay or until a wound was healed or the medical device discontinued.

Based on interview and document review the facility failed to ensure 2 of 5 residents (R21, R31) were offered and/or provided updated vaccinations for pneumococcal disease in accordance with the Centers for Disease Control (CDC) vaccinations. Findings include: R21's Minimum Data Set (MDS) dated [DATE], indicated R21 was admitted on [DATE], was currently [AGE] years old, had intact cognition and diagnoses of renal failure and diabetes which puts her at higher risk for pneumococcal diseases. It further indicated her pneumococcal vaccinations were up to date. R21's Minnesota Immunization report dated 12/5/24, indicated R21 received the pneumococcal polysaccharide vaccine (PPSV 23) on 9/20/12 and the pneumococcal conjugate vaccine (PCV13) on 10/20/17. The CDC's PneumoRecs VaxAdvisor for Vaccine Providers dated 2/4/25, identified based on R21's age and vaccine history: though the vaccines were considered complete, based on shared clinical decision-making, decide whether to administer one dose of PCV20 or PCV21 at least 5 years after the last pneumococcal vaccine dose. R21's medical record lacked documentation of a discussion of shared clinical decision making regarding additional pneumococcal vaccines. R31 R31's admission Minimum Data Set (MDS) dated [DATE], indicated R31 was admitted on [DATE], was currently [AGE] years old, had intact cognition and diagnoses of chronic pneumothorax, chronic respiratory failure with hypoxia, and dependence on supplemental oxygen which puts him at a higher risk for pneumococcal diseases. It further indicated R31's pneumococcal vaccinations were up to date. R31's Minnesota Immunization Report dated 5/18/24, indicated R31 received the PPSV23 on 1/19/1999 and the PCV13 on 7/23/15. The CDC's PneumoRecs VaxAdvisor for Vaccine Providers dated 2/4/25, identified based on R31's age and vaccine history: though the vaccines were considered complete, based on shared clinical decision-making, decide whether to administer one dose of PCV20 or PCV21 at least 5 years after the last pneumococcal vaccine dose. R31's medical record lacked documentation of a discussion of shared clinical decision making regarding additional pneumococcal vaccines. During interview on 2/5/25 at 9:35 a.m., the administrator stated the vaccinations the facility offered were listed in the admission packet and the admitting nurse was responsible for checking to see if the resident has had those vaccinations or not and either administering them or having them sign a declination form. If the resident declined the vaccinations, the nurse was responsible for providing education on the risk and benefits and documenting it in their medical record. During interview on 2/5/25 at 8:15 a.m. the health information manager (HIM) stated when a resident was admitted to the facility, they are offered all vaccinations (COVID, pneumococcal, influenza, etc.) and were required to sign a consent form. If they decline the vaccination, staff should educate the resident on the risk versus (vs) benefits. If they decide to receive the vaccinations, the facility was responsible for getting a doctor's order and then administering it. During interview on 2/6/25 at 11:27 a.m., the infection preventionist (IP) stated when there was a new admission, the facility offered the pneumococcal, influenza, and COVID vaccinations. If the resident chose to receive the vaccinations, a consent form was signed by either the resident or the resident's representative and the vaccine was administered. If the resident declined, they document it on the bottom of the form and education was provided regarding the risk vs benefits. The IP verified the medical record for R21 and R31 lacked documentation of a discussion of shared clinical decision making regarding additional pneumococcal vaccines. The facility's policy regarding pneumococcal vaccinations dated 2/2024, indicated it's purpose was to follow recommendations of the Advisory Committee on immunization Practices (ACIP), Centers for Disease Control (CDC) and/or the state Department of Health for prevention of Pneumococcal disease by identifying those residents at risk for Pneumococcal disease and offering Pneumococcal vaccination.

Based on interview and document review the facility failed to comprehensively assess proper full body mechanical lift sling type and size according to manufacturer recommendations to ensure safety for 1 of 1 residents (R1). This resulted in immediate jeopardy (IJ) for R1 who had a history of behaviors during lift transfers, fell from the lift and suffered a shoulder fracture. The immediate jeopardy began on 1/19/25, when staff used a hygiene (toileting) sling that was too large causing R1 to experience pain resulted in behaviors and fell through the lift sling to the floor. The administrator, director of nursing, corporate nurse, and regional director of operations were notified of the IJ at 5:00 p.m. on 1/27/25. The facility implemented immediate corrective action on 1/19/25 to prevent recurrence, so the IJ was issued at past none compliance. Findings include: A facility Reported Incident (FRI) submitted to the state agency (SA) on 1/19/25 at 12:40 p.m., alleged potential caregiver neglect when R1 fell through the open area of the toileting (hygiene) sling and hit her head on the lift, sustained a shoulder fracture, had increased pain, and was evaluated at the emergency department (ED). R1's annual Minimum Data Set (MDS) dated [DATE], indicated R1 had mild cognitive impairment, with fluctuating behaviors of inattention. R1 was dependent on staff for all transfers and toileting. R1 was frequently incontinent of urine but always continent of bowel. R1's diagnoses included heart failure, osteoporosis (condition that weakens the bones and make them more prone to fractures), and morbid obesity. R1's Lift/Mobility Status Form dated 6/26/24, indicated R1 had severe pain/discomfort which impacted transfers and repositioning. R1 required a full body lift with two staff assist. The form did not identify or assess for appropriate type of full body lift sling size or if R1 was safe to use the specialty sling or toileting sling. R1's care plan in place on 1/19/25, indicated R1 was to transfer with two staff assist using the full body lift. The care plan did not include the type or size of slings used for R1's transfers. R1's progress notes on 1/19/25 at 9:54 a.m., indicated at 8:35 a.m., staff were transferring R1 from the bed to commode with the Hoyer (brand name of full body lift) and toileting sling when R1 complained of pain in her shoulder and began to lift her arm up causing her body to fold and slide out of the bottom of the toileting sling. R1 hit her head and complained of pain. R1 was transferred by emergency medical services (EMS) to the ED for evaluation and treatment. R1's progress noted on 1/19/25 at 2:45 p.m., indicated R1 had returned from the ED with a shoulder fracture and was requesting pain medication. The facility Incident Review and Analysis dated 1/21/25, identified the root cause of the fall from the lift was R1 lifted arms while in toileting sling and slid through lift sheet, falling to the floor, and hitting her head. Immediate Intervention identified was R1 would no longer use the toileting sling and will use the full body sling and the bedpan for toileting. During an interview on 1/27/25 at 11:35 a.m., licensed practical nurse (LPN)-A indicated R1 used the toileting sling, the straps go underneath the armpits, so arms are out of the sling. On 1/19/25, LPN-A assisted nursing assistant (NA)-A with transferring R1 when R1 fell from the lift. LPN-A explained R1 was in the toileting sling and the sling had been hooked up to the lift when she arrived in R1's room. When they began to lift R1 up in the sling, R1 complained of pain in her shoulder and shimmied her right arm around the strap, then got her left arm out, and fell out through the bottom hole with legs still in the sling. R1 always complained about being in the toileting sling, she had a habit of trying to pull that arm through, staff had to constantly remind her to keep her arm out. LPN-A further identified an extra-large sling was used to transfer R1 when she fell out of the lift. R1 should have used a large sling instead but they did not have the listing of the sling size to be used prior to that fall so did not know they were using the wrong size sling and stated, we basically went off [used] what wrapped around them. During an interview on 1/27/25 at 3:45 p.m., NA-A indicated she assisted R1 with the full lift transfer on 1/19/25 when R1 fell out of the lift. NA-A put the toileting sling on R1 and then called LPN-A for assistance to lift her to the commode. When they lifted R1 up into the sling, R1 complained her shoulder hurt, and they tried to put her back to bed but she fell out of the lift. NA-A was not sure what caused the fall because it happened so fast. NA-A stated R1 does not have assigned lift sheets [slings] so they would have use the biggest one for her The toileting sling that was used was hanging on the back of R1's door and was the one they always used to transfer R1. R1 always complained about her arms hurting when she was in the sling and had reported to the charge nurse, but they were already aware that R1 had pain. During an interview on 1/27/25 at 1:00 p.m., NA-B indicated R1 would always complain about her shoulders hurting and would try to lift the arms over the sling We would really have to watch her and tell her not to. NA-B had reported the pain and R1's attempts to lift her arms over the sling to the charge nurse but not sure what they did with that information. Prior to R1's fall, staff would have to know the resident's weight, look at the sizing chart in the utility room where the slings were stored, and pick out the sling that had the matching weight. After R1's fall, the residents name with the sling size was posted and there was a sticker on the resident's door with the color sling to use. During an interview on 1/27/25 at 1:25 p.m., NA-C indicated prior to R1's fall out of the full body lift, staff were directed to look at the resident's last weight and refer to the manufacturer's weight chart posted in the utility closet and decide what size sling to use. After R1's fall, the facility put list with the resident name, weight, size, and color of the sling as well as posting the color of the sling on the resident door with the sling hanging on the hook. NA-B further identified R1 always complained of pain in her shoulders when they used the toileting sling but did not use the toileting sling after the fall. During an interview on 1/27/25 at 11:00 a.m., registered nurse case manager (RNCM) was working the day R1 fell out of the lift and responded immediately after the fall. RNCM identified LPN-A and NA-A used an extra-large toileting sling to transfer R1, but it should have been a large sling used to transfer R1 according to her weight. RNCM immediately did re-education and took the toileting sling and full body lift out of use. During a follow up interview on 1/27/25 at 1:45 p.m., RNCM indicated prior to R1's fall out of the lift on 1/19/25, the facility assessed R1 for the use of the lift but did not assess for the sling size or appropriateness of use of the specialty slings. The RN also indicated the sling size was not listed on the care plan until after R1's fall. The RNCM identified she was aware of R1's chronic pain in her shoulders but not that R1 would try to get her arms out of the sling. During an interview on 1/27/25 at 2:10 p.m., the director of nursing identified after the facility investigation, it was determined the root cause of R1's fall from the lift was that the sling size used was an extra-large and should have been a large. R1 pulling her arms over the toileting sling contributed. R1 was assessed for the use of the lift but not assessed for the safety and appropriateness of the specialty (toileting) sling. Prior to R1's fall, the staff would determine the sling size by the resident weight alone and not by any other factors. After R1's fall from the lift, facility systems were changed, and education was provided to the facility staff. During an interview on 1/27/25 at 4:30 p.m., the administrator deferred to nursing but identified that facility wide changes had gone into effect on 1/19/25 after R1 fell out of the lift. During an interview on 1/27/25 at 10:15 a.m., an EZ Way representative indicated if a resident used a large full body sling to transfer, the toileting sling should also be a large. When using the toileting sling, the resident must be able to keep their arms outside of the sling. If the resident were to use a sling that was too large, it could result in a fall out of a lift and if a resident moved their arms to the inside of the sling that could also cause a fall from the lift. The EZ Way representative identified the facility contacted the company after the fall from the lift and would be going to the facility to do training on the lifts and the slings. EZ Way Sling Sizing Chart, Form #2-150 Revised 9/13/24, indicated it is important to evaluate the width of a patient in relation to the width of the sling; it is important that no portion of the patient overlap the sides of the sling; color coding is used on the binding of sling but not used for specialty slings; it is important that the base of the sling be positioned two inches below the tailbone and the top of the sling is parallel with the top of the shoulder line (base of the neck). Further identifies the size/weight designations are merely estimates and basic guidelines. A proper fit will depend on factors other than weight measurements, including the height and girth of a patient. A proper fit will involve the judgement of the caregiver. The EZ Way Belted Mesh Hygiene Sling Operating Instructions, Form #2-038 Reviewed 10/24/24, indicated to be eligible for the use of the sling, a resident must have adequate upper body strength and torso stability. If the patient has poor muscle tone and sinks down in the sling, the sling is not appropriate for the individual. When using the sling: The sling must be securely belted and tightened around the patient's torso. 2. The leg straps of the sling should be pulled tightly under the patient's legs close to the upper thigh area, and be crossed between the thighs, hooking the loops of the leg straps to the hanger bars hooks furthest from the patient. If a patient has sufficient muscle tone the straps can be placed closer to the knees, however this can result in a sunken position if a patient does not have adequate strength. You may use any of the three loops on each leg to attach to the hanger bar hooks but must always be consistent with using the same loop level on each leg strap. Example: If you use the longest loop on the right leg, you must use the longest loop on the left leg. 3. The shoulder strap loops should go under the patient's armpits, so their arms are on the outside of the sling. The patient can then place their hands along the sides of the sling. The loops should be hooked onto the sling hanger bars, again maintaining consistency with the identical length of loop used on each side. 4. Lift the patient and pull the patient's pants down as much as possible. 5. Lower the patient onto the toilet until they are in a seated position and unhook all loops of the sling from the hanger bars. Remove leg straps from under the patient's legs. You may now pull the patient's pants down further if necessary and remove or move the sling. When transferring the patient back to the bed or chair, follow the instructions above. The facility's Safe Resident Handling Program last reviewed 3/2020, indicates the facility interdisciplinary team will use the safe patient handling (SPH) program in determining and identifying the means for providing transfer and mobility assistance of residents. Each resident will be assessed for the safe patient handling needs during the admission process to the facility using the MHM Lift/Mobility Status Form and for each relevant activity in the care delivery process. The information from his assessment will be contained in the care plan for each resident and the care plan will identify the safe patient handling requirements for that individual. The immediate jeopardy was removed, and the deficient practice corrected by 1/19/25, after the facility implemented a systemic plan that included the following actions: R1 was assessed using manufacturer's guidelines, and care plan was updated to add the correct sling size and NOT to use a toileting sling; other residents that used full body lifts and slings were assessed, and care plans updated as appropriate for correct sling size and type; all staff education for sling sizing and where to find that information; mechanical lift competencies completed for all staff prior to next working shift; Safe Patient Handling policy was reviewed, and staff educated; the electronic record transferring tasks were updated to include sling size and color; and toileting slings were removed from service.

Based on interview and document review, the facility failed to have evidence of a Performance Improvement Project (PIP) which focused on high risk or problem-prone areas identified thorough and appropriate data collection and analysis and evaluation of the identified concern(s) during QAPI. This had the potential to affect all 35 residents. Interview on 2/7/24 at 1:56 p.m., with registered nurse (RN)-A identified she has heard of a PIP before, and thinks maybe some staff are watching for urinary tract infections, but was unsure what the PIP was or what her role in the PIP project could be. RN-A thought if there was a PIP there may be signage in the staff breakroom. RN-A received online general QAPI training but had not received training specific for the facilities QAPI plan. Observation on 2/7/24 at 1: 58 p.m. of the staff breakroom identified there was no signage related to a PIP project posted in the staff breakroom. Interview on 02/7/24 at 2:00 p.m., with trained medication aide (TMA)-E identified she was unaware what a PIP project is and could not recall ever being trained to a PIP or the facilities specific QAPI plan. Interview on 2/7/24 at 2:01 p.m., with the director of nursing (DON) identified the facility did a monthly all staff training. In their they speak of some QAPI stuff but was unsure if staff had been trained to the facility's specific QAPI plan or a any PIP project. The facility did online overall QAPI training yearly to staff, but agreed it was not specific. to the facilities QAPI plan and deferred to the administrator. Interview on 2/7/24 at 2:03 p.m., with the administrator identified there were no meeting minutes from their monthly staff meetings kept by management. There was no training to staff of the facility's specific QAPI or PIP plan. She was unaware if the facility had to have a PIP. She was also unaware not educating the staff to the facilities QAPI plan or having a PIP did not meet the purpose of training or staff involvement in order to appropriately implement the QAPI plan and have focus on high risk problem areas to find solutions to improve quality of care. There was no policy related to QAPI or a PIP provided by the end of the survey.

Based on interview and document review, the facility failed to provide mandatory training on the facility's specific QAPI Program to include goals and various elements of the program, how the facility intends to implement the program, staff's role in the facility's QAPI program, or how to communicate concerns, problems, or opportunities for improvement to the facility's QAPI program. This had the potential to affect all 35 residents. Findings include: Interview on 2/7/24 at 1:56 p.m., with registered nurse (RN)-A identified she has heard of a PIP before, and thinks maybe some staff are watching for urinary tract infections, but was unsure what the PIP was or what her role in the PIP project could be. RN-A thought if there was a PIP there may be signage in the staff breakroom. RN-A received online general QAPI training but had not received training specific for the facilities QAPI plan. Observation on 2/7/24 at 1: 58 p.m. of the staff breakroom identified there was no signage related to a PIP project posted in the staff breakroom. Interview on 02/7/24 at 2:00 p.m., with trained medication aide (TMA)-E identified she was unaware what a PIP project is and could not recall ever being trained to a PIP or the facilities specific QAPI plan. Interview on 2/7/24 at 2:01 p.m., with the director of nursing (DON) identified the facility did a monthly all staff training. In their they speak of some QAPI stuff but was unsure if staff had been trained to the facility's specific QAPI plan or a any PIP project. The facility did online overall QAPI training yearly to staff, but agreed it was not specific. to the facilities QAPI plan and deferred to the administrator. Interview on 2/7/24 at 2:03 p.m., with the administrator identified there were no meeting minutes from their monthly staff meetings kept by management. There was no training to staff of the facility's specific QAPI or PIP plan. She was unaware if the facility had to have a PIP. She was also unaware not educating the staff to the facilities QAPI plan or having a PIP did not meet the purpose of training or staff involvement in order to appropriately implement the QAPI plan and have focus on high risk problem areas to find solutions to improve quality of care. There was no policy related to QAPI training provided by the end of the survey.

Based on interview and document review the facility failed include with their Abuse Prohibition/Vulnerable Adult policy reporting of reasonable suspicions of a crime and coordination with the QAPI program to define how staff will communicate situations of abuse, neglect, misappropriation of resident property and exploitation for review and oversight. Findings include: Review of 1/30/24, nursing home incident report (NHIR) identified at 12:05 p.m., the administrator filed a report that identified on 1/29/24, at 8:13 p.m., the administrator had been made aware of incident where nursing assistant (NA)-A had reported the HR director at 8:12 p.m., that NA-B had showed her a picture of NA-B posing with R2 on the stand lift in R2's bathroom. The picture showed NA-B posing with R2 in the resident's bathroom hooked up to a lift and NA-B giving the peace sign. NA-B had giggled about the situation when showing NA-A the picture. The report identified that the staff involved had been immediately suspended pending an investigation. There had been no other agencies notified at the time. R2's 1/24/24, annual Minimum Data Set (MDS) assessment identified R2's cognition was moderately impaired, she had fluctuating times of inattention, she required substantial to total assistance from staff for cares and transfers. R2 took an antipsychotic and antidepressant. R2 had diagnosis of multiple sclerosis, depression, psychotic disorder (other than schizophrenia), depression, and dementia. R2's 10/27/22, care plan identified she was at risk for alteration in psychosocial well-being and staff were to monitor for changes in mood. The care plan lacked identification of risk for abuse and/or increased risk related to R2's dementia. Interview on 2/5/24 at 6:28 p.m., with NA-A identified she reported to HR director via text message on 1/29/24 at 7:56 p.m., that she had been shown a picture of R2 and NA-B, she stated instantly she knew it was not right. The picture showed R2 seated on the toilet holding onto the EZ stand and NA-B posing, in the picture you could see skin by the private part and that her pants were pulled down and she was sitting on the toilet. NA-B told her that R2 told NA-B to stop it and do her job. She was unsure why NA-B showed her the picture but she was glad she did so she knew what was going on and could report it. Additional Interview on 2/6/24 at 9:30 a.m., with NA-A identified she had been shown a picture on 1/28/24, of R2 and she reported that to the HR director on 1/29/24. She said she could not believe they took the picture, and she was very upset and cried when telling her mom about it who told her she needed to report that. She stated she knew she should have reported it right away, but she had a lot of anxiety about it and the resident in the picture was someone she really connected with. She revealed she would have reported it to the DON or the administrator, but she did not have their numbers and only had HR director's number. When she was shown the picture NA-B had said to her don't tell anyone Then showed her the picture and giggled. NA-A had waited almost 24 hours before reporting to the HR director. Interview on 2/6/24 at 9:48 a.m., with HR director identified she had received a text message from NA-A on 1/29/24 at 7:56 p.m., identifying she needed to report another NA. NA-A then texted her that she had been shown a picture of R2 who was on a lift in the bathroom with NA-B also in the picture. Once she received the text from NA-A she reported the information to the administrator. Review of 1/29/24 at 7:56 p.m., text message from NA-A to HR director identified NA-B said to NA-A don't show anyone and showed NA-A a picture of NA-B posing with R2 on the stand lift in the bathroom. NA-A could see her bottom half skin and pants pulled down while she just stared confused. After NA-B put her phone away she laughed and said to NA-A that R2 told NA-B to stop doing that and to be doing her job. NA-A continued to text HR director and reported she was sorry and should have said something earlier it hurt, and she was crying a lot when she tried to talk to her mom about it, but she wanted to say something. HR director had responded to NA-A something like this needed to be reported right away, the facility only had 2 hours to report and investigate. Interview on 2/6/24 at 10:00 a.m., with administrator identified that she had been informed of the picture of R2 and NA-B late Sunday evening on 1/29/24 and had waited to file the reported until the next day on 1/30/24. She identified she did not report on 1/29/24 because she had always been told she only had to report within 2 hours if there was serious body injury or harm otherwise, she had 24 hours to submit her report. She revealed that she had contacted the corporate nurse consultant who confirmed she had reported the incident timely. She stated, that is our policy. The administrator revealed that NA-C had not been terminated yet even though it was identified in the submitted 5-day investigation summary as the facility had not finalized that yet. NA-B will be retrained as NA-B did not have control of NA-C taking the picture. NA-B had not been retrained yet but would not be able to work until she completes her training. She had spoken to R2's family and they agreed of the facilities action to terminate NA-C and retrain NA-B. She confirmed NA-B should have reported the picture immediately and NA-A should have reported immediately when she was shown the picture. She was unsure why NA-A had reported to HR director verse the director of nursing (DON) or herself as she never asked NA-A about that. She then stated maybe she should post a sign at the nurse's station for the chain of command for reporting. The administrator revealed that she did not report until 1/30/24, because it was not physical abuse and after visiting with R2 who has dementia had no mental anguish from the picture, so it was not mental abuse either. She confirmed that R2 had not been interviewed until 1/30/24, and that the facility had spent hours trying to figure out the correct way to even fill out the NHIR as there was not a place for pictures being taken. Interview on 2/6/24 at 2:44 p.m., with the medical director (MD) identified he had been notified that something had occurred with R2 but was not given any details so he was unsure if it was even the same incident but would expect to be informed. He was unaware that the facility had knowledge of the incident and did not report to the state agency (SA) no later than 2 hours after having knowledge of the potential abuse and would expect the facility to follow the federal regulations for reporting. He further was unaware that the facility Abuse Prohibition/Vulnerable Adult policy had no mention of reporting suspicion of a crime or that the policy needed to identify crimes that must be reported to the local law enforcement. He was also unaware that there should be coordination with the QAPI program to define how staff will communicate situations of abuse, neglect, misappropriation of resident property and exploitation for review and oversight. Interview on 2/6/24 at 4:48 p.m., with family member (FM)-A who reported the facility reported that a picture had been snapped of R2 while in the lift in the bathroom. The facility had terminated the staff who took the picture and the picture had been deleted. FM-A said but of course the picture was still in the cloud and the facility was unsure who might have seen the picture. FM-A revealed she was pretty sure R2 had no idea the picture was taken. FM-A reported that R2 would have been severely embarrassed and angry if she knew someone took a picture of her in the bathroom, as she would not want anyone to see something like that. FM-A further identified if R2 was not confused she would feel awful if she knew someone seen a picture of her in the bathroom. She stated it was just common sense not to do that to someone. She said she could not be there all the time to watch things, you put your trust in the staff to care for your family and then this happened. Review of August 2023, Abuse Prohibition/Vulnerable Adult policy identified events that must be reported to MDH included: mistreatment (inappropriate treatment or exploitation of a resident), neglect, abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. , photographs that would demean or humiliate a resident, injuries of unknown source, all serious injuries, misappropriation of resident property, resident to resident abuse, elopement, involuntary seclusion, and financial exploitation. The policy identified how and when an employee should report to the Office of Health Facility Complaints (OHFC). Any time there was suspected abuse OHFC report must be made not later than 2 hours after forming the suspicion of abuse. Suspicion of neglect, exploitation, or misappropriation of resident property an OHFC report must be made not later than 2 hours if the incident resulted in serious bodily injury. If the suspected neglect, exploitation, or misappropriate of resident property did not result in serious bodily injury, the OHFC report must be made within 24 hours. There was no mention of reporting suspected crime or what types of crime needed to be reported to the local law enforcement. Additionally, there was no mention of coordination with the QAPI program to define how staff will communicate situations of abuse, neglect, misappropriation of resident property and exploitation for review and oversight.

