Every finding on record at St Gertrudes Health & Rehabilitation Center

Based on observation, interview, and record review, the facility failed to comprehensively assess, monitor, and/or treat skin conditions for 2 of 3 residents (R2, and R3) reviewed for skin integrity.Findings includeBased on observation, interview, and record review, the facility failed to comprehensively assess, monitor, and/or treat skin conditions for 2 of 3 residents (R2 and R3) reviewed for skin integrity.Findings include R2's admission Minimum Data Set (MDS) dated [DATE], identified R2 admitted to the facility 5/6/26 and had intact cognition and no behaviors or rejection of care. R2 was dependent on staff for most activities of daily living. R2 diagnoses included fractures and other multiple trauma, renal failure, hyponatremia, anxiety disorder, depression, and respiratory failure. R2 was at risk of developing pressure ulcers.R2's activities of daily living care plan identified an intervention dated 5/18/26, which indicated R2 was educated on the risks of refusing a shower, such as skin breakdown, odor, and infection, versus benefits of personal hygiene maintenance and skin monitoring.R2's skin care plan dated 5/22/26, indicated R2 was at risk for skin alteration and directed staff to:-Turn and reposition R2 approximately every two to three hours.-Consult with wound care nurse as needed.-Give nutritional supplements as ordered.-Observe pressure areas and follow-up with provider as needed.-Initiate barrier creams/ointments per standing house orders with observed skin irritations and follow-up with provider as needed.-Avoid shearing resident's skin during positioning, transferring, and turning.-Monitor skin under any devices per orders.-See bowel and bladder and activities of daily living care plan. On 5/31/26 at 9:51 p.m. and 6/7/26 at 9:23 p.m., R2's Skin Checks identified R2 had a right chest port and no visible skin impairments.R2's Skin Check on 6/22/26 at 4:51 p.m., identified R2 had a chest port and scrape to the front of her right lower leg. The area was covered with an island dressing. R2's progress note on 6/22/26 at 9:31 p.m., indicated R2 scratched her left lower extremity with her shoe and caused a scrape. A Mepilex (brand name of foam dressing) dressing was falling off and removed, and the area was cleansed and covered with an island dressing instead.Although R2's record identified R2 obtained a scrape to right lower leg and scratch to left lower extremity there was no indication of either wounds had completed comprehensive assessments that would have included (but not limited to) measurements, pain, and wound characteristics or further description nor evident areas were monitored for improvement or deterioration. Further, no indication R1's care plan interventions for skin were reviewed for appropriateness and effectiveness and/or new individualized interventions developed and implemented to prevent and/or decrease the risk of wounds.R2's Skin Check on 6/30/26 at 10:54 p.m., indicated no impairment or skin concerns.R2's Skin Check on 7/5/26 at 8:04 p.m., identified R2 had a small skin tear to right antecubital (area in the crook of your arm in front of the elbow) area, and R2 scratched herself.Although R2's record identified R2 obtained a small skin tear to right antecubital, there was no indication of a comprehensive assessment that would have included (but not limited to) measurements, pain, and wound characteristics or further description nor evident areas were monitored for improvement or deterioration. Further, no indication R1's care plan interventions for skin were reviewed for appropriateness and effectiveness and/or new individualized interventions developed and implemented to prevent and/or decrease the risk of wounds.During interview on 7/9/26 at 11:44 a.m., R2 sat in her wheelchair in her room with a visitor. R2 stated she scratched herself last night, and a nurse gave her lotion to apply on herself. R2 had visible reddish blue colored spots to the inside, lower part of right arm. A skin tear was not visible. R2 had a faint brownish-red colored area to the lower part of the back of her left arm.During interview on 7/9/26 at 1:30 p.m., nursing assistant (NA)-B verified R2 had bruises and stated she previously notified a nurse but did not recall when she notified the nurse or who she told. NA-B stated nursing assistants let the nurses know of any changes with residents' skin.During interview on 7/9/26 at 1:34 p.m., registered nurse (RN)-B stated R2 had spots on her body which looked like bruises and was not aware of their cause. RN-B stated R2 had thin skin and stated some of R2's bruises looked like they were improving and others looked the same. RN-B was not aware of a skin tear on R2. RN-B stated staff monitored residents' skin through weekly skin assessments and documented new skin conditions with measurements, asked residents how the skin condition occurred, and notified the nurse manager.R2's record between 6/22/26 through 7/9/26 did not address nor include comprehensive assessments nor monitoring of R2's bruising.During interview on 7/9/26 at 2:08 p.m., RN-A, who was also a nurse manager, stated she was not aware R2 had a skin tear or bruising. RN-A stated R2 was on a transplant list for a new liver. RN-A verified R2's care plan had generic skin interventions and did not see an event or monitoring order for R2 related to bruising or skin tears. RN-A expected staff to document new skin concerns and note the size, color, and other description as needed in a progress note. RN-A stated staff also had event documentation for new bruising, skin tears, and other skin conditions. RN-A expected staff to let her know of any new skin concerns and placed in specific skin monitoring until the area was healed.During interview on 7/9/26 at 4:32 p.m., the director of nursing (DON) stated she was not aware R2 had a skin tear and would need more information about the skin tear to decide if the nurse should have created a skin event and contacted the provider. The DON expected nursing assistants to report new bruises to the nurse. Then, the nurse completed an assessment of residents' skin, created an event to document how the bruise occurred and skin assessment, and notified the nurse manager as necessary. The DON stated the clinical managers updated the care plan after an event. The DON reviewed there were no recent updates to R2's skin care plan. R3R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 admitted to the facility 5/22/24 and a re-admission on [DATE]. R3 was cognitively intact and had no behaviors or rejection of care. R3 had an impairment to one upper extremity and both lower extremities. R3 required staff assistance for most activities of daily living (ADLs). R3's diagnoses included hypertension, renal failure, anxiety, depression, and chronic obstructive pulmonary disease. R3 was at risk for developing pressure ulcers and had moisture associated skin damage (MASD).R3's skin care plan dated 10/17/25, identified R3 was at risk of skin status related to impaired mobility, dialysis, and current skin impairment. Interventions dated 6/7/24, directed staff to:-Avoid shearing resident's skin.