Every finding on record at Samaritan Bethany Home on Eighth

Based on interview and document review, the facility failed to obtain and document an informed consent, including with explanation of risk and benefits and alternatives for psychotropic medications for 3 of 5 residents (R10, R22) reviewed for unnecessary medications.Findings include:R22R22's admission Minimum Data Set (MDS) assessment, dated 3/10/26, indicated R22 had intact cognition with no hallucinations, delusion, or rejection of care. MDS indicated R22 was on an antidepressant (psychotropic medication).R22's medical diagnosis report, dated 3/24/26, included the following relevant diagnoses: major depressive disorder, acute respiratory failure with hypoxia (a critical condition where the lungs are unable to adequately oxygenate the blood), acute on chronic congestive heart failure (a life-threatening condition when your heart cannot deliver enough oxygen to your body), and type 2 diabetes (condition which results in elevated blood sugar levels).R22's Order Summary Report, dated 3/24/26, included the following orders: -duloxetine (antidepressant medication) 60 milligram (mg) capsule: give one capsule by mouth one time a day related to major depressive disorder with a start date of 3/5/26-trazodone (antidepressant medication): give 50 mg by mouth at bedtime for insomnia related to major depressive disorder with a start date of 3/4/26. R22's medication and treatment administration record (MAR/TAR) for 3/1/26 to 3/24/26 included the following:-duloxetine 60 mg capsule: give one capsule by mouth one time a day related to major depressive disorder with a start date of 3/5/26. Documentation indicated administered as ordered. -trazodone: give 50 mg by mouth at bedtime for insomnia related to major depressive disorder with a start date of 3/4/26. Documentation indicated administered as ordered. R22's progress notes, dated 3/4/26 to 3/24/26, were reviewed and lacked documentation of education being provided regarding risks, benefits and alternatives for duloxetine or trazodone. R22's hospital Discharge summary, dated [DATE], was reviewed and lacked evidence of a conversation with provider regarding risks, benefits and alternatives for duloxetine or trazodone. Review of R22's entire electronic medication record (EMR) and paper medical record lacked evidence of either a signed consent for antidepressant medications which would include risks, benefits and alternatives or a conversation occurred regarding the risks, benefits or alternatives of antidepressant medications. During an interview on 3/24/26 at 5:18 p.m., licensed practical nurse (LPN)-C stated they do not complete consents for medications with residents or their families. LPN-C stated she might review the side effects, if asked, when administering a medication but does not do any sore of consents regarding medications. LPN-C stated she has never talked to a resident or family about risks, benefits or possible alternatives of psychotropic medication.During an interview on 3/24/26 at 5:46 p.m., registered nurse care coordinator (RN)-C stated a consent form for antipsychotic medications is completed which includes risks, benefits and alternatives. During a follow up interview at 6:12 p.m., RN-C stated if consent for psychotropics (not antipsychotics) was received, it would be verbal consent and believed it would be documented in a note. At 6:42 p.m., RN-C stated consent would be obtained from the provider/prescriber of the medication and should be in the provider's note. Documentation of consent which would include risks, benefits and alternatives was requested. During an interview on 3/24/26 at 7:17 p.m., director of nursing/clinical mentor (DON) stated the expectation would be the facility would obtain consent for antipsychotic medications due to the black box warnings. DON stated the facility does not do written consents for psychotropic medications. DON stated the provider would typically discuss any risks, benefits and alternatives with the residents or their representative. DON stated this conversation would be documented in the physician notes. Documentation of consent which included risks, benefits and alternatives was requested.A provider note, dated 3/19/2020, was provided and reviewed. The document indicated R22 has depression, anxiety and insomnia. Furthermore, she is on treatment with duloxetine (Cymbalta), Rexulti, trazodone, melatonin. She is followed by her psychology, psychiatry, provider as well. She is compliant with treatment. Her mood disorder and sleep have improved with treatment. She has no side effect of treatment. The document indicated R22 was prescribed duloxetine 90 mg with a start date of 2/20/2017 along with trazodone 50mg 1-2 tablets as needed at bedtime with no start date. The note lacked evidence of a conversation regarding risks, benefits and alternatives for duloxetine or trazodone. Furthermore, there is no indication if R22 has remained on these medications the entire time since 2017 as the doses have changed. A facility policy titled Psychotropic Medications, reviewed 10/25, indicated if psychotropic medications are initiated or increased during their stay, consent including risk, benefits, alternatives and any associated black box warnings discussed.

Based on observation, interview, and record review, the facility failed to ensure proper use of personal protective equipment (PPE) for 1 of 1 resident (R11) reviewed for enhanced barrier precautions (EBP).Findings include: R11's quarterly Minimum Data Set (MDS) dated [DATE], identified R11 was cognitively intact, was hard of hearing, had clear speech, had the ability to understand, and had no refusals of care. R11's diagnosis included heart failure, high blood pressure, anxiety and malnutrition (requiring feeding through an external tube medically inserted through the abdominal wall). R11 had a percutaneous endoscopic gastronomy (PEG tube) placed on 8/14/25 due to complete intestinal blockage. A PEG tube is considered an indwelling medical device, according to the Center for Disease Control (CDC). Due to this, R11 required additional personal protective equipment (PPE) requiring Enhanced Barrier Precaution (EBP) isolation. EBP are designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes; they require gown and glove use during high-contact resident care activities. R11's undated, current care plan lacked information regarding infection prevention and need for EBP due to PEG tube. R11's undated, current physician's orders lacked an order to use EBP. During an observation on 3/23/26 at 8:36 a.m., licensed practical nurse (LPN)-A entered R11's room to perform medication administration and initiate tube feeding via PEG tube. LPN-A failed to don an isolation gown and put on the proper PPE before providing personal cares to R11. LPN-A completed medication administration and initiated tube feeding and exited R11's room without performing hand hygiene. During an observation on 3/23/26 at 12:10 p.m., registered nurse (RN)-A entered R11's room to administer medication and complete the tube feed and flush the PEG tube. RN-A failed to don an isolation gown and put on the proper PPE before providing personal cares to R11. RN-A was unable to disconnect the PEG tube from the tube feed line, so RN-B entered the room to aid with disconnecting the line. RN-B failed to don an isolation gown and put on the proper PPE before providing personal cares to R11. During an observation on 3/23/26 at 1:24 p.m., nursing assistant (NA)-A and nursing assistant (NA)-B entered R11's room and failed to don an isolation gown prior to entering R11's room to assist R11 with changing her soiled undergarments. NA-A and NA-B failed to put on the proper PPE before providing personal cares to R11. During an interview on 3/25/26 at 2:29 p.m., licensed practical nurse (LPN)-B stated R11 required EBP due to her PEG tube. LPN-B stated anyone administering medication, starting or stopping tube feeding, or providing personal cares such as changing undergarments should have worn EBP. LPN-B stated appropriate use of EBP is important because it prevents the spread of infection from one resident to another. During an observation and interview on 3/25/26 at 2:40 p.m., registered nurse (RN)-A stated staff know who required EBP by looking at the list in the main office, and by opening the cabinet door outside of each resident room. If a resident was in EBP, there would be an isolation sign inside the cabinet door. RN-A confirmed R11 had an EBP sign on the inside of her cabinet door and R11 required EBP precautions due to her PEG tube. Additionally, RN-A confirmed she should have been wearing EBP when she stopped the tube feeding in R11's room. RN-A confirmed it is important to wear EBP to keep the residents safe and to stop the spread of infection from residents to residents. A facility policy titled Enhanced Barrier Precautions dated 1/2026, residents with any of the following require enhanced barrier precautions during high-contact cares: indwelling medication devices; urinary catheter, feeding tube, wound drains, etc. High contact care consists of providing any care for indwelling medical devices and changing incontinent products. When high-contact care is required, staff must: complete hand hygiene prior to entering room and put on gown and gloves prior to entering room. Precautions are implemented and kept in place for the duration of the resident's stay or until their wound is healed or the indwelling medical device is discontinued (no longer in use).

Based on observation, interview, and document review, the facility failed to provide a clean room and bathroom for 1 of 1 resident (R11) reviewed for a safe, clean, comfortable, home-like environment.Findings include: R11's quarterly Minimum Data Set (MDS), identified R11 was cognitively intact, was hard of hearing, had clear speech, had the ability to understand, and had no refusals of care. R11's diagnosis included heart failure, high blood pressure, anxiety and malnutrition (requiring feeding through an external tube medically inserted through the abdominal wall) During an observation and interview on 3/23/26 at 8:36 a.m., R11's room identified the intravenous (IV) pole, used when giving tube feeding, had several drops of tube feeding on all four legs extending from the base. The floor around the IV pole had carpet stained with tube feeding residue. The bathroom sink counter had dried brown drops that appeared to be residue from crushed medication. The bathroom sink basin had dried, tan-colored residue in it. The floor between the television and foot of bed had 3 pieces of Kleenex laying there. R11 stated she would prefer the messes to get cleaned up. Since she can't do it on her own, she must rely on facility staff, and it can take them a while to get it cleaned. If she were at home, she would have had it cleaned already. Further observations on 3/24/26 at 11:44 a.m. and 6:19 p.m., and again on 3/25/26 at 8: 33 a.m., R11's room identified the environment observations from the previous day were still present: dirty IV pole, dirty carpet, medication residue on sink in bathroom, dirty bathroom sink basin, Kleenex in front of TV remained. During an interview on 3/25/26 at 9:04 a.m., housekeeper (H)-A, stated resident rooms are cleaned daily. The cleaning included minor dusting, wiping tables, windows and dressers, mopping the bathroom, vacuuming the floor, and wiping down the bathroom vanity and mirror. H-A stated again this cleaning was done every day. H-A stated it is important to keep the residents' rooms clean to prevent infection and keep the rooms looking nice for the residents. During an interview on 3/25/26 at 8:57 a.m., licensed practical nurse (LPN)-B stated resident rooms are cleaned daily by the housekeeping staff. The housekeepers wipe down hard surfaces, vacuum the floors, wipe down sink in bathroom, mop the bathroom floor, and clean windows and mirrors. LPN-B was not sure who cleans the medical equipment like the IV pole, bed, and oxygen machines. LPN-B stated it is important to keep the residents' room clean to prevent infection and so the residents live in a clean room. During an interview on 3/25/26 at 2:20 p.m., registered nurse (RN)-A confirmed the housekeeping team cleans every room every day. When each room is cleaned, the floors were to be cleaned or vacuumed. Mirrors and hard surfaces bathroom sinks, and showers were also to be cleaned. RN-A confirmed any spilled tube feeding liquid should be cleaned by the nurse who spilled it or by the housekeeping team. RN-A confirmed there was tube feeding residue on the floor under the IV pole and on the IV pole. RN-A stated it is important for resident rooms to be cleaned to prevent infection, and so residents had a clean environment to live in. A housekeeping policy was requested but not received.

Based on observation, interview and document review the facility failed to ensure appropriate medication side effect monitoring for psychotropic medication use was completed for 1 of 5 residents (R22) reviewed for unnecessary medication use. Findings include: R22's admission Minimum Data Set (MDS) assessment, dated 3/10/26, indicated R22 had intact cognition with no hallucinations, delusion, or rejection of care. MDS indicated R22 was on an antidepressant (psychotropic medication). R22's medical diagnosis report, dated 3/24/26, included the following relevant diagnoses: major depressive disorder, acute respiratory failure with hypoxia (a critical condition where the lungs are unable to adequately oxygenate the blood), acute on chronic congestive heart failure (a life-threatening condition when your heart cannot deliver enough oxygen to your body), and type 2 diabetes (condition which results in elevated blood sugar levels). R22's baseline care plan, dated 3/4/26, indicated R22 used antidepressant medications related to depression with the goal to be free from adverse reactions related to antidepressant therapy through the review date. The only intervention listed was administer medication as ordered. The baseline care plan lacked any interventions to monitor or document any side effects for antidepressant. Furthermore, lacked identification of what side effects to monitor for. R22's care plan, printed 3/24/26, indicated R22 used antidepressant medications related to depression with the goal to be free from adverse reactions related to antidepressant therapy through the review date. The only intervention listed was administer medication as ordered. The care plan lacked any interventions to monitor or document any side effects for antidepressant. Furthermore, lacked identification of what side effects to monitor for. R22's Order Summary Report, dated 3/24/26, included the following orders: -duloxetine (antidepressant medication) 60 milligram (mg) capsule: give one capsule by mouth one time a day related to major depressive disorder with a start date of 3/5/26-trazodone (antidepressant medication): give 50 mg by mouth at bedtime for insomnia related to major depressive disorder with a start date of 3/4/26.R22's order summary report lacked documentation or any direction to monitor for side effects. R22's medication and treatment administration record (MAR/TAR) for 3/1/26 to 3/24/26 included the following:-duloxetine 60 mg capsule: give one capsule by mouth one time a day related to major depressive disorder with a start date of 3/5/26. Documentation indicated administered as ordered. -trazodone: give 50 mg by mouth at bedtime for insomnia related to major depressive disorder with a start date of 3/4/26. Documentation indicated administered as ordered. R22's MAR/TAR lacked evidence of any side effect monitoring in place. Furthermore, MAR/TAR lacked evidence of what side effects to monitor for. R22's progress notes, dated 3/4/26 to 3/24/26, were reviewed and lacked documentation of side effects being monitored for duloxetine or trazodone.Review of R22's entire electronic medication record (EMR) and paper medical record lacked evidence of side effect monitoring or identification of what side effects to be monitored with use of two antidepressants. During an interview on 3/24/26 at 5:18 p.m., licensed practical nurse (LPN)-C stated they have worked in the facility for over 2 years. LPN-C stated they were unsure if they do side effect monitoring for psychotropic medications. LPN-C stated if it was done, it would probably be documented on the MAR or in a progress note. LPN-C stated they were not sure if side effects to monitor would be listed on the care plans. During an interview on 3/24/26 at 5:49 p.m., registered nurse care coordinator (RN)-C stated, we are always monitoring for side effects. RN-C stated if any new symptoms or side effects develop, the provider would be notified. Documentation for any side effect monitoring or what side effects to monitor for was requested. At 6:45 p.m., RN-C stated it would be expected the LPN's are monitoring for side effects for psychotropic medications. RN-C stated LPN's have access to the care plan and the side effects for psychotropics are initiated on the baseline care plan so would be on the care plan. During a follow up interview on 3/25/26 at 3/20/26, RN-C stated it is a standard of practice to monitor side effects for psychotropics and when residents admit to the facility a baseline care plan is created while populate tasks for staff to monitor. RN-C reviewed the baseline care plan for R22, dated 3/4/26, and stated it should contain the required monitoring for medications. After review, RN-C verified the baseline care or comprehensive care plan did not contain the side effect monitoring for antidepressant medications and was not being completed. A facility policy titled Psychotropic Medications, reviewed 10/25, indicated if side effects or adverse reactions occur, notification will occur to the resident's provider.

Based on observation, interview, and document review, the facility failed to ensure oxygen tubing was changed according to standards of care to prevent respiratory infections for 1 of 1 residents (R22) who was admitted for acute respiratory failure with hypoxia (a critical condition where the lungs are unable to adequately oxygenate the blood) who required oxygen.Findings include:R22's admission Minimum Data Set (MDS) assessment, dated 3/10/26, indicated R22 had intact cognition with no hallucinations, delusion, or rejection of care with admission date of 3/4/26. Section O indicated R22 required continuous oxygen therapy.R22's medical diagnosis report indicated on 3/4/26, R22's primary diagnosis for admission to the facility was acute respiratory failure with hypoxia. Additional relevant diagnoses included: acute on chronic congestive heart failure (a life-threatening condition when your heart cannot deliver enough oxygen to your body), acute eosinophilic pneumonia (lung disease that develops suddenly that progresses rapidly to sever respiratory failure), and atrial fibrillation (heart beats abnormally).During an interview on 3/23/26 at 2:05 p.m., R22 was observed wearing oxygen. The oxygen tubing was not dated. R22 was not sure if staff changed the oxygen tubing.R22's care plan, printed 3/24/26, indicated R22 reviewed oxygen therapy related to acute respiratory failure with hypoxia. The care plan had one intervention: provide oxygen as ordered 1-2 liters (L) nasal canula (NC) l to maintain oxygen levels (SP02) at 90% or above.The care plan lacked any indication on how often the oxygen tubing should be changed or who was responsible for changing the oxygen tubing.R22's Order Summary Report, dated 3/24/26, included the following order:- 1-2L NC to maintain SPO2 above >/= 92%. Wean oxygen as able. every shift related to acute respiratory failure with hypoxia with a start date of 3/13/26.The Order Summary Report lacked evidence of an order to change oxygen tubing. R22's medication and treatment administration record (MAR/TAR) for 3/1/26 to 3/24/26 included the following orders:- 1-2L NC to maintain SPO2 above >/= 92%. Wean oxygen as able. every shift related to acute respiratory failure with hypoxia with a start date of 3/13/26. The document included oxygen saturations which ranged from 91-98 which were monitored every shift. The document did not include how much oxygen was being delivered via nasal canula.- 1-2L NC to maintain SPO2 above >/= 90%. Wean oxygen as able. every shift related to acute respiratory failure with hypoxia with a start date of 3/5/26 and discontinue date of 3/13/26. The document included oxygen saturations which ranged from 93-98 which were monitored every shift. The document did not include how much oxygen was being delivered via nasal canula. R22's task log was reviewed and did not include any changing of oxygen tubing. R22's progress notes dated 3/4/26 to 3/24/26 were reviewed and included the following:-3/24/26: Discussed with resident that we assessed her oxygen need at rest, sleep and with activity and she continues to require oxygen.-3/23/26: On 1L oxygen. Sat 91% this afternoon.-3/23/26: Oxygen saturations assessed to see if resident is able to be weaned from 02. Oxygen levels decreased with o2 off. o2 with activity dropped to 88-89% RA, 02 dropped 89-91% RA at rest, and 02 dropped at bedtime with o2 off 86-88% RA. Resident continues to require oxygen at this time.-3/18/26: On 1L oxygen. Sat 96% this afternoon.-3/18/26: On 1L oxygen with a 96% sat.-3/15/26: On 1L oxygen with a 95% sat.-3/14/26: On 1L oxygen with a 96% sat.-3/13/26: She is to have her supplemental 02 weaned to as able for goal of Spo2 of >/=92%-3/12/26: On 1L oxygen with a 98% sat.-3/11/26: On 1L oxygen with a 97% sat.-3/10/26: On 1L oxygen. Sat 97% this afternoon. -3/9/26: On 1L oxygen with a 96% sat.-3/6/26: Goal to maintain o2 sats >90% (greater) and wean supplemental oxygen as able. Continues on prednisone taper r/t pneumonia. -3/5/26: on 1L oxygen with 95% sat.-3/4/26: On 1L oxygen. Sat 97% this afternoon. The progress notes lacked any indication of oxygen tubing being changed during R22's admission at the facility. During an interview on 3/24/26 at 2:07 p.m., trained medication aid (TMA)-A stated they work as a TMA and nursing assistant at the facility. TMA-A stated they have worked at the facility for over 2 years. TMA-A stated the oxygen tubing should be changed weekly. TMA-A stated they are unsure of who changes the oxygen tubing as it previous was night shift, but it might have moved to day shift. TMA-A stated the tubing previously was dated but doesn't believe that was the practice any longer. TMA-A stated they have not changed any oxygen tubing for a long time. TMA-A stated the oxygen tubing was kept in the medication room which only TMA's and nurses have the key for so only nurses and TMA's would be responsible for changing the oxygen tubing. During an interview on 3/24/26 at 2:21 p.m., R22 stated she was unsure when the oxygen tubing was last changed. The oxygen tubing appeared clean. During an interview on 3/24/26 at 4:54 p.m., nursing assistant (NA)-C stated they have worked in the facility for over 2 years. NA-C stated they believe oxygen tubing should be changed weekly. NA-C stated oxygen tubing used to be changed every Saturday but that was no longer the practice. NA-C stated they give a resident new oxygen tubing when they notice the tubing was dirty. NA-C stated they do not document when the oxygen tubing was changed or date the tubing. NA-C stated they are unsure of when R22's oxygen tubing was changed.During an interview on 3/24/26 at 5:16 p.m., licensed practical nurse (LPN)-C stated they have worked in the facility for over 2 years. LPN-C stated oxygen tubing should be changed weekly and as needed. LPN-C stated they date oxygen tubing when they provide a resident with new tubing. LPN-C stated they do this so then everyone would know when the resident got new tubing. LPN-C stated nurses or TMA's are responsible for changing oxygen tubing. LPN-C stated they do not document when a resident's oxygen tubing was changed. LPN-C verified R22's oxygen tubing on portable oxygen tank and on oxygen tubing on oxygen concentrator was not labeled. LPN-C stated they are unsure of when or if R22's oxygen tubing had been changed and should be changed. During an interview on 3/24/26 at 5:44 p.m., registered nurse care coordinator (RN)-C stated the expectation would be oxygen tubing to be changed weekly and as needed so that it would not be contaminated. RN-C stated the expectation would be to follow that standard practice. During a follow up interview at 6:41 p.m., RN-C stated the expectation would be oxygen tubing would be changed with the shower schedules. RN-C stated when a resident received their weekly shower or bath, their oxygen tubing should be changed as we integrated that into the bath schedules like our nail care. RN-C stated they do not document the changing of the oxygen tubing. During an interview on 3/24/26 at 7:03 p.m., NA-D stated they worked at the facility for 1 1/2 years. NA-D stated they have never changed any oxygen tubing. NA-D verified they are responsible for providing resident showers and baths. NA-D stated nursing assistants do not change oxygen tubing here. A facility policy, dated 2/26/26, indicated oxygen tubing is replaced weekly on the resident's bath/skin day.

Based on observation, interview, and record review, the facility failed to ensure safe independent medication administration for 1 of 1 residents (R59) reviewed for self-administration. Findings include: R59's quarterly Minimum Data Set, dated [DATE] indicated R59 was cognitively intact with no delirium or behaviors, no upper/lower body impairment, and was independent with activities of daily living and transfers. R59's diagnoses list included back pain, high blood pressure, depression, high cholesterol, osteoporosis, indigestion, and vitamin d deficiency R59's careplan indicated R59 was independent with activities of daily living. R59's medication administration record indicated R59 receives the following scheduled medications: -Morning: atorvastatin 40mg (high cholesterol), vitamin d 50 mcg (supplement), losartan 37.5 mg (high blood pressure), omeprazole 20 mg (indigestion), sertraline 100 mg (depression), senna-s 1 tablet (stool softener), acetaminophen 1000 mg (pain)-Noon: calcium citrate 3 tablets (calcium supplement) , acetaminophen 1000 mg (pain) R59's medication administration record did not indicate it was safe to leave medications at bedside. During observation and interview on 3/23/26 at 7:26 a.m., R59 was sitting in the recliner with a plastic medication cup containing several oral medications located on the table next to her. R59 stated she takes them after she eats breakfast. During observation and interview on 3/23/26 at 12:48 p.m., R59 was sitting in the recliner with lights off stating she was getting ready to take a nap. A clear plastic medication cup containing 3 large white pills was located on the table next to her. R59 stated the medications were her noon meds and she takes them slowly. During observation on 3/25/26 at 8:32 a.m., R59 was sitting in the recliner with a clear plastic medication cup of medications located on the table next to her. During interview on 3/25/26 at 9:01 a.m., licensed practical nurse (LPN)-D stated residents wishing to self-administer medications require a self-administration assessment. If a resident is deemed appropriate, a provider signs the approval, and it is placed on the medication administration record. LPN-D confirmed R59 did not have a self-administration assessment on file. During an interview on 3/25/26 at 9:39 a.m., registered nurse (RN)-D stated self-administration assessments are determined by a resident's diagnoses and cognition. Residents are evaluated for their ability to stated what a medication is, what it is for, identify the medication, and administer it safely. After the assessment, the provider signs order authorizing self-administration of medications and ability to keep at bedside. RN-D confirmed R59 did not have a self administration order on the medication administration record and should have. A policy titled Self-Administration of Medication revised 10/25 indicated, in part, each resident who expresses the wish to self-administer medication is permitted to do so if it has been determined by the licensed nurse and resident's provider that the practice would be safe for the resident. The procedure indicated: the resident will be evaluated for competency and physical ability to self-administer, a Self-Administration of Medication Evaluation will be completed by a licensed nurse to determine if the resident can self-administer medications/treatments safely. The decision and the procedure will be explained to the resident and legal representative if deemed capable of self-administer. A physician's order will be obtained and recorded in the medical record. the licensed nurse or TMA (trained medication aide) administering medications/treatments that a resident takes after set-up, will check with the resident after end of the time the medication/treatment is to be given/completed to assure appropriate medication administration.

Based on observation, interview, and document review, the facility failed to ensure 1 of 1 direct-care nursing staff (Licensed Practical Nurse (LPN)-A) was appropriately trained and competent in the assessment and care of tube feeding and lidocaine patch application for 1 of 1 (R11) resident.Findings include: R11 was admitted to the facility on [DATE], R11 had a gastric tube surgically implanted 8/14/25 to provide enteral feedings due to malnutrition R11's quarterly Minimum Data Set (MDS), identified R11 was cognitively intact, was hard of hearing, had clear speech, had the ability to understand, and had no refusals of care. R11's diagnosis included heart failure, high blood pressure, anxiety, and malnutrition requiring a feeding tube medically inserted through R11'S abdominal wall. R11's current, undated physician's orders included:Enteral tube Feed of Nutren 1.5 at 100 (milliliters/hour (ml/hr) for a total of 250 ml, twice per day.60 ml water flush before and after enteral feedings.Medications given via G-tube:flush 30ml of water prior to medication administration,finely crush and mix together Tylenol, amlodipine, buspirone, cetirizine, hydrochlorothiazide, melatonin, oxycodone, senna, and sertraline with at least 30ml of water.Flush with 30ml of water following medication administration every shift.Aspiration precautions:Sit the resident (R11) upright with all oral intake and when completing oral cares. Ensure R11 ate small bites, took small sips, and would eat slowly. Avoid laying down for 30 minutes after meals. Provide good oral care 3-5 times each day. Watch R11 closely for signs of aspiration. Ensure R11's mouth was Empty before adding more food/liquid.Alternate solid food with small amounts of liquid. Do not allow use of straws. Require supervision/assistance every shift for aspiration precautions.Resident to sit up during tube feeding or keep the head of the bed elevated to 45 degrees, and remain upright 1 hours after feedings, three times per day. R11's undated, current care plan indicated R11 had a self-care performance deficit related to her gastric tube and required assistance from facility staff to manage her gastric tube. Additionally, R11 had a nutritional problem, requiring tube feedings. Staff were to ensure no pureed food was given, provide set up assistance, and ensure a regular diet with soft, bite-sized textures was provided. R11 was also to have thin liquids, small portions, and staff were to allow R11 to have regular snacks if she requested. R11 was able to eat slowly and self-monitor eating. Staff were to ensure she sat as upright as possible, provide tube feedings, and provide supplements and snacks as ordered. During an observation and interview on 3/23/26 at 8:36 a.m., licensed practical nurse (LPN)-A was administering medication to R11. LPN-A administered 30cc of water, crushed THE medications, then administered them through her gastric tube, and flushed the tube with 30cc of water. LPN-A then applied a lidocaine patch to R11's left shoulder, placing the lidocaine patch so it slightly covered an existing lidocaine patch on R11 without removing the old patch. LPN-A stated she had not had any recent education about administering tube feeding via a gastric tube. LPN-A stated it had been a long time since she had cared for a resident requiring a tube feeding via a gastric tube. LPN-A stated she didn't think it would be an issue to place the lidocaine patches so they overlap; she just needed to place them where the resident had pain. During an observation and interview on 3/23/26 at 12:10 p.m., registered nurse (RN)-A entered R11's room to complete the tube feeding. RN-A stopped the tube feeding portion and tried programming the pump to administer the 60 ml water flush. RN-A stated she was not familiar with this pump and could not get the pump programmed correctly. RN-A turned the pump off, elevated the head of the bed higher to approximately 45 degrees, and gave the 60 ml water flush via a syringe. RN-A stated staff had received education about tube feedings and gastric tubes before the resident arrived. During an interview on 3/25/26 at 2:29 p.m., LPN-B stated any nurse working with R11 should have received tube feeding and gastric tube education prior to caring for her. LPN-B stated she completed this education the week prior to the resident returning to the facility. During an interview and document review on 3/25/26 at 2:40 p.m., RN-A stated staff who worked with R11 were provided education prior to her arrival. RN-A stated staff were provided with information about how to specifically care for R11 and the care she required for her tube feedings and gastric tube. Any staff who worked with R11 should have had pertinent tube feeding and gastric tube education. RN-A confirmed LPN-A had not had the required tube feeding and gastric tube education. RN-A stated it is important for staff to have education about tube feedings and gastric tube before the resident arrived so that staff feel comfortable using the gastric tube, ensure resident safety, and prevent complications RN-A confirmed LPN-A should have had the education prior to working with R11 and confirmed the resident's head of bed should have been placed at 45 degrees for the duration of the tube feeding and up to an hour after to prevent aspiration. Additionally, RN-A confirmed LPN-A had administered the lidocaine patch incorrectly when the 2nd patch was placed over top the first patch. Staff are educated about medication administration upon hire and annually. That was important as medications are administered safely and accurately. A facility medication administration titled Enteral Medicine Administration dated 02/26 was received, the policy lacked information to assure the head of the bed was elevated for medication administration and tube feeding administration.