Based on interview and document review the facility failed to ensure 1 of 1 resident (R2) was free from potential psychosocial abuse using the reasonable person concept when R2's family reported R2 would have been severely embarrassed and angry when R2 had a photograph taken of her by staff while being toileted. Findings include: Review of 1/30/24, the nursing home incident report (NHIR) identified at 12:05 p.m., the administrator filed a report that on 1/29/24, at 8:13 p.m., the administrator had been made aware of an incident where nursing assistant (NA)-A had reported the HR director on 1/29/24 at 8:12 p.m., that NA-B had showed her a picture of NA-B posing with R2 in the residents bathroom hooked up to a lift and NA-B giving the peace sign. NA-B had giggled about the situation. The report identified that the staff involved had been immediately suspended pending an investigation. There had been no other agencies notified at the time. R2's 1/24/24, annual Minimum Data Set (MDS) assessment identified R2's cognition was moderately impaired, she had fluctuating times of inattention, she required substantial to total assistance from staff for cares and transfers. R2 took an antipsychotic and antidepressant. R2 had diagnosis of multiple sclerosis, depression, psychotic disorder (other than schizophrenia), depression, and dementia. R2's 10/27/22, care plan identified she was at risk for alteration in psychosocial well-being and staff were to monitor for changes in mood. The care plan lacked identification of risk for abuse and/or increased risk related to R2's dementia. Interview on 2/5/24 at 6:28 p.m., with NA-A identified she reported to HR director via text message on 1/29/24 at 7:56 p.m., that she had been shown a picture of R2 and NA-B on 1/28/24, she stated instantly she knew it was not right. The picture showed R2 seated on the toilet holding onto the EZ stand and NA-B posing, she reported in the picture you could see skin by the private part and that her pants were pulled down and she was sitting on the toilet. NA-B told her that R2 told NA-B to stop it and do her job. She was unsure why NA-B showed her the picture but she was glad she did so she knew what was going on and could report it. Additional Interview on 2/6/24 at 9:30 a.m., She said she could not believe they took the picture, and she was very upset and cried when telling her mom about it who told her she needed to report that. She stated she knew she should have reported it right away, but she had a lot of anxiety about it and the resident in the picture was someone she really connected with. She revealed she would have reported it to the DON or the administrator, however, she did not have their numbers and only had HR directors' number. She said NA-B had said to her don't tell anyone then showed her the picture and giggled. Interview on 2/6/24 at 9:48 a.m., with HR director identified she had received a text message from NA-A on 1/29/24 at 7:56 p.m., identifying she needed to report another NA. NA-A then texted her that she had been shown a picture of R2 who was on a lift in the bathroom with NA-B. Once she received the text form NA-A she thanked her and reminded her she needed to report sooner and set up a meeting for the next morning for an interview. She then reported the information to the administrator. Review of 1/29/24 at 7:56 p.m., text message from NA-A to HR director identified last night NA-B and NA-A were charting and NA-B said to NA-A don't show anyone and quickly showed NA-A a picture of NA-B posing with R2 on the stand lift in the bathroom. In a quick glance NA-A could see R2's bottom half skin and pants pulled down while she just stared confused. After NA-B put her phone away she laughed and said to NA-A that R2 told NA-B to stop doing that and to be doing her job. NA-A continued to text HR director and reported she was sorry and should have said something earlier, but it hurt, and she was crying a lot when she tried to talk to her mom about it but she definitely wanted to say something. HR director had responded to NA-A something like this needed to be reported right away, the facility only had 2 hours to report and investigate. HR director then asked if NA-A could come in the next day to begin the interview process. NA-A responded she could come in around 10 a.m. There was no mention in the SA report that the picture showed R2 with her bottom half of skin showing and pants pulled down. Interview on 2/6/24 at 10:00 a.m., with administrator identified that she had been informed of the picture of R2 and NA-B late Sunday evening on 1/29/24. She had reported the incident the next day on 1/30/24. She identified she did not report on 1/29/24 because she had always been told she only had to report within 2 hours if there was serious body injury or harm otherwise, she had 24 hours to submit her report. She revealed that she had contacted the corporate nurse consultant who confirmed she had reported the incident timely. She stated, that is our policy. The administrator revealed that NA-C had not been terminated yet even though it was identified in the submitted 5- day investigation summary as the facility had not made their determination yet. NA-B would be retrained as NA-B did not have control of NA-C taking the picture. NA-B had not been retrained yet but would not be able to work until she completed her training. She had spoken to R2's family and they agreed of the facilities action to terminate NA-C and retrain NA-B. She confirmed NA-B should have reported the picture immediately and NA-A should have reported immediately when she was shown the picture. She was unsure why NA-A had reported to HR director verse the director of nursing (DON) or herself as she never asked NA-A about that. She then stated maybe she should post a sign at the nurse's station for the chain of command for reporting. The administrator revealed that she did not report until 1/30/24, because it was not physical abuse and after visiting with R2 who has dementia had no mental anguish from the picture so it was not mental abuse. She confirmed that R2 had not been interviewed until 1/30/24, and that the facility had spent hours trying to figure out the correct way to even fill out the NHIR as there was not a place for pictures being taken. Review of 1/29/24 at 8:02 p.m., text message between HR director and administrator identified HR director texted a heads-up that NA-A was texting something she needed to report about another NA. Then HR direct had copied the message she had received from NA-A and sent it to the administrator. The text message identified NA-A had been shown a picture of R2 and NA-B where NA-A could see R2's bottom half skin and pants pulled down while she just stared confused. The copied message also indicated that NA-B had reported to NA-A that R2 had told NA-B to stop doing that and said to be doing their job. There was no mention in the SA report that the picture showed R2 with her bottom half of skin showing and pants pulled down. Review of 1/30/24, facility interview documentation with NA-B at 3:30 p.m., with the administrator and HR director identified NA-B initially denied there being a picture. NA-B then revealed that NA-C had taken the picture and that it was only of NA-B wearing her N95 mask on her forehead and that NA-B did not think that R2 was even in the picture. Additional interview on 2/1/24 at 4:00 p.m., with the administrator and HR director NA-B identified that NA-C took the picture and then sent it via messenger to NA-B. NA-B did not recall who initiated the idea of the picture as it all happened fast from NA-C taking out her phone and taking the picture that NA-B felt like she did not have time to react appropriately. NA-B reported from R2's stomach and up were in the picture with NA-B. Review of 1/30/24, facility interview documentation with NA-C at 3:30 p.m., with the director of nursing (DON) and social services identified NA-C denied there being a picture. When NA-C was informed the facility knew about the picture and if there was anything NA-C wanted to bring forward and share she replied no. Additional interview on 2/1/24 at 1:30 p.m., with administrator, DON, and HR director NA-C identified a picture had been taken in the bathroom but it was only a picture of R2's face and NA-B. NA-C reported that NA-B wanted the picture taken and NA-B handed her NA-B's phone and she felt obligated to take the picture. NA-C reported she did not have the picture and she never did have it. Review of 2/1/24, facility interview documentation with NA-A at 3:20 p.m., with administrator and HR director identified NA-A when asked if she could without a doubt say she seen R2's private areas exposed NA-A replied no, she could not say she seen that but did say she saw exposed skin. NA-A also reported that R2 looked visibly upset in the picture. NA-A reported that NA-B was smiling and holding either a thumbs up or the peace sign in the picture. NA-A further reported that NA-B had told her that R2 told them to knock it off and stop. NA-B was laughing while telling NA-A what R2 said. Interview on 2/6/24 at 10:31 a.m., with R2 who had no recollection of any picture being taken. Interview on 2/6/24 at 2:44 p.m., with the medical director (MD) identified he had been notified that something had occurred with R2 but was not given any details so he was unsure if it was even the same incident but would expect to be informed. He was unaware that the facility had knowledge of the incident and did not report to the state agency (SA) no later than 2 hours after having knowledge of the potential abuse and would expect the facility to follow the federal regulations for reporting. He further was unaware that the facility Abuse Prohibition/Vulnerable Adult policy had no mention of reporting suspicion of a crime or that the policy needed to identify crimes that must be reported to the local law enforcement. Interview on 2/6/24 at 3:28 p.m., with NA-B who confirmed there had been a picture taken of herself and R2 while R2 was in the bathroom. NA-B revealed the picture had been taken on 1/26/24. NA-B further revealed that R2 did not agree to the picture being taken. NA-B reported there was no reason the picture was taken it just had been. She identified she had been interviewed about the picture by the administrator and the HR director last Thursday and again on Tuesday. She had been informed that she was suspended while they the incident was being investigated. She further reported that she had not heard anything from the facility yet. Interview on 2/6/24 at 4:48 p.m., with family member (FM)-A who reported the facility reported that a picture had been snapped of R2 while in the lift in the bathroom. The facility had terminated the staff who took the picture and the picture had been deleted. FM-A said but of course the picture was still in the cloud and the facility was unsure who might have seen the picture. FM-A revealed she was pretty sure R2 had no idea the picture was taken. FM-A reported that R2 would have been severely embarrassed and angry if she knew someone took a picture of her in the bathroom, as she would not want anyone to see something like that. FM-A further identified if R2 was not confused she would feel awful if she knew someone had seen a picture of her in the bathroom. She stated it is just common sense not to do that to someone. She said she could not be there all the time to watch things, you put your trust in the staff to care for your family and then this happened. Interview on 2/7/24 at 7:33 a.m., with director of nursing (DON) identified the facility had no documentation of their interview with NA-A that occurred on 1/30/24, all the facility had was a text message that NA-A would come in for an interview on 1/30/24 at 10:00 a.m. The DON revealed NA-A interview information was being typed into the SA report as the administrator was completing it. Interview on 2/7/24 at 12:06 p.m., with NA-C who identified a picture of R2 with staff had been taken on 1/26/24. NA-C revealed she had taken the picture of NA-B and R2 while R2 was seated on the toilet. She reported that herself and NA-B had asked R2 if she wanted her picture taken and R2 had agreed. She further revealed that the facility had no policy about not taking pictures that she was aware of, and she had not had any training that it was not okay to take a picture of a resident. NA-C confirmed she had been told she could not work until the facility completed an investigation and reported she had not heard anything back yet from the facility as to when she could return. Review of August 2023, Abuse Prohibition/Vulnerable Adult policy identified events that must be reported to MDH included: mistreatment (inappropriate treatment or exploitation of a resident), neglect, abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. , phonographs that would demean or humiliate a resident, injuries of unknown source, all serious injuries, misappropriation of resident property, resident to resident abuse, elopement, involuntary seclusion, and financial exploitation. The policy identified how and when an employee should report to the Office of Health Facility Complaints (OHFC). Any time there was suspected abuse OHFC report must be made not later than 2 hours after forming the suspicion of abuse. Suspicion of neglect, exploitation, or misappropriation of resident property an OHFC report must be made not later than 2 hours if the incident resulted in serious bodily injury. If the suspected neglect, exploitation, or misappropriate of resident property did not result in serious bodily injury, the OHFC report must be made within 24 hours. There was no mention of reporting suspected crime or what types of crime needed to be reported to the local law enforcement.

Based on interview and document review the facility failed to follow or revise and/or update facility policies and ensure reports to the State Agency (SA) not later than 2 hours after alleged abuse, neglect, exploitation or mistreatment for 1 of 1 resident (R2) after the facility had knowledge of the incident. The facility further failed to revise and/or update their policy to include to report reasonable suspicion of a crimes against a resident receiving care at the facility to the local law enforcement, or what those may entail. Findings include: Review of 1/30/24, nursing home incident report (NHIR) identified at 12:05 p.m., the administrator made a report that on 1/29/24, at 8:13 p.m., the administrator had been made aware of incident where nursing assistant (NA)-A had reported the HR director at 8:12 p.m., that NA-B had showed her a picture of NA-B posing with R2 on the stand lift in R2's bathroom. The picture was shown to NA-A while the staff were charting cares at the table in the common area. The picture showed NA-B posing with R2 in the resident's bathroom hooked up to a lift and NA-B giving the peace sign. NA-B had giggled about the situation. The report identified that the staff involved had been immediately suspended pending an investigation. There had been no other agencies notified at the time. R2's 1/24/24, annual Minimum Data Set (MDS) assessment identified R2's cognition was moderately impaired, she had fluctuating times of inattention, she required substantial to total assistance from staff for cares and transfers. R2 took an antipsychotic and antidepressant. R2 had diagnosis of multiple sclerosis, depression, psychotic disorder (other than schizophrenia), depression, and dementia. R2's 10/27/22, care plan identified she was at risk for alteration in psychosocial well-being and staff were to monitor for changes in mood. The care plan lacked identification of risk for abuse and or increased risk related to R2's dementia. Interview on 2/5/24 at 6:28 p.m., with NA-A identified she reported to HR director via text message on 1/29/24 at 7:56 p.m., that she had been shown a picture of R2 and NA-B on 1/28/24, she stated instantly she knew it was not right. The picture showed R2 seated on the toilet holding onto the EZ stand and NA-B posing, in the picture you could see skin by the private part and that her pants were pulled down and she was sitting on the toilet. NA-B told her that R2 told NA-B to stop it and do her job. She was unsure why NA-B showed her the picture but she was glad she did so she knew what was going on and could report it. Additional Interview on 2/6/24 at 9:30 a.m., with NA-A identified she could not believe they took the picture, and she was very upset and cried when telling her mom about it who told her she needed to report that. She stated she knew she should have reported it right away, but she had a lot of anxiety about it and the resident in the picture was someone she really connected with. She revealed she would have reported it to the DON or the administrator however, she did not have their numbers and only had HR director's number. She was shown the picture at end of shift on 1/28/24, and NA-B had said to her don't tell anyone then showed her the picture and giggled. NA-A had waited almost 24 hours before reporting to the HR director. Interview on 2/6/24 at 9:48 a.m., with HR director identified she had received a text message from NA-A on 1/29/24 at 7:56 p.m., identifying she needed to report another NA. NA-A then texted her that she had been shown a picture of R2 who was on a lift in the bathroom with NA-B. Once she received the text form NA-A she thanked her and reminded her she needed to report sooner and set up a meeting for the next morning for an interview. She then immediately reported the information to the administrator. Review of 1/29/24 at 7:56 p.m., text message from NA-A to HR director identified last night NA-B said to NA-A don't show anyone and showed NA-A a picture of NA-B posing with R2 on the stand lift in the bathroom. NA-A could see her bottom half skin and pants pulled down while she just stared confused. After NA-B put her phone away she laughed and said to NA-A that R2 told NA-B to stop doing that and to be doing her job. NA-A continued to text HR director and report she was sorry and should have said something earlier it hurt, and she was crying a lot when she tried to talk to her mom about it but she definitely wanted to say something. HR director had responded to NA-A something like this needed to be reported right away, the facility only had 2 hours to report and investigate. HR director then asked if NA-A could come in the next day to begin the interview process. NA-A responded she could come in around 10 a.m. Interview on 2/6/24 at 10:00 a.m., with administrator identified that she had been informed of the picture of R2 and NA-B late Sunday evening on 1/29/24 and reported the incident the next day on 1/30/24. She identified she did not report on 1/29/24 because she had always been told she only had to report within 2 hours if there was serious body injury or harm otherwise, she had 24 hours to submit her report. She revealed that she had contacted the corporate nurse consultant who confirmed she had reported the incident timely. She stated, that is our policy. The administrator revealed that NA-C had not been terminated yet even though it was identified in the submitted 5-day investigation summary as the facility had not determined that yet. NA-B will be retrained as NA-B did not have control of NA-C taking the picture. NA-B had not been retrained yet but would not be able to work until she completes her training. She had spoken to R2's family and they agreed of the facilities action to terminate NA-C and retrain NA-B. She confirmed NA-B should have reported the picture immediately and NA-A should have reported immediately when she was shown the picture. She was unsure why NA-A had reported to HR director verse the director of nursing (DON) or herself as she never asked NA-A about that. She then stated maybe she should post a sign at the nurse's station for the chain of command for reporting. The administrator revealed that she did not report until 1/30/24, because it was not physical abuse and after visiting with R2 who has dementia had she had perceived there was no mental anguish from the picture, so in her opinion, it was not mental abuse either. She confirmed that R2 had not been interviewed until 1/30/24, and that the facility had spent hours trying to figure out the correct way to even fill out the NHIR as there was not a place to check if pictures being taken. Interview on 2/6/24 at 2:44 p.m., with the medical director (MD) identified he had been notified that something had occurred with R2 but was not given any details so he was unsure if it was even the same incident but would expect to be informed. He was unaware that the facility had knowledge of the incident and did not report to the state agency (SA) no later than 2 hours after having knowledge of the potential abuse and would expect the facility to follow the federal regulations for reporting. He further was unaware that the facility Abuse Prohibition/Vulnerable Adult policy had no mention of reporting suspicion of a crime or that the policy needed to identify crimes that must be reported to the local law enforcement. Interview on 2/6/24 at 4:48 p.m., with family member (FM)-A who reported the facility reported that a picture had been snapped of R2 while in the lift in the bathroom. The facility had terminated the staff who took the picture and the picture had been deleted. FM-A said but of course the picture was still in the cloud and the facility was unsure who might have seen the picture. FM-A revealed she was pretty sure R2 had no idea the picture was taken. FM-A reported that R2 would have been severely embarrassed and angry if she knew someone took a picture of her in the bathroom, as she would not want anyone to see something like that. FM-A further identified if R2 was not confused she would feel awful if she knew someone seen a picture of her in the bathroom. She stated it is just common sense not to do that to someone. She said she could not be there all the time to watch things, you put your trust in the staff to care for your family and then this happened. Review of August 2023, Abuse Prohibition/Vulnerable Adult policy identified events that must be reported to MDH included: mistreatment (inappropriate treatment or exploitation of a resident), neglect, abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. , photographs that would demean or humiliate a resident, injuries of unknown source, all serious injuries, misappropriation of resident property, resident to resident abuse, elopement, involuntary seclusion, and financial exploitation. The policy identified how and when an employee should report to the SA. Any time there was suspected abuse the SA report must be made aware no later than 2 hours after forming the suspicion of abuse. For suspicion of neglect, exploitation, or misappropriation of resident property, an SA report must be made not later than 2 hours if the incident resulted in serious bodily injury. If the suspected neglect, exploitation, or misappropriate of resident property did not result in serious bodily injury, the SA report must be made within 24 hours. There was no mention of reporting the suspicion of a crime to the local law enforcement.

Based on interview and document review the facility failed to thoroughly investigate an allegation of abuse for 1 of 1 resident (R2). Findings include: Review of 1/30/24, nursing home incident report (NHIR) identified at 12:05 p.m., the administrator filed a report that on 1/29/24, at 8:13 p.m., the administrator had been made aware of incident where nursing assistant (NA)-A had reported to the HR director on 1/29/24 at 8:12 p.m., that NA-B had showed her a picture of NA-B posing with R2 in the residents bathroom hooked up to a lift and NA-B giving the peace sign. NA-B had giggled about the situation. The report identified that the staff involved had been immediately suspended pending an investigation. R2's 1/24/24, annual Minimum Data Set (MDS) assessment identified R2's cognition was moderately impaired, she had fluctuating times of inattention, she required substantial to total assistance from staff for cares and transfers. R2 took an antipsychotic and antidepressant. R2 had diagnosis of multiple sclerosis, depression, psychotic disorder (other than schizophrenia), depression, and dementia. R2's 10/27/22, care plan identified she was at risk for alteration in psychosocial well-being and staff were to monitor for changes in mood. The care plan lacked identification of risk for abuse and or increased risk related to R2's dementia. Interview on 2/5/24 at 6:28 p.m., with NA-A identified she reported to human resources (HR) director via text message on 1/29/24 at 7:56 p.m., that she had been shown a picture of R2 and NA-B, she stated instantly she knew it was not right. The picture showed R2 seated on the toilet holding onto the EZ stand and NA-B posing, in the picture you could see skin by the private part and that her pants were pulled down and she was sitting on the toilet. NA-B told her that R2 told NA-B to stop it and do her job. She was unsure why NA-B showed her the picture but she was glad she did so she knew what was going on and could report it. Additional Interview on 2/6/24 at 9:30 a.m., with NA-A identified she could not believe they took the picture, and she was very upset and cried when telling her mom about it who told her she needed to report that. She stated she knew she should have reported it right away, but she had a lot of anxiety about it and the resident in the picture was someone she really connected with. She revealed she would have reported it to the director of nursing (DON) or the administrator, however she did not have their numbers and only had HR director's number. NA-B had said to her don't tell anyone then showed her the picture and giggled. NA-A had waited almost 24 hours before reporting to the HR director. Interview on 2/6/24 at 9:48 a.m., with HR director identified she had received a text message from NA-A on 1/29/24 at 7:56 p.m., identifying she needed to report another NA. NA-A then texted her that she had been shown a picture of R2 who was on a lift in the bathroom with NA-B. Once she received the text form NA-A she thanked her and reminded her she needed to report sooner and set up a meeting for the next morning for an interview. She then reported the information immediately to the administrator. Review of 1/29/24 at 7:56 p.m., text message from NA-A to HR director identified NA-B said to NA-A don't show anyone and showed NA-A a picture of NA-B posing with R2 on the stand lift in the bathroom. NA-A could see her bottom half skin and pants pulled down while she just stared confused. After NA-B put her phone away she laughed and said to NA-A that R2 told NA-B to stop doing that and to be doing her job. NA-A continued to text HR director and reported she was sorry and should have said something earlier it hurt, and she was crying a lot when she tried to talk to her mom about it, but she wanted to say something. HR director had responded to NA-A something like this needed to be reported right away, the facility only had 2 hours to report and investigate. HR director then asked if NA-A could come in the next day to begin the interview process. NA-A responded she could come in around 10 a.m. There was no mention in the SA report that the picture showed R2 with her bottom half of skin showing and pants pulled down. Interview on 2/6/24 at 10:00 a.m., with administrator identified that she had been informed of the picture of R2 and NA-B late Sunday evening on 1/29/24 and reported the incident the next day on 1/30/24. She identified she did not report on 1/29/24 because she had always been told she only had to report within 2 hours if there was serious body injury or harm otherwise, she had 24 hours to submit her report. She revealed that she had contacted the corporate nurse consultant who confirmed she had reported the incident timely. She stated, that is our policy. The administrator revealed that NA-C had not been terminated yet even though it was identified in the submitted 5-day investigation summary as the facility had not determined that yet. NA-B would be retrained as NA-B did not have control of NA-C taking the picture. NA-B had not been retrained yet but would not be able to work until she completes her training. She had spoken to R2's family and agreed of the facilities action to terminate NA-C and retrain NA-B. She confirmed NA-B should have reported the picture immediately and NA-A should have reported immediately when she was shown the picture. She was unsure why NA-A had reported to HR director vs the director of nursing (DON) or herself as she never asked NA-A about that. She then stated maybe she should post a sign at the nurse's station for the chain of command for reporting. The administrator revealed that she did not report until 1/30/24, because it was not physical abuse and after visiting with R2 who has dementia had no mental anguish from the picture, so it was not mental abuse either. She confirmed that R2 had not been interviewed until 1/30/24, and that the facility had spent hours trying to figure out the correct way to even fill out the NHIR as there was not a place for pictures being taken. Review of 1/29/24 at 8:02 p.m., text message between HR director and administrator identified HR director texted a heads-up NA-A was texting something she needed to report about another NA. Then HR direct had copied the message she had received from NA-A and sent it to the administrator. The text message identified NA-A had been shown a picture of R2 and NA-B where NA-A could see R2 bottom half skin and pants pulled down while she just stared confused. The copied message also indicated that NA-B had reported to NA-A that R2 had told NA-B to stop doing that and said to be doing their job. Review of 1/30/24, facility interview documentation with NA-B at 3:30 p.m., with the administrator and HR director identified NA-B initially denied there being a picture. NA-B then revealed that NA-C had taken the picture and that it was only of NA-B wearing her N95 mask on her forehead and that NA-B did not think that R2 was even in the picture. Additional interview on 2/1/24 at 4:00 p.m., with the administrator and HR director NA-B identified that NA-C took the picture and then sent it via messenger to NA-B. NA-B did not recall who initiated the idea of the picture as it all happened fast from NA-C taking out her phone and taking the picture that NA-B felt like she did not have time to react appropriately. NA-B reported that R2's stomach and up were in the picture with NA-B. Review of 1/30/24, facility interview documentation with NA-C at 3:30 p.m., with the director of nursing (DON) and social services identified NA-C denied there being a picture. When NA-C was informed the facility knew about the picture and if there was anything NA-C wanted to bring forward and share she replied no. Additional interview on 2/1/24 at 1:30 p.m., with administrator, DON, and HR director NA-C identified a picture had been taken in the bathroom but it was only a picture of R2's face and NA-B. NA-C reported that NA-B wanted the picture taken and NA-B handed her NA-B's phone and she felt obligated to take the picture. NA-C reported she did not have the picture and she never did have it. Review of 2/1/24, facility interview documentation with NA-A at 3:20 p.m., with administrator and HR director identified NA-A when asked if she could without a doubt say she seen R2's private areas exposed NA-A replied no, she could not say she seen that but did say she saw exposed skin. NA-A also reported that R2 looked visibly upset in the picture. NA-A reported that NA-B was smiling and holding either a thumbs up or the peace sign in the picture. NA-A further reported that NA-B had told her that R2 told them to knock it off and stop!. NA-B was laughing while telling NA-A what R2 said. Interview on 2/6/24 at 10:31 a.m., with R2 identified they had no recollection of any picture being taken. Interview on 2/6/24 at 2:44 p.m., with the medical director (MD) identified he had been notified that something had occurred with R2 but was not given any details so he was unsure if it was even the same incident but would expect to be informed. He was unaware that the facility had knowledge of the incident and did not report to the state agency (SA) no later than 2 hours after having knowledge of the potential abuse and would expect the facility to follow the federal regulations for reporting. He further was unaware that the facility Abuse Prohibition/Vulnerable Adult policy had no mention of reporting suspicion of a crime or that suspicion of a crime that must be reported to the local law enforcement. Interview on 2/6/24 at 3:28 p.m., with NA-B who confirmed there had been a picture taken of herself and R2 while R2 was in the bathroom. NA-B revealed the picture had been taken on 1/26/24. NA-B further revealed that R2 did not agree to the picture being taken. NA-B reported there was no reason the picture was taken it just had been. She identified she had been interviewed about the picture by the administrator and the HR director last Thursday and again on Tuesday. She had been informed at that time that she was suspended while they the incident was being investigated. She further reported that she had not heard anything from the facility yet. Interview on 2/6/24 at 4:48 p.m., with family member (FM)-A who reported the facility reported that a picture had been snapped of R2 while in the lift in the bathroom. The facility had terminated the staff who took the picture and the picture had been deleted. FM-A said but of course the picture was still in the cloud and the facility was unsure who might have seen the picture. FM-A revealed she was pretty sure R2 had no idea the picture was taken. FM-A reported that R2 would have been embarrassed and angry' if she knew someone took a picture of her in the bathroom, as she would not want anyone to see something like that. FM-A further identified if R2 was not confused she would feel awful if she knew someone seen a picture of her in the bathroom. She stated it is just common sense not to do that to someone'. She said she could not be there all the time to watch things . you put your trust in the staff to care for your family and then this happened. Interview on 2/7/24 at 7:33 a.m., with director of nursing (DON) identified the facility had no documentation of their interview with NA-A that occurred on 1/30/24, all the facility had was a text message that NA-A would come in for an interview on 1/30/24 at 10:00 a.m. The DON revealed NA-A interview information was being typed into the SA report as the administrator was completing it. Interview on 2/7/24 at 12:06 p.m., with NA-C who identified a picture of R2 with staff had been taken on 1/26/24. NA-C revealed she had taken the picture of NA-B and R2 while R2 was seated on the toilet. She reported that herself and NA-B had asked R2 if she wanted her picture taken and R2 had agreed. She further revealed that the facility had no policy about not taking pictures that she was aware of, and she had not had any training that it was not okay to take a picture of a resident. NA-C confirmed she had been told during her interview that she could not work until the facility completed an investigation and reported she had not heard anything back yet from the facility as to when she could return. Review of the acknowledgement form that staff had signed that they had received a copy of the facility's Abuse Prohibition/VA and cell phone policies, 28 staff had signed between 1/30/24 and 1/31/24. There was no mention that the staff were trained on the policies including giving example or having a discussion of the policy only that staff had received a copy of the policy. Review of the facility's investigation staff interview questions and answers identified staff were asked if they had seen other staff on their phones and if so where they had been on their phones at. There were 7 out of 16 staff reported they had seen staff on their phones in varied areas of the facility. There were reports of staff on their phones in the tub room, resident room, reception desk area, nurses' station, the hallway, standing behind residents in the tubs, toileting room, and while at the table on east wing. Review of the facility's investigation resident interview questions and answers identified residents were asked if they had any concerns with cares provided at the facility, any concerns with staff at the facility, if they felt safe at the facility, if they knew who to report any concerns to, and if they had ever seen a staff person use their cell phone in their room. Out of 31 interviewed, 2 residents reported they did not know who to report concerns to and 1 resident reported a staff used their cell phone camera to take a picture of a puzzle in their room. It is unknown how the facility interviewed residents's families for those who had cognitive impairments. Review of August 2023, Abuse Prohibition/Vulnerable Adult policy identified investigation and protection would begin immediately. The facility would review all incident reports no later than the next working day. The facility investigation team would determine if an investigation needed to continue. The team would complete interviews with witnesses, staff, and residents. Based on the investigation the team would implement corrective action. The facility would maintain all documentation in a confidential file. The facility would ensure all reports were filed in accordance with State Law. Trends summaries would be forwarded to the QAPI committee. Social services would provide ongoing support and counseling for the residents and family as needed.

