Every finding on record at Sauer Health Care

Based on interview and document review, the facility failed to ensure the provision of 24-hour on-call physician services to respond to 1 of 1 resident (R2) needs, including non-emergent situations that did not require transfer to an alternative setting. This had the potential to affect all 47 residents residing in the facility. Findings include:See F684: R2 who was on blood thinners had a change in condition after a fall (frank blood) and provider was not notified immediately. During an interview on 3/18/26 at 3:13 p.m., licensed practical nurse (LPN)-A indicated she was responsible for R2 when the resident fell on 2/4/26 at 7:15 p.m. R2 was new to the facility and taking blood-thinning medication. The fall caused an existing wound on the resident's bottom to reopen. LPN-A applied a dressing but acknowledged that neurochecks were not performed. She did not notify the provider immediately because the facility did not have an on-call provider; instead, she documented the fall in the communication book for the provider to review during rounds the following day.During an interview on 3/18/26 at 2:59 p.m., registered nurse (RN)-A reported caring for R2 on the morning of 2/5/26. R2 requested to go to the emergency department for a headache rated 7/10. RN-A expressed concern for a possible brain bleed given the fall, blood-thinning medication, and altered cognition. Neurochecks had not been performed after the fall, and the provider was not notified immediately. RN-A confirmed the facility had not had 24-hour on-call physician coverage for the past four years, local providers did not round at the facility or have access to resident medical records, and did not offer on-call coverage.During an interview on 3/19/26 at 10:08 a.m., the director of nursing (DON) stated that after a resident fall, nursing staff are expected to assess for injury, take vital signs, initiate neurochecks, notify the provider, inform the family, and document in risk management. Following R2's fall, neurochecks were not completed despite the resident being on blood-thinning medication and having moderate cognitive impairment. At 2:05 a.m. on 2/5/26, frank blood was noted in the toilet. Staff did not notify the physician immediately, although the DON indicated this should have prompted an ED transfer due to increased risk of bleeding. The DON confirmed that normal vital signs alone were not sufficient to rule out internal bleeding and emphasized that failure to perform neurochecks or notify the provider promptly increases the risk of serious harm.Facility policy, Physician Services, revised 12/23/16, indicated that the facility is responsible for providing or arranging physician services 24 hours a day for emergencies. The policy identified that the primary physician should be contacted first for emergent situations, and if unavailable, the on-call physician should be notified to provide intervention. If the on-call physician does not respond in a timely manner, the medical director is to be contacted. If no physician is reachable and the resident requires immediate assessment, the nurse is to notify the resident's family and transport the resident to the emergency department as needed.

Based on observation, interview, and record review, the facility failed to assess, monitor, and timely notify the physician of a change in condition following a fall for 1 of 3 residents (R2) reviewed for falls, who was receiving anticoagulant (blood thinning) medication and at increased risk for bleeding.Findings include:R2's admission Minimum Data Set (MDS), dated [DATE], indicated moderately impaired cognition with diagnoses including cerebral infarction (stroke), chronic systolic and diastolic heart failure, muscle weakness, unsteadiness on feet, fatigue, abnormalities of gait and mobility, and cognitive communication deficit. The MDS further indicated impaired range of motion to one upper extremity, required partial to moderate assistance with hygiene and dressing, utilized a walker and wheelchair for mobility, had one fall without injury since admission, and was receiving anticoagulant medication. The MDS also indicated a stage 2 pressure injury present on admission.R2's care plan, dated 1/27/26, identified a self-care deficit related to congestive heart failure. Interventions indicated R2 required assistance from one staff member for ambulation with a walker and gait belt, dressing, hygiene, bed mobility, and toileting. The care plan also identified R2 at moderate risk for falls related to gait and balance problems. An intervention dated 2/1/26 included ensuring the call light was within reach, encouraging its use for assistance as needed, and providing prompt response to all requests for help.R2's care plan lacked a focus on anticoagulation management with individualized goals and management of treatment. R2's order summary date 2/2/26 identified to give warfarin (medication that thins the blood) 3 milligram (mg) tablet on Thursday and 4 mg all other days until 2/10/26. R2's Fall report dated 2/4/26 at 7:15 p.m., identified that R2 was up in her recliner when staff arrived for assessment. R2 was not able to remember how she fell and self-reported the fall. The nurse noted that R2 was bleeding from the bottom due to a reopened coccyx wound. Post-fall assessment included evaluation of range of motion (within normal limits), level of pain (0), and mental status (oriented to person), and R2 denied hitting her head. Predisposing factors identified included impaired memory, gait imbalance, and ambulating without assist. Notifications were documented for the POA healthcare/emergency contact, Director of Nursing, Social Services, Administrator, and physician; however, physician notification did not occur at documented time of 8:37 p.m.R2's post-fall follow-up note dated 2/5/26 at 1:49 a.m. identified no new physical findings, no new complaints of pain, stable vital signs, and no new skin issues. Provider did not need to be notified. Lacked neuro assessment.R2's progress note dated 2/5/26 at 2:05 a.m. identified frank blood in the toilet after toileting, observed by nursing assistant (NA). R2 did not report any complaints. Vital signs were taken and documented as stable. The note lacked a neurological assessment, and the provider was not notified of the change in condition.R2's progress note dated 2/5/26 at 5:23 a.m., no blood after toileting this time, likely from skin tear from fall on 2/4/26.R2's transfer progress note dated 2/5/26 at 10:32 a.m. identified that R2 had a fall during the PM shift the night before. R2 had breakthrough bleeding noted on her right gluteal/thigh region. She complained of head pain rated 7/10, was lethargic, and alert and oriented x2, stating she wanted to be assessed by the ED. Vital signs were within normal limits, and pupils were equal, round, and reactive to light. R2 was transferred at 9:20 a.m. via ambulance with two standby assist to the stretcher. At the time of transfer, R2 continued to complain of right-sided pain, and her level of consciousness remained x2.R2's ED note dated 2/5/26 at 10:37 a.m. identified that she presented following a fall the night before while on blood thinners. R2 was alert and oriented x2 and reported left-sided head pain. She had no weakness. Her INR was elevated at 5.3, indicating a higher risk of bleeding. CT of the head and neck was negative for acute changes. Discharge instructions included close monitoring for falls and adjustment of warfarin dosing.R2's progress note dated 2/5/26 at 5:11 p.m., identified a report from the ED was received by the nurse. R2 had a head and neck CT, which showed no concerns. R2's INR, a blood test that measures how long it takes for blood to clot, was elevated at 5.3 (therapeutic range for most patients on warfarin is typically 2.0-3.0), indicating her blood was too thin. The warfarin order was adjusted.During an interview on 3/19/26 at 1:06 p.m., R2 stated she has had a couple of falls since admission and does not always use her walker or call light when ambulating to the bathroom.During an interview on 3/18/26 at 3:13 p.m., licensed practical nurse (LPN)-A stated she was the nurse working when R2 had a fall on 2/4/26 at 7:15 p.m., resulting in a reopened coccyx wound. Vital signs were within normal limits. LPN-A acknowledged neurological checks were not initiated at the time of the fall and that timely provider notification did not occur due to no on-call physician. Fall interventions included checking on the resident every two hours and providing ADL assistance.During an interview on 3/18/26 at 2:59 p.m., registered nurse (RN)-A verified that R2 had a fall on 2/4/26. The fall resulted in a reopened coccyx wound. Neurological checks were not initiated at the time of the fall, and the provider was not notified. On 2/5/26 at 2:05 a.m., frank blood was noted in the toilet, and no neuro checks were completed or provider notification occurred at that time. R2 later reported head pain of 7/10 and requested transfer to the ED. RN-A sent R2 for a non-emergent transfer to the ED due to concern for a possible brain bleed related to her anticoagulant use and altered cognition.During an interview on 3/19/26 at 10:08 a.m., director of nursing (DON) stated that following an unwitnessed fall, nursing staff are expected to assess for injury, obtain vital signs, initiate neurological checks, notify the provider and family, and document in risk management. Regarding R2's fall on 2/4/26 at 7:15 p.m., the DON confirmed that the fall was self-reported, R2's coccyx wound reopened, and neuro checks were not initiated, though they should have been due to R2's moderate cognitive impairment, anticoagulant use, and the fall being unwitnessed. At 2:05 a.m. on 2/5/26, frank blood was noted in the toilet, and staff did not notify the provider or perform neuro checks at that time. The DON confirmed that a resident on anticoagulants is at increased risk for serious bleeding even with normal vital signs, and that neuro checks are required after any fall, even if no head strike is witnessed. She stated that immediate notification to the provider or transfer to the ED is warranted if a resident on anticoagulants shows signs of bleeding, including frank blood in the toilet, and failure to perform neuro checks or notify the provider could result in an emergent situation.Facility policy titled Change of Condition Awareness, dated 11/26/19, identified the goal was to ensure timely communication of changes in resident condition. The policy directed staff to notify a licensed nurse of any change from baseline, including but not limited to pain, changes in appearance, or increased confusion/lethargy.Facility policy titled Change of Condition Notification, revised 6/1/22, identified nursing staff are responsible to notify the physician of changes in a resident's condition, including accidents/incidents, significant changes in physical condition, and the need for hospital transfer. The policy also directed nurses to assess the resident, gather pertinent information, and document notification and any resulting orders.Facility policy titled Fall Prevention and Management, identified staff are responsible to assess residents for fall risk, implement and monitor interventions, and update the care plan as needed. The policy directed that following a fall, the nurse must assess the resident (including vital signs, level of consciousness, injuries, and pain), initiate neurological assessments for unwitnessed falls or when indicated, notify the physician and interdisciplinary team, complete an incident report, and implement follow-up monitoring and interventions.

Based on observation, interview and document review the facility failed to comprehensively assess sling/harness sizes according to manufacturer's instructions to ensure safe transfers for 2 of 2 residents (R4 and R1) who utilized mechanical lifts sit to stand lift and full body mechanical lifts for transfers.Findings include:R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1's cognition was intact, with diagnoses of cerebral infarction (stroke), hemiparesis (one-sided weakness), hemiplegia (one-sided paralysis), unsteadiness on feet, and need for assist with personal care. Further indicated an impairment in range of motion (ROM) on one side of upper and lower extremities and required substantial to maximal assist for transfers and used a motorized wheelchair for mobility. R4's care plan dated 11/12/20, identified a focus of an activity of daily living (ADL) self-care deficit related to ischemic stroke, left hemiparesis, weakness impaired balance, limited mobility, incontinence, impaired vision, history of falls and potential for pain. An intervention dated 11/12/20 indicated that R4 required extensive assistance from 1-2 staff for transfers using a gait belt and walker, or with a as needed (PRN) EZ Stand lift (brand name of sit-to-stand lift). R1's care plan did not identify the size of the harness required and did not identify if the leg strap was to be utilized for safe transfers using a sit-to-stand mechanical lift. R4's Group Assignment sheet last updated 2/20/26, directed staff that R4 required pivot/) EZ Stand for transfers. R1's assignment sheet did not identify the size of harness R4 required for transfers nor identify if the leg strap was to be used during the transferReview of R4's record identified no documentation of a comprehensive assessment for harness size was completed that would include the resident's weight and circumference of the torso where the harness is applied that is required by the manufacturer for appropriate sizing and safety. Further did not address utilization of the leg strap.R4's fall report dated 2/27/26 at 5:33 p.m., identified that R4 was elevated in an EZ Stand lift with both feet under him and the leg strap not in use. R4 was yelling for help. The writer got behind R4, supported his weight and weak side, and moved his feet in front of him so the aide could safely lower him to the floor. R4 stated, that his foot did not get all the way on the EZ Stand platform. Both feet slipped off because my shoe slipped. Then I was hanging on until you came. R4 was then lifted from the floor to a wheelchair using a Hoyer lift (brand name of a full body mechanical lift). The resident reported soreness to his arm/shoulder but stated it did not feel like anything was broken and later reported it did not get any worse. Does not identify if the leg strap was used.R4's record did not include a comprehensive assessment that would identify the size of sling required for the use of a full body mechanical lift.During an observation and interview on 3/18/26 at 1:47 p.m., R4 was seated in his electric wheelchair and described a prior incident with the EZ Stand lift in his room. R4 stated that during a transfer, a staff member did not position his feet correctly on the platform and failed to use the leg strap, resulting in his legs sliding and becoming trapped underneath him. He reported that his left foot was not on the platform, that's the leg I can't move, and that staff didn't use the strap on the back of my legs. R4 stated the staff member left the room to get help, leaving him hanging, and he was scared while in the lift. A nurse later assisted him safely from the floor.During an interview on 3/18/26 at 2:35 p.m., registered nurse (RN)-A stated that she was working the night of the incident when R4 was hanging in the EZ Stand lift with his feet buckled under him. RN-A reported that R4's left foot had slipped out of his shoe, and both legs were trapped underneath him, and R4 was not strong enough to hold himself up. RN-A got behind R4 and lifted him, repositioning his feet so he could be safely lowered to the floor. She stated that R4 had no injury, only some soreness on his weak side. RN-A noted that the aide said she could have positioned R4's left foot more fully on the platform. RN-A did not believe the leg strap was used during the transfer. RN-A provided coaching and re-education to the aide at that time but did not specifically educate her on using the leg strap, as she had not realized it during the incident.R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1's cognition was intact, with diagnoses of multiple sclerosis, generalized weakness, repeated falls, dependence on wheelchair and need for assist with personal care. Further indicated an impairment in range of motion (ROM) on both sides of lower extremities and was dependent on staff for transfers and used a motorized wheelchair for mobility. R1's care plan dated 7/11/25, identified a focus of self-care deficit related to Multiple Sclerosis. An intervention dated 7/11/25 identified assistance of 2 staff needed with transfers with Hoyer Lift. R1's care plan did not identify the size of sling R1 required for a safe transfer with a full body mechanical lift.Review of R1's record did not include a comprehensive assessment for sling size that identified resident-specific measurements such as height, weight, girth, and the distance from tailbone to base of neck, as required by manufacturer guidelines to ensure proper fit and safety.During an observation and interview on 3/17/26 at 3:37 p.m., R1 was seated in her electric wheelchair in her room. R1 stated that two staff were required to transfer her using a Hoyer lift. R1 was unaware of what sized sling they used for her but assumed the staff should know. R1 stated she was told R4's legs gave out a couple weeks ago when he slid out of his lift.During an interview on 3/18/26 at 2:05 p.m., nursing assistant (NA)-A indicated that sling/harness size was not identified on the care plan or assignment sheet for residents who require mechanical lift transfers. NA-A stated each resident had a sling in their room; however, she was unable to identify the correct size or how to determine appropriate sizing. NA-A reported that if a sling became soiled, she would obtain another from the supply closet but would not know how to select the correct size. NA-A further indicated that use of the EZ stand leg strap was inconsistent among staff, some use the leg strap with the sit to stand lift and others did not. NA-A expressed concerns that the leg strap should be used to prevent a resident's legs from slipping out.During an interview on 3/18/26 at 2:17 p.m., NA-B stated sling and harness sizes were not identified on assignment sheets and she was unsure what size residents required for EZ stand transfers. NA-B reported that while slings were kept in resident rooms, if a sling became soiled, replacements were obtained from the linen room; however, some slings had worn or unreadable tags, making it difficult to determine the correct size. NA-B indicated she would need to ask a nurse for guidance if the size could not be identified.During an interview on 3/18/26 at 2:22 p.m., NA-C indicated that sling/harness size was not identified on the care plan or assignment sheet for residents who required mechanical lift transfers. NA-C performed transfers using an EZ Stand lift but had not received training on use of a leg strap and was unfamiliar with it. NA-C indicated sling or harness sizes were not identified on assignment sheets, and although slings/harnesses were kept in resident rooms, she was unsure how to determine the correct size. NA-C reported that if a sling became soiled, she would not know where to obtain a replacement or how to select the appropriate size without asking staff.During an interview on 3/18/26 at 2:26 p.m., NA-D stated she was unsure how sling or harness sizes were determined for mechanical lift transfers and reported relying on estimation based on resident size or color-coding of straps, although she was not confident in this method. NA-D indicated that sling or harness size was not identified on the Kardex or assignment sheets but stated it should be. NA-D reported she would ask a nurse if unsure of the correct size.During an interview on 3/18/26 at 2:35 p.m., RN-A stated the facility did not complete formal, documented sling or harness size assessments for residents requiring mechanical lifts. Staff generally selected sling sizes based on weight using a reference chart and did not routinely monitor for weight changes that may require size adjustments. RN-A further stated sling or harness size was not documented in the medical record, care plan, or assignment sheet, and nursing assistants must ask nursing staff if unsure which size to use.During an interview on 3/18/26 at 3:53 p.m., the director of nursing (DON) stated the leg strap should always be used with the EZ Stand lift and described R4's incident as a near miss in which the resident's leg slipped during transfer. The DON acknowledged that the facility did not perform formal sling or harness size assessments with mechanical lifts and instead relied on a reference chart based on weight located in the linen room. The DON confirmed sling or harness size was not documented in the care plan and there was no system in place to monitor weight changes that may require a different size. The DON indicated nursing staff were expected to determine appropriate sizing; however, no consistent process or documentation existed to ensure safe transfers.During an interview on 3/19/26 at 3:07 p.m., occupational therapist (OT)-A stated the leg strap was essential for safe EZ Stand transfers as it maintains proper positioning and stability, prevents the resident's legs from separating or buckling, and reduces the risk of sliding out of the device, falls, and injury. OT-A indicated residents with weakness, impaired balance, cognitive impairment, or neurological conditions were at higher risk if the leg strap was not used. OT-A further stated safe transfer procedures included verifying the correct lift and properly fitted sling or harness according to manufacturer guidelines. OT-A confirmed that nursing was responsible for determining sling or harness size based on resident-specific measurements and manufacturer recommendations, including weight and body measurements, indicating the importance of an individualized assessment to ensure safe transfers.During a phone interview on 3/19/26 at 2:35 p.m., EZWay lift representative (ELR)-A stated that it was policy to use the leg straps as an extra safety measure to prevent a resident's feet from falling off the platform and increasing the risk of an accident. ELR-A explained that staff should have a system in place to assess harness and sling sizes for mechanical lift use and a way to communicate the appropriate size to staff for safe transfers. ELR-A stated that harness and sling sizes are based on the manufacturer's sizing charts, which are color-coded for each size. Harnesses are determined by the resident's weight and torso circumference where the harness is applied, and slings are determined by weight and the measurement from the bottom of the tailbone to the base of the neck.Facility policy and procedure for mechanical lift equipment and sling/harness assessments was requested and was not received.EZ Way Classic Lift operator's instructions, revised 5/5/25, identified.patient lifts and stands should only be operated by trained personnel, and a full patient assessment should be conducted to determine the appropriate accessory size and type prior to each use.EZ Way Classic Stand operators' instructions revised 4/11/25, identified. The Classic Stand(R) was designed specifically for toileting and changing briefs of patients. The Classic Stand(R) can also be used for transferring the patient from chair, wheelchair, toilet or bed, and can be used for ambulation. As patients do vary in size, shape, weight and temperament, these conditions must be taken into consideration when deciding if the Classic Stand(R) is suitable for their needs. Patients should be able to bear some weight, have upper body strength and be able to follow simple commands. If a patient does not meet each of these three criteria, an EZ Way total body lift must be used .patient lifts and stands should only be operated by trained personnel, and a full patient assessment should be conducted to determine the appropriate accessory size and type prior to each use.Ez Way Sling Size Chart, revised 9/13/24, identified a sling color coding system based on weight of patient and maximum distance from patient's tailbone to base of the neck:Small: gray; 70-100 pounds; 21 inchesMedium: beige; 90-220 pounds, 24 inchesLarge: burgundy; 190-320 pounds; 26 inchesExtra-large: green; 280-450 pounds; 26 inchesExtra extra large: 400 -600 pounds; black; 36 inchesExtra extra extra large: brown; 600 + pounds 37 inchesNote: The size/weight designations are merely estimates and basic guidelines. A proper fit will depend on factors other than weight measurements, including the height and girth of a patient. A proper fit will involve the judgment of the caregiver. It is important to evaluate the width of a patient in relation to the width of the sling. It is important that no portion of the patient overlap the sides of the sling. It is important that the base of the sling be positioned two inches below the tailbone, and the top of the sling is parallel with the top of the shoulder line (base of neck). Note: Slings using Wipeable fabric use beige binding for all sizes and do not follow the color-coding system. Slings using antimicrobial fabric use silver binding for all sizes and do not follow the color-coding system.Ez Way Harness Size Chart, revised 9/13/24, identified a sling color coding system based on weight of patient and circumference of patient's torso where harness is applied:Small: gray; 70-100 pounds; 26 to 38 inchesMedium: beige; 90-220 pounds, 34 to 46 inchesLarge: burgundy; 190-320 pounds; 40 to 56 inchesExtra-large: green; 280-450 pounds; 50 to 64 inchesExtra extra large: 400 -600 pounds; black; 55 to 72 inchesExtra extra extra large: brown; 600 + pounds; 65 + inchesNote: The size/weight of designations are merely estimates and basic guidelines. A proper fit will involve the judgement of the caregiver. Color coding applies to the binding of the harnesses. Harnesses and accessories using Wipeable fabric use burgundy binding for all sizes and do not follow the color-coding system. Harnesses using antimicrobial fabric use silver binding for all sizes and do not follow the color-coding system.