Based on observation, interview, and document review, the facility failed to ensure the nursing daily staffing report was posted in a readily available, visible location within the care center. This had the potential to affect all 95 residents, visitors, and staff who wished to view the information. Findings include: During an observation on 3/24/26 at 4:42 p.m., the nursing daily staffing report was posted on the wall behind the receptionist desk. Office specialist (OS)-A stated the nursing daily staffing report was posted in the morning. OS-A stated if the nursing daily staffing report needed to be changed throughout the day they would cross off the one entered and write in the new totals on the nursing daily staffing report. OS-A stated from where she was sitting, at the reception desk by the computer, the nursing daily staffing report was hard to visualize the information. During an interview on 3/25/26 at 10:17 a.m., the nursing daily staffing report was posted on the wall behind the receptionist desk. OS-B stated the nursing daily staffing report was posted every morning. OS-B stated she would take the nursing daily staffing report down and change the numbers with any changes that needed to be made throughout the day. OS-B stated the nursing daily staffing report had been posted on the wall behind the reception desk since she had started working four years earlier. OS-B stated she could not read the nursing daily staffing report from the desk. OS-B stated people in wheelchairs could not see the nursing daily staffing report and other people would have to lean over the counter to see the nursing daily staffing report. and might not be able to read it. During an interview on 3/25/26 at 10:25 a.m., Administrator stated she had been at the facility for 14 years and the nursing daily staffing report had always been posted behind the reception desk. The administrator stated no one had ever said anything about it. The administrator stated the nursing daily staffing report does not mean a thing to the residents because it is in hours and it is only regulatory thing. The administrator stated she could not read the nursing daily staffing report and had to lean into the reception desk to see the nursing daily staffing report behind the desk. The administrator stated the font could be bigger for people to read. A facility policy was requested and none was provided.

Based on observation, interview and document review, the facility failed to accommodate resident needs by ensuring the call light was accessible for 2 of 2 residents (R60, R187) reviewed for call lights. Findings include: R60's annual Minimum Data Set (MDS) dated [DATE] identified R60 with cognitive impairment, diagnoses included Parkinson's, heart failure, osteoarthritis, and non-Alzheimer's dementia. R60's care plan with start date of 12/6/23 identified, Be sure my call light is within reach and encourage me to use it for assistance as needed. I need response to all requests for assistance. R60's kardex (nursing assistant care sheet) printed 12/12/24 at 11:13 a.m., instructed nursing assistants to, Please remind me to utilize my call light, as I am getting used to my new environment. During observation and interview on 12/9/24 at 3:00 p.m., R60 sitting in wheelchair in his room watching the television set. Call light cord was placed on nightstand behind him out of reach. R60 stated the call light, [was] not in reach. I don't know where it is. I don't see it. R60 stated he was able to press the call light for assistance but did not know how to ask for help if he did not have it in reach. R187 R187's quarterly MDS dated [DATE] identified R187 with limitations in range of motion for both upper and lower extremities, required extensive assist of two or more people for bed mobility and was totally dependent on two or more people to transfer out of bed into wheelchair. Also, R187 with diagnoses of arthritis, heart failure, lung disease, and vision impairment. In addition, R187 on continuous oxygen. R187's care plan with start day of 11/10/21 identified, BED MOBILITY: Assist of 2 and I am able to use call light appropriately. R187's kardex printed 12/10/24 identified, BED MOBILITY: Assist of 2 and I am able to use call light appropriately. During observation and interview with R187 on 12/10/24 at 8:29 a.m., R187 lying in bed with soft touch call light resting on top of nightstand three feet from the head of her bed. R187 stated, I should have it on my body so I can use it if I want to. I can't reach it to ask for help if I need it. During interview with nursing assistant (NA)-A on 12/10/24 at 12:26 p.m., NA-A stated she worked full time at facility for five years and was familiar with the residents. NA-A stated call lights should always be in reach of patients. During interview with NA-B on 12/10/24 at 12:42 p.m., NA-B stated she had worked at facility many years and was familiar with the residents. NA-B stated, call lights, should always be in reach of the patient. If they can't reach it, then they cannot use it and they may try to get up without help and fall. So, they gotta be in reach. During interview with R187 significant other on 12/11/24 at 2:04 p.m., significant other stated, [R187] would not be able to reach over and grab the call light thing without someone helping her if she is in bed. [R187] uses it when she needs help. During interview with director of nursing (DON) on 12/12/24 at 10:14 a.m., DON stated expectation call lights should be in reach of all residents. In addition, [R187] could not reach the call light and ask for help if the call light is not in reach. Same thing goes for [R60]. Facility policy titled Call Light Response with review date of 9/24 identify Resident's call light must be within reach for the resident to use.

Based on observation, interview, and document review the facility failed to follow the care plan for transfers to prevent or mitigate risk for falls and/or falls with major injury for 2 of 4 residents (R1 and R4) reviewed for falls. This resulted in actual harm for R1 who experienced a witnessed ground level fall resulting in a subdural, subarachnoid, and intraventricular hemorrhages, two left rib fractures, and a left clavicle fracture, requiring intensive care unit (ICU) hospitalization for eight days. Findings include: Subdural hemorrhage is a serious medical condition where blood collects beneath the dura mater, the outermost membrane surrounding the brain. This accumulation of blood puts pressure on the brain, potentially causing life-threatening consequences. Subarachnoid hemorrhage is bleeding in the space between the brain and the tissue covering the brain. Intraventricular hemorrhage is bleeding inside or around the ventricles-spaces in the brain that contain the cerebral spinal fluid. Bleeding in the brain can put pressure on the nerve cells and damage them. If the nerve cells are severely damaged, it can result in irreversible brain injury. R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had severe cognitive impairment and had diagnoses of atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), thrombocytopenia (low platelets) and hypertension (high blood pressure). R1 had impairment in bilateral (both) upper extremities, required extensive assist of one staff with bed mobility, transfers, eating and toilet use, used walker and wheelchair for mobility. Did not identify any recent falls. R1's Fall risk assessment dated [DATE], identified a score of 28 indicating R1 was at moderate risk for falls due to diagnoses of diabetes, cardiovascular disease, and bone weakness or osteoporosis. R1 had chronic bowel and urinary incontinence, unsteady gait, unable to ambulate independently, vision and hearing impairment, cannot safely transfer independently, and was on hypertensive and diuretic medications. R1's care plan dated 2/22/24, identified a focus of an activities of daily living (ADL) self-care performance deficit related to limited mobility, incontinence, cognitive impairment, glaucoma, and diabetes. Intervention for transfer was assist of one staff with front wheeled walker (FWW), gait belt for all transfers with contact guard assist (CGA) at all times. An additional focus identified risk for falls related to limited mobility, incontinence, poor balance, hypertension, glaucoma, osteoporosis, and diabetes. Interventions included: anticipate and meet my needs, typically does not attempt to self-transfer, and use gait belt for all transfers/ambulation with CGA at all times. R1's physician visit dated 2/23/24, identified R1 had functional impairments limited by mobility, increased risk of falls, required full assist with all functional cares, hygiene and reading. Family shares R1 had some mobility, but unable to self-advocate needs, will not hydrate independently, or use the bathroom without prompting and transfers are harder due to higher risk of falls. No behaviors, mood changes or concerns with resistance to cares. R1's occupational therapy (OT) note dated 2/28/24, included facilitated bed mobility with moderate to maximum assist. R1 transfers from edge of bed to standing with walker with minimal assist, then trial of stand pivot due to timing and noting fatigue from R1. Stand pivot with gait belt, minimal assist, and pivot to toilet with minimal assist to rise. Moderate assist to ensure turning completely, minimal assist from toilet to the wheelchair. R1 benefited from multisensorial verbal cueing. Noted potential variances due to timing of the session will further assess for safety in upcoming sessions. R1's physical therapy (PT) note dated 3/4/24, indicated R1 required moderate assist with FWW with sit to stand (STS) from recliner, required 100 % verbal/tactile/visual cues for forward trunk flexion, hand placement, foot placement. Stand-sit CGA with cues to reach back armrest. Recliner to wheelchair with FWW, moderate assist to stand, CGA while pivoting with FWW, wheelchair to edge of bed (EOB) with FWW minimal assist to stand, CGA while pivoting with FWW. R1 responded best with multiple forms of cueing. R1 required cues for walker management and occasional minimal assist for navigating walker, cues for increasing step height and step length. R1's gait was discontinuous and varied from step through partial step, primarily would shuffle. R1's progress note dated 3/4/24 at 6:00 p.m., included nurse was notified by a nursing assistant (NA) that R1 had fallen. R1 was observed laying at the foot of her bed on the left side with glasses in front of R1. R1's left arm was parallel to left side and right arm was behind her. Nurse and two aides used the EZ-lift (full body mechanical lift) to pick R1 up off the floor and place R1 in bed, gait belt was around R1's waist. CNA stated that R1 was pivoting when R1 lost her balance, attempted to catch R1 but was not strong enough or fast enough to catch R1 from falling. 1/4 inch superficial abrasion was noted across the bridge of R1's nose, circle of blood blisters on left shoulder and hematoma noted around R1's left elbow, and was transferring with assistance. R1 was alert to self, family member (FM)-A notified of the fall at 7:15 p.m. R1's progress note dated 3/4/24 at 8:22 p.m., was given 500 milligrams (mg) of acetaminophen (pain reliever), due to R1 stated, I hurt. R1's progress note dated 3/5/24 at 7:30 a.m., identified R1 had bruising on both arms and left shoulder and a small abrasion on the bridge of nose. R1 had some facial grimacing with left arm ROM but was unable to say if the discomfort was in the shoulder or arm. R1 was transferred out of bed with two staff assist and the EZ-lift. Left for appointment at 8:15 a.m., FM-A went with. R1's progress note dated 3/5/24 at 7:51 p.m., a fall follow up: R1 had a witnessed fall in room when transferring via pivot to shower chair with NA using gait belt. Shower chair brakes were on. R1 lost her balance during the transfer, clothing and footwear were appropriate. Care plan was reviewed/followed at the time of the fall. Daughter notified of fall on 3/4/24 at 7:15 p.m. injuries noted to the bridge of nose (abrasion) and left shoulder/left arm bruising. R1 seen in emergency department (ED) on 3/5/24 related to fall. R1's hospitalization in the intensive care unit (ICU) dated 3/5/24 to 3/12/24 identified R1 sustained a ground level fall at the nursing home resulting in a traumatic brain injury (TBI) to include treatment for a right temporal lobe subdural hemorrhage subarachnoid hemorrhage and intraventricular hemorrhage as well as a second and third left rib fracture and a left clavicle (the bone connecting the breastbone and shoulder) fracture. During a phone interview on 3/13/24 at 4:15 p.m., family member (FM)-A indicated she got a call from a nurse on evening of 3/4/24, R1 fell in the bathroom trying to get to the shower and fell on her left side. Every time R1 has fallen in the past she has broken a bone. FM-A got to the facility on [DATE] around 7:30 a.m., staff had R1 up in the chair. FM-A noticed a big bruise on the right arm, a large bruise on the left upper arm, and an abrasion on R1's nose. R1 had her head down and seemed really sleepy, we took the shuttle to the appointment. FM-A indicated when at the appointment R1 had mental status changes, she was unable to remember her name or birth date or who FM-A was. R1 was then sent to the emergency room and admitted to the ICU for eight days where she was diagnosed with bilateral subdural hematoma and a subarachnoid bleed, two left fractured ribs and a left fractured clavicle. R1 did have a seizure a few days into the stay, so now R1 will be on antiseizure meds for a couple months. FM-A stated the last couple days R1 had been alert and talking. FM-A explained R1 transferred by putting both her hands on the walker but the gait belt needed to be on, and you can't let go or R1 will fall otherwise she transferred just fine. During a phone interview on 3/13/24 at 12:40 p.m., nursing assistant (NA)-B indicated working the evening of 3/4/24. NA-B stated it was R1's shower day. NA-B informed NA-A through how to give R1 a shower and went through the care plan. NA-B informed NA-A to make sure to put the brakes on the shower chair, use the gait belt, take R1 to the bathroom, have R1 grab onto the bar on the wall to stand up to take R1's pants off. R1's fall happened right after supper approximately 5:45 p.m. Licensed practical nurse (LPN)-B found NA-B and asked her to grab the lift because R1 was on the floor. NA-B and LPN-B went to R1's room got R1 back into bed, R1 did not say a thing, no facial grimacing, nothing. R1 did have some rug burn on the left shoulder, some little bruising clusters down the left arm, then got R1 undressed and in a gown. NA-B stated the rest of her shift she checked on R1 frequently and gave R1 drinks of water, R1 never had any complaints of pain. During an interview on 3/13/24 at 4:03 p.m. NA-A was in R1's room and demonstrated how she had been transferring R1 when she fell on [DATE]; NC-A was also present. NA-A explained, she was told to give R1 a bath by NA-B and NA-B briefly walked her through how to do it; NA-B left to go answer some call lights on the other side of the facility. NA-A indicated R1 was seated in her wheelchair in front of the recliner next to the bed by the window side of the bed. NA-A put the shower chair directly across from R1's wheelchair, she did not lock the brakes on the shower chair because she did not know the shower chair had brakes. Then NA-A put the gait belt on R1 and asked her to stand up. NA-A hung on to the gait belt and kind of just pulled her [R1] up. R1 started walking to the right toward the foot of her bed, lost her balance, and fell to the floor on her left side. NA-A stated R1 was too heavy for her. NA-A stated she did not use a walker during the transfer because she did not realize the care plan directed this. R1 did not make a sound during the fall or after the fall. NA-A checked to make sure R1 was breathing and then left to go get the nurse. NA-A was not sure if R1 had hit her head, it happened so fast. R1 did have a cut on her left arm and NA-A never heard R1 say anything while she was in the room. NA-A stated LPN-B and NA-B got R1 off the floor with the mechanical lift and she was instructed to go help on the other unit while they finished with R1. During an interview on 3/13/24 at 2:37 p.m., LPN-B indicated she was the nurse for the evening shift on 3/4/24 when R1 had fallen. LPN-B stated she was on the other side of the nurses station when NA-A came to get her and told her R1 had fallen. LPN-B explained she went to R1's room, R1 was lying on her left side at the foot of her bed, and R1 still had the gait belt around her. R1's walker was not in sight, so LPN-B guessed it was not used during the transfer. NA-B and LPN-B transferred R1 back into bed using the full body mechanical lift. LPN-B completed an assessment and notified family. R1 did not have any facial grimacing or indicators of pain until a little after 8:00 p.m. which LPN-B gave R1 some acetaminophen. LPN-B stated this fall was 100 % preventable, it was a simple pivot transfer. LPN-B could not understand how R1 could have fallen R1 took commands well and never got up without help. LPN-B indicated she had not completed a causal analysis of the fall and/or interviewed NA-A after R1's fall to determine the root cause. During an interview on 3/13/24 at 3:17 p.m., neighborhood coordinator (NC)-A indicated on the day of R1's fall on 3/4/24, NA-A was still in orientation and that NA-A did not have any supervision when NA-A transferred R1 and had fallen. During a phone interview on 3/13/24 at 1:01 p.m., NA-C indicated working the night shift on 3/4/24 and had heard during report R1 had fallen on the evening shift. NA-C stated, she heard that R1 was being transferred from her recliner to the bathroom. R1's baseline was very unsteady on her feet. R1 did not move unless she was asked by staff to do so NA-C was confused how R1 could have fallen. During a phone interview on 3/13/24 at 1:19 p.m., LPN-C indicated working the night shift on 3/4/24 and had gotten report from LPN-B. LPN-C was told in shift report R1 had hit her left side, her face, her shoulder, and her elbow and given acetaminophen for the pain. LPN-C indicated she assessed R1 for pain and changes throughout the night, with no changes or signs of pain noted. During an interview on 3/13/24 at 11:30 a.m., licensed practical nurse (LPN)-A indicated she worked the day shift of 3/5/24. LPN-A stated that morning she informed the aides to not get R1 up until she could do an assessment from the fall. R1 had grimacing with left shoulder range of motion (ROM) so staff got R1 up with an EZ-lift to try and protect that arm, R1 was brought to the dining room where she was fed breakfast. R1 had an eye appointment that morning and FM-A assisted R1 to the appointment. LPN-A stated, she got a phone call from the nurse at the eye clinic mid-morning that R1 was not recognizing FM-A had a change in condition and was brought to the emergency department (ED). During an interview on 3/14/24 at 8:24 a.m., registered nurse (RN)-A stated R1's care plan for transfers was to use a gait belt with CGA at all times and FWW. The wheeled walker would be important to use for R1's balance that was what R1 used prior to coming here when R1 was at home with FM-A. R1 was very unsteady on her feet and would lose her balance very easily. RN-A indicated being involved in the investigation of R1's fall on 3/4/24 and stated, we never checked to see if the FWW was being used during the fall, we were more focused on if the gait belt was used and to make sure the neuro assessments were being completed per policy. During an interview on 3/14/24 at 8:52 a.m., therapy program director (TPD)-A indicated if a resident had an order to use a gait belt with CGA at all times and FWW with transfers this would be used for strength and balance for the resident. TDP-A verified R1 had this order for transfers and was seen by OT and PT for strengthening and balance. TDP-A stated it was very important to follow the care plan exactly for transfers to prevention falls. R4's quarterly MDS dated [DATE], identified R4 to have moderate cognitive impairment and had diagnoses of dementia, anemia, and hypertension. No recent falls. R4's care plan dated 11/30/23, identified a focus of ADL self-care performance deficit related to limited mobility and incontinence, dementia, and diabetes. Intervention to transfer was assist of one staff using CGA to pivot transfer with FWW and gait belt. R4's Fall risk assessment dated [DATE], identified a score of 22 indicating 4 was at moderate risk for falls due to diagnoses of diabetes, cardiovascular disease, and anemia. R1 had chronic bowel and urinary incontinence, unable to ambulate independently, cannot safely transfer independently, and was on hypertensive medications. During an observation and interview on 3/14/24 at 8:41 a.m., R4 was seated on his bed with the gait belt around the waist, the wheelchair was directly across from R4. R4's walker was noted to be on the other side of the room. NA- D was standing to the right of R4 holding the gait belt. R4 had his hands on the arms of the wheelchair in front of him, wheelchair brakes were locked. R4 stood with the help of NA-D pulling up on the gait belt, R4 did not fully standup and tried to sit before reaching the wheelchair. NA-D had to physical lift and guided R4 to the wheelchair with difficulty of ensuring R4 was in a safe position to sit down squarely in the wheelchair. NA-D reviewed R4's care plan on the door and stated, I didn't realize R4 should have used the walker to standup with the transfer, I suppose that would have been easier. During an interview on 3/14/24 at 11:27 a.m. director of nursing (DON) stated an investigation was completed for R1's fall on 3/4/24 at 6:00 p.m. and they were not able to come up with a true root cause to the fall. The investigation focused on the gait belt being used and making sure neuro assessments were being completed per facility policy. The interdisciplinary team (IDT) did not check to see if the walker was used for the transfer with R1's fall. DON was notified of R4's transfer with NA-D not using a walker to transfer R4 to the wheelchair as directed by the care plan. DON stated, the care plan should be followed with all resident transfers. Facility policy, Resident Transfer Policy, revised 6/2023 identified It is Samaritan [NAME]'s policy to transfer residents from one location to another following the residents individualized care plan to prevent resident and staff injuries from occurring. PROCEDURE: 1. Residents will be evaluated for transfers at the time of move-in to the facility and is noted is the residents care plan. 2. The resident care plan will be updated as changes occur. 3. If a resident has fallen a two assist with EZ Lift equipment will be used. 4. When a resident transfer occurs, the staff member assisting must follow the care plan. 5. Resident's arms and pants are not used as a lifting device. 6. Samaritan [NAME] Types of Transfers include: a. Independent: Resident can transfer independently from sitting to standing positioning or from a standing to sitting position and does not require assistance from staff. b. One-staff Assist: Resident can bear weight on one or both legs and requires a gait belt with all transfers, which helps to provide support and balance for the resident. i. A walker, cane, or other support equipment may be used. Facility policy, Fall Protocol, revised 3/2024, identified when a fall occurs, it will be Samaritan [NAME]'s practice to investigate the contributing factors/circumstances surrounding the fall, looking for patterns, etc. to prevent further falls and/or minimize the risk of injury. PROCEDURE: 1. When a resident sustains a fall he or she will not be moved until a licensed nurse has evaluated their condition. 2. Pulse, respirations, and blood pressure, o2 saturation, and temperature obtained and recorded. 3. If an injury has occurred, it will be evaluated by the licensed nurse. Skin tears, bruises, abrasions, etc. will be treated using the facility standing orders. 4. If the fall was not witnessed and/or the resident hit their head, neuro checks will be initiated. 5. The nurse practitioner / MD will be notified immediately when there is need for further evaluation, emergency room visit or hospitalization . 6. A huddle is conducted, with staff present at the time of the fall, to determine contributing factors and what immediate intervention is to be put in place, to prevent further falls. These contributing factors and interventions will be documented in the electronic medical record. 7. A comprehensive assessment will be completed after each fall by the Care Coordinator looking for patterns, contributing factors, resident observation, fall history, physical limitations, medications, environment, and diagnoses. 8. IDT (Inter Disciplinary Team) meetings are held for 2 falls in 24 hours, 3 falls in a month, or after a fall with significant injury. Documentation of the IDT meeting will be entered in the progress notes in the resident's electronic medical record, including interventions put in place to prevent further falls. 9. Care Plan and Kardex are reviewed and updated when changes occur. 10. Resident falls are reported at stand-up meetings. A meeting is conducted with the Care Coordinators after stand-up after each fall to review fall and new intervention. 11. Fall Investigation Reports will be kept for one year. This report is a quality assurance investigation and is not part of the residents' record. 12. Falls are reviewed, and trends reported at Quality Assurance meetings.

Based on interview and record review the facility failed to accurately transcribe physician's orders into the electronic heath record (EHR) for 1 of 3 residents (R1) who recieved 14 wrong doses of aspirin. Findings include: R1's physician visit dated 2/23/24, identified R1 to have quite a bit of drainage from her nose, constant in nature and many times is bloody/serosanguinous (yellowish with samll amounts of blood) from history of recurring nose bleeds was receiving aspirin (medication to thin the blood) 325 milligrams (mg) daily. New orders to discontinue aspirin 325 mg daily and change to aspirin 81 mg daily due to frequent nose bleeds. R1's order summary dated 2/23/24, identified an order of aspirin 325 mg daily for permanent atrial fibrillation. R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 to have severe cognitive impairment and diagnoses of atrial fibrillation (An irregular, often rapid heart rate that commonly causes poor blood flow), thrombocytopenia (low platelets) and hypertension (high blood pressure). R1's February and March 2024 medication administration records (MAR) identified R1 received aspirin 325 mg daily from 2/23/24 through 3/5/24. R1 received the wrong dose of aspirin for 14 days. During a phone interview on 3/13/24, at 4:15 p.m., family member (FM)-A reported a concern that on 2/23/24 R1 was seen by the physician and had ordered a change in R1's aspirin dosage from 325 mg to 81 mg due to frequent nose bleeds. FM-A stated, this was never changed and R1 received 325 mg daily when she should have been getting 81 mg daily. During an interview on 3/14/24 at 2:20 p.m., director of nursing (DON) indicated when a medication error occurs, the nurse would document the error of a medication error report form, assess, and monitor the resident and notify the doctor. DON indicated an unawareness of the transcription medication error with R1's aspirin. Facility policy Medication error, dated 11/23, identified It is Samaritan Bethany's policy to evaluate medication and treatment errors that occur at the facility and provide education/corrective action to the person making the error. A medication error is the observed or identified preparation or administration of medications or biologicals which is not in accordance with: The prescriber order, Manufacturers specifications (not recommendations) regarding the preparation and administration of the medication or biological; or accepted professional standards and principles which apply to professionals providing services. The Licensed nurse that identifies the error initiates the Medication Error Report. The error must be determined as significant or non-significant. A significant error is one that causes the resident discomfort or jeopardizes the residents health or safety and follows these three general guidelines: Resident condition, Drug category, and Frequency of the error. Any significant medication error or resident reaction must be reported to the following: MD/NP, Resident or the residents representative, an explanation must be made in the residents record for a significant error. If the medication error is significant, it will be reported under Vulnerable Adult guidelines. The medication error is reviewed with the individual making the error looking at any potential contributing factors