Based on interview and document review, the facility failed to notify the county (designated State Mental Health Authority (SMHA)) for 1 of 1 resident (R2) with new onset mental illness. Findings include: R2's [DATE], Admission Record identified that R2 had been admitted to the facility in [DATE]. R2's [DATE], annual Minimum Data Set (MDS) assessment identified R2's cognition was moderately impaired, she had fluctuating times of inattention, she required substantial to total assistance from staff for cares and transfers. R2 took an antipsychotic and antidepressant. R2 had diagnosis of multiple sclerosis, depression, psychotic disorder (other than schizophrenia), depression, and dementia. R2's prior MDS's had no identification of a psychotic disorder. R2's diagnosis list printed [DATE], identified a new diagnosis of unspecified psychosis not due to a substance or known physiological condition on [DATE]. R2's care plan printed [DATE], identified at risk for alteration in mood related to dementia with behavioral disturbances, major depression, and multiple sclerosis. R2 had history of accusing staff of not knowing what to do, yelling at staff, and hitting out. R2 had some delusional thinking and would look for her deceased husband. R2 also had risk for alteration in psychosocial well-being related to dementia with behavioral disturbances, depression, and multiple sclerosis. R2 took psychotropic medications daily including antipsychotic. R2's [DATE], Initial Pre-Admission Screening (PAS) Results did not identify a diagnosis of mental illness and did not indicate the need for a Level II PASARR to be completed. Interview on [DATE] at 2:20 p.m., with social service designee identified the facility had received the diagnosis of psychosis to support R2's Seroquel medication related to R2's behaviors. She reported she had never contacted the lead agency with a new diagnosis as she had never thought to do that. Review of [DATE], Pre-Admission Screening (PASARR) policy identified social services would be responsible to review the resident's pre-admission screening and OBRA II requirements to ensure residents meet the level of care. Social services would also be responsible to request a redetermination and refer the resident to the lead agency for situations like: if there was no indication of the resident having a serious mental illness, but the facility believed the resident did, a change in the resident's situation that significantly changes the resident's mental health symptoms or a need for mental health services. The policy identified that would include previously undiagnosed condition or diagnoses that were not present on hospital discharge but are added to the resident chart later.

Based on observation, interview and document review, the facility failed to provide sufficient nursing staff to ensure residents' safety and overall care and needs were maintained by ensuring scheduled medications to treat pain, blood sugar (insulin), blood thinners, blood pressure, and [MEDICAL CONDITION] were administered, and failed to ensure wound dressings were completed for 14 of 41 residents (R3, R6, R8, R14, R29, R15, R13, R33, R24, R20, R27, R12,R15, and R18). The facility also failed to ensure breakfast was provided for 17 of 38 residents (R31, R30, R5, R33, R32, R38, R28, R11, R17, R40, R7, R12, R8, R21, R25, R9, R23) between the dates of [DATE] and [DATE], and failed to ensure repositioning was completed to prevent pressure ulcers for 1 of 1 resident (R28). The facility failed to implement their emergency staffing plan to cross-train non-certified staff prior to an emergency and before performing direct care duties. This affected all 41 residents who resided in the facility and resulted in an immediate jeopardy (IJ) for all residents. The IJ began on [DATE], when the facility failed to ensure sufficient staffing to provide meals, treatment and medication administration, and repositioning. The administrator and director of nursing (DON) were notified of the IJ on [DATE] at 2:45 p.m. The IJ was removed on [DATE] at 6:36 p.m. however, non-compliance remained at the scope and severity level of G, isolated, actual harm that is not immediate jeopardy. Findings include: Interview on [DATE] at 9:36 a.m., with anonymous staff (AS)-B identified they were unlicensed and uncertified to provide cares, but had worked all weekend ([DATE] through [DATE]) caring for the residents. They had no training on how to provide direct care and felt overwhelmed. Interview on [DATE] at 10:19 a.m., with director of nursing (DON)-B identified the first COVID positive case had been from nursing assistant (NA)-D who reported on [DATE] she tested positive. The DON stated the facility had also been notified that a resident (R30) who had been at the emergency room for stroke symptoms and had returned a couple days prior, had been tested and was positive. The DON verified the facility was unaware R30 had been tested while at the hospital for COVID until the hospital had called on [DATE] to report the positive results. R30 was immediately isolated to her room following the results. The facility already had planned facility wide testing for [DATE], and positive results started coming in on Thursday afternoon [DATE]. The DON stated positive residents were placed on isolation, positive staff were removed from the facility and everyone pitched in as the results came in. During interview with the administrator (A) on [DATE] at 12:27 p.m., A stated there were no non-certified or non-licensed staff providing direct resident care. All non-certified staff helped with housekeeping, laundry, passed meal trays, and were to be the second staff during a mechanical lift transfer. Interview on [DATE] at 12:32 p.m., with R26 stated there had been three staff working who normally do not assist her or her husband (who is in the same room) helping them. Care service was slow, but they thought they did get help. Interview on [DATE] at 12:38 p.m., with AS-D identified they were not certified or licensed and had no training to provide direct care. AS-D had been told by consultant administrator (C)-A to step up and was expected to work on the floor providing direct care to the residents. AS-D had used a mechanical lift, provided personal cares, worked alone on the upper west wing. The residents did not get the care they needed. The residents deserve better than this. AS-D was unaware of what she was doing or how to care for the residents while working on the floor. Corporate had been told staff need help as residents were not getting cared for. Half of the residents did not get breakfast today. Today had been the best staffing the facility has had for days. Interview on [DATE] at 1:10 p.m., dietary director (DD) identified seventeen residents missed their breakfast this morning. DD provided list of residents who did not get breakfast. Those residents included R31, R30, R5, R33, R32, R38, R28, R11, R17, R40, R7, R12, R8, R21, R25, R9, R23. There is not enough staff to assist these residents who need help to eat. DD identified that there were approximately eight residents who also did not get breakfast Saturday [DATE] or Sunday [DATE] however, stated she could not recall who they were. Additionally, on [DATE], the following residents did not receive their breakfast R5, R33, R32, R38, R11, R40, R7, R25. DD confirmed R7, R25, and R28 who were among the residents who missed their breakfast, are being monitored for identified weight loss. These residents were identified as needing staff assistance to eat. Interview on [DATE] at 1:11 p.m., with family member (FM)-A identified there have been long wait times for call light to be answered ½ hour or longer, the facility does not have enough staff, and staff are overworked. FM-A's parent had been told she is not the only one here by staff when she requested help. When the facility started to allow visitors with precautions, FM-A's parent was observed to have sat on the toilet for over one half hour at that time and got a sore bottom. Interview on [DATE] at 2:48 p.m., with AS-B identified themselves as a non-certified staff with no formal training to provide direct care. AS-B provided personal cares, toileted residents, had to use both hoyer and standing mechanical lifts themselves and reported residents had not been getting bathed. AS-B did have crash course on how to run lift one time and then was on their own several times. There had not been two staff utilized during transfer and running the lift. No documentation was recorded as AS-B was unaware of how to document cares in electronic medical record. AS-B started working on the floor with the residents on [DATE], after the consulting administrator-CA-(A) told uncertified staff they had to work the floor. Staff advised the CA-A they did not feel comfortable or safe and had been instructed they had to care for the residents so they did not get an IJ (immediate jeopardy) tag. Interview on [DATE] at 2:58 p.m., AS-C identified they were to be the second person for mechanical lift transfers. They had to assist a couple residents with a gait belt to walk to the bathroom but could not remember who they were or if they were able to be transferred safely in that manner. AS-C assisted residents to eat including last evening on [DATE]. AS-C had no training in feeding residents or ambulating residents. AS-C worked [DATE] and [DATE], and would ask others how to do stuff to see if it was something they could do. Staff were told by CA-A they had to step up and do more on Friday [DATE]. AS-C felt unsafe after helping a resident walk with a gait belt so they would not do it anymore. There is not enough staff here to care for the residents. Some residents did not get care, they wait for long times, some are not getting to bed timely. One resident looked like she had not checked before bed at all she as she had crusted bowel dried on her and was incontinent this morning (R4). AS-C identified they had no medical background however, this morning R30 had felt warm so she told the nurse who did not have time to check R30. AS-C checked R30's temperature and her forehead seemed okay. When the thermometer was over R30's neck, it registered 102.2. AS-C told the unidentified nurse. AS-C was advised all residents are warm and that was not a good place to check a temperature. R30's progress notes dated [DATE] at 19:54 (7:54 p.m.) identified R30 had been lethargic this shift. Temperature 103.6 Tylenol suppository administered and effective temperature decreased to 98.4. There lacked any documentation that a temperature had been checked or monitored during the morning shift. Interview on [DATE] at 3:58 p.m., with AS-A identified the facility needed to shut down or send our resident someplace else in order to be cared for. There were residents who did not eat this morning these residents needed assistance to eat and we just do not have enough staff to help with this. The facility had the activity director and human resources staff working the floor doing everything a nursing assistant would do .use lifts, feed residents and provide cares and we still do not have enough staff to provide appropriate cares. Nurses have had to pass medication for all residents and medications have been given late or not at all. R32 had a low blood sugar (BS) and was given orange juice, but she did not get breakfast. There has been new skin breakdown as R28 has a new area. We have not had time to update the doctor but did clean and apply a dressing to the wound. They have orders that they have not gotten to that are sitting on the nurses desk. They have several residents with increased temperatures and no more oxygen's concentrators. Facility staff were using portable tanks but only have so many of them. AS-A felt A-A and DON-B are trying to help on the floor as staff literally cannot do it .we cannot care for the residents at this point. I would like to throw in my keys and go .we cannot provide care due to not having enough staff. Today there is no one to relieve us, staff did not show up at 2:00 p.m Corporate staff have not notified any of us on the floor that no one is coming in and we are sinking fast. Interview on [DATE] at 7:56 a.m., with LPN-B identified there was no one scheduled to relieve her after her twelve hour shift that was finishing up at 10:00 a.m. that day. LPN-B was scheduled to be back in eight hours at 6:00 p.m., for another twelve hour shift. The residents are not getting cared for appropriately, no one here is getting showed, rooms are dirty, residents smell, we do not have enough staff. The two day shift girls came in at 4:00 a.m., so they could start to get residents up so they did not miss breakfast for not being up anyway's. There is not enough staff to get everyone up on time to eat and not enough staff to assist the residents who need help to eat. Management just tells us they are working on it and to do the best you can. Interview on [DATE] at 10:00 a.m., with C-A identified there are no competencies for training for the uncertified or unlicensed staff that are working on the floor. Interview on [DATE] at 9:38 a.m., with FM-B identified receiving information via automated system about a positive resident and positive staff. FM-B was told by one of the staff (unknown name), there was 36 residents and 22 staff positive and they did not have enough help. A call was placed to CA-A who reassured things were under control and confirmed that there were several positive cases but they did not believe the results. FM-B identified he felt the facility was not being very transparent and gave him different information daily. FM-B was concerned for his family who was a resident, along with other residents at the facility. On [DATE] at 10:49 a.m., C-A reports she had reached out to the corporate pool staff, Minnesota Department of Health, AnnLeo, and Redwood County Emergency Management between the dates of [DATE] and [DATE], for staffing assistance with no success. C-A stated she hoped to reach out to the Minnesota Board of Nursing today to see if they are able to assist in any way. Interview on [DATE] at 2:19 p.m., with R4 identified she had not been out of her recliner since she had risen for the day. Staff that normally help her have not helped her. Interview on [DATE] at 3:10 p.m., C-A and RN-C identify they are working on finding staff to fill the afternoon shift. One day person had agreed to stay on but they were still working on filling the afternoon shift. Interview on [DATE] at 3:14 p.m., with RN-D asked the surveyor, What can we do to get these residents out of here? They need care. Interview on [DATE] at 3:14 p.m., with A-A identified she did not know what the plan for the evening shift was, as they had no one to work. She stated that C-A was still trying to work on it. Interview on [DATE] at 3:55 p.m., with NA-D identified Saturday ([DATE]) night during work she reported she started to feel like she had a head cold coming on. Sunday ([DATE]) she felt a little worse but continued to work as she thought maybe it was allergies [REDACTED]. She reported she did not have a temperature but did have a headache, dry cough and noticed some wheezing when breathing out, and also body aches. LPN-C was unaware of facility protocol and let NA-D work regardless of her having symptoms. LPN-C advised NA-D she was aware of residents on the upper west wing having temperatures between 99.0 and 99.7 with no changes being made like isolation to their room. NA-D worked the shift Monday ([DATE]) night into Tuesday. In the morning she left work and reported she slept a little. NA-D had body aches and a temperature of 101.5 degrees F, and decided to go to the local clinic on [DATE]. Her test came back positive on [DATE], and she notified the facility right away. NA-D identified there was a new admission, R11 who was diagnosed with [REDACTED]. There were other residents identified with loose stools, and facility nursing staff were notified. No new interventions were placed. It is hard to get information from management about what is happening and the staff are overworked. Observation on [DATE] at 11:21 p.m., of R28 identified they were laying in bed, had oxygen on, covers off, bed is in lowest position, was awake, coughing and pulling at their oxygen tubing. R28 had not been dressed for the day and was unkempt. Observation on [DATE] at 12:03 p.m., of registered nurse (RN)-E identified they carried a meal tray into R28 room and told R28 it was time to eat. R28 was laying twisted slightly to the left side. RN-B raised head of bed, and attempted to assist with noon meal which R28 was observed to eat poorly. RN-E lowered bed to floor and left room at 12:32 p.m. with R28 remaining in same position. At 12:35 p.m. RN-E walked by R28's room again and shut the door. At no time did RN-E attempt to reposition R28 during the observation. There was no documentation to support R28 had been repositioned in any way that day. Continuous observations identified no staff had entered R28's room by 2:22 p.m. to reposition R28. Interview on [DATE] at 12:56 p.m., with trained medication aid (TMA)-B identified the nurse usually does the dressing changes and was unaware R28 had any wound dressings. Observation and interview on [DATE] at 1:00 p.m., with RN-E while reviewing R15's physician orders [REDACTED]. There was no insulin pen in the medication cart. RN-E had not administered R15's insulin yet that day. RN-E went to retrieve R15's insulin from the medication room, and returned with insulin pen for R15. She waited for staff currently in R15's room to finish laying R15 down. RN-E entered the room at 1:44 p.m., to administer R15 their insulin that was due earlier that morning prior to lunch. RN-E confirmed insulin was late and should have been given within thirty minutes of the noon meal. Observation on [DATE] at 1:51 p.m., RN-E verified R32 ate noon meal and she is to get 7 units of [MEDICATION NAME] for meal coverage. At 1:54 p.m., prior to administration, R32's insulin pen was noted not to have an open or expired date labeled on the pen. RN-E disposed and obtained a new insulin pen. RN-E confirmed R32's insulin was also late. Observation on [DATE] at 2:12 p.m., RN-E preparing to give R29 her [MEDICATION NAME] 2 units of insulin with meals and sliding scale for blood sugar of 155. The insulin pen did not have an open date or expired date identified RN-E disposed and obtained a new insulin pen. RN-E confirmed insulin was late and should have been given within thirty minutes of the noon meal. Observation on [DATE] at 2:18 p.m., RN-E preparing R14's Humalog 24 units subcutaneous with meals, with no labeled open date identified. RN-E disposed and obtained new insulin. RN-E confirmed R14's insulin was late being administered. Observation and interview on [DATE] at 2:26 p.m. with nursing assistant (NA)-C identified she thought RN-E had possibly repositioned R28 at noon but was unsure. R28 was observed to still have head of bed elevated approximately 75 degrees and was still positioned on her back with body slightly twisted to left. TMA-B entered R28's room after being advised by the surveyor R28 had not been repositioned timely. TMA-B assisted R28 to the side to check her for incontinence at that time. R28 was observed to be soiled with bowel. R28 had a bandage in left gluteal fold that was soiled with bowel and had drainage saturated through an area approximately an inch in diameter. TMA-B called for the nurse to come. RN-E entered R28's room and identified R28 had left gluteal unstageable wound that was overall 4.8 centimeters (cm) x 3.5 cm including the dark reddened boarders. The actual open area within measured 1.5 cm x 2.4 cm and also within that was an area was a hardened spot measuring 1 cm x 2 cm. RN-E identified the areas were new pressure ulcers not previously known for R28. RN-E described an open coccyx wound that measured 0.5 cm x 0.9 cm and two open wounds on her right buttocks the proximal measured 0.5 cm x 0.8 cm x 0.1 cm and the distal measured 0.4 cm x 0.6 cm. RN-E cleansed, applied dressing and planned to notify the doctor. R28 was noted to moan during the wound treatment. Staff repositioned R28 on her right side with RN-E instructing staff she should be repositioned hourly. RN-E identified she would also be updating hospice for an air mattress and notifying the family. RN-E confirmed that resident should have been repositioned when new areas of pressure were identified. Any time skin breakdown was observed direct care staff, they were to notify the nurse to assess, notify doctor, get wound orders, place resident on wound rounds, complete a Braden skin assessment, begin skin assessments, and notify family. Review of R28's progress notes dated [DATE] at 4:11 p.m., identified the R28's primary doctor was left a message that R28 had four pressure ulcers. At 4:21 p.m., R28's son was updated that R28 had four pressure sores on her bottom with family requesting the facility keep her comfortable. Review of R28's weekly skin inspection dated [DATE], identified that R28 had new 3 cm x 1 cm area on her right left gluteus that was slightly open and a chronic problem. Wound care was to evaluate and treat on [DATE]. There was no drainage noted at that time. R28 would sit in her wheelchair and wheel herself around all day. A skin inspection note dated [DATE], identified R28 had a chronic left buttocks wounds, that were not open. A standard barrier cream was to be applied. There was no mention of the new open area in her gluteal fold. Review of R28's assessment records found no pressure wound evaluation from [DATE] to [DATE]. R28's current, undated care plan identified R28 had potential for skin breakdown related to infrequent self-mobility or repositioning and incontinence. Interventions included having a foam covering on wheelchair frame where foot peddles attach, geri-sleeves to help protect arms and hands, monitor red area under left breast every shift, pressure reducing cushion in wheelchair and in recliner, pressure reducing mattress when she chooses to use bed, turn and reposition every ,[DATE] hours, with weekly skin observations by licensed nurse. There was no mention R28's care plan had ever been updated to identify the need for more frequent repositioning related to her health or history. Review of the Medication Administration and Treatment Administration records identified R15, R36, R12, R22, R13, R8, R23, R24, R27, R3, R20, R6, R18, R39, R19, R14, R33, R38, R29 had not received medications timely or at all, on varied dates and times from [DATE] through [DATE]. Of those administration records the following critical medications were not received or administered such as insulin for R14, R29, R15, R13, heart medications were not administered for R20, R3, R27, R13, R12, R15, R6, nutritional supplements R22, R8, R33, R38, [MEDICAL CONDITION] medication for R29, pain medication for R33, R8, R24, R3, R6, and blood thinners for R20, R27, R13. There were also multiple other medications that were not administered as ordered during this time frame. Additionally, R18 did not receive a wound dressing change as scheduled. Interview on [DATE] at 10:58 a.m., with C-B identified the facility reached out to the MDH telling them we did not have enough staff and we needed help. MDH advised the facility was to staff according to the residents needs. If residents needs were unable to be met, the facility was to transfer residents to a number they could provide care for. We attempted to get staff into work as soon as possible. The C-B confirmed the contingency staffing plan and emergency staffing plan had not been fully implemented and non-certified staff should not have worked the floor. C-B also confirmed there had been residents who missed breakfast due to short staffing. All residents were to be provided three meals a day with no more than 14 hours between the evening meal and breakfast the next day. He would expect medications to be given and treatments completed as ordered by the physician. He would expect staffing levels to meet the needs of the residents to ensure repositioning of residents at risk for skin breakdown or and repositioning completed. C-B identified the Quality Assurance Performance Improvement (QAPI) committee should have provided oversight to ensure a plan was in place in case of a COVID or other infectious disease outbreak. It was the overall responsibility of the administrator to ensure residents receive the care and services they require. Interview on [DATE] at 12:38 p.m., with medical director (MD) identified his expectation would be that the facility had adequate staffing to ensure basic care needs are being met such as personal hygiene, repositioning, meals provided to residents, and residents who require assistance with meals receive that assistance. Further, the MD would expect enough staffing to ensure medications are timely and given. The MD confirmed the facility should not have had non-certified or non-licensed staff providing direct care to the residents. The facility should have followed their contingency staffing plan and staff should not have provided direct care without any training. He was notified about the immediate jeopardy situation and care was compromised at the facility, however, was not made aware of any concerns or issues before the immediate jeopardy. The facility was discharging some residents to a sister facility to reduce census to manageable level. The MD expected the facility notify him of the inability to provide care to residents. Review of the ,[DATE], Meal times policy identified the facility was to serve meals no more than 14 hours between the evening meal of one day and the breakfast meal of the next day. Review of the [DATE], Prevention of Pressure Ulcers/Injuries policy identified assessing the resident for existing pressure ulcer upon admission and for risk factors, repeat the assessment weekly and upon any changes in condition. Reposition residents as indicated on the care plan. Staff were to provide preventative interventions, monitor, evaluate and document potential changes in the skin and review interventions and strategies for effectiveness on an ongoing basis. Review of the [DATE], Emergency Staffing policy identified the facility was to give competent, conscientious, and consistent quality care to each resident 24 hours per day. Nursing, laundry, culinary, and maintenance departments must be adequately staffed and therefore, it may be necessary to stay on duty until replacements could report for duty. If more staff were needed, the designee person in charge of the facility will contact the corporate office to contact sister facilities in the company for staff assistance. Critical staffing shortages during an emergency had the potential to result in staff injury or illness and post-traumatic stress. In order to prepare for potential staffing shortages, licensed and unlicensed personnel and volunteers were to be recruited and trained for emergency assistance. The facility was not to engage in non-credentialed or untrained volunteers for direct resident care. Review of the [DATE], Long-Term Care Contingency Staffing Plan policy identified a training plan to cross-train staff to fulfill different roles in case the primary staff responsible for a given function was not available. In emergency situations, direct care would be performed by facility staff, then the corporate float pool, outside agencies, and lastly via cross-trained staff from other departments. Quality of care was deemed the highest practicable level of care to meet the needs of residents with proactive steps to have been taken before a crisis occurs to minimize the risk of crisis staffing. The IJ was removed on [DATE] at 6:36 p.m.-when it could be verified by observation, interview and document review, the facility took steps to remove the immediacy by discharging 8 residents to the local hospital to receive safe care, with an additional 3 resident discharged to the hospital for a change in condition. The facility then transferred additional residents to other nursing facilities until they were able to a manage a census of 16. Policies and procedures were reviewed and revised. Sufficient staffing levels were verified and audited. Non-certified and non-licensed staff were not allowed to provide direct care unless they had completed training to do so.