Based on observation, interview, and document review, the facility failed to identify, assess, and implement an individualized toileting program to maintain or improve bladder continence, for 1 of 1 resident (R2) reviewed for falls.Findings include:R2's admission Minimum Data Set (MDS), dated [DATE], indicated moderately impaired cognition with diagnoses including cerebral infarction (stroke), chronic systolic and diastolic heart failure, muscle weakness, unsteadiness on feet, fatigue, abnormalities of gait and mobility, and cognitive communication deficit. The MDS further indicated impaired range of motion to one upper extremity, required partial to moderate assistance with toileting hygiene and dressing, and utilized a walker and wheelchair for mobility. No trial of a toileting program, including scheduled toileting, prompted voiding, or bladder training, had been attempted on admission despite noted urinary incontinence. R2 had occasional urinary incontinence (less than 7 episodes) and was always continent of bowel. R2 also received diuretics, a medication that can increase urination.R2's record was reviewed and lacked a comprehensive bowel and bladder assessment. R2's Care Area Assessment (CAA), dated 2/3/26, identified R2 was frequently incontinent of urine with modifiable factors such as restricted mobility, underlying conditions including stroke and congestive heart failure, and medications such as diuretics. The CAA did not specify whether R2's incontinence was stress, mixed, transient urge, overflow, or functional. Care plan considerations identified a general objective to avoid complications and improve continence.R2's care plan, dated 1/27/26, identified a self-care deficit related to congestive heart failure. Interventions included R2 required assistance from one staff member for ambulation with a walker and gait belt, dressing, hygiene, bed mobility, and toileting. R2 was frequently incontinent of bladder. R2's care plan did not address urinary incontinence and lacked individualized interventions, including a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training), interventions based on contributing factors such as impaired mobility and cognitive impairment, and monitoring of continence status. The care plan also did not identify the type of incontinence.Review of R2's bladder incontinence record from 3/2/26 to 3/19/26, identified that R2 was continent of urine18 times and incontinent of bladder 15 times. During an observation and interview on 3/19/26 at 12:55 p.m., R2 was observed in her bathroom, with her walker placed next to her recliner. At 1:06 p.m., R2 was seated in her recliner wearing a shirt and a pink pull-up brief, with the walker to the right of her. R2 stated she did not use the call light to request assistance for toileting and reported she walked to the bathroom independently when needed. R2 stated she forgets to use her walker and did not receive assistance from staff for toileting. R2 also reported having episodes of incontinence when attempting to get to the bathroom.During an interview on 3/19/26 at 12:58 p.m., nursing assistant (NA)-E stated R2 was expected to use the call light when she needed assistance; however, staff did not routinely check or offer assistance with toileting. NA-E stated R2 was supposed to use her walker when ambulating but was forgetful and did not always use it.During an interview on 3/18/26 at 3:37 p.m., registered nurse (RN)-A stated the facility did not complete comprehensive bowel and bladder assessments, including three-day assessments, to develop individualized toileting programs. RN-A confirmed R2 was frequently incontinent of bladder and that, although the care plan identified R2 required assistance and was frequently incontinent, no toileting plan or interventions were in place to maintain or improve continence.During an interview on 3/19/26 at 11:15 a.m., director of nursing (DON) stated R2's care plan identified she required one-person assistance with toileting and was frequently incontinent of bladder. The DON confirmed the facility did not complete comprehensive bowel and bladder assessments to develop individualized toileting plans. The DON further confirmed that although R2 was frequently incontinent, no individualized toileting plan or interventions were in place to maintain or improve continence. The DON reported the facility's standard practice was to offer toileting every two hours and confirmed this was not individualized or reflected in R2's care plan.Facility policy, Urinary Incontinence-Clinical Protocol Policy, revised 4/2/14, identified that upon admission and quarterly, residents are to receive a comprehensive bladder assessment as part of the nursing assessment, with updates to the care plan as needed. The policy requires nursing staff to identify and document circumstances related to incontinence, including frequency and contributing factors. The policy further identifies that the physician will assist in determining the underlying causes and categorizing the type of incontinence. Based on assessment findings, staff are to implement individualized interventions, including scheduled toileting, prompted voiding, or other toileting programs to improve continence. Ongoing monitoring and documentation of the resident's response to interventions is required to determine effectiveness and update the care plan accordingly.

Based on observation, interview, and record review, the facility failed to ensure sufficient staff were available to meet resident needs for 1 of 1 resident (R4) resulting in a pattern of delayed call light responses and care for R4 Findings include:R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1's cognition was intact, with diagnoses of cerebral infarction (stroke), hemiparesis (one-sided weakness), hemiplegia (one-sided paralysis), unsteadiness on feet, and need for assist with personal care. Further indicated an impairment in range of motion (ROM) on one side of upper and lower extremities and required substantial to maximal assist for transfers and used a motorized wheelchair for mobility.R4's care plan dated 11/12/20, identified a focus of an activity of daily living (ADL) self-care deficit related to ischemic stroke, left hemiparesis, weakness impaired balance, limited mobility, incontinence, impaired vision, history of falls and potential for pain. An intervention dated 11/12/20 indicated that R4 required extensive assistance from 1-2 staff for transfers using a gait belt and walker, or with a PRN (as needed) EZ Stand lift (brand name of sit-to-stand mechanical lift) During an interview on 3/18/26 at 1:47 p.m., R4 was observed seated in his electric chair and reported that, due to a stroke, he has limited mobility on his left side and required staff assistance for transfers, typically using the EZ Stand lift. R4 stated he had experienced multiple episodes of incontinence related to long call light response times and expressed significant frustration with the delays. He reported that call lights take a good hour to get answered and expressed concern that in a medical emergency, he would not receive timely assistance. R4 stated that he typically used the call light to get in or out of bed or to use the bathroom. R4 described staff response as inconsistent, stating that although staff indicated call lights should be answered within 5-7 minutes, this did not occur in practice. He reported that sometimes call lights were turned off without assistance being provided. R4 noted that while some aides are diligent in providing care, staffing levels were insufficient to meet resident needs. He emphasized his perception that staff did not consistently prioritize resident requests, contributing to delays in assistance.R4's Call light log report was reviewed from 3/5/26 to 3/18/26 (14 days) and identified that R4's call light was active for over 15 minutes on 38 occasions. The longest delays in response primarily occurred in the early morning hours between 5:00 a.m. and 9:00 a.m., with additional prolonged waits observed midday and in the late afternoon to early evening. The average wait time for all call light events were over 15 minutes and approximately 27 minutes and 40 seconds. The longest individual wait times exceeded over 40 minutes on four occasions.R4's Call Light Events with Wait Times Over 15 Minutes:Thursday, 3/5/26:6:41 a.m. to 7:02 a.m., for a total wait time of 21 minutes and 7 seconds.10:24 a.m. to 10:48 a.m., for a total wait time of 24 minutes and 7 seconds.12:23 p.m. to 12:42 p.m., for a total wait time of 18 minutes and 26 seconds.7:30 p.m. to 7:46 p.m., for a total of 16 minutes and 49 seconds. Friday, 3/6/26:6:23 a.m. to 6:42 a.m., for a total of 19 minutes and 57 seconds.9:15 a.m. to 9:32 a.m., for a total wait time of 17 minutes and 15 seconds.12:37 p.m. to 1:15 p.m., for a total wait time of 38 minutes and 19 seconds. Saturday, 3/7/26:9:08 a.m. to 9:37 a.m., for a total wait time of 29 minutes and 15 seconds. Monday, 3/9/26:5:20 a.m. to 5:36 a.m., for a total wait time of 16 minutes 23 seconds.7:24 a.m. to 8:02 a.m., for a total wait time of 37 minutes and 44 seconds.11:28 a.m. to 11:45 a.m., for a total wait time of 17 minutes and 2 seconds.3:15 p.m. to 3:42 p.m., for a total wait time of 26 minutes and 50 seconds. Tuesday, 3/10/26:8:12 a.m. to 9:04 a.m., for a total wait time of 52 minutes and 18 seconds.Wednesday, 3/11/26:5:04 a.m. to 5:32 a.m., for a total wait time of 27 minutes and 23 seconds.8:02 a.m. to 8:37 a.m., for a total wait time of 35 minutes and 38 seconds. Thursday, 3/12/26:5:03 a.m. to 5:46 a.m., for a total wait time of 43 minutes and 28 seconds.7:47 a.m. to 8:10 a.m., for a total wait time of 27 minutes 0 seconds.11:21 a.m. to 11:38 a.m., for a total wait time of 16 minutes 25 seconds.12:23 p.m. to 12:47 p.m., for a total wait time of 23 minutes 49 seconds.2:57 p.m. to 3:15 p.m., for a total wait time of 17 minutes 48 seconds.6:44 p.m. to 7:00 p.m., for a total wait time of 15 minutes 25 seconds. Friday, 3/13/26:5:19 a.m. to 5:47 a.m., for a total wait time of 28 minutes and 21 seconds.3:28 p.m. to 3:57 p.m., for a total wait time of 29 minutes and 56 seconds.9:09 p.m., to 9:34 p.m., for a total of 25 minutes and 28 seconds. Saturday, 3/14/26:5:55 a.m. to 6:25 a.m., for a total wait time of 29 minutes and 20 seconds. Sunday, 3/15/26:5:09 p.m. to 5:29 p.m., for a total of 20 minutes and 33 seconds. Monday, 3/16/26:8:26 a.m. to 8:51 a.m., for a total wait time of 25 minutes and 59 seconds.9:12 a.m. to 9:54 a.m., for a total wait time of 42 minutes and 37 seconds.12:30 p.m. to 12:53 p.m., for a total wait time of 23 minutes and 47 seconds. Tuesday, 3/17/26:5:16 a.m. to 5:33 a.m., for a total wait time of 17 minutes 58 seconds.9:18 a.m. to 9:49 a.m., for a total wait time of 31 minutes 23 seconds.6:49 p.m. to 7:12 p.m., for a total wait time of 27 minutes 52 seconds. Wednesday, 3/18/26:5:35 a.m. to 6:07 a.m., for a total wait time of 27 minutes and 52 seconds. (bed 1)5:36 a.m. to 6:03 a.m., for a total wait time of 26 minutes and 23 seconds. (bed 2)6:02 a.m., to 6:42 a.m., for a total wait time of 40 minutes 46 seconds. (bed 2).8:24 a.m. to 9:02 a.m., for a total wit time of 38 minutes and 9 seconds (bed 2)11:44 a.m. to 12:11 p.m., for a total wait time of 27 minutes and 22 seconds.4:53 p.m. to 4:21 p.m., for a total wait time of 28 minutes and 23 seconds. During an interview on 3/19/26 at 12:32 p.m., nursing assistant (NA)-F reported that they may not always see or hear call lights if they were in a resident's room. NA-F stated, ideally, calls should be answered within five minutes; however, during busy periods-early mornings around 6:00 a.m., after lunch, and during shift changes-residents may wait up to 30 minutes. NA-F confirmed that R4 most frequently complains about long call light response times. NA-F was unaware that R4 had experienced incontinence due to delayed response times and stated they do their best to respond to all residents promptly.During an interview on 3/19/26 at 12:58 p.m., NA-E reported that she answered R4's call light earlier that day when he wanted to lie down to rest before an activity. NA-E noted that R4 frequently complains about long call light response times and that staff should aim to answer lights within 10 minutes, although this does not always occur.During an interview on 3/19/26 at 10:42 a.m., the Director of Nursing (DON) indicated that R4 was one of the residents who regularly complained of long call light response times. The DON stated that waits over 20 minutes were considered a problem but was unable to specify the expected response time for all residents. She reported that when R4 complained about long wait times, typically exceeding 30 minutes, she reviewed the call light log with him. The DON was unaware that R4 had experienced episodes of incontinence due to delayed response times.Facility policy regarding call light responses was requested and not received.

Based on observation, interview and record review, the facility failed to ensure food stored in the refrigerator were labeled, dated and free of expired foods. This deficient practice had the potential to affect all residents, staff and visitors who received food from facility kitchen.Findings include:During the initial kitchen tour on 1/5/26 at 11:41 a.m., dietary (D)-A greeted surveyor inside the kitchen. The following items were observed in the fridge and freezer expired, undated food, and uncovered food:-Marinara sauce dated 9/29/25 with crystallization on top of marinara and lid of container-Pepperoni dated 6/30/25, was brown in color with crystallization on container lid-3 to 5 chicken breasts in an unmarked plastic bag thawing with a date of 12/27 (indicated pulled from freezer)-Three 5-pound tubes of ground beef thawing with a date of 12/27During a second kitchen walk through and interview on 1/7/26 at 12:07 p.m., the thawing meat remained in the refrigerator. When asked if there are plans to serve the meat; D-A stated the hamburger would be served for this evening's meal and the chicken to be cut up and served in a soup with this evening's meal. The outdated pepperoni remained in the freezer at time of second walk through; D-B looked at date on container and removed from fridge and thrown. Both D-A and D-B stated the hamburger and chicken were safe to serve.During an interview on 1/7/26 at 2:05 p.m., D-C confirmed foods thawing in the refrigerator should be in the original packaging in a pan. D-C confirmed each of the 5-pound hamburger tubes would take no longer than 2 days to thaw and be served as soon as possible after thawing. The standard chicken breasts would take no longer than overnight to thaw and served as soon as possible . D-C stated he is unsure why the chicken and hamburger were pulled on 12/27/25 for thawing when they weren't being served until 1/7/26. During an interview on 1/7/26 at 2:12 p.m., the administrator stated the facility had a food safety and thawing policy. The administrator stated the importance of food safety is to make sure each resident is getting the healthiest, most nutritious, and safe food at each meal.A facility policy titled Food Preparation and Handling dated 11/19/24, food is cooked as soon as possible after defrosting.

Based on observation and interview, the facility failed to ensure enhanced barrier precautions (EBP) were implemented in accordance with Centers for Disease Control (CDC) recommendations to reduce the risk of infection for 2 of 2 residents (R55, R22) reviewed for infection control.Findings include: R55's admission Summary note dated 1/6/26 at 3:09 p.m., identified R55 with new admission to facility for short term rehabilitation. Diagnoses include epilepsy, seizures, stroke, diabetes, urinary tract infections and a catheter in place due to failing two voiding trials. During observation on 1/6/26 at 3:49 p.m., physical therapist (PT)-A entered R55's room wearing a surgical mask and no other personal protective equipment (PPE) such as gloves, or gown. R55 room had an EBP sign posted on the door. PT-A performed assessment for therapy which included hands on assistance with standing, sitting, and lifting legs into bed. PT-A also handled R55's Foley catheter bag during transfers, without gloves or gown. During observation on 1/6/26 at 3:57 p.m., the director of nursing (DON) walked past R55's room and verified R55 had a foley catheter and verified R55 was to be on EBP. If there is hands on care, then our staff must put on gown, gloves, and mask. During interview with PT-A on 1/6/26 at 3:59 p.m., PT-A verified he did not wear gloves or a PPE gown when working with R55. PT-A stated this was first time he ever worked with R55 and did not see the EBP sign posted on his door. PT-A stated importance of following EBP is for infection control, and when touching the resident or during any contact. During interview with infection control preventionist (IP) on 1/7/26 at 9:22 a.m., IP stated R55 was on EBP due to having a foley catheter and staff were expected to follow the signage posted for EBP . R22 R22's admission Minimum Data Set (MDS) dated [DATE] indicated R22 had moderate cognitive impairment, required partial assist for eating, and was dependent on staff for activities of daily living, hygiene, bed mobility, and transfers. R22 had an indwelling urinary catheter and 2 pressure injuries (chronic wounds caused by pressure exposing underlying tissues and structures). R22's careplan indicated R22 had an indwelling catheter, pressure injuries to buttock and foot, self-care deficit related to multiple sclerosis(neurologic disorder affecting ability to move limbs), and dependence on staff for all cares. R22's treatment administration record (TAR) indicated the following: change indwelling catheter monthly, change urinary drainage bag and tubing every 15 days, and flush catheter twice a week and as needed to prevent sediment buildup. R22's orders also included dressings to left buttocks wound and left ankle as well as instruction to reposition R2 every 2 hours to offload the left side of the body, use wedge pillow when in bed, and be up for meals only. R22's diagnoses list included: multiple sclerosis, paraplegia (inability to move legs) , pressure ulcer of left buttock, urinary incontinence, bowel incontinence, and neuromuscular bladder dysfunction (inability of the bladder to empty due to nerve damage). During observation on 1/6/26 at 8:39 a.m., an enhanced barrier precautions (EBP) magnet was observed attached to the door frame outside R22's room. An orange sign titled enhanced barrier precautions listed instructions for donning personal protective equipment and when PPE should be worn was located inside R22's room. A set of plastic drawers and garbage can containing unused and used yellow isolation gowns was located just outside the bathroom. Nursing assistant (NA)-E, trained medication aide (TMA)-A, and registered nurse (RN)-B arrived to perform a bandage change to R22's wound and get R22 ready for the day. NA-E, TMA-A, and RN-B performed hand hygiene and applied gloves. Without applying a gown, NA-E removed R22's urinary drainage bag, cleaned the port with an alcohol swab, and applied a urinary leg bag. NA-E took the drainage bag into the bathroom. Upon returning, NA-E performed hand hygiene and applied new gloves. Without applying a gown, NA-E removed R22's blankets and heel protectors, applied lotion, compression sleeves, and socks to R22's legs. NA-E performed hand hygiene and applied new gloves. NA-E then stood the right side of R22's bed, reached across the bed, and used draw sheet to pull R22 on his right side. TMA-A stood on the left side of the bed, place both hands on R22's back to help support. NA-E and TMA-A did not don gowns. While R22 was on his right side, RN-B performed incontinence care and the dressing change to R22's buttocks. RN-B performed proper hand hygiene during the dressing change however did not wear an isolation gown. After the dressing change, TMA-A applied a cream to R22's back, removed gloves, performed hand hygiene and left the room. RN-B performed hand hygiene, applied new gloves, and assisted NA-E with performing catheter care. Neither wore isolation gowns. NA-E and RN-B performed hand hygiene, applied new gloves, and without wearing isolation gowns, got R22 dressed and transferred R22 to his wheelchair. RN-B performed hand hygiene and left the room. Without donning a gown, NA-E changed R22's bedding. During interview on 1/6/26 at 9:45 a.m., NA-E stated stated staff receive infection control and PPE education annually. NA-E stated gowns and gloves are worn during catheter care and wound care. NA-E stated they technically should have worn gowns when getting R22 for the day. During an interview on 1/5/26 at 9:49 a.m., TMA-A stated staff receive online infection control training annually and a hand hygiene and PPE procedure skills fair twice a year. TMA-A stated staff should wear gown and gloves when performing catheter care however wasn't sure if nurse are required to for wound care. During an interview on 1/6/26 10:26 a.m., RN-A stated R22 is on EBP due to having a urinary catheter. Staff should wear PPE when changing urinary bags or performing catheter care. RN-A stated residents with chronic wounds do not require EBP During an interview on 1/7/26 at 12:15 p.m., the director of nursing stated staff receive infection control training online upon hire. The infection preventionist also sends out information to staff instructing when PPE is used. The DON stated she would expect staff to wear gloves and gowns during any high contact activities and confirmed staff should have worn proper PPE during R22's cares and dressing change. Facility policy titled MDRO (Multidrug-resistant Organisms) Risk Assessment and Prevention Plan, revised 3/27/2024 referenced CMS Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of MDROs from March 20, 2024, which instruct staff to wear gloves and gown prior to high contact care activity which includes, dressing, bathing/showering, transferring, providing hygiene, changing linens, device care or use: urinary catheter.