Based on observation, interview, and record review, the facility failed to ensure appropriate use of personal protective equipment (PPE) when entering a COVID positive resident (R73) room after the facility failed to ensure all staff were fit tested (test used to determine appropriately sized N95 mask) for the use of N95 masks. This had the potential to affect all 84 residents in the facility. In addition, the facility failed to ensure protection from blood-borne pathogens when an outside lab technician (lab tech) was observed drawing blood from R334 at the dining room table. This had the potential to affect 2 of 2 residents (R3 and R51) and a family member who were also seated at the table. Findings include: During an observation on 1/30/24 at 12:25 p.m., a dietary aide (DA-A) was observed entering R73's room wearing face shield, gown, and surgical mask. A sign on the outside of R73's room indicated caution PPE required. Another sign on the door demonstrated putting on PPE. A white cart containing PPE supplies was located outside of the room. A sign on top of the cart indicated contents of the cart, including N95 masks. DA-A walked out of R73's room, removed PPE, washed hands, and replaced surgical mask. During an interview on 1/30/24 at 12:28 p.m., DA-A indicated the nurses told her PPE was required to protect the resident's and herself due to R73 having COVID. She was not told a different mask was required. DA-A stated she was unsure if she had been fit tested but did receive transmission-based precautions education through the facility. During an observation on 1/31/24 at 8:40 a.m., DA-A applied PPE including an N95 mask prior to entering R73's room. During an interview on 1/31/24 at 8:27 a.m., NA-A was observed entering R73's room wearing an N95 mask. She indicated she had not been fit tested at the facility. During an interview on 1/31/24 at 2:02 p.m., the assistant clinical mentor (ACM) stated COVID positive residents are placed on modified droplet precautions. Staff are required to wear N95 masks when in a COVID positive resident's room. The director of nursing (DON) stated staff have been fit tested in the past and fit testing will be implemented with onboarding. Documentation of fit tested staff members was requested. During an interview on 2/1/24 at 10:11 a.m., the ACM stated staff are expected to be fit tested . If staff are not fit tested , they are expected to do a seal check (a procedure to ensure there is no air escaping around the mask). The ACM stated seal checks were approved by the regulation and would provide her source. During an interview on 2/1/24 at 11:18 a.m., The DON was unable to provide list of fit tested staff members and the employee who performed the fit testing is no longer with the facility. The ACM stated the facility's current practice is for staff to perform seal checks when putting on N95 masks. A Donning/Doffing (on/off) for confirmed COVID-19 (droplet precautions) policy dated 9/2023, indicates when a resident is confirmed positive with COVID-19, the facility's practice is to utilize droplet Personal Protective Equipment in attempt to prevent and spread further infection to resident, staff, and visitors. Supplies needed include: PPE cart, gowns, N95 respirator, eye protection, gloves, hand sanitizer, and garbage bags. Donning procedure indicates, in part, staff are to put on N95 face mask (if available) and ensure mask is fitted to nose bridge and has a tight seal over face, completing a seal check. A COVID-19 N95 Face Mask policy dated February 2023, indicates it is the facilities policy to ensure staff are protected from respiratory hazards through proper use of respirators (N95 mask) when working with confirmed COVID-19 positive residents. If [the facility] is unable to perform fit-testing, a seal check method will be completed. Staff who will use an N95 mask will be evaluated by a medical provider to ensure they are physically able to perform their tasks. A fit test will be completed after a medical evaluation is performed. A Fit-Test is conducted to ensure that the N95 face mask fits the staff member properly and a good seal is obtained. If the face mask does not seal, the face mask does not offer adequate protection and the staff member will need to try another mask. After the initial Fit-Test, the Fit-Test will occur annually, per frequency of medical provider discretion for staff members (if applicable), if a change in model of type of respirator occurs, or change in staff members body weight by more than 20 pounds. Seal check procedure indicates, staff who use an N95 face mask will perform a positive pressure seal check to ensure that adequate seal is achieved each time the respirator is put on. A Centers for Disease Control and Prevention (CDC)/National Institute for Occupational Safety and Health (NIOSH) User Seal Check FAQ provided by the facility indicates, The Occupational Safety and Health Administration (OSHA) (29 CFR 1920.134) requires an annual fit test to confirm the fit of any respirator that forms a tight seal on the wearer's face before it is used in the workplace. Once a fit test has been done to determine the best respirator model and size for a particular user, a user seal check should be done every time the respirator is to be worn to ensure an adequate seal is achieved . A user seal check is sometimes referred to as a fit check. A user seal check should be completed each time the respirator is donned (put on). It is only applicable when a respirator has already been successfully fit tested on the individual. The user seal check does not have the sensitivity and specificity to replace either fit test methods, qualitative or quantitative, that are accepted by OSHA. A user should only wear respirator models with which they have achieved a successful fit test within the last year. Blood Draw R334's Admission Minimum data set (MDS) assessment dated [DATE], indicates R334 is cognitively intact and requires partial to moderate assist for activities of daily living. R334's medical record indicates lab orders for comprehensive metabolic profile, vitamin B12, TSH, and Vitamin D total to be drawn the week of 1/29/24. During an observation on 2/1/24 at 8:20 a.m., a lab tech was in the dining room drawing blood at table while 3 residents and a family member ate breakfast. R334 was seated at the table, R3 was seated to the right of R334, R51 was seated at the head of the table to the left of R334, and R334's family member was seated across the table from him. All three resident's and the family member had food in front of them. The lab tech knelt on the floor between R334 and R51. R334 was angled away from table far enough for the lab tech to reach R334's right hand. The lab tech was observed to attempt to draw blood from resident's right hand. When unsuccessful, the lab tech wrapped R334's right hand and attempted to draw blood from left hand. R334 remained at the table. Used items were placed in sharps container that was on the floor. During an interview on 2/1/24 at 8:35 a.m., the lab tech stated if a resident is at table she will ask resident to move back away from table prior to drawing blood. She stated she did not ask resident if R334 was ok with being drawn at the table. The lab tech stated they can usually draw labs at the table. She stated it would not be ok to draw blood at table and confirmed she did not move resident away from table. During an interview on 2/1/24 at 8:43 a.m., TMA-A and LPN-B indicated residents are supposed to go back to their room for blood draws per facility policy. During an interview on 2/1/24 at 8:47 a.m., LPN-A indicated blood draws should be done in a resident's room for sanitary and dignity purposes. If a resident is ok with labs being drawn in public, they should be pulled away from the table. During an interview on 2/1/24 at 9:21 a.m., the administrator stated lab draws should not be done at the table. During an interview on 2/1/24 at 9:50 a.m., the DON indicated blood draws should not be performed at the dining room table due to dignity and infection control issues.

Based on observation, interview, and document review, the facility failed to comprehensively assess for ability or safety, and then care plan the self administration of medication for 1 of 1 resident (R48) observed to have medications prepared by staff and then left with him to take at leisure. Findings include: R48's quarterly Minimum Data Set (MDS) assessment, dated 11/9/23, identified R48 had intact cognition and had multiple medical conditions including high blood pressure, diabetes mellitus, and hemiplegia/hemiparesis (muscle weakness or partial paralysis on one side of the body). R48's most recent Nursing - Self Administration of Medication Evaluation, dated 5/2021, identified multiple questions to be answered which helped evaluate if R48 was able to safely self-administer medications including what, if any, medical diagnoses R48 had, if he was physically capable to self-administer them, and if he had the ability to recognize the medications when provided. The evaluation identified R48 did not have knowledge on the purpose of his medications, was not able to recognize his medications, nor had the ability to read the medication label, if needed. The evaluation outlined R48 was determined to not be a candidate for self-administer medications with dictation present, . nursing will provide and administer medications to resident. However, on 1/31/24 at 7:28 a.m., licensed practical nurse (LPN)-C prepared R48's medications using a mobile computer station outside of his room where the medications were stored in a cabinet. LPN-C removed each medication punch-pack and placed a dose of each medication into a white-colored, disposable medication cup. A total of 11 oral medications were placed into the cup including baclofen (a muscle relaxant), Metformin (for diabetes), and lisinopril (for high blood pressure). In addition, a dose of Miralax (for constipation) was mixed into a glass of orange juice. LPN-C then brought the medication cup and medication-laced orange juice over to R48 who was seated in a wheelchair in the commons area of the unit with another female resident sitting immediately adjacent. R48 had a bedside table place in front of him which had another cup of orange juice present along with other various items (i.e., TV remote). LPN-C set the cup of prepared medications on the table and expressed aloud those were his morning medications. LPN-C then turned back to the mobile computer station and started to leave the area telling the surveyor aloud, I am going to follow up with some others who wanted me [on the other unit]. LPN-C then left the unit with R48's prepared medications sitting in the medication cup on the table. A few minutes later, nursing assistant (NA)-B approached R48 with his morning breakfast meal and provided it to him on the same table. NA-B then left and returned to the kitchen. R48 started to eat the provided meal until several minutes later, at 7:38 a.m., when R48 picked up the cup of prepared medications, brought it to his mouth and took the entire cup at once. R48 then used the medication-laced orange juice to swallow them down. There were no dropped doses observed, and LPN-C was not observed ever returning to the area to ensure R48 consumed them all without complication. When interviewed immediately following, on 1/31/24 at 7:39 a.m., R48 stated the nurses usually give him cups of his medications and leave it with him to take later. R48 stated he could not recall ever being talked to or evaluated for this, however, voiced he felt comfortable taking them on his own. When asked if he had an issue taking them (i.e., dropped one, choked on them), R48 stated he would yell to get help. On 1/31/24 at 7:42 a.m., LPN-C was interviewed and verified they had left R48's prepared medications with him to take on his own. LPN-C stated doing such was their typically practice with R48, and they believed R48 had been evaluated for safety and ability to self-administer medications. LPN-C stated they believed R48 would let me know if any issues with taking his medications arouse. R48's Order Summary Report, signed 12/7/23, identified R48's current physician-ordered medications and interventions. These included active orders for Metformin, baclofen, and lisinopril along with other medications, including Fosamax, which had special post-administration instructions (i.e., remain upright for 30 minutes afterward). However, the signed orders lacked approval or evidence R48's physician had approved the self-administration of medications. In addition, R48's care plan, last reviewed 11/2023, identified R48 was alert and oriented, had diabetes which was managed with medications, and had a history of behaviors which included verbal aggression to others. The care plan outlined R48 had a self-care deficit with resulted limited mobility due to several medical complications including spasms and a prior stroke. However, the care plan lacked any evidence R48 had been evaluated and approved to self-administer medications after set-up by the nurses, nor any interventions to ensure R48 safely consumed them (i.e., check back). R48's medical record was reviewed and lacked evidence R48 had been comprehensively assessed for safety and ability to self-administer medications since 2021, where he had been determined to be ineligible to do so for various reasons; nor evidence R48 had been evaluated by the interdisciplinary team (IDT) and approved to self-administer medications despite staff routinely leaving them with him to take at leisure. On 1/31/24 at 11:13 a.m., licensed practical nurse (LPN)-A and registered nurse (RN)-A were interviewed. LPN-A explained residents' who wished to self-administer were evaluated using the self-administration of medication evaluation tool (such as was completed for R48 in 2021) and the results were then reviewed by the IDT. LPN-A stated they felt R48 was physically able to self-administer his own medications, after set-up, but may possibly not be able to recognize all of them, if asked. LPN-A reviewed R48's medical record and verified it lacked any further self-administration of medication evaluations or assessments since 2021; nor were there any care planned interventions for such on R48's care plan. LPN-A added, This needs to be readdressed with him [R48]. LPN-A and RN-A both verified they were unaware the floor nurses were leaving the medications with R48 to take at leisure, and LPN-A stated it was important to ensure the ability to self-administer medications was assessed and care planned so we know they can safely take their medications. A provided Administration of Medication policy, dated 11/2023, identified medications were administered only by licensed nursing or trained medication aides (i.e., TMA). The policy continued, Residents are assessed for self-administration of medication ability when they move into the facility, quarterly, and PRN [as needed] as requested following. However, the policy lacked any further information to clarify that sentence meaning or how such would be evaluated (i.e., tools used, responsibility to do).

Based on interview and record review, the facility failed to ensure completion of a laboratory test ordered by the provider for 1 of 1 residents (R11) evaluated for urinary tract infection (UTI). Findings include: R11's quarterly Minimum Data Set (MDS)assessment, dated 12/28/23, identified R11 was cognitively intact with frequent incontinence and had a UTI in the previous 30 days. R11's care plan dated 1/10/24, identified R11 required 1 assist for toileting, stand by assist for activities of daily living, and is incontinent of bladder. During an interview on 1/29/24 at 2:28 p.m., R11 indicated she was receiving antibiotics for a UTI. She reported being unsure why a urine sample was collected. She stated she has to go go go all the time and her urine runs out of her. R11's indicated orders were received for a midstream urine on 1/25/24. With a follow up note from 1/25/24 indicates R11 was diagnosed with a UTI by the nurse practitioner based on urinalysis results. Nurse practitioner wrote orders for Cefdinir (antibiotic) 300 mg twice a day for 7 days. During an interview on 1/30/24 at 2:10 p.m., licensed practical nurse (LPN)-B indicated the provider is updated when a resident has a certain number of urinary symptoms. The provider will occasionally start an antibiotic immediately after receiving the results of the urinalysis (test to determine presence of infection) and change the antibiotic when the urine culture returns. During an interview on 1/31/24 at 12:42 p.m., LPN-A indicated R11's urine culture results had not returned, and she would need to follow up with the nurse practitioner. LPN-A called the nurse practitioner and stated the nurse practitioner was not sure why the culture results had not returned and would look into it. LPN-A indicated lab results usually go directly to the provider for evaluation and it is very rare for the provider to not follow up on urine culture results. During an interview on 1/31/24 at 2:02 p.m., the assistant clinical mentor (ACM), indicated R11 had quite a few symptoms prompting a urinalysis to be ordered. The ACM confirmed the urine culture was not performed as ordered. She stated the providers check for the results and update the facility of changes. The ACM indicated it would normally be the care coordinator's responsibility to follow up on urine labs. During an interview on 2/1/24 at 8:46 a.m., LPN-A stated the provider follows up on urine culture results. She indicated the care coordinator should be following up to make sure urine culture results come back and update the provider. LPN-A stated it is the facility's responsibility to make sure ordered labs are performed. During an interview on 2/1/24 at 8:55 a.m., registered nurse (RN)-A indicated she was the nurse at the time R11's urine sample was collected. She stated the provider informs the facility if an antibiotic needs to be ordered. She stated it is usually the care coordinator or ACM who watch for urine culture results. During an interview on 2/1/24 at 9:21 a.m., the administrator stated it is the provider's responsibility to follow up on labs ordered. During an interview on 2/1/24 at 9:42 a.m., the director of nursing indicated it is the facility's responsibility to make sure labs are performed.

Based on interview and document review, the facility failed to ensure developed bowel incontinence was comprehensively reassessed to determine what, if any, interventions were needed to promote routine, normal bowel function and reduce the risk of bowel incontinence for 1 of 1 resident (R13) reviewed who complained about their bowel function. Findings include: R13's significant change in status Minimum Data Set (MDS) assessment, dated 10/30/23, identified R13 had moderate cognitive impairment but demonstrated no delusional episodes or behaviors. The MDS outlined R13 as always incontinent of bowel, having no constipation, and not being on a bowel toileting program. On 1/29/24 at 7:06 p.m., R13 was interviewed and expressed concerns about their bowel patterns. R13 felt she had been having more issues with bowel incontinence and, at times, bowel constipation over the past few months. R13 stated they were unsure of what, if any, medications for bowel function they consumed and expressed the staff had never discussed a bowel management program, or subsequent options for one, to her recall adding, Not really. R13 stated staff just keep telling her you have to be patient with her bowel issues adding staff seemed so unsympathetic sometimes. R13's most recent Nursing - Bowel Assessment - V4, dated 9/2023, identified the evaluation as R13's admission assessment. R13 was recorded as being incontinent of bowel along with multiple questions to be addressed or answered for bowel incontinence including signs and symptoms of incontinence; however, these were left blank and not completed. The evaluation outlined R13 as having an 'every other day' bowel pattern and concluded with dictation reading, . has had one continent and one incontinent bowel movement since move in . requires A01 [assist of one] with transfers and clean up. A subsequent Nursing - Bowel Assessment - V4, dated 1/18/24, identified a quarterly review was to be completed, however, the assessment was unsigned and had dictation present on top reading, Errors. The assessment outlined R13 was incontinent of bowel, however, again, the section to record signs and symptoms of incontinence and the normal bowel pattern was left blank. The assessment included sections to review R13's medical conditions which could impact bowel continence along with her medication use, however, these also were left blank and not completed. The assessment identified R13 was able to recognize the time and place to defecate and feel the urge to do so concluding with dictation, Resident is aware of when she needs to use the toilet to have a bowel movement but does not always put her call light on in time . transfers with the e-z stand [mechanical lift] and AO1 [assist of one]. R13's medical record lacked any further completed bowel assessment(s) for R13 since admission to the care center in 9/2023. R13's care plan, last reviewed 11/14/23, identified R13 had a self-care deficit due to limited mobility, pain, and incontinence. However, the care plan outlined a problem statement which read, I am continent of bowel, along with several risk factors including limited mobility, pain, history of stroke, and needing assistance with toileting. The care plan outlined to give medications as ordered, observe for changes in bowel continence and update the nurse, and toilet every morning around 6:30 a.m. R13's POC (Point of Care) Response History, printed 1/31/24, identified R13's recorded bowel continence over the past 30 day period. This identified a total 23 continent bowel movements and seven (7) incontinent bowel movements with one recorded as, Loose. There were no recorded constipation episodes identified on the record. In addition, R13's Order Summary Report, printed 2/1/24, identified R13's active, discontinued, and completed physician's orders and interventions. R13 had current, active orders listed for Miralax (a laxative medication) as needed (i.e., PRN) with a start date listed, 10/23/2023; and for Senna-Docusate Sodium (a laxative medication) as needed with a start date listed, 01/04/2024. The orders included a discontinued order, ended 1/4/24, for a daily, scheduled dose of Senna-Docusate for constipation. When interviewed on 1/31/24 at 9:04 a.m., nursing assistant (NA)-E explained R13 had really bad anxiety and could be forgetful, however, did remember some. NA-E stated R13 used the mechanical lift to use the toilet, however, NA-E was not sure if R13 was continent or not of bowel as R13 doesn't go that much. NA-E verified R13 was able to ask for help when she needed to use the bathroom but expressed they were not sure if R13 was on any type of bowel management program or not adding, We just help her whenever she wants most of the time. On 1/31/24 at 10:02 a.m., licensed practical nurse (LPN)-D was interviewed and verified they had worked with R13 prior describing her as needing assistance from staff with everything. LPN-D explained R13 used the toilet for voiding and defecation, and she was able to verbalize when she needed to do so most times adding R13 was both continent and incontinent of stool. LPN-D stated R13 had sustained a hip fracture prior and with the associated narcotics was given bowel medications. However, LPN-D stated they had, about a month prior, changed R13's bowel medications due to increased incontinence and had them now only as-needed and not routinely scheduled. LPN-D stated they believed R13 was more continent of bowel now as a result, but explained the care coordinators were the ones who do the formal assessments and evaluations adding, They do the follow-up. However, R13's medical record was reviewed and lacked evidence R13 had been comprehensively reassessed for her total bowel status and what, if needed, interventions (i.e., bowel management program, toileting program) were needed to promote continence and reduce the risk of complication (i.e., constipation) since she admitted to the care center nearly four months prior; nor evidence the care plan had been revised to match the actual bowel continence level of R13 despite multiple recorded incontinent episodes. Further, the record lacked evidence R13 had been re-evaluated for her bowel needs and overall status, including with R13's input and wishes, since 1/4/24 when her scheduled bowel medications were discontinued and changed to as-needed only. On 1/31/24 at 10:24 a.m., licensed practical nurse (LPN)-A and registered nurse (RN)-A were interviewed. LPN-A verified they had reviewed R13's medical record and explained R13 seemed to have regular bowel movements on a near-daily basis with periods of incontinence noted. LPN-A explained the evaluations, including the bowel assessments, were placed in the record and the floor staff helped to complete them in accordance with the MDS' schedule (i.e., quarterly) and then routed to the care coordinator to be reviewed and care plan updated with interventions, if needed. LPN-A acknowledged R13's incomplete and unsigned bowel assessment (dated 1/18/24) and expressed they were unsure why it was not completed adding, I don't know why it didn't come to me. LPN-A reviewed R13's care plan and acknowledged it outlined R13 as continent when she had multiple incontinent episodes adding, Her [R13] care plan needs to be adjusted. LPN-A and RN-A both verified any incontinence episodes need to be reported and acted upon, and LPN-A stated timely evaluation or reassessment of bowel incontinence was important to do so everybody is informed of R13's needs and for continuity of care. A provided Bowel and Bladder Evaluation policy, dated 4/2023, identified a systematic evaluation would be completed to assist with determining what, if any, treatment and management of bowel and bladder function was needed. The policy outlined, Based on the resident's comprehensive assessment the facility will determine casual and contributing factors of bowel and bladder incontinence, develop regularity of body excretory functions for incontinent residents, and develop a plan for bowel and bladder retraining when indicated. In these ways the facility will ensure that each resident with bowel and/or bladder incontinence will receive appropriate individualized treatment and services to restore as much normal function as possible. The policy listed a procedure which directed a licensed nurse would complete any required bowel or bladder assessments and, based on those, a toileting plan would be noted in the care plan.

Based on observation, interview, and document review, the facility failed to comprehensively reassess and develop interventions, if needed, to ensure timely repositioning and appropriate care was provided to prevent pressure injuries for 1 of 2 residents (R60) reviewed who had a decline in status and was at risk for pressure ulcer formation. Findings include: R60's quarterly Minimum Data Set (MDS) assessment, dated 1/9/24, identified R60 had severe cognitive impairment, was dependent on staff for nearly all self-cares, and multiple mobility-related tasks (i.e., sitting to standing, walking) were not attempted due to medical condition or safety concerns. Further, the MDS outlined R60 was at risk for pressure ulcer development, however, had no current, unhealed ulcers present. R60's most recent Braden Scale For Predicting Pressure Sore Risk, dated 1/9/24, identified R60 had slightly limited perception to sensory items, had very moist skin, and was bedfast. The evaluation scored all R60's risk factors with a recorded score of, 12.0, which was outlined as, HIGH RISK [for skin breakdown]. Further, R60's care plan, last reviewed 1/23/24, identified R60 was at risk for impaired skin integrity due to limited mobility, incontinence and dementia. The care plan listed several interventions which included use of a pressure relieving mattress and cushion, keeping the skin clean and dry, and observing R60's skin with peri-care and bathing. The care plan continued and outlined R60 had a self-care deficit due to dementia and physical frailty with several interventions including, BED MOBILITY: I am able to reposition myself. However, on 1/29/24 at 2:32 p.m., R60 was observed lying in bed while in her room. R60 appeared comfortable and was on her left side with a pillow placed behind her right-side back. R60 was non-verbal with conversation and did not open her eyes. Immediately following, nursing assistant (NA)-C was interviewed, and they expressed R60 was on hospice care and had declined in condition over the last few weeks now being mostly unresponsive. On 1/29/24 at 4:35 p.m. (over two hours later), R60 was again observed and remained in bed as prior on her left side with a pillow placed behind her. Further, again on 1/29/24 at 6:20 p.m. (nearly four hours later), R60 was observed and again remained in bed as prior, on her left side with a pillow placed behind her. R60 remained nearly unresponsive to verbal interaction. On 1/29/24 at 6:21 p.m., NA-D was interviewed and stated they were an agency NA who had only worked a few shifts on campus prior; however, they verified they were currently assigned and responsible for R60's cares. NA-D stated they started working at 4:00 p.m. and had not yet been in to provide any cares, including repositioning, to R60 further adding, I have not seen her yet. NA-D stated the previous NA had told them R60 was OK but didn't mention when they had last repositioned her so, as a result, NA-D stated they could not answer when R60 had been last formally repositioned (i.e., significant change in position, or one-minute off-loading). NA-D stated they tried to reposition all residents every two hours as a rule of thumb but expressed they were not sure how often R60's care plan called for R60 to be repositioned. NA-D verified they had not repositioned R60 since their shift started which was over two hours ago, and they attributed the delay in being new and not having enough staff present to do home-maker duties (i.e., serve meals, clean up) which caused them to have those tasks, too, that shift. NA-D explained, to their knowledge, there was no tracking system or charting done when someone was repositioned and added they had just learned resident' care plans were stored on their supply cabinets to reference, when needed, while doing cares. NA-D then showed this care plan to the surveyor which was attached to their supply cabinet inner door. The care plan listed R60's name with a revised date 10/2023 which NA-D stated was almost four months ago. The care plan instructed R60 was able to reposition independently which NA-D stated aloud, I don't think that's correct. NA-D stated the care plan needed to be updated as R60 had declined and now needed more help with cares. Immediately following, on 1/29/24 at 6:29 p.m., NA-D and the surveyor observed R60's skin. NA-D removed the covers from R60 which exposed the pillow placed under her back. R60 was visibly saturated and incontinent of urine to which NA-D stated, [R60] definitely needs to be changed. R60 was assisted by NA-D to turn onto her side with no physical assistance provided by R60. R60's coccyx' skin intact, with no redness present, however, R60's left shoulder and the left lateral side of her back had multiple light-pink colored areas present where the linen had creased and indented her skin. NA-D verified these observations. On 1/29/24 at 7:11 p.m., licensed practical nurse (LPN)-E was interviewed. LPN-E explained there was typically one NA on each side of the unit with 'staggered' hours being completed; however, there had been a call-in so the NA was helping to do homemaker duties in addition to their own assigned workload. LPN-E stated resident' care plans were attached to the inner-cabinet doors for each resident to help the NA(s) know what, if needed, cares were to be done for each person. Those along with a verbal report were used to relay information like repositioning and toileting episodes. LPN-E stated R60 seemed to have nine lives but verified R60 had had a decline over the past week or so and, as a result, staff were now doing a majority of her cares like toileting and repositioning. LPN-E stated they believed R60 was on a every two hours schedule for repositioning. LPN-E stated the care coordinators were responsible to assess any changes and update the cabinet-attached care plans. When interviewed on 1/30/24 at 11:57 a.m., NA-C explained they had worked with R60 in the past, and they described R60 has being on hospice care and having declined in condition which had been for a good two months or so. NA-C stated R60 still would, at times, open their eyes to verbal interaction but was mostly unresponsive and needed help to complete repositioning cares. NA-C stated they were trying to reposition R60 every two or three hours or so adding R60 seemed to have increased incontinence and flood out in the later-day hours. NA-C stated the facility used care plans attached to the inner-cabinet doors to help ensure staff are aware of what is needed for each resident. NA-C then reviewed R60's door-attached care plan at the request of the surveyor. The care plan prior (dated 10/2023) remained and NA-C stated multiple interventions listed, including R60 being independent with repositioning, were inaccurate since she had declined so much. NA-C stated the care coordinator was usually the person who updated the care plans but added, When we have one. NA-C verified they had not been given guidance or direction on how often R60 needed to be repositioned since she had declined adding they had just kind of been doing it when able on the shift. R60's POC (Point of Care) Response History, printed 1/31/24, identified a look-back period of 30 days and included a generic question for staff to answer on their shift which read, Did you turn and reposition? This was answered affirmatively for each shift, however, lacked direction or guidance on how often R60 should be turned or repositioned; nor documentation on how many times a shift such task was completed to demonstrate consistency or continuity of care. In addition, R60's medical record was reviewed and lacked evidence R60 had been comprehensively reassessed to determine what, if any, interventions for skin care and management to prevent pressure injuries (i.e., repositioning) were needed or appropriate despite an obvious physical decline in condition; nor evidence the skin care plan had been re-evaluated or updated with current interventions to ensure R60's skin management needs, if any, were being met. On 1/31/24 at 10:41 a.m., licensed practical nurse (LPN)-A and registered nurse (RN)-A were interviewed, and LPN-A explained condition changes were everybody's responsibility to monitor and respond to with any changes being promptly reported to the care coordinators. LPN-A stated it had been approximately a month since they had seen R60 get up from bed, and expressed repositioning needs were typically evaluated using a tissue tolerance which helped determine how long a resident could be left in the same position without having breakdown begin. LPN-A verified R60 was no longer able to reposition herself, as outlined in her care plan, and the medical record lacked evidence R60 had been comprehensively evaluated for what, if any, skin interventions were needed since she had declined adding, I think that's very fair to say. LPN-A and RN-A both reiterated if direct care staff members were seeing changes, such as obvious declines in condition, then it needed to be brought to the care coordinators for action adding such was important to do for resident' comfort and ensuring all their needs are being met and addressed. A provided Skin/Wound Care Policy, dated 9/2023, identified the care center would provide care to prevent or heal skin impairments or wounds unless such was unavoidable. The policy outlined, All residents are evaluated for skin integrity using the Braden Scale . [it] will be done on all residents quarterly, and with any significant change in condition. Further, the policy outlined, Caregivers will report any concerns related to skin to the licensed nurse.