Based on observation, interview and document review, the facility failed to follow Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) guidelines for COVID-19 to prevent or minimize the transmission of COVID-19 which resulted in an ongoing facility outbreak when 31 of 41 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R6, R17, R18, R19, R12, R21, R22, R23, R24, R27, R28, R20, R30, R31, R32, R33, R34, R35, R36, R38, R38, R39, R40, R42, and R42) whom had COVID-19 symptoms. As a result of this, 39 of 41 residents tested positive for COVID-19. The facility's failures resulted in an immediate jeopardy (IJ) situation for all residents. The IJ began on 9/16/20, when R30 was identified as positive for COVID-19. The facility failed to have a system for daily cumulative surveillance to identify potential symptoms of COVID-19, implement droplet precautions, quarantined residents, and implement appropriate (PPE) to mitigate COVID-19 transmission which resulted in 39 of 41 residents testing positive for COVID-19. The administrator and director of nursing (DON) were notified of the IJ on 9/23/20 at 3:30 p.m. The IJ was removed on 9/24/20 at 2:35 p.m. Non-compliance remained at the scope and severity of F, widespread- potential for harm that is not immediate jeopardy. Findings include: SURVEILLANCE Interview on 9/21/20 at 9:15 a.m., with NA-B identified none of the 17 residents who admitted from a local nursing home that closed, were quarantined upon admission and staff did not wear gowns when providing care. NA-B was unaware if any residents had symptoms of COVID. Continued interview on 9/22/20 at 9:50 a.m., with nursing assistant (NA)-B identified a month or so ago, there was one resident whom had [DIAGNOSES REDACTED] (severe intestinal infection) was quarantined when they admitted from a local nursing home that closed. No other residents admitted from the facility were placed on quarantine for COVID-19, and staff were not instructed to don a gown in addition to using standard PPE precautions to provide care. NA-B also reported that a month ago the entire west wing of the facility had diarrhea. There were no precautions implemented during that time. NA-B was unaware if any residents had COVID symptoms in the facility. Interview on 9/21/20 at 2:00 p.m., with licensed practical nurse (LPN)-A identified none of the 17 residents were placed on precautions/quarantine when they were admitted from a local nursing home that closed and were admitted to their facility. LPN-A was unaware if any residents had symptoms of COVID prior to the facility outbreak on 9/16/20. Review of July 2020, August 2020, and September 2020, Infection Prevention Surveillance documentation only identified infections treated with antibiotics. There was no documentation of potential COVID-19 symptoms or other symptoms prior to the first identified positive COVID tests on 9/16/20. CDC defines symptoms of COVID-19 to include but not limited to Fever, either 100.4 or subjective, cough, shortness of breath, headache, new loss of taste or smell, congestion or runny nose, sore throat, diarrhea, myalgia (muscle aches, body aches), tiredness or fatigue Review of resident's electronic medical records (EMRs) identified the following: R1's nurse notes identified on 7/9/20, R1 admitted to the facility from the local facility that closed. The notes made no mention R1 was quarantined R1's vital sign report identified on 7/26/20, R1's temperature was 99.0 degrees Fahrenheit (F) and on 8/20/20, R1's temperature was 99.1 (F). Between 8/4/20, and 9/7/20, R1 also complained of intermittent [MEDICAL CONDITION] stools for several days. On 9/17/20, R1 tested positive for COVID. R1's July through September 2020, nurse notes made no mention R1 was quarantined upon admission or when potential COVID symptoms occurred. There was no mention R1's provider was notified of potential symptoms of COVID. R2's nurses' notes identified R2 was admitted from a hospital. On 8/28/20, R2 admitted to the hospital and returned to the facility on [DATE]. R2's vital sign report identified on 9/14/20, R2's temperature was 99.1 degrees F. On 9/17/20, R2 tested positive for COVID. R2's August and September 2020, nurse notes made no mention R2 was placed on isolation upon return from the hospital 14 days to mitigate potential transmission of COVID. R3's 9/2/20, nurses' notes identified R3 had a headache was feeling off, had difficulty standing, and was unresponsive to verbal cues. R3's vital sign report identified on 9/15/20, R3's temperature was 99.1 degrees F. R3's September 2020, progress notes made no mention R3 had potential symptoms of COVID-19 was placed on precautions, or whether R3's provider was notified of potential COVID symptoms. R5's nurses' notes identified on 7/16/20, R5 was admitted from local facility that closed. R5's July 2020, notes made no mention precautions were implemented. R5's vital signs showed R5 had a temperature of 99.7 degrees F on 7/17/20. 99.2 on 9/22/20; and 100.2 F on 9/24/20. On 8/21/20, R5 was having loose stools. On 9/6/20, R5 had an emesis, had wet breath sounds, mumbled speech, and flaccid limbs. R5 was transported to the emergency department (ED), was admitted to the intensive care unit (ICU) with [DIAGNOSES REDACTED]. There was no indication R5 had been tested for COVID in the hospital and was not identified as being placed on precautions when he returned. On 9/12/20, R5 was congested and productive with slight yellow-tinged sputum. On 9/15/20, R5's guardian declined COVID-19 testing. The guardian was informed R5 would then be placed on quarantine and would not be allowed visitors. R6's progress notes identified on 7/16/20, R6 was admitted from a local facility that closed. R6's vital sign report identified on 8/7/20, R6's temperature was 99.1 degrees F; and 99.3 on 9/14/20. On 9/16/20, R6 intermittently coughed up blood tinged sputum, experienced chest pain, dizziness, had productive cough with yellow sputum, shortness of breath, hoarseness, and diminished wheezy lung sounds. On 9/17/20, R6 tested positive for COVID-19. There was no indication R6 had been placed on any precautions until they were diagnosed with [REDACTED]. R7's vital sign record identified R7's temperature was 99.4 degrees F on 9/8/20; 99.1 on 9/13/20 through 9/15/20; 100.6 on 9/17/20; 99.5 on 9/18/20; 99.1 on 9/20/20; and 100.6 on 9/17/20 There was no indication R12 had been placed on any precautions until they were diagnosed with [REDACTED]. R8's nurses' notes identified on 7/24/20, R8 admitted from a local closed facility. Between 8/21/20 through 9/9/20, R8 intermittently had symptoms of loose stools and a cough. R8's vital sign record identified between 8/11/20, and 9/14/20, R8 had intermittent elevated temperatures. On 9/20/20, R8 tested positive for COVID-19. There was no indication R7 had been placed on any precautions until they were diagnosed with [REDACTED]. R9's nurses' notes identified on 7/23/20, R9 admitted from a local facility that closed. There was mention R8 was placed on transmission based precautions upon admission. R11's nurses' notes identified they were admitted to the facility from a local facility that closed with [DIAGNOSES REDACTED]. On 8/27/20, R11's precautions were discontinued and were not renewed when R11 had a temp on 9/9/20, of 99.5 degrees F. On 9/15/20, it was 99.1 degrees F. On 9/17/20, R11 tested positive for COVID-19. There was no indication R11 had been placed on any precautions until they were diagnosed with [REDACTED].>R12's nurses' notes identified on 7/29/20, R12 was admitted to the facility from another local facility that closed. R12's temperature was 99.5 degrees F on 9/8/20; 100.3 degrees F on 9/13/20. R5's temperatures ranged from 99.1 degrees F 102.3 degrees F on 9/14/20. On 9/15/20 R12's 101.0. R12's progress notes identified between 9/13/20 and 9/15/20, R12 also had symptoms of being flushed and was weak. On 9/16/20, R12's temperature was 99.4. R12 was diagnosed with [REDACTED]. There was no indication R12 had been placed on any precautions until they were diagnosed with [REDACTED]. R13's nurses' notes identified on 7/2/20, R13 admitted from the hospital. On 8/21/20, R13 had loose stools, staff requested a stool culture and [MEDICATION NAME] for diarrhea. The notes made no mention R13 was placed on precautions at that time. R13 tested positive for COVID on 9/17/20. R14's nurses' notes identified on 9/13/20, R14 complained of getting a chest cold. R14's temperature on 9/13/20 was 99.1 degrees F and 99.2 degrees on 9/15/20. R14 tested positive for COVID on 9/17/20. There was no mention isolation precautions were implemented until they were diagnosed with [REDACTED]. R15's nurses' notes identified between 9/9/20 and 9/13/20, R15 had loose stools. R15's notes made no mention precautions were implemented to prevent potential transmission of COVID, and no mention R15's provider was contacted regarding potential COVID-19 symptoms. On 9/17/20, R15 tested positive for COVID-19. R16's nurses' notes identified on 7/13/20, R16 was admitted from from a locally closed facility. R16's note made no mention R16 was quarantined to prevent potential transmission of COVID-19. On 9/17/20, R16 tested positive for COVID-19. R17's nurses' notes identified between 8/25/29 and 9/1/20, R17 had intermittent increased confusion, lethargy, and decreased appetite. On 9/13/20, R17 was hospitalized for [REDACTED]. R17 returned to the facility on [DATE]. R17's notes made no mention R17 was quarantined upon identifying symptoms or when they returned from the hospital. On 9/17/20, R17 tested positive for COVID-19. R19's nurses' notes identified on 9/11/20, R19 had a temperature of 100.8 degrees F. On 9/12/20 through 9/14/20, R19 complained of upset stomach, not feeling well, poor appetite, and wanted to see her provider. R19's notes made no mention R19 was quarantined and COVID precautions were implemented when symptoms were identified. On 9/17/20 R19 tested positive for COVID. R22's nurses' notes identified between 8/19/20 and 9/16 20, R22 had symptoms of cough and vomiting. On 9/22/20, R20 tested positive for COVID. R22's notes made no mention he was placed on quarantine or that droplet precautions were implemented when potential COVID symptoms were identified. R23's nurses' notes identified on 7/9/20, R23 admitted from a local facility that was closed. R23's notes made no mention R23 was quarantined at the time of admission to prevent potential transmission of COVID. Between 8/24/20, and 9/15 /20, and 9/15/20, R23 had loose stools, a red, goopy eye, allergy symptoms, cough, and elevated temperature, and crackles in her lungs. On 9/17/20, R23 tested positive for COVID. R23's notes made no mention R23 was quarantined and droplet precautions implemented to prevent potential transmission of COVID at the time potential COVID symptoms were identified. R24's nurses' notes identified on 9/2/20, R24 admitted to the hospital with [REDACTED]. R24 continued to have a productive cough. R24's notes made no mention R24 was quarantined upon admission to prevent potential transmission of COVID. On 9/21/20, R24 tested positive for COVID. R25's nurses' notes identified on 8/18/20, R25 reported flu-like symptoms. Staff were to continue to monitor R25's symptoms. R25's progress notes made no further mention R25's symptoms were monitored, whether R25 was quarantined, and if droplet precautions were implemented to prevent potential transmission of COVID. R26's August and September 2020, nurses' notes identified between 8/17/20, to 9/2/20, R26 complained of loose stools. R26's progress notes made no further mention R26's symptoms were monitored, whether R26 was quarantined, and if droplet precautions were implemented to prevent potential transmission of COVID. R28's nurses' notes identified on 8/22/20, R28 had a large amount of phlegm she was unable to clear. R28's lung sounds had fine crackles. Between 8/22/20 and 9/6/20, R28 continued to receive as needed (PRN) medications for cough and congestion symptoms. R28's August and September, 2020, nurse notes made no mention R28's symptoms were monitored or whether R28 was placed on droplet precautions. On 9/17/20, R28 tested positive for COVID. R29's nurses' notes identified R29 was admitted from the hospital on [DATE]. R29 was hospitalized for [REDACTED]. The August and September, 2020, nurse notes made no mention R29 was quarantined to prevent potential COVID Transmission upon admission to the facility or after the second hospitalization . On 9/17/20, R29 tested positive for COVID. R30's nurses' notes identified between 8/22/20 and 9/16/20, R30's had a runny nose, sore scratchy throat, and increased lethargy. On 9/11/20, R30 was not feeling well, leaning to the right side, had a temperature of 100.7, pulse rate of 99, and was transferred to the ED for evaluation. R30 returned on 9/11/20 with a [DIAGNOSES REDACTED]. There was no mention R30 was placed on precautions to prevent spread of COVID. R31's nurses' notes identified R31 was admitted on [DATE], from a local facility that recently closed The notes made no mention whether R31 was quarantined upon admission. On 9/17/20, R31 tested positive for COVID. R33's nurses' notes identified on 8/21/20 to 9/7/20, R33 had intermittent loose stools and was not feeling well. The notes made no mention R33 was placed on precautions when loose stools began. On 9/17/20, R33 tested positive for COVID. R34's nurses' notes identified on 7/30/20, R34 admitted to the facility on [DATE]. Between 8/21/20 and 8/27/20, R34 reported intermittent loose stools. There was no mention R34 was placed on precautions upon admission or when loose stools began on 8/21/20. R34 tested positive for COVID. R35's nurses' notes identified on 7/30/20, R35 was admitted from a locally closed facility. On 8/26/20 R35 had loose stools. On 9/16/20, R35 had a productive cough, clammy skin, and was not feeling well. Staff was to continue to monitor. On 9/17/20, R35 tested positive for COVID. R37's nurses' notes identified on 8/11/20, R37 admitted to the facility from a hospital. The July 2020, nurse notes made no mention whether R37 was placed on precautions upon admission. On 9/4/20, R37 complained of shortness of breath (SOB). On 9/5/20, R37's temperature was 100.0 degrees F. There was no mention R37 was placed on precautions upon admission or when loose stools or SOB began. R41's July 2020, nurses' notes identified on 7/16/20, R41 admitted to the facility from a local facility that closed. The notes made no mention R41 was quarantined upon admission. R44's nurses' notes identified on 7/22/20, R44 was admitted from a local facility that closed. On 8/8/20 through 8/9, R44 had increased productive cough. On 8/21/20, R44 had loose stools and again on 8/25/20. There was no mention R44 was quarantined or placed on transmission based precautions upon admission. On 9/18/20, R44 tested positive for COVID. Review of the September 2020, residents' Electronic Medication Administration Documentation (EMAR)s identified staff were to record temperature, and oxygen saturations on the MAR and monitor residents for fever, chills, shortness of breath, new or a change in cough, sore throat, muscle pain, headache, new loss of taste or smell, nausea, vomiting, and diarrhea three times daily. Additionally, staff were to document in the supplementary documentation section of the nurse notes when any of COVID symptoms were identified and update the clinical leadership, provider, and initiate droplet precautions. Interview on 9/23/20 at 4:00 p.m., with RN-C identified only infections treated with antibiotics were included in the infection control line listing. Infection documentation was monitored monthly to identify potential infection issues and was not done as daily cumulative monitoring. RN-C agreed all potential symptoms of infection should be documented on the line list as the occur and reviewed on an ongoing basis to identify potential infection outbreaks and to implement precautions as soon as possible to mitigate transmission of COVID or any infections. The infection preventionist was responsible to oversee the infection control program and provide oversight to ensure infection were identified and responded to in a timely to prevent transmission. Audits of hand hygiene and PPE use were requested. RN-C identified no competencies were documented and no audit documentation was available as evidence staff were monitored to ensure staff were using PPE appropriately. No line list of staff illness or symptoms was implemented to ensure staff were not working ill prior to the COVID outbreak. Interview on 9/29/20 at 12:38 p.m., with the medical director identified staff with symptoms should not have been allowed to work. Staff were expected to monitor residents for potential symptoms of COVID, implement droplet precautions, and notify their providers to prevent potential transmission. The medical director had a family member who transferred from the closed facility, and was told residents transferring from the closed facility were to be quarantined and staff to wear appropriative PPE during quarantine of newly admitted residents. Staff were expected do don gowns, gloves, N-95 masks, and eye protections when caring for residents with suspected and known COVID residents and perform and hygiene prior to leaving rooms, and before and after donning gloves. STAFF Review of staff screening forms and time sheets found the following on: 1) 9/16/20, licensed practical nurse (LPN)-D identified symptoms of muscle pain, headache. Nursing assistant (NA)-F identified symptoms of migraine and proceeded to work from 1:56 p.m. to 10:47 p.m., and later tested positive for COVID. The health information director (HID)-D identified symptoms of chills, muscle pain, headache and had been sick the day prior. Proceeded to work 7:32 a.m. to 8:25 a.m. ,and later tested positive for COVID. NA-G identified symptoms of headache and proceeded to work 3:28 p.m. to 9:34 p.m., and later tested positive for COVID. 2) 9/17/20, NA-G identified symptom of headache, had headache day prior also proceeded to work another shift 6:00 a.m. to 1:30 p.m., and later tested positive for COVID. NA-H identified symptoms of new/changed in cough, muscle pain, headache proceeded to work 11:07 a.m. to 2:19 p.m., and later tested positive for COVID. 3) 9/18/20, NA-O identified symptoms of new/changed cough, sore throat, and headache. NA-C identified symptom of sore throat, headache and proceeded to work 2:47 a.m. to 2:48 p.m. NA-M identified symptom of new/changed cough, muscle pain, proceeded to work 3:57 a.m. to 2:55 p.m., and later tested positive for COVID. RN-H identified symptom of new/changed cough proceeded to work 6:31 a.m. to 11:30 p.m. NA-N identified symptom of muscle pain, headache and proceeded to work 6:00 p.m. into 6:00 a.m. next day. NA-F who had symptoms identified on 9/16/20 proceeded to work 1:54 p.m. to 4:30 p.m., and later tested positive for COVID. HID-D who had symptoms identified on 9/16/20 proceeded to work 8:00 a.m. to 12:30 p.m., and later tested positive for COVID. 4) 9/19/20, NA-O who had symptoms identified on 9/18/20 proceeded to work the morning and night shift unspecified number of hours. NA-E identified symptom of sore throat, muscle pain and proceeded to work from 9/18/20 at 9:00 p.m. into 6:34 a.m. on 9/19/20. RN-H had symptoms identified on 9/18/20 proceeded to work 9:53 a.m. to 11:23 a.m. 5) 9/20/20, NA-N who had symptoms identified on 9/18/20 proceeded to work 3:45 p.m. to 12:02 a.m NA-E had symptoms identified on 9/19/20 proceeded to work 9/19/20 8:17 p.m. into 6:44 a.m. on 9/20/20. Dietary Aide (DA)-A identified symptom of chills proceeded to work 5:28 a.m. to 2:58 p.m. Interview on 9/21/20 at 2:58 p.m., with anonymous staff (AS)-C identified they had no medical background however, R30 felt warm this morning and the nurse did not have time to check her. AS-C took her temperature and reported to the nurse that R30's temperature on her forehead seemed okay but when she held the thermometer over R30's neck it registered 102.2. The nurse advised AS-C all residents are warm and that was not a good place to check a temperature. AS-C reported R30 had been in the hospital on [DATE], and had a COVID test. The facility was called by the local hospital on [DATE], identifying R30 was positive for COVID. She had only been at hospital during the day and did not have an overnight stay so she was not isolated. They encourage the residents to stay in their rooms but it is not required. A-C is unaware if a resident had symptoms like a temperature if they would have to isolate. Interview on 9/22/20 at 10:04 a.m., with NA-E identified she is screened at the door when arriving for work on 9/19/20, verifying she had body aches that could related to her [MEDICAL CONDITION] (MS) and a sore throat that could be related to sinus problems as her sinus had been draining. She identified it was a nightmare working and she cried each night, they said we would get tested again this Wednesday but no one has contacted her to come in. They had uncertified staff that were thrown into working on the floor. Those untrained staff did transfers, cares, feeding. NA-E verified she worked all weekend and does not work now until her next weekend unless they call her in. Interview on 9/22/20 at 10:43 a.m., with consulting administrator (C)-A identified if staff have symptoms upon screening at the beginning of their shift the nurse should assesses to see if it is an allergy or something. If not they are sent to be tested and not to work. Additional interview at 3:40 p.m., identified she was unaware of what staff screening reviews had been done, but believed COVID may have come in the building via NA-D who did not feel well who was tested and was negative. NA-D continued to not to feel good but worked, was tested again and was positive. C-A believes NA-D was returning to work tomorrow. Interview on 9/22/20 at 3:55 p.m., with NA-D identified Saturday (9/12/20) night during work she reported she started to feel like she had a head cold coming on. Sunday (9/13/20) she felt a little worse but continued to work as she thought maybe it was allergies [REDACTED]. She reported she did not have a temperature but did have a headache, dry cough and noticed some wheezing when breathing out, and also body aches. LPN-C was unaware of facility protocol and let NA-D work regardless of her having symptoms. LPN-C advised NA-D she was aware of residents on the upper west wing having temperatures between 99.0 and 99.7 with no changes being made like isolation to their room. NA-D worked the shift Monday (9/14/20) night into Tuesday. In the morning she left work and reported she slept a little. NA-D had body aches and a temperature of 101.5 degrees F, and decided to go to the local clinic on 9/15/20. Her test came back positive on 9/15/20, and she notified the facility right away. NA-D identified there was a new admission, R11 who was diagnosed with [REDACTED]. There were other residents identified with loose stools, and facility nursing staff were notified. No new interventions were placed. It is hard to get information from management about what is happening and the staff are overworked. Interview on 9/22/20 at 3:40 p.m., with RN-C identified staff were to ring the doorbell if staff was not present by the entrance door. The staff were to be screened. If symptoms were present, staff were not to be allowed to enter the facility. A nurse was to assess the staff person with symptoms to see if it is allergies [REDACTED]. The infection control nurse (ICP) was responsible for reviewing and monitoring the screening logs for staff. The ICP however, was currently out ill. The administrator (A)-A was doing that at this time. Interview on 9/22/20 at 4:41 p.m. with administrator (A)-A identified she does not review any screening forms however, she does file them in her office. A-A was unsure who reviewed the screening forms but believed that would be the DON's responsibility. PPE Observation on 9/23/23 at 8:45 a.m., identified registered nurse (RN)-A was in the hallway passing medications. RN-A entered resident rooms on the West wing to administer medication without wearing a gown. Without wearing a gown RN-A entered R34's room to assist with care. RN-A exited R34's room and continued to administer medications in the West wing. At 9:05 a.m., without wearing a gown, RN-A entered R23's room and administered R23's medication. R23 was COVID positive. R23's had a coarse cough and coughed with her mouth open while RN-A was stood next to her. RN-A exited the room while wearing her gloves. RN-A removed her gloves in the hallway, without performing hand hygiene, RN-A walked to a PPE cart in at the main entrance, opened the drawer and grabbed a gown. Interview with RN-A on 9/23/20 at 9:15 a.m., identified RN-A had started working at the facility this week. She had not had training yet, as she was needed on the floor immediately due to the COVID outbreak. Staff were supposed to wear a gown at all times in the facility. Only two residents were negative for COVID at the present time. RN-A verified she had not donned a gown when she entered the facility, and had not worn a gown while administering medications on the West wing. RN-A had not donned a gown because she forgot to do so. RN-A had training regarding PPE and hang hygiene at the time the outbreak occurred. Review of the 9/19/20, through 9/21/20, Donning and Doffing COVID training roster identified RN-A was not included on the roster. Interview on 9/23/20 at 3:30 p.m., with RN-C identified no documentation was found as evidence RN-A received PPE training on 9/21/20, or prior to the start of her first shift. RN-A was expected to don a gown at the start of the shift and change PPE and perform hand hygiene prior to exiting resident rooms. RN-C agreed RN-A should have received training for PPE use prior to working the floor. The undated [MEDICAL CONDITION] (COVID-19) policy identified staff were to be trained regarding general infection information upon hire and on an ongoing basis as needed. Training included utilization of PPE, hand hygiene, and importance of adhering to the necessary requirements. The Infection Prevention and Control Program identified the purpose of the program was to ensure infections were detected, addressed, and prevented among residents and staff. The program included coordination and oversight, policies and procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection and employee health. All staff were to be trained upon hire and periodically. The infection preventionist was responsible for oversight of the infection control program. Surveillance consisted of using tools to recognize occurrence of infections, recording the number of infections, frequency, detection of outbreaks and epidemics, monitoring employee infections and detecting unusual patterns with infection control issues. Outbreak management was a process of determine the presence of outbreak, managing affected residents, preventing spread to other residents, documenting information about the outbreak, reporting to the appropriate public health authorities, educating staff and the public, monitoring for recurrences, and recommending new or revised policies for future outbreaks. The infection preventionist was to review data to determine sporadic cases from true outbreaks. The undated Coronavirus (COVID-19) policy identified staff were to take reasonable steps to promptly detect, triage, and isolate potentially infectious residents and prevent unnecessary exposures among residents, healthcare workers, and visitors at the facility. Staff were to monitor residents daily for potential symptoms of COVID. Symptoms included fever, chills, shortness of breath, new or change in cough, sore throat, muscle pain, headache, new loss of taste or smell, nausea, vomiting, or diarrhea. Staff were to document absence or presence of symptoms in the EMR daily. The facility was to maintain a line listing of residents with respiratory symptoms. Residents with symptoms of acute respiratory illness or suspicion of COVID according to identified symptoms were to have droplet precautions implemented. Staff were to notify providers, resident representatives, department of health, medical director, facility infection preventionist, DON, and administrator. Resident temperature, oxygen saturation, respiratory status, and other symptoms were to be monitored each shift. Staff were to perform hand hygiene before and after all resident contact, contact with infectious material, and before and after removal of PPE, including gloves. Staff were to be screened for symptoms prior to reporting to work and actively screen for COVID symptoms and take their temperatures. If staff were ill, they were to leave the workplace. The facility was to maintain a line list of staff with identified symptoms. Staff were to leave the workplace if symptoms of respiratory infection occurred during their shift, inform the infection preventionist, contact their primary provider, and limit contact with the public as much as possible. Residents who were new admissions, had suspected COVID symptoms, or whose infection status was unknown, were to be screened for symptoms of COVID, and placed in a single room or in a separate observation area to monitor for evidence of COVID-19. Recommended PPE (gown, gloves, mask, eye protection) were to be worn during care of residents under observation. The IJ was removed on 9/24/20 at 2:35 p.m. when it could be verified by observation, interview and document review, that the facility took steps to remove the immediacy by implementing daily cumulative infection control surveillance of residents and staff, implemented appropriate use of PPE and verified the facility quarantine protocols would be implemented as required. In addition, the facility provided staff re-education, and policies and procedures were reviewed and revised.