Based on observation, interview and document review, the facility failed to ensure dignity was maintained who utilized a urinary catheter (tube from bladder to a bag outside the body). In addition, the facility failed to accommodate resident needs by ensuring the call light was accessible for 1 of 1 resident (R6) reviewed for resident rights.Findings include:Uncovered Urine Drainage BagR6's quarterly Minimum Data Set (MDS) assessment, dated 10/17/25 identified R6 with severe cognitive impairment and was dependent on staff for all cares. R6 had an indwelling catheter and was receiving hospice services (end of life). In addition, R6's diagnoses included Neurocognitive disorder with Lewy Bodies (progressive brain disorder leading to loss of thinking, movement, behavior, mood, and other body functions), Non-Alzheimer's Dementia, Parkinson's, and arthritis.During observation on 1/5/26 at 1:14 p.m., R6 was lying in bed with eyes closed. Uncovered urine drainage bag attached to bed frame and was visible from the hallway. At 2:39 p.m., two staff members walked past the room.During observation and interview on 1/5/26 at 4:28 p.m., nursing assistant (NA)-C verified she could see R6's uncovered urine drainage bag from the hallway and should be hidden from view and or be covered. During interview on 1/6/26 at 8:30 a.m., NA-B stated urine bags should be covered for personal dignity.During interview on 1/6/26 at 10:10 a.m., registered nurse (RN)-A stated the expectation would be for staff to cover the urine bags so it is not visible to others.During interview on 1/6/26 at 2:21 p.m., family member (FM)-A stated, R6 would not like it if the bag was exposed so people can see the urine.During interview on 1/7/26 at 9:49 a.m., infection control preventionist (IP) stated expectation would be to cover the urine bags for dignity of residents. IP verified staff, residents, and visitors should not have to see another person's urine.Facility policy on dignity was requested and not received.Call LightDuring observation on 1/5/26 at 1:14 p.m., R6 lying in bed sleeping. Call light was not in sight or reach of resident as it was coiled up and hanging on the wall next to the call light wall unit. At 2:39 p.m., two staff members walked past the room with the call light still coiled up on the wall out of sight and reach of resident.During observation and interview on 1/5/26 at 4:38 p.m., nursing assistant (NA)-C verified the R6's call light was not in sight or reach. NA-C stated the expectation is to have the call light within arm's reach of R6.During interview on 1/6/26 at 8:30 a.m., NA-B stated the expectation is to have the call light placed within reach and sight of R6.During interview on 1/6/26 at 10:10 a.m., registered nurse (RN)-A stated she was the primary hospice nurse for R6 and confirmed the call light should be placed within reach of the residents at all times. RN-A verified R6 has used the call light.During interview on 1/6/26 at 2:21 p.m., family member (FM)-A stated R6 used to use the call light. FM-A said, the call light gives R6 comfort to know that she can press it if she wants something.During interview on 1/7/26 at 9:49 a.m., infection control preventionist (IP) and director of nursing (DON) verified the expectation of call light placement is to be within reach in order to call for help or assistance if needed.Facility policy on call light placement and reasonable accommodation of needs was requested but not received.

Based on interview and record review the facility failed to complete medication side effect monitoring for 2 of 5 resident (R5 and R45) reviewed for unnecessary medications who received antipsychotics. Findings include R5's quarterly Minimum Data Set (MDS) assessment dated [DATE] identified R5 with intact cognition, required substantial assistance for toileting and personal hygiene and did not reject cares. In addition, R5 with diagnoses of heart failure, arthritis, dementia, depression, and was taking antipsychotics. R5's physician orders dated 9/17/25, included: -Quetiapine Fumarate (Seroquel) Oral Tablet 50 MG, Give 50 mg by mouth at bedtime related to Major Depressive Disorder R5's care plan had a focus area dated 10/18/23 identified R5 uses an antipsychotic, Seroquel, to help manage her hallucinations related to major depressive disorder with severe psychotic features. Care plan intervention dated 10/9/24 identified orthostatic blood pressure to be completed monthly. During review of R5's electronic medical record (EMR) and monthly treatment administration records (TARs) from June 2025 to December 2025, August and October had documented orthostatic blood pressures. R5's record lacked orthostatic blood pressures documented for the other months reviewed. During interview with registered nurse (RN)-C on 1/6/26 at 12:54 p.m., RN-C stated expectation of staff to obtain monthly orthostatic blood pressures for residents taking antipsychotic medications to see if the medication is affecting the blood pressure and to monitor effectiveness [of the medication]. RN-C reviewed R5's EMR and verified orders and care plan were present for Seroquel and that it lacked orthostatic blood pressures were documented for June, July, September, November, and December of 2025. During interview with infection control preventionist (IP) and director of nursing (DON) on 1/7/26 at 9:55 a.m., DON stated we do [orthostatic blood pressures] monthly for residents on antipsychotics. Should be in the order and in care plan. Both IP and DON reviewed R5's EMR and verified orders and care plan were present for Seroquel and that it lacked orthostatic blood pressures were documented for June, July, September, November, and December of 2025. DON stated rationale for obtaining orthostatic blood pressures for residents on antipsychotics was high fall risk which is why staff need to assess for changes in blood pressure upon sitting and standing from a lying position. R45 R45's quarterly Minimum Data Set (MDS) dated [DATE] indicated R45 had no cognitive impairment with no behaviors. R45 required partial to moderate assistance with personal and toileting hygiene and was independent with chair-to-chair transfers. R45's diagnosis list included: vascular dementia, neuropathy, muscle weakness, atrial fibrillation (irregular heart rhythm originating in the heart atrium), left-side hemiplegia (paralysis) from a stroke. R45's care plan titled R45 uses the antidepressant medication and antipsychotics related to hallucinations and mood disorder indicated: R45 will be free from discomfort or adverse reactions related to medication therapy, obtain orthostatic BP's monthly. R45's Medication Administration Record (MAR) indicated the following: -Give Seroquel (an antipsychotic medication used to treat psychiatric symptoms) 25mg one time a day at 2pm. -Give Seroquel 50mg one time a day at 8pm. -Obtain orthostatic blood pressures: lying to sitting to standing, in the specific order-one time a day every 30 days for antipsychotic medication use. The treatment administration record (TAR) indicated orthostatic blood pressures were not completed for the months of March, April, June, July, November, and December. R45's vital signs record lacked orthostatic blood pressures were attempted. R45's progress notes lacked documentation orthostatic blood pressures were attempted or any refusals. During interview on 1/6/26 at 9:21 a.m., nursing assistant (NA)-D stated sometimes the NA's have difficulty getting the orthostatic blood pressures; resident refusal, resident out of facility, resident out of room, or resident sleeping and doesn't want to be woke. NA-D stated NA's will mark the orthostatic in the TAR to follow up later. NA-D stated orthostatic measurements can be forgotten when marked for follow up later. During and interview on 1/6/26 at 9:32 a.m., licensed practical nurse (LPN)-A stated R45 had active orders for nursing to complete monthly orthostatic blood pressures. LPN-A stated if an orthostatic measurement is missed one day, it is an expectation that staff will try again the next day until the measurement is completed. LPN-A stated it is best practice that any orthostatic measurement marked as follow up later should be completed by the end of the day. During an interview on 1/6/26 at 9:26 a.m., director of nursing (DON) confirmed R45 had nursing orders to complete orthostatic blood pressures monthly. DON confirmed orthostatic blood pressures were not obtained for the months of March, April, June, July, November, and December. DON stated R45 needed monthly orthostatic blood pressures because he was taking antipsychotics; these types of drugs can cause adverse drug events. DON stated it is an expectation that any task, such as orthostatic measurements, should be completed; especially since they have an entire month to complete the task. DON stated orthostatic blood pressure measurements for residents taking antipsychotics are important so the team can identify adverse medication side effects. During interview on 1/7/26 at 2:44 p.m., medical doctor (MD) stated orthostatic measurement are built into routine monitoring to be done at least monthly while residents are taking antipsychotic medications. MD would expect to be notified by nursing or pharmacy if orthostatic measurements weren't being done or were abnormal. Facility policy titled Psychotropic Medication Management revised 6/29/2023, identified, Monitoring of orthostatic blood pressure will be completed as indicated for use of Antipsychotic Medications in residents who are ambulatory or able to attempt to stand unassisted. Facility policy titled Psychotropic Medication Management revised 6/29/2023, identified, Monitoring of orthostatic blood pressure will be completed as indicated for use of Antipsychotic Medications in residents who are ambulatory or able to attempt to stand unassisted.

Based on interview and document review, the facility failed to ensure a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) (comprehensive assessment) was completed in a timely manner when hospice services were initiated for 1 of 1 resident (R6) reviewed for hospice care. Findings include:R6's quarterly MDS assessment dated [DATE] identified R6 with severe cognitive impairment, and dependent on staff for all cares including oral hygiene, toileting, dressing, and turning side-to-side in bed. Also, R6 with indwelling catheter (tube to drain urine from bladder to bag outside the body). R6's medical conditions include neurocognitive disorder with Lewy Bodies (progressive brain disorder leading to cognitive decline) and Non-Alzheimer's Dementia. In addition, R6 also on hospice (end of life care).R6's electronic medical record (EMR) identified an admission MDS assessment dated on 1/13/25, quarterly assessments dated 4/10/25 and 7/11/25 were completed and submitted.During interview with registered nurse (RN)-A on 1/6/26 at 10:10 a.m., RN-A stated she was R6's hospice nurse and verified R6 admitted to facility in January of 2025 and started on hospice services April of 2025.During interview with infection control preventionist (IPCP) and director of nursing (DON) on 1/7/26 at 10:01 a.m., both verified R6 was admitted to hospice services on 4/17/25 and R6's EMR lacked a MDS SCSA and should have had one completed.Facility policy on MDS timing and accuracy was requested and not received.

Based on interview, observation and document review, the facility failed to monitor, review and update the care plan with specific person-centered interventions after a fall for 1 of 1 resident (R23) reviewed for accidents.Findings include:R23's quarterly Minimum Data Set MDS) assessment, dated 10/22/25, identified R23 had no cognitive impairment. R23 used a motorized wheelchair for mobility. R23 required set up for eating and hygiene. R23 required partial/moderate assistance for transfer from bed to chair. R23 required substantial/maximal assistance for dressing and bathing. R23's admission care plan dated 1/8/24 noted a risk for falls with interventions including wearing proper non-skid footwear when transferring and to call for assistance when help is needed. Further, on 2/23/24 the care plan reflected R23 used and electric wheelchair throughout the facility and in the community with interventions including a flag on the electric wheelchair, let staff know she is leaving facility, use sign-out sheet when she leaves and sign-in sheet when she returns; primary provider is aware of wheelchair use in community. On 1/9/25 at 13:05 p.m., R23's suffered a fall in the community while out in her motorized wheelchair, incurring a broken humerus (long bone of upper arm) and broken right ankle. R23's record review lacked a root cause analysis (RCA) of the fall R23 experienced in the community. R23's current care plan lacked updated resident-specific interventions for falls and using the motorized wheelchair in the community. During an interview on 1/7/26 at 10:16 a.m., director of nursing (DON) stated an RCA was not done due to the resident sustaining a fall outside of the facility; did not think they needed an RCA if the fall was not at the facility. DON stated the care plan should have been updated after the MDS significant change was done on 1/16/25. DON stated the importance of updating the care plan after a fall is to ensure the resident is safe at the facility and in the community. During an interview on 1/7/26 at 11:13 a.m., administrator confirmed the RCA was not done due to the fall not happening at the facility. Further, a risk assessment and updated care plan after the fall was not completed. The administrator stated a RCA, risk assessment, and updated care plan are important, so the resident is safe in the facility and the community. A policy titled Falls Prevention and Management dated 1/4/25, for any falls that may occur, (witnessed, unwitnessed, intercepted), the procedure below must be followed: Evaluation, documentation, care plan, and task list.

Based on interview and record review, the facility failed to ensure the pharmacy consultant identified irregularities in monthly drug regimen reviews for 2 of 5 (R5 and R45) residents reviewed for unnecessary medications who received antipsychotic medications.R5 R5's quarterly MDS assessment dated [DATE], identified R5 with intact cognition, required substantial assistance for toileting and personal hygiene and did not reject cares. In addition, R5 with diagnoses of heart failure, arthritis, dementia, depression, and was taking antipsychotics. R5's physician orders dated 9/17/25, identified Quetiapine Fumarate (Seroquel) Oral Tablet 50 MG, Give 50 mg by mouth at bedtime related to Major Depressive Disorder. R5's care plan identified R5 uses an antipsychotic, Seroquel, to help manage her hallucinations related to major depressive disorder with severe psychotic features. identified orthostatic blood pressured to be completed monthly. R5's pharmacist reviews dated June 2025 to December 2025 lacked indication of missing orthostatic blood pressures. During interview with registered nurse (RN)-C on 1/6/26 at 12:54 p.m., RN-C stated expectation of staff to obtain monthly orthostatic blood pressures for residents taking antipsychotic medications . RN-C reviewed R5's EMR and verified orders and care plan were present for Seroquel and it lacked orthostatic blood pressures were documented for June, July, September, November, and December of 2025. During interview with infection control preventionist (IP) and director of nursing (DON) on 1/7/26 at 9:55 a.m., DON stated orthostatic blood pressures are completed monthly for residents on antipsychotics. IP and DON reviewed R5's EMR and verified orders and care plan were present for Seroquel and that it lacked orthostatic blood pressures were documented for June, July, September, November, and December of 2025. Facility policy titled Psychotropic Medication Management, revised 6/29/2023 identified, The Pharmacy Consultant will monitor drug therapy monthly with recommendations to provider as indicated. R45 R45's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R45 had no cognitive impairment with no behaviors. R45 required partial to moderate assistance with personal and toileting hygiene and was independent with chair-to-chair transfers. R45's diagnosis list included: vascular dementia, neuropathy, muscle weakness, atrial fibrillation (irregular heart rhythm originating in the heart atrium), left-side hemiplegia (paralysis) from a stroke. R45's care plan titled R45 uses the antidepressant medication and antipsychotics related to hallucinations and mood disorder indicated: Consultant pharmacist to monitor monthly and advise physician as indicated, obtain orthostatic BP's monthly, review of medication regime by psychotropic drug committee or as indicated. R45's Medication Administration Record (MAR) indicated the following: -Seroquel (an antipsychotic medication used to treat psychiatric symptoms) 25mg one time a day at 2pm and Seroquel 50mg one time a day at 8pm. -Obtain orthostatic blood pressures: lying to sitting to standing, in the specific order-one time a day every 30 days for antipsychotic medication use. The treatment administration record (TAR) indicated orthostatic blood pressures were not completed for the months of March, April, June, July, November, and December. R45's pharmacy reviews dated January 2025 through December 2025 lacked noting the missing orthostatic measurements for the months of March, April, June, July, November, December and did not recommend for them to be completed. During interview on 1/6/26 at 9:26 a.m., director of nursing (DON) confirmed R45 had active orders for monthly orthostatic blood pressures. DON confirmed orthostatic blood pressures are charted in the vital signs tab or in the TAR. DON confirmed orthostatic blood pressures were missing for the months of March, April, June, July, November, and December. DON stated orthostatic blood pressure measurements for residents taking antipsychotics are important so the team can identify adverse medication side effects. During interview on 1/7/26 at 12:11 p.m., pharmacist stated pharmacy reviews were conducted monthly per regulation. Pharmacist stated she reviews the side effect monitoring, target behaviors, and vital signs. Pharmacist stated if she notices orthostatic blood pressures are missing, she will recommend in the monthly pharmacy review that the orthostatic measurements be completed. Pharmacist stated the MD had written orders for orthostatic measurements to be discontinued for some residents. Pharmacist confirmed R45 and R5 did not have orders to stop orthostatic measurements. Pharmacist stated orthostatic measurements are important so that the medical team could identify possible adverse reactions to medications. During interview on 1/7/26 at 2:44 p.m., medical doctor (MD) stated orthostatic measurement are built into routine monitoring to be done at least monthly while residents are taking antipsychotic medications. MD expected pharmacy to confirm orthostatic blood pressures were being completed during the monthly pharmacy reviews; to make recommendations to complete if not being done. MD would expect to be notified by nursing or pharmacy if orthostatic measurements weren't being done or were abnormal. A policy titled Pharmacy Services dated 12/22/2016 indicated the pharmacist review involves a thorough review of resident's records and involves reporting findings with recommendations for improvement. The pharmacist will define general guidelines for specific monitoring related to medications, when ordered or indicated, including specific item(s) to monitor (e.g., blood pressure, pulse, blood sugar, weight). Facility policy titled Psychotropic Medication Management, revised 6/29/2023 identified, The Pharmacy Consultant will monitor drug therapy monthly with recommendations to provider as indicated.