-Observe pressure areas daily.-See bowel and bladder care plan.-Turn and reposition approximately every two hours.-Universal pressure redistribution mattress to bed.-Weekly skin assessment by licensed nurse. R3's physician order dated 1/30/26, directed R3 to receive nystatin powder 100,000 unit/gram topically under breasts twice a day until healed, then twice a day as needed (PRN)R3's Skin Check dated 6/3/26 at 9:18 p.m., indicated R3 had MASD under breast.R3's Skin Check dated 6/10/26 at 11:07 p.m., R3 had scanty redness under both breasts. On 6/17/26 at 9:07 p.m., R3's skin was clean, dry, and intact.R3's Skin Check dated 6/24/26 at 4:52 p.m., R3 had MASD to chest area.In review of R3's record between 6/3/26 through 7/9/26 identified no comprehensive assessments that would address size/extent, pain, wound status, drainage, open areas, etc. In addition, there was no indication the impaired skin integrity was routinely monitored for improvement/deterioration. Further, not evident R3's care plan interventions and/or treatment regimen was reviewed for effectiveness and/or new individualized interventions developed and implemented to prevent or improve MASD. During observation and interview on 7/9/26 at 1:43 p.m., NA-C stated he assisted R3 with activities of daily living. NA-C stated he helped R3 apply a glove and R3 would wash and dry her chest herself. NA-C gave R3 a powder to apply to herself when she asked. NA-C stated last week was the last time he observed under R3's breasts, and R3's skin was dry and not red. NA-C went to R3's bathroom and showed surveyor a Thera antifungal powder with an ingredient of miconazole nitrate 2%.During interview on 7/9/26 at 11:31 a.m., RN-C stated R3's red area on breasts comes and goes, and R3 liked the nystatin powder whether her skin was red or not. R3 did not want the regular house-stock body powder. RN-C stated some days nursing applied the powder and other days R3 applied the powder herself. RN-C stated she did not apply the nystatin powder 7/9/26 and was unsure whether it had already been applied. RN-C stated nurses documented R3's skin weekly on bath days. RN-C stated her documentation and description of an area of MASD on bath days depended on whether the MASD was chronic, how red the area was, and how big the area was. R3 was not available at the time of interview for skin observation.During interview on 7/9/26 at 1:58 p.m., RN-D, who was also a manager, reviewed R3's past four skin assessments. RN-D stated staff could use general, non-descriptive terms like MASD unless the area was worsening. RN-D expected nurses to clarify with the provider about the use of Thera antifungal body powder instead of, or in addition to, the nystatin powder. RN-D expected nursing to change R3's order to PRN use after the MASD cleared per the order, unless nursing clarified R3's continued use of nystatin powder per R3's preference with the provider.During interview on 7/9/26 at 4:32 p.m., the director of nursing (DON) expected nurses to monitor areas of MASD and redness for improvement by shrinking in size and decreasing in redness in weekly skin assessments or progress notes. The DON verified lack of documentation to tell if R3's MASD was improving or not. The DON expected staff to clarify with the provider if Thera body powder was appropriate to use instead of, or in addition to, nystatin powder.The facility Prevention and Treatment of Skin Breakdown dated 6/2026, indicated residents at risk for impaired skin integrity were provided preventive measures to reduce the potential for skin breakdown. A resident centered care plan was implemented and/or updated for skin risk with interventions based upon areas of risk, resident assessment, Braden evaluation, clinicians' assessments and evaluations, and resident preferences. The policy directed staff to monitor and document abnormal findings of skin during daily cares and weekly skin audits by a licensed nurse.

Based on interview and record review, the facility failed to ensure medications were available for administration per physician order for 1 of 3 resident (R1) reviewed for quality of care.Findings includeFindings includeR1's Resident Face Sheet dated 7/8/26, identified R1 admitted to the facility on [DATE] with diagnoses of end stage renal disease, dependence on renal dialysis, weakness, disorientation, acute on chronic diastolic heart failure, hypertension, paroxysmal atrial fibrillation, obesity, and fluid overload.R1's progress note on 7/2/26 at 12:45 p.m., identified R1 admitted to the facility from the hospital and was alert and oriented x3 (times three; aware of person, place, and time). R1 diagnoses of heart failure and atrial fibrillation, a new fistula to right AC (antecubital; right arm near the elbow), and a new dialysis port to upper right chest.R1's hospital discharge medication listing dated 7/2/26 included a listing of R1's medications which included the following:-b complex-vitamin c-folic acid 1 mg (milligram) capsule by mouth once daily with evening meal for end stage renal disease on dialysis.-insulin aspart (U-100) 100 unit/mL (milliliter) (3 mL) pen for type two diabetes mellitus with retinopathy of both eyes, with long-term current use of insulin, macular edema presence unspecified, and unspecified retinopathy severity. The order directed staff to inject medication subcutaneously three times daily with meals per blood glucose (mg/dL; milligrams per deciliter) based on the sliding scale:Less than 70; see hypoglycemia protocol70 to 149; no insulin, give prandial insulin (bolus insulin; covers increased blood sugar levels following meals), if ordered150 to 199; 1 unit200 to 249; 2 units250 to 299; 3 units300 to 349; 4 units350 to 399; 5 units400 or greater; 6 units and call provider-Eliquis (a blood thinner which reduces blood clotting) 2.5 mg tablet by mouth two times daily.-pravastatin (slow how much cholesterol your body makes) 80 mg tablet by mouth at bedtime for pure hypercholesterolemia (a lipid disorder in which bad cholesterol, low-density lipoprotein, is too high) R1's medical record identified R1's blood sugar was 205 mg/dL on 7/2/26 at 5:07 p.m.R1's medication administration record (MAR) dated 7/2/26 to 7/9/26, identified R1's blood sugar was an x (indicating order was not active) for the 5:30 p.m. administration of Novolog FlexPen U-100 Insulin (insulin aspart u - 100); and PM Med Pass (3:00 p.m. to 6:00 p.m. evening medication pass) b complex-vitamin c-folic acid tablet. R1's MAR indicated the HS Med Pass (7:00 p.m. to 10:00 p.m. bedtime medication pass) dose of Eliquis and pravastatin were not administered due to drug unavailability.R1's progress note dated 7/3/26 at 12:05 a.m., identified no blood pressure medications given this evening because none were available in the ADU (automated dispensing unit) but also due to low blood pressure readings.Review of R1's record identified no indication the pharmacy was contacted nor evident the physician was notified of the medication omission errors on 7/2/26.During interview on 7/8/26 at 1:31 p.m., licensed practical nurse (LPN)-A stated she did not remember if R1 ate the evening of 7/2/26. LPN-A encouraged