Based on observation, interview and document review, the facility failed to appropriately assess, monitor and implement care for 2 of 3 residents (R1 and R4) with facility acquired pressure ulcers to prevent worsening of pressure ulcers. This caused actual harm for R4 who developed an unstageable pressure ulcer. Findings include: During interview with nursing assistant (NA)-B on 11/13/20, at 10:50 a.m., NA-B stated R1 had been recently admitted to the facility. She stated while a resident in the facility, R1 developed a pressure ulcer on the inside of her right heel. NA-B stated she'd found the blister a few days ago, and had accidentally pulled the skin off the blister while removing the resident's sock during morning cares. NA-B said the blister was reported to the nurse when she found it and after the blister was found, staff were instructed to float R1's heels with a pillow. NA-B stated R4 was a resident who also had skin issues. NA-B stated R4 had developed a reddened bottom after becoming ill with COVID-19 last month. NA-B stated both of these residents require staff assistance for repositioning. During interview with NA-F on 11/13/20 at 2:38 p.m., NA-F stated she worked on the evening shifts between 2:30 and 10:00 p.m., where recent staffing has included two NAs, one nurse and one trained medication aid (TMA) who was on light-duty assignment and therefore unable to assist with many NA duties. NA-F said the evening shifts were staffed this way about 25 percent (%) of the time. She said normally, three aids were supposed to be scheduled, which worked well but when only two aids worked, resident cares were rushed and not always done as they should be. NA-F stated there were 10 residents who required extensive assistance of 2 staff to transfer and several residents required assistance of two staff for a portion of their cares. Therefore, ensuring residents were repositioned timely has been difficult, and often residents are not repositioned in a timely manner during the evening shift. NA-F identified R1 had a blister on her heel according to the shift report, but said she was not informed of any changes to R1's care plan. During the interview, NA-F reviewed R1's Resident Care List and confirmed no specific repositioning directions were included on the list, and there were no new instructions provided in the Special Instructions column. Communication for changes in resident care were included in the NA communication books, and in the electronic medical record (EMR). R1's 11/6/20, Baseline Care Plan (CP) identified R1 had limited mobility and required assistance of two staff for transfers. Further interventions indicated R1 was at risk for skin breakdown and staff were to treat open areas according to provider orders, measure wounds weekly, monitor for symptoms of infection, and document skin conditions. R1's [DIAGNOSES REDACTED]. R1's 11/5/20, Admission/Initial Data Collection assessment identified R1 had cognitive issues including a memory problem. In addition, the assessment indicated R1 required extensive assistance of two staff to transfer, toilet, and move in bed. Additional information on the assessment included: R1 had unspecified tremors and dry skin. R1 had multiple bruises in various stages of healing and a skin tear on her right elbow. R1 had redness present on her buttocks after 3 hours of sitting in her wheelchair, and staff were to use protective cream on her buttocks. R1 had no pressure ulcers identified on the data collection assessment. The Assessment Data Collection indicated staff were to reposition R1 every 2 to 3 hours and as needed. The assessment made no mention of R1's risk for pressure ulcers, and did not include anything related to floating R1's heels on a pillow while in bed. R1's 11/5/20, Tissue Tolerance Observation Sitting and Standing documents identified R1's skin was intact on all bony prominences. The observation component indicated R1 had redness observed after 3 hours, and was to be repositioned while sitting every 2 to 3 hour, and while lying every 2 hours. R1's 11/12/20, progress note identified a NA reported an open area discovered while removing R1's socks. The area was a 4.4 centimeter (cm) by 4.5 cm blister that had opened. The area was cleaned and dressed with a [MEDICATION NAME] (special protective dressing). No Braden Score was completed upon admission, and no initial pressure wound assessment or sitting and lying tissue tolerance tests were included in R1's EMR at the time the blister was discovered. R1's 11/13/20, care plan identified R1 had multiple bruises and a skin tear. Staff were to monitor skin integrity daily during cares. Staff were to turn and reposition R1 every 2 to 3 hours and as needed. The care plan made no mention R1 had an open blister on her right heel, and made no mention of interventions to float her heels. The 11/13/20, NA care sheets included information regarding bath day, how residents transfer, use of devices like Wanderguard and or mechanical lifts, and whether residents required repositioning. The care sheet had a column to write special notes if residents required additional care not included in the routine information. This care sheet made no mention R1 had a pressure ulcer, required repositioning, or that staff she float R1's heels with a pillow while in bed. The 11/16/20, NA care sheet made no mention R1 had a pressure ulcer, required repositioning, or needed heels floated with pillow while in bed. During an observation on 11/16/20 at 4:45 p.m., R1's right ankle wound was observed with registered nurse (RN)-K. The wound was identified as a 3.5 cm (centimeter) by 2 cm open area surrounded by a 1.5 cm area of dark pink skin. The wound was 50 % covered by a flap of skin. The exposed area of the wound was dark pink with granulated tissue. The dressing removed from the area had a small amount of serous (clear) drainage. R1 exhibited no signs of pain during the dressing removal. RN-K identified the wound was new and R1 had history of rubbing her feet together while in bed. RN-K identified the wound as a stage 2 pressure ulcer even though the area was 50% covered by the remaining skin flap. R1's 11/16/20, Weekly Pressure Wound Evaluation identified R1 had a 4.4 cm by 4.5 cm stage 2 blister on her right heel. The wound bed had 100 % granulation (new tissue). There was no indication why the observation and documentation, both performed on the same day had conflicting measurements and observation of the pressure ulcer. During observation on 11/17/20, from 7:05 a.m. until 7:50 a.m., R1 was lying on her back with legs and feet covered with a blanket level with the mattress. At 7:20 a.m., NA-D walked past R1's room and asked R1 if she was ready to get up. R1 said, No At 7:44 a.m., licensed practical nurse (LPN)-F put on personal protective equipment and entered R1's room. LPN-F pulled the covers off of R1's feet and verified her feet were lying flat on the bed with no pillows or other pressure relieving devices. LPN-F placed a pillow under R1's legs suspending R1's heels off the bed. At 7:49 a.m., LPN-F confirmed R1 had a pressure ulcer on her heel. There was a sign above R1's bed reminding staff to float her heels. LPN-F stated this was the first time this shift she had been in R1's room. During interview on 11/17/20 at 8:45 a.m., physical therapist assistant (PTA)-A stated R1 had a blister on her heel and stated she'd posted a sign above the headboard to remind staff to float her heels. PTA-A confirmed staff had been instructed to float R1's heels as there was a sign with the directions posted at the head of the bed, and also information was included in the NA communication book. PTA-A stated she was unsure of any additional places for staff to be notified of changes to R1's care plan. During observation on 11/17/20 at 8:45 a.m., there was a sign observed on the wall above R1's bed identifying staff were to float R1's heels while in bed. R1's 11/16/20, revised care plan identified R1 had an open blister on her right heel. Staff were to float R1's heels with a pillow. The nursing assistant care sheet for R1 provided by NA-G 11/17/20, was dated 11/16/20. No updates to float R1's heels had been included on the care sheet, and no information had been included for when to reposition R1 was included either. Review of the 11/8/20 through 11/16/20, nursing assistant communication book documents were divided into the East and West Wing and included a grid with the date, resident room number, resident name, and blank columns to document resident care information. Review of the communication book sheets identified there was no mention R1 had a blister on her heel and made no mention to float her heels off the bed. Review of the NA Communication notes between 11/4/20, and 11/17/20, made no mention R1 had a pressure ulcers, or that R1 required a pillow under her heels to off load pressure. R4's nurse's note from 10/7/20, indicated R4 had blanchable redness on her buttocks. Further, the note indicated R4 received barrier cream for protection of the area. The notes made no mention if R4 required repositioning. No Weekly Wound Evaluation was completed. Nurses' notes from 11/4/20, indicated R4 had complained of pain on her buttocks. LPN-E observed an open area approximately 0.7 centimeter (cm) by 0.8 cm on R1's coccyx (tail bone). The area was cleansed with wound cleaner and padded gauze. Review of R4's EMR did not include a Weekly Pressure Wound Evaluation on 11/4/20, and did not include Braden Scales, Tissue Tolerance Observations, or Tissue Tolerance Tests were completed on 10/7/20 or on 11/4/20. R4's 10/21/20, quarterly Minimum Data Set (MDS) identified R4's cognition was intact. R4's [DIAGNOSES REDACTED]. R4 required extensive assistance of one staff to move in bed, transfer, use the toilet, dress, and perform personal hygiene. R1 was occasionally incontinent of bladder, and was not at risk for pressure ulcers. R4's 11/5/20, Weekly Skin Inspection identified R4's skin was intact with no areas of concern and indicated an area to her coccyx continues with treatment and no further decline. R4's care plan dated 9/27/20, identified R4 was noted by the dietician to have an open area on her coccyx and a nutritional supplement was started. Nursing also noted redness on R4's coccyx and inner buttocks. Staff were to apply a protective ointment after toileting, monitor skin daily during cares and weekly by the nurse for a formal assessment on bath days. Further, the CP indicated staff were to offer to turn and reposition R4 every 2 to 3 hours and as needed. Staff were also to use pressure reducing devices in her bed and wheelchair, monitor for skin breakdown, document findings, and report those concerns to the provider (MD). R4's 10/29/20, Weekly Skin Inspection assessment identified there were no skin issues noted however, a note made by nursing staff identified area to coccyx continues with treatment .no further decline. There were no measurements or characteristics recorded by staff. There were no progress notes recorded from 10/27 through 10/29/20 to identify the wound discovered on 10/29/20, or how the wound was described on the 10/29/20 Weekly Skin Inspection assessment. R4's 11/4/20, nursing progress note identified R4 was complaining of (c/o) pain in her coccyx area. The note indicated that upon inspection, staff had noted a wound measuring 0.7 cm x 0.8 cm. Further, the note indicated the area was cleansed and a padded gauze was applied. R4's 11/4/20, Order Summary Report identified an order was placed and included to cleanse R4's pressure ulcer with wound cleanser, and to apply a dressing every other day. There was no mention the MD had ordered a wound consult request by family on the report. Review of the 11/8 through 11/16/20, nursing assistant communication book documents were reviewed. The documents were divided into the East and West Wings and included a grid with the date, resident room number, resident name, and blank columns to document resident care information. Review of the communication book sheets made no mention R4 had a pressure ulcer to her coccyx. Review of the NA Communication notes between 11/4 and 11/17/20, made no mention R4 had a pressure ulcer nor did the notes indicated R4 should be offered repositioning. R4's 11/11/20, Weekly Pressure Ulcer Wound Evaluation, identified on 11/4/20, R4 had a 1 cm by 1 cm unstageable pressure ulcer to her coccyx. The evaluation described the wound bed as being covered with 100 percent (%) yellow slough with the edges were marked as pink. A fax was noted to have been sent to R4's physician at the family's request for R4 to go to the local hospital wound clinic for wound care. R4's 11/11/20, Care Conference Form also indicated R4's family had requested a wound consultation regarding the area on R4's buttock. R4's 11/11/20, Braden Scale identified the resident was at mild risk for skin breakdown. R4 ambulated infrequently and sat in her recliner or wheelchair most of the day. The Braden Scale indicated she was at risk for skin breakdown due to immobility and not changing positions very often. There was no mention staff had identified the newly unstageable areas on R4 buttocks when performing the Braden assessment. R4's current 11/13/20, revised care plan identified R4 had incontinence, limited mobility and required extensive assist of one staff for bed mobility, transfers, and assistance with toileting in bed. The CP indicated R4 was at risk for skin breakdown related to her weakness and recent [DIAGNOSES REDACTED]. The note indicated R4 required pressure reducing cushions in her chair and a pressure reducing mattress in her bed. However, R4's turning and repositioning schedule had not been changed or updated to reflect the need to turn and reposition more often after having developed the unstageable pressure ulcer. When interviewed on 11/13/20 at 4:30 p.m., R4 stated she had a sore on her bottom that hurt, but said she thought it was getting better. R4 stated her bottom had been red for a while before she'd developed the sore but said she was unsure what it looked like. She stated she required assistance of one staff to reposition and transfer but stated she was not on a repositioning program. R4 said she had to call for help if she needed to reposition. R4's 11/15/20, nursing progress note identified R4's family member called to ask if R4 had been seen by the MD or whether the MD had faxed the facility back about the referral for wound care at the local hospital. The progress note indicated staff had identified they had not received a response and would refax the request the following day, (11/16/20) if they had not received a response. There was no indication staff had identified the need to call the provider as soon as possible for assessment and medical intervention. R4's 11/16/20, Weekly Pressure Ulcer Wound Evaluation identified R4 had a 1 cm by 1 cm unstageable pressure ulcer to her coccyx with a wound bed with 95% yellow slough and 5% granulation tissue. The wound was described as pink and purple in color. It was also documented there were no changes to the wound progress. Staff noted the wound bed was covered with slough, unable to determine depth and stage. The evaluation indicated a fax sent on 11/11/20 to the MD was still awaiting response and indicated staff were to cleanse with a wound cleanser and apply a dressing every other day. There was no indication staff had informed R4's MD the wound was unstageable. During observation of R4's wound on 11/16/20 at 4:20 p.m., RN-K provided the care and identified R4 had a figure-8 shaped open area that measured 1 cm by 1 cm on her coccyx. RN-K described the wound bed as consisting of a pale yellow slough (build up of tissue, whereas the depth and details of the wound cannot be visualized) covering the entire wound bed, and wound margins were described as rolled and dark pink. The surrounding skin was pale pink and intact. R4 denied pain during the dressing change. The [MEDICATION NAME] dressing removed from the wound had a small amount of serous drainage on it. RN-K measured the wound as a 1 cm by 1.4 cm open area on R4's coccyx. RN-K described the wound bed as 95% covered by yellow slough. The wound margins as dark pink, and smooth. She was unable to describe the 5% of the wound bed, and agreed the wound bed was not visible because the wound bed was covered with yellow slough. RN-K identified she was not aware of R4's pressure ulcer on her coccyx prior to this observation. She worked at the facility Monday through Friday, and assisted the director of nursing (DON) with wound care when needed. She was not assigned any specific wounds, and was not the wound consultant for the facility. She was unsure how wounds were determined because the DON was responsible weekly wound rounds. During the observation, RN-K stated she was unsure whether R4 had a wound consultation. RN-K agreed R4's wound was unstageable, due to the presence of slough. RN-K stated not all aspects of the pressure ulcer policy had been implemented for R1 and R4. The facility's untitled 11/17/20, interdisciplinary team (IDT) notes identified R4 had a stage 2 pressure ulcer on her coccyx. When interviewed on 11/13/20 at 2:00 p.m., with the facility's nurse consultant (NC) provided a list of all residents who had pressure ulcers or other skin issues. NC stated the list was used for weekly RN wound rounds, and stated all wounds were to be noted in the resident's electronic medical record. The facility's undated Wound Round list, was reviewed at that time with the NC, The list included resident room numbers, names, type of skin impairment, treatment, measurement, descriptions of the wound bed, surrounding tissue, amount, and character of wound drainage, pain, and a column of other notes. The residents on the list included: 1) R27, Stage II pressure ulcer (UP) on their coccyx. 2) R20, left (L) heel and ankle UP. 3) R16, open area near the L inner buttock. 4) R31, redness to the buttocks. 5) R22, red scrotum. 6) R40, deep tissue injury to the L heel. 7) R485, reddened buttocks and back of the thighs. 8) R370, UP to the L and right (R) heels and a reddened buttocks. 9) R6, reddened coccyx. 10) R1, who had some bruising and skin tears. R4 was not identified however, the form indicated 11 residents were being actively monitored for pressure ulcers or skin conditions. At the bottom of the form under the section Instructions, was a note indicating staff were to update the MD if a wound worsened, or if staff changed or adjusted the treatment, followed by instructions to enter a progress note. For new opened areas of skin, staff were to enter Risk Management and include a progress note, enter an order, update the MD, the family, and add the concern to the care plan. If the new area was a pressure ulcer, a Braden was to be performed along with a tissue tolerance test within 24 hours. The NC could not provide any other documentation or completed Wound Round form as requested. Skin Risk Assessments were requested but not provided by the end of the survey. During interview on 11/16/20 at 12:52 p.m., licensed practical nurse (LPN)-E identified she was unsure if R1 had any pressure ulcers. She stated she was also unsure if there were any other residents with new or ongoing pressure pressure ulcers. LPN-E stated RN-K was responsible for assessing and managing pressure ulcers in the facility, and stated routine dressing changes were completed by the DON (director of nursing) or charge nurses. LPN-E stated she was the nurse who found R4's open area on her bottom. LPN-E confirmed she did not measure the wound, but recorded the approximate size of the wound in the progress notes, and confirmed a description of the wound bed's characteristics were not included in the progress note. LPN-E recalled R4's wound bed was covered with whitish tissue. She said she had faxed the provider notification and covered the wound with gauze. LPN-E said she was a newer nurse at the facility, and had not received any facility specific wound care training. LPN-E said when new pressure ulcers were identified, charge nurses were to measure and document the wound in the progress notes, and report new wounds to the wound nurse. She was unsure of any further facility protocol for wound care, and was unsure if new onset or worsening pressure ulcers needed to be called to the MD right away for appropriate assessment. The MDS coordinator stated during interview on 11/16/20 at 2:30 p.m., the DON and RN-K were responsible to update staff regarding information related to wound assessments and wound care. The MDS coordinator said she was responsible for updating care plans and Resident Care Lists. Resident Care Lists were updated when there were new admissions. Resident Care Lists included information for repositioning, and included a column to write special notes to alert staff to residents requiring additional needs not included in the routine information columns. Any other updates or changes in resident care plans after admission were communicated verbally during daily report, and also communicated in writing in the NA communication sheets located in a binder nurse desks. The MDS coordinator agreed the care lists lacked repositioning information for both R1 and R4's pressure ulcers. Additionally, she verified the care lists made no mention R1 needed to have her heels floated off the bed, and made no mention R4 would require more frequent repositioning due to her unstageable pressure ulcer. The MDS coordinator stated she expected the information to be documented in the NA communication books, and said the communication books were updated by many different staff. She acknowledged the importance of care plans and NA communication forms being updated to reflect the current level of care all residents would require. Interview on 11/17/20, at 10:00 a.m., with the Medical Director identified he thought the facility had a wound care team in place. He expected staff to follow policies for wound care management and have a system in place to ensure staff followed care planned wound interventions implemented by the wound team or designee. He further stated the facility had a wound care team process improvement plan, and expected the team to ensure wound interventions and the wound care program were actively being monitored. The Medical Director stated the facility should arrange for wound care services as needed in a timely manner and should notify the physician by telephone when a new onset pressure ulcer was identified. Further, he stated when a family requested a wound care consultation the facility was expected to request an order for [REDACTED]. The DON was unavailable for interview prior to the end of the survey. When interviewed on 11/17/20 at 11:47 a.m., the administrator identified staff should have followed R1's care plan and floated R1's heels. The administrator said the Resident Care Lists were not expected to include whether or not a resident had a pressure wound, but was a tool for NAs to use to ensure they followed the care plans. The administrator agreed keeping care lists current was needed to ensure staff followed resident care plans. The administrator confirmed the DON and RN-K were responsible for wound care. The MDS coordinator was responsible for updating care plans. Charge nurse wound care responsibilities included to perform routine dressing changes, to report wound changes to the DON and RN-K, and to document the initial wound information in the progress notes. The DON or designated wound care nurse was to complete any additional assessments required according to wound care policy. The administrator agreed R1 and R4 should have had updated information on the Wound Care list ensure wounds were monitored and assessments were completed timely manner according to the facility wound care policies. The administrator confirmed wound specialist appointments had not been arranged for R1 or R4 yet due to the recent COVID outbreak (October 2020). However verified no documentation was available to support attempts to obtain a wound consultations or to identify why consultations were not available at the present time. Review of facility documentation and resident progress notes indicated no root cause analysis was completed by the wound care nurses or the pressure ulcer team to determine the cause of the pressure ulcers, or to identify whether or not R1 and R4's pressure ulcers were preventable. A copy of any additional wound care documentation, NA electronic documentation to identify the NA's plan of care, and Risk Management reports for R1 and R4's new pressure ulcers were requested, but were not provided. The facility's 7/20/2018, Skin Assessment and Wound Management policy identified when new skin problems occur, staff were to notify the nurse manager or wound nurse, update the care plan, and update resident care lists. When a new pressure ulcer was identified staff were to notify the MD and residents family, and initiate a Weekly Pressure Wound Evaluation, notify the nurse manager or wound nurse, complete a Braden Scale, complete a Tissue Tolerance Observation sitting and lying, complete a Tissue Tolerance Evaluation, update the care plan, and update resident care lists. There was no indication the policy had been reviewed by the medical director or updated yearly as required.

Based on interview and document review, the facility failed to provide adequate supervision and assistive devices to prevent accidents for 1 of 5 residents reviewed, (R1), when staff failed to follow the careplan and manufacturer instructions. This resulted in actual harm when R1 sustained multiple fractures, and died on e week later as a result of the injuries. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 required two staff and physical assistance with transferring, and one staff physical assistance with bathing. R1's care plan revised [DATE], indicated R1 required two staff assistance when transferring in and out of the tub, and one staff assistance with bathing. R1 required two staff and a total lift and large high back sling for transfers. A checklist for pool nursing assistants dated [DATE], and signed by licensed practical nurse (LPN)-C and nursing assistant (NA)-E, indicated LPN-C reviewed resident care plans, safety rules, incident reports, use of mechanical lifts, transfers, and the safe resident handling program with NA-E. An incident report dated [DATE], indicated NA-E informed LPN-C that R1 fell out of the tub lift chair. LPN-C observed R1 on the tub room floor. R1 was on her back with arms crossed over her chest and right leg straight out. R1's left leg was straight out with the left foot and ankle in full counter clock rotation. Dark red blood and various sizes of blood clots were pooling by the left foot and ankle. R1 was alert and complained of right knee and neck pain. 911 was called and LPN-C remained with R1 until the ambulance arrived. Ambulance run sheet dated [DATE], indicated skin from the left side of R1's left leg held R1's foot on the leg, and the bones of the left leg were visible. The ambulance transported the resident to the local hospital. R1's hospital records dated [DATE], indicated R1 arrived at the emergency room via ambulance and x-rays were done. R1's x-rays indicated R1 had comminuted bilateral tibial and fibula fractures (break or splinter of the bones into more than two fragments in both lower legs). R1 had an open fracture of the left ankle (open wound or break in the skin near the site of the broken bone). R1 was transferred to a higher level of care hospital by helicopter. R1's records at the higher level of care hospital dated [DATE], indicated hip fractures were suspected, however R1 was not a good candidate for any surgical interventions or procedures. R1 was placed on comfort cares and remained at the hospital until discharged to another facility on [DATE], where R1 recieved hospice services until R1's death on [DATE]. The facility internal investigation dated [DATE], indicated NA-E transferred R1 to the swivel lift chair with no second staff assistance. After the bath NA-E raised the resident in the swivel lift chair up and over the side of the tub, removed the seat belt with the chair elevated to 3 ,[DATE] feet, and attempted to put the sling under R1 when R1 fell out of the chair. NA-E left the resident on the floor and ran for help. R1's death certificate (undated) indicated R1 died on [DATE], due to complications of multiple skeletal fractures, caused by a fall from a lift raised multiple feet. When interviewed on [DATE], at 10:35 a.m., NA-E stated he had worked with R1 in the past and knew R1 required two staff to transfer. NA-E was assigned to give R1 a bath on [DATE]. When it was time to give R1 a bath, NA-E stated he felt rushed and did not want to wait for help. NA-E transferred R1 alone from R1's wheelchair to the tub chair using the total lift, and gave R1 a bath. NA-E stated he did not want to wait for staff assistance or for the water to drain from the tub to properly transfer R1 through the tub door, so instead NA-E removed R1 from the tub by lifting the tub chair with R1 in it up and over the side of the tub. NA-E stated R1 was elevated about 3 feet, at NA-E's chest level, when NA-E dried R1 off with a towel. R1 remained elevated as NA-E removed the seat belt, and attempted to place the lift sling under R1. R1 was wet and slippery which made it difficult for NA-E to hang onto R1, as NA-E moved R1 forward in the chair to place the lift sling. As R1 leaned forward in the chair, NA-E lost his grip on R1 and R1 fell out of the chair, landed on her feet, and fell on to her left side. NA-E stated R1's left ankle was twisted and the left leg broke. NA-E moved R1 away from the door by pulling on R1's gown, and left the tub room to get help. NA-E did not attempt to obtain help by using the phone, walkie talkie, or call light. When interviewed on [DATE], at 6:50 p.m., LPN-C stated NA-E ran down the hallway and told LPN-C to call 911, as R1 fell and was injured. LPN-C went to the tub room and found the swivel lift chair elevated above R1, who was lying on the floor with her left ankle detached from the bottom of her leg. LPN-C saw blood and blood clots around the injury, and R1 complained of right knee, neck, and head pain. LPN-C stabilized R1's head and neck, and provided support until EMS arrived. LPN-C stated the swivel lift chair should not have been elevated, NA-E should not have been transferring R1 alone, and NA-E should have stayed with R1 and used the phone, call light, or walkie talkie to call for help. When interviewed on [DATE], at 4:10 p.m., NA-F stated she heard R1 scream and found LPN-C with R1 in the tub room and R1's left foot was almost detached from her leg. NA-F stated NA-E did not request help to transfer R1 from the tub after R1's bath, as indicated on the careplan and kardex (medical information system used by nursing staff to identify individual resident needs). When interviewed on [DATE], at 3:20 p.m., NA-G stated staff are trained on and expected to follow the resident's careplan, and to transfer residents out of the tub in the tub chair through the tub door after the water has drained from the tub. When interviewed on [DATE], at 2:50 p.m., LPN-D stated she reviewed the checklist for pool nursing assistants dated [DATE], with NA-E. The areas reviewed included resident care plans, safety rules, incident reports, use of mechanical lifts, transfers, and the safe resident handling program. When interviewed on [DATE], at 3:50 p.m., the administrator stated he saw R1 on the tub room floor with half her left ankle bone visible through R1's skin. NA-E told the administrator R1 was elevated in the tub chair, and when NA-E prepared to transfer R1 she fell out of the chair. NA-E was immediately suspended. When interviewed on [DATE], at 4:30 p.m., the interim director of nursing (DON) stated she would expect staff to transfer R1 with two staff as directed on the careplan and kardex, and to follow the tub directions and transfer residents in and out of the tub through the tub door, and not up and over the side of the tub. The DON stated NA-E failed to follow the careplan, tub instructions, and the facility's safe resident handling program. When interviewed on [DATE], at 4:35 p.m., the bathing system representative stated the top front edge of the swivel lift chair seat could be raised up to 3 ,[DATE] feet. The representative stated they train the facility staff to follow the safe operation and daily maintenance instructions. The safe operation and daily maintenance instructions for the bathing system revised on [DATE], indicated after the bath the tub is drained completely, the door is unlocked and opened to the widest position to dry the resident. The resident is moved out of the tub through the tub door on the swivel lift and lowered completely to the locked position. Carefully remove the seat belt to ensure the resident does not slip out of the swivel lift chair. This may require the assistance of another staff to control the resident's transfer. The facility Bathing Procedure revised May, 2017, indicated the procedure for tub (whirlpool) and shower bathing included using appropriate safety measures and equipment to prevent accidents. Manufacturer's directions should be followed for use of bathing equipment. Safety belts for bathing units, shower chairs and bathing lifts should be used at all times. Do not leave resident unattended. The facility Fall Prevention and Management Policy and Procedure revised May, 2016, indicated avoidable accidents mean that an accident occurred because the location failed to: implement interventions, including adequate supervision, consistent with a resident's needs, goals, plan of care, and current standards of practice in order to reduce the risk of an accident. The facility Abuse and Neglect Policy and Procedure revised November, 2016, indicated the purpose is to ensure the location has in place an effective system that, regardless of the source, prevents mistreatment and neglect of residents, and to ensure that all identified incidents of alleged or suspected abuse/neglect are promptly investigated, reported and to prevent future injuries.