Based on observation, interview, and document review, the facility failed to ensure appropriate use of personal protective equipment (PPE) when going from room to room of residents with (R24, R36) and without (R6, R16) COVID-19 positive diagnoses. Findings include: The Center for Disease Control (CDC) Underlying Conditions and the Higher Risk for Severe COVID-19 guidance dated 7/30/24, identified the following high-risk underlying conditions which placed a person at higher risk for severe COVID-19: 1. Age is the strongest risk factor with a 340 times higher risk of death from COVID-19 in those age 85+ and 140 times higher in those ages 75 to 84. 2. High risk medical conditions with a higher risk of death from COVID-19 included asthma, cancer, cardiovascular disease, chronic kidney disease, lung disease, mental health conditions such as depression and neurologic conditions such as dementia. R24's progress note dated 12/8/24 at 3:05 p.m., identified positive for COVID-19. R24's progress note dated 12/17/24 at 10:33 a.m., identified R24 remained on isolation and reported an infrequent cough. During a continuous observation on 12/18/24 from 8:06 a.m., through 8:10 a.m., -At 8:06 a.m. R24's room was identified with posters and a PPE bin as on enhanced respiratory precautions (ERP) with instructions for staff to follow the Centers for Disease Control (CDC) guidelines to wear N95, eye protection, gloves and a gown when entering. Dietary aide (DA)-A brought R24's room tray into her room with an N95 mask on, but no other PPE, set the tray of food on the tray table directly in front of R24, removed the lid covering the food, set to the side, and had a short conversation with the resident. R24 did not have a mask on. While DA-A removed the food tray lid, her scrub top brushed against the room tray table. DA-A exited the room and used alcohol-based hand sanitizer on her hands. R6's diagnosis list dated 12/18/24, identified age 92 and diagnoses of heart failure and pulmonary disease. -At 8:07 a.m., DA-A went directly from R24's room to the food cart and removed a tray, entered R6's room who was not on COVID-19 precautions. DA-A did not change her N95 mask, set the tray on the tray table in front of R6, removed the lid covering the food, had a short conversation with the resident. DA-A exited the room, used alcohol-based hand sanitizer, and did not remove her N95 mask. R36's progress note dated 12/15/24 at 7:55 a.m., identified positive for COVID-19. R36's progress note dated 12/17/24 at 18:18 (6:18 p.m.), identified he remained on isolation, had shortness of breath when coughing, dry cough and hoarse voice. -At 8:08 a.m., DA-A went directly from R6's room to the food cart and this time removed gloves from her scrub pants pocket and put them on her hands, took a food tray out of the cart and entered R36's room, which was also identified as having ERP in place for COVID-19. DA-A set the tray on the tray table in front of R36, removed the lid and had a short conversation with the resident. Removed gloves, used alcohol-based hand sanitizer, and exited the room did not change her N95 mask. R16's diagnosis list dated 12/18/24, identified age 79, and diagnoses of stroke, heart disease, depression, and emphysema. -At 8:09 a.m., DA-A went directly from R36's room to the food cart and removed a tray, entered R16's who was not on COVID-19 precautions. DA-A kept the same N95 mask on, set the tray on the tray table in front of R16, removed the lid, had a short conversation with the resident. Used alcohol-based hand sanitizer, exited the room, and did not change her N95 mask. -At 8:10 a.m., registered nurse (RN)-A who was in the hallway at the same time as the dietary staff delivering room trays stated she was not sure if dietary needed to wear full PPE to enter COVID-19 rooms and would need to check with the infection preventionist (IP). -At 8:10 a.m., dietary staff were stopped from delivering trays, when asked, DA-A stated she was not trained to wear full PPE when entering COVID-19 rooms for room tray delivery. Dietary manager (DM) who was also delivering room trays and pushing the cart agreed they did not need to as it was a short time they were in the rooms. The DM stated they delivered room trays to all residents in the facility. During an interview at 8:17 a.m., RN-B stated dietary staff did not need to wear full PPE going into resident rooms with COVID-19 to deliver room trays. During an interview on 12/18/24 at 8:28 a.m., the IP stated all staff have gone through training to don (put on) full PPE when entering the rooms of COVID-19 residents due to risk of touching contaminated items in the resident rooms and transmitting the germs to other locations and people. The facility's COVID-19 Plan and Core Principles of Infection Prevention and Control dated 4/4/24, identified the facility would activate and implement updated guidance based on regulations from local, state, and federal government agencies, including appropriate staff use of PPE. The CDC's Infection Control Guidance dated 6/24/24, identified: this guidance applied to all U.S. settings where healthcare is delivered, all health care personnel (HCP) who enter the room of a patient with suspected or confirmed COVID-19 infection should adhere to standard precautions and use a NIOSH approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face).

Based on observation, interview and document review, the facility failed to implement appropriate, person-centered interventions to prevent further falls and potential injury for 1 of 1 resident (R20) reviewed for accidents. Findings include: R20's Minimum Data Set (MDS) dated [DATE], indicated R20 was severely cognitively impaired. MDS also indicated R20 had delusional behavior, required two-person physical assist for transferring, position changes, and toileting, required set up only for eating, and bowel and bladder incontinence. R20's medical diagnosis included: dementia with psychotic disturbance and agitation, recurrent urinary tract infection (UTI), disorientation, repeated falls, weakness, lack of coordination, and muscle weakness. R20's care plan dated 3/6/24 indicated R20 had a risk for falls related to gait and balance problem, incontinence, safety unawareness, use of psychotropic medication, and wandering. Further, R20 had a self-care deficit related to dementia and incontinence. During observation on 12/16/24 at 3:01 p.m., R20's room door was shut, upon entering the room, R20 was alone, sitting in her recliner. R20 did not want to answer questions about her care or the facility at this time. Asked to return after dinner. During observation on 12/16/24 at 6:04 p.m., R20's room door was shut, upon entering the room, R20 was alone , sitting in her bed. R20 was not receptive to answering questions. R20 stated she is just too tired today. R20's progress notes dated 9/3/24 at 6:23 a.m., indicated R20 was found sitting on her bottom in the bathroom with feet towards the radiator and head by the sink. Resident reported she fell out of bed and crawled to the bathroom. Fall assessment in this note, R20 was wearing gripper socks at time of fall. Physical assessment was negative for injury; family was notified, updated round book, and email sent to interdisciplinary team (IDT). Intervention at time of fall was to remind resident to use call light for assistance when feeling weak. R20's multidisciplinary care conference notes dated 9/4/24 at 9:22 a.m., did not address R20's last fall; additional fall prevention interventions were not implemented. R20's quality review note dated 9/4/24 at 1:46 p.m., care plan was reviewed at this time and no violations occurred along with no injuries. Care plan remained up to date and R20 was given reminders to call for help if she is feeling weak. Provider was updated and provider requested post-fall resident status updates every shift for 24 hours starting on 9/4/24. No further recommendations noted. No resident-specific interventions updated after fall. R20's progress notes dated 10/8/24 at 6:12 p.m., indicated R20 was found sitting on the floor in her room in front of the recliner chair with feet pointed towards wall. Resident reported she was trying to get to recliner so she could take a nap. Fall assessment in this note, R20 was wearing gripper socks at time of fall. Physical assessment was negative for injury; family was notified, updated round book, and email sent to IDT. Interventions at time of fall was to remind resident to use call light for assistance when feeling weak. R20's quality review note dated 10/9/24 at 3:11 p.m., care plan reviewed, and no violations occurred along with no injuries. The care plan remains up to date as this is believed to be an isolated incident. R20 was given reminders to call for help using her call light if she felt weak prior to transfers. Provider was updated and provider requested post-fall resident status updates every shift for 24 hours starting on 10/8/24. No further recommendations noted. No resident-specific interventions updated after fall. R20's progress note dated 11/6/24 at 4:00 p.m., indicated R20 was lying on her left side on the floor parallel to her bed with her feet closer to the door. Facility staff noted her wheelchair was closer to the bathroom door than her bed. Fall assessment was in this note, R20 had been wearing gripper socks at time of fall and call light was within reach but had not been activated by R20. R20 stated at this time she was trying to get into her bed from her wheelchair. Her wheelchair had ended up by her bathroom door while she was by her bed. Physical assessment was negative for injury; family was notified, updated rounds book, and email sent to IDT. R20's quality review note dated 11/8/24 at 9:35 a.m., care plan reviewed at this time and no violations occurred along with no injuries. Care plan was updated to reflect the use of antiroll backs on R20's wheelchair. Provider was updated about fall and agreed with care plan addition of antiroll backs on R20's wheelchair. Provider requested post-fall resident status updates every shift for 24 hours starting on 11/8/24. No further recommendations noted. No resident-specific interventions updated after fall. R20's progress note dated 12/7/24 at 7:07 p.m., indicated R20 turned the wrong way during an assisted transfer and went down to her knees. Head was laying on the bed, did not hit head. Fall assessment was in this note, R20 had been wearing gripper socks at time of fall. Physical assessment was negative for injury; family notified, updated rounds book, and email sent to IDT. No changes or updates done at this time. R20's progress note dated 12/8/24 at 8:41 a.m., indicated R20 fell out of her wheelchair to the floor and hit her head. Fall assessment was in this note, R20 was noted to have a large bruise on the right side of her face. R20 assisted back to bed and vital signs taken; were stable. Family notified, updated rounds book, and message sent to provider for additional directions. No changes made to care plan. R20's progress note dated 12/9/24 at 9:45 a.m., indicated the provider had seen a picture of R20's hematoma from the fall; the provider wanted R20 seen in the emergency room (ER) for further evaluation. R20 was sent via ambulance to local ER at 10:00 a.m. R20 had a CT scan while at the ER and this was negative for any acute findings. R20 was sent back to facility at 3:37 p.m. Provider requested post-fall resident status updates every shift for 24 hours starting on 12/8/24. No further recommendations noted. R20's quality review note dated 12/12/24 at 1:31 p.m., care plan reviewed at this time and no violations occurred for either fall. No additional changes made to care plan after falls. No further recommendations from provider after falls. No resident-specific interventions updated after fall. During interview on 12/18/24 at 10:44 a.m., nursing assistant (NA)-A stated R20 had fallen multiple times since admission. NA-A stated she would expect to see a care plan or interventions to include the standard call before you fall sign, correct shoes for ambulation, call light within reach, direct eye supervision, time checks, bed sensors, floor mats, and bed in lowest position for someone like R20 with a history of falls. NA-A confirmed R20 had a care plan in place which included a risk for falls related to gait imbalance, incontinence, safety awareness and psychotropic medications. NA-A confirmed R20 had a call before you fall sign on her closet door, had wheelchair rollbacks, and her call light was within reach. NA-A confirmed these were the generic fall orders all residents have. NA-A verified in the electronic medical record (EMR) R20 did not have resident-specific interventions implemented. During interview on 12/18/24 at 10:52 a.m., registered nurse (RN)-B stated R20 had fallen twice the previous week and R20 has had multiple falls prior to last week. RN-B confirmed R20 had basic falls interventions entered in the care plan. RN-B confirmed R20 had a call before you fall sign on the closet door, wheelchair rollbacks, and her call light within reach. RN-B stated she would have expected interventions such ambulating with proper footwear, specific toileting plan, bed alarms, direct vision, chair sensors, physical therapy consult, and floor mats. RN-B verified in the EMR R20 did not have any person-centered interventions implemented. During interview on 12/18/24 at 11:03 a.m., director of nursing (DON) stated R20 had a history of multiple falls since her initial admission. DON confirmed the facility completed a quality review after each fall. DON confirmed R20 should have resident-specific interventions in place due to high risk for falls. DON confirmed R20 was a risk for falls due to gait and balance problem, incontinence, safety unawareness, use of psychotropic medication, and wandering. DON confirmed R20 had the facility generic fall interventions in place including the call before you fall signage and call light within reach. Based on R20's fall history and quality review, the DON stated she would expect documentation/interventions for a physical therapy consult, direct view of staff, proper footwear, floor mats, supervision with walking, active toileting, and change in condition observations. Facility policy titled Sauer Health Care Fall Policy and Procedure dated 4/5/22; the facility will ensure residents live in an environment which is free from hazards over which the facility has control and provide appropriate interventions to each resident to prevent avoidable accidents and injuries. This policy directly states care plans will be updated to reflect the current fall risk/actual fall/fall history, goals, and current interventions. Further, staff will monitor for effectiveness of fall prevention plans and modify approaches to prevent further falls.

Based on interview and document review, the facility failed to employ either a full-time registered dietitian (RD) or a qualified dietary manager (DM) to carry out the functions of the food and nutrition service since 8/21/23, which had the potential to affect all 40 residents who resided in the facility. Findings include: The facility's undated list of new hires identified the dietary supervisor (DS) was hired on 8/21/23. The DS's undated employment and certification history lacked the required qualifications for a dietary manager. The DS's undated Dietary New Employee Orientation Checklist lacked completion of the required qualifications for a dietary manager. The RD Consultant Log identified the following: - 8/1/23 through 8/31/23, total number of hours worked was 27 - 9/1/23 through 9/30/23, total number of hours worked was 45.5 - 10/1/23 through 10/16/23, total number of hours worked was 11. The RD had not worked on a full-time basis since the DS was hired. During an interview on 10/16/23 at 2:18 p.m., the DS stated was the dietary manager, was hired a couple months ago and had not started the courses to be certified in food or nutrition services yet. The DS stated there was an RD that came in about weekly to the facility. During an interview on 10/17/23 at 2:19 p.m., the administrator stated their RD was contracted and had not worked full-time at the facility. Additionally, the DS was hired with a condition of employment to complete the coursework to obtain certification in food and nutrition services. During an interview on 10/18/23 at 9:58 a.m., the RD stated was employed as a part-time consultant for the facility and was not full-time. The RD stated was not aware of the need to be full-time if there was not a certified or qualified dietary manager in place. The facility policy titled Dietary Supervisor dated 6/2/23, identified the minimum experience and qualifications included high school diploma or general education development (GED), and willing to acquire certified dietary manager certificate or, Minnesota certified food protection manager and willing to acquire serve-safe certificate. The policy lacked identification of the need for a full time RD until the DS qualifications had been obtained.

Based on interview and document review, the facility failed to ensure the comprehensive assessment was developed, completed, and implemented for one of one resident (R26) reviewed for assessments. Findings include: R26's Medical Diagnosis form indicated R26 had the following diagnoses: chronic diastolic congestive heart failure, chronic respiratory failure, mild persistent asthma, chronic kidney disease stage 3A, chronic obstructive pulmonary disease and major depressive disorder. R26's Hospice Notice of Election form indicated R26 began hospice on 5/24/23. R26's facility admission summary note dated 9/5/23, indicated R26 admitted to the facility, was on three liters of oxygen continuously, and was already enrolled in hospice. R26's clinical physician orders dated 9/5/23, indicated R26 had an order for three liters of oxygen continuously. R26's treatment administration record (TAR) dated 9/5/23, indicated R26 received oxygen three liters continuously until 9/18/23. R26's Initial Recreation Assessment form dated 9/11/23, indicated R26 had preferred participation levels of being independent and in group programs, did not like to read, enjoyed all kinds of music, being around animals, working in the garden, was Catholic, and enjoyed visiting with others. R26's care plan dated 8/31/23, indicated R26's admitted was 9/5/23, and was enrolled in hospice upon admission to the facility on [DATE]. The care plan identified R26 had major depressive disorder and R26 verbalized sadness and loneliness, however the care plan lacked nonpharmacologic interventions that addressed sadness and loneliness. R26's care plan dated 9/18/23, indicated R26's cognition would remain stable based on evidence of a brief interview for mental status (BIMS), and R26's mood would remain stable or improved by evidence of a PHQ-9 (patient health questionnaire which identifies and tracks symptoms of depression) score and interventions included completing a BIMS score as indicated or as needed, and completing a PHQ-9 score as indicated or as needed. R26's care conference note dated 10/2/23, indicated R26 desired more activities and IDT would be looking into crafts or activities to keep R26 busy in R26's room. Further indicated R26 was already on hospice at the time of admission. R26's social worker (SW) note dated 10/13/23, indicated R26's family had concerns of R26's mood being down. R26's admission MDS dated [DATE], section labeled, Section C-Cognitive Patterns identified a BIMS should have been conducted, however a dash was marked under the section, Summary Score indicating the BIMS was not conducted. The MDS section labeled, Section D-Mood identified a resident mood interview should have been conducted, however a dash was marked under the section, Total severity Score indicating a resident mood interview was not conducted. The MDS section labeled Section F-Preferences for Customary Routine and Activities identified an interview for daily and activity preferences should have been conducted, however the section was marked with dashes indicating the interview was not conducted. Further, under the MDS section labeled Section J-Health Conditions, identified a pain assessment interview should have been conducted, however, the MDS did not identify the presence of pain, frequency of pain, pain effect on sleep, pain interference with therapy activities, day to day activities, pain intensity, or a verbal descriptor scale. Last, the MDS section labeled Section O-Special Treatments and Programs did not indicate R26 had oxygen on admission or while a resident, nor did the MDS indicate R26 was on hospice on admission or while a resident. During interview on 10/17/23 between 8:38 a.m., and 8:44 a.m., R26 stated staff were so busy and R26 did not want to bother them. R26 further stated a desire to have more company due to feeling lonely and stated feeling isolated in R26's room. During interview on 10/19/23 at 9:29 a.m., the administrator stated licensed practical nurse (LPN)-A completes the MDS and registered nurse (RN)-A oversees the completion and further stated their MDS coordinator left at the end of September. During interview on 10/19/23 at 9:53 a.m., SW-A stated she started working at the facility in February 2023, and was responsible for completing sections C, D, E, F, and Q of the MDS assessment. SW-A verified section C, D, and F was not completed and should have been completed and did not know why the assessments were not completed and added the MDS coordinator left and they were doing a different process than previously. SW-A stated R26 had heart failure and major depressive disorder and stated completing the MDS assessment would have been beneficial to R26 in order to monitor for changes in R26's mood and added completing R26's preferences interview would have been another opportunity for R26 to express what was important to her. SW-A verified R26 came into the facility with portable oxygen when she was first admitted . During interview on 10/19/23 at 10:12 a.m., RN-A stated either RN-A, LPN-A, or another staff person completes the pain assessment for Section O of the MDS assessment and LPN-A would enter the information on the MDS. RN-A stated she was working the day R26 was admitted to the facility and verified R26 had oxygen when she was admitted and was on oxygen prior to admission and should have had oxygen marked on the MDS. Further RN-A verified R26 was on hospice prior to admission to the facility and stated there were no progress notes to indicate why a pain assessment was missed and stated the pain assessment on the MDS should have been completed and added the whole MDS interview was not completed. During interview on 10/19/23 at 10:40 a.m., the director of nursing stated she expected the MDS sections should have been completed regarding areas marked not assessed, and the MDS should have been accurate. A policy, Comprehensive Resident assessment dated [DATE], indicated the primary purpose of assessing the resident is to gather detailed information that will help to develop a plan of care that is appropriate for the resident. The interdisciplinary team conducts timely resident assessments and reviews according to the following schedule: within 14 days of the resident's admission or re-admission to the facility; when there has been a significant change in the resident's condition; at least quarterly; and once every 12 months. Comprehensive assessments should include cogitative status or patterns, mood and behavior patterns, health conditions, activity preferences, and special treatments, procedures or care needs.