R1 to drink, and R1 took little sips at a time. LPN-A documented when residents refused meals staff offered other food items, such as toast or Jell-O. During follow-up interview on 7/9/26 at 2:45 p.m., LPN-A stated the facility pharmacy required a second nurse to check resident orders before medications were delivered to the ADU machine or delivered to the facility. LPN-A stated evening medication deliveries often arrived after residents went to bed or the evening shift ended. Eliquis and pravastatin usually were delivered on a card (bubble pack) from the pharmacy and verified she did not speak with a provider on 7/2/26 about R1's unavailable medications.During interview on 7/9/26 at 2:08 p.m., registered nurse (RN)-A stated staff called the pharmacy when medications were not available and then called the provider if needed and wrote a progress note. The facility had issues with their pharmacy bringing medications timely, and staff pulled what medications they could out of the medication ADU machine. RN-A reviewed R1's blood sugar of 205 mg/dL and MAR. RN-A indicated R1 should have received 2 units of Novolog the evening of 7/2/26 and did not. The health unit coordinator placed orders in the electronic medical record and a nurse did a second check. RN-A further reviewed R1's medical record and stated the second check of R1's Novolog order was completed after the evening administration time on 7/2/26, so Novolog did not show up to give until the morning dose. RN-A verified Eliquis and pravastatin were not administered on 7/2/26, and R1's medical record did not have a note to indicate pharmacy or provider contact.During interview on 7/9/26 at 4:32 p.m., the director of nursing (DON) reviewed R1's MAR related to R1's Eliquis and pravastatin and expected staff to call the pharmacy when medications were not available to give as ordered. The DON expected nursing to write a progress note if they had to contact the provider about unavailable medication. The nurse expected nursing documentation to identify directions given from the provider, such as alternate medications or medication timing changes. The DON reviewed R1's evening blood sugar and MAR, which indicated no Novolog was given around meal time the evening of 7/2/26, and DON stated she would have to check with nursing staff if R1 had plans to eat dinner that night or if there was another reason the Novolog was not given. The DON stated R1's medical record indicated R1 required set up assistance with her evening meal on 7/2/26 but amount eaten or other intake amount were not charted in the electronic medical record. The DON reviewed the x on the MAR for R1's b complex-vitamin c-folic acid capsule and verified the medication was not administered the evening of 7/2/26 and should have been given. The DON stated staff could order admission medications stat if staff did not receive medication in a timely manner.During interview on 7/9/26 at 3:53 p.m., the consultant pharmacist (CP) stated missed Novolog administration could lead to increased blood sugar levels and other issues. CP stated Eliquis was an important medication and missed medication administration increased risk of blood clots. The CP stated he was not aware of any concerns between the facility and pharmacy deliveries and was available to work with the facility and the pharmacy if there were any concerns.The facility Provider Pharmacy Requirements policy dated 8/2014, indicated emergency or stat medications were available for administration as soon as reasonably possible after order received by pharmacy and verbally notified by the facility. Medications ordered stat should be available within one hour of the time ordered during normal pharmacy hours and if not already available in the facility emergency drug supply. Stat medications were available and administered within two hours of the time ordered when the pharmacy was closed. All other new medication orders were received and available for administration on the next routine delivery. The policy directed staff to implement procedures when medication delivery was delayed or medications were not available.The facility Administering Medications policy dated 8/31/23, directed the person preparing or administering the medication to contact the provider if there were questions or concerns regarding medication.

Based on observation, interview, and document review, the facility failed to ensure frozen food items were stored in a manner to reduce the risk of cross contamination and potential foodborne illness in a walk-in freezer. The facility failed to ensure scoops were not stored in 2 of 3 bulk containers to prevent cross contamination. The facility also failed to ensure hair and beard nets were used in the food preparation area and kitchen utensils sanitizing area. In addition, the facility failed to consistently monitor the dishwasher machine temperature. This had the potential to affect all 98 residents, staff, and visitors who consumed food from the facility kitchen.Findings include:On 1/12/26 at 1:19 p.m., an initial kitchen tour was completed with cook/kitchen supervisor (C)- A, the following was observed: Walk-in freezer- One speed rack had 2 trays of uncovered, unlabeled, uncooked hamburger patties. One of the trays had 5 frozen hamburger patties and the other one had 7 - A second speed rack had one tray of 15 uncooked fish filets which were uncovered, and unlabeled.Bulk containers- The lids of a triple bulk container used to store flour, white rice, and brown rice contained debris of flour and rice. Scoops were observed inside the flour and white rice bins. Hair nets- Dietary aid (DA)-A was sanitizing and storing dishes and cookware was not wearing a hair net. High temp dish machine -The log labeled January 2026 had no temperatures recorded on January 1st, 2nd, 3rd and 7th. On January 5th, 2 out of three temps were recorded, and on January 6th, 8th, 9th, 11th and 12th only one of three were recorded. -During the initial tour DA-A was actively using the dish machine. A cycle was observed and the wash cycle temp indicated 150 degrees Fahrenheit (F) while the rinse cycle indicated 180 degrees F. C-A stated the wash temp was low and it should be160 degrees. CA-A did not provide additional instruction to DA-A who continued to use the dish machine. On 1/12/26 at 4:15 p.m. a subsequent kitchen tour was completed. At 4:19 p.m. C-B was setting up the steam table, gathering serving tools, and removing buns from a plastic bag for dinner and placing them on an open tray next to the steam table. C-B had a full beard, about 1 inch long below his chin. C-B stated, I didn't know I had to wear a beard net.During interview on 1/12/26 at 4:23 p.m., food service director (FSD) stated C-A had updated him regarding the concerns found during the initial kitchen tour. Regarding the use of hair and beard nets, FSD stated, my staff knows better. FSD added the kitchen staff needs to use hair and beard nets. During this interview C-B entered the FSD's office and asked where he could find the beard nets. FSD pointed to a shelf in his office, C-B took one and started to put it on as he left FSD's office. During a subsequent visit to