Based on observation, interview, and document review, the facility failed to comprehensively assess, monitor, and treat pressure ulcers in order to heal current pressure ulcers and prevent further development of others for 3 or 3 residents (R17, R1, R10) who developed pressure ulcers while residing in the facility. This resulted in actual harm to R17 who developed new pressure ulcers to the heels and had worsening of a chronic coccyx pressure ulcer. Findings include: R17 developed facility acquired pressure ulcers to the coccyx area and bilateral heels without a comprehensive pressure ulcer skin assessment to determine appropriate interventions. R17 was at further risk for development and worsening of pressure ulcers due to refusal of cares. However, the facility did not implement timely recommended support surfaces to reduce pressure to the pressure ulcers. R17 did not have weekly pressure ulcer assessments completed from nursing staff, and care planned interventions of repositioning and application of boots to the heels were not implemented consistently. R17's annual Minimum Data Set ((MDS) dated [DATE], identified a severe cognitive impairment due to [MEDICAL CONDITION], with physical and verbal behaviors which interfered with his care, and rejection of cares. It further identified R17 needed extensive assistance with transfers, bed mobility, and toileting, indicating he was always incontinent of urine and continent of bowel. Furthermore, the MDS identified R17 was at risk for pressure ulcer development, and currently had one Stage 2 (partial-thickness loss of skin with exposed dermis) pressure ulcer, identifying current skin treatments of a pressure reducing device for his chair, nutrition and hydration interventions, and pressure ulcer care. R17's Pressure Ulcer Care Area Assessments (CAA) dated 12/2/16, indicated R17 had a Stage 2 pressure ulcer on his coccyx containing granulation tissue and was at risk for further impairments. It further indicated current treatments included dressing changes with calcium Ag silver, nutritional supplements and vitamins, repositioning every two hours day and night, a pressure reducing mattress and cushion in wheelchair. The CAA identified R17 received routine toileting for incontinence related to immobility and urinary urgency. R17's CAA also identified a decreased nutritional intake and being resistive to cares for contributing factors to his pressure ulcer development. The CAA further identified, During resistive episodes, staff do re-approach resident with repositioning and toileting/cares, and directed to the care plan for more information. The goal of treatment at the time was to improve healing and minimize the risk of development. R17's Behavioral CAA completed 12/2/16, identified R17 was not always easily redirected, staff had to re-approach and fatigue, sleep disturbance, [MEDICAL CONDITION], and dementia contributed to the behaviors. The Behavioral CAA lacked identification of the nature of the behaviors including things such as antecedents, effective/ineffective interventions, illnesses/conditions contributing to behavioral symptoms, and an overall goal. There was no description of how the behaviors impacted R17 and simply indicated, will proceed to care plan due to behaviors. R17's quarterly MDS dated [DATE], identified he continued to have one Stage 2 pressure ulcer. In addition, the MDS indicated R17 had acquired one new Stage 3 (Full-thickness loss of skin, in which fat is visible in the ulcer and granulation tissue and rolled wound edges are often present) pressure ulcer and one new unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar) pressure ulcer since his annual MDS. Although the Stage 3 and unstageable pressure ulcers were clearly acquired after R17 had been a resident in the facility, his MDS did not identify any pressure ulcers as being facility acquired since his last annual assessment. The interventions listed to treat R17's current ulcers included a pressure reducing device for chair and pressure ulcer care. R17's undated Bedside Kardex, directed staff to reposition every two hours with re-approaching if necessary, pressure reducing cushion in wheelchair, and to check and change R17 every two hours. During continuous observation on 4/19/17, at 7:06 a.m. R17 was observed sitting in his wheelchair in his room, his head bent forward, eyes shut and was observed sleeping. R17 was dressed and wearing bilateral blue foam boots to his lower extremities, which were resting on his foot pedals. At 7:34 a.m. an unidentified staff member came to take R17 to breakfast, and asked if he wanted to use the bathroom before breakfast, which he refused. R17 was observed eating breakfast until 8:55 a.m., at which time licensed practical nurse (LPN)-B brought R17 back into his room. LPN-B returned a few minutes later to adjust R17's bedside table and water pitcher within reach. R17 was overheard yelling get the hell out, and LPN-B left the room. There were no offers of repositioning at this time. R17 was observed sitting in the wheelchair in the same position and continued to wear the bilateral blue foam boots until 9:28 a.m., when LPN-B brought R17 out to an activity. R17 was observed in the activity until 10:01 a.m. when the surveyor informed nursing assistant (NA)-A that R17 had not been offered repositioning for three hours and had not been offered toileting in over two hours. On 4/19/17, at 10:07 a.m. NA-A reported she was not sure when R17 was last toileted or repositioned since another nursing assistant could have offered and they usually communicated verbally with one another. NA-A went over to the wall computer stating they were suppose to chart in Point of Care when they re-approached/offered toileting and repositioning, further stating R17 was scheduled to be toileted at 9:00 a.m. NA-A usually checked at 2:00 p.m. before she left. NA-A reported R17 had been repositioned last when he got up at 5:00 a.m. and was last toileted at 5:34 a.m., stating R17 had been up when NA-A had gotten to work at 6:00 am., so he should be checked here shortly. NA-A reported R17 was toileted and repositioned every three hours or when he is deciding to move on us, because he had a reoccurring wound on the coccyx and wound on the heels. She further stated they repositioned him to get him off his heels. During observation on 4/19/17, at 10:19 a.m. NA-A asked R17 if he needed to use the bathroom and brought R17 into his room. While in his room, NA-A and NA-E used a sit to stand lift to assist R17 into a upright position, then quickly changed his brief. R17 swore and hollered during the change. R17 was observed to have the blue foam boots on while standing with the lift. NA-A called LPN-B into the room to observe R17's coccyx ulcer, however, LPN-B stated R17 had to be in bed to do the dressing change and would complete it later in the afternoon. Due to his behaviors, R17 was not laid down at that time, instead NA-A and NA-E assisted R17 back into the wheelchair. LPN-B instructed NA-A and NA-E to re-approach R17 later. NA-A stated R17's brief was dry, however, she changed it because he had been in it for a while. NA-A further stated R17 was usually incontinent of bladder but was usually continent of bowel and could sit on the commode to have a bowel movement. R17 was observed to wear the blue foam boots during the entire observation. R17 was not offered/provided repositioning from 5:34 a.m. to 10:19 a.m. (4.75 hours). On 4/19/17, at 11:55 a.m. LPN-B stated R17 was repositioned when he allowed staff to assist. He had a pressure reducing cushion in his wheelchair for his coccyx ulcer, and wore the blue foam boots at all times for the right heel. In addition, she stated staff was to put appropriate foot wear with grips on when using the sit to stand lift. LPN-B reported R17 had the foam boots since the right heel wound started, then stated he had had the foam boots at night before the heel wound, however, R17 refused to wear them. The physician ordered them as needed when R17 allowed staff to put them on. She further stated R17 wouldn't allow staff to prop his feet up or float his heels even after staff re-approached him. LPN-B confirmed R17 was now wearing the foam boots all the time. LPN-B stated R17 was seen by the wound nurse who took measurements, wounds were measured for sure once a week and when allowed, and could be documented in both the Wound Data Collection sheets or the Wound RN Assessment. She further stated the Wound Data Collections could be done by an LPN or RN, and were completed everyday to every other day. During interview on 4/19/17, at 12:39 p.m. occupational therapist (OT)-A stated about a month ago, OT had called in a separate agency to perform pressure mapping of R17's wheelchair. OT-A stated she performed an evaluation of R17's wheelchair/cushion, trialed different wheelchair cushions and ordered a pressure reducing cushion. During the interview, OT-A observed R17's wheelchair cushion and confirmed it had been ordered for pressure reduction. On 4/19/17, at 1:55 p.m. R17 was observed lying in bed as his dressings to the coccyx and right heel were changed. NA-A assisted to turn R17 to his right side as LPN-B sprayed wound cleanser on a 4 x 4 gauze and patted the open coccyx ulcer. R17 stated, Oow goddamn it that is sore! as LPN-B cleansed the wound. LPN-B cut a piece of [MEDICATION NAME] Ag and placed it over the ulcer, then covered it with a foam [MEDICATION NAME] dressing. LPN-B stated the coccyx contained a small opening which was pink with drainage that could have been from his incontinence brief. LPN-B stated she forgot to measure the coccyx and would measure it later that night. NA-A assisted R17 to lie on his back while LPN-B changed the right heel dressing. R17 was observed not wearing the foam boots, which were sitting in a chair across the room. Instead, he was wearing gray boots with a hard rubber sole and white fur inside. LPN-B took off the right boot, cleansed the area with 4 x 4 gauze and wound cleanser, measured the heel ulcer 3.5 cm x 2.5 cm, and placed [MEDICATION NAME] Ag over the ulcer covered with a foam [MEDICATION NAME] dressing. The wound bed appeared to have pink and red tissue, however, LPN-B stated the wound bed had been yellow. LPN-B placed the gray boot on R17 right foot, instructing NA-A that R17 was only to have the gray slippers on for short transfers NA-A was reminded to replace them with the blue foam boots. LPN-B left the room, while NA-A assisted R17 with the sit to stand lift to the commode to have a bowel movement. At that time, NA-A stated R17 had a medium amount of urine in his brief. R17 had no further verbal or non verbal signs of pain during cares or dressing change. On 4/19/17, at 2:34 p.m. NA-A stated, to her knowledge, R17 had last been offered toileting around 9:00 a.m., when she had last checked on him, which meant almost four hours had gone by before R17 had been offered toileting. On 3/13/16, a Wound RN (registered nurse) Assessment indicated R17 had a stage 2 coccyx pressure ulcer, which had completely healed with no open areas or redness. R17's Skin Observation, dated 8/10/16, identified the resident had a soft reddened open area to coccyx. PROGRESS NOTES: R17's progress notes indicated the following: - 8/13/16, at 12:53 p.m. R17 had behaviors and refused toileting in the morning, but allowed staff to dress him and allowed staff to toilet him after lunch. - 8/13/16, at 7:52 p.m. staff attempted to apply a 2 x 2 [MEDICATION NAME] (foam) dressing to R17's right buttock for Open sore. R17 refused. During the week of 8/14/16 - 8/20/16, the coccyx ulcer was not assessed nor were any measurements documented. The National Pressure Ulcer Advisory Panel (NPUAP) indicates a pressure ulcer assessment should contain: stage, location, size (length x width x depth) , undermining/tunneling, wound bed tissue (granular, non-viable, eschar), and exudate (amount, color, odor). On 8/19/16, at 9:44 p.m. staff applied a 2 x 2 [MEDICATION NAME] dressing to R17's right buttocks. During the week of 8/21/16 - 8/27/16, the coccyx ulcer was not assessed nor were any measurements documented. On 8/22/16, at 8:26 p.m. staff recorded that the 2 x 2 [MEDICATION NAME] dressing had not been changed, and at 11:28 p.m. the open area on the coccyx was noted and house cream was applied. The note indicated the open area would be addressed with the physician. On 8/23/16, at 2:08 a.m. two staff transferred R17 from his bed into wheelchair, and the notes indicated R17 had been incontinent at the time. The note further indicated, Area on buttocks assessed by nurse. Barrier cream applied. However, there was no documentation of the assessment. The note from 8/24/16, at 3:18 a.m., indicated staff used a sit to stand lift to transfer R17 into a recliner. The note indicated, Approx (approximately) 20 min (minutes) later he wanted to get out of the recliner stating it hurts my butt too much. There was no further documentation about R17's buttocks or the pain identified. During the week of 8/28/16 - 9/3/16, the coccyx ulcer was not assessed. During the week of 9/4/16 - 9/10/16, the coccyx ulcer was not assessed. On 9/4/16, at 10:15 p.m. staff noted (R17) has let staff toilet him without behaviors. (R17) has been complaining of butt pain so we have been trying to get repositioned out of wheelchair as frequently as possible and put barrier cream on bottom. During the week of 9/11/16 - 9/17/16, the coccyx ulcer was not assessed. During the week of 9/18/16 - 9/24/16, the coccyx ulcer was measured but lacked any assessment information. On 9/22/16, at 1:45 a.m. over a month after the open area had been observed, R17's open coccyx wound was measured 2.5 cm (centimeters) x 1 cm. The nurse noted, There are new sores in proximity to the open wound that were bleeding tonight. New [MEDICATION NAME] dressing applied. It further noted R17's behaviors prevented staff from toileting him. The record lacked a comprehensive assessment related to the development of new pressure ulcers. During the week of 9/25/16 - 10/1/16, the coccyx ulcer was measured, and new areas of concern were noted. There was no assessment of the wounds. On 9/28/16, at 12:10 a.m. R17's was observed to have two open areas, with a larger area measuring 2 cm x 1.5 cm and a smaller open wound measuring 1 cm x 2 cm. At 3:12 p.m. R17's coccyx was observed again. This time his open area was measured 2 cm x 0.5 cm and abrasions were noted on the left and right gluteus. During the week of 10/2/16 - 10/8/16, the coccyx ulcer was measured, but lacked any further assessment of the buttocks/coccyx. On 10/5/16, at 3:32 p.m. R17's coccyx was assessed and measured 0.5 cm x 1.5 cm. It identified staff was changing the [MEDICATION NAME] dressing daily due to feces getting under the [MEDICATION NAME]. WOUND ASSESSMENTS: R17's Wound RN Assessments (a formalized assessment the facility used which included staging, evidence of healing, and interventions), Wound Data Collection (which contained measurements, daily monitoring, and wound bed characteristics), and WOC (Wound Ostomy Continence) Nurse Practioner (NP) Notes were reviewed for further ulcer information: During the week of 10/9/16 - 10/15/16, nearly three months after R17's coccyx had opened, the first formal wound assessment was completed. On 10/15/16, R17's first Wound Data Collection was completed, with the ulcer measuring 1.3 cm x 0.7 cm. The wound bed was observed 50% [MEDICATION NAME] and 50% granulation (healthy tissues) with a [MEDICATION NAME] dressing changed every three days. For the week of 10/16/16 - 10/22/16: On 10/19/16, the Wound RN Assessment identified a new re-occurring Stage 2 coccyx pressure ulcer with no drainage, slough, or eschar. The assessment noted the size slightly increased over the past few days. On 10/19/16, Wound Data Collection measured the ulcer as 2.0 cm x 1.0 cm x 0.3 cm, and the wound bed was observed 50% [MEDICATION NAME] and 50% granulation tissue. On 10/18/16, at 3:38 p.m. staff notified family of R17 refusals of cares/medications/treatments. For the week of 10/23/16 - 10/29/16: On 10/24/16, the Wound Data Collection measured the coccyx ulcer to be 2 cm x 1 cm x 0.5 cm depth, noting the area was improving but was now open again with small areas that were beginning to open and (R17) complained that it hurt when doing cares. The wound bed was observed 50% [MEDICATION NAME], 45% granulation, and 5% slough (yellow, devitalized/unhealthy tissue) with yellow drainage, indicating a higher stage. However, on 10/28/16, the Wound RN Assessment continued to assess the coccyx ulcer as a Stage 2, was observed with no healing over the past week, and had increased wound size, increased drainage, increased maceration surrounding the wound. At that time, the assessment noted the treatment would be changed to calcium alginate (soft, absorbing dressing) daily and would address pain by asking for an increase in Tylenol. For the week of 10/30/16 - 11/5/16: On 11/3/16, the Wound Data Collection identified the coccyx measured 2 cm x 1 cm x 0.5 cm in depth, and the wound bed was observed to be 50% [MEDICATION NAME] and 50% granulation tissue. On 11/3/16, Wound RN Assessment indicated the coccyx ulcer was a Stage 2 coccyx and had decreased redness of the peri wound and showed no deterioration. The assessment indicated R17 continued with a pressure reducing mattress and cushion in wheelchair, but was refusing to rest in bed on his sides. For the week of 11/6/16 - 11/12/16: On 11/10/16, the Wound Data Collection identified the coccyx measured 2.1 cm x 1.0 cm x 0.5 cm with 50% [MEDICATION NAME] tissue and 50% granulation. The ulcer was noted with serosanguineous (clear fluid with blood) drainage and the peri wound was blanchable and healing. On 11/10/16, the Wound RN Assessment indicated the coccyx ulcer was identified as a Stage 2 with decreased maceration of the peri wound, however, the size had no change in two weeks. The assessment indicated the physician would be notified for a new treatment. For the week of 11/13/16 - 11/19/16: On 11/15/16, the Wound Data Collection identified the coccyx measured to be 2.5 cm x 1.0 cm x 0.5 cm with 50% [MEDICATION NAME] and 50% granulation tissue with sanguineous (bloody) drainage and minimal odor. On 11/15/16, the Wound RN Assessment noted the coccyx ulcer remained a Stage 2 but the size had increased. The assessment indicated R17's treatment had changed on 11/11/16, to apply [MEDICATION NAME] Ag (soft, absorbing dressing containing silver which kills a variety of wound microbes) dressing every 3 days and as needed. For the week of 11/20/16 - 11/26/16: On 11/25/16, the Wound Data Collection identified the coccyx measured 2.0 cm x 1.0 cm x 0.5 cm with 50% [MEDICATION NAME] and 50% granulation tissue with sanguineous drainage and minimal odor. On 11/25/16, the Wound RN Assessment noted the coccyx ulcer as a Stage 2 and had decreased in size. R17's interventions remained the same and staff encouraged him to rest on sides in bed between meals as he tolerated. During the week For the week of 11/27/16 - 12/3/16: On 12/2/16, the Wound Data Collection identified the coccyx measured 2.0 cm x 0.7 cm x 0.5 cm with 25% [MEDICATION NAME] and 75% granulation tissue with sanguineous drainage and minimal odor. On 12/2/16, the Wound RN Assessment identified the coccyx ulcer continued to be a Stage 2 and was assessed Width of wound slightly decreasing. The assessment directed R17 was now repositioned every two hours and an air mattress had been discussed, but felt may be risk for Rt (resident), and was not added. The assessment did not identify the risk the air mattress posed for R17. For the week of 12/4/16 - 12/10/16: The 12/9/16, Wound Data Collection form identified the coccyx measured 1.5 cm x 1.0 cm x 0.5 cm noting there was sanguineous drainage and minimal odor. However, there was no description of the wound bed. On 12/9/16, the Wound RN Assessment identified the coccyx ulcer as a Stage 2 with increased maceration (softening, whitening of the skin usually associated with moisture) around the wound, noting R17 had increased behaviors during the past week. For the week of 12/11/16 - 12/17/16: On 12/11/16, the Wound Data Collection identified the coccyx measured 2.0 cm x 1.0 cm x 0.5 cm with minimal serosanguineous drainage. The wound bed was 25% [MEDICATION NAME] and 75% granulation tissue and the peri wound was reddened. R17 was identified to have pain at the site. On 12/14/16, the Wound RN Assessment indicated the coccyx ulcer was a Stage 2 with no maceration around the ulcer. It identified staff continued to use [MEDICATION NAME] Ag for dressing changes and continued to offload and reposition every two hours as tolerated. A wound nurse appointment had been set up for 1/4/17. For the week of 12/18/16 - 12/24/16: On 12/20/16, the Wound Data Collection the coccyx measured 2.0 cm x 1.0 cm x 0.5 cm with 75% [MEDICATION NAME] and 25% granulation tissue with sanguineous drainage and minimal odor. On 12/20/16, the Wound RN Assessment indicated the coccyx was a Stage 2 and had pink tissue showing healing. However, it identified the dressing at the time of assessment was saturated with urine and the Dressing that was on the coccyx was not done correctly. For the week of 12/25/16 - 12/31/16: On 12/26/16, the Wound Data Collection identified the coccyx measured 1.5 cm x 1.0 cm x 0.5 cm with the wound bed 75% [MEDICATION NAME] and 25% granulation tissue. The ulcer had minimal serosanguineous drainage with the peri wound showing maceration and redness. On 12/29/16, the Wound RN Assessment identified the coccyx ulcer continued as a Stage 2 and had no change to size or depth but had deteriorated with blanchable redness and maceration of the peri wound. The assessment noted R17 refused to lay in bed for the assessment. On 1/4/17, nearly four months after the coccyx ulcer had formed, the first wound nurse practitioner (NP) visit occurred for a new occurrence of ulcerated area on the coccyx region. The NP described, Coccygeal region shows a Stage 3 pressure ulcer in the crease measuring 2 cm x 1.3 cm and a small area on the right gluteal aspect measuring 0.7 cm x 0.2 cm there is also extensive excoriation on both gluteal aspects. The NP further noted, wound bed appears to be 100% slough covered, and recommended [MEDICATION NAME] Ag applied to the coccyx with zinc oxide applied to areas of excoriation. In addition, she recommended pressure mapping for R17's wheelchair, a high grade Roho cushion be ordered, and to be encouraged to offload frequently and make position changes throughout the day. Follow up would be in two weeks. On 1/11/17, the wound NP visited and upon arrival, R17 had been sitting on the commode for an extended period of time, and the dressing ordered was not in place leaving the ulcer area open and exposed. The NP measured the Stage 3 coccyx ulcer 1.1 cm x 0.5 cm x 0.1 cm and recommended dressing changes with [MEDICATION NAME] Ag every third day and as needed when saturated with urine/stool, not sitting on the commode over 10 minutes, and minimize time sitting dependent on the coccyx. On 1/18/17, the wound NP visited and noted R17 continues to sit in his wheelchair for extended periods of time throughout the day and (R17's) prescribed Roho cushion has not been ordered yet pressure mapping has not been done although this is been my recommendation, which the NP had ordered on [DATE]. The Stage 3 coccyx pressure ulcer was now 2 cm x 5 cm x 0.3 cm in depth and noted two new open areas on the right gluteal aspect measuring 2 cm x 0.5 cm and 1 cm x 0.5 cm with extensive excoriated tissue. The NP further observed an area of deep redness measuring 8 cm x 7 cm. The NP recommended applying [MEDICATION NAME] Ag over the coccyx ulcer and a foam dressing over the new gluteal ulcers. Additionally, the NP directed It's my recommendation of the Roho cushion be purchased and pressure mapped as soon as possible. (R17) should continue to be offered assistance with lying in bed and offloading the affected area frequently throughout the day. On 1/20/17, the Wound Data Collection noted newly formed blisters on bilateral heels. The left heel measured 5 cm x 1.5 cm while the left heel measured 7 cm x 1.2 cm. At that time, R17 stated it hurts, and the assessment noted foam boots were being used. However, R17's medical record lacked evidence to support the foam boots were being used. For the week of 1/22/17 - 1/28/17, the wound nurse did not visit. Although R17's ulcers were measured, the documentation lacked a description of the wound bed for the coccyx and left heel. On 1/27/17, the Wound Data Collections were performed on the coccyx measuring 2.0 cm x 2.0 cm and left heel blister had opened measuring 6 cm x 2 cm with a red peri wound measuring 2 cm x 4 cm with intact wound margins. On 1/27/17, a week after blisters had formed, the Wound RN Assessment of the right heel ulcer identified the ulcer was unstageable with Dark area, possible Eschar (dead tissue), 3 cm diameter, with approximately 3-5 cm of [DIAGNOSES REDACTED] (superficial reddening) around dark area. No blister at present. Drainage is serous with faint odor. It further noted the Wound care nurse assesses would (sic) weekly at present. No Wound RN Assessment was provided for the left heel. On 2/1/17, R17 was seen by the wound NP for his coccyx and new concerns on bilateral heels. The NP noted the coccyx Stage 3 ulcer measured 1.6 cm x 0.7 cm x 0.2 cm has stalled and healing. The right heel measured 9 cm x 12 cm with deep tissue injury in the center measuring 5.5 cm x 6 cm, which was classified as unstageable. In addition, it was noted to contain necrotic tissue. The left heel had opened measuring 7 cm x 7.5 cm and was classified as a Stage 2 pressure ulcer, which was draining bright red sanguinous fluid along with serous fluid. Both heels were debrided during the visit. The NP recommended [MEDICATION NAME] Ag to all open areas with [MEDICATION NAME] foam dressings. In addition, she recommended heel protectors worn at all times along with frequent position changes and encouraged to lie in bed. During the week R17's had the following behaviors: On 1/29/17, at 1:34 p.m. R17 didn't eat breakfast or take medications, but did allow staff to reposition every two hours and allowed toileting. On 1/31/17, at 2:10 a.m. R17 was pleasant until staff placed the transfer belt on his when he attempted to strike staff, was transferred into bed then settled down and fell asleep. No other behaviors noted. On 2/2/17, at 9:50 p.m. R17 was swearing at breakfast, threw his breakfast plate at the table, refused toileting and refused medications. R17 was laid down in bed as he allowed, was eventually calm in bed sleeping. On 2/4/17, at 12:19 a.m. R17 refused to go to bed for the evening shift and refused the first attempt on night shift. During the week of 2/5/17 - 2/11/17, the wound nurse did not visit. On 2/6/17, the Wound Data Collection was completed on the coccyx, however, it lacked measurements or any description of the wound bed. It directed to see the wound nurse charting. On 2/9/17, the Wound Data Collection noted the right heel measured 5 cm x 2 cm with minimal odor, serous drainage, and redness around the ulcer. The left heel measured 6 cm x 6 cm and did not have an odor or drainage. The data collection lacked descriptions of the wound bed for either heels. No RN Wound Assessment or staging was completed. During the week of 2/12/17 - 2/18/17, the wound nurse did not visit. On 2/12/17, the Wound Data Collection noted the right heel measured 5 cm x 2 cm with a moderate amount of drainage, but did not describe the type of drainage, and had a strong foul odor. The left heel measured 7 cm x 6 cm with minimal drainage and a strong foul odor. The data collections lacked descriptions of the wound bed for either heel, or address the change in odor. On 2/18/17, the Wound Data Collection indicated the coccyx was 2.0 cm x 1.0 cm, however, it lacked any description of the wound bed. No RN Wound Assessment or staging was completed for the week. On 2/22/17, the wound NP noted R17 had not been allowing staff to change incontinence briefs or reposition him. The NP observed the coccyx to be more denuded measuring 6 cm x 4 cm and extensively [DIAGNOSES REDACTED]tous with skin cracking and drainage that is serous. The Stage 3 coccyx ulcer measured 1.5 cm x 0.5 cm with no decrease in size and did not have the appropriate dressings in place, and there is extensive peri wound [DIAGNOSES REDACTED] that's related to pressure. The NP noted the left heel ulcer had healed and the right heel continued to contain black eschar in the central aspect measured 1.5 cm in diameter. The NP debrided the necrotic slough at the time of the visit, and recommended the right heel dressing be changed daily or when saturated, the coccyx ulcer continued to be changed with [MEDICATION NAME] Ag and a foam dressing, while denuded areas were treated with zinc oxide. Follow up was noted within the next two weeks. The week of 2/26/17 - 3/4/17, the wound nurse did not visit. On 3/1/17, Wound Data Collection noted the right heel measuring 2 cm x 3 cm with black eschar and the coccyx measured 2 cm x 0.6 cm. It did not give any further description of the wound bed for that week. On 3/3/17, the Wound RN Assessment identified the right heel ulcer as unstageable, noting eschar was present with no increase in odor or drainage. On 3/8/17, the wound NP noted R17 was more belligerent and swearing during visit. The Stage 3 coccyx ulcer was observed with increased wound margins and drainage, measuring 1.5 cm x 0.5 cm x 0.2 cm. The NP noted an area in the center had a deep tissue injury. A new Stage 1 area of pressure was noted on the right gluteal aspect measuring 2.5 cm x 3 cm, while the left gluteal had new Stage 1 pressure ulcerations measuring 6 cm x 2 cm. The right heel was measured 1 cm x 2.5 cm with thick black and yellow tissue, with an odor and felt boggy. The coccyx treatment continued with daily dressing change using [MEDICATION NAME] Ag, however, staff were instructed to use a thick layer of zinc oxide over new Stage 1 areas. R17's treatment was changed to include Iodosorb (antimicrobial and desloughing) topically to the eschar on the right heel before covering with [MEDICATION NAME] Ag daily. The NP recommended monitoring the right heel for signs of infection. Wound follow up in one week. On 3/15/17, the wound NP noted R17 had heel protectors on during the visit, however, staff admit to increased drainage in the right foot and continued ulceration in the coccyx area related to (R17) not offloading as much as possible many days refuses to lie in bed and he sits in his wheelchair for extended periods of time. During visit the right heel measured 4 cm x 2.7 cm x 1.0 cm with the eschar evolving into slough. The heel was debrided during the visit until it was 90% slough and 10% granulation tissue. The coccyx continued to measure 1.7 cm x 0.7 cm x 0.3 cm, observed to be larger that day. The left gluteal aspect had a 2 cm x 2 cm area of excoriation. The NP recommended the coccyx dressing be changed every two to three days or when saturated, with zinc oxide applied thickly to gluteal aspects, and the right heel changed daily with Iodosorb to the necrotic slough. On 3/22/17, the wound NP noted R17 was agitated and yelling during visit. The right heel unstageable ulcer was noted to evolve to a Stage 3 ulcer, which was not measured or debrided due to agitation. The coccyx ulcer was measured 1.4 cm x 0.8 cm x 0.2 cm and two Stage 2 ulcers were noted in the left gluteal aspect, which were not measured as R17 was incontinent during the dressing change. The treatment was not changed during this visit. For the week of 3/26/17 - 4/1/17, the wound nurse did not visit. On 3/27/17, Wound Data Collection on the coccyx was documented as 1.0 cm x 2.0 cm and the right heel to be 2 cm x 3 cm. No Wound RN Assessment or staging was completed