Based on interview and document review, the facility failed to ensure the Minimum Data Set (MDS) assessments completely and accurately reflected oxygen usage, activity prefereces, and hospice status for R26. Additionally, the facility failed to ensure the comprehensive assessment was completed for R26. Findings include: R26's Medical Diagnosis form indicated R26 had the following diagnoses: chronic diastolic congestive heart failure, chronic respiratory failure, mild persistent asthma, chronic kidney disease stage 3A, chronic obstructive pulmonary disease and major depressive disorder. R26's Hospice Notice of Election form indicated R26 began hospice on 5/24/23. R26's facility admission summary note dated 9/5/23, indicated R26 admitted to the facility, was on three liters of oxygen continuously, and was already enrolled in hospice. R26's clinical physician orders dated 9/5/23, indicated R26 had an order for three liters of oxygen continuously. R26's treatment administration record (TAR) dated 9/5/23, indicated R26 received oxygen three liters continuously until 9/18/23. R26's Initial Recreation Assessment form dated 9/11/23, indicated R26 had preferred participation levels of being independent and in group programs, did not like to read, enjoyed all kinds of music, being around animals, working in the garden, was Catholic, and enjoyed visiting with others. R26's care plan dated 8/31/23, indicated R26's admitted was 9/5/23, and was enrolled in hospice upon admission to the facility on [DATE]. The care plan identified R26 had major depressive disorder and R26 verbalized sadness and loneliness, however the care plan lacked nonpharmacologic interventions that addressed sadness and loneliness. R26's care plan dated 9/18/23, indicated R26's cognition would remain stable based on evidence of a brief interview for mental status (BIMS), and R26's mood would remain stable or improved by evidence of a PHQ-9 (patient health questionnaire which identifies and tracks symptoms of depression) score and interventions included completing a BIMS score as indicated or as needed, and completing a PHQ-9 score as indicated or as needed. R26's care conference note dated 10/2/23, indicated R26 desired more activities and IDT would be looking into crafts or activities to keep R26 busy in R26's room. Further indicated R26 was already on hospice at the time of admission. R26's social worker (SW) note dated 10/13/23, indicated R26's family had concerns of R26's mood being down. R26's admission MDS dated [DATE], section labeled, Section C-Cognitive Patterns identified a BIMS should have been conducted, however a dash was marked under the section, Summary Score indicating the BIMS was not conducted. The MDS section labeled, Section D-Mood identified a resident mood interview should have been conducted, however a dash was marked under the section, Total severity Score indicating a resident mood interview was not conducted. The MDS section labeled Section F-Preferences for Customary Routine and Activities identified an interview for daily and activity preferences should have been conducted, however the section was marked with dashes indicating the interview was not conducted. Further, under the MDS section labeled Section J-Health Conditions, identified a pain assessment interview should have been conducted, however, the MDS did not identify the presence of pain, frequency of pain, pain effect on sleep, pain interference with therapy activities, day to day activities, pain intensity, or a verbal descriptor scale. Last, the MDS section labeled Section O-Special Treatments and Programs did not indicate R26 had oxygen on admission or while a resident, nor did the MDS indicate R26 was on hospice on admission or while a resident. During interview on 10/17/23 between 8:38 a.m., and 8:44 a.m., R26 stated staff were so busy and R26 did not want to bother them. R26 further stated a desire to have more company due to feeling lonely and stated feeling isolated in R26's room. During interview on 10/19/23 at 9:29 a.m., the administrator stated licensed practical nurse (LPN)-A completes the MDS and registered nurse (RN)-A oversees the completion and further stated their MDS coordinator left at the end of September. During interview on 10/19/23 at 9:53 a.m., SW-A stated she started working at the facility in February 2023, and was responsible for completing sections C, D, E, F, and Q of the MDS assessment. SW-A verified section C, D, and F was not completed and should have been completed and did not know why the assessments were not completed and added the MDS coordinator left and they were doing a different process than previously. SW-A stated R26 had heart failure and major depressive disorder and stated completing the MDS assessment would have been beneficial to R26 in order to monitor for changes in R26's mood and added completing R26's preferences interview would have been another opportunity for R26 to express what was important to her. SW-A verified R26 came into the facility with portable oxygen when she was first admitted . During interview on 10/19/23 at 10:12 a.m., RN-A stated either RN-A, LPN-A, or another staff person completes the pain assessment for Section O of the MDS assessment and LPN-A would enter the information on the MDS. RN-A stated she was working the day R26 was admitted to the facility and verified R26 had oxygen when she was admitted and was on oxygen prior to admission and should have had oxygen marked on the MDS. Further RN-A verified R26 was on hospice prior to admission to the facility and stated there were no progress notes to indicate why a pain assessment was missed and stated the pain assessment on the MDS should have been completed and added the whole MDS interview was not completed. During interview on 10/19/23 at 10:40 a.m., the director of nursing stated she expected the MDS sections should have been completed regarding areas marked not assessed, and the MDS should have been accurate. A policy, Comprehensive Resident assessment dated [DATE], indicated the primary purpose of assessing the resident is to gather detailed information that will help to develop a plan of care that is appropriate for the resident. The interdisciplinary team conducts timely resident assessments and reviews according to the following schedule: within 14 days of the resident's admission or re-admission to the facility; when there has been a significant change in the resident's condition; at least quarterly; and once every 12 months. Comprehensive assessments should include cogitative status or patterns, mood and behavior patterns, health conditions, activity preferences, and special treatments, procedures or care needs.

Based on observation, interview, and document review, the facility failed to implement safety prevention interventions for 1 of 1 resident (R31) reviewed for safety. Findings include: R31's Medical Diagnosis form indicated the following diagnoses: alcoholic cirrhosis liver with ascites, metabolic encephalopathy (a condition affecting brain function), other frontotemperoral neurocognitive disorder (damage to neurons in the frontal and temporal lobes of the brain), restlessness and agitation, dementia in other diseases classified elsewhere unspecified severity with agitation, and other symptoms and signs involving appearance and behavior. R31's quarterly minimum data set (MDS) dated [DATE] indicated severe cognitive impairment, required set up for eating and hygiene, substantial assist for toileting hygiene, was independent with upper and lower body dressing, transfers, and ambulation, rejected cares one to three days, did not have hallucinations or delusions, physical behavior, or verbal behavior, and was frequently incontinent of bowel and bladder. R31's clinical physician orders dated 1/12/23, indicated R31 had an order for QUEtiapine fumarate 25 mg tablets, take 1.5 tablets by mouth twice a day for agitation. R31's care plan dated 10/28/22, indicated R31 was at risk for nutrition problems and an intervention for nursing staff, nursing assistants, dietary, and dietary manager indicated, provide R31 with finger foods and plastic silverware with meals due to cognitive impairment and history of physical aggression and resistiveness. When angry, R31 tried to use regular metal eating utensils as a weapon against staff. R31's diet order indicated R31 was on a regular diet texture with regular consistency foods. There was a heading titled, Additional Directions however no additional instructions were provided. R31's care plan dated 11/2/22, indicated R31 had a history of wandering into other resident's rooms when searching for the bathroom. R31's care plan dated 11/10/22, indicated R31 was on psychotropic medications due to major neurocognitive disorder and agitation with interventions to monitor and record occurrence of behaviors that included violence and aggression towards staff and others. R31's risk management report dated 1/8/23, indicated R31 attempted to strike a staff person with a flashlight and then grabbed a fork off the breakfast try and attempted to stab the nursing assistant. The report indicated the behavior began when staff attempted to change R31's wet clothing. Further, R31's room was checked for sharp items and these items were removed and the kitchen was contacted suggesting finger foods and no metal flat ware. R31's Task form for targeted behaviors from 9/30/23, through 10/19/23, indicated R31 had physical aggression one time on 9/20/23, additionally. R31 refused cares 29 times. R31's nursing progress notes dated 10/10/23, indicated R31 had two episodes of physical aggression in the past 30 days. During interview and observation on 10/17/23 at 9:05 a.m., R31 was in his room and had a breakfast tray with a plate and bowel with two fruit loop type cereal pieces. At 9:07 a.m., dietary aide (DA)-A arrived to take R31's meal tray and when asked if R31 received regular silverware, DA-A stated R31 does receive regular silverware and has for quite a while. R31 had a metal spoon, fork, and knife located on the meal tray. During interview on 10/17/23 at 2:44 p.m., nursing assistant (NA)-A stated R31 wandered and sometimes became agitated. During interview and observation on 10/17/23 from 3:19 p.m., to 3:24 p.m., dietary supervisor (DS) stated when a patient has special utensils or adaptive equipment, it was documented in the electronic medical record (EMR) and further stated they may receive information from nursing that is posted on the refrigerator regarding which residents received any adaptive equipment. A sign located on the refrigerator identified certain residents who required various adaptive equipment, but lacked information R31 required plastic silverware. DS further stated DA-A instructed DS to review the care plan and added in a red marker on 10/17/23, on a board R31 required plastic silverware for every meal until further notice. DS was not sure whether DA's had access to the EMR and verified R31 was supposed to have plastic silverware according to the EMR. During interview on 10/17/23 at 3:34 p.m., the operations director (OD) stated the kitchen has a list of residents who require assistive devices such as sippy cups to tube grips to silverware and divided plates located on the refrigerator. OD further stated they were working on the process for updating the process weekly as they receive more admissions and stated it was a miscommunication on OD's end and verified R31 was not on the list of the refrigerator. Requested a policy related to dietary orders and food utensils, however on 10/17/23 at 4:04 p.m., OD stated there was no policy on adaptive equipment. During interview on 10/18/23 at 8:07 a.m., licensed practical nurse (LPN)-A stated R31 wandered and stated R31 had agitation twice in October on 10/4/23, and 10/10/23, and refused cares 36 times. LPN-A further stated R31 had more agitation when he first arrived and thought R31 read lips and was doing better now that staff no longer had to wear a face mask. During interview on 10/18/23 at 9:54 a.m., the director of nursing stated any time something is placed on the care plan, the departments involved were notified and should be aware and further stated sometimes diet orders under special instructions would indicate the plastic silverware, but it was not listed. DON stated she expected dietary to be aware because R31 had agitation and it was important to have the plastic utensils for safety. A policy, Care Plan Policy, dated 11/25/16, indicated the care plan was based on the resident's comprehensive assessment findings and was developed by a care planning interdisciplinary team (IDT) that included the resident's attending physician, registered nurse, dietary manager and dietician, social worker, and each resident's comprehensive care plan was designed to incorporate identified problem areas, incorporate risk factors associated with identified problems, and identify the professional services that are responsible for each element of care.

Based on interview and document review, the facility failed to ensure gradual dose reductions (GDR) were attempted, or an adequate medical justification for the use of psychotropic medications for 1 of 5 residents (R31) reviewed for unnecessary medications. Findings include: R31's Medical Diagnosis form indicated the following diagnoses: alcoholic cirrhosis liver with ascites, metabolic encephalopathy (a condition affecting brain function), other frontotemperoral neurocognitive disorder (damage to neurons in the frontal and temporal lobes of the brain), restlessness and agitation, dementia in other diseases classified elsewhere unspecified severity with agitation, and other symptoms and signs involving appearance and behavior. R31's quarterly Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment, had disorganized thinking that fluctuated, did not have hallucinations, or delusions, did not have physical, verbal, or other behavioral symptoms, and rejected care one to three days. Additionally, the MDS indicated R31 required set up for eating, oral hygiene, and required substantial toileting hygiene assistance, was independent with dressing, transfers, and ambulation, was incontinent of bowel and bladder, took antipsychotics on a routine basis, no gradual dose reduction (GDR) had been attempted, and a GDR had not been documented by a physician as clinically contraindicated. R31's physician orders dated 1/12/23, indicated R31 had an order for quetiapine fumarate 25 mg tablet give 1.5 tablets by mouth two times a day for agitation. R31's care plan dated 11/10/22, indicated R31 took a psychotropic medication quetiapine fumarate due to major neurocognitive disorder and agitation and his goal was to be free from drug related complications including movement disorder, discomfort and intervention indicated to consult with the pharmacy and physician to consider dosage reduction when clinically appropriate. R31's pharmacy medication regimen reviews (MRR) were reviewed and indicated no concerns reported for the following dates: 11/9/22, 12/9/22, 2/22/23, 3/30/23, 4/13/23, 5/10/23, 6/14/23, 8/11/23, and 9/13/23. On 11/2/22 there were no urgent action irregularities identified and question the maximum dose limitation of 2000 milligram (mg) per day on Tylenol with revision of instructions for use to limit total daily dosing. On 1/24/23, an MRR was completed and R31's immunization was overdue. On 7/11/23, the MRR was completed and a report was issued for GDR consideration. R31's Psychotropic Medication Regimen Review report dated 7/11/23, indicated R31 had frontotemporal dementia, insomnia, and agitation and took quetiapine 37.5 mg and citalopram (an antidepressant) 10 mg. The report indicated on 1/23/23, R31's quetiapine was increased from 25 mg twice daily on January 12, and citalopram 10 mg a day was started on January 12. The report further indicated R31 was due for tapering of the above regimen and if a reduction was not appropriate, the clinical contraindication to tapering must be documented and R31's target symptoms of physical aggression had greatly improved, but were not completely resolved. The physician response dated 7/17/23, indicated to discontinue citalopram 10 mg daily and start citalopram 5 mg daily for major depressive disorder. The report lacked information whether a GDR should be attempted on the quetiapine fumarate or a documented clinical contraindication to tapering the medication. R31's nurse practitioner (NP) noted dated 7/12/23, indicated R31's aggressive behaviors resolved and staff reported R31 settled in well and continued on quetiapine 37.5 mg twice a day and citalopram 10 mg daily. The note lacked information regarding a GDR for the quetiapine or a clinical contraindication to tapering the medication. R31's nursing progress note dated 7/13/23, indicated R31's quetiapine and citalopram was reviewed at monthly psych drug meeting and R31 was due for a GDR review and was awaiting provider response. The note further indicated R31 was quite stable on medications and behaviors and physical aggression had decreased greatly with increased doses. R31's psychotropic drug review nursing note dated 7/17/23 at 2:10 p.m., indicated a GDR was accepted for citalopram and the medication was decreased to 5 mg daily. R31's psychotropic drug review nursing note dated 8/9/23, indicated citalopram was discontinued 7/23, and continue quetiapine as ordered. R31's psychotropic drug review nursing note dated 9/13/23 indicated a GDR for quetiapine would be due in January 2024. R31's physician progress note dated 8/31/23, indicated R31's mood and behavior was appropriate. The note lacked information regarding a GDR for the quetiapine or a clinical contraindication to tapering the medication. R31's Task form for targeted behaviors from 9/30/23, through 10/19/23, indicated R31 had physical aggression one time on 9/20/23, additionally. R31 refused cares 29 times. R31's nursing progress notes dated 10/10/23, indicated R31 had two episodes of physical aggression in the past 30 days. During interview on 10/17/23 at 2:44 p.m., nursing assistant (NA)-A stated R31 can sometimes get agitated because he did not like assistance. During interview on 10/18/23 at 8:07 a.m., licensed practical nurse (LPN)-A stated R31 had agitation when he first was admitted and stated R31 read lips and his agitation was much better after staff no longer were required to wear face masks. LPN-A reviewed documentation and stated in the last 30 days R31 had two episodes of physical aggression on 10/4/23, and 10/10/23 and refused cares 36 times. During interview on 10/18/23 at 9:54 a.m., the director of nursing (DON) stated the pharmacist reviews medications on new admissions and additionally comes two days a month and emails his findings and the findings are reviewed with the provider during rounds and stated sometimes there was a lag between when the physician responded. DON further stated the physician documents their responses on the form and the nurse enters a note and any order changes are placed under physician orders. DON provided the psychotropic drug review nursing note dated 9/13/23 and stated she would look for documentation of the clinical contraindication in the hard chart. During interview on 10/13/23 at 11:00 a.m., DON verified there was no documented GDR clinical contraindication for the quetiapine. During interview on 10/18/23 at 2:53 p.m., the pharmacist consultant (PC) stated the purpose of a GDR is a regulatory requirement to find the minimum effective dose and re evaluate doses a resident may tolerate and to monitor for drug interactions and stated R31 had significant behavioral disturbance when R31 was first admitted . A policy, Psychotropic Medication Management dated 6/29/23, indicated psychotropic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to GDR and review per CMS guidelines. The pharmacy consultant will monitor drug therapy monthly with recommendations to provider as indicated. The provider shall respond appropriately by documenting based on assessing the situation why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences. Residents receiving psychotropic medications will have GDR attempted unless clinically contraindicated with appropriate documentation by the provider.