the kitchen on 1/13/26 at 12:01 p.m., FSD stated the dishwasher broke while the staff was washing the breakfast plates that morning. FSD stated they were going to use disposable plates and cups until the wash machine was repaired. Food Storing and kitchen sanitary, and cleaning schedule policies were requested but not received. During observation and interview on 1/14/26 at 11:13 a.m. dietary aid DA-A was washing pots and stainless-steel bins. The dish machine cycle was observed, and the wash cycle indicated 109.6 degrees, and the rinse cycle temp was 194 degrees. DA-A stated he had not paid attention to the temperatures. The dish machine temperature log had no documentation of the morning temp. The Ecolab Service Call Summary dated 1/14/26 at 9:47 p.m., indicated Scale issues are causing issues that require deliming until Softener is repaired. The document indicated the wash temperature was 162 degrees F and rinse temperature was 183 degrees, both In Range. Additional comments included Machine Condition: Issue Found, and Lime scale buildup due to down water softener. Will need to delime more frequently in the interim.The Ecolab Extra Service Request dated 1/14/26 at 9:44 p.m., indicated the facility requested service for the EC-44 Dish Machine as it was In constant wash cycle and wasting chemicals; attempted flipping delime switch. Service Comments included Found a metal lid tucked behind first paddle. During observation and interview on 1/15/26 at 9:31 a.m., breakfast dishes were being washed in the dish machine and the cycle was observed. The wash temperature rose to 108 degrees F, and the rinse temperature rose to 194.3 degrees. DA-B confirmed the wash temperature was low. DA-B prepared to load another tray of dishware for machine washing. During interview on 1/15/26 at 9:50 a.m., FSD responded to the following concerns:Wash machine - FSD stated he was not informed about the wash machine temperatures observed that morning at 9:31 a.m. FSD stated they were having problems with the wash machine. FSD stated an engine component broke 6 weeks ago, but the technician forgot to fill the component with oil and the machine broke again on Tuesday 1/13/26. FSD added, yesterday 1/14/26 the wash cycle was stuck and would not go to the rinse cycle. FSD stated every time the wash machine was serviced, the ECOLAB technician emailed a service report. Hair and beard nets - FSD stated he had talked repeatedly to the staff about the use of hair and beard nets. FSD stated on a regular basis I found staff not wearing hair nets. FSD stated he expected staff to wear hair and beard nets to prevent hair falling in the food, cooking or serving gear. Food storage - FSD stated storing uncovered food in the freezer was honestly, lazy. All items on the speed racks should be individually covered or cover the whole cart with a proofing bag. FSD stated it was unsanitary because something can land on it.Bulk containers - FSD stated the scoops should not be left inside the containers because it was a concern for cross contamination. During interview on 1/15/26 at 1:08 p.m., FSD stated the water softener had been down for weeks, and with that not functioning properly, lime and scale had built up in the heating element of the dishwasher. He stated the water softener was back online as of last Friday, but the dishwasher might not be getting soft water yet as it took a while to work through the system. He stated the scaling was building up pretty badly and the heating element didn't run consistently because of that. They used lime away and a descaler and reached out to Ecolab tech and there will be a deep scrub on the heating element. FSD stated they had not had a scrub done previously, and it has been an ongoing situation. FSD stated the heating element fluctuated from time to time, and it was a difficult problem because it was inconsistent. When staff notice the temperature is out of range, they should address the temperature and delime it and go back to normal operation. He stated the facility did not have a 3-compartment sink, and they found the issue on Tuesday and then used full disposable dishware. He indicated the service tech was in the facility this afternoon. During interview on 1/15/26 at 1:00 p.m., the administrator stated storing uncovered fish filets and hamburger patties was concerning, not only for cleanliness but because it could affect the patients. Administrator stated she expected the staff to wear hair and beard nets because it was a standard practice, so they did not get hair in the food. Regarding the storage of scoops on dry goods, the administrator stated the scoops should be stored outside of them. Regarding the wash machine, the administrator stated the facility needed to have an appropriate temperature to be in regulation. The Ecolab EC-44 Dishmachine brochure dated 2012, indicated a required wash temperature of 160 degrees F and a rinse temperature of 180 degrees F. The undated facility policy titled Dishwashing Procedures, indicated the facility will implement dishwashing practices that prevent the spread of food-borne illness. The dish machine will be operated in accordance with the manufacturer's instructions.

Based on observation and interview, the facility failed to accommodate resident needs by ensuring the call light was accessible for 1 of 1 resident (R26) reviewed for call lights.Findings include: R26's quarterly Minimum Data Set (MDS) dated [DATE], identified R26 with impaired cognition, no rejection of cares or wandering, impairment in lower extremity range of motion, required a walker or wheelchair for mobility, and needed partial to moderate assistance with dressing, transfers, and hygiene. Diagnoses include heart failure, kidney disease, arthritis, depression and anxiety. During observation and interview with R26 on 1/12/26 at 5:01 p.m., R26 was lying in bed with call light out of reach on nightstand next to head of bed. R26 stated she could not see it and wanted assistance to get up out of bed to go to dinner. Normally I use the call light if I need help. If it is out of reach then I make noise to get attention to get [staff] to answer my pleas. During observation and interview with nursing assistant (NA)-B on 1/12/26 at 5:04 p.m., NA-B verified R26's call light was out of reach, It should be in reach to ask for help. During interview with NA-D on 1/15/26 at 6:52 a.m., NA-D stated it was important to place the call light next to patients at all times. If out of reach the residents can fall. For safety.During interview with registered nurse (RN)-G on 1/15/26 at 7:04 a.m., RN-B stated, [staff] always make sure [call light] is in reach and [residents] know how to use it.During interview with director of nursing (DON) on 1/15/26 at 9:57 a.m., DON stated expectation of staff to place the call light call within reach at all times so residents can call for help if needed.Facility policy titled Call Lights-Call System Activation and Response dated 5/28/2024 identified:Each resident is provided with a means to call staff directly for assistance. The call system must be accessible to residents while in their bed or other sleeping accommodations within the resident's room.