Based on observation, interview, and document review, the facility failed to ensure routine personal hygiene cares (i.e., nail care) was provided to reduce the risk of complication (i.e., infection, skin scratches) for 1 of 2 residents (R76) reviewed for activities of daily living (ADLs) and whom was dependent on staff for their care. Findings include: R76's quarterly Minimum Data Set (MDS) assessment, dated 11/28/23, identified R76 had intact cognition, demonstrated no rejection of care behaviors during the review period, and did not have diabetes mellitus. R76's care plan, dated 12/2023, identified R76 had a self care deficit and was enrolled in hospice care for end-stage heart failure. The care plan outlined an intervention which read, PERSONAL HYGIENE . [R76] require assist of 1 to help . brush hair, brush teeth, apply deodorant, wash/dry face and hands. However, the care plan lacked information or direction on nail care (i.e., how often, length preference, who would assist). On 1/29/24 at 2:13 p.m., R76 was observed lying in bed. R76's hands were present on top of the bed covers, and R76 had visibly long fingernails present on both hands with several nails having a dark-brown colored substance or debris present under the nail. R76 woke to verbal interaction and, when asked, expressed he would like them clipped but was unable to remain awake for additional questions when attempted. Later on 1/29/24, at 5:40 p.m., R76 was again observed lying in bed while in his room. R76's family member (FM)-A was present at the bedside and was interviewed. FM-A stated R76 was on hospice care and had declined fairly quickly over the past weeks with the pain medications making him very sleepy and hard to converse with. FM-A stated staff were supposed to be helping R76 with bathing and personal hygiene cares. FM-A then looked at R76's fingernails, which remained long and soiled, and said aloud, They should be shorter. FM-A stated R76 typically had a shorter clipped nail as was his preference. The following day, on 1/30/24 at 11:33 a.m., R76 was again observed lying in bed while in his room, and his fingernails remained long and visibly soiled as they had been the day prior. R76's POC (Point of Care) Response History, printed 1/31/24, identified the past 30 days worth of bathing support provided to R76 by the care center staff members. There were three completed episodes dated 1/3/24, 1/10/24, and 1/24/24; however, all of these were recorded with a response of, ADL activity itself did not occur or family and/or non-facility staff provided care 100% of the time. There were no recorded tasks identified to demonstrate nail care had been offered, provided, or refused during the same period of time. R76's facility' progress notes, dated 1/1/24 to 1/30/24, were reviewed. These identified a series of notes labeled, Bath/Skin Note, which were completed on 1/2/24, 1/9/24, 1/16/24, and 1/22/24, respectively. These outlined R76 received a bed bath last on 1/22/24, however, all of the notes lacked evidence R76 had been offered, provided or refused nail care. When interviewed on 1/30/24 at 12:04 p.m., nursing assistant (NA)-C explained they had cared for R76 multiple times prior and described him as declining in overall status now needing help to complete most cares. NA-C stated R76 did not have a history of refusing personal cares when offered but would, at times, refuse a full shower from the hospice caregivers. NA-C stated R76 was scheduled for a Monday bath (i.e., bed bath) and nail care should be completed then; however, there was no place to record such cares in the medical record to their knowledge adding, There's not even a spot on our charting for that. NA-C then observed R76's fingernails while he laid in bed, and stated they were long and had a couple spots which had debris present (i.e., soiled) adding, They could be clipped. NA-C stated R76 was not diabetic, to their knowledge, and so the NA(s) could clip them on bath days or when noticed adding a clipped, short kept nail was important so R76 couldn't scratch himself and because germs can stick under there [under the nail]. When interviewed on 1/31/24 at 10:18 a.m., licensed practical nurse (LPN)-D explained R76 was on hospice and their staff typically did the bathing and personal hygiene cares as a result. LPN-D stated R76 would, at times, use his fingers to pick up food items and eat them and, to their recall, had been somewhat resistant in the past to having his nails clipped as he liked to use them to get tops off containers. However, LPN-D stated they were unsure if that remained accurate now since R76 had declined in condition over the past week or so and added such preference would likely not be care planned for him, either, adding, I don't think so. LPN-D explained baths, when completed, should be recorded in the 'bath/skin check' notes and any refusals of care, including nail care, should be documented in there, too. However, R76's medical record was reviewed and lacked evidence when the last time R76's fingernails had been clipped or cleaned; nor any evidence R76 had a preference to have long fingernails as mentioned by LPN-D. On 1/31/24 at 11:05 a.m., licensed practical nurse (LPN)-A and registered nurse (RN)-A were interviewed, and LPN-A explained R76 had been more challenging with cares of late due to a physical and mental decline. LPN-A stated either the nurse or NA would be able to complete nail care and expressed they don't know why the care was not provided. LPN-A stated nail care should be done when it's noticed as being needed and, if refused, then the nurse should be told so it could be documented accordingly as there was no formal tracking system to record nail care currently in place (i.e., tasks). LPN-A stated R76 was on hospice and those staff members were doing a majority of R76's cares which is why the bath charting indicated such for the support recorded; however, LPN-A verified the medical record lacked evidence nail care had been offered or provided to R76 within the past several weeks. A facility' provided Personal Hygiene policy, dated 5/23, identified the care center would provide personal hygiene according to resident' preferences to maintain dignity. A procedure was listed which directed, Nail care . is provided at the time of bath and as needed. Nails should be cleaned and trimmed without jagged edges, according to resident preferences. The policy continued, Personal hygiene cares are documented by the caregiver or nurse providing the care. Report any concerns, or if a resident chooses not to have care provided, to the nurse. Further, the policy concluded with, The individual care plan must reflect resident care needs and preferences related to personal hygiene.

Based on observation, interview, and document review, the facility failed to ensure the most recent survey results were posted in a prominent location and readily accessible to any person wanting to review the information. This had the potential to affect all 84 residents residing in the nursing home or any visitors who wanted to review the information. Findings include: During observation on 1/29/24, at 2:35 p.m., 1/30/24, at 11:35 a.m., and 1/31/24, at 1:33 p.m., the facility had their past survey results, in a three-ring binder, situated behind their front door receptionist desk which was behind a partial glass partition. This prevented a resident or visitor from being able to readily access and review the past facility's survey results without either asking a staff member to retrieve the three-ring binder or walking behind the receptionist's desk. On 1/31/24, at 2:08 p.m., an informal resident council meeting was held with R21, R22, and R72 present. The residents were asked, as part of the meeting, if the most recent survey results were readily posted within the facility for them to review. The three residents stated knowing where the past survey results were posted, at the facility's reception desk, behind a glass partition. When asked about how they would retrieve the survey results, since they were behind the desk and glass partition, the three residents stated they would ask a staff member to retrieve the results. On 01/31/24, at 11:08 a.m., the receptionist was interviewed. She stated facility's past survey binder is kept behind the main desk, also behind a glass partition, and is the only copy the facility keeps, to her knowledge. The receptionist further stated, if someone wants to review the binder, she'll, or whomever is working the reception desk, would retrieve it for them. Binder contained the last 5 years of survey results. On 01/31/24, at 5:43 p.m., the administrator was interviewed. She stated the facility's past survey binder has been in that same location for as long as she's been at the facility, which is around [AGE] years. The administrator further stated the glass partition was installed early on during the COVID-19 pandemic, as a safety barrier for staff, residents, and visitors, and the facility has left the glass partition up and has never moved the past survey binder from the location. When asked, the administrator stated the facility would not want residents or visitor going behind the receptionist desk to retrieve the binder. On 02/01/24, at 12:30 p.m., the administrator stated It's important the results are posted in a readily accessible location for transparency to staff, residents, family, and the community to show how we are doing in following state and federal regulations. This is important to show how the facility is doing in providing the best quality of care.

Based on interview and document review the facility failed to ensure resident protection from abuse when staff restrained and forced cares that caused bruising and a skin tear for 1 of 2 residents (R1) reviewed for abuse. This resulted in an immediate jeopardy (IJ) for R1. The IJ began on 4/24/23, when nursing assistant (NA)-A caused bruising to R1's wrist when R1 was combative followed by NA-A and NA-B forcibly transferring R1 into bed, provided care against R1's wishes resulting in a skin tear, and failed to immediately implement protection measures. The acting administrator, director of nursing (DON), and assistant director of nursing (ADON), were notified of the immediate jeopardy on 5/11/23, at 2:57 p.m. The facility implemented corrective action and the deficient practice was corrected on 4/27/23, prior to the survey and was issued at Past Noncompliance. Findings include: Facility reported incident (FRI) submitted on 4/25/23, at 1:34 p.m. identified that on 4/24/23, at 6:30 p.m. R1 had peaches clenched in her hand and was agitated during dinner, NA-A tried to move R1 to a different table and tried removing the peaches from R1's hands. Further identified NA-A did not follow R1's care plan. NA-A assisted R1 to her bed using a pivot stand transfer while R1 was refusing cares. NA-A did not allow R1 space or try re-approaching, also did not use a stand aide for the transfer. This resulted in a 1.0-centimeter (cm) x 0.5 cm skin tear below R1's right elbow and two bruises near R1's right wrist that measured 3.5 cm x 3.0 cm that was faint in color and 2.4 cm x 3.0 cm that was dark purple and raised. NA-A was identified as the perpetrator and suspended. R1's Order Summary Report, included a physician order dated 11/10/22, that included offer (R1) to return to her room after dinner 5:30 p.m If (R1) refuses, reapproach every 15 minutes, document in progress notes every day. R1's quarterly, Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment, was independent with eating, unable to walk, and required extensive assist of one with all other activities of daily living (ADL)'s. Further indicated diagnoses of moderate dementia with agitation, Alzheimer's disease, bilateral (both) hearing loss, right shoulder and low back pain. R1's care plan dated 4/12/22, identified R1 was resistive to care related to dementia, and could get agitated and combative with staff that were providing reminders or offering help. Corresponding interventions directed staff to provide reassurance, leave and return/reattempt in 15-30 minutes. Further intervention indicated R1 would cooperate more and become less easily upset if she were approached by one person and provided opportunities with choices. The care plan also informed staff R1 was not able to report concerns of maltreatment (abuse, neglect, or financial exploitation of a vulnerable adult). Associated intervention directed staff upon notification of a possible/actual vulnerable adult incident, immediately assess, prevent further harm and notify the community leader R1's progress note dated 4/24/23, at 9:57 p.m. indicated R1 was frustrated at supper time. R1 pushed herself away from the dining table and declined to eat. When R1 was assisted to bed she received a skin tear to her right arm, R1 would not allow licensed practical nurse (LPN)-A to see it. R1's progress notes between 4/24/23 and 4/25/23 did not include a comprehensive assessment of the skin tear to R1's right arm and did not identify how R1 obtained the skin tear. Further not evident R1's resident representative was notified of the injury or how R1 sustained the injury. R1's Physician Progress note, dated 4/26/23, indicated R1 was evaluated for bruising and swelling to right hand and wrist. The injury was believed to occur on 4/24/23, and could have occurred during a care interaction. R1 had difficulty yesterday using her right hand to eat. Currently R1 able to hold a nearly empty cup of coffee. R1 did not recall how the bruising occurred. The physician assessment identified R1's right hand at the base of metacarpals (bones between the wrist and the finger) at the thumb had red raised bruising approximately 2.5 centimeters (cm) x 2.5 cm and was non-tender with gentle touch. Right lateral (side of) and dorsal (back of) right wrist area had purple bruising and was nontender with gentle touch. The physician ordered an x-ray of right wrist to ensure no fracture was present. During an interview on 5/11/23, at 12:03 p.m. R3 who did not have cognitive impairment on MDS dated [DATE], stated, he knew R1 really well. R1 sat at the table next to him in the dining room. R3 explained R1 could be feisty at times. Most staff would crouch down next to R1 when talking to her so they were at her level; R1 seemed to do better that way. R3 explained a couple of Monday nights ago, R1 was mad about something and started throwing peaches. NA-A did not crouch down next to R1 to talk to her, instead NA-A grabbed [R1's] wrist and restrained her. R3 stated after the incident he saw bruises on R1's wrists. R3 did not see NA-A hurt anyone else and has not seen NA-A working since the incident. Facility investigation included an interview on 4/26/23 at 2:15 p.m., with LPN-A. Documentation of the interview indicated that on 4/24/23, at 5:50 p.m. LPN-A went to break, while on break NA-A called LPN-A and sounded frustrated. When LPN-A got back around 6:20 p.m. NA-A told her R1 had refused her supper, so NA-A offered R1 some peaches but R1 wheeled back from the table. NA-A removed R1 from the dining room and wheeled her backwards into her room. NA-A reported to LPN-A that NA's had to hold R1 down to change her, as a result R1 sustained a skin tear on her arm. LPN-A further reported NA-B did not report any concerns to her. LPN-A reported R1 would not let her see the skin tear. LPN-A reported to the administrator who told LPN-A she needed to file a vulnerable adult report and send send NA-A home. LPN-A reported she did not notify the family that night of R1's injuries. Facility investigation included an interview on 4/26/23 and 4/27/23, with NA-B. Documentation of the interview indicated NA-B stated on 4/24/23 after 5:00 p.m. R1 was agitated. NA-B further reported NA-A held onto R1's hands to keep her form striking out at anyone. NA-A wheeled R1 backwards toward her room, while being rolled backwards R1 tried grabbing the wheels of her wheelchair. NA-A grabbed R1's arms, put R1's arms on her stomach area, and restrained her. NA-A held onto her wrist for probably 30 seconds. They (NA-B and NA-A) discussed how to transfer R1 and decided to transfer R1 with their arms laced under R1's arms. R1 was kicking and pulling hair. They (NA-B and NA-A) were cleaning R1 up, R1 kicked NA-A near her collar bone. When R1 was in bed she was also biting and scratching NA-A and NA-B. NA-B kept R1's legs down as directed by NA-A. R1 did get hurt on her arm when she was in bed. NA-A reported this to the nurse. NA-B worked with NA-A until the facility sent NA-A home. NA-B would have given R1 more time, reapproach, and try other things or get someone else but did not feel comfortable telling NA-A how to correct her actions because of NA-A's demeanor. Review of the facility staff schedule on 4/24/23, identified NA-A and NA-B were both scheduled to work the evening shift. Facility records identified NA-A was sent home early and indicated NA-B completed the rest of her shift without re-education. Review of facility's investigative report identified NA-A did not receive re-education on resident behaviors until 4/25/23 and NA-B did not receive re-education until 4/27/23 (NA-A and NA-B did not return to work after the incident according to staff schedule). During a phone interview on 5/10/23 at 12:02 p.m., NA-A indicated she worked the evening shift on 4/24/23, and remembered working with R1. NA-A stated at suppertime R1 started backing up from the table so she pushed her sideways up to the table so R1 could eat better. R1 then pushed back away from the table again with a bowl of peaches in her hand that she would not let go of. R1 was swinging and fighting with NA-A. NA-A stated she temporarily restrained R1's right hand because R1 was wild and combative. NA-A locked R1's wheelchair breaks so she could get away from R1. NA-A explained R1 continued to be upset when it was time to put her to bed. Since R1 had been so combative NA-A asked NA-B to help put R1 to bed. NA-A reported she pulled R1's wheelchair backwards to her room so R1 could not see her; She [R1] had already beat me up once. NA-A stated she was aware R1 was supposed to use a stand aid for transfers, however, R1 was still combative. NA-A indicated her and NA-B grabbed R1 under the arms and transferred her into bed. R1 was yelling, kicking, and fighting the whole time. NA-A stated she asked NA-B to hold R1's legs down so she could get her top half cleaned up to put her pajamas on. R1 pulled NA-B's hair. NA-A stated, [R1]'s leg got loose and [R1] kicked me hard in the neck, my reflex was to push her leg down. [R1] was very upset trying to get her pajamas on, she might have given herself the skin tear. NA-A reported after R1 was comfortable in bed she did notice the skin tear on on R1's arm that was bleeding. NA-A reported the skin tear to the nurse. NA-A stated she continued to work with residents on 4/24/23, she was not sent home until around 8:30 p.m. Phone calls to NA-B were attempted on 5/10/23, at 12:01 p.m., 1:45 p.m., and again at 2:12 p.m. messages were left without return phone call from NA-B. During an interview on 5/10/23, at 1:59 p.m. NA-C stated she worked the evening of 4/24/23. NA-C stated that NA-A seemed really bossy and overbearing. NA-C indicated that night she had been told NA-A forced R1 to bed and the aides did not use the stand aid. NA-C went into R1's room after she had been told and noticed a black and blue mark on R1's wrist. During a phone interview on 5/10/23, at 11:32 a.m., LPN-A stated she was the nurse for R1 that worked the evening of 4/24/23. LPN-A stated she was on break when the incident between NA-A and R1 happened. LPN-A stated NA-A reported to her R1 had a skin tear; she reported it to the acting administrator who was in the building. LPN-A stated since she had a concern with R1's cares, the administrator told her to send NA-A home which she did. LPN-A stated she tried to do a skin assessment on R1, but R1 refused. LPN-A stated, All I knew about was the skin tear on [R1's] right arm and was not aware of any bruising. During an interview on 5/10/23, at 2:14 p.m. licensed social worker (LSW)-A, stated she headed the investigation on this abuse allegation, and they found that abuse did happen. SW-A stated after she interviewed NA-A, she found that NA-B was in the bedroom holding down R1's legs while R1 was trying to refuse cares. LSW-A indicated NA-B did not feel comfortable correcting NA-A and should not have been involved in holding down R1's legs. LSW-A stated NA-B continued to work the rest of her shift after the incident. LSW-A further stated that NA-A did tell LPN-A that R1 had to be held down to get her changed. During an interview on 5/10/23, at 3:21 p.m., the acting administrator, director of nursing (DON) and the ADON were interviewed. The ADON stated the allegation of NA-A hurting R1 during cares happened the evening of 4/24/23. The ADON stated in the morning of 4/25/23 they met right away to discuss the incident. That was when they found R1 had bruises to her wrists in addition to the skin tear. The ADON stated neither NA-A or NA-B followed R1's care plan, and they refused to let R1 make her own choices. The ADON stated they also found NA-A was holding R1's wrist, resulting in the bruise. The ADON stated the facility determined abuse did occur. Facility policy titled, Reporting and Response revised 6/2020, I. POLICY: Staff at Samaritan [NAME] are responsible for notifying the Community Leader about all reportable incidents involving residents. A. Any individual who is aware that mistreatment has occurred or suspect such will IMMEDIATELY report to a supervisor or member of Vulnerable Adult Committee. B. Immediate steps will be taken to remove the resident from further harm or danger. A supervisor will immediately assess the resident(s) and collect necessary data for incident reporting. The supervisor will review the initial report of mistreatment and make necessary staffing decisions that could include staff reassignment or sent home pending the outcome of the investigation. Staff will not be suspended without notification from a supervisor. C. The supervisor will IMMEDIATELY assess the resident and surrounding environment upon being notified of incident. Supervisor will document findings in resident's EMR. E. A supervisor or Vulnerable Adult Committee member will be responsible for IMMEDIATELY reporting to the Community Leader, MDH-OHFC or MAARC. For incidents involving criminal activity the Rochester Police Department will be immediately notified (called). Appropriate licensing boards will be notified as required by law. Any staff, resident or family member has the right to report. F. Per federal and state regulation, a report shall be made to MDH-OHFC IMMEDIATELY, but not later than 2 hours if the alleged violation involves abuse or results in serious bodily injury; OR not later than 24 hours if the alleged violation does not involve abuse and does not result in serious bodily injury. Protection: B. Upon completion of the investigation and a request, the resident, the resident's representative, the ombudsman, MDH, accused individuals, etc., will be provided a written report of the findings of the investigation and a summary of corrective action taken to prevent such incident from recurring. The Past Noncompliance immediate jeopardy that began on 4/24/23, the Immediate jeopardy was removed, and the deficient practice corrected by 4/27/23, after the facility implemented a systemic plan that included the following actions: -NA-A was suspended on 4/24/23. -NA-B was re-educated on 4/27/23 and removed from the schedule. -The facility initiated an investigation which substantiated abuse. -The facility reviewed their abuse policy and procedure. -R1's care plan was reviewed for appropriate behavior monitoring every shift, with appropriate interventions in place. -Education was immediately developed and provided to all staff on idnetification of abuse, proper reporting guidelines, and measures how to approach residents with challenging behvaviors during cares. -Additional abuse education was added to the training the new staff and new pool staff receive upon onboarding.

Based on observation, interview, and document review, the facility failed to notify the family representative timely of a change of condition (COC) for 1 of 1 residents (R1) who received bruising and a skin tear to her arm during cares, reviewed for abuse. Finding include: Facility reported incident (FRI) submitted on 4/25/23, at 1:34 p.m. identified that on 4/24/23, at 6:30 p.m. nursing assistant (NA)-A did not follow R1's care plan when R1 was pivot transferred to bed while R1 was refusing cares. NA-A did not allow R1 space or try reapproaching, also did not use a stand aide for the transfer. This resulted in a 1.0-centimeter (cm) x 0.5 cm skin tear below R1's right elbow and two bruises near R1's right wrist that measured 3.5 cm x 3.0 cm that was faint in color and 2.4 cm x 3.0 cm that were dark purple and raised. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment, was independent with eating, unable to walk, and required extensive assist of 1 with all other activities of daily living (ADL)'s. Further indicated diagnoses of moderate dementia with agitation, Alzheimer's disease, bilateral hearing loss, right shoulder and low back pain. R1's care plan dated 10/21/20 informed staff she wanted her family to be involved in updates to my plan of care with an intervention to notify R1's daughter or her son immediately after an incident happens. R1's progress note dated 4/24/23 at 9:57 p.m. indicated R1 was frustrated at the meal and pushed herself away from the dining table and declined to eat. When R1 was assisted to bed she received a skin tear to her right arm, R1 would not allow [licensed practical nurse] (LPN)-A to see it. R1's Physician Progress note, dated 4/26/23, indicated R1 was evaluated for bruising and swelling to right hand and wrist. The injury was believed to occur on 4/24/23, and could have occurred during a care interaction. R1 did not recall how the bruising occurred. The physician assessment identified R1's right hand at the base of metacarpals (bones between the wrist and the finger) at the thumb had red raised bruising approximately 2.5 centimeters (cm) x 2.5 cm and was non-tender with gentle touch. Right lateral (side of) and dorsal (back of) right wrist area had purple bruising and was nontender with gentle touch. The physician ordered an x-ray of right wrist to ensure no fracture was present. In review of R1's record it was not evident R1's family was notified of the skin tear and/or how R1 sustained a skin tear or bruising. During an observation on 5/10/23, at 10:38 a.m. R1 was seated up to the table in her wheelchair in the dining room eating her breakfast, R1 appeared well dressed and groomed. During a phone interview on 5/10/23, at 11:32 a.m., LPN-A stated she was the nurse for R1 that worked the evening of 4/24/23. LPN-A stated she was on break when the incident between NA-A and R1 happened. LPN-A stated NA-A reported to her R1 had a skin tear. LPN-A stated she tried to do a skin assessment on R1, but R1 refused. LPN-A stated, All I knew about was the skin tear on [R1's] right arm and was not aware of any bruising. LPN-A indicated she had not reported the incident or the resulting injuries to R1's family. During an interview on 5/10/23, at 2:14 p.m. licensed social worker (LSW)-A, stated she headed the investigation on this abuse allegation. The conclusion of the investigation identified abuse did occur. LSW-A stated LPN-A should have reported this injury to the family and did not, she missed it. During a phone interview on 5/11/23, at 11:27 a.m. family member (FM)-A indicated she had not been notified of R1's injuries as a result of R1's abusive actions on 4/24/23. FM-A indicated she saw the bruising on R1's wrist when she visited on 4/25/23. FM-A indicated she had asked staff what had happened that caused the injuries however was not immediately provided with information. It wasn't until 4:30 p.m. on 4/25/23, LSW-A informed her of the incident with NA-A. FM-A indicated she expected the facility to inform her immediately. During an interview on 5/10/23, at 3:21 p.m., the acting administrator, director of nursing (DON) and the ADON were interviewed. The ADON stated the allegation of NA-A hurting R1 during cares happened the evening of 4/24/23, and stated the family was not notified of R1's injuries and should have been. Facility policy, titled, Change of Condition reviewed 6/2022, indicated, Samaritan [NAME] will communicate information regarding resident changes to the resident, family/responsible party, and physician/nurse practitioner in a timely manner. 1. Samaritan [NAME] nursing staff will inform the resident, consult with the resident's physician, or nurse practitioner, and notify the resident's legal representative or family member when: The resident is involved in an accident or incident that results in an injury and has the potential for requiring physician intervention. This includes notification of injury of unknown origin. 3. Date, time and name of person notified will be documented in the resident record.