Based on record review, interview, and policy review, the facility failed to consistently monitor and document the progression of pressure ulcers for one (Resident (R) 25) out of two residents reviewed for the development of pressure ulcers in the total sample of 21 residents. The facility staff failed to monitor a pressure ulcer identified on a care plan on 05/10/22 through 07/12/22 when the pressure ulcers progressed to the depth of exposed tendon and bone resulting in harm to R25. Findings include: Review of a document provided by the facility titled Skin Management Policy, dated 02/03/09, indicated . To identify residents at risk for impaired skin integrity, and to provide direction for proper prevention, treatment, and documentation of skin impairments. Full Body Skin Assessment . Wound/Ulcer Assessment . Documentation should include, but not limited to, the size, location, and characteristics (color, drainage, etc) of the injury in the form of a skin/wound progress note . A pressure ulcer is localized to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear . Under a category titled Measuring the document revealed . Length/Width . Depth . Undermining . Tunneling . Periwound [surrounding condition of the wound margins] . Under a category titled Exudate Types indicated Serous drainage . Sanguineous drainage . Serosanguinous exudate . Seropurulent exudate . Purulent exudate . Review of a document provided by the facility titled Hospital Discharge Note, dated 04/27/22, indicated R25 had a closed nondisplaced bimalleolar (both ankle bones) fracture of the right lower leg with routine healing. The discharge note indicated the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a document provided by the facility titled Admission Record, indicated R25 was admitted to the facility on [DATE] with a nondisplaced ankle fracture, [CONDITION(S)] disease, and [CONDITION(S)]. Review of a document provided by the facility titled Order Summary Report, dated 04/27/22, indicated R25 was to have a CAM boot on at all times. In addition, there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no indication the facility questioned the medical provider to permit the clinical staff to remove the CAM boot as part of the full body skin assessment. Review of a document provided by the facility titled Comprehensive Assessment, dated 04/27/22 (date of admission to facility), indicated R25 had no skin issues. Review of a document provided by the facility titled Braden Scale for Predicting Pressure Sore Risk, dated 04/27/22, indicated R25 was at mild risk for developing a pressure ulcer with a score of 17. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/04/22 indicated a Brief Interview of Mental Status (BIMS) score of 15 out of 15 which revealed R25 was cognitively intact. This MDS assessment indicated R25 required extensive assistance of one staff member for bed mobility and extensive assistance of two staff for transfers. This MDS assessment revealed R25 was at risk for the development of pressure ulcers and had no pressure ulcers upon admission to the facility. Review of a document provided by the facility titled Progress Note, dated 05/06/22, indicated the resident had her toenails debrided and there was no mention of pressure ulcers on her right foot. Review of documents provided by the facility titled Resident Weekly Summary, dated 05/07/22, documented no skin issues for R25. Review of a document provided by the facility titled Care Plan, dated 05/10/22, indicated R25 had a non-surgical right ankle fracture and pressure ulcers under her CAM boot. There were no associated interventions identified in the care plan that addressed the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no description or measurements of the pressure ulcers on the care plan. Review of the EMR Progress Notes, Orders, Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of documents provided by the facility titled Resident Weekly Summary, dated 05/14/22, documented no skin issues for R25 despite the care plan, dated 05/10/22, stating there was a pressure ulcer under the CAM boot. Review of a document titled Message, which was written by Podiatrist F and dated 05/20/22, which revealed he saw R25 on this same date, indicated the resident was safe wearing the CAM boot while transferring and wanted to see R25 in one week to check on the status of a new . pressure injury . Podiatrist F ordered R25 to put some pressure to her right foot if this added her in safe transfers. Podiatrist F directed staff to keep the boot on at all times Further review of this document and the EMR Orders tab revealed no description of the pressure injury and no orders for treatment. Review of a document provided by the facility titled Podiatry Note Clinic, dated 05/27/22, written by Podiatrist F, indicated R25 was seen as a follow-up for her ankle fracture. Podiatrist F indicated in the report, in addition to being seen for the ankle fracture, the resident's skin was intact and had small superficial abrasions, pressure ulcers at the lateral foot. The report indicated the resident had well managed [CONDITION(S)] in this region. Further review of this note and the EMR Orders tab revealed no description of the pressure ulcer at the lateral foot and no orders for treatment. Review of a document provided by the facility titled ER (emergency room ) Urgent Care-Provider, dated 05/28/22, indicated R25 was transferred to the ER for evaluation of neuropathic pain. Further review of this document revealed R25 had a pressure ulcer of the dorsum (top) of right foot. This document included no description of the pressure ulcer. Review of a document provided by the facility titled Admission/Discharge/Transfer . Physician Plan of Care . , dated 05/28/22, indicated R25 had pressure ulcers on her foot and to change padding in boot every three days. The orders for care indicated to remove the CAM boot to right foot as needed based on resident's symptoms and to change padded foam every three days. Review of this document revealed no description of the pressure ulcer. Review of documents provided by the facility titled Resident Weekly Summary, dated 05/30/22, documented no skin issues for R25. Review of a document provided by the facility titled Treatment Administration Record (TAR), dated 05/31/22, R25 had an order to remove the CAM boot to the right foot and to change padded foam every three days. Review of the TARs revealed this order was carried out as ordered and continued until 06/15/22. Review of EMR Progress Notes and TARs revealed no description of the pressure ulcer even though the nursing staff was removing the CAM boot and changing the padded foam every three days. Review of a document provided by the facility titled Wound/Ulcer Assessment, dated 06/01/22, indicated the top right foot had a 1 x (by) 2 centimeters (cm) pressure ulcer. On the right outside of the foot on the pinky toe was a 0.5 x 0.5 cm pressure ulcer. The assessment indicated four scabbed areas on front of the right shin. The assessment reiterated the physician order, dated 05/28/22, to replace foam padding in boot and rewrap with gauze and replace boot every three days. This is the first description of the pressure ulcers since first mentioned in the Care Plan, dated 05/10/22, that indicated R25 had pressure ulcers under her CAM boot. This nursing Wound/Ulcer Assessment did not describe the characteristics (color, drainage, peri wound, odor, tissue of wound base) of the injury. Review of a document provided by the facility titled Nursing Home Comprehensive Note, dated 06/01/22, indicated R25 had multiple pressure sores on her foot of which the Medical Director was aware. The progress note revealed the clinical staff applied cast padding to her foot and it was to be changed every three days. There were no measurements or description of the pressure sores included in the progress note. Review of a document provided by the facility titled Nursing Home Notes, dated 06/01/22 and written by the Nurse Practitioner revealed the NP did not remove R25's CAM boot to look at her pressure ulcers. Review of a document provided by the facility titled Resident Weekly Summary, dated 06/06/22, indicated R25 had right foot sores which revealed a wound on the top of her foot which measured 1 cm x .75 cm, 1 cm x .5 cm, sore back of heel is .1 cm x .1 cm. Medial ankle sore 2 cm x 1 cm. Further review of this document revealed no description of the pressure ulcers other than measurements. The measurement of the pressure ulcer on the top of the foot now included a depth of 0.5cm which indicated a worsening of the area and a new pressure ulcer on the back of the right heel. Review of a document titled Laboratory Results, dated 06/11/22 indicated a culture was obtained from R25's right foot pressure ulcer and results revealed the resident had microbes found and there was a potential for infection. The results stated the bacterial organisms may not require therapy. The provider must use clinical assessment of the resident's symptoms to make a final judgement on antibiotic use or not. Review of a document provided by the facility titled RN note, Progress Note, dated 06/13/22, revealed a culture taken of R25's wound did not indicate the initiation of antibiotics. Review of a document provided by the facility titled Wound Care, dated 06/13/22, revealed R25 was seen by a wound Registered Nurse (RN). The wound RN identified the wound on R25's right foot as mixed arteriovenous ulceration and described the wound on the top of the foot of an UTD (unable to determine) depth and required debridement (the removal of nonviable, dead tissue). The wound on the right ankle posterior area was measured at 2cm x 1cm x .2 cm and required debridement. Both areas were assessed as full thickness (damage extends below all layers of skin into the subcutaneous tissue or beyond to muscle, bone, tendons). The RN wrote to apply Santyl for debridement and place an oil emulsion to provide a non-stick covering. The orders continued by placing a super absorbent dressing to wick away excess exudate away from the wound and peri-wound. This order was to be done daily and directed the clinical staff to monitor for decline in wound healing or the development of necrotic tissue. Further review of the note written by the wound nurse revealed it was written the same day as the following facility nursing note titled Resident Weekly Summary, dated 06/13/22: R25's top right foot pressure ulcer measured 1.0 cm x 1.0 cm x 0.5. The resident's medial ankle pressure ulcer measured 0.1 cm x 0.1 cm. The back of the resident's heel measured 2.0 cm x 1.0 cm. There was no description of the wounds other than the measurements. Review of a document provided by the facility titled provider's order note Progress Note, dated 06/15/22, indicated for wounds to the right fifth toe lateral, right dorsal mid-foot, right proximal foot, and right posterior ankle to cleanse area, pat dry, and to apply Santyl about nickel thick. To cover with oil emulsion, secure with roll gauze and tape, to apply low stretch (setopress) wraps as ordered and to change daily. Review of a document provided by the facility titled medication administration Progress Note, dated 06/18/22 indicated R25's treatment to her wounds was to cleanse, pat dry and to apply nickel thick Santyl. Then to cover the area with oil emulsion and secure with rolled gauze and tape. To apply low stretch (setopress) wraps as ordered and to change daily. Review of a document provided by the facility titled TAR, for the month of June 2022, indicated the treatments were administered as ordered and continued until 07/11/22. Review of a document provided by the facility titled Provider's Order, dated 06/20/22 ordered clinical staff to change the bandages of R25 to foot wounds every other day and to monitor for signs of infection. Review of a document provided by the facility titled Resident Weekly Summary, dated 06/27/22 stated details of R25's wounds were on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the June 2022 and July 2022, MARs revealed no descriptions of the wounds. Review of a document provided by the facility titled skin note Progress Note, dated 06/30/22, indicated there were wounds to the right lower extremity (no measurements). The progress note revealed the resident had slough covering the wound beds and wound was not showing any improvement. The progress note indicated the nurse attempted to use calcium alginate and covered with bordered foam and wrap to help remove slough from wound bed. There was no indication the facility notified the physician of the lack of improvement for the resident's right ankle. Review of a document provided by the facility titled skin note Progress Note, dated 07/01/22 indicated R25 had a pressure ulcer on the top of her right foot which measured 1.5 cm and was 3 cm redness around. The wound bed was noted to have slough, had bloody drainage, redness around the area. There was no documentation that the physician was notified of these findings. Review of a document provided by the facility titled Order Summary Report, dated 07/04/22, indicated the physician ordered R25 to have an ulcer/wound assessment completed for each ulcer on her right foot. Review of a document provided by the facility titled skin note Progress Note, dated 07/11/22, indicated R25 had a posterior wound caused by an ankle fracture and use of a CAM boot. The measurements were 1.0 cm x 1.0 cm and scabbed over the healing wound. The wound bed and peri-wound were intact. Another wound located on the top of the right foot measured 1.5 cm by 1.0 with unstageable slough present. The wound bed and peri-wound had some drainage. Review of a document provided by the facility titled Order Summary Report, dated 07/11/22 indicated the medical provider ordered treatment to R25's right foot/ankle on 07/11/22. The treatment was to cleanse the area, pat dry and apply nickel thick Santyl on the right proximal foot and right posterior ankle. To apply low stretch (setopress) wraps and change daily. Review of a document provided by the facility titled Wound Care Skin Integrity Evaluation, dated 07/12/22, indicated R25 was seen by a wound RN. The evaluation revealed the resident had a right dorsal mid-foot mixed arteriovenous ulceration, non-pressure, which measured 0.90 cm x 1.00 cm x 0.3 cm. The evaluation noted the wound bed was yellow 20 percent and had soft and slimy slough. The resident had exposed tendon/muscle/bone at 80 percent. The treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Change daily. A second wound was on the resident's right posterior ankle and measured 1.50 cm x 0.80 cm x 0.3 and was full thickness and was a mixed arteriovenous ulceration non-pressure. The treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Then cover with super absorbent dressing. Secure with roll gauze and tape then apply setopress wraps and to change daily. Review of a document provided by the facility titled RN note Progress Note, dated 07/12/22, indicated R25 was seen by the wound RN on this date and new recommendations were made from the visit. The progress note revealed the resident had an exposed tendon on the anterior surface of her right foot with increased drainage today. There is no indication that the physician was notified of the exposed tendon since last week after the slough came loose from the wound bed. Review of a document provided by the facility titled ED/Urgent Care Note, dated 07/14/22, indicated R25 was seen in the ER for [CONDITION(S)] pain and had skin ulcerations. The note revealed the resident had skin ulcerations on the dorsum of her right foot and over the Achilles tendon. During this visit the physician stated the wounds did not appear infected. There was no treatment ordered. Review of a document written by the hospital staff and provided by the titled Urgent Care Note, dated 07/14/22, indicated R25 had two open ulcerations on her right lower extremity. Specifically, .One is on her lower leg posteriorly proximal to the ankle that is about 1.5 cm in diameter is moist. There is a smaller ulceration on the dorsum of her right foot that is also about 1.5 cm in diameter and is quite moist. The note continued by stating there was a pulse to the foot and there was no evidence of infection or [CONDITION(S)]. Review of a document provided by the facility titled Progress Notes, dated 07/18/22, written by Podiatrist F, indicated the dorsal foot wound was deep and frankly exposed tendon and positive probe to the bone. The note indicated some redness and drainage and indicated the need for antibiotic use. The progress notes specifically revealed . Dressings to right foot are to be left in place. They will be changed at next office visit as scheduled . Review of a document provided by the facility titled infection control note Progress Note, dated 07/18/22 revealed R25 was to begin the antibiotic [MEDICATION(S)] 100 mg po BID times 10 days. A RN Progress Note, indicated the resident went to theER on [DATE] and revealed the resident had skin ulcerations on the dorsum right foot and over the Achilles tendon. The wounds did not appear to be infected. Review of a document provided by the facility titled Provider's Order, dated 07/21/22 and written by Podiatrist F, revealed to remove the CAM boot from R25's right foot for comfort. To continue with antibiotics and to leave dressings clean, dry, and intact. Review of a document provided by the facility titled Progress Notes, dated 07/25/22, indicated R25 had a pressure wound which measured 0.5 cm by 0.3 cm and was partial thickness destruction through the epidermis extending into but not through the dermis. There was no exudate or odor present. The wound edges were defined, and the peri-wound was pink with no tunneling. The progress notes indicated a wound culture was taken of the resident's pressure ulcers while at the Podiatrist's office. Review of a document provided by the facility titled Provider's Order dated 07/25/22, written by Podiatrist F, revealed R25 was placed in a CAM boot based on resident symptoms. During this visit, Podiatrist F wrote to change dressings to foot wounds daily both the anterior and posterior ankle wounds covered with allyven dressings. The dorsal foot wound was dressed with [MEDICATION(S)] and a small piece of gauze. The orders continued by indicating a small piece of foam was around a wound for off-loading pressure and could be left there unless it was significantly soiled. The foot was then to be lightly wrapped with Kling (rolled gauze) and a light layer of compression. Review of the MAR, dated July 2022, revealed the treatments were administered as ordered by the physician. Review of a document provided by the facility titled Provider's Order dated 07/27/22 indicated R25 was to receive [MEDICATION(S)] 2 grams intravenously every 24 hours for suspected [CONDITION(S)] times 28 days. Review of a document provided by the facility titled Progress Notes, dated 07/28/22, written by Podiatrist F, revealed R25 had surgery on her right foot. Review of a document provided by the facility titled RN Progress Note, dated 08/10/22 indicated R25 had an above the knee amputation of her right leg. During an interview on 09/28/22 at 12:42 PM, Staff L, Licensed Practical Nurse (LPN), stated if a resident was at risk for the development of pressure ulcers, skin should be checked daily by the Certified Nursing Assistants (CNA). Staff L stated as a nurse we need to look at the resident physically to see if there are any pink area and the nurse would then complete a tissue tolerance test. CNAs would reposition a resident. Staff L stated the skin assessment was to be completed on a weekly basis and stated there was no wound nurse since all the facility nurses complete wound care. Staff L stated as part of wound care, measurements would be taken. Staff L stated R25 would not allow the staff to remove her CAM boot. Staff L was asked to show any information on R25's refusals and Staff L stated she could not locate this information. During an interview on 09/28/22 at 2:13 PM, with Staff C, MDS Coordinator, and she stated she would have expected the staff to remove R25's CAM boot for a full skin assessment which would be head to toe. Staff C confirmed the only interventions for the CAM boot were done after 06/01/22 when the facility received orders to loosen the straps on the resident's boot and this was done after the development of the pressure ulcers. Staff C stated the resident had no pressure ulcers when she was first admitted and the pressure ulcers on her foot developed while at the facility. Staff C stated part of the nursing assessment when looking at a wound was to gather the measurements, appearance, the edges, wound bed, signs and symptoms pf infection, and drainage. During an interview on 09/28/22 at 2:51 PM, Staff M, LPN stated R25 would refuse to have her CAM boot removed. Staff M stated the only thing the resident would permit them to do was to loosen her bootstraps. Staff M was asked to locate information in the clinical record which would indicate the resident's refusal to have the boot removed. Staff M was unable to identify this in the clinical record during this interview. During an interview on 09/28/22 at 2:58 PM, R25 denied that she refused to have her CAM boot removed. During an interview on 09/28/22 at 3:28 PM, Staff F confirmed he saw R25 on 05/20/22 for a follow-up to her right ankle fracture. Staff F stated the next time he saw the resident was on 05/27/22 and there were superficial abrasions to her right lateral foot. Staff F stated he saw the resident on 06/20/22 and there were wounds that had healed and some wounds on the dorsal foot in varying stages of healing. Staff F stated wound care treatment was changed and was aware the resident had extremely poor circulation and was not a good candidate for surgery. Staff F stated he did classify her wounds as pressure ulcers on 07/18/22. Staff F stated he wanted the boot to remain on since the CAM boot was like a cast and not to be removed. Staff F stated it was a balancing act to keep the boot on to heal the fracture or to take it off with the resident to be at risk for the development of pressure ulcers. During an interview on 09/28/22 at 3:59 PM, the Staff H, Infection Control Preventionist (ICP), confirmed there were no other skin descriptions other than the measurements of R25's wound on 06/06/22 and on 06/13/22. Staff H stated there were no stages identified. During an interview on 09/28/22 at 4:23 PM, the Staff E, Medical Director stated the staff were very concerned about R25's skin. The Staff E stated the resident initially had superficial areas on her foot. Staff E stated the resident was initially non-weight bearing and could not comply and so the Podiatrist then made her partial weight bearing. Staff E stated R25 had very poor circulation and had a great deal of [CONDITION(S)] which contributed to her vascular issues. Staff E stated she had placed R25 on diuretics and encouraged the resident to elevate her legs, but the foot was enormously swollen. Staff E stated it was the swelling that caused the pressure ulcers to the right foot. During an interview on 09/29/22 at 9:23 AM, the Staff H had the electronic medical records accessible. Staff H was asked about the nursing note dated 06/30/22 and indicated the wounds on R25 had not improved and if the physician was notified. Staff H stated the resident was seen the prior day by a physician and the issue of a possible urinary tract infection for R25. During an interview on 09/29/22 at 10:20 AM, Staff I, Registered Nurse (RN)confirmed she worked with R25 frequently. Staff I stated the resident was seen by the Podiatrist on 05/20/22 and the skin was grossly intact. Staff I said padding was changed every three days and there was no other wound care ordered at this time. Staff I stated the resident complained of pain on 05/31/22 and this was when the Podiatrist was reached out to, and he gave permission to open the CAM boot. Staff I stated the facility was watching the resident during this time. Staff I stated cultures were gathered, an x-ray was performed and again no concerns. Staff I stated the resident was even seen by a wound clinic. Staff I stated nutritional needs were evaluated during this time as well. A subsequent interview was conducted on 09/29/22 at 1:12 PM, Staff I stated there were no skin checks done from 06/14/22 through 06/27/22. Staff I stated Podiatrist F saw R25 on 06/20/22. Staff I confirmed there were no notes to reflect the physician was notified of worsening pressure ulcers from a note written on 06/30/22 or from a progress note entry dated 07/01/22.