Based on observation, interview, and document review, the facility failed to ensure resident rooms were maintained at a comfortable temperature between 71 and 81 degrees Fahrenheit for 1 of 1 residents (R57) reviewed who indicated their rooms were cold.Findings Include:R57's admission Minimum Data Set (MDS) assessment, dated 12/22/25, indicated a diagnosis of cerebral infarction (stroke) with intact cognition.During an interview on 1/12/26 at 5:19 p.m., R57 stated his room was cold. R57 was observed wearing a winter coat while sitting in a recliner chair in his room between the bed and the window which he reported was where he spent the majority of his time. R57 stated he had reported his concerns to staff and had been told this room is always like this. R57 stated, I am froze. The thermostat on the wall indicated 72.9 degrees Fahrenheit (F). At 5:50 p.m., surveyor obtained temperatures in the room: 66.2 degrees F by the tv, 68.3 degrees F around the chair R57 was sitting in, and 67.7 degrees F between the chair and the wall.During an interview on 1/12/26 at 5:58 p.m., nursing assistant (NA)-C stated R57 had complained of his room being cold about a week or so ago. NA-C stated he thought a form had been filled out for maintenance to look at R57's room temperature. NA-C verified that R57 was wearing a winter coat due to being cold when he brought him to the bathroom this evening.During a follow up interview on 1/13/25 at 9:55 a.m., R57 stated he did not use his personal refrigerator as it was cold enough in the room to keep items on the counter to keep them cold. On 1/14/26 at 10:46 a.m., surveyor obtained temperatures in R57's room. It was 66.5 degrees F around R57's chair.During an interview on 1/14/26 at 12:20 p.m., director of maintenance (DOM) stated that he had received a complaint of R57's room being cold last week and had the vendor come out and look at his room. DOM stated after the vendor was out, the room was above 71 degrees F. The next day, DOM check the room temperature via computer as temperatures can be checked from the thermostats via computer without having to disrupt the residents. He stated the computer indicated the room was above 71 degrees F. DOM and surveyor obtained temperatures in R57's room: the area around R57 was 69.7 degrees F, and the middle of the room was 70.2 degrees. R57's thermostat indicated 72.3. DOM stated R57's room temperatures are not within the required 71-81 degrees F and would call the vendor out again.During an interview on 1/15/26 at 11:15 a.m., administrator stated temperatures are to be between 71-81 degrees F. Administrator stated the vendor came out yesterday for R57's room and switched the wires. Administrator stated the room was currently temping at 74 degrees F where the resident sits.A facility policy on room temperatures was requested and not received.

Based on observation, interview and document review, the facility failed to provide and document an appropriate diagnosis for a prescribed psychotropic medication for 1 of 5 (R100) residents and failed to provide appropriate side effect monitoring (i.e., orthostatic blood pressure) with antipsychotic medication consumption for 1 of 3 (R49) residents reviewed for unnecessary medication use. Findings include: R100's quarterly Minimum Data Set (MDS), dated [DATE], indicated R100 was admitted to the care facility on 6/14/22 and was cognitively intact. The MDS further indicated R100 had no documented hallucinations or delusions during the look-back period. R100's Diagnoses List, indicated R100 had diagnoses including vascular dementia, history of stroke and adjustment order with anxiety. R100's Physician Order Report, dated 12/1/25 - 12/31/25, indicated an order, dated 9/11/25, for Abilify 5 milligrams (mg) once a day for bothersome and frightening hallucinations. R100's Consultant Pharmacist Recommendation to Physician, printed 12/29/25, indicated, this resident [R100] is receiving antipsychotic agent Aripiprazole [Abilify] (currently listed on the MAR for hallucinations), but lacks an allowable diagnosis to support its use. R100's progress note, dated 1/13/26, indicated the nurse practitioner reviewed the pharmacist recommendation from December and due to R100 not having an appropriate diagnosis for antipsychotic medication the Abilify was discontinued. During an interview on 1/14/26 at 12:25 p.m., the assistant director of nursing (ADON) stated it would be expected that the nurse managers review psychotropic medications for an appropriate diagnosis when ordered, stating the pharmacist will also review medications and inform the facility staff if there is not an appropriate diagnosis attached to the medication order, confirming R100's Abilify, ordered 9/11/25, did not have an appropriate diagnosis. A facility policy titled Psychotropic Medication Use, reviewed 9/7/23 indicated psychotropic medications are ordered by the medical provider to treat a specific condition as diagnosed and documented in the medical record. R49's admission Minimum Data Set (MDS) assessment, dated 10/20/25, indicated R49 had intact cognition with no hallucinations or delusions and no behavioral symptoms including physical or verbal behavioral symptoms directed at others, or behavioral symptoms not directed toward others. Further it indicted R49 received an antipsychotic medication. R49's January 2026 Medication and Treatment Administration Record (MAR)/TAR), printed 1/15/26, included the following orders: -aripiprazole (antipsychotic medication used to treat mental/mood disorder) 10 milligram (mg) tablet – give 10 mg by mouth at bedtime for moderate episode of recurrent major depressive disorder with a start date of 10/14/25. Medication was documented as administered every day in January. -orthostatic blood pressure related to antipsychotic use once a month on the 14th with a start date of 10/14/25. The MAR/TAR indicated a signature of completion. The document lacked documentation of the blood pressures. -per therapy recommendations: discontinue assist of 2 with [NAME] steady assist of 1 with [NAME] steady for all transfers. Knee brace as needed for comfort with a start date of 1/5/26. -per therapy recommendations: discontinue ceiling lift assist of 2 with [NAME] steady for all transfers. No ambulation at this time. Knee brace as needed for comfort with a start date of 12/16/25 and discontinue date of 1/7/26. R49's December 2025 MAR/TAR included the following orders: -aripiprazole (antipsychotic medication used to treat mental/mood disorder) 10 milligram (mg) tablet – give 10 mg by mouth at bedtime for moderate episode of recurrent major depressive disorder with a start date of 10/14/25. Medication was documented as administered every day in December. -orthostatic blood pressure related to antipsychotic use once a month on the 14th with a start date of 10/14/25. The MAR/TAR indicated a signature of completion. The document lacked documentation of the blood pressures. -per therapy recommendations: discontinue ceiling lift assist of 2 with [NAME] steady for all transfers. No ambulation at this time. Knee brace as needed for comfort with a start date of 12/16/25 and discontinue date of 1/7/26. -per therapy recommendations: discontinue ceiling lift. Assist of 2 staff with [NAME] steady for all transfer.[NAME] on right lower extremity at all times except skin checks. Please support right lower extremity to maintain right knee during extension during transfers. No ambulation at this time with a start date of 12/16/25 and discontinue date of 12/18/25. -per therapy recommendations: discontinue ceiling lift. Assist of 2 with [NAME] steady for all transfers. No ambulation at this time. Knee brace as needed for comfort with a start date of 12/16/25 and discontinue date of 1/7/26. R49's care plan, printed 1/15/26, identified the following: -Under Activities of Daily Living (ADL)s Functional category, the care plan identified R49 had a self-deficit with ambulation, transferring, mobility, oral cares, grooming and bathing and indicated Resident has a tendency to self-transfer, self-ambulate, and not use her call button for assistance. -Under the Mood state category, the care plan identified R49 had a diagnosis of major depressive disorder and to obtain monthly orthostatic blood pressure per pharmacy recommendations. R49's blood pressure and pulse logs for 12/1/25 to 1/15/26 were reviewed. The document lacked evidence of orthostatic blood pressure being completed and documented. R49's progress notes for 12/1/25 to 1/15/26 were reviewed. The document lacked evidence of orthostatic static pressures being