Based on interview and document review, the facility failed to follow a physician's order to report elevated blood sugars, and failed to respond to a change in condition of 1 of 3 resident's (R1) reviewed for diabetic care. This resulted in harm when R1's symptoms and significantly elevated blood sugar levels lead to re-hospitalization within five days of admission to the facility. Findings include: R1's admitting diagnosis sheet from 12/13/22 indicated diagnoses that included type 2 diabetes mellitus with hyperglycemia (late on-set diabetes with an associated issue of high blood sugars), a recent case of COVID-19, weakness, a fall and subsequent fractures of pubic bone and left hip socket. The hospital after visit summary of care dated 12/13/22, identified R1 had been admitted to the hospital due to weakness. During hospitalization , R1 was found to have hyperglycemia that required insulin administration during her stay. As R1's condition improved, she required less insulin, and insulin was stopped immediately prior to discharge to the nursing home. The admitting physician orders of 12/13/22, identified that R1 was not receiving insulin at the facility, but was receiving metformin hydrochloride (an oral medication that increases the body's ability to use its own insulin) 500 milligrams (mg), two tablets to be taken twice daily with breakfast and supper. On 12/14/22 an order was added indicating R1's blood sugar was to be checked each morning before breakfast, and the medical provider was to be notified if blood sugar levels were greater than 180 milligrams per deciliter (mg/dl) for three consecutive days. R1's care plan dated 12/13/22, indicated: I have diabetes mellitus; goal-I will have no complications with diabetes mellitus through the review date. The only intervention listed was: Diabetic medications as ordered. Observe for side-effects and effectiveness. Progress note dated 12/13/22, 12:14 p.m. indicated R1 had previously been independent, was able to communicate her needs, but had some impaired cognition, struggled with some short term memory issues. R1 has some pain on that date. Progress note dated 12/14/22, 2:26 p.m. indicated R1 was confused, but was up and ambulating on her own. Progress note dated 12/16/22, 2:07 p.m. indicated R1 was alert and oriented to person and place, but had some confusion. The note indicated R worked with therapy, but had also been found to self-transfer at times. On that date R1 did not complain of pain or discomfort. Progress note dated 12/17/22, 1:25 p.m. indicated R1 was only oriented to herself, was up walking on her own quite a bit, required more redirection, and complained of pain. Progress note dated 12/18/22, 2:42 p.m. indicated R1 complained of pain, but was unable to describe her pain; she required more assistance and had not been up walking all day. R1 was oriented to herself and surroundings only. Progress note dated 12/18/22, 4:16 p.m. indicated R1 had requested assistance to the bathroom, but was found unable to stand. Progress note dated 12/18/22, 6:33 p.m. indicated a family member (FM)-A expressed concerns about R1, and stated she seemed too sleepy, which was not her usual. FM-A also stated R1 seemed to have increased confusion, and FM-A wanted to know what medications had been given. The note indicated the writer, a licensed practical nurse (LPN)-A told FM-A that R1 had needed more help with transfers and had not been up walking that day. FM-A requested R1's blood sugar to be checked. The note indicated R1's blood sugar was 517 mg/dl and vital signs showed a low grade temp of 100.3 F, an increased pulse of 100 beats per minute, a respiratory rate of 18 breaths per minute and a slightly low oxygen level of 93%. The note indicated a call was to be placed to the on-call medical provider. Progress note dated 12/18/22, 7:11 p.m. indicated FM-A asked if the facility was able to give R1 some insulin. The on-call medical provider had returned their call and advised transfer to the emergency department, and R1 was taken to the hospital via ambulance. R1's medication administration record (MAR) for December of 2022 indicated blood sugar monitoring had been done each morning after admission to the facility. On 12/15/22, the level was 134, on 12/16/22, it was 200, on 12/17/22, it was 302 and on 12/18/22, it was 307. The levels on 12/16, 12/17 and 12/18 met the criteria for reporting if levels were greater than 180 mg/dl for three consecutive days. R1's medical record did not contain documentation of these results having been reported to a medical provider. When interviewed on 12/20/22, at 1:40 p.m. a licsensed practical nurse (LPN)-B stated nurses were responsible to monitor the blood sugar levels of diabetic residents. LPN-B stated a resident's MAR would provide criteria for notification to providers. LPN-B stated a provider should be notified right away if a diabetic resident exhibited changes outside of their norm. LPN-B described symptoms of concern to be unusual sleepiness, shakiness, or getting more confused. LPN-B stated the on-call provider should be notified after hours or on weekends if the primary provider was unavailable. When interviewed on 12/20/22, at 2:04 p.m. a registered nurse (RN)-A stated each diabetic patient would have different orders for when to notify a medical provider of their blood sugar levels. RN-A stated R1 had been on insulin when in the hospital but when discharged from the hospital and admitted to the facility, there were no orders to check her blood sugars. RN-A stated the facility liked to have an order to check blood sugars if a person had changed from insulin to an oral anti-diabetic medication so the provider for the facility had been contacted upon R1's admission to write an order to monitor R1's levels. RN-A stated that even without an order, as a nurse she would have concerns about any blood sugar level higher than 250 or 300 mg/dl; however, because R1's order indicated to call if greater than 180 mg/dl for three consecutive days, she did not expect a nurse should call for a single level higher than 180. RN-A did expect the provider should have been notified of the three consecutive days R1's levels were higher than 180 mg/dl. When interviewed on 12/20/22, 3:25 p.m. a certified nurse practitioner (NP)-A stated a nurse should have reported R1's three consecutive days of blood sugars greater than 180 mg/dl within 1-2 hours of the findings. NP-A stated the results showed rising levels, but they were not of an emergent level at that time, and a provider could have decided on whether treatment should have been initiated and/or if further monitoring should have been started. NP-A stated a blood sugar of greater than 500 mg/dl was concerning as this could indicate the person was progressing to diabetic Ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS) [both of these can be life threatening and require prompt treatment]. NP-A stated the symptoms of hyperglycemia frequently noted are: complaints of not feeling well and increasing confusion. When interviewed on 12/20/22, 4:04 p.m. LPN-A stated she first met R1 on 12/17/22, when she obtained her morning blood sugar level. LPN-A stated R1 had been up on 12/17/22, without the need of a wheel chair. On 12/18/22, LPN-A remembered a nursing assistant (NA) had brought R1 to the breakfast table in a wheelchair rather than walking her, stating R1 wanted to eat. LPN-A proceeded to check R1's blood sugar and noted it was around 300. LPN-A stated she had looked at R1's chart and saw there was not an insulin order, but instead R1 took metformin. LPN-A also noted the order to notify the provider of blood sugar levels greater than 180 mg/dl for three consecutive days, and stated R1 had had elevated blood sugars meeting that criteria. LPN-A said she wrote herself a note to write an SBAR (a notification form used to describe a resident's change in condition) to notify the nurse practitioner of the blood sugars on Monday [the next morning]. LPN-A stated she did not see R1 again until later in the morning when she needed assist to the bathroom. LPN-A attempted to assist R1, but discovered she was unable to stand on her own and a lift was needed which was a change from the day before. LPN-A said R1 complained of pain, but was very vague. LPN-A did not see R1 again until around 3:00 p.m. when an NA asked if they could lay R1 down as a visitor had reported she was not herself and could not sit up any more. LPN-A assisted with cares and said R1 complained of pain, but again was not really able to describe her discomfort. LPN-A stated, I was really focused on her comfort at that time. Several hours later, LPN-A went to R1's room to give a medication. FM-A was present and asking to have her check R1's blood sugar which is when she got the result of 517 mg/dl. LPN-A stated she assured FM-A that R1 had received all ordered medications and thought they should call the on-call provider. LPN-A said she notified the facility charge nurse and then LPN-A obtained a set of vital signs while the charge nurse called the provider. LPN-A stated the symptoms of hyperglycemia (high blood sugar) were confusion and lethargy, and was able to state, left untreated, a diabetic could progress into a coma. LPN-A stated, looking back, I should have notified the charge nurse and called the provider right away that morning. When interviewed on 12/20/22, 5:02 p.m. RN-B stated a nurse should contact a provider when a diabetic resident's blood sugar was out of their normal range. RN-B stated the provider often designated a number and if the resident was out of that range a notification should be made right away as you don't know what is going on with that person, or what might be needed. RN-B stated the provider might choose to monitor the blood sugar more frequently or may order a change in medications. When interviewed on 12/20/22, 5:08 p.m. the facility director of nursing (DON) stated she had been notified of R1 being sent to the hospital and about the order to report the elevated blood sugars not having been followed on 12/19/22. The DON stated nursing leadership met to discuss the incident, and had reported it to the state entity to be on the safe side. The DON said they try to do interviews with the persons involved as soon as possible when there is a significant event at the facility, and they had started interviews on 12/20/22. The DON stated they had identified the original order had not had specific parameters for when the notifications were to be made, but DON stated, if a nurse observed a blood sugar greater than 300 mg/dl and no other parameters were defined, the nurse should notify the provider as soon as possible. DON stated an SBAR for the provider to review the next day was not soon enough when the person was symptomatic. The DON stated she had talked with the nurses involved about the situation with R1, but had not yet started training any other nurses on other shifts, or other units. A facility policy titles Diabetic Protocol and last reviewed on August 2021, indicated blood sugar levels will be checked per provider order and as needed if a resident is experiencing a change in condition. The policy referred to standing orders diabetic management for treatment of hypoglycemia and hyperglycemia episodes unless specified by a provider order. A document titled Standing Orders for Samaritan Bethany Home on 8th, dated 5/8/22 indicated: diabetic management - initiate QID [4 times daily] blood glucose (BG)[blood sugar]monitoring upon admission for three days for all diabetic patients unless the orders specify otherwise. -notify provider if two BG results are [less than]70 or [greater than] 400 in a 24 hour period and/or change in condition; if no condition change, notify provider on the next business day.

Based on interview and document review, the facility failed to provide necessary monitoring and supervision for 1 of 3 residents (R1) reviewed and identified at risk for elopement. R1 successfully eloped from the building, undetected, and was found by staff about three blocks away. The IJ began on 1/08/2022, at approximately 4:00 p.m. when R1 eloped and was found across the street. The administrator and director of nursing were notified of the IJ on 1/27/2022 at 3:47 p.m The immediate jeopardy was removed on 1/14/2022 when the facility implement corrected action, therefore the deficiency is being issued at past noncompliance. Findings include: R1's face sheet printed 1/5/2022, indicated R1's diagnoses included [CONDITION(S)], hypertension, [CONDITION(S)], [CONDITION(S)], diabetes, dementia, chronic obstructive pulmonary disease. R1's Elopement Risk assessment dated [DATE], identified R1 as at risk for elopement, [R1] continues to wander at times, is disoriented, impaired safety awareness. [R1] is independent with ambulation and transfers. [R1] has impaired cognition and safety awareness r/t dx of dementia. Interventions listed for R1 included Wanderguard, recreational activities, music, exercise, familiar objects in the room, doors decorated to look like something else, visual barriers-stop sign, strip to cover door opener, photo on wander list, staff aware of wander risk, and having lobby doors opening to elevator shut at night. R1's quarterly Minimum Data Set (MDS) dated [DATE]/22, identified R1 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 6/15. The MDS also identified R1 had diagnoses that included unspecified dementia without behavioral disturbance. R1's care plan dated as last revised on 1/10/2022, indicated R1 was at risk for elopement r/t history of leaving the faculty unattended in May of 2020 and January of 2022, multiple attempts to leave the facility, impaired safety awareness, and resident wanders aimlessly. For this reason, I wear a Wanderguard. R1's care plan directed staff to provide the following interventions: -Provide reminders and cues about my environment as needed. Initiated 11/16/2018, last revised 7/17/2020. -Distract from wandering by offering pleasant diversions, structured activities, food, coffee, conversation, television, book, talking about sports, family, my cabin in Canada, and woodworking. Initiated 11/16/2018, last revised 10/12/2021. -List on the facility elopement risk to alert all staff of wandering and elopement from my neighborhood (unit) and from the facility. Initiated 11/16/2018. -Walk around the neighborhood (unit) and sitting at the big windows overlooking the south and the east. Easily redirected if needed. Initiated 6/11/2020, last revised 1/10/2022. -Wear a Wanderguard on my ankle and on my walker to alert staff if attempt to leave unattended. Initiated 11/16/2018, last revised 7/6/2020. -Accompany by staff or family to/from all events off the neighborhood (unit). Initiated 1/17/2022. -If looking for daughters, remind R1 they are at home and offer to assist in calling them. Initiated 6/11/2020. -If wearing a jacket and is not going on an outing, offer a sweater or sweatshirt and attempt to reorient. If states [R1] needs to leave the facility due to being confused or disoriented, attempt to reorient to staying at facility. Initiated 1/10/2022. -If awake overnight and disoriented, offer a snack and drink and attempt to reorient time and location. Initiated 12/3/2021. -Please check Wanderguard device weekly and PRN to ensure it is attached to ankle and working correctly. Initiated 11/16/2018, revised 10/12/2021. -Provide structured activities: toileting, reorientation strategies including signs, pictures, memory boxes. Initiated 11/16/2018, revised on 1/10/2022. -The lobby doors opening to the elevator will be shut with a stop sign to serve as a visual reminder from 2000 to 0800 in attempt to keep from visualizing the location of the elevators. Initiated 7/17/2020, revised on 10/12/2021. -There is a mural on the exit door hoping to divert attention away from door. Mural was changed on 7/13/2020 due to attempts to leave facility 7/5 through 7/13. Initiated 7/17/2020. -There is a sign on room door stating [R1]'s Cabin to serve as a visual reminder that this is [R1]s room and assist in orienting when confused or disoriented. Initiated 1/10/2022. The facility internal investigation indicated: - During an interview on 1/13/2022, at 10:00 a.m. volunteer (V)-A stated R1 was approached and offered assistance back to R1's unit. R1 declined by responding, no, I'm OK. V-A left the area and continued to assist other residents. - During interview on 1/13/2022, at 10:15 a.m. CNA-A stated by around 4:30 p.m. R1 had not returned to the unit. Stated staff members were notified and a search of the unit was initiated. R1 was not found. Stated went to the first floor Found [NAME]-B and asked if she had seen R1. [NAME]-B related [NAME]-A told her a door alarm sounded but no one was seen in the area. CNA-A stated alerted other staff members and started searching outside of the facility after notifying Registered Nurse (RN)-C. CNA-B and CNA-C accompanied CNA-A began searching outside. CNA-A stated R1 was found about 20 minutes after R1 was discovered to be missing. Stated CNA-C located R1 about 3 blocks from the facility walking south on Broadway Street. - During interview on 1/13/2022, at 2:00 p.m. CNA-C stated R1 was spotted on the west side of Broadway walking south. State R1 was approached and told he would need to return to the facility. Stated R1 did not resist. Stated R1 willingly accompanied CNA-C to a nearby business establishment to warm up. CNA-C used a walkie-talkie to notify RN-A, CNA-B and CNA-A that R1 had been found. CNA-C stated R1 did not seem to be in any distress. R1 was transported back to the facility via automobile. CNA-C stated R1 was off-campus for about 40 minutes, timeline was not certain. CNA-C stated when found, R1 was wearing a jacket, blue jeans, shoes, and a face mask. R1 was using his walker. CNA-C stated when R1 was approached later in the evening, R1 did not seem distressed nor recall the incident. - During interview on 1/14/2022, at 10:30 a.m. RN-A stated she was notified between 4:30-4:40 p.m. R1 could not be located. Stated a search was initiated immediately on all floors and all units. RN-A went to the first floor and was told staff at the AL they had noticed R1 outside walking on 7th street headed toward Broadway. They stated they believed R1 was a visitor. Staff was sent to intercept R1. RN-A stated a head-to-toe assessment was completed upon return. R1 was uninjured, not distressed, and stated, I am back where I started. RN-A stated the director of nursing (DON), administrator, and R1's daughters were notified of the event. Review of progress notes on 1/26/2022, indicated R1 has worn a Wanderguard since 11/16/2018. R1 had a history of wandering and elopement attempts. R1 last eloped on 5/30/2020. Other unsuccessful attempts to leave the facility unaccompanied occurred on 5/18/2020, 5/20/2020, 9/13/20, 1/31/21, 4/23/21, 6/30/21, and 7/24/21. During an interview on 1/26/2022, at 11:48 a.m. social worker (SW)-A stated R1 was attending a concert held on the first-floor lobby area of the facility. R1, who was wearing a functioning Wanderguard, successfully eloped from the facility through an alarmed door and went off the facility grounds. R1 exited the building after the concert at about 4:30 p.m. The door connected the facility to the Arbor Terrace Assisted Living (AL). R1 exited through this door, set off the Wanderguard alarm, exited through a second door in the AL to 7th street, and proceeded towards Broadway Street. SW-A stated R1 was wearing a coat, shoes, and a face mask. The nursing staff noted he did not return from the concert and began searching for R1 on the units. Certified nursing assistant (CNA)-A went downstairs to look for him. Life enrichment mentor, ([NAME])-B told CNA-A she did not see him, but a Wanderguard alarm had sounded earlier. CNA-A communicated via walkie-talkie system to all staff that R1 may have exited via the door to the AL. CNA-C and CNA-B searched outside and located him on Broadway Street across from the Taco Bell and escorted him back to the facility. Upon return to R1's unit, R1 was placed on visual checks every fifteen minutes. SW-A stated the elopement policy was followed. The administrator, the director of nursing, and the family were made aware of the occurrence. SW-A stated the timeline of events and notifications was not exact. SW-A was not at the facility when the event occurred. Stated SW-A and SW-B were given the details of the event on Monday morning. The report was written and submitted to the Minnesota Department of Health later that day. During an interview on 1/26/2022, at 12:18 p.m. Life enrichment mentor ([NAME])-A stated R1's daughter approached and asked that R1 be taken to the concert later in the afternoon. R1's daughter stated a friend (another resident) would also attend and sit with R1. [NAME]-A agreed. At 2:45 p.m., [NAME]-A escorted R1 to the first-floor lobby where the concert was being held. [NAME]-A stated R1 was wearing blue jeans, shoes, and a jacket. R1 was seated next to his friend. [NAME]-A stated she was seated near them for the duration of the concert. At 3:50 p.m. R1's friend left the concert and returned to her unit to attend another event. R1 remained and continued to listen to music. At the conclusion of the concert, [NAME]-A stated she assisted other residents to their unit. R1 remained in his seat. When [NAME]-A returned to help escort other residents to their units, R1 was not in the area. During an interview on 1/26/2020, at 12:18 p.m. [NAME]-B stated she sat near the back of the room, behind the residents, and did not notice R1 had attended. Stated she started escorting residents back to their units and heard the Wanderguard door sound at about 4:35 p.m. Stated she did not see anyone in proximity to the alarm. The alarm is connected to a that door leads to a hallway that leads to the Assisted Living (AL) facility next door. [NAME]-B stated she looked in the stairwell, chapel, outside courtyard through the window, exercise room, and the hall to the AL. Stated she believed someone may have just gotten too close and the alarm may have been triggered the alarm. Stated returned to assist residents. During an interview on 1/26/2020, at 1:00 p.m. DON stated the daughters have been informed the facility does not have a memory care unit that is locked. R1 would benefit by transferring to a memory care unit with a locked ward for better safety. DON stated daughters agreed and have started searching for another facility with help from social services staff members. The past noncompliance immediate jeopardy began on 1/08/2022. The immediate jeopardy was removed, and the deficient practice corrected by 1/14/2022, after the facility successfully implemented a systemic plan that included the following actions: - Electronic medical record reflects a comprehensive elopement risk assessment for R1 was done on 1/10/2022. Care plan revisions included visual checks every 15 minutes. - A new policy, Wanderguard Safety During Life Enrichments Programs was created and implemented on January 14, 2022. Document, Dept Meeting Samaritan Bethany Sign in Sheet, was signed by all life enrichment department staff members. Inservice was titled Life Enrichment Wanderguard Safety Policy Review. Inservice dates were indicated to be 1/14/22-1/17/22. A copy of the new policy was attached. A copy of this policy and the Wanderguard resident roster was posted in the department on the wall. - Policy titled Wanderguard Use, policy number RPP-16A originated May 1999, was revised and dated 1/22. Revisions included: -f. If the Wanderguard system alarms on the neighborhood, staff must immediately respond to the exit with the sounding alarm and search surrounding areas to determine what triggered the alarm. Staff must account for the whereabouts of all residents who wear a wanderguard on the neighborhood at this time. -g. If the Wanderguard system alarms on the main floor, staff must respond immediately to the exit with the sounding alarm and search the area until it is determined what triggered the alarm. - Document, Dept. Meeting Samaritan Bethany Sign in Sheet, was signed by nursing, maintenance, corporate, and environmental services staff members. Inservice was titled Life Enrichment Wanderguard Safety Policy Review. Dates of signatures were listed as 1/13/2022 to 1/17/22. Updated policy was attached.

Based on interview and document review, the facility failed to recognize, assess and implement interventions to prevent pressure ulcers, for 1 of 1 resident (R1) who developed a stage 4 pressure ulcer, resulting in immediate jeopardy when R1 was transferred to the emergency department (ED) due to a change of condition and the pressure ulcer was first identified. Although noncompliance was present at the time of the event, the facility had implemented appropriate corrective action prior to the survey, resulting in a finding of past-noncompliance immediate jeopardy for R1. The past noncompliance IJ began on [DATE]. The IJ was removed and the deficient practice was corrected by [DATE], after the facility had developed and implemented a systemic plan that included: re-education of staff regarding the importance of comprehensive skin inspections, comprehensive skin inspections were conducted by licensed staff of residents' skin, and the facility immediately suspended, and subsequently terminated the licensed staff member who was responsible for the completion of the skin inspections. A facility house wide plan to audit all charts for completion of skin inspections was also developed and initiated. Findings include: R1's ED visit note dated [DATE], indicated R1 presented to the ED with altered mental status. The Impression and Plan Section of the note indicated R1 had presented with [MEDICAL CONDITION](increased heart rate) and was febrile (had a fever), and responded to painful stimuli only. Further, the ED visit note indicated the physician had ordered a CT scan to rule out deep seated abscess given the significance of a coccyx wound. R1's CT scan (computed tomography, scan allows doctors to see inside the body) report dated [DATE], indicated R1 had arrived at the ED at 4:21 p.m. and the CT imaging study of R1's pelvis was ordered at 4:47 p.m The CT report further indicated CT scan had been initiated at 6:43 p.m. and was completed at 6:59 p.m. The radiologist report included, Findings: Sacral ulcer with gas and fluid extending to the tip of the coccyx cannot exclude osteo[DIAGNOSES REDACTED]. Gas and fluid also tracks from the skin near the superior gluteal crease into the pelvis towards the right lateral wall of the rectum. No definite connection to the rectum or sigmoid colon. Significant surrounding inflammation and overlying skin thickening. Exact measurements are difficult given the irregular shape but the connection likely measures at least 7 cm (centimeters) in greatest dimension. A vulnerable adult report submitted to the State Agency on [DATE], indicated R1 was transferred to the emergency room related to a change of condition on [DATE]. The report indicated upon arrival to the ED the physician rolled R1 over and identified a stage 4 decubitus ulcer on R1's buttock area. The facility transfer records had not identified and/or addressed any skin ulcer. R1's hospital discharge summary dated [DATE], included [DIAGNOSES REDACTED]. The hospital course note included, (R1) was a [AGE] year old female with past history of significant dementia and came to us from a skilled nursing facility due to increased cognitive decline, confusion, fever. While in the ED, CT was remarkable for sacral ulcer with gas and fluid filled extending to the tip of the coccyx. (R1) was admitted to (location of hospital) [MEDICAL CONDITION] secondary to a sacral decubitus ulcer. After evaluation and discussion with family, patient was deemed to not be an appropriate candidate for surgery. She was transitioned to comfort cares, R1 died on [DATE], at 7:54 a.m. R1's Admission Record, included [DIAGNOSES REDACTED]. R1's activities of daily living care plan dated [DATE], indicated R1 had a self-care performance deficit, and included R1 required skin inspections daily, observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse. For bathing R1 required help for sponge baths every Monday and Thursday mornings. R1's skin care plan dated [DATE], included R1 had the potential for pressure ulcer development related to decreased mobility and incontinence; R1's goal was to have intact skin free from redness, blisters, or discoloration. The pressure ulcer care plan directed staff to follow facility policies for the prevention/treatment of [REDACTED]. The care plan also indicated R1 had a behavioral problem related to senile degeneration of brain and had a history of [REDACTED]. R1's Braden Scale for Predicting Pressure Ulcer Sore Rick dated [DATE], indicated R1 was at moderate risk for pressure ulcers because R1 had slightly limited sensory perception, skin was occasionally moist, the resident was chair fast, had very limited mobility, probable inadequate nutrition, and had the potential for friction and shear. R1's progress note on [DATE], at 2:27 p.m. indicated R1 had refused her shower and also refused nurse to look at her skin, however the note indicated the nurse was able to see R1's bottom while R1 was being changed, and the nurse documented it was not red, irritated or broken down. R1's progress note dated [DATE], at 10:43 a.m. indicated R1 refused her shower and all cares and reattempts were made with continued refusals. R1's progress note dated [DATE], at 10:43 a.m. indicated R1 refused shower/bed bath and all cares twice. The note indicated R1 was combative and agitated with the caregiver. R1's progress note dated [DATE], at 3:37 p.m. indicated a complete skin check was done. The note included: No areas of redness, irritation, or skin breakdown over bony prominences were present. Skin appears pale/dry/warm. Coccyx/heels are intact. A late entry for [DATE], dated as documented [DATE], at 7:08 a.m. (31 days later) included: Resident refused bath/shower. Caregiver attempted to assist resident; was only able to change her incontinent pad. A late entry for [DATE], dated as documented on [DATE], at 7:11 a.m. (28 days later) included: Resident refused shower today. No redness, irritation, or skin breakdown observed. Nails need to be trimmed however, resident refuses nail care. Heels/coccyx are intact. R1's record lacked evidence of any further skin evaluations/assessments by a licensed nurse documented in real time after [DATE]. R1's progress note dated [DATE], indicated family member were concerned about the resident's weakness and that R1 leaned to the right or forward while sitting in wheelchair or at meal times. R1's progress note dated [DATE], indicated R1 declined repeated attempts at getting her up and dressed for the day. The note indicated the caregiver had approached resident on 3 separate occasions, however, after working with the resident, R1 became agitated and attempted to hit staff. The note further indicated the caregiver had been able to dress R1's bottom half of her body, including a clean, dry incontinence brief. R1's progress note dated [DATE], indicated R1 received a tilt-n-space wheelchair for better positioning. R1's progress note dated [DATE], at 2:15 p.m. indicated R1 had refused to get up that morning/mid-day/afternoon, temperature was 99.0 degrees and respirations were 16. The note indicated staff changed R1's incontinent pad once that morning and that R1 had refused since that time. The note further indicated the nurse had instructed caregivers to continue with efforts at changing and repositioning for comfort, as well as skin protection. R1's progress note dated [DATE], at 6:12 p.m. indicated the nurse had been made aware of R1's status during change of shift at 3:00 p.m. The note indicated when the nurse had gone to check on R1, R1 was laying in bed and was unable to open her eyes or follow verbal commands, was lethargic, and had mental status changes. Vitals were taken and documented as: temperature 99.3 degrees, heart rate 111, respirations 22, and blood pressure ,[DATE]. The note indicated R1's family had been contacted, and the daughter had expressed concern that her mother was off the night prior, [DATE]. The daughter requested her mother be sent to the ED, so the ambulance had been called and R1 was transferred to the emergency room at 4:05 p.m. R1's progress note dated [DATE], at 11:15 p.m. indicated at 11:00 p.m. a family member called the facility to notify staff the resident was being admitted to the hospital for comfort care. A progress note dated [DATE], at 12:15 a.m. indicated a facility nurse had contacted the hospital to get an update on R1. Hospital staff had stated they were busy and the nurse should call back later. Documentation indicated the facility's nurse had attempted twice more to contact the hospital for an update, and had left the facility's phone number for a return call. At 1:30 a.m. a hospital nurse had returned the call and provided an update. The hospital nurse reported the Resident has a pressure ulcer to her coccyx area along with a UTI (urinary tract infection) and was septic. The hospital nurse also reported the family was not pursuing any further treatment and R1 was put on comfort care. During an interview on [DATE], at 10:50 a.m. physician assist (PA)-A reviewed R1's hospital course to discuss with the surveyor. PA-A stated upon admission to the ED, a large pressure ulcer was identified on the coccyx. PA-A stated pictures of the ulcer were uploaded to the electronic health record on [DATE] at 4:41 p.m. PA-A viewed the pictures and confirmed there was an ulcer to the coccyx, but stated from the picture it was difficult to determine the exact staging. However, PA-A reviewed the radiologist report and stated the ulcer had fluid tracks around the sacrum and rectum which was indicative of infection. PA-A stated the gas and fluid tracks referred to tunneling. PA-A also stated R1's wound would have required extensive surgical debridement. PA-A stated through discussion it had been determined the surgical procedure would be too much for R1. As a result, the family and physicians determined palliative/comfort care was more appropriate. PA-A stated, There is no way that pressure ulcer developed in a couple of hours. PA-A further stated it would be difficult to determine how long the ulcer had been there or when it started, but stated it had not just happened, when R1 was admitted to the ED. During an interview on [DATE], at 11:20 a.m., registered nurse (RN)-A stated no staff had ever reported any concerns regarding R1's skin condition to her, and stated she had never seen R1's skin breakdown before. However RN-A acknowledged she did not provide direct care for R1. RN-A further stated R1 had started to have a decline in condition and did not want to get out of bed at times before going to the ED. RN-A reviewed R1's record and confirmed the lack of skin evaluations since [DATE]. In addition, RN-A confirmed the late entries entered for ,[DATE] and [DATE] were very late. RN-A stated R1's care plan lacked a turning and repositioning schedule which should have been determined based off a tissue tolerance test. RN-A stated R1's skin was supposed to be evaluated by a licensed practical nurse (LPN) at least once per week, and if impaired skin was identified an RN would be notified to conduct weekly wound assessments. RN-A stated she had gone through nursing progress notes and identified that LPN-Z had not conducted any weekly skin progress notes. RN-A also stated LPN-Z was not instructed to make the late entries on [DATE]. RN-A stated LPN-Z was put on a personal improvement plan. RN-A indicated on [DATE], she had personally assessed the skin of each resident from the 4th floor where LPN-Z worked, but had not identified any other areas of impaired skin integrity. RN-A also stated she had initiated immediate education for all direct care staff, and had begun audits of watching staff provide personal cares including perineal care. RN-A stated as soon as the issue had been identified for R1, the facility had initiated an effective auditing system to ensure skin evaluations were completed. During an interview on [DATE], at 12:49 p.m. the facility's RN directors of nursing, referred to as clinical mentors (CM)-A and CM-B were interviewed. CM-A and CM-B stated LPN-Z had been terminated because it was verified through the facility's investigation LPN-Z had not completed R1's weekly skin inspections per facility protocol. CM-A added it could not be determined whether the documented late entry skin assessments had been completed on ,[DATE] and [DATE], and stated they had been unable to identify why LPN-Z had documented the assessments so late. CM-A indicated documentation was supposed to be completed in real time. CM-A and CM-B stated all staff that worked on R1's unit had been interviewed and none of the staff stated they had seen any kind of wound and/or skin breakdown on R1's bottom. In addition, CM-A stated nursing assistant (NA) staff interviewed consistently verified LPN-Z would tell the NAs to complete residents' skin inspections, and let her (LPN-Z) know if they found anything, or LPN-Z would tell the NAs she would check the resident's skin later. CM-A stated while interviewing staff, they had also provided education pertaining to responsibilities of the licensed staff member, and had provided re-education on completing thorough skin checks while providing personal cares. CM-A stated skin checks had been completed for all residents who resided on R1's unit as of [DATE], and an auditing system to ensure completion of weekly skin checks had been developed and implemented. During an interview on [DATE], at 2:49 p.m. NA-B stated NA's completed personal care training annually. NA-B was able to articulate the bony prominences that were at risk for pressure ulcer development, and stated licensed staff were to complete skin inspections on bath days. NA-B said if an NA found any open areas during cares they were suppose to immediately report them to the nurse. During an interview on [DATE], at 2:57 p.m. NA-C stated licensed nurses were supposed to complete skin checks on each resident on their bath day. NA-C stated the NAs would report to a nurse if they found any skin problems during personal cares. During an interview on [DATE], at 3:20 p.m. NA-D stated she was very familiar with R1 and had provided care the day R1 went to the hospital. NA-D stated when she had provided R1 with cares that morning, R1 was a little resistive however, she was able to wash her face and washed her peri area. NA-D stated, I didn't see a thing. NA-D further stated she was always very thorough and was diligent when it came to checking skin for breakdown, but had never seen anything on R1's bottom, not even a red dot. NA-D stated R1 used the bathroom, was not incontinent very often, required bed baths because she did not like water, and sometimes was resistive to cares. NA-D stated she would report LPN-Z when R1 was ready for her skin inspection, and LPN-Z would tell her (NA-D) she was too busy, so just to let her know if she (NA-D) found anything wrong, and that she (LPN-Z) would tell NA-D she'd check the residents' skin later. NA-D stated she did not know if LPN-Z ever completed the skin inspections. NA-D stated after R1 went to the hospital, the facility's nursing administrative staff had provided education about who could complete the weekly skin inspections, and had re-educated staff about checking skin daily with cares. During an interview on [DATE], at 3:33 p.m. NA-E stated she had worked with R1 a week or two prior to her hospitalization and had not seen any areas of skin breakdown or anything different on R1's bottom. NA-E also said R1 had not voiced pain, and did not appear to be in pain. NA-E stated it wouldn't be uncommon for her to refuse cares, and said staff would leave R1 alone and attempt later. NA-E stated R1 received bed baths twice a week, and used the standing lift for toileting. NA-E stated LPN-Z was supposed to complete the skin checks but wasn't, and LPN-Z would expect the NA's to do the skin inspections and just let her know if we found anything. NA-E stated LPN-Z was the only nurse that would expect the NA's to do that. NA-E verified after R1 was hospitalized , she was provided with education on expectation of nurses to complete the skin assessments no matter what. During an interview on [DATE], at 8:29 a.m. NA-F stated she started working on the 4th floor unit after R1 was hospitalized . NA-F described the protocol appropriately for nurses to complete the weekly skin inspections, and described that the NAs were supposed to check the skin daily with cares and report to the nurse if they found any concerns. During an interview on [DATE], at 8:43 a.m. LPN-Z stated R1 had started to have decline in condition about a week before hospitalization and had started refusing to get out of bed. LPN-Z stated the day R1 went to the hospital R1 was refusing cares. LPN-Z stated R1 had been changed twice that day before she was transferred, and LPN-Z stated she had visualized R1's bottom both times and there had been no evidence of skin breakdown at all. LPN-Z further stated she was told the next morning that R1 had been diagnosed with [REDACTED]. LPN-Z confirmed she had instructed the NAs to complete weekly skin inspections, and said she would tell the NAs she would check the residents' skin later, and NAs would not let her know when residents were ready for the skin inspections. During an interview on [DATE], at 10:39 a.m. NA-G stated she had provided cares for R1. NA-G stated LPN-Z would tell her it was her job to complete the resident's skin inspections, and to let LPN-Z know if there were any skin problems. NA-G stated she had not provided care for R1 the day she was hospitalized , but said she had completed her bed bath three weeks prior and had not seen any skin problems. On [DATE], at 3:30 p.m. pictures of the ulcer were obtained from the hospital's records department. It was observed R1 had a significant size pressure ulcer between her rectum and the coccyx where the inside of the wound was not visible, in addition inside the gluteal folds, the skin was red and denuded/abraded (scraped or worn away). The size of the ulcer was compared to a gloved fingertip in the photos; the size of the ulcer was larger than a quarter, smaller than a half dollar coin. At the 8:00 o'clock position to the 10:00 o'clock wound edges were black consistent with necrosis. Between the 12:00 and 1:00 o'clock position the inside edges had white slough. During an interview on [DATE], at 1:01 p.m. the complainant reported not having visualized the stage 4 pressure ulcer, and stated the ED physician who identified the ulcer during physical assessment upon R1's arrival, had reported the findings. The complainant stated the ED physician had also reported the family was not aware of the wound, the wound was not identified on any of the medical records provided, so therefore a vulnerable adult report for allegations of neglect of care were forwarded to the State Agency for further investigation. On [DATE], at 10:53 a.m. family member (FM)-A stated the facility had never informed her of any areas of skin breakdown on R1's bottom. FM-A stated R1 had been transferred to the hospital from the facility on [DATE], and died 7 days later on [DATE], while still in the hospital. FM-A stated R1, died a horrible death, and did not deserve that, it was a horrible week, and it hurt everybody. FM-A stated the doctors had reported to her the extent of infection in R1's wound caused R1's death. FM-A further stated she had arrived minutes after R1 arrived in the emergency department. FM-A stated upon arrival at the ED, she'd been greeted by the nurse practitioner who had informed her that R1 had a very serious stage 4 pressure ulcer on her bottom, and had then been shown a photo of the wound. FM-A described the pictures of the wound as shocking. FM-A stated the doctor and surgeon had then joined the conversation and had reiterated for FM-A how bad R1's wound was. FM-A stated they'd told her R1 probably wouldn't survive surgery to remove the infection and had given the family 3 options: 1) surgery to clean out the wound, 2) antibiotics that would take a couple of weeks to be effective, or 3) palliative comfort care. FM-A stated at that point, it was decided to put R1 on comfort care. FM-A stated later that day, she had visualized the open area on R1's bottom herself, when hospital staff turned R1 on her side. FM-A said, It (the wound) was right there and could not be missed or mistaken. There is no way anybody could have missed that. FM-A further stated, The staff didn't even have to spread the buttocks apart to see how big it was. To see the depth, they probably would have had to pull back on the buttocks a little bit. The wound was very deep, and the doctors reported it went all the way to her bone. FM-A also stated during R1's hospitalization , the wound caused a lot of pain and anytime any pressure was placed on the wound area, or when staff rolled R1, tried to position her, or performed wound care, R1 would display pained facial grimaces. FM-A stated R1 was on a lot of pain medication. FM-A stated when R1 was at the nursing home, she (FM-A) was not in the room when NA staff would provide incontinent care, and since R1 was transferred by a standing lift she could not see R1's bottom because there was not enough room to get behind her to allow for visualization of R1's bottom. FM-A stated during extended visits, which she had frequently, she (FM-A) had never witnessed the NAs repositioning R1 to a different position, or standing R1 with the lift. FM-A stated R1 was not strong enough to independently change her position off her bottom. FM-A stated upon reflection of the time before R1's death, FM-A now questioned whether R1's wound had been the reason R1 had started to lean to the right and forward in her wheelchair at the nursing home. The facility's [DATE] Skin/Wound Care Policy, included: It is the policy of the facility to identify and assess residents whose clinical conditions increase the risk for development of skin issues and pressure ulcer/wounds, to implement preventative measures, and to provide appropriate treatment measures for pressure ulcers/wounds .4. Skin integrity is inspected daily during the performance of nursing care, paying close attention to bony prominences. Caregivers will report any problems or concerns to licensed nurse . 6. A licensed nurse inspects areas of bony prominences weekly, and documents the findings. The past non-compliance immediate Jeopardy began on [DATE], The immediate jeopardy was removed and the deficient practice corrected [DATE] when the facility had implemented corrective action. Verification of corrective action implementation was confirmed by interview with a number of facility staff, and by review of documentation. When the facility became aware of R1's pressure ulcer on [DATE], they immediately implemented an investigation and conducted assessment of skin for all other residents residing on the same unit as R1, and developed a system for systemically monitoring residents throughout the building. All nursing caregivers were re-educated on completion of thorough skin checks, and policies for notifying the nurse of any changes in skin condition, pain, and interventions were reviewed with staff. The facility verified LPN-Z had failed to complete skin assessments in accordance with the facility's required policies resulting in LPN-Z's termination [DATE].