Based on interview and document review, the facility failed to ensure residents were free of mental abuse when resident photographs were attached to a power point presentation that was derogatory and demeaning in nature were shared on social media for 2 of 2 residents (R1 and R2) reviewed for allegations of mental abuse, resulting in an immediate jeopardy (IJ) situation for both R1 and R2. The IJ began on 11/11/21, when facility staff shared an inappropriate power point presentation at a party that included residents and later posted on Snapchat (social media). The administrator and director of nursing were notified of the immediate jeopardy at 12:14 p.m. on 11/18/21. The IJ was removed, and the deficient practice corrected on 11/12/21, prior to the start of the survey and was therefore past non-compliance. Findings include Facility Reported Incident (FRI) submitted to the State Agency on 11/12/21, at 4:26 p.m. identified allegations of emotional or mental abuse that occurred on 11/11/21, at 11:00 p.m. The report did not identify which residents were affected by the allegation. The description of the incident included, 11/12/21 it was reported to Admin [administrator] by 2 CNA's [certified nursing assistants] that another CNA had on his Snapchat story (social media account) a video taken last night at his house where someone created a power point and were speaking negatively about the facility, residents, and other staff. A short clip of the video was sent to Admin, who reviewed with the DON [director of nursing] and investigation immediately began. The description also included, Based on the investigation, this is what was determined [NA-B] invited everyone over to his house for a party. [NA-B] had created a power point. In this power point, pictures from the facilities [sic] Facebook were used to create the power point and there were extremely inappropriate comments about residents and staff. The report included At this time, no residents are aware of this video. No residents have been harmed. The report also outlined the facility's corrective action. During an interview on 11/17/21, at 8:15 a.m. administrator indicated on 11/12/21, at around 8:30 a.m. she had received a video taken of a power point presentation that portrayed the facility negatively. Administrator indicated after receiving the video, the facility immediately started investigating. Administrator indicated the video was a short clip of a room where the party was and what was going on in NA-B's apartment. Administrator indicated the content in the clip was really nothing significant and there was nothing on the video that was derogatory. Administrator stated the gravity of the inappropriateness came from the actual power point and not what was viewable or audible on the Snapchat video. Administrator stated the photos of residents were taken from the facility's public Facebook page. The director of nursing (DON) stated when something is shared on someone's story on Snapchat it remains for 24 hours unless the person who posted it takes it down. The administrator indicated on 11/12/21, everyone involved were instructed to write down their own version of what happened and who was involved as part of the investigation. Administrator indicated based on the findings of the investigation staff members that had highest level of involvement were suspended, the LPN involved was reported to the board of nursing and indicated NA-B's employment had been terminated. Administrator indicated all involved had been instructed to delete any trace of this power point and Snapchat video. Administrator indicated all 8 staff involved were assigned education modules that pertained to resident rights and vulnerable adults, in addition those involved received individual education/coaching on the seriousness of the behavior. Administrator indicated all staff were provided with immediate education on VA policy, specifically related to social media. Administrator indicated residents were not made aware nor were their families/resident representatives notified resident pictures were shared on social media without permission. The video of the social gathering with a portion of the power point shared on Snapchat was reviewed during entrance conference on 11/17/21. The video identified the person [NA-B's first name] who shared the video on Snapchat and the duration of time that lapsed since the video was posted on Snapchat which was 8h [hours] ago but did not include the date. The video showed facility staff sitting around a television with a power point slide show playing on a television. The first slide included the title, The Predators of Sauer Health Care with a picture of the administrator and the facility. The next slide seen was a respectable photo of R1 fully clothed on the left side of the slide and the right side had R1's first and last name with four partial bullet points where the context was not discernable. The next slide included a very clear respectable picture of R2. The next slides included names and pictures of staff members along with undiscernible context of the bullet points. In the video staff present could not be heard making derogatory and/or demeaning comments about the residents who were featured in power point. R1's significant change Minimum Data Set (MDS) dated [DATE], identified R1's primary medical condition as stroke. The MDS indicated R1 did not have cognitive impairment and did not have behaviors. R1's care plan dated 11/16/21, included R1 has been known to make inappropriate sexual comments or touching at times. R2's quarterly MDS dated [DATE], identified R2's primary medical condition as medically complex and had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's care plan dated 8/9/2018, included [R2] has almost daily behaviors of inappropriate comments to the female staff. He will at times come out of his room not appropriately dressed and somewhat exposed. He has made comments about staff's bodies, statements about wanting a particular staff person to give him a shower, asking about staff's boyfriends and has called one staff' person's church to attempt to find out more information about her. During an interview on 11/17/21, at 9:04 a.m. licensed practical nurse (LPN)-A stated on 11/11/21, she was in attendance of NA-B's and dietary assistant (DA)-A's social gathering along with 5 other staff members. LPN-A stated typically these social gatherings started off with a few board games or cards, this time it was a little different. LPN-A stated NA-B pulled out a power point that used pictures from the Sauer Facebook page. LPN-A stated the power point was about The Pillow Treatment which LPN-A described as putting a pillow on someone's face to knock them out and the title of the power point was Predators of Sauer. LPN-A indicated she remember R1's picture being in the power point. LPN-A stated, We shouldn't have had the power point to begin with, the topic was very horrible. LPN-A added, We should have stopped what they were doing. When asked why certain residents were selected to be in the power point, LPN-A stated from her understanding, R1 was probably selected because although R1 did not have cognitive impairment, he had sexual behaviors directed towards staff and stated she knew people were frustrated with R1's behaviors. LPN-A indicated during the gathering, some of the group had conversation about R1's behaviors. LPN-A stated NA-B had made a short video recording while the power point played over the television for the group and then shared the video on his Snapchat. LPN-A indicated the video showed an 8 second clip of presentation and did not include derogatory/demeaning language that she could recall and did not include the group's discussion about R1's sexual behaviors. LPN-A stated she had not given permission for NA-B to make a video of her or share the video on social media, and had she known a video was taken would have stopped it. LPN-A stated if the resident and/or the resident representative were aware of the power point and the video posted to social media they would be very upset and would not want their family members to be talked about in that way. LPN-A stated, I am really regretting being in attendance [at the social gathering]. If I wasn't there, I wouldn't have been involved in anyway. LPN-A indicated she was remorseful and did not want this to ruin her career. LPN-A indicated on 11/12/21, she had a meeting with administration and received education/coaching/counseling. LPN-A's written statement dated 11/12/21, included, On 11/11/21 I and five other coworkers went over to [DA-A's] and [NA-B's] apartment for a small social gathering of only coworkers. [Names of attendees]. A power point was played on the TV in regards to a selected few residents at Sauer Health care. The power point was not of malicious intent. There was no information on the PowerPoint in regards to resident care or information related to the resident it was a mistake to be in attendance of this social gathering that had occurred. I wish that I had spoken up and stopped the events that had taken place along with stopped the publication of it going on social media If I were to go back in time I would take different action to prevent this from ever occurring. During an interview on 11/17/21, at 9:06 a.m. NA-C stated she attended NA-B's social gathering on 11/11/21. NA-C stated after she arrived, NA-B pulled out a power point presentation that she had no prior awareness of. NA-C stated, I didn't see the entire power point. I just know of one of the residents [R1]. NA-C stated, I just remember the picture of him [R1] and can't remember what it said on the slide. NA-C stated she did not recall statements made that were derogatory. NA-C indicated she was not aware that NA-B had made a video and was not aware he had shared the video on Snapchat until she was notified by administration on 11/12/21. NA-C stated, I can't imagine how [R1] would feel, I feel very sad, I'm sure he would feel betrayed in a way, especially since we are the ones taking care of him. NA-C indicated her involvement was a lack of character on my part, I was in the moment and got caught up in it. NA-C indicated on 11/12/21, she had been contacted by administration, she gave a written statement and received coaching/counseling and education. During an interview on 11/17/21, at 10:00 a.m. NA-A stated she had not been present at NA-B's social gathering. NA-A stated when she checked messages on Snapchat the morning of 11/12/21, she saw the video shared by NA-B the evening of 11/11/21. NA-A stated in the video you could see the television with the power point presentation; the first slide was Predators of Sauer with [name of administrator] and the building in the background, then there was a zoomed in slide of R1 but couldn't see the writing on the slide, then the next slide was [R2's] picture. NA-A stated the photo of R1 and R2 were very clear. NA-A stated during the slides you could not really hear what was going on and indicated the only residents that were in the video were R1 and R2. NA-A stated right after she saw it, she conferred with NA-D who had also just viewed the video, and both reported the video to facility administration soon after viewing. During an interview on 11/17/21, at 10:10 a.m. NA-D stated she did not go to NA-B's social gathering. NA-D stated she had seen the video posted on Snapchat by NA-B when she woke up the morning of 11/12/21. NA-D stated you could see the power point presentation on the television. NA-D stated the pictures used were from the facility Facebook page. NA-D stated the first slide had Predators of Sauer written on it but was hard to see, the slide had administrator's picture on it. NA-D stated the next slide was of [R1] with words on it but couldn't read what they were, and the following slide was [R2's] blown up picture. NA-D stated during the video, staff did not say anything derogatory or that could be heard. NA-D stated NA-A had also just seen the video and they both reported it to the facility administrator. NA-D indicated if residents and/or resident families were aware, I think families would be hurt, irate, and question the trust level. During an interview on 11/17/21, at 11:42 a.m. NA-E stated staff were going to go hang out over at NA-B's place on 11/11/21, because they were all friends outside of work. NA-E indicated the group had taken the idea for the power point from Tik Tok. The presentation is intended to be amongst friends and not intended to be work related, however, someone made it about work and the conversations were more derogatory. NA-E stated, It presentation] got more intense than what it was intended and I was kind of sitting there as it unfolded because I didn't know how to control the conversation. NA-E stated she thought the presentation was talking about bad things that happened at work, part of it was about residents' behaviors, and thought that the presentation had information about one resident shown, but couldn't remember. NA-E stated the residents included in the presentation was R1 and R2. NA-E stated she was not aware that NA-B had made a video and did not participate in the making of the power point. NA-E stated on 11/12/21, she met with facility administration and wrote her statement. NA-E stated she received coaching/counseling at that time. NA-E's written statement dated 11/12/21, included, The PM [evening] staff had a night where they presented power point presentations with various titles. The people involved [names of attendees]. We were all equally involved because all of us were made part of the power points as well. Like why we would be admitted Sauer healthcare and some decided to make it more violent and gross. I am unaware of any other videos besides the video that was [sic] made aware of .I was not aware of the full VA [vulnerable adult] guidelines which I feel foolish for now. I am deeply sorry for this event to have occurred and will comply as needed. During an interview on 11/17/21, at 1:03 p.m. NA-B stated a couple of days prior to his social gathering R1 had sexually harassed a co-worker. NA-B stated the original plan was to make a power point, I didn't think it was necessarily funny, I guess it was made more to shed light on the issue and make it humorous to a degree. NA-B stated he had created the power point presentation the evening of the gathering after people had been there and after he had quite a few drinks and was pretty intoxicated. NA-B stated he used resident pictures off the facility's Facebook page. NA-B indicated he thought the title of the presentation was Predators of Sure. NA-B indicated the slide with R1 had bullet points about his behavior that were probably rude, however, did not think the bullet points were visible on the presentation. NA-B indicated on 11/12/21, he got a phone call from facility administration, and gave a written statement and received coaching/counseling. NA-B stated his next scheduled shift was the following Monday and when he showed up for work the facility had terminated him. NA-B stated, I think the families would be relieved to know that the person responsible was no longer working there at least, it was a bad situation, and they would not be happy about it. NA-B stated it was pretty rude and a mean thing to do and I do regret it though 100% NA-B's written statement on 11/12/21, included the following: I in poor judgement made a power point that was to be a joke while we were all drinking. It was in bad taste and I crossed a line as well. As someone who takes care of these people I failed to protect them on my own accord. For that I am deeply sorry. I regret my actions and take full responsibility for them I made the power point after inviting people over and after all of us had lots to drink .I put the power point up to get a few laughs. I then posted a few pictures and videos to what I thought was my private story on Snapchat but instead I put it on my main story. I meant to only show [sic] but I put resident pictures in the videos as well . During an interview on 11/17/21, at 1:30 p.m. family member (FM)-A stated they had not been notified R1's picture had been shared over social media. Surveyor informed FM-A of the content of the video pertaining to R1. FM-A indicated they had not given permission for R1's photo to be used in that manner and was not something that was approved of. During an interview on 11/17/21, at 2:27 p.m. NA-F stated there was a group of co-workers that were going to hang out at NA-B's place on 11/11/21 and there was an idea for a power point presentation night. NA-F indicated the presentation was supposed to be super lighthearted. NA-F stated, We were all in the living room talking about something random and then all of sudden there was this power point on the screen. NA-F stated she only remembered R2's face on the power point and did not remember what other residents were shown. NA-F indicated the power point made her feel uncomfortable and tried to start a different conversation. NA-F's written statement on 11/12/21, included the following: Last night on 11/11 myself [names of staff] all got together to hang out and a power point was presented that was using harsh and violent words with residents on it. I did not make this power point or know that it would be containing the things it did. Although I did not create or have a part in the PowerPoint, I was still in the living room. I personally wouldn't have put myself in the situation if I would have known that was what would have been shown and not lighthearted things that don't involve the residents. I got caught up in the moment being with my coworkers and I should have spoken up about how that kind of behaviors is unacceptable towards the people we are supposed to love and care for. Instead tried to avoid the presentation by going on my phone or trying to start a different conversation. I understand the severity of the situation and that I should have spoken up about it. During an interview on 11/17/21, at 3:45 p.m. R2 stated he had not been informed his photo had been used on social media. R2 stated it was ok to have his picture on the facility's Facebook page, however, felt violated someone posted a picture on social media without having his permission. R2 stated his was a Christian and would forgive and forget and tomorrow was another day. During an interview on 11/17/21, at 4:15 p.m. FM-B stated the facility had not been aware R1's photo had been shared on social media. FM-B stated he did not think it was appropriate and expressed disappointment that had happened. During an interview on 11/17/21, at 4:30 p.m. FM-C stated an unawareness that R2's picture was used on social media, was not going to make a big deal about it and could see how something like that could happen. FM-C stated she did feel the same way as R2. The following interviews are from staff that wished to remain anonymous for fear of reprisal from facility peer(s) and/or facility administration. The staff identifiers and time of interviews were intentionally omitted. During an interview on 11/17/21, (time intentionally omitted) an unidentified facility employee (UFE)-A indicated they had not attended NA-B's social gathering, however, had become aware of the presentation when LPN-B showed them the presentation while working their scheduled shift at the facility prior to NA-B's social gathering. UFE-A stated they were shocked in what they saw and could not believe it, it was very demeaning and not at all funny. UFE-A stated the presentation was called Predators of Sauer with [name of administrator] and contents included the article from the news about when the facility had COVID. UFE-A stated LPN-A showed the slides that had R1 in it and talked about how he was a pervert and most likely to assault an aide, for R2 it talked about sexual behaviors, for R3 it talked about a pornography collection, for R4, it talked about how R4 was most likely to pay for sex, and R5 how he was most likely to die alone. UFE-A indicated there were also several staff members in the presentation that were referred to. UFE-A indicated they did not report to administration at the time because they did not have any evidence and planned to talk with trusted co-workers on how this could be brought up the next day. UFE-A indicated the residents, and the families would be very disappointed and devastated if they found out about the power point and that a portion was shared over social media. During an interview on 11/17/21, (time intentionally omitted) UFE-C stated they were at NA-B's social gathering. UFE-C stated when they were called in by administration on 11/12/21, they gave a written statement, however, needed to recant the statement and set the record straight because it was not accurate. UFE-C stated NA-B had not created the power point, that another staff member had, and it had been determined by the group including NA-B that he would take full responsibility to protect the other's future. UFE-C stated there were some gaps in their written statement because I didn't know what was being said about it [by the other staff at the gathering]. UFE-C stated everyone else at the gathering made the same statement; the statement being we just went over to the gathering and NA-B made the presentation for the group. During an interview on 11/18/21, at 9:20 a.m. R1 stated he was quite aware of what social media was and how it worked. R1 stated the facility had not been informed him his picture was shared on Snapchat. R1 stated, That's not right, that's wrong, they [facility staff] can't do that can they? they shouldn't have done that, I hope nothing bad was in there. On 11/18/21, at 11:32 a.m. dietary assistant (DA)-A was called, however, was not available. DA-A returned call on 11/18/21, at 1:31 p.m. DA-A indicated she lived with NA-B and was at the social gathering on 11/11/21. DA-A indicated prior to the social gathering R1 had sexually assaulted one of her co-workers and thought that is what had prompted the idea of the power point presentation. DA-A indicated NA-B had created the presentation and presented the presentation at the gathering, however, did not know when. NA-B had made it and stated she had not seen it prior to the party. DA-A indicated the content of this power point was Predators of Sauer. DA-A stated, Bullet points associated with the residents and staff were rude and [CONDITION(S)] and not in good taste, although I don't remember what the points were exactly. DA-A stated the group was making fun of R1's sexually based behaviors and was put in the power point because of his behaviors. DA-A indicated R2 was included in the presentation because he can be kind of gross, he stalked a CNA [certified nursing assistant]. DA-A stated she was not aware NA-B had made a video and was informed of the video the next morning by NA-B after he had gotten a call from the director of nursing. DA-A indicated on 11/12/21, she had to have a meeting with administration, received coaching/counseling and education. Dietary assistant (DA)-A's written stated dated 11/12/21, included [NA-B] and I had friends over and we drank. After a few hours and being intoxicated [NA-B] brought out a power point for us to look at. People included [names of staff at gathering] Even though I was under the influence I understand the severity of the issue and the harm it caused. I should have stepped up to say something and did not and I am extremely apologetic. Facility Social Media Policy dated 8/2016, included POLICY: social media includes all means of communicating or posting information or content of any sort on the internet including to your own or another person's web log, blog, journal, diary, personal website, social networking, web bulletin board, chat rooms, or any other form of electronic communication. Facility Vulnerable Adult Policy dated 2/18/21, included Definitions: Abuse means the willful infliction of injury, unreasonable conferment, intimidation, or punishment with resulting physical harm, pain or mental anguish. It includes the deprivation of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Also, verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Mental Abuse includes but not limited to, humiliation, harassment, threats of punishment or deprivation. Mistreatment is inappropriate treatment or exploitation of a resident. Social media Nursing home staff, residents, and visitors are prohibited from taking or using photographs or recordings in any manner that would demean or humiliate a resident(s). This would include using any type of equipment to take, keep, or distribute photographs on social media. Willful means the individual must have acted deliberately, not that he/she must have intended to inflict injury or harm. The past non-compliance IJ began on 11/11/21, was removed on 11/12/21, when the facility implemented a systemic plan that included the following actions: 1) The facility protected residents by ensuring staff involved did not have contact with residents until the completion of the investigation. 2) Ensure the video that was shared via social media was removed and deleted along with the power point presentation in the video. 3) Once the investigation was completed: person responsible for sharing the video was terminated, and the LPN involved was reported to State Board of Nursing. Staff involved were provided with individual coaching/counseling in addition to completing education pertaining to resident rights and facility policies pertaining to social media and vulnerable adults. 4) All facility staff were provided with immediate education pertaining to VA policy, specifically related to social media.