completed and documented. During an interview on 1/15/26, R49 was observed sitting in her wheelchair. R49 stated things were going well, denied any concerns and engaged in the conversation. During an interview on 1/15/26 at 10:20 a.m., licensed practical nurse (LPN)-B stated if a resident needed to have orthostatic blood pressures taken then an order was put in the electronic medical record (EMR). LPN-B stated the orders would show up under the treatments and documented on the MAR/TAR, and the vital signs would flow over to the vital signs section of the EMR. LPN-B stated some residents who were on antipsychotic medications had orders for orthostatic blood pressures to be taken but not all residents. LPN-B was not sure how it was decided who needed to have orthostatic blood pressures taken when a resident was on antipsychotic medications and stated the health unit coordinator or nurse manager put the orders in. LPN-B verified R49 had an order to have orthostatic blood pressures taken monthly and verified it was signed off for 12/14/25 and 1/14/26 as completed. LPN-B verified there were not blood pressures on the MAR/TAR and no blood pressures entered in the vital signs section of the EMR on 12/14/25 or 1/14/26. LPN-B stated, it looks like they weren't done. LPN-B stated R49 was able to stand with assist of 1 and EZ stand (device that assists person to stand). LPN-B stated there was a risk of orthostatic hypotension when a person took antipsychotic medication(s). During an interview on 1/15/26 at 11:04 a.m., director of nursing (DON) stated the expectation would be any resident on an antipsychotic medication should be getting orthostatic blood pressures done monthly. DON stated it's important to monitor orthostatic blood pressures as antipsychotic medications can affect blood pressures which can increase falls. DON could not find any orthostatic blood pressures documented for R49 the last few months. A facility policy titled Psychotropic Medication Use, reviewed 9/7/23, indicated When psychotropic medications are ordered, the IDT identifies target behaviors, medication side effects to be monitored and implements a resident centered care plan with both non-pharmacologic and pharmacological interventions.

Based on interview and document review the facility failed to ensure a resident's preferences were care planned to ensure preferences were honored for 1 of 1 resident (R127) reviewed who preferred to have female only caregivers. Findings include:R127's admission Minimum Data Set (MDS), dated [DATE], indicated R127 was admitted to the care facility on 1/4/26 and was cognitively intact. The MDS further indicated R127 required substantial assistance with toileting and partial to moderate assistance with bathing. R127's progress notes, dated 1/4/26, indicated R127, strongly prefers female caregivers. Patient was instructed that the facility does its best to fulfill these requests but that there was no guarantee that we could provide all female caregivers throughout her stay. Patient understood but stated 'I will just do it myself if there is not female to support me.' R127's care plan and care guide sheets used to direct resident care lacked mention of any care preferences voiced by R127, including the preference for female only caregivers. During an interview on 1/12/26 at 3:48 a.m., R127 stated she had told multiple staff members, multiple times, that she prefers female caregivers, but that male staff keep coming in and she has to remind that that she would prefer a female. During an interview on 1/15/26 at 8:32 a.m., nursing assistant (NA)-J stated R127 did like men caring for her and if there was a man working on the unit they would try to switch assignments. NA-J stated when a resident voiced a preference such as female only care givers staff would pass it along shift to shift via word of mouth. During an interview on 1/15/25 at 8:39 a.m., clinical manager and registered nurse (RN)-H stated she was unaware that R127 had a preference for female only caregivers, stating she would have expected such a preference to be communicated to her to ensure it was care planned. RN-H stated if she was aware R127 had a preference for female only caregivers she would generally talk with staffing and ensure if there were no female nursing assistants working on the unit that the float NA was a female. During an interview on 1/15/26 at 8:45 a.m., licensed social worker (LSW)-A stated R127's preference for female only care givers was communicated to them through the hospital prior to R127 being admitted to the care facility. The Social Services Director (SSD) stated in the same interview that it would be expected that those preferences would be communicated to the nurse manager and care planned as floor staff often float to different units, so it is important to have care plans up to date to ensure preferences are honored and care needs are met. A facility policy titled Comprehensive Assessments and Care Planning, revised 9/27/23, indicated the comprehensive assessment and care plan must include a resident's customary routine and preferences.

Based on observation, interview, and document review, the facility failed to ensure 1 of 4 residents (R45) reviewed for activities of daily living (ADLs) and were dependent on staff for their ADLs, routinely had their fingernails cleaned and trimmed.Findings include:R45's quarterly Minimum Data Set (MDS) 10/25/25, indicated R45 had intact cognition and was diagnosed with arthritis. R45 was dependent on staff for toileting hygiene, lower body dressing, and putting on and taking off footwear. The MDS indicated R45's most recent admission/entry to the facility was on 7/23/25. R45's Weekly Skin Checks dated 11/7/25 through 1/9/25, included a section with the question Was nail care completed? with the options of fingernails trimmed, toenails trimmed, refused, or not necessary. All checks from this period were either checked as not necessary or left blank. R45's care plan dated 1/9/25, indicated she had a self-deficit with ADLs such as grooming, bathing, and oral care. R45's medical record was reviewed and did not indicate R45 had refused toenail care. During an interview and observation on 1/12/26 at 2:43 p.m., R45 was observed sitting in a chair in her room. R45 stated that she felt like her toenails needed to be trimmed and confirmed that they were not causing her pain. R45 stated she didn't think anyone had offered to help her cut her toenails since she was admitted in July of this year. R45's toenails were observed to have grown past the end of her toes, with a varying nail length, and some toenail curling was observed. During an interview on 1/13/26 at 12:45 p.m., registered nurse (RN)-B stated that R45 was not a diabetic, so the aides could assist her with cutting her finger and toenails. When asked when the last time toenail clipping was completed or where it was documented RN-B stated she was not sure. During an interview and observation on 1/13/26 at 12:47 p.m., nursing assistant (NA)-C stated he had assisted R45 with her personal care this morning. NA-C was observed to lift R45's blanket, look at her toes, and state her toenails looked like they could use a trim. R45's toenails were observed to have grown past the end of her toes, with a varying nail length, and some toenail curling was observed. NA-C stated he didn't work on this unit very often, so he was not sure if R45 refused to get her toenails trimmed or the last time toenail trimming was completed. NA-C confirmed he had not offered to cut R45's toenails. During an interview on 1/14/26 at 8:22 a.m., RN-C, the clinical manager for the unit, stated she had reviewed R45's records and did not find evidence that R45 had gotten nail care or refused it recently. RN-C stated staff should either document nail care/nail care refusals in a progress note or on the weekly skin check observation form. RN-C stated she saw that staff had been documenting that it was not applicable to the question of whether R45 had her nails done. RN-C stated that after assessing R45's nails, she felt that they should have been previously cut, so she talked with R45 this week, and R45 had consent to having her toenails trimmed. RN-C stated she was unable to cut all of her toenails, so she was going to ensure a consult was made with podiatry for additional nail care. RN-C stated the nurse was supposed to assess the resident's nails on bath days and ensure that nail care was completed as necessary.The facility's Activities of Daily Living policy dated 7/21 was received but did not include guidance regarding nail care.