Based on observation, interview and document review, the facility failed to comprehensively investigate and ensure resident protections for 1 of 2 residents (R1) reviewed for an allegation of abuse. The facility's failure to protect residents resulted in an immediate jeopardy situation. The immediate jeopardy began on 5/11/19, when the facility failed to protect and investigate an allegation of abuse for R1 who was noted to have scratches and bruising of unknown origin. The IJ was identified on 5/24/19, and the assistant director of nursing, director of nursing and administrator were notified at 5:36 p.m. The immediate jeopardy was removed on 5/26/19, at 1:20 p. m., after it could be verified the facility had implemented an acceptable removal plan however, noncompliance remained at the lower scope and severity level of G, isolated with actual harm for R1, who experienced injuries to the face and leg of unknown source. Findings include: During observation on 5/23/19, at 10:40 a.m., R1 laid in bed sleeping. There were no staff present in R1's room or within eye sight outside of R1's room. At 10:46 a.m., unit coordinator (UC)-A looked into R1's room and then stood outside of R1's room by a piece of wooden furniture along a wall. At 10:48 a.m., R1 sat up on the side of the bed. R1 had one shoe on and held the other shoe in her hand while standing holding onto her walker. UC-A informed an unidentified staff person to go into R1's room and help her. R1's progress note (PN) identified on 5/7/19, at 11:02 a.m., a 1:1(staff present with resident 24/7) had been initiated due to R1's increase in wandering. The note indicated R1 had also been added to the facility's wanderguard list, and indicated R1's care plan would be reviewed and updated. An undated sheet of paper located outside R1's room in a drawer identified 1:1 Tracking: Do not leave resident unattended for any reason. If you are going on break you need to find the nurse, let them know you are leaving and who is covering while you are gone. You are not to leave unless there is someone to cover 1:1 hours. If you are covering someone's break, your are to sit with the resident in full view and not move. Please carry a radio so you can call for assistance with coverage. An initial report to the State Agency (SA) dated 5/11/19, at 1:13 p.m. identified an allegation of physical abuse of unexplained injury. Details on the report included: 2 abrasions to forehead and purplish bruise to left lateral leg occurred in the resident's (R1) room. A description of incident included: Family notified nursing that resident had abrasions to forehead. Staff completed an assessment and talked with nursing staff on duty as well as the resident. Resident reported, (Staff name) was hitting the hell out of me and then was scared when I saw blood. Resident had also stated to daughter, Have you ever seen blood on a black person before. Nursing asked if she had fallen and she stated No. Nursing reviewed report sheets and did not find a staff named (name). Review of the facility's internal investigation regarding R1's allegation, included a panel interview with possible witnesses, alleged perpetrators (AP), and residents. The investigation panel included the director of nursing (DON), administrator, social worker, assistant DON, unit coordinator and registered nurse (RN). Although the facility claimed no wrongdoing occurred, the investigation indicated R1 had made similar comments to that of a police report, such as: It was like a girl getting raped and someone beating her, hitting the hell out of her and scared once the (AP) saw blood. The investigation also included an interview with nursing assistant (NA)-C. The investigation indicated NA-C had verified R1 was agitated and was refusing to go to bed to be changed. NA-C stated R1 had said, do not touch me. The interview with NA-C also indicated she had to get another staff (NA-E) to put R1 to bed because R1 was refusing cares. The facility's investigation report also included an interview from NA-E which confirmed R1 was very agitated, and had taken 15-20 minutes to lay R1 down. NA-E had stated R1 was grabbing at her (NA-E) so she'd allowed R1 to hold her hands the whole time. NA-E had reported trying to calm R1 down while NA-C changed her. R1 was talking of random things such as car, house, blue car. Both NA-C and NA-E stated they'd noticed a bump on R1's forehead and claimed they'd updated the nurse on duty. R1's 30-day Minimum Data Set (MDS) assessment dated [DATE], included [DIAGNOSES REDACTED]. The MDS also indicated R1 had moderate cognitive impairment, did not have any verbal, physical, or rejection of care behaviors, and indicated wandering had occurred during 1 to 3 days out of 7 days in the assessment period. The MDS further indicated R1 required extensive assistance from one staff for dressing and limited assistance for transfers, bed mobility, toileting and personal hygiene. R1's vulnerable adult care plan dated 4/12/19, included: I am considered a vulnerable adult due to my need for inpatient therapy and some assistance with my daily care needs. I am at risk for elopement. I am not at risk of harming others or myself. I would not be able to report maltreatment d/t (due to) dx (diagnosis) of dementia. The care plan directed all staff to keep her safe, upon notification of possible/actual Vulnerable Adult incident; immediately assess, prevent further harm and notify the Community Leader (administrator), and Remove me from an actual or potentially dangerous situations. The care plan also indicated R1 had cognitive impairment and indicated staff were to speak in a calm voice, reorient as needed/appropriate, allow resident choices offering no more than 2 at a time to prevent overwhelming with decision making. Reproach if resident becomes overly anxious and keep her informed of what is happening. (R1) would like staff to allow her to express herself because (R1) is at risk for both receptive and expressive communication problems. The care plan also indicated R1 had impaired visual function and can see objects/shapes/light/dark; required assistance with one caregiver for dressing and toilet use; Uses a FWW (front wheeled walker) to ambulate to and from the bathroom; Had a potential for disruptive behaviors, and would like staff to be aware of when she may be becoming more agitated/distressed. Care plan approaches indicated staff were to reassure and reproach the resident as necessary and to explain the reasons for both care and other interventions. R1's Visual/Bedside Kardex Report (used by nursing staff), hung outside the resident's room. Information on the Kardex indicated staff are to speak in calm clear voice, reorient as needed/appropriate, allow resident choices- offer no more than 2 at a time, to prevent problems with decision-making. Re-approach if resident becomes overly agitated and keep her informed of what is happening. In addition, the Kardex indicated R1's toileting would be done by one caregiver, and use of gait belt with FWW to ambulate to/from bathroom. A Police Department event report dated 5/11/19 regarding an incident for R1, indicated an officer had been dispatched to the facility on [DATE] at 3:15 p.m. to respond to an allegation of assault. After interviews, the officer's conclusion indicated there was no evidence to indicate an assault occurred. Case status is unfounded. The police report included interviews with family members, staff and residents: Family member (FM)-A interview indicated FM-A had last seen R1 5/9/19, and R1 had been fine. FM-A reported when visiting R1 today (5/11/19), there were beating marks on R1's forehead and face. FM-A was alarmed because the marks hadn't been there Thursday (5/9/19), and no one called FM-A to update about any injuries to R1. FM-A had also reported a softball sized bruise on R1's left shin. FM-A was concerned R1 had been kicked. The interview documentation indicated FM-A had stated R1 had her own room and someone was assisting her 24/7. FM-A had reported not feeling the injuries were consistent with a fall. FM-A had reported, A few years ago a similar incident with (R1)'s husband occurred. Licensed practical nurse (LPN)-A had reported to the police officer that R1 was normally 1:1 to make sure R1 does not wander or fall. LPN-A had reported if there was a shortage, staff members would check in R1's room frequently because (R1) is quick. LPN-A had also reported R1 made frequent trips to the bathroom although she was supposed to press the call button for staff to assist. LPN-A reported during the police interview R1 yells often and will aggressively yell when she doesn't want something. LPN-A said she had been at work at 5:50 a.m. on date of allegation and R1 was already up walking around. Registered nurse (RN)-A had reported to the police officer she'd seen R1 the night prior and had not noticed any marks on the resident at that time even when she was helping with R1's neck brace. RN-A had reported to the police she understood R1's family was upset because of an incident that happened a few years ago with R1's husband. RN-A also reported R1 was supposed to be on 1 to 1 because she would wander into other residents' rooms. RN-A had further reported there was insufficient staff the previous day to ensure a 1-to-1. RN-A reported an employee who came in that morning (5/11/19) had noticed the marks on R1's forehead and had asked night shift nursing assistant (NA)-C about it. RN-A reported NA-C had told that employee she did not know how it had happened, and NA-C had told the employee she'd been with R1 all night. RN-A said R1 made a comment at the lunch table asking another resident, Have you ever seen blood on a black person before. (NA-C and NA-E are both black.) RN-A had reported R1's injuries must have happened sometime overnight. Finally, RN-A verified NA-C and NA-E had been placed on leave until the investigation is completed. The police officer's report indicated all R1's scratches were scabbed over, but were still slightly red in color. R1 had a softball sized bruise on her left shin, which was purple and blue in color. The officer documented R1's answers to the officer's questions were inconsistent, although when the officer had asked R1, Did someone give you those scratches? R1 answered, like if there was a girl getting raped, that was it. R1 had stated not knowing how it had ever gotten to that point. The officer asked, Can you describe the person who gave you the marks on your forehead? R1 answered, He was kind of starky (starkly) and thinks they were both there. They were so, hard fisting back and forth. Officer asked, They were fighting? R1 said, yes with her. A guy in the back was twisting arms and legs. The officer asked R1, Did you fight with someone last night? R1 said, between the two of them they 'beat the hell outta me'' Documentation indicated NA-E had also been interviewed by the police officer. NA-E had reported to the officer R1 was antsy that night, did not have a good day according to the day shift, and was rather agitated. NA-E reported having helped R1 to bed around 2:00 a.m. at which time NA-E reported having noticed the small bump on R1's forehead when they (NA-C and NA-E) put R1 to bed. NA-E also told the police officer R1 was supposed to be 1 to 1 during the day, but did not think they had someone with her that day due to staff shortages. Documentation indicated NA-C was interviewed by the police officer. NA-C said there was a lady that was up all night and refused to go to bed. NA-C reported she'd been with the lady the whole night walking around and being out in the common area. NA-C described the lady as wearing a neck brace and walking with her head down a lot. NA-C further identified the lady as R1, and reported R1 had been screaming about not wanting to go to bed and had not wanted NA-C or NA-E to check to see if she had peed herself. NA-C told the police officer she had finally grabbed a wheelchair and they helped R1 back to her room. NA-C stated they'd put R1 to bed around 1:49 a.m. and NA-C reported she'd noticed a bruise on R1's forehead when she put her to bed. The documentation indicated NA-C did not remember seeing a bruise on R1's forehead when she'd arrived for work at 6:00 p.m. R1 skin observation record was reviewed from 4/16/19-5/28/19. NA-B who worked on R1's unit documented: -5/10/19 none of the above observed -5/11/19 scratched -5/15/19 scratched R1's PN reviewed from 4/16/19-5/24/19, included: A PN from 5/9/19, indicated R1's skin inspection was completed that evening after a shower; (R1's) skin is pink, warm, dry and intact overall. Scab over right elbow, small older bruise turning yellow on hip, no other concerns. R1's PN dated on 5/11/19, at 11:30 a.m. included, There is a bruise on her left lateral leg that is black is 5 x 2 inches. The abrasion on the left side of the head is 0.5 x 0.5 cm (centimeters). The abrasion in the middle of the forehead is 4 cm x 1 cm. The lacerations on the right side of the head, one is 1 cm, and the other is 2.5 cm. NA-E was interviewed on 5/23/19 at 1:49 pm. NA-E verified having worked the overnight shift on Friday 5/10-Saturday 5/11/19. NA-E stated she'd been told not to come back to work until an investigation related to R1's injuries had been completed. NA-E said she'd seen the scratches on R1's forehead but had not reported them because she'd only gone over to help NA-C get R1 to bed. NA-E reiterated she'd been working on the other side, and did not report because she thought other staff had reported it already. When asked how R1 had acted the night she'd assisted her to bed, NA-E said R1 had been agitated, confused, not making sense, and had been walking around up and down the halls from what she could see from her unit. NA-E stated she'd assisted NA-C with getting R1 to bed and once in bed they had changed R1. NA-E said R1 was holding her (NA-E)'s hands and said R1 was talking about random things such as blue car and billing. NA-E stated when they had provided pericare the light was on low but she had noticed a scratch on R1's forehead and had asked R1 what had happened, but R1did not know. NA-E stated, This happened about 1-2 a.m. when NA-E helped NA-C with R1 and noticed the forehead, NA-E stated no blood was noticed. During an interview on 5/23/19, at 2:13 p.m. FM-A acknowledged having visited R1 on 5/11/19, at 11:30 a.m. FM-A stated R1's face was messed up and that she'd taken pictures. FM-A stated NA-D had reported to her she'd started her day at 6:00 a. m. and had helped R1 get ready for the day, but there was no communication to the nurses regarding R1 injuries to her face. FM-A said, I would have thought someone would have noticed. FM-A stated R1 would have to have fallen several times to get those injuries. FM-A also said she'd received a call from staff the Monday before the incident (5/6/19), letting her know they were going to place R1 on one to one (1:1) supervision because R1 was wandering, and stated they also placed an ankle bracelet on R1. FM-A said staff have since told her no one is aware why there was no 1:1 with R1 the night of the incident. During an interview on 5/24/19, at 8:05 a. m. NA-C stated, Unfortunately the incident happened on my shift. (R1) was supposed to be on 1:1, but no one was available. NA-C said she had noticed the bruise on R1's forehead at about 1:45 a.m. NA-C added, She (R1) is usually continent, but she was incontinent that night and does not like people touching her. (R1) was walking around with her walker when another resident called her (NA-C) to tell her (R1) had to go to the bathroom. NA-C said she'd said to R1 Let's go to the bathroom. NA-C said she could tell R1 was incontinent because she'd felt R1's disposable underwear over her pants. NA-C said R1 had stated, No, no, no, no, no when NA-C took R1 to her the room. NA-C stated she'd tried to put R1 in bed but R1 kept saying no no when NA-C tried to lay R1 down. NA-C then said if she could not get R1 to bed, she couldn't change her and stated it was hard to put R1 to bed. When NA-C was asked what R1 was doing while she was trying to get her in her room, NA-C said R1 was pushing her away, but stated R1was not strong enough to hurt her (NA-C). NA-C also stated R1 was moving her arms and kept saying no, I don't want to go with you. NA-C said when R1 wouldn't go to bed, she (NA-C) had called NA-E from the other unit to help her. When asked how the two of them got R1 to bed, NA-C said, With one in back and one in front. NA-C said they completed it fast and flipped her in bed. NA-C added, (R1) is not normally a two people assist. NA-C said when she first started; R1 had required limited assist, but did not like people doing stuff for her. NA-C said, When (R1) gets like she did that night, she needs 2 assist. When questioned about the 1:1, NA-C said she did not know why R1 did not have a 1:1 that night. NA-C also stated she did not know how the bruise happened because she hadn't heard any screaming. NA-C said, If she hurt herself, I would have heard her screaming, I did not hear any screaming that night, but I was not with her the whole night. NA-C said although she'd noticed the marks on R1's head, she couldn't recall whom she told. NA-C added, It would be neglect if I kept her wet. NA-C was asked about what training she'd had to care for R1. NA-C said she had not been working at the facility long, and stated, It's a learn as you go, depends on the residents. (R1) does not like people to do stuff for her or touch her. (R1) has no behaviors if she's in a good mood, but if she's in a bad mood, she will not let anyone touch her. NA-C said, If I know she is dry and in a safe place, I let her be. During a follow-up interview with NA-E on 5/24/19 at 9:14 a.m., NA-E again said she'd helped NA-C put R1 to bed. NA-E said R1 was already in her room sitting on her bed when she'd arrived on the unit. NA-E said both she and NA-C had tried to get R1 to roll (over), and R1 got a hold of my hands. NA-E said R1 was saying a lot of random things. When asked how they got R1 to lay down NA-E said, We assisted with two people, one had the shoulders and the other had the legs. NA-E said it took them about 10 minutes to lay R1 down because she was very confused. R1 walked around and stood up, sat down. When asked whether they had left the room when R1 was confused and didn't want to lay down, NA-E said no, they stayed in the room. NA-E said they finally got R1 to lay down. When asked what the resident did after she laid down, NA-E said, We would roll her over and she (R1) would roll her self back onto her back saying, NO. We would try to roll over again, and R1 would not roll over. NA-E stated she had held onto NA-E hands, because she (R1) kept moving over onto her back and would not move onto the other side so they could change her pants. When asked how R1 had acted while they were changing her, NA-E said, She calmed down after we changed her but was still agitated during it and was saying random things. NA-E said, (R1) would not roll over, she grabbed my hands hard, before that she was moving her hands and arms around. NA-E said R1 was talking and mumbling and NA-E said at one time she thought R1 was going to hit herself in the face. NA-E verified during interview she had received training to let residents calm down. When asked whether she'd done this for R1, NA-E confirmed she had not left R1 alone to calm down, but had stayed in the room until the cares were done. NA-E said she'd stayed with R1 because R1 had ahold of her (NA-E) arms. NA-E said NA-C had stepped away from the bed but remained in the room. During an interview on 5/24/19 at 2:22 p.m., the director of nurses (DON) said she was aware of the incident with R1. The DON said they had investigated the incident and found there was no indication someone hurt R1. The DON said most likely R1 hit a corner or scratched herself. The facility found no evidence of wrongdoing. When asked about training provided for staff to deal with resident with behaviors, the DON said, During interviews about incidents we take the opportunity to educate staff during the interviews. The DON said the alleged perpetrators (AP)'s were taken off the schedule during the investigation, but verified there had been no monitoring put in place for the two NA's and confirmed they had been allowed to come back and work with R1 without any additional monitoring. The DON stated she was unaware of R1 refusals of care that night (5/10-5/11/19), until the investigation of the incident was completed. The DON said she would expect staff to document refusals, not to pressure the resident, and to give the resident a little time to calm down if the resident continued to refuse. In addition, the DON said she would not expect staff to force a resident to be changed even if they were incontinent, if the resident had refused to be changed initially. The DON said R1's 1:1 supervision had started 5/7/19, because she was falling and had begun wandering. The DON was updated about staff indicating R1 was made to roll back and forth to change her, even though the resident had refused. The DON said she was surprised to hear that, and said residents would only have 2 staff instead of 1 in a unsafe situation. The DON also stated she wouldn't expect anyone to be forced to have his or her pants changed. During interview on 5/24/19, at 2:55 p.m., the DON stated, We cannot neglect the other residents because of having to have a one to one for R1. We would always try to have a person in sight of the resident requiring one to one and if we do not have the staff, we have someone check on the resident frequently. I do not always have staff to provide one to one. It is kind of a tuff thing. In a follow up interview on 5/24/19 at 4:12 p.m., the DON provided documentation to verify there had been no 1:1 scheduled for the night shift 5/10-5/11/19. The IJ was removed on 5/26/19, at 1:20 p.m. when implementation of an acceptable removal plan could be verified: NA-C and NA-E were removed from the schedule to complete additional training and education, and monitoring was identified to be completed each shift worked for one month. In addition, all staff on the unit were retrained about how to respect resident choices, and staff received education to confirm the use of force during provision of care would be unacceptable. The facility's policy and procedures related to Skin Injury and Abuse Prevention were reviewed for adequacy, and staff were provided training. All residents on the unit were assessed and interviewed as able to help determine the impact, or any concerns about harm related to care provided by NA-C and NA-E.