Based on observation, interview, and document review, the facility failed to identify the hazard related to the unsafe practice of placing a call light cord and/or bulb in the mouth, and wrapping the cord around the neck resulting in the risk for choking, aspiration and strangulation, for 1 of 1 (R40) resident with self-injurious behaviors and suicidal threats. This resulted in an immediate jeopardy (IJ) situation for R40. The IJ began on 11/25/13 when the facility became aware of R40 placing the call light cord and/or bulb in her mouth and chewing on it. According to the record, R40 had been observed on many occasions to put the bulb into her mouth and chew on it and the staff had not assessed the call light bulb as a potential choking risk for R40. In addition, on 1/21/14 at 2:08 p.m. R40 was observed to have wrapped the call light cord around her neck. Following the incident there had been no risk assessment of the continued use of the call cord for R40 completed, and R40 continued to use the call cord as observed on first day of survey. These findings were identified on 3/13/14 at 12:45 p.m. The administrator and director of nursing (DON) were notified of the IJ on 3/13/14 at 1:05 p.m. The IJ was removed on 3/14/14 at 11:00 a.m., but noncompliance remained at the lower scope and severity level of D which is isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R40 was observed on 3/11/14 at 9:45 a.m. while walking past her bedroom to have a rubber call light bulb in her mouth. Staff was immediately alerted by the surveyor and a staff member went and removed the call light bulb from the resident's mouth. At 11:25 a.m. R40 was observed in her room in a Geri chair with her brows furrowed and a distressed looking expression on her face, and was again observed to have the call light bulb in her mouth. Staff were again alerted by the surveyor and at 11:30 a.m., licensed practical nurse (LPN)-A was interviewed about R40 chewing on the call light bulb. LPN-A stated the resident had regular behaviors of chewing on the call light cord. LPN-A further stated they had replaced the call light with one that did not have electrical wires because R40 would chew on the cord and they did not want R40 to get an electric shock. LPN-A was asked if anything had been tried to alleviate the chewing and she said they had tried to use a baby doll for distraction, but R40 threw it on the floor. LPN-A could not recall anything else being tried. On 3/12/14 at 9:40 a.m., R40 was observed to be in bed and R40 told the surveyor she had just recently put on the call light and the staff had put her to bed because her back hurt. The call light was observed near her hand and faint teeth indentation marks were observed on the bulb. R40's record was reviewed and the facesheet indicated she had been admitted to the facility in 2009. A physician's progress note dated 2/12/14, indicated in 2013 the resident had suffered a cardiac arrest which had resulted in traumatic brain injury due to ischemic [DIAGNOSES REDACTED], and cerebral vascular accident (CVA). That physician note indicated the resident's behavior was very poor as the resident became very argumentative, yelled, screamed, and threw things. The physician had documented the resident, "clearly takes inappropriate risks and shows inappropriate behaviors with regard to her personal safety." On 3/12/14 at 10:45 a.m., two nursing assistants (NA)-B and NA-C were interviewed and both indicated when the resident gets very anxious and wants someone with her, she will have attention seeking behaviors, such as calling out to people walking by, putting on her call light, throwing things, and chewing on the call light. They acknowledged that when they go in and ask her what she wants she generally doesn't want anything other than for someone to sit and hold her hand. These NAs stated she is the same way with her family, and wants them to visit but then gets mad when they have to leave and will yell and swear at them. They indicated a quiet room with music on sometimes helps R40 to calm down. Review of the medical record also indicated R40 had been hospitalized at a local behavioral health unit for treatment of [REDACTED]. The discharge summary dated 10/31/13, indicated the resident had been admitted for severe agitation, paranoia, hallucinations, and combativeness. During the hospital stay the psychiatric evaluation dated 10/22/13, indicated R40 would often say to staff that she wished to die and requested staff kill her. The discharge summary identified discharge [DIAGNOSES REDACTED]. In addition, the hospital discharge summary and subsequent physician orders [REDACTED]., Remeron 15 mg for mood disorder at bedtime (HS), Trazodone 100 mg at HS for sleep disturbances and Zyprexa (antipsychotic) 5 mg bid for psychotic disorder with hallucinations. Nursing progress notes were reviewed from 11/1/13 to 3/11/14 and the staff documented numerous behaviors of chewing and putting call light cord into mouth, yelling, screaming, throwing objects at staff, swinging call light around trying to hit staff, chewing on call light cord, making statements that she wanted to die, refusing to eat, seeing food crawl up pant leg, etc. Progress notes (PN) dated 11/25/13 at 5:56 p.m., indicated that R40 was observed chewing on her call light. Call light (round tap light) was replaced with a bubble type call light, which being more light weight would not cause injuries when resident swung the light around. Staff offered her 1 to 1 monitoring, and redirection which was effective for a short time. The call light was pinned to the resident's chair, but the resident unpinned it, and began chewing on the bulb part of the call light. 12/11/13 at 2:12 p.m., the PN indicated staff observed R40 biting on the bulb end of her call light. The RN supervisor was notified of the episode and the resident was removed from the room. Staff offered the resident 1 to 1, redirection, food and drink. Unsure if the interventions were effective. 1/3/14 at 9:34 p.m., PN indicated R40 had pulled two dimes out of her mouth after BINGO. There were no interventions developed to prevent R40 from having access to coins to prevent risk of chocking. 1/4/14 at 2:13 p.m., PN indicated R40 was chewing on call light cord and bulb, staff indicated they would remove it (call light) from R40's hand and clip it to the blanket within reach. R40 would pull it from the blanket and put in her mouth again. Staff offered the resident 1 to 1 monitoring, reassurance, assessed for pain which were all ineffective. 1/7/14 at 2:08 p.m., PN indicated R40 was putting call light cord in her mouth, shaking it, and growling at staff when they tried to remove it. Staff offered the resident 1 to 1, reassurance, and assessed for pain. However the note further indicated staff were unsure if the interventions were effective. 1/8/14 at 6:22 p.m., PN indicated that staff were walking past the resident's room and noticed resident's feet firmly planted on the ground and the resident had lifted her torso up and rested her neck on the grab bar. R40 stated to the staff that she had wanted to kill herself, but denied having a plan to harm herself. R40 indicated she wanted to get out of there and get to her baby. Was asked again if she was going to harm herself to which resident replied, "No you are going to kill me." A call was placed to the physician, after consultation with the social worker and a nurse on duty. Resident was to be sent into the emergency room . The Patient/Resident Care Summary report dated 1/8/14, which had been sent with the emergency medical service personnel (EMS) to the hospital emergency room included, "Threatened to hang herself with call light cord (there is no documentation to support this statement in R40's records), sucks on call light, says staff is going to kill her. Tried to strangle herself by hanging her head over the grab bars on her bed, and non-stop threats to kill herself. Behaviors have escalated since the discontinuation of Zyprexa." The emergency room Report, dated 1/8/14, received by the facility upon her return, indicated R40 had been seen in the emergency room for suicidal threats and acting on these threats. It was discovered R40 had a urinary tract infection (UTI) at this time. In the emergency room the resident denied wanting to die. The nursing home reported to the EMS that the resident, "tried to strangle herself by hanging her head over the grab bars on her bed, and nonstop threats to kill herself." emergency room Report indicated behaviors have escalated since discontinuing the Zyprexa. After consulting with resident's physician and family it was decided to start Risperdal (antipsychotic) 0.5 mg bid, also to start on an antibiotic for the UTI, and send the resident back to the nursing home. 1/13/14 at 10:38 a.m., PN indicated staff was walking past the resident's room and noted the resident with her shirt pulled up over her head. When asked what she was doing, the resident responded, "Trying to kill myself." Staff sent a message to social services. An eight page fax dated 1/13/14, with progress notes describing R40's behaviors was sent to the attending physician regarding the attempts to harm herself on 1/8/14 when trying to hang self on positioning bar connected to the bed. Staff asked for any ideas to help with the behavioral issues. Staff indicated Behavioral Health Agencies and/or hospitals had been contacted at two different places but they both were unable to assist with the resident's behaviors. The physician responded back with orders to discontinue the Risperdal and restart the Zyprexa at 10 mg bid along with Methadone (an opioid used to treat moderate to severe pain) 5 mg qid. 1/14/14 at 6:02 p.m., PN indicated R40 clenched down on call light with teeth and refused to let go. When staff tried to assist the resident she scratched the staff and wouldn't let go of them. 1/15/14 at 8:00 a.m., PN noted R40 was biting on her call light cord and refused to take it out of her mouth. No interventions were identified as being implemented. 1/17/14 at 1:45 p.m., PN indicated staff noted resident to be chewing on bedside rubber mat in her room and to have chewed off two chunks from the mat. Mat was taken away from R40 and placed in the bathroom. When mat was observed on 3/14/13 at approximately 3:00 p.m., the mat which was about 6 feet long by 2 feet wide was noted to have 5 areas that were in the shape of a mouth bite where the rubber had been removed. 1/20/14 at 1:37 p.m., PN indicated that R40 was provided a Kleenex with which to wipe her face, but shoved it in her mouth. Staff observed her to have put a small plastic bag from her garbage can into her mouth and her call light in her mouth. Staff indicated that R40 wouldn't take the call light out of her mouth so staff told R40 they would go and assist someone else and come back later and then the resident spit her call light out of her mouth. PN do not indicate what happened to the Kleenex or plastic bag. 1/21/14 at 2:08 p.m., PN referenced that R40 had the bulb for her call light in her mouth and wouldn't let go and one episode noted where R40 had call light cord wrapped around her neck. Staff offered the resident 1 to 1 monitoring. Even though the call cord was wrapped around R40's neck, the facility had not assessed the cord for a safety risk nor developed interventions to prevent the possibility of R40 from again wrapping cord around neck. 1/21/14 at 2:31 p.m., PN indicated R40 placed the bulb of the call light in her mouth and had it clenched in her teeth. The resident would not let go of the bulb. The staff member offered to take her to breakfast and attempted to pull on the cord which the resident would not release. After a second staff member came, and after several attempts, the resident did let go. 1/23/14 at 1:46 p.m., PN indicated R40 to be chewing on call light bulb. 1/24/14 at 1:01 p.m., PN indicated R40 continued to take call light bulb and putting it in her mouth and that staff had a hard time getting her to let go of it. 2/5/14 at 2:05 p.m., PN indicated that R40 got a hold of her daughter's keys and was chewing on them; also noted to be chewing on call light and cord. 2/13/14 at 1:46 p.m., PN indicated R40 chewing on the call light cord. 2/14/14 at 2:02 p.m., PN indicated R40 chewing on call light cord and swinging the cord 2/19/14 at 1:56 p.m., PN indicated that R40 continues to chew on call light daily. 2/27/14 at 2:00 p.m., PN indicated R40 chewing on cord was the only behavior exhibited. Staff offered 1 to 1 and redirection which the PN indicated were effective. 3/1/14 at 2:19 p.m., PN indicated R40 was chewing on the call light cord. Staff offered 1 to 1 and encouragement which were not effective. 3/8/14 at 5:35 a.m., PN indicated R40 had cord from call light in her mouth and did not want to let it go. 3/11/14 at 2:02 p.m., PN indicated R40 had several episodes of chewing on call light cord and bulb during shift. Staff offered 1 to 1 monitoring, and assured resident needs were being met. Staff offered food/drink and redirection none of which were effective for any length of time. The annual Minimum Data Set (MDS) (an assessment to determine current health needs) dated 8/21/13, indicated the resident had cognitive deficits. A Brief Interview for Mental Status (BIMS) indicated a score of 8 out of 15 which was indicative of cognitive impairment. According to the MDS, R40 was identified as having hallucinations and delusions, having daily behavioral issues of verbal symptoms towards others, daily behavioral symptoms not directed towards others which included self injurious behaviors. The Care Area Assessment (CAA) completed 8/21/13, indicated R40 had delusional thoughts, screams, cries daily and wishes she were dead. Many times during the day she needed 1 to 1 monitoring because she screams, cries out, "I want to die." The quarterly MDS dated [DATE], indicated the resident had a BIMS score of 7 which indicated cognitive deficits. She again was identified as having delusions, daily behavioral symptoms not directed towards others which included self injurious behaviors, and less than daily behavioral issues of verbal symptoms towards others. R40's comprehensive care plan, current as of 3/9/13, indicated yelling out even when needs were met, manipulative behaviors, hallucinations and delusional thinking patterns. The care plan indicated the resident would swear, cry, throw things, and chew on the call light and cord. The staff determined there were no safety risks with chewing on the bulb and cord as there were no electrical wires running through the call light cord into the bulb. The care plan directed the staff to keep routine consistent and try to provide consistent care givers. Staff was to monitor, document and report ongoing signs and symptoms of anger, irritability, crying, agitation, and suicidal ideation's. Staff were directed to provide 1 to 1 monitoring if necessary which would usually change her mood, along with music. The care plan indicated R40 had impaired thought processes, however, she was able to convey her feelings to the staff and did so readily. The care plan directed staff to provide two call lights due to resident's risk for falls with rapidly changing moods and attempts to stand. Observation on 3/13/14 at 2:55 p.m., indicated R40 was observed with only one call light available. On 3/12/14 at 9:55 a.m., maintenance (M)-A and M-B were interviewed. They both indicated they had observed R40 chewing on the call cord and the bulb, but felt the current call light was safe, because it had no electrical wires running through it. During interview on 3/12/14 at 4:00 p.m., registered nurses (RN)-C and RN-D were asked about R40's self injurious behaviors and safety. Both RN-C and D indicated they were aware of the behaviors exhibited by R40 in regards to the chewing of the call light. In fact, the regular hard call light was replaced when the resident would swing it around and injure self and others. She then was given the gray flat plate call light, but she chewed on that causing fraying. RN-C indicated she did not think she had swallowed any of the pieces hanging from the flat plate. R40 was then given the soft bulb call light which she currently had. The current call light has no wires to expose so the resident was considered safe from getting an electric shock. However, the facility did not consider the possibility of choking on the call light bulb, or parts of the bulb as a potential hazard. On 3/13/14 at 10:35 a.m., the director of nursing (DON) was interviewed about safety concerns related to self-injurious type behaviors and threats of wanting to die for R40. She indicated staff had done a lot to protect the resident and keep her safe. The DON stated the call light had been changed out three times and she thought the one R40 had now was a safe one with no electrical cords. When the DON was told of the observations of R40 having the entire bulb in her mouth, the chewing on the call light cord and possible choking risks, the DON agreed that could be a choking risk. She further agreed that R40 had been putting the bulb in her mouth and chewing on the cord for some time, but was unsure how long. She was only aware of one time that R40 had put the call cord around her neck and stuffed non-edible items in her mouth. On 3/14/14 at 10:25 a.m. the social worker (SW)-A was interviewed. She was aware of the call light being put around her neck and trying to choke self on the grab bar. She indicated after the incident with the grab bar she was called and she directed staff to watch her closely and to send her to the emergency room , which they did on 1/8/14. The behavior unit at Winona hospital would not admit the resident because she was too high of care needs and she was brought back to the home. The grab bars were removed from R40's bed following the attempt to choke self. SW-A indicate she contacted alternative placement the day after R40 returned from the emergency room however, no one would take the resident because of her behaviors and high physical needs. SW-A indicated she had tried about three places following her emergency visit (January 8, 2014) but nothing recently. No further information was provided in regards to intervention for R40's behaviors and safety concerns. Also SW-A indicated chewing on the call light cord and the bulb was discussed with the interdisciplinary team (IDT). They talked about the chewing issue, but due to dignity issues they did not pursue other chew items. SW-A stated they only looked at the safety in regards to the call light cord not having electrical wires running through it and not in regards to the resident choking on the bulb or being able to bite off pieces and swallow them or wrapping the cord around neck. She agreed choking would be a risk. An interview was attempted with the medical director on 3/14/14 at 12:00 p.m. however, the clinic staff indicated he was unavailable for 2 weeks. On 3/14/14 at 12:45 p.m., the resident's medical doctor (MD)-H was called. He indicated he was aware of all of her behaviors and he felt they were not credible self harm attempts. He believed them to be attention seeking behaviors. He felt staff had done everything possible for the resident but what the resident needed was constant 1 to 1 and he did not know where the resident could receive that kind of care. He indicated the resident never needed resuscitation for any of these incidents and he felt the situations had been taken care of. On 3/14/14 at 2:25 p.m., a phone interview with licensed practical nurse (LPN)-D about R40 was completed. LPN-D had been working on 1/8/14, and recalled the incident with the resident and the grab bar. She indicated she was walking by the room and observed R40 with feet firmly planted on the floor. The resident was holding onto the grab bars with her neck on top of the bar putting her weight and neck down on the bar. She described how the resident's eyes looked different, almost detached. She stated the resident's color did not appear blue. She indicated it took a while to get her hands pried loose and LPN-D said R40 had said she wanted to die. The resident's breathing did not seem to be labored. After R40's hands were removed from the grab bar, they laid her down and her face became reddened. LPN-D thought it was more emotional as the resident began to cry. The policy and procedure titled, Suicidal Ideation Policy revised 1/2/14, directed the staff if resident verbalized thoughts of self harm it should be reported immediately to the charge nurse or social services. The nurse or social worker would assess the resident and situation for potential for harm. If the resident does have a plan of self harm staff should assess for causes, monitor the resident and update the care plan. If the resident has an attainable plan of self harm the attending physician and power of attorney (POA) need to be notified immediately to determine the next steps and the resident should be sent to the emergency department for an evaluation. The immediate jeopardy that began on 11/25/13, was removed on 3/14/14 at 11:00 a.m., when the facility had implemented a corrective action plan. The corrective action plan included, immediate 1 to 1 supervision for R40, education of staff, removal of the call cord from R40's room, and facility review of their Suicide Precaution's Policy. In addition, R40 was sent to the emergency roiagnom on [DATE] for evaulation, and was admitted to the acute care hospital for observation until a psychiatric facility could be found to admit her for further evaluation and treatment. Noncompliance remained at the lower scope and severity of a D, as the facility had not had time to fully assess environmental risks, to develop additional interventions, assess whether other interventions would be effective, review and/or develop policies and procedures in regards to environmental risk, and provide more specific education to staff in regards to assessing and reassessing environmental risks and behavioral risks that could potentially cause harm to residents.

Based on document review and interview, the facility failed to have an adequate system in place to ensure accurate transcription and implementation of admission physician's order [REDACTED]. hospitalization due to a critical INR. Findings include: R1 ' s hospital discharge summary indicated that she had been hospitalized from 03/15 - 03/22/12 with [MEDICAL CONDITION]-resistant staph aureus pneumonia and a urinary tract infection. R1's history included a [DIAGNOSES REDACTED]. R1 ' s hospital discharge summary indicated that she was discharged from the hospital and admitted to the facility on [DATE]. R1's physician ' s transfer orders s indicated that she was to receive [MEDICATION NAME] 2 mg daily, which represented an increase in dosage due to a subtherapeutic INR of 1.7 (a lab test that measures blood coagulation, typically ranging from 2.0 - 3.0) at the time of hospital discharge. The physician's transfer orders also indicated that staff were to check R1's INR on 03/26/12. R1 ' s admission comprehensive assessment, dated 03/22/12, indicated that at the time of facility admission, R1 was deconditioned and required extensive staff assistance with all activities of daily living. R1 could stand and pivot, to transfer, with staff assistance. R1 was alert with partial disorientation. Interviews of RN/(D) on 05/17/12 at 9:00 a.m. and LPN/(F) on 04/30/12 at 10:00 a.m. indicated that the facility's system for the transcription of admission physician's orders [REDACTED]. The HUC then prints the computerized data, which constitutes the facility's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The HUC sends the printed MAR indicated [REDACTED]. After the resident is admitted to the specific unit, the resident's admission physician's orders [REDACTED]. This system failed to identify that R1 needed to have an INR drawn four days after admission, on 03/26/12. As a result, R1 ' s INR was never completed, as ordered. The nurse's notes on 04/10/12 indicated that staff discovered a bruise of unknown origin on R1's right arm and right axilla area, while performing R1's morning care. RN/(D) assessed the bruise and observed that it measured 18.5 cm x 6 cm from the upper right shoulder to elbow which was deep purple in color, 12 cm x 11 cm from the right elbow to forearm which was red/purple in color, and 7.5 cm x 2.5 cm in the right axilla which was fading green in color. R1 told RN/(D) that no one hurt her but she did not know how she sustained the bruise. An incident report, dated 04/10/12, described the location and measurements of R1's bruise (as noted above). The incident report indicated that the location of R1's bruise matched up with the location of R1's wheelchair arms, and it was possible that R1 sat down too hard or "plopped" into the back and arm of the wheelchair. The incident report also noted that R1 had a [DIAGNOSES REDACTED]. R1's care plan was revised by RN/(D) on 04/11/12 to reflect that R1 was at risk for injury related to fragile skin and long-term anticoagulant use. The interventions regarding this problem indicated that staff were to keep sharp edges of R1's wheelchair/furniture padded or covered and encourage R1 to seat self gently in wheelchair. The interventions did not include evaluation of R1's INR. There was no evidence that RN/(D) explored the possibility that R1's large bruise of unknown origin was related to her anticoagulant status. The nurse's notes on 04/12/12 reflected that R1 had known skin areas of bruising and a sore on her chin. There was no evidence of further nursing follow up of R1's bruising or facial sore until the night shift of 04/14/12, when it was noted that R1 had been picking the sore area on her chin, causing bleeding. The nurse's notes on 04/14/12 at 7:30 a.m. indicated that R1 was again picking at the sore on her chin and blood was observed on her fingers, smeared across her face, and down her neck. At 10:20 a.m., R1's chin sore was bleeding through the opsite dressing, requiring a pressure dressing. The nurse's notes on the afternoon of 04/14/12 (time not documented) indicated that RN/(E) assessed R1 and observed that R1's blood pressure was 75/50. She had an irregular pulse of 100 and her respirations were 28. Her oxygen sats were 71%, while receiving 2 liters/oxygen per minute. RN/(E) also observed that the sore on R1's chin continued to bleed, despite numerous dressing changes. In addition, RN/(E) observed that R1 had a large area of bruising that continued to spread across her right upper arm and torso. The physician was notified of these findings and at 4:45 p.m., R1 was emergently transported to the hospital for further evaluation of her symptoms. RN/(E) was interviewed on 04/30/12 at 10:38 a.m. She worked on 04/14/12 from 10:00 a.m. to 6:00 p.m., as the House supervisor. At the beginning of her shift, she gets a report from the nurses who are staffed on each unit at the facility. On 04/14/12, the unit nurse did not report any information to her regarding R1. On the afternoon of 04/14/12, sometime between 3:45 p.m. - 4:00 p.m., the second shift unit nurse called her and said that R1 had a big bruise underneath her arm and she couldn't get a sore on R1's chin to stop bleeding. RN/(E) went to the unit and assessed R1, who was very hypotensive. R1 told RN/(E) that she "didn't feel right and wanted to go the hospital." RN/(E) reviewed R1's medical record, observing that she was on [MEDICATION NAME] and had no INR since admission to the facility on [DATE]. RN/(E) called the physician immediately with these findings and R1 was sent to the hospital. The Emergency Department (ED) record and CT scan of the abdomen/pelvis, both dated 04/14/12, indicated that R1 presented to the ED with a large hematoma involving the lateral chest wall, measuring 6.7 x 8.6 x 5.5 cm, and a critical INR greater than 10. She was also suffering from [MEDICAL CONDITION], with a hemoglobin of 9.2 (normal 12 - 16), resulting from bleeding due to a supratherapeutic INR. She was admitted to the Intensive Care Unit where coagulopathy was successfully reversed and stabilized, after she was transfused with four units of fresh frozen plasma and vitamin K. She returned to the facility on [DATE].