Based on observation, interview and document review, the facility failed to ensure communication and collaboration was maintained with a dialysis provider for 1 of 1 resident (R7) reviewed for dialysis. Findings include: R7's quarterly Minimum Data Set (MDS), dated [DATE], indicated R7 was admitted to the care facility on 5/10/24 and was cognitively intact. The MDS further indicated R7 required substantial to maximum assistance with activities of daily living and received dialysis. R7's Orders, dated 11/20/25 directed staff to monitor R7's dialysis fistula and to document R7's vital signs and monitor for shortness of breath, chest pain, nausea and vomiting or seizure activity prior to dialysis. R7's care plan, dated 5/13/24, directed staff to, obtain Dialysis care plan and coordination of care communication sheet. Check for orders or changes from Dialysis Unit. The care plan further indicated R7 went to dialysis three times a week, on Mondays, Wednesdays, and Fridays. R7's electronic medical record contained only one dialysis communication sheet (Dialysis Run Sheet), dated 10/15/25. R7's paper medical record contain multiple dialysis communication sheets (Dialysis Run Sheets), with the most current being dated 8/25/25. During an interview on 1/14/26 at 8:46 a.m., licensed practical nurse (LPN)-A stated R7 left around 5:00 a.m. for dialysis and arrived back to the care facility around 10:00 a.m. LPN-A stated the facility staff sent along an envelope with the dialysis communication sheet in it but that the facility staff often did not receive the sheet back from dialysis. During an interview on 1/14/26 at 12:25 p.m., the assistant director of nursing (ADON) stated it was expected that staff send the dialysis communication sheet with residents to dialysis, and the nurse was expected to review the sheet for new orders or residents' status when they returned from dialysis. During a follow up interview on 1/15/26 at 9:08 a.m., the ADON confirmed the most current dialysis communication sheet for R7 was from October, stating, we send the sheet and it doesn't always come back.During an interview on 1/15/26 at 10:50 a.m., the director of nursing confirmed it would be expected that the nurses are following up with the dialysis communication sheets, stating, we try our best but there is always communication breakdown.A facility policy titled Dialysis Services via Contracted Vendor, revised 5/28/24, indicated, the licensed nurses have ongoing communication and collaboration with the dialysis facility regarding dialysis care and services.

Based on observation, interview and document review the facility failed to ensure a resident was appropriately assessed and had an appropriate order in place to self-administer nebulizer medication for 1 of 1 resident (R80) reviewed for self-administration of medications. Findings include: R80's significant change Minimum Data Set (MDS), dated [DATE], indicated R80 was cognitively intact and required partial to moderate assistance with most activities of daily living. R80's active orders, printed 1/15/26, contained an order for albuterol sulfate for nebulization once a day in the morning and three times a day as needed for difficulty breathing, shortness of breath, wheezing and/or bronchospasm prevention. R80's care plan, dated 10/30/25, indicated, I [R80] will independently administer respiratory treatments as ordered and I will receive assistance setting up, disassembling, and cleaning respiratory equipment from a licensed nurse. with interventions to include, acquire physician's order for self-administration of respiratory treatments and, perform a self-administration medication assessment per facility protocol.R80's electronic medical record lacked an order and an assessment for self-administration of her respiratory treatments (i.e. albuterol sulfate via nebulization).During an interview on 1/14/26 at 10:30 a.m., licensed practical nurse (LPN)-A stated R80 administered her nebulizer independently. She indicated licensed staff would put the medication in the nebulizer and leave R80 with the medication who would turn off the nebulizer machine on her own when the medication was gone, stating he checked back with her in 10-15 minutes after starting the nebulizer. During observation on 1/14/26 at 11:45 a.m., LPN-A entered R80's room, handed her the hand-held nebulizer mouthpiece, already filled with the albuterol medication, turned on the nebulizer machine, and left R80 to self-administer the medication independently. During an interview on 1/15/26 at 9:08 a.m., the assistant director of nursing (ADON) confirmed there was not an order or assessment in place for R80 to self-administer her nebulizer medication and that it would be expected to have those in place prior to self-administration of any medications. A facility policy titled Self-Administration of Medications, revised 4/10/25, indicated each resident will be assessed for the ability to physically and mentally self-administer any medication and, if deemed appropriate, a physician order would be obtained to self-administer the assessed medications.