Based on interview and document review the facility failed to assess, monitor, evaluate and respond to 1 of 2 residents (R 33) reviewed for pain after a fall. This practice resulted in harm due to, R33 had increased pain after a fall, due to a fracture to the right leg identified two days later. Findings include: R33's significant change Minimum Data Set (MDS), dated [DATE], indicated R33 required one to two person physical or total assist for transfers, bed mobility, locomotion and toilet use. R33's Move in Record, dated 4/11/19, included [DIAGNOSES REDACTED]. In addition, R33's was moderately cognitively impaired. R33's Fall Quality Investigation, documented by licensed practical nurse (LPN)-B indicated date of fall was 12/19/18. Time of fall was 19:45 (7:45 p.m.). The report indicated location of the fall was in the residents room. Resident had been watching television. Resident said he was getting out of bed. There was injury of the right ankle and foot. Immediate plan to prevent additional falls was resident will be observed during overnight shift for any signs of restlessness. R33's care plan, last review completed dated, 4/5/19 included pain r/t (related to) right ankle fracture receiving [MEDICATION NAME] PRN. (R33) will appear comfortable daily through the review date. (R33) will verbalize a statement of reasonable comfort daily through next review. Administer my medication as ordered. Monitor and document for effectiveness. Follow up with MD(medical doctor)/CNP(certified nurse practitioner)/PA(physician assistant) for concerns. (R33) Need assistance with verbalizing my pain. Please use pictures to help me properly state my pain level. Encourage me to take my pain medications and follow up to make sure interventions have been effective. Observe for non-verbal s/sx (signs and symptoms) of pain, furrowed brow, agitation, resistance to cares, moaning, grimacing, [MEDICAL CONDITION], restlessness, decreased oral intake, combativeness, etc. R33's review of progress notes summarized: 12/19/18, at 19:45 (7:45 p.m.), CNA (certified nursing assistant) found resident on floor laying parallel to bed. Nurse asked resident what he was doing and his answer was he did not know. ROM(range of motion), palpation of lower extremities produced a pain in right ankle and foot. Resident could move extremities independently and stated pain was 10/10 (10 out of 10 on a scale 0-10). Residents blood pressure was 210/93. 12/19/18, at 20:31 (8:31 p.m.), Resident assessed after complaining of left (right) foot pain. Resident complains of pain when rotating the left (right) foot. Resident is able to move ankle and foot on his own. Resident blood pressure was 163/80. Ice and elevation to left (right) foot/ankle initiated and nursing staff to continue to monitor if pain in left (right) foot/ankle get worse. Resident had scheduled dose of Tylenol given this evening as well. correction of the about note 12/24/18, at 13:23 (1:23 p.m.), writer assessed both left and right ankle, but the complaint of pain were from right ankle. 12/22/18, at 07:06 (a.m.), Observed bruising and swelling to resident's left (right) medial ankle. Resident unable to bare weight on foot in EZ stand (mechanical lift) due to pain. RN (registered nurse) on duty notified. 12/22/18, at 10:24 (a.m.), Bruising assessed. Healing bruise on right ankle with noted swelling. Limited range of motion on right ankle. Aide directed to offload lower extremities to reduce swelling. Will continue to observe. 12/22/18, at 14:24 (2:24 p.m.), Resident continues to complain of right foot pain. He is currently in bed with feet elevated. Ice has been applied. 12/22/18, at 17:30 (5:30 p.m.), Late Entry: Note Text: Resident was sent to (hospital name) this evening for evaluation of ankle. Resident fell on Wednesday 12/19/18. NA on duty notified RN that he is unable to bear his weight in usual manner, and that his leg appeared to be swollen. Measurements were taken at calf, ankle, and foot of right leg. Measurements are 4 cm (centimeters), 2 cm and 2 cm greater than left leg respectively. Range of motion is very limited and resident is in pain to the point that he was tearful. On call MD was notified, who recommended he be seen at (hospital name). Family was notified and agreed to have him sent in. 12/22/18, at 21:59 (9:59 p.m.), Daughter showed up on floor at 2100 (9:00 p.m.). She reports that her dad has been admitted to hospital for pain management due to two fractures to lower right leg. R33's vulnerable adult (VA) report dated 12/22/18, indicated the incident occurred on 12/19/18, at 20:45 (8:45 p.m.). The report indicated R33's had fallen three days ago. 12/22/19 work up in the emergency department this evening shows that the patient has a significant fracture that may require surgical intervention to correct. R33's Hospital note dated 12/22/18 through 12/26/18, identified presented toER on [DATE] after a fall on 12/19/18. RLE (right lower extremity) reveals closed ankle fracture, placed in a cast. R33's record had no documentation of nurse assessment or monitoring for changes after the fall which occurred 12/19/18, at 8:31 p.m. A physician was not notified regarding the fall with continued complaints of pain (highest 10/10), change in status with limitations, change in appearance of the right ankle/foot/leg and change in status with transfers. There was no documentation R33's FM-G had been notified of the fall with complaints of pain on 12/19/18 until 12/22/18, at 07:06 a.m. In addition, R33's medication administion record (MAR) dated for the month of 12/18 identified R33 had not been administered any pain medication for complaints of pain from 12/19/18 at the time of the fall until on 12/22/18, at 14:24 (2:24 p.m.), when R33 was given Tylenol 650 milligrams. During interview on 4/10/19, at 4:06 p.m., FM-G received a call on 12/22/18 between 1:30 and 2:00 p.m., The staff coming on duty said they had noticed it (ankle) when they got there and by the look on R33's face, they could tell he was in pain. FM-G informed the caller a call was never received updating family of R33 fall. FM-G asked about pain medication and R33 only was given Tylenol after FM-G asked to give it. FM-G saw my R33 right leg/ankle/foot on Saturday 12/22/18, the leg was swollen three times the size from foot to knee with different shades of bruising. The doctor in the ER stated the bruising was not from a couple of hours ago, but was from a few days ago. R33 sometimes becomes confused and you cannot have a normal conversation with him. When I asked my dad what happened he said he was dropped and that he was fearful. When my dad told me, he had started crying. The hospital had to give my dad [MEDICATION NAME] (narcotic) medication right away due to the incredible pain he was having. During interview on 4/11/19, at 12:27 p.m., LPN-B, confirmed he was the nurse on duty when R33 had fallen on 12/19/18. LPN-B completed ROM and R33 had complained of leg pain and I notified the RN. LPN-B said he did not do anything else for R33 at the time of the fall, because RN-F was down in five minutes. LPN-B did not give R33 any pain medication, no other interventions because he was waiting for direction from RN-F assuming RN-F would take care of the situation. The following day LPN-B observed R33 ankle only once and noticed swelling a little bit, which he added, could have been [MEDICAL CONDITION]. Although LPN-B did not check ROM again. LPN-B did not call the physician or family to notify them of the fall or pain. During interview on 4/11/19, at 12:55 p.m., RN-F stated she had assessed R33 on 12/19/18 after he had fallen around 8:30 p.m. Upon entering the room, R33 lifted up his right leg and pointed. R33 was complaining of right foot pain when assessed. RN-F asked if his right leg and foot bothered him and he said yes. Everything was normal when we completed ROM. Visually looking at legs, both had the same amount of [MEDICAL CONDITION] and there was no redness or bruising. RN-F recommended placing a pillow under his leg and offered ice. RN-F asked LPN-B to give him Tylenol and LPN-B stated R33 already had received Tylenol. However, R33's records lacked documentation Tylenol was given. RN-F stated our policy for falls was to follow up every shift. On 12/20/18, RN-F checked with LPN-B on how R33 was doing with his pain in right foot. LPN-B stated he had not heard anything from report. RN-F did not observe or reassess R33 again because nothing was reported in report. RN-F did not notify the physician of R33 having pain and no implementation of monitoring after R33 fall. During interview on 4/11/19, at 1:20 pm., nursing assistant (NA)-Q provided bedtime cares for R33 the evening of 12/19/18. NA-Q stated R33 was sitting on the side of the bed, yelling out he wanted Pepsi. When I went into the room, the Pepsi was too far away for him to reach it. We try not to give him so much Pepsi, because he drinks it all the time. NA-Q asked him if he wanted water and he said no, so NA-Q put his legs back into bed. An hour later, NA-Q found him on the floor in his room. NA-Q notified LPN-B. LPN-B asked R33 if anything hurt and R33 said his right leg hurt, by showing his right ankle. We transferred R33 back into bed with an EZ lift. LPN-B left to fill out paper work. RN-F had us apply an ice pack to R33 right ankle. The following day when NA-Q was helping R33 transfer with the stand lift, R33 was not able to stand straight up on both legs as usual. He was leaning to the right and was not able to stand straight up on the right leg. He was like that the whole week. I told LPN-B and he suggested we put an ice pack on his ankle. We continued to use the stand lift to transfer R33 after the fall. The day after the fall, R33's ankle was red and swollen. R33 will tell you he has no pain when he is probably more than a zero (scale of 0 to 10). During interview on 4/11/19, at 1:19 p.m., certified nurse practitioner (CNP)-O, stated there were no documented clinical notes of the facility staff having notified R33's primary physician or himself from 12/19/18 through 12/22/19, regarding R33's fall, complaints of pain, skin color changes and ability to stand on the right ankle. CNP-O stated the fracture R33's had was usually caused by a weight bearing activity. The fracture was a substantial fracture and would not happen from someone just moving in bed. During interview on 4/11/19, at 1:37 p.m., RN-I stated she was the care coordinator and she had not assessed R33 after his fall. RN-I also confirmed there was a lack of documentation in the charts for the two days after the fall. RN-I stated normally when a significant change of care occurs with resident, RN-I would go talk with the resident and if somebody informed her resident had complaints of pain, swelling, bruising RN-I would initiate looking at it and notify the physician. During interview on 4/11/19, at 2:10 p.m., NA-R stated she worked with R33 the day after the fall assisting R33 to the bathroom using the stand lift. The first time he tried to stand, he could not. NA-R asked him if he was o.k. and he said shook his head no. He tried to stand a second time and was able to. I assisted him with toileting and placed him back into his wheelchair. Later that afternoon he kept pointing to his foot and kept saying Ow. NA-R noticed R33's right foot when using the stand lift, the back of the right foot was twisted outwards. NA-R stated she had not informed the nurse. although NA-R told LPN-B R33 was in pain. NA-R tried a hot pack, but R33 did not like that, and then tried elevating, which he did not want that either. LPN-B stated, you have tried everything you can. During interview on 4/11/19, at 2:30 p.m., LPN-C stated on 12/22/18, at the end of night shift in the a.m. (7:06 a.m. LPN-C documented note) the caregiver came to me and informed R33 could not get up because he was unable to stand, his right ankle hurt and was swollen and bruised. LPN-C stated she went into R33's room and touched R33's ankle and he said it hurt and there was bruising purple in color that looked old. LPN-C said that was the first time she saw R33 for her shift. I told the caregiver not to put R33's Teds (compression stockings) on and informed the RN coming on duty of R33's status and he needed to be looked at. I then went home. During interview on 4/11/19, at 2:38 p.m., NA-S stated on 12/22/18 when entering R33 room his ankle was super swollen, there was a ton of bruising from the ankle going up his leg. NA-S informed RN-G and she stated she would wait until Monday (12/24/18) to inform the care coordinator to look at R33. R33 was unable to get up out of bed Saturday a.m. He was crying and it was obvious he was in a lot of pain. During interview on 4/11/19, at 2:53 p.m., the clinical mentor (CM) stated R33 had fallen and it was not recognized there was the possibility of a fracture. R33 was not very verbal, had limited vocabulary and ability to talk. There was not a thorough assessment of the ankle at the time of the fall. I would expect staff to reassess R33, call the physician, and call the family with changes. CM said she would expect the nurse monitoring for follow up after a fall every shift, especially with complaints of pain 10/10. CM verified there was no documentation by the nurses of R33's condition after the fall on 12/20/18 and 12/21/18. CM stated she would expect the nurses to be documenting on R33's condition and the physician should have been called. During interview on 4/12/19, at 10:57 a.m., the CM and assistant clinical mentor (ACM) stated the staff should have assessed R33 at the time of the fall, with appropriate follow-up after the fall for pain and intervention. There should have been definitely an ongoing assessment and re-assessment on different shifts. If bruising or advanced bruising, swelling, changes in mobility and ongoing pain noted the physician should have been called if needed. The facility policy Change in Resident Condition Notification, dated 4/18, included Policy: The facility will communicate information regarding the resident changes to the resident, family/responsible party, and physician/nurse practitioner in a timely manner. Procedure: Nursing staff will inform the resident, consult with the resident's physician or nurse practitioner, and notify the resident's legal representative or family member when: The resident is involved in an accident or incident that results in an injury and has the potential for requiring physician intervention. This includes notification of injury of unknown origin. There is a significant change in the resident's physical, mental or psychological status. There is a need to alter the resident's treatment significantly. Any of the above points will be documented in the electronic medical record, including notification of the resident, the resident's physician or nurse practitioner, the resident's legal representative, or responsible party.

Based on observation, interview and document review, the facility failed to comprehensively assess and monitor pressure ulcers to determine resident centered treatment(s), and to ensure treatment measures were implemented to promote healing and prevent further pressure ulcer development, for 2 of 3 residents (R73 & R69) reviewed who had current pressure ulcers. R73 sustained harm due to lack of timely treatments/services following identification of coccyx pressure ulcer which deteriorated from a stage II to unstageable in one week. Findings include: R73's readmission Move In Record, indicated she'd been readmitted to the facility on [DATE], and included [DIAGNOSES REDACTED]. Admission documentation indicated R73 had been a resident at the facility prior to discharge home on 12/22/17, was hospitalized for [REDACTED]. A PRE MOVE IN assessment dated [DATE], indicated R73 had a stage II pressure area to her coccyx. A Wound Monitoring document indicated R73 had a stage II pressure area monitored duirng her previous admission and 1/1/18. The document had documentation from 12/6/17 (from her previous admission), and 1/1/18 (current admission) indicating an area 1 centimeter (cm) x 1 cm with no pain, exudate or odor. The documentation for both dates also described the skin around the area as healthy. The 1/1/18 note on the document indicated an Allyven dressing was in place. R73's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R73 was cognitively intact, had a stage two pressure ulcer and required extensive assist with bed mobility and transfers. The corresponding CAA dated 1/10/18, indicated R73 had been admitted with a stage II sacral ulcer, and indicated R73 was at risk for skin problems due to actual issues, and dependency upon staff for transfers and mobility due to debility. The interventions identified included use of a pressure reducing mattress on R73's bed, and a pressure relieving cushion in the wheelchair. The goal was identified as: to resolve skin issues and keep skin free of breakdown, and the CAA indicated this would be addressed on the care plan. Review of R73's (MONTH) (YEAR), and (MONTH) (YEAR), treatment administration records (TAR) indicated no treatment had been initiated to the coccyx wound until 1/9/18 when Santyl ointment was prescribed. Although the Wound Monitoring document indicated R73 had a 1 cm x 1 cm stage II pressure area on the coccyx on 1/1/18, R73's admission Braden Scale dated 12/28/17, indicated the resident had a 3 cm x 1 cm stage II pressure ulcer to the coccyx area. The Braden score was 20, indicating low risk for pressure ulcers. Also a left heel pressure ulcer blister area on her heel that is opened. On 12/28/17, the facility had conducted an admission tissue tolerance (an assessment to determine how long skin tissue could tolerate pressure over a bony prominence) which indicated R73 was unable to reposition self independently while in bed, and was unable to stand/off-load independently when sitting. The tissue tolerance summary indicated R73 required staff assist of one to reposition and offload (remove pressure to skin areas over bony prominences) however, no repositioning schedule for sitting/lying was identified to prevent skin damage and allow current pressure ulcers to heal. R73's care plan dated 1/8/18, indicated a problem area of two pressure ulcers related to immobility on sacral/coccyx and heel. Interventions included: provide pressure relieving measures; reposition every two hours; pressure relieving device alternating pressure mattress; supplemental protein to promote wound healing; dry dressing changes as ordered for sacral wound; assess/record/monitor wound healing weekly- measure length, width and depth where possible; assess and document status of wound perimeter, wound bed and healing progress; report improvements and declines to the MD (medical doctor); and 4 oz (ounces) mighty shake supplement 1 time per day with midday meal initiated 1/4/18. No previous other care plan or interventions was provided by the facility. On 12/29/17, a full nutritional assessment completed for R73 indicated the resident had experienced a 4.8 percent (%) weight loss from a prior admission. The assessment indicated a current weight of 111 #(pounds) and indicated the resident's weight was down from 116.2# on 12/6/17. In addition, the nutritional assessment indicated R73 had been started on 4 oz of Mighty Shake one time daily, but did not include any mention of the coccyx pressure ulcer. On 1/8/18, a Medicare Note indicated R73 had a large blackish/purple wound on her coccyx with foul smelling-blackish-brown drainage coming from the area. Also documented on 1/8/18, a skin/wound note identified presence of a large amount of drainage on the coccyx dressing. The note identified a stage 3 ulcer (decubitus ulcer extends into the underlying subcutaneous tissue layer, but not all the way to the bone) was observed in the gluteal fold (coccyx/sacrum) region. The immediate surrounding tissue was described as dark purple and intact. Drainage from the ulcer was described as brown and foul smelling. According to the note, the area was cleansed with saline and a new dressing applied. The note also indicated the certified nurse practitioner (CNP)-B was notified of the ulcer. Documentation indicated staff were to continue to offload frequently and observe for signs of systemic infection. A corresponding nursing note indicated the coccyx area was open, about 5 cm x 3 cm with a necrotic area measuring about 3.5 cm x 3 cm and the certified nurse practitioner (CNP) had been notified. On 1/8/18, a clinical note from CNP-B confirmed the CNP-B had received a note from nursing staff that same day regarding R73's wound areas. CNP-B's note indicated the most worrisome condition was the sacral wound. CNP-B documented, it sounds like nursing feels this may have been present prior to patient's return back to facility. Nursing reports include R73 had developed a necrotic area around the sacral wound and very malodorous discharge which is dark to black in color with copious amounts of drainage, enough to saturate the Allevyn dressings applied. Nursing has been cleansing the area with saline and applying Allevyn daily. The CNP-B identified the sacral pressure ulcer area as unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) sacral ulceration indicating, this lesion (pressure ulcer) is concerning as it could be full thickness given the bogginess noted on exam around the eschar region centrally. This wound probably should be debrided with sharp debridement. Therefore, I plan to send the patient to the Wound Clinic for this wound . and for recommendations on wound care and also debridement. As a result of the CNP-B's assessment, treatment ordered included 0.25 percent acetic acid soaks for 15-25 minutes, and to follow by cleansing the area with normal saline or clean water/wound cleansing agent, and to apply Santyl to the necrotic areas. CNP-B further indicated staff should proceed to cover the area they used Santyl on with 4 X 4 gauze, and a foam dressing, which should be changed twice daily. On 1/8/18, a progress note indicated an alternating pressure mattress was applied to R73's bed. On 1/8/18, the physician prescribed a treatment to sacral area; 1/4 strength acetic acid wet to dry dressing, change twice daily or three times daily if needed. ProSource liquid (high protein supplement) 3 times daily at meals due to impaired skin. On 1/9/18, a progress note indicated the ProSource liquid 30 cc (cubic centimeters) with meals had been added to the resident's nutritional regime for impaired skin, and indicated Santyl ointment daily had been added as an intervention. On 1/14/18, a nursing progress note included R73's wound on the sacral area was irregular shaped, full thickness area measuring 5.5 cm by 5 cm that is 75% slough and 25 % necrosis. There is a 0.8 cm depth in a small area of the wound. There is a large amount of serosanguinous drainage on the old dressing that is very odorous. On 1/22/18, nurses note identified the sacral wound as being much deeper measuring 3.5 cm with tunneling at 3 O'clock of 3 cm. The wound was cultured which grew Proteus Mirabilis and R73 was started on the antibiotic Sulfamethoxaxole-[MEDICATION NAME]. On 1/30/18, a nurses note Identified R73 went to wound clinic. Dressing changes changed to everyday and as needed and included Santyl to wound bed on coccyx as well as packing area with [MEDICATION NAME] AG. Pressure area identified at stage 4 ulcer by the wound clinic. On 1/31/18, a Clinical document from CNP-B had identified stage IV sacral pressure injury wound, sacral ulcer changed to [MEDICATION NAME] AG daily and as needed (PRN), follow up in wound clinic in 3 weeks. On 2/5/18, a Skin wound note identified sacral wound as full thickness wound with beefy red wound base. Skin around wound dry and scaly. There is no odor and the wound is clean with a beefy red base. This wound is measuring 3.7 cm by 3.5 cm and 2.4 cm deep. There is tunneling at 6 o'clock measuring 2.5 cm and at 12 o'clock measuring 1.7 cm. The sound base is 25 % [MEDICATION NAME] and 75% granulation tissue. Wounds monitored weekly. On 2/12/18, a Skin wound note identified the sacral wound as a full thickness wound draining a moderate amount of yellowish green drainage, no odor and wound is clean with a beefy red base. Wound measures 5 cm by 3.5 cm. It is 1.5 cm deep. There is tunneling at 6 o'clock measuring 2.8 cm and at 12 o'clock measuring 2.8 cm with the wound base base 55 slough and 95% granulation tissue. 1 cm by 0.1 cm area of maceration at 6 o'clock. Continue to monitor wounds weekly. On 2/18/18, a Skin wound note identified sacral wound as full thickness and is draining a moderate amount of serosanguinous drainage. There is a slight odor but the wound is clean with a shiny beefy red base. This wound measures 5.4 cm by 3.6 cm and 1 cm deep. No longer tunneling at 6 o'clock and 12 o'clock tunneling and decreased to 1 cm. New area of undermining at 9 oclock measuring 2.5 cm, the wound base remains 5% slough and 95% granulation tissue. A 1 cm by 0.1 cm are maceration at 6 o'clock. Continue to monitor wounds weekly. On 2/21/18 a wound care clinic care plan report identified treatment as [MEDICATION NAME] AG to ulcer base, moisten slightly with saline, cover with sot dry gauze and secure with cover roll stretch. Change once a day and as needed (PRN) depending on drainage amount. General instruction included, watch for signs of infection, offload pressure areas in prevention of skin breakdown, turn/reposition every 2 hours and PRN to help in prevention of skin breakdown, continue with nutritional support and consider applying wound vac to sacral ulcer. On 2/26/18, a Skin/wound note identified sacral wound as full thickness and is draining a moderate amount of tan colored drainage, no odor and wound is clean with a shiny beefy red base. Wound measuring 4.4 cm by 3.4 cm and 1.6 cm deep. Tunneling at 12 oclock is 1.7 cm. New area of undermining at 9 o'clock measuring 2.3 cm. Wound base is 100% granulation tissue. No maceration at this time. Continue to monitor wounds weekly. On 3/9/18, a Physician order [REDACTED]. On 3/13/18, a Skin/wound note included a dressing changed to sacral ulcer. Upon removing dressing a foul odor noted with brown drainage saturating dressing. Appeared to be bowel movement under the dressing. Area around dressing red and irritated. Full thickness and drainage is difficult to assess as bowel movement had gotten under the dressing creating a foul odor. Wound had shiny beefy red bad, measures 3.6 cm by 3.8 cm and 1.5 cm deep. Tunneling at 12 o'clock is 1.9 cm, with undermining at 9 o'clock measuring 2.5 cm. The wound base is 100% granulation tissue. 0.4 cm of maceration at the distal end of the wound. Periwound is reddened possibly form the irritation of the stool. Continue to monitor wounds weekly. On 3/15/18, a physician's orders [REDACTED]. The facility's Wound Monitoring document for the coccyx/sacral ulcer, included measurements and interventions including: -1/1/18: 1 cm length by 1 cm width, no depth, no exudate, no odor. Mattress and cushion in wheelchair, Allevyn dressing on. -1/14/18: 5.5 cm length by 5 cm width and 0.8 depth and staged as unstageable with 100 percent slough and /or eschar, yellow/green heavy exudate and foul odor. treatment of [REDACTED]. -1/22/18: length 6 cm by width 4.5 cm and 3.5 cm deep now staged as a IV with foul odor, heavy purulent drainage, pain rated 5 (1 to 10 scale and 10 excruciating). Treatment continued with acetic acid, santyl ointment and started packing wound with Nu-Gauze. -1/30/18: [MEDICATION NAME] AG, Santyl cover everyday -2/5/18: [MEDICATION NAME] AG, Santyl Alt pressure -2/12/18: Santyl, [MEDICATION NAME] AG, alt pressure mattress, cover with border dressing -2/19/18: [MEDICATION NAME] AG, E-stimulation started -2/26/18: [MEDICATION NAME] AG, E-stimulation -3/5/18: [MEDICATION NAME] AG, border dressing, E-stimulation -3/13/18: E stimulation, [MEDICATION NAME] AG Border Dressing During an observation on 3/14/18, at 11:35 a.m. R73 had been moved from her room to the dining room. She had a pressure reducing cushion in her wheel chair (w/c). At 2:38 p.m., R73 was observed sitting up in her wheel chair and stated, I just got up. They aren't putting that patch on my bottom till 4:30 p.m. and that is way to long for me to be in bed! At 4:06 p.m. R73 was sitting in the lobby listening to music. During an observation on 3/15/18, at 7:15 a.m. R73 was up in the w/c beside her bed wearing a nightgown. Nursing assistant (NA)-A stated she'd just gotten R73 up and needed the nurse to check R73's wound vac. An alternating air mattress was observed on R73's bed. At 7:55 a.m. R73 was observed lying on her back in bed, with a pillow propped under her left side. At 9:30 a.m. R73 stated she'd just gotten up for breakfast because she'd been in bed because of the new machine (wound vac). At 10:45 a.m. R73 was still sitting in the dining room and was visiting with company. At 11:30 a.m. R73 was seated in a chair in the dining room but stated she'd been back to her room to have a treatment done to her bottom. At 1:05 p.m. R73 was returned to bed and positioned on her right side. On 3/16/18, at 9:00 a.m. R73 was sitting in the dining room eating breakfast. She stated, I just have to drink the rest of this then I am going to get my nails done. When asked how her bottom was today, she stated not too bad, it doesn't hurt a lot, only if I am up too much. I am going to get off it as soon as I'm done with my nails. During interview on 3/16/18, at 9:40 a.m. licensed practical nurse (LPN)-A stated, I wasn't here as the care coordinator when she came in, I was a floor nurse so I don't know too much about the ulcer. LPN-A attempted to find documentation of any monitoring or interventions from 1/1/18-1/8/18, for R73's coccyx/sacral ulcer. When she was unable to find anything she stated, the other coordinator left, I don't see anything documented here. During interview with the neighborhood coordinator (NC)-C on 3/16/18, at 9:50 a.m. she also stated, I don't see any treatments in the record for that time period. NC-C was asked if there were any nursing assistants working who would have worked with R73 at the time of her admission. However when she checked the schedule, she stated none of them are here. During interview with the director of nursing (DON) on 3/16/18, at 10:57 a.m. she stated, I can't tell you anymore than what is in the report. From our investigation of this, staff told us they were doing treatments but there is no documentation of the treatments being completed. I would have expected interventions to have been put into place on admission when she had a current pressure area on her coccyx. R69's admission face sheet indicated admission to the facility 12/28/15, with [DIAGNOSES REDACTED]. Additional medical record review indicated hospice care was initiated for R69 on 1/11/18 due to R69's declining health status and worsening dementia symptoms. R69's significant change Minimum Data Set ((MDS) dated [DATE], indicated R69 had moderate cognitive impairment, required extensive assist of one for bed mobility and transfers, was at risk for/currently had pressure ulcers; one stage three pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining and tunneling) measuring 2 cm (centimeter) x 2 cm x 1 cm, and had an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough: yellow, tan, gray, green or brown; and/or eschar: tan, brown or black colored in the wound bed). The MDS indicated pressure ulcer interventions included pressure reducing device for bed/chair, nutrition or hydration interventions and pressure ulcer care. During continuous observation on 3/14/18 beginning at 12:34 p.m., R69 was observed in bed laying on her right side, covered with blankets. At 1:17 p.m., R69 remained the same. At 1:47 p.m., R69 remained on her right side. At 2:23 p.m., R69 remained the same. At 2:42 p.m., R69 remained the same. At 2:56 p.m., R69 remained the same. At 3:10 p.m., nursing assistant (NA)-I entered R69's room with an EZ stand lift (mechanical lift device) and asked R69 if she wanted to get up. During the observation, it was noted R69 had an alternating pressure mattress on her bed, gripper socks on her feet, a pillow between her legs and a pillow behind her back. Before transferring R69 from the bed to the wheelchair, NA-I and licensed practical nurse (LPN)-H checked R69's right hip wound and stated the Allevyn (dressing) covering the wound was intact, and the skin surrounding it was normal in color. R69 had remained in bed on her right side for 2 hours and 36 minutes without repositioning. During interview on 3/14/18 at 3:17 p.m., LPN-H said she was unsure how often R69 was to be repositioned. LPN-H proceeded to look at the care plan (used by the nursing assistants for care delivery) located on the inside of R69's cupboard door, and stated R69 was suppose to be repositioned every one to two hours. When interviewed at 3:20 p.m. on 3/14/18, NA-I stated R69 was suppose to be repositioned every two hours or so. When NA-I was informed R69 had remained positioned on her right side for 2 hours and 39 minutes, NA-I offered no further information. A Braden Scale assessment (for predicting pressure sore risk) conducted for R69 on 1/22/18, indicated R69's risk to include: sensory-slightly limited, moisture- rarely moist, activity-chairfast, mobility-slightly limited, nutrition- adequate, and identified friction and shear as potential problems. The Braden Scale assessment indicated R69 was at risk to develop pressure ulcers. R69's care plan, last reviewed 2/1/18, included: alteration in skin integrity because I need help with mobility and I am no longer walking. I have depression, hypertension, [MEDICAL CONDITIONS] -stage four. I have a stage three pressure ulcers to my coccyx and an unstageable pressure ulcer to my left hip. Interventions identified included: administer treatments as ordered and monitor for effectiveness, avoid positioning me on my coccyx, float left foot off the mattress while in bed, follow my elimination and mobility care plans, I use an alternating pressure mattress on bed and tempurpedic cushion in my w/c (wheelchair), observe my skin with daily cares and weekly bathing, use house products to protect my skin, obtain and monitor lab/diagnostic work as ordered, report results to MD (medical doctor) and follow up as indicated. I have a terminal prognosis related [MEDICAL CONDITION] and [MEDICAL CONDITION]. I am on Hospice care. I need help with ADL's (activities of daily living) and mobility because I have limited mobility. Interventions were identified as Repositioning: I need 1 staff to reposition in bed and chair every 2 hours. I am able to use assist rails properly to help with my repositioning. R69's currently has the following pressure ulcers in various stages of healing. Each pressure ulcer that follows includes, observation, interviews and record reviews as follows: C[NAME]CYX PRESSURE ULCER: On 9/28/17, first developed sacral pressure ulcer stage III, according to RN-F during interview on 3/15/18 at 7:54 p.m. From 9/28/17 to 3/6/18, the facility missed weekly wound assessments on several occasions, although the treatments were completed as ordered. On 3/15/18, observed with LPN-A during wound care to be 2.4 X 2.5 X 1.3 cm (slight deterioration from 2/27/18 measurements) with red wound base, foul smell (this is new finding). LEFT HIP PRESSURE ULCER: On 11/21/17, skin/wound note, skin was observed, quarter size red area left hip. Skin protectant and Allevyn applied. From 11/21/17 to 3/6/18, weekly documentation of wound status was missed on several weeks. Wound was noted to show slow healing, treatments given as ordered. On 3/15/18, at 8:10 a.m. observed left hip pressure ulcer when LPN-H completed wound treatment. Observed wound to be white/yellow tissue around base and measure 2 X 1.8 X 0.8 cm with some improvement since last measurement on 2/27/18 or seventeen days ago. RIGHT HIP PRESSURE ULCER: On 2/6/18, a physician's progress note indicated right lateral hip/greater trochanter region stage one/unstageable wound. Though the skin is intact, there are discolored punctuated areas at the central region of this skin discoloration concerning for unstageable wound. Nursing has been covering this with a foam border protective dressing for a time but when I examined the area today there was no dressing present. Asked nursing to continue to dress with productive foam border dressing moving forward. We will have to monitor this closely for eschar and development of ulceration. Goals of care are aimed towards comfort, continues to work with hospice. From 2/6/18 to 2/27/18, the ulcer deteriorated in status, continued hospice services due to decline in health and nutritional intake. On 3/15/18, at 8:10 a.m. observation along with LPN-H and registered nurse (RN)-F provided wound care to pressure ulcer on right hip. Wound base had black and white tissue with red surrounding skin, measures 1.2 X 0.9 cm. RN-F said the wound had opened today. RIGHT LATERAL (OUTSIDE) FOOT BY THE FIFTH TOE PRESSURE ULCER: On 2/27/18, a skin/wound note, Right lateral foot next to 5th toe (little toe) had a large intact blister with purple center. Blister measured 1.8 x 1.5 cm. Cover with Allevyn to relieve pressure. From 2/27/18 to 3/6/18 the weekly wound assessment had not been completed each week. On 3/15/18, at 8:10 a.m. LPN-H and RN-F were observed to complete wound treatment for [REDACTED]. The last wound assessment was on 2/27/18 or sixteen days ago. RIGHT LATERAL (OUTSIDE) ANKLE PRESSURE ULCER: On 3/15/18, at 8:10 a.m. (nine days after stage II pressure ulcer was discovered by facility) during an observation of wound treatment with LPN-H and RN-F. The stage II ankle ulcer measured 1 X 1.5 cm with intact pink skin. RN-F said before the treatment was completed she had not been aware of this pressure ulcer. Also the ankle pressure ulcer discovered on 3/6/18 had not been comprehensively assessed nor had the physician been notified of its development. RN-F said that she would complete the comprehensive wound assessment today as well as notify the physician of its development. During interview on 3/15/18, at 10:54 a.m , RN-F had reviewed the information regarding the pressure ulcers located on R69's coccyx, left hip, right hip, right foot and right ankle. RN-F confirmed weekly measurements and complete wound assessments had not been done consistently. The left hip pressure ulcer was first noted on 11/21/17 and had not been comprehensively assessed until 12/21/17 a month later. During interview on 3/16/18, at 10:09 a.m., the director of nursing (DON) stated she would expect staff to measure/document description of wounds weekly in the resident progress notes. I would expect newly identified pressure areas to be assessed and interventions developed timely to prevent the area from opening. I would expect all areas of wound treatment to be on the current physician orders. The DON also stated she would expect the resident to be repositioned per the plan of care. The policy SKIN/WOUND CARE TREATMENT AND HEALING PROGRAM: last reviewed 11/2017, identified it is the policy of the facility to identify and assess residents whose clinical conditions increase the risk for development of skin issues and pressure ulcers, to implement preventative measures, and to provide appropriate treatment measures for pressure ulcers. 1. Assessment A. Each resident who develops a Stage I, II, III, IV ulcer, deep tissue injury, and stasis ulcer will be evaluated. The nurse making the initial evaluation will initiate the wound monitoring tool. B. For development of a Stage II, III, IV pressure ulcer a MDS may be generated per significant change criteria. C. Document weekly on Wound Monitoring Tool. Do not down stage a pressure ulcer. Criteria to be included in an assessment: 1. Location of wound(s) 2. Stage of pressure ulcer 3. Size including length, width, and depth measured in centimeters 4. Appearance of the wound bed including a description of the type of tissue present. When there is a combination of tissue types each type should be identified by the percentage present - i.e. 50% granulation and 50% fibrous slough 5. Undermining can be assessed by gently probing the wound base with a cotton swab. Measure depth in centimeters and describe location in relation to the face of a clock. 6. Drainage/exudate should be described using amount, color or type, consistency, odor of exudate. 7. Periwound tissue should be palpated and described if [DIAGNOSES REDACTED]tous, indurate, [MEDICAL CONDITION], macerated. 8. Pain and tenderness should be evaluated. D. A clean ulcer should exhibit some evidence of healing within 2 weeks. Consider reassessment if there is no improvement or an ulcer increases in size. E. Every effort will be made to set treatment goals consistent with the values and lifestyle of the resident, and family. 2. Managing Tissue Load - refers to the distribution of pressure, friction, and shear on the tissue. A. Include all preventative measures that involve positioning. B. Avoid positioning residents on pressure ulcers. C. Residents at risk and those who have a pressure ulcer are at risk for developing further ulcers. D. Provide all residents with Tempurpedic mattresses. E. Residents who have pressure ulcers on seating surfaces should avoid prolonged sitting. F. Reposition and use of devices should be individualized on care plan. Tempurpedic cushions are available. 3. Ulcer Care per MD, NP or Wound Clinic recommendations A. Follow facility Wound and Skin Formulary for all wound care. B. The Clinical Supervisor and MD/NP will collaborate for other modalities for Stage II-IV pressure ulcers that don't respond to conventional therapy. 4. Managing Bacteria Colonization and Infection A. Pressure ulcers may be colononized. Minimize this through effective wound cleaning and debridement. If foul odor or purulence develops, cleanse more frequently. B. Protect pressure ulcers from urine, feces or other contamination. C. Always follow Universal Precautions. D. If a resident has multiple pressure areas attend to the most contaminated on last. 5. Quality Improvement A. Wound will be assessed weekly to monitor prevention, healing and treatment of [REDACTED]. B. A report identifying any notable trends will be presented by the Clinical Supervisor at the monthly CQI Committee Meeting.