Based on observation, interview and document review, the facility did not provide the supervision necessary to ensure each resident's safety, related to elopement with the potential for exposure to unsafe temperatures, for 1 of 3 residents (R40) reviewed in the sample for accidents. This resulted in immediate jeopardy for R40. Findings include: R40 [DIAGNOSES REDACTED]. The significant change minimum data set ((MDS) dated [DATE], revealed R40 had moderately impaired cognitive skills for daily decision making, with signs and symptoms of delirium present. The MDS identified R40's wandering behavior occurred multiple times on a daily basis and she was at significant risk for wandering into dangerous places, such as outside of the facility. The cognitive loss/ dementia care area assessment (CAA) dated 10/23/12, added R40's wandering behavior to the outdoors began to increase around 7/12. The CAA noted, "Since that time, wandering has escalated to daily." The visual function CAA dated 10/18/12, noted, "(R40) walks throughout facility all day long and will go outside to walk from one door to another. Staff are alerted to exiting building with use of wander guard. Able to redirect back inside with offers of food/drinks, and when unsuccessful staff walk with resident to ensure safety." The behavioral symptoms CAA dated 10/23/12, noted, "Wandering behavior is an immediate threat to the resident, especially with winter weather approaching... Of most concern is attempts to leave the building during the overnight hours... Wandering behavior has no real pattern, occurs regularly throughout the day, it may escalate in the late afternoon, early evening hours... (R40's) short attention span makes it difficult to engage in activities she has enjoyed in the past." The falls CAA dated 10/18/12, noted, "(R40) wanders outside the facility numerous times a day. (R40) has been observed taking exaggerated steps when the flooring changes... (R40) will be at risk for increased falls when winter weather arrives and snow and ice become a factor in parking lot condition, the location where she often walks." Review of interdisciplinary assessments and summary reviews dated 10/25/12, authored by registered nurse (RN)-C revealed R40's wandering was a concern of the facility, related to R40's safety "as weather becomes colder." Alternative placement was discussed with R40's family and "team agreed that for (R40's) safety, (seeking alternative placement) would be in the best interest of (R40)." A note dated 11/21/12 detailed a team meeting where Administrator again discussed with R40's family "that due to (R40's) lack of safety judgment and danger of her going outside, we need to find alternative placement. We recommend a secure unit." The written plan of care dated 10/25/12, detailed the following interventions for R40's wandering/ elopement risks: An alarm was to be in place to alert staff that R40 was near the exterior doors. The alarm was to be checked per the facility's protocol. Staff were to redirect R40 when she attempted to leave the building. If unable to redirect, staff were to walk outside with R40. Juice and snacks were to be offered when R40 attempted to leave the building. R40 was to be invited to leisure programs during times of confusion and elopement. Staff were to explain that R40's daughter was still at school, when R40 attempted to elope to look for her daughter. Review of clinical monitoring/ acute care flow sheets from 9/21/12 through 10/30/12, revealed R40 eloped to outside of the facility and was unable to be redirected by staff to remain within the facility for an average of 8.9 times per day. The monitoring indicated R40 averaged an additional 6.2 attempts daily to exit the facility, but was able to be redirected by staff. Review of incident report investigation dated 11/16/12, authored by RN-C detailed a fall, without injury that occurred on 11/14/12, when R40 tripped over another resident's wheelchair while wandering within the facility. As part of the investigation, RN-C noted, "(R40) continues to attempt to go outside doors, despite cold temperature. Lacks understanding of danger to herself... (RN-C) will talk with social service about discussing giving 30-day discharge notice. Nursing staff are unable to provide 1 (one) - 1 (one) care at all times. (R40) is immediate danger to self." Upon arrival to the facility on [DATE], at 12:15 p.m. (prior to survey entrance), R40 was observed walking outside on the grass, along the North side of the facility. R40 was noted to walk approximately half the length of the building (approximately 15 yards), before a facility employee was observed to come out of the building and guide R40 back indoors. R40 was wearing a blue sweatshirt and slacks. No hat, mittens or coat were observed to be worn by R40 during this observation. The outside temperature during the time of this observation was approximately 20 degrees Fahrenheit, with a wind chill of 15 degrees Fahrenheit. Intermittent observations on 11/26/12, from time of the initial tour at 12:30 p.m. through initial stage one observations at 3:00 p.m., R40 was noted to attempt to exit the facility more than 20 times. For each attempt, an audible alarm was noted to sound when R40 approached an exterior door to the facility. Facility employees were noted to respond to the alarm, by approaching R40 and attempting to redirect her. R40 was unable to be redirected on several occasions. During these occasions, facility employees retrieved a winter coat from the facility exits, placed the coat around R40 and went for a walk with R40 outside the facility. Outside of times when audible alarms were sounding due to R40 exiting the building, no staff were noted to be checking on R40's whereabouts. One nurse and one nursing assistant were noted to be assigned to the wing where R40 resided, along with eight other residents. During a random observation on 11/26/12, at 3:15 p.m., R40 was noted to be wandering in the facility courtyard, in her wheelchair. The facility courtyard was an outdoor space, fully surrounded by four facility hallways, with glass doors accessing the facility on the West and East sides of the courtyard. The North and South sides of the courtyard had windows to resident rooms. No audible alarm was sounded and no facility employees were noted to respond, until they were informed that R40 was in the courtyard. R40 was noted to be wearing a sweatshirt and slacks. No hat, mittens or coat were observed to be worn during this observation. The outside temperature during the time of this observation was approximately 20 degrees Fahrenheit, with a wind chill of 15 degrees Fahrenheit. During interview on 11/26/12, at 3:30 p.m., RN-C and Administrator verified that R40 frequently wandered and attempted to exit the facility, including frequent exiting into the facility's courtyard. RN-C reported that R40's wandering had been increasing since 7/12, when her physical abilities and mobility improved, post rehabilitation from a hip fracture in 2/12. RN-C reported that R40's attempts to leave the building were "almost constant... She seems determined to leave (the building)." They reported that facility interventions for her wandering included audible alarms to the exterior doors, staff walking with R40 outside if they were unable to redirect her inside and availability of winter coats at all of the exterior entrances to protect R40 from cold weather temperatures. RN-C and Administrator verified R40 was not being checked on with any frequency by facility staff. They also verified that the courtyard doors were not alarmed and were not secured/ locked at any time. RN-C and Administrator verified that facility employees did not have a way to know R40 had exited to the courtyard, unless they had randomly observed her there. They also verified that coats were not available at the courtyard entrances for staff to provide to R40 if they had randomly notice she had exited to the courtyard. RN-C and Administrator reported that facility employees "just know to be aware" of where R40 was at all times. During interview on 11/26/12, at 8:12 p.m., Administrator reported that there was no life safety code reasoning for the courtyard doors to remain unlocked. She pointed out that keyed locks were available on the doors and verified the doors had the capability of being locked. Administrator reported that the doors had always been unlocked for resident's to freely access the space. Administrator denied facility staff had thought of adding an audible alarm to the courtyard doors or thought of locking the courtyard doors during cold weather months, to ensure R40's safety. Administrator reported that the maintenance director held the keys to the courtyard doors and he would be contacted immediately to come in and lock the doors. The facility's Elopement Policy revised 7/08 instructed that when an elopement occurred, immediate efforts to locate the resident would be taken, all occurrences would be documented and follow-up would occur. The facility's Elopement Procedure revised 10/12 revealed all residents would be assessed for elopement risk upon admission and as needed. The procedure identified a review/audit of the physical environment and safety would be conducted as needed. A sample care plan included in the procedure included interventions of accounting for the resident's whereabouts every 15-30 minutes and using door/ resident safety alarms. The procedure also indicated that all elopements were to be documented and an incident report completed. The procedure indicated an Elopement Checklist Worksheet was to be completed after each elopement, which included assessment of appropriate and individualized care plan interventions, adequate supervision, and assessment of whether the exit door used had an alarm or was within constant sight of a staff member. On 11/26/12, at 9:00 p.m. the Administer and the director of nurses were notified of an immediate jeopardy situation related to the elopement with the potential for exposure to unsafe temperatures for R40. The immediate jeopardy that began on 11/26/12, was removed on 11/28/12, at 9:40 a.m. when the facility took steps to review the safety of R40 who was identified in the immediate jeopardy and assessed other residents that were identified as risk for elopement. The steps the facility took to ensure the safety for R40 included every 15 minute checks, the door to the courtyard was locked, R40 was re-assessed for elopement, the care plan was updated and the social worker actively sought placement for a facility with a secure unit. Education was also provided to staff. The immediate jeopardy was removed on 11/28/12, at 9:40 a.m. but noncompliance remained at the lower scope and severity level of a isolated scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy.

Based on documentation and interviews, the facility failed to ensure that each resident's physician was consulted immediately, when the resident experienced a significant change in status, in one of one residents reviewed (Resident #1). Findings include: Medical record review indicated that Resident #1 coughed with food in her mouth while being fed the evening meal on [DATE] at 5:30 p.m. Documentation noted that the resident coughed and then gasped. Staff were concerned that the resident may have aspirated, so staff began monitoring the resident's lung sounds. Her vital signs were: temperature = 96.3, pulse = 73, respirations = 20, and oxygen saturation level = 87% on room air. Her blood pressure was not measured. Documentation noted that her oxygen saturation was "later" 94%, but the time this measurement was obtained was not documented. At 10:00 p.m., documentation indicated that the resident had developed a cough with diminished lung sounds in all fields. At 10:00 p.m., Nurse (D)/RN updated the physician with this information via fax. There was no evidence that the physician received the fax. The only documented notation by Nurse (D)/RN, during the night shift of ,[DATE] - [DATE], indicated that the resident's lung sounds continued to be diminished and her temperature was 99.6 (no time documented). Nurse (D)/RN medicated the resident with [MEDICATION NAME] at 1:45 a.m. (an antianxiety agent that is administered as needed), but there was no documentation pertaining to the reason that the resident needed the [MEDICATION NAME], nor was there any documentation regarding the efficacy of the medication. Medical record review indicated that Resident #1 was next reassessed at 1:30 p.m. on [DATE] (12 hours later). Documentation reflected that the resident's temperature was 98.4, she had "snore-sounds" in her lungs, and her oxygen saturation level was 89% on room air. The resident did not eat any breakfast. At noon, the resident ate only 25% of her meal and 60 cc of fluids. She was lethargic at times and let the food/fluids run out of her mouth. Her dental appointment that day was cancelled due to her lethargy. There was no evidence that the physician was consulted regarding the resident's change in status. There was no evidence that facility staff followed up on the fax that was sent to the physician on [DATE] regarding the resident's possible aspiration. Medical record review indicated that Resident #1 was next reassessed by Nurse (G)/LPN, at 4:15 p.m. (three hours later). The resident's vital signs were: temperature = 99.5, pulse = 65, respirations = 24, blood pressure = ,[DATE], and her oxygen saturation level was 72% on room air. Documentation noted that the resident was consistently moaning, her breathing was labored, and her fingertips were dark blue in color. Nurse (G)/LPN gave the resident [MEDICATION NAME] "to promote comfort and decrease agitation," and initiated 2 liters of oxygen per minute. The interdisciplinary notes reflected that Administrative Nurse (B)/RN was notified, in-person, of the resident's status, at 4:15 p.m. The physician was notified of the resident's condition via fax, which was flagged as "urgent." The entry noted that the fax was sent three times to the physician (between 4:15 p.m. and 5:00 p.m.), before a response was received. Medical record review reflected that the physician responded via fax (to the above fax) at 5:00 p.m. on [DATE], which indicated "Advise ER eval." The interdisciplinary progress notes on [DATE] at 5:15 p.m. indicated that Nurse (G)/LPN called for an ambulance. The interdisciplinary progress notes on [DATE] at 6:00 p.m. indicated that the resident's respirations were 8 per minute with periods of apnea. The resident's oxygen saturation level was 86% while receiving 2 liters of oxygen per minute. The interdisciplinary progress notes on [DATE] at 6:30 p.m. indicated that the ambulance arrived at the facility and Resident #1 was in "[MEDICAL CONDITION]." Resident #1 expired at 6:56 p.m. The death certificate listed Resident #1's cause of death as cardio-[MEDICAL CONDITION]. No contributing conditions were identified. The death certificate was signed by the resident's attending physician. The facility's policy on Notification of Change in Resident Status indicates that "the center will IMMEDIATELY consult with the resident's physician...in the following cases...Significant change in the resident's physical, mental, or psychosocial status." The facility's policy on Notification of Condition Change and Observation indicates that the purpose of the policy is "To assist in collection of pertinent data prior to providing notification of a change in resident's status to physician." This policy further specifies that staff are to "Notify the physician of the change in resident's condition...Notify the director of nursing services...take appropriate action as ordered by the physician."

Based on documentation and interviews, the facility failed to ensure that each resident was properly assessed by a registered nurse, when there was a significant change in the resident's condition, and the facility failed to ensure that resident care was coordinated by a registered nurse, in accordance with professional standards of quality, in one of one residents reviewed (Resident #1). Findings include: The Minnesota Nurse Practice Act (Developed 1994; Reviewed [DATE]) indicates that the "assessment, care planning, and evaluating functions lie within the RN definition and scope of practice...the LPN contributes...by reporting pertinent observations and suggesting nursing intervention modifications based on client responses...because the evaluation phase includes ongoing reassessment of the client,...the LPN participates by observing and reporting the client's response to nursing actions, to the RN." Medical record review and interviews of Nurses (E and G)/LPNs established that both LPNs informed Administrative employee (B)/RN of Resident #1's declining symptoms. The RN was informed three times (once on day shift and twice on evening shift) and did not assess the resident. Administrative employee (B)/RN was the only RN in the facility on [DATE], when less qualified nursing personnel informed her of the resident's sudden decline. Medical record review indicated that Resident #1 coughed with food in her mouth while being fed the evening meal on [DATE] at 5:30 p.m. Documentation noted that the resident coughed and then gasped. Staff were concerned that the resident may have aspirated, so staff began monitoring the resident's lung sounds. Her vital signs were: temperature = 96.3, pulse = 73, respirations = 20, and oxygen saturation level = 87% on room air. Her blood pressure was not measured. Documentation noted that her oxygen saturation was "later" 94%, but the time this measurement was obtained was not documented. At 10:00 p.m., documentation indicated that the resident had developed a cough with diminished lung sounds in all fields. At 10:00 p.m., Nurse (D)/RN updated the physician with this information via fax. The only documented notation by Nurse (D)/RN, during the night shift of ,[DATE] - [DATE], indicated that the resident's lung sounds continued to be diminished and her temperature was 99.6 (no time documented). Nurse (D)/RN medicated the resident with [MEDICATION NAME] at 1:45 a.m. (an antianxiety agent that is administered as needed), but there was no documentation pertaining to the reason that the resident needed the [MEDICATION NAME], nor was there any documentation regarding the efficacy of the medication. There was no documented evidence regarding the resident's pulse, respirations, blood pressure, oxygen saturation, or level of consciousness. Medical record review indicated that Resident #1 was next reassessed by Nurse (E)/LPN at 1:30 p.m. on [DATE] (12 hours later). Documentation reflected that the resident's temperature was 98.4, she had "snore-sounds" in her lungs, and her oxygen saturation level was 89% on room air. The resident did not eat any breakfast. At noon, the resident ate only 25% of her meal and 60 cc of fluids. She was lethargic at times and let the food/fluids run out of her mouth. Her dental appointment that day was cancelled due to her lethargy. There was no evidence that the physician was consulted regarding the resident's change in status. There was no evidence that facility staff followed up on the fax that was sent to the physician on [DATE] regarding the resident's possible aspiration. Medical record review indicated that Resident #1 was next reassessed by Nurse (G)/LPN, at 4:15 p.m. (three hours later). The resident's vital signs were: temperature = 99.5, pulse = 65, respirations = 24, blood pressure = ,[DATE], and her oxygen saturation level was 72% on room air. Documentation noted that the resident was consistently moaning, her breathing was labored, and her fingertips were dark blue in color. Nurse (G)/LPN gave the resident [MEDICATION NAME] "to promote comfort and decrease agitation," and initiated 2 liters of oxygen per minute. The interdisciplinary notes reflected that Administrative Nurse (B)/RN was notified, in-person, of the resident's status, at 4:15 p.m. The physician was notified of the resident's condition via fax, which was flagged as "urgent." The entry noted that the fax was sent three times to the physician (between 4:15 p.m. and 5:00 p.m.), before a response was received. Medical record review reflected that the physician responded to the above fax at 5:00 p.m. on [DATE], which indicated "Advise ER eval." The interdisciplinary progress notes on [DATE] at 5: 15 p.m. indicated that Nurse (G)/LPN called for an ambulance to transfer Resident #1 to the hospital for further evaluation. Nurse (G)/LPN also contacted the hospital to update ER staff on the resident's status and pending arrival. The interdisciplinary progress notes on [DATE] at 6:00 p.m. indicated that when Nurse (G)/LPN checked the resident, her respirations were 8 per minute with periods of apne and her oxygen saturation level was 86%, while receiving 2 liters of oxygen per minute. . There was no evidence of any other assessment, including temperature, pulse, and blood pressure. The resident's vital signs had not been reassessed since 4:15 p.m. The interdisciplinary progress notes on [DATE] at 6:25 p.m. indicated that Nurse (G)/LPN re-contacted the ambulance service because the ambulance had not yet arrived at the facility. There was no evidence that Resident #1 was reassessed or monitored after 6:00 p.m., even though the resident had demonstrated critically low respirations with periods of apnea. The interdisciplinary progress notes on [DATE] at 6:30 p.m. indicated that the ambulance arrived at the facility and Resident #1 was in "[MEDICAL CONDITION]." The interdisciplinary progress notes on [DATE] at 6:56 p.m. reflected that Resident #1 had expired. The death certificate listed Resident #1's cause of death as cardio-[MEDICAL CONDITION]. No contributing conditions were identified. The death certificate was signed by the resident's attending physician. The facility's staffing schedule indicated that the nurses assigned to provide care for Resident #1 on the day shift of [DATE] and the evening shift of [DATE] were both LPNs. Nurse (E)/LPN was interviewed on [DATE] at 10:45 a.m. She worked the day shift of [DATE] on the West unit. She is familiar with Resident #1's needs. On [DATE], the resident was more sleepy than usual. Her somnolence seemed to alternate with agitation. She didn't eat any breakfast and ate only bites for lunch. Her lung sounds were congested and her dental appointment had to be cancelled due to her lethargy. Her oxygen saturation level was 89% on room air. Nurse (E)/LPN apprised Administrative employee (B)/RN of the resident's change in condition. When Nurse (G)/LPN (the second shift nurse) came on duty, Nurse (E)/LPN went to the training room to complete some inservice requirements. Afterward, Nurse (E)/LPN went back to the West unit at 6:00 p.m. Administrative nurse (B)/RN was on the West unit at the time. Nurse (G)/LPN was interviewed on [DATE] at 12:35 p.m. She worked the evening shift of [DATE] on the West unit. She is a full-time employee and is assigned to work on the facility's East unit, with the exception of two days per pay period, during which she works the West unit. Regardless of the unit she is assigned to work on, she is the unit's only nurse during her shift and she functions as the charge nurse of her assigned unit. On [DATE], she was assigned to work on the West unit, where Resident #1 resided. On [DATE], the only RN in the facility was Administrative employee (B). The second shift nurse on the East unit was also a LPN. Nurse (G)/LPN stated she was familiar with Resident #1 prior to [DATE]. The resident required extensive assistance with activities of daily living. She was nonambulatory. She was transferred with a mechanical lift. She was fed by staff. She was talkative but most of her verbalizations reflected her declining cognition. She had no active health problems. At 3:30 p.m., Nursing Assistant (I) told Nurse (G)/LPN that Resident #1 wasn't doing well. Nurse (G)/LPN had not seen the resident yet as she was performing other duties. She went to check the resident immediately after the nursing assistant told her that the resident wasn't doing well. When she entered the resident's room, Resident #1 was moaning. She was curled up in a fetal position with a grimace on her face. She obtained vital signs. The resident's pulse was 65, faint and irregular. Her respirations were 24 and labored. Her oxygen saturation level was only 72% on room air. Her blood pressure was ,[DATE]. Nurse (G)/LPN stated that the resident's symptoms signified that the resident was in respiratory distress. The resident was agitated and appeared as if she was experiencing pain. Nurse (G)/LPN initiated oxygen at 2 liters/minute. Nurse (G)/LPN administered [MEDICATION NAME] 0.5 mg rectally to ease the resident's discomfort. Nurse (G)/LPN administered the oral tablet rectally because Resident #1 was unable to swallow a pill, due to her lethargy and agitated state. After Nurse (G)LPN started the oxygen and administered the [MEDICATION NAME] to Resident #1, Nurse (G)/LPN informed Administrative Nurse (B)/RN, in-person, of the resident's status and declining condition. It was approximately 4:15 p.m. when Nurse (G)/LPN spoke to Nurse (B)/RN. Nurse (G)/LPN stated that Nurse (B)/RN did not assess the resident, after receiving the status report. Nurse (G)/LPN stated that she then notified the physician of the resident's status, via fax, which she marked "urgent." Nurse (G)/LPN stated that she sent three faxes to the physician between 4:15 and 5:00 p.m., all marked "urgent," with no response from the physician. At 5:00 p.m., the physician responded via fax, "Advise ER eval." At 5:15 p.m., Nurse (G)LPN called for an ambulance. Nurse (G)/LPN also contacted the hospital, advising them of the resident's status and soon arrival. In addition, Nurse (G)/LPN advised Nurse (B)/RN, in-person, that she had called an ambulance for Resident #1 and that the resident was continuing to decline. This was the second time during the shift that Nurse (G)/LPN had communicated with Administrative employee (B)/RN about the resident's change in condition. Despite this information, Nurse (B)/RN did not assess the resident. The resident had not been assessed since 4:15 p.m. At 6:00 p.m., Nurse (G)/LPN re-assessed the resident (two hours after her last assessment). The resident's respirations were 8 per minute, with periods of apnea (not breathing) and her oxygen saturation level was 86% on 2 liters of oxygen. Nurse (G)/LPN did not take any other vital signs or perform any additional assessment. Nurse (G)/LPN stated that Nurse (B)/RN was on the West unit at 6:00 p.m., talking to the staffing coordinator. Nurse (B)/RN inquired about whether or not the ambulance had arrived yet (which had been called at 5:15 p.m.). Even though Nurse (G)/LPN's response was "no," Nurse (B)/RN never checked the resident, to conduct a more thorough assessment of the resident's status. At 6:25 p.m. (one and a half hours after the ambulance was first called), Nurse (G)/LPN re-contacted the ambulance service to inquire about the whereabouts of the ambulance. Nurse (G)/LPN acknowledged that both times she called the ambulance service for Resident #1 (5:00 p.m. and 6:25 p.m.), she did not indicate it was an emergency. She acknowledged that she told the Dispatcher she needed an ambulance for "transport" of a resident to the hospital. At 6:30 p.m., the ambulance arrived and Resident #1 was found in [MEDICAL CONDITION]. The resident expired at 6:56 p.m. Administrative nurse (B)/RN was interviewed on [DATE]. She stated that staff suspected that Resident #1 had aspirated during the evening meal of [DATE], so staff began monitoring her. On the morning of [DATE], the resident seemed "okay," and her lung sounds were "okay," per report from Nurse(E)/LPN. Nurse (E)/LPN last checked the resident at 1:30 p.m. Nurse (B)/RN acknowedged that she did not assess Resident #1 during the day shift of [DATE], even though she was present in the facility and was informed that the resident possibly aspirated the previous evening and subsequently, had diminished lung sounds, somnolence, and minimal food/fluid intake. Administrative Nurse (B)/RN stated that Nurse (G)/LPN checked Resident #1 when she came on duty for the evening shift. Nurse (G)/LPN then notified the physician of the resident's status, via fax, at 4:15 p.m. No response was received from the physician. Nurse (G)/LPN faxed the physician three times about the resident's declining condition (between 4:15 p.m. and 5:00 p.m.) with no response. When the physician responded via fax (at 5:00 p.m.), the physician indicated that the resident should be sent to the hospital. Nurse (G)/LPN called for an ambulance at 5:00 p.m., called the hospital to inform them of the resident's pending arrival, and called the family. Nurse (G)/LPN had the nursing assistants check on the resident while she completed paperwork, called the family, and passed her medications (both nursing assistants stated that Nurse (G)/LPN never asked them to check on the resident or to complete vital signs). When the ambulance didn't come after Nurse (G)/LPN first called for one, she re-contacted the ambulance service around 6:00 p.m. The Dispatcher from the ambulance service acknowledged that their office failed to send an ambulance after the first call. The ambulance did not arrive until 6:30 p.m., at which time Resident #1 was failing. Although Nurse (B)/RN acknowledged that Nurse (G)/LPN notified her of the resident's change in condition at 4:15 p.m., Nurse (B)/RN stated that Nurse (G)/LPN did not inform her of the resident's specific symptoms or the gravity of the resident's abrupt decline. Nurse (B)/RN acknowledged that she did not assess the resident at any time on [DATE] or [DATE], even though she knew that the resident possibly aspirated the previous evening of [DATE] and was demonstrating signs of an aspiration on [DATE]. Nurse (B)/RN also acknowledged that she was present in the facility on [DATE] until 5:30 p.m. (which was inconsistent with two other staff statements that she was present in the facility until 6:00 p.m.), was aware that the resident had only been checked by LPNs (on day shift and evening shift), aware that Nurse (G)/LPN had called for an ambulance for Resident #1, and aware that the ambulance had not arrived for an extended period. Nurse (B)/RN still did not assess the resident or intervene to assist Nurse (G)/LPN in obtaining prompt medical assistance for Resident #1. Nurse (B)/RN maintained that she felt the staff monitored Resident #1 adequately. Nurse (B)/RN stated that staff recognized that the resident needed to be transferred to the hospital, however, the ambulance service delayed that transfer when they failed to respond timely. Nurse (B)/RN acknowledged that she was available in the facility (during Resident #1's sudden decline) to conduct a higher level of assessment of Resident #1 (than that performed by LPNs), but did not do so. Nurse (B)/RN failed to evaluate and coordinate the resident's care, including the initiation of an immediate care plan which facilitated the resident's prompt transfer to a hospital, where the resident could obtain the medical care she needed.