Based on interview and document review, the facility failed to ensure residents were adequately supervised and free from abuse by another resident, for 1 of 7 residents (R1) reviewed. R1 experienced harm, fear and emotional distress related to having been grabbed by another resident in her room, causing bruising to her wrist. The findings include: R1's care plan, last review date 7/21/17, indicated R1 had a history of [REDACTED]. The care plan also indicated R1 required minimal staff assist with daily cares. R1 was independent with mobility using a wheeled walker, could make her needs known and was able to use the call light. The care plan indicated R1 was able to report to staff if she experienced maltreatment and on 8/27/15, a care plan goal was initiated for R1 to feel safe and comfortable in her own home. In addition, the care plan indicated that if staff suspected or witnessed any VA incident, the incident was to be reported to a supervisor immediately. R2's care plan dated 6/30/17, indicated R2 had a history of [REDACTED]. The care plan also indicated R2 had moderate cognitive impairment and required assist of staff for cares. The care plan indicated R2 was able to ambulate independently but required supervision for wandering behaviors and safety. A progress note dated 7/3/17 at 6:23 p.m., by licensed social worker (LSW)-D indicated R1 had concerns that the STOP sign at her door was not discouraging R2 from entering her room. The note indicated R1 was a reliable reporter and was keeping track of how many times R2 came into the room. The LSW documented R1 had been reassured that staff were aware of the concern and was reminded that change takes time. A progress note dated 7/11/17 at 5:13 p.m., by LSW-D indicated R1 had again reported that R2 had wandered into her room, and that the stop sign on the door wasn't working. The note indicated R1 had reported R2 just takes the sign off and walks right in. LSW-D documented having told R1 that all residents needed a place to live where they were able to receive the care they need. The documentation further indicated that R1, being alert and oriented times three, was able to express her needs and understands the needs of others. R1 acknowledged that all other residents, including R2, deserved to live there equally, and R1 was willing to try to be more understanding/tolerant of other resident's challenges. Progress notes dated 7/24/17 at 3:13 p.m., indicated a quarterly care conference was held with R1 with family present. R1 and a family member stated they had concerns with a wandering resident (R2). A nursing progress note dated 8/17/17 at 3:00 p.m., indicated a weekly skin audit was performed and no bruising was noted. A nursing progress note dated 8/18/17 at 7:15 a.m., documented by licensed practical nurse (LPN)-E documented that R2 was in R1's room without invitation and R1 was in distress and crying. R1 stated that R2 had woken her up from sleep and grabbed her wrists but did not hurt her. R1 was examined for injury and no observable injury was noted at that time. A nursing progress note dated 8/18/17 at 11:44 a.m., indicated there was a 1 centimeter (cm) x 1 cm bruise on the base of R1's left thumb. LPN-E had documented that R1 had stated it came from that morning's encounter with R2. A progress note dated 8/18/17 at 4:55 p.m., indicated LPN-E had notified the charge nurse of the incident. A progress note dated 8/18/17 at 5:35 p.m., indicated registered nurse (RN)-I had assessed R1 for bruises. A progress note documented by LPN-F, dated 8/19/17 at 12:28 a.m., indicated R1 was very upset about the incident that had occurred when R2 entered her room. A progress note dated 8/19/17 at 6:46 a.m. documented by RN-I, indicated family member (F)-N had called with concerns about the incident on the morning of 8/18/17. The note indicated RN-I had reassured the family member that R2 was being monitored by staff every 30 minutes. A progress note documented by LPN-F on 8/19/17 at 10:04 p.m., indicated R1 was very restless and anxious, sharing that she was afraid to go to sleep that night, because of the incident with R2. A progress note documented by LPN-E on 8/20/17 at 10:34 a.m., indicated when R1 was asked how her day was going and R1 had replied, I can't eat I'm so afraid. The note indicated R1 was upset and weepy. Reassurance was offered and observations continued. On 8/22/17 at 12:31 p.m., LSW-D documented that since R1 may have experienced an injury during the incident on 8/18/17, a vulnerable adult incident report was submitted. Per progress note dated 8/22/17 at 3:12 p.m., police were at the facility to interview R1. R1 requested a nurse to be with her during the interview. According to a progress note dated 8/22/17 at 5:36 p.m., LSW-D documented that R1 had reconsidered an offer of a room transfer when it was available. LSW-D documented R1 had been reassured and that R1 understood that staff wanted to make the unit a comfortable and safe place for all residents, no matter what their needs are. R1 also wanted to avoid a room transfer if at all possible. During observations of the unit on 8/25/17 at 12:45 p.m., three of nine rooms were observed to have stop sign swags on them. During an interview on 8/25/17 at 12:50 p.m., R3 stated was a problem with a resident wandering. R3 stated R2 has wandered into her room and constantly goes into the resident's room next door. She stated that a couple of weeks ago, R2 was missing during the night and staff came into her room looking for him and it had scared her. R3 stated that R2 'scares her half to death'. R3 also stated the stop signs were not keeping R2 out of resident rooms. R3 stated she had been offered to move to a different room, but had declined because she liked her room. During observations on 8/25/17 at 1:05 p.m., R2 walked out to the kitchen area and sat down on the couch. R2 did not engage in conversation or turn to look my way when the surveyor sat down next to him. R2 remained seated on the couch quietly. At 2:35 p.m., R2 wandered down the hall, and was redirected from the hallway back to the couch by staff. During an interview with R1 on 8/25/17 at 1:45 p.m., R1 stated R2 wandered into her room. She described an incident that occurred on Friday 8/18/17 around 7:15 a.m., when R2 came into her room and 'shook' her. She said she'd been able to turn on the call light, but stated R2's hand was tight around her wrist and that she'd told him to let go, but he only held it tighter. R1 said staff did come in, at least 15 minutes later, but that it had seemed like an eternity. R1 said it left a bruise on her left wrist and stated R2 was 'twice as big' as she was. R1 stated she was afraid to go to the bathroom, to get dressed or to go to bed. R1 said she was offered to move to a different room on a different unit, but had declined because she liked her room and the staff. R1 also stated that the stop swag in the doorway did not keep R2 out. R1 said one other time, when she had the stop swag across the doorway, R2 took it off so she went over there and they got into a 'tug of war'. R1 said she'd also placed the wheelchair in the doorway but that didn't keep him out either, as he was able to move the wheelchair even with the brakes on. During an interview on 8/25/17 at 2:20 p.m., R4 stated he'd been sound asleep when R2 came into his room one night. R4 said R2 was five inches from his face, startling him. R4 said his spouse has been able to redirect R2 out of the room, but he was not re-directable all the time. R4 also said his spouse had spoken to administration about the concern, but the wandering continued. The director of nursing (DON)-Awas interviewed on 8/25/17 at 3:15 p.m DON-A said the problem with R2 was really at night time when he would get up and start wandering, because there's always less staff working at night. DON-A said they'd realized that R1 was upset and really afraid. In addition, DON-A said there were other women that didn't like R2 coming into their rooms but who had not had that same kind of fear R1 experienced. During an interview on 8/28/17 at 1:45 p.m., R5 stated that R2 had wandered into her room, sat down in a chair and took his shoes off. R5 said staff were watching R2 and had asked him to come out of the room, but that R2 didn't want to leave. R5 stated she was afraid of R2. During interview with RN-C on 8/28/17 at 2:15 p.m., RN-C acknowledged R2 wandered into some of the female resident's rooms, without any contact, but the potential was there. RN-C said scheduled checks on R2 were done every 30 minutes starting approximately on the 17th of August. RN-C said every 15 minute checks were not realistic based on the number of staff on the unit. RN-C also said it was their administration's policy that if a resident was unhappy, they had the choice to move. RN-C said R2's roommate, R8, had been affected by R2's behavior too and had moved to a different room. Review of a documentation titled Safety Checks Every 30 Minutes, indicated the safety checks had been completed regularly between 8/17 and 8/27/17. The checklist dated 8/18/17 at time 7:00 a.m., indicated R2 was in bed, however at 7:20 a.m., documentation indicated R2 had wandered into R1's room. The documentation indicated the incident with R1 had occurred while R2 was being checked on every 30 minutes. During interview with LPN-B on 8/28/17 at 2:56 p.m., LPN-B said R7 had reported that R2 came into her room during the night and 'scared the hell out of her'. LPN-B stated that R2's wandering seemed worse during the overnight hours. During interview with LSW-D on 8/28/17 at 3:33 p.m., LSW-D said R8 would wake up during the night and find R2 standing over him and staring. R8 would push the call light and if staff would not come right away, R8 would holler out. LSW-D verified R8 had asked to move to another room. During interview with LPN-F on 9/12/17 at 12:39 p.m., LPN-F verified that on the evening following the incident when R2 grabbed R1's wrist, R1 was fearful to sleep. LPN-F said she'd done checks every 15 minutes that shift, feeling that every 30 minutes was not frequent enough. LPN-F stated that R1 had exhibited aggressive behaviors toward staff that evening. (F)-L was interviewed on 9/12/17 at 1:50 p.m., and stated R2 came into R3's room a couple of times during the night and that R3 was scared to death. F-L spoke to administration who offered to move R3 to a different room. During interview with NA-G on 9/20/17 at 9:15 a.m., NA-G said R2 had been combative to staff, but that she'd never witnessed him harming other residents. However, NA-G said more than once, R2 had attempted to crawl into another female resident's bed, rubbing the resident's back, arm or hair. NA-G said the incident was reported to lead staff and they'd been told that if a resident was unhappy, then that resident had to move. NA-G said the scheduled every thirty minute staff checks on R2 were not put into place until the very end. During interview with RN-I on 9/21/17 at 9:32 a.m., RN-I stated she was not aware of a wandering problem until a family member of R1 talked to her about it. R2's care plan, review dated 6/30/17,indicated approaches for redirection due to wandering. The care plan indicated if the wandering upset other residents, redirection was to be done as soon as R2 was seen going into others' rooms. The care plan interventions were not initiated until 8/28/17, the day R2 was discharged to another facility. Family member-N was interviewed on 9/22/17 at 1:41 p.m., F-N stated they'd expressed concern with R2's wandering into R1's room. R1 was given options to move to another room, another floor or another facility. F-N said the incident that occurred on the morning of 8/18/17 was not reported to them. They found out about it that evening by phone from R1. LPN-E stated on 9/25/17 at 9:03 a.m., that while walking down to R1's room with medications, she'd heard Get out now! and observed R2 in R1's room. LPN-E said she'd removed R2 from the room. R1 reported that R2 grabbed her. LPN-E did not witness any physical contact and didn't report immediately because LPN-E didn't think any harm had occurred. LPN-E said she'd later documented a 1cm x 1cm bruise on R1's wrist. When LPN-E was asked about reporting suspicions of any abuse, including resident to resident, LPN-E stated that the facility could have had better training for staff on reporting maltreatment. During interview with NA-J on 9/26/17 at 4:37 p.m., NA-J said she knew R1 was scared of R2 but never saw R2 in R1's room. NA-J said R2 would wander into R-6 and R4's rooms, and they would put the call light on. By the time staff could get there, R2 had usually left the room. During interview on 10/30/17 at 12:40 p.m., NA-K stated that some of the female residents expressed fear and staff were trained to reassure them and help them feel safe. They were instructed to put their call lights on if R2 wandered into their room. NA-K said checks had ben increased to every half hour and recorded. During an interview with F-O on 10/31/17 at 11:07 a.m., she stated that she had expected more supervision for R2 than what the facility provided and that R2 needed to live in a locked unit. In the policy titled Abuse Prevention Plan of Vulnerable Adults, dated (MONTH) (YEAR), under the section Titled Ongoing Plan of Prevention; Resident Assessment, indicates that each resident's individualized care plan will include; an assessment of: the person's susceptibility to abuse by others-including other vulnerable adults, specific measures to be taken to minimize risk of abuse to him/her and other vulnerable adults. Section II titled Identification of Incidents of Maltreatment, lists examples of abuse, neglect and financial exploitation that includes the failure to provide care or services, i.e.: food, clothing, shelter, health care or supervision that is needed for the resident to maintain their physical or mental health or safety. Lastly, the policy indicates that any individual who is aware that maltreatment has occurred or suspect such will IMMEDIATELY (bolded and capitalized) report to a supervisor. Immediate steps will be taken to remove the resident from further harm or danger. The supervisor will then report to the Community Leader, CEP and MDH-OHFC.

Based on observation, interview and record review the facility failed to evaluate a known risk factor for falls and implement interventions to reduce the resident's risk for falls and injury (which included the evaluation and use of an available assistive device of wheelchair footrests for staff assisted wheelchair mobility) for 1 of 3 residents (R1) reviewed for falls; R1 was known to place her feet down on the floor when staff pushed her in the wheelchair and R1 fell and sustained head injuries during a time of staff assisted wheelchair mobility. Additionally, based on observation, interview and record review, the facility failed to ensure the use of a nursing recommended intervention of spoke covers on a resident's wheelchair to prevent any future reoccurrence of a hand injury for 1 of 2 residents (R1) identified by third floor staff as being at risk for accidents/hazards related to wheelchair use. Findings include: Record review for R1 revealed a medical [DIAGNOSES REDACTED]. Review of integrated progress notes for R1 showed R1 fell head first out of her wheelchair on 05/01/2012 while being pushed in her wheelchair by a staff member. Continued review of this entry dated 05/01/2012 showed the following: R1's shoe came off during the fall, nursing staff suspected that contact of R1's foot with the floor was a likely contributor to the fall, R1 sustained a 6 centimeter (cm) by 5 cm bruised contusion to the forehead with a raised 2 cm area, R1 sustained an abrasion next to the left eye, R1 complained of head and neck pain and R1 was noted to be drowsy after the fall. Additional record review for R1 showed an integrated progress note dated 05/02/2012 that showed R1 can independently propel herself in the wheelchair for short distances but required staff assistance to get to her desired location. An observation of R1 on 05/15/2012 at 10:51 a.m. showed R1 seated in a wheelchair with both hands placed on the wheels of the wheelchair and both feet positioned on the wheelchair footrests. R1 yelled "Help me; Help me; I can't find my way home." Nursing Assistant (NA) (Z) entered the area occupied by R1 and the investigator informed NA (Z) of R1's request. NA (Z) slowly pushed R1's wheelchair a few feet towards the living room area. NA (Z) informed R1 it was almost mealtime and asked R1 if she was alright with sitting in this area and R1 agreed to this. Household Coordinator/Nursing Assistant (NA) (A) was interviewed on 05/15/2012 at 1:02 p.m. and stated R1's foot got caught on the floor when NA (A) pushed R1 in R1's wheelchair from the living room towards R1's room. NA (A) stated that R1's foot getting caught on the floor caused R1 to fall forward out of her wheelchair and R1 appeared to initially land on her face. NA (A) stated R1's footrests were not on the wheelchair at the time of this incident and verified footrests were available for use with R1's wheelchair at the time of this incident. NA (A) indicated it is not a facility practice for staff to apply footrests to a resident's wheelchair when pushing a resident in the wheelchair, unless the resident is going outside of the facility or going a long distance. NA (A) indicated he was not aware that R1 had a history of [REDACTED]. NA (C) was interviewed on 05/16/2012 at 10:34 a.m. and indicated R1 is occasionally forgetful and also stated R1 has a history of suddenly placing her feet down on the floor when being pushed by staff in her wheelchair. At times that NA (C) pushed R1 in her wheelchair (prior to the fall incident of 05/01/2012), NA (C) always placed one of her hands on R1's shoulder to prevent R1 from falling out of her wheelchair in the event that R1 would suddenly "slam" her feet on the ground. NA (C) stated R1 has difficulty keeping her feet up and sometimes needs reminders to keep her feet up when being pushed by staff in her wheelchair. NA (C) also indicated it is not a staff practice to place footrests on resident wheelchairs when being pushed by staff and R1's wheelchair footrests were available prior to this fall incident. NA (C) stated R1 now uses footrests at all times when in her wheelchair and R1's feet remain on the footrests. NA (G) was interviewed on 05/16/2012 at 1:41 p.m. and indicated that R1 had a history of [REDACTED]. NA (G) provided reminders to R1 to keep her feet up off the ground when being pushed in the wheelchair. NA (G) indicated other residents have a history of placing their feet on the ground during staff assisted wheelchair mobility and indicated staff do not currently use footrests during these times. Physical Therapy assistant (PTA) (D) was interviewed on 05/16/2012 at 11:50 a.m. and verified R1 received a therapy evaluation on 04/30/2012 and was noted to have some lower extremity weakness. R1's therapy evaluation of 04/30/2012 was ordered for wheelchair positioning due to R1's history of leaning forward and to the side in her wheelchair; it was determined that R1 would use a wedge cushion and left lateral support in her wheelchair to decrease this. PTA (D) indicated that on 05/02/2012 therapy was informed of R1's fall incident of 05/01/2012 and therapy initiated a recommendation to caregivers on 05/02/2012 for the immediate use of wheelchair foot pedals and calf supports; physical therapy first learned of R1's history of placing her feet down during staff assisted wheelchair mobility after the 05/01/2012 fall incident. R1's record did not contain any evidence that R1's history of placing her feet on the ground during staff assisted wheelchair mobility was evaluated, nor was there evidence of any interventions implemented to address this risk for falls and injury. Director of Nursing (DON) (F) was interviewed on 05/16/2012 at 12:53 p.m. and stated she became aware of R1's history of placing her feet down on the ground during times of staff assisted wheelchair mobility after the incident; DON (F) stated they asked other staff about R1's history of this and staff indicated R1 had a history of [REDACTED]. DON (F) verified that footrests are available to staff if they choose to use them. DON (F) stated that other than the changes for R1 following the 05/01/2012 fall incident, no other follow up or facility practice changes have occurred. DON (F) stated she did not know if any other residents have a history of placing their feet on the ground during staff assisted wheelchair mobility. Additional review of an integrated progress note dated 04/06/2012 for R1 showed that R1's thumb got caught in the wheel of her wheelchair. R1 sustained redness to her thumb and nursing staff recommended R1's wheels of her wheelchair be padded to prevent a reoccurrence. An observation on 05/15/2012 at 11:55 a.m. showed R1 sitting in her wheelchair in the dining room (with her back towards the living room area) with her hands on the wheels of her wheelchair; R1 moved herself back and forth in the wheelchair and maintained her same position. The spokes of R1's wheelchair wheels were visible and no spoke covers or other protective accessory was noted on R1's wheelchair wheels. Homemaker (J) approached R1 and turned R1's wheelchair around in an approximate 180 degree turn (R1 now faced the living room); R1's hands remained on the wheelchair wheels during the time Homemaker (J) turned her around. After this, Homemaker (J) recognized R1's hands on the wheels of the wheelchair and placed R1's hands on R1's lap. NA (A) was interviewed on 05/15/2012 at 1:02 p.m. and indicated he thought R1 used some type of guard on her wheelchair to prevent R1 from getting her fingers pinched in her wheelchair. DON (F) was interviewed on 05/16/2012 at 12:53 p.m. and stated it was requested that R1's wheelchair contain wheel protectors to prevent R1's hands from getting into the spokes of the wheels. DON (F) was uncertain as to the date these were applied and expected they were already applied to the wheelchair. DON (F) also added that staff are to be observant for the placement of resident's hands prior to moving a resident's wheelchair. On 05/16/2012 at 1:34 p.m. the investigator accompanied DON (F) to observe R1's wheelchair and DON (F) verified R1's wheelchair did not contain any spoke covers or accessory to protect a resident's hands from getting in the spokes.