Based on documentation and interviews, the facility failed to provide the necessary care and services to each resident, when a resident exhibited a significant change in condition, in one of one residents reviewed (Resident #1). Findings include: Medical record review indicated that Resident #1 had chronic nutrition deficits related to weakness. She was unable to consume food or fluids in regular texture. She received a mechanically altered diet with nectar-like liquids. The progress notes indicated that Resident #1 coughed with food in her mouth while being fed the evening meal on [DATE] at 5:30 p.m. Documentation noted that the resident coughed and then gasped. Staff were concerned that the resident may have aspirated, so staff began monitoring the resident's lung sounds. Her vital signs were: temperature = 96.3, pulse = 73, respirations = 20. Oxygen saturation was 87% on room air. The resident's blood pressure was not measured. Documentation noted that the resident's oxygen saturation level was re-checked and was 94%, but the entry did not indicate what time it was. At 10:00 p.m. on [DATE], documentation indicated that the resident had developed a cough with diminished lung sounds in all fields. Nurse (D)/RN updated the physician with this information via fax. There was no evidence that the physician responded to the fax. The only documented notation regarding the resident's status, during the night shift of ,[DATE] - [DATE], indicated that the resident's lung sounds continued to be diminished and her temperature was 99.6 (no time documented). She was medicated with [MEDICATION NAME] at 1:45 a.m. (an antianxiety agent that is administered as needed). There was no documentation pertaining to the reason that the resident needed the [MEDICATION NAME], nor was there any documentation regarding the efficacy of the medication. There was no documented evidence regarding the resident's pulse, respirations, blood pressure, oxygen saturation, or level of consciousness. Medical record review indicated that the Resident #1 was next reassessed at 1:30 p.m. on [DATE] (12 hours later), by Nurse (E)/LPN. Documentation reflected that the resident's temperature was 98.4, she had "snore-sounds" in her lungs, and her oxygen saturation level was 89% on room air. There was no documented evidence that the resident's pulse, respirations, or blood pressure were measured. The entry reflected that the resident did not eat any breakfast. At noon, the resident ate only 25% of her meal and 60 cc of fluids. The entry also reflected that she was lethargic at times and let the food/fluids run out of her mouth. Her dental appointment that day was cancelled due to her lethargy. Medical record review indicated that Resident #1 was next reassessed at 4:15 p.m. on [DATE] (three hours later), by Nurse (G)/LPN. The resident's vital signs were: temperature = 99.5, pulse = 65, respirations = 24, blood pressure = ,[DATE], and her oxygen saturation level was 72% on room air. Documentation by Nurse (G)/LPN noted that the resident's lung sounds were clear, she was consistently moaning, her breathing was labored, and her fingertips were dark blue in color. The resident was given [MEDICATION NAME] to promote comfort and decrease agitation, and started on 2 liters of oxygen per minute. The interdisciplinary notes reflected that Nurse (G)/LPN notified Administrative Nurse (B)/RN, in-person, of the resident's status. The physician was notified of the resident's condition via fax, which was flagged as "urgent." The entry noted that the fax was sent three times to the physician (between 4:15 p.m. and 5:00 p.m.), before a response was received. Medical record review reflected that the physician responded to the above fax at 5:00 p.m. on [DATE], which indicated "Advise ER eval." The interdisciplinary progress notes, written by Nurse (G)/LPN, on [DATE] at 5: 15 p.m. indicated, "Contacted Redwood Sheriff's department for transport of resident to Redwood ER via ambulance service. Also contacted Redwood Hospital ER to update on resident status and soon arrival." The interdisciplinary progress notes, written by Nurse (G)/LPN, on [DATE] at 5:30 p.m. indicated that the resident's family was updated regarding her status and transfer to the hospital. The interdisciplinary progress notes, written by Nurse (G)/LPN, on [DATE] at 6:00 p.m. indicated that the resident's oxygen saturation level was 86% while receiving 2 liters of oxygen per minute. Her respirations were 8 with periods of apnea. There was no evidence of any other assessment, including vital signs. The resident's vital signs had not been reassessed since 4:15 p.m. The interdisciplinary progress notes on [DATE] at 6:25 p.m. indicated that Nurse (G)/LPN contacted the Redwood Sheriff's Department again and spoke with the Dispatcher, who was unaware of the previous page for an ambulance. The ambulance was re-paged at this time. There was no evidence that Resident #1 was reassessed or monitored after 6:00 p.m., even though the resident had demonstrated critically low respirations with periods of apnea. The interdisciplinary progress notes on [DATE] at 6:30 p.m. indicated that the ambulance arrived at the facility and Resident #1 was in "[MEDICAL CONDITION]." Documentation reflected that Nurse (G)/LPN was on the phone with the resident's family member when the ambulance arrived. The interdisciplinary progress notes on [DATE] at 6:56 p.m. reflected that Resident #1 had expired. The death certificate listed Resident #1's cause of death as cardio-[MEDICAL CONDITION]. No contributing conditions were identified. The death certificate was signed by the resident's attending physician. Several attempts to interview Nurse (D)/RN were unsuccessful. Nurse (D) worked the evening shift of [DATE] and the night shift of ,[DATE] - [DATE]. Nursing Assistant (H) was interviewed on [DATE] at 7:20 a.m. She worked the night shift of ,[DATE] - [DATE]. She was responsible for nursing assistant duties on both the East and West wings of the facility. Although there was a nurse on each of the wings, she was the only nursing assistant for both wings. She checked on Resident #1 every two hours. Usually Resident #1 is able to help turn herself some, but that night she was unable to do so. The resident was restless and sounded very congested like she was coming down with a cold. Nursing Assistant (H) was in Resident #1's room for only brief periods, just long enough to turn Resident #1. Nurse (E)/LPN was interviewed on [DATE] at 10:45 a.m. She worked the day shift of [DATE] on the West wing. She received shift report from Nurse (D)/RN, who told her about Resident #1's possible aspiration and resultant increased monitoring by nursing staff. Nurse (D)/RN also told her that she had sent a fax to the physician regarding the resident's status. Nurse (E)/LPN stated that she was familiar with Resident #1's needs. On [DATE], the resident was more sleepy than usual. Her somnolence seemed to alternate with agitation. She didn't eat any breakfast and ate only bites for lunch. Her lung sounds were congested and her dental appointment had to be cancelled due to her lethargy. Her oxygen saturation level was 89% on room air. When Nurse (G)/LPN came on duty for the evening shift, Nurse (E)/LPN gave her a status report about Resident #1's condition. Nurse (E)/LPN then went to the training room to complete some inservice requirements. Afterward, Nurse (E)/LPN went back to the West unit and Nurse (G)/LPN told her that staff were waiting for an ambulance to transfer Resident #1 to the hospital. It was 6:00 p.m. at that time. Administrative nurse (B)/RN was on the West unit at the time. Nurse (G)/LPN was interviewed on [DATE] at 12:35 p.m. She stated she has been working at the facility for approximately one year on the evening shift from 2:30 p.m. to 10:30 p.m. She is normally assigned to work on the facility's East unit, with the exception of two days per pay period, during which she works the West unit. Regardless of the unit she is assigned to work on, she is the unit's only nurse during her shift and she functions as the charge nurse of her assigned unit. On [DATE], she was assigned to work on the West unit, where Resident #1 resided. She received shift report from Nurse (E)/LPN, who told her that Resident #1 wasn't doing well, had been sleepy during the day, and wasn't eating or accepting fluids. Nurse (G)/LPN stated that she was familiar with Resident #1 prior to [DATE]. The resident required extensive assistance with activities of daily living. She was nonambulatory. She was transferred with a mechanical lift. She was fed by staff. She was talkative but most of her verbalizations reflected her declining cognition. She had no active health problems. At 3:30 p.m., Nursing Assistant (I) told Nurse (G)/LPN that Resident #1 wasn't doing well. Nurse (G) had not seen the resident yet as she was performing other duties. She went to check the resident immediately after the nursing assistant told her that the resident wasn't doing well. When she entered the resident's room, Resident #1 was moaning. She was curled up in a fetal position with a grimace on her face. She obtained vital signs. The resident's pulse was 65, faint and irregular. Her respirations were 24 and labored. Her oxygen saturation level was only 72% on room air. Her blood pressure was ,[DATE]. Nurse (G)/LPN stated that the resident's symptoms signified that the resident was in respiratory distress. The resident was agitated and appeared as if she was experiencing pain. Nurse (G)/LPN initiated oxygen at 2 liters/minute. Nurse (G)/LPN administered [MEDICATION NAME] 0.5 mg rectally to ease the resident's discomfort. Nurse (G)/LPN administered the oral tablet rectally because Resident #1 was unable to swallow a pill, due to her lethargy and agitated state. At approximately 4:00 p.m., Nurse (G)/LPN started oxygen for Resident #1, administered [MEDICATION NAME] to her, and sent a status report to the physician, via fax. Afterward, Nurse (G)/LPN informed Administrative Nurse (B)/RN, in-person, of the resident's status and declining condition. Nurse (G)/LPN stated that Administrative Nurse (B)/RN did not assess the resident, after receiving the status report. Nurse (G)/LPN stated that she then notified the physician of the resident's status, via fax, which she marked "urgent." Nurse (G)/LPN stated that she sent three faxes to the physician between 4:00 and 5:00 p.m., all marked "urgent," with no response from the physician (the medical record reflects that Nurse B sent one fax to the physician at 3:20 p.m.). At 5:00 p.m., the physician responded via fax, "Advise ER eval." At 5:15 p.m., Nurse (G)/LPN contacted the Sheriff's Department "for transport of resident to ER via ambulance service." Nurse (G)/LPN also contacted the hospital, advising them of the resident's status and soon arrival. In addition, Nurse (G)/LPN advised Administrative Nurse (B)/RN that she had called an ambulance for Resident #1 and that the resident was continuing to decline. Despite this information, Administrative Nurse (B)/RN did not assess the resident. At 5:30 p.m., Nurse (G)/LPN contacted the resident's family and informed them that the resident was being transferred to the hospital. At 6:00 p.m., Nurse (G)/LPN re-assessed the resident (two hours after her last assessment). The resident's oxygen saturation level was 86% on 2 liters of oxygen. Her respirations were 8 per minute, with periods of apnea (not breathing). Nurse (G)/LPN did not take any other vital signs or perform any additional assessment. Nurse (G)/LPN stated that Administrative Nurse (B)/RN was on the West unit at 6:00 p.m., talking to the staffing coordinator. Administrative Nurse (B)/RN inquired about whether or not the ambulance had arrived yet (which had been called at 5:00 p.m.). Even though Nurse (G)/LPN's response was "no," Administrative Nurse (B)/RN never checked the resident, to conduct a more thorough assessment of the resident's status. At 6:25 p.m. (one and a half hours after the ambulance was first called), Nurse (G)/LPN re-contacted the Sheriff's Department to inquire about the whereabouts of the ambulance. Nurse (G)/LPN stated that the Dispatcher indicated she was unaware of the previous page for an ambulance. The Dispatcher stated she would page the ambulance service immediately. Nurse (G)/LPN acknowledged that both times she called the Sheriff's Department for an ambulance for Resident #1 (5:00 p.m. and 6:25 p.m.), she did not indicate it was an emergency. She acknowledged that she told the Dispatcher she needed an ambulance for "transport" of a resident to the hospital. At 6:30 p.m., the ambulance arrived. Nurse (G)/LPN stated she was on the phone with the resident's family when the ambulance came. No staff were with the resident. She accompanied emergency personnel to Resident #1's room and the resident was found in [MEDICAL CONDITION]. The resident expired at 6:56 p.m. Nursing Assistants (I) and (J) were interviewed on [DATE] at 1:32 p.m. and 12:00 p.m., respectively. Both nursing assistants worked the second shift of [DATE] on the West unit, with Nurse (G)/LPN. One nurse and two nursing assistants represent the typical staffing pattern for the West unit on the second shift, however one of the nursing assistants works a short shift. On [DATE], Nursing Assistant (I) worked the full shift from 2:30 p.m. to 10:30 p.m.. and Nursing Assistant (J) worked from 4:45 p.m. to 9:30 p.m. Nursing Assistant (I) stated she conducted initial rounds to Resident #1's room at about 3:15 p.m. on [DATE]. She immediately noticed that Resident #1 "wasn't breathing right." The resident was taking short breaths and moaning as if she was in pain. The resident was unable to talk, due to her breathing problem. Nursing Assistant (I) told Nurse (G)/LPN immediately about the resident's inability to breathe normally. Nurse (G)/LPN checked the resident right away. Nursing Assistant (I) saw Nurse (G)/LPN go in the resident's room several times afterward. Nursing Assistant (I) did not have the opportunity to check on Resident #1 again. Nursing Assistant (I) stated she did not perform any vital signs on Resident #1 on [DATE]. Nursing Assistants do not perform vital signs at the facility. Vital signs are done only by nurses. Sometimes the nurse might ask a nursing assistant to complete vital signs on a particular resident, but Nurse (G)/LPN never asked Nursing Assistant (I) to take any vital signs on Resident #1 on [DATE]. Nursing Assistant (J) stated she reported to work at 4:45 p.m. on [DATE]. Nurse (G)/LPN told her about Resident #1's decline. Nursing Assistant (J) checked on Resident #1 immediately afterward at 4:50 p.m. Resident #1 was "laughing/coughing hysterically." When nursing assistant (J) was asked to further describe the resident's laughing/coughing, Nursing Assistant (J) stated that she didn't think the resident was really laughing, rather, she thought the resident was gasping for air. Nursing Assistant (J) did not see Resident #1 again after 4:50 p.m. Nursing Assistant (J) stated that she thought Nursing Assistant (I) was checking up on Resident #1 periodically. Nurse (G)/LPN never asked her to do any vital signs on Resident #1 on [DATE]. Administrative nurse (B)/RN was interviewed on [DATE]. She stated that staff suspected that Resident #1 had aspirated during the evening meal of [DATE], so staff began monitoring her. On the morning of [DATE], the resident seemed "okay," and her lung sounds were "okay," per report from the day shift nurse (Nurse (E)/LPN). Nurse (E)/LPN had last checked the resident at 1:30 p.m. When second shift staff came on duty, one of the nursing assistants checked Resident #1 during initial rounds and thought she was having a hard time breathing. The nursing assistant reported that to Nurse (G)/LPN and the nurse checked the resident. Nurse (G)/LPN then notified the physician of the resident's status via fax. Between 3:00 p.m. and 4:00 p.m., Nurse (G)/LPN faxed the physician three times about the resident's declining condition. At 5:00 p.m., the physician responded via fax and indicated that the resident should be sent to the hospital. Nurse (G)/LPN called for an ambulance at 5:00 p.m., called the hospital to inform them of the resident's pending arrival, and called the family. Nurse (G)/LPN had the nursing assistants check on the resident while she completed paperwork, called the family, and passed her medications. When the ambulance didn't come after Nurse (G)/LPN first called for one, she re-contacted the Dispatcher. The Dispatcher acknowledged that their office failed to send an ambulance after the first call. The ambulance did not arrive until 6:30 p.m., at which time Resident #1 was failing. Although Administrative Nurse (B)/RN acknowledged that Nurse (G)/LPN notified her of the resident's change in condition at 4:00 p.m., Administrative Nurse (B)/RN stated that Nurse (G)/LPN did not inform her of the resident's specific symptoms or the gravity of the resident's abrupt decline. Administrative Nurse (B)/RN acknowledged that she did not assess the resident at any time on [DATE] or [DATE]. Administrative Nurse (B)/RN also acknowledged that she was present in the facility on [DATE] until 5:30 p.m. (which was inconsistent with two other staff statements that she was present in the facility until 6:00 p.m.), was aware that staff had called for an ambulance for Resident #1, and was aware that the ambulance had not arrived for an extended period. Administrative Nurse (B)/RN still did not assess the resident or intervene to assist Nurse (G)/LPN in obtaining prompt medical assistance for Resident #1. Administrative Nurse (B)/RN maintained that she felt the staff monitored Resident #1 adequately. Administrative Nurse (B)/RN stated that facility staff recognized that the resident needed to be transferred to the hospital immediately. However, the ambulance service delayed the resident's transfer when they failed to respond timely. Administrative employee (A) was interviewed on [DATE] at 10:30 a.m. She stated that the process for obtaining ambulance assistance has been for staff to call the Sheriff's office (County Dispatcher) rather than calling 911. Employee (A) stated that the Sheriff's office directed facility staff to call the County Dispatcher when they need an ambulance, even in cases of emergency. Employee (A) changed this procedure immediately following the [DATE] incident. In the future, staff will call 911 whenever an ambulance is needed, even if it is not an emergency. All staff were re-educated regarding this new procedure. Sheriff (C) was interviewed on [DATE] at 10:45 a.m. He acknowledged that the Dispatcher on [DATE] failed to send an ambulance to the facility after the facility placed the first call at 5:15 p.m. He stated he had reviewed all of the tapes from [DATE], including the calls from the facility at 5:15 p.m. and 6:25 p.m. Both times when facility staff called for the ambulance, staff did not indicate the ambulance was needed for an emergency. Rather, staff requested an ambulance for "transfer of a resident to the hospital." Both times facility staff called the seven digit telephone number (for the County Dispatcher) rather than calling 911. Had staff called 911, the request for an ambulance and pertinent information about the victim would have remained on the EMS (emergency medical services) board until an ambulance was dispatched to the location in need. When anyone calls the seven digit number and gets the Dispatcher, the information provided is not entered on the EMS board. On [DATE], the Dispatcher received several other calls after the facility's initial call at 5:15 p.m. The Dispatcher prioritized other calls ahead of the facility's call for an ambulance. When the facility called the Dispatcher the second time at 6:25 p.m., an ambulance was dispatched immediately and was at the facility within five minutes. Physician (K) was interviewed on [DATE] at 12:30 p.m. He stated that he has been the facility's medical director for [AGE] years. He was also Resident #1's attending physician for the past four years. He last saw Resident #1 on [DATE]. At that time, Resident #1 had no major health problems. She was mainly confused, which had gradually progressed over the years. Physician (K) heard about the [DATE] incident at a meeting (date unknown). He was told by facility staff that the nurse had noticed some weakness and breathing difficulty...an ambulance was called but it didn't come...staff called back a half hour later and the ambulance was sent...the resident died . Physician (K) had not reviewed Resident #1's facility medical record after her death. However, Physician (K) had reviewed the resident's clinic record. Physician (K) stated that whenever facility nurses contact a physician regarding a resident's care, a copy of the fax or a notation of the verbal conversation is kept in the resident's clinic record. Physician (K) stated that the resident's clinic record contained no evidence that nurses from the facility ever called a physician on ,[DATE] or [DATE] regarding Resident #1's declining status. In addition, the clinic record contained no copies of any faxes sent to the physician on [DATE]. Physician (K) stated that the process for physician notification of a resident problem is for staff to fax the information to the physician, during clinic hours from 8:00 a.m. to 5:00 p.m. Faxes that are marked "urgent" are given to the physician right away When the clinic is closed, staff are to call the hospital and hospital staff then contact the physician on-call. Physician (K) stated that staff should have been quicker to call the physician about Resident #1's change in condition and quicker in obtaining emergency medical assistance for her.