Based on interview and record review the facility failed to ensure a resident was free from abuse for 1 of 3 (R1) residents when registered nurse (RN)-A witnessed nursing assistant (NA)-A respond to R1 by punching him in the leg when providing cares.Findings include: R1's care plan dated 12/4/25 indicated R1 was to use the Sara Steady lift for transferring from the bed to the chair and to the toilet. R1 was not to ambulate, pivot transfers only. R1's care plan dated 12/8/25 indicated R1 was to receive care in pairs until further notice with the of nursing assistants and nursing. No other guidance was documented. R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1's Brief Inventory of Mental Status (BIMS) score was 13 indicating R1's was cognitively intact. R1 did not have any physical or verbal behavior symptoms toward others. R1 was dependent upon staff for eating, showing, lower body dressing and personal hygiene. He required maximal assistance with oral and toileting hygiene, upper body dressing, rolling in bed and transferring from lying to sitting and sitting to standing. R1's diagnoses were sepsis (life-threatening infection in the blood), alcohol-induced chronic pancreatitis (inflammation of the pancreas), lymphedema (swelling of lymphatic fluid in the arms or legs) and osteoarthritis of the right hip. The facilities Witness Investigation Form dated 12/14/25 at 1:15 p.m. an interview with NA-A indicated NA-A was providing cares to R1 who wanted to get in his chair. NA-A got R1's pants on and when she assisted him to get up, he became aggressive. NA-A gently grabbed his hand and stated she was there to help. RN-A entered the room right when NA-A placed her hand on R1's hand. NA-A described R1's aggressiveness as he was raising his voice. NA-A denied R1 hitting out at her and was not combative and denied she struck R1. NA-A stated cares in pairs meant two people were to be in his room and she did not know why there was not two staff in his room. She stated when a resident becomes aggressive staff is to grab another staff member, document, and redirect. The facilities Witness Investigation Form dated 12/14/25 at 1:57 p.m., indicated an interview with RN-A indicated she was near R1's door and heard yelling, she thought it was the television, but then realized it was R1 and NA-A's voices then she saw NA-A's arm pull back and punch into R1's left knee. The facilities Witness Investigation Form dated 12/14/25 at 2:00 p.m. an interview with R1 indicated R1 stated he did not feel safe and the facility because a caregiver slugged him. He stated he wanted to transfer from his bed to his wheelchair and that NA-A slugged him and he slugged her back. RN-A then entered the room. R1 showed the interviewers how the interaction occurred by placing his hand at his side and moved it across the truck of his body with a closed fist. Upon observation and interview on 12/17/25 at 10:20 a.m. R1 stated he was abused when a staff member slugged him, and he slugged her back. NA-A was in the process of transferring him from his bed to his wheelchair. NA-A and R1 began arguing about how she was lifting him. She was not using that machine, and lifting him under his arms and she would not stop. He stated as he was sitting on the side of his bed with his pants around his ankle NA-A made a fist with her right hand and walloped him on his left knee. The next thing he knew was RN-A came into the room, NA-A left, and RN-A finished his cares. He demonstrated with his right hand by making a fist and thrusting his arm out towards the surveyor. R1 denied any pain or emotional concerns during the interview. He stated he was not harmed. Upon interview on 12/17/25 at 2:03 p.m. RN-A stated on 12/14/25 she was outside of R1's room setting up medications on her cart and heard yelling in R1's room, thinking it was the television until she realized it was R1 and NA-A. She stated she rushed to the room and just as she pushed open the curtain, she witnessed R1 seated on the edge of his bed, tilted to the right side as NA-A was supporting his body with her left hand. She closed the fist of her right hand and punched his left knee. RN-A immediately asked NA-A what she was doing? NA-A responded that R1 had hit her. RN-A responded that did not mean she could hit him back. NA-A was removed from the room and away from all the other residents while RN-A notified the charge nurse. RN-A with the assistance of the physical therapy assistant (PTA)-A completed R1's cares. RN-A asked for assistance with cares as R1 was to have all his cares completed in pairs. Upon interview on 12/17/25 at 2:45 p.m. PTA-A stated she did not witness R1 being punched on 12/14/25. She spent time with him after her and RN-A got him up. She completed his physical therapy walking. During the walk R1 told her that an NA had punched him he punched her back. He did not feel safe at the facility. Upon interview on 12/17/25 at 3:27 p.m. NA-A stated she was caring for R1 on 12/14/25 and she answered his call light. He was requesting to get up and sit in his wheelchair. She stated she put R1's pants on up to his knees as he was lying in bed then she pivoted him to be seated on the side of the bed before standing him up, pulling up his pants and attempting to stand him. She stated he became aggressive and attempted to hit her. Just as she was putting her hands over his hands to stop him from hitting her RN-A walked in the room confronted NA-A and asked her to leave. NA-A stated she did not tell the facility that R1 was hitting her because the facility placed her in a room without her consent and she was frightened. She stated she had floated to different units in the facility and does not have time to read the care plans of residents. She was in the room with R1 by herself and attempted to transfer him without the mechanical Sara Steady lift. Upon interview on 12/17/25 at 4:40 p.m. the director of nursing stated she received a call from the facility about potential physical abuse between R1 and NA-A. She arrived at the facility where R1, NA-A, and RN-A were interviewed immediately. R1 demonstrated how NA-A punched him, and his story matched-up with RN-A's interview of her witnessing NA-A punching R1. The facility did terminate R1 on 12/17/25 and substantiate their findings. The DON denied re-education of staff on managing residents with behaviors and/or cognitive impairment. Education was started on 12/17/25 during the survey process, included in the education was defining the cares in pairs intervention. As NA-A was caring for R1 alone when the abuse occurred. Upon interview on 12/18/25 at 11:09 a.m. the Administrator stated the facility substantiated the allegations of physical abuse. She stated the facility had zero tolerance. The root cause of the incident was an isolated incident where NA-A did not follow the care plan was potentially stressed. She stated re-training of how to manage residents with cognitive and behavior concerns was started 12/17/25 during the survey process. A facility policy titled Abuse Prevention plan dated 2017 indicated Abuse: The willful infliction. of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.(1) hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult.

Based on interview and record review the facility failed to thoroughly investigate allegations of witnessed physical abuse for 1 of 3 residents (R1) reviewed for abuse investigation when the facility did not interview any residents to determine if they were abused. Registered nurse (RN)-A witnessed nursing assistant (NA)-A respond to R1 by punching him in the leg when providing cares.Findings include: R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1's Brief Inventory of Mental Status (BIMS) score was 13 indicating R1's was cognitively intact. R1 did not have any physical or verbal behavior symptoms toward others. R1 was dependent upon staff for eating, showing, lower body dressing and personal hygiene. He required maximal assistance with oral and toileting hygiene, upper body dressing, rolling in bed and transferring from lying to sitting and sitting to standing. R1's diagnoses were sepsis (life-threatening infection in the blood), alcohol-induced chronic pancreatitis (inflammation of the pancreas), lymphedema (swelling of lymphatic fluid in the arms or legs) and osteoarthritis of the right hip. The facilities Witness Investigation Form dated 12/14/25 at 1:15 p.m. an interview with NA-A indicated NA-A was providing cares to R1 who wanted to get in his chair. NA-A got R1's pants on and when she assisted him to get up, he became aggressive. NA-A gently grabbed his hand and stated she was there to help. RN-A entered the room right when NA-A placed her hand on R1's hand. NA-A described R1's aggressiveness as he was raising his voice. NA-A denied R1 hitting out at her and was not combative and denied she struck R1. NA-A stated cares in pairs meant two people were to be in his room and she did not know why there was not two staff in his room. She stated when a resident becomes aggressive staff is to grab another staff member, document, and redirect. The facilities Witness Investigation Form dated 12/14/25 at 1:57 p.m., an interview with RN-A indicated she was near R1's door and heard yelling, she thought it was the television, but then realized it was R1 and NA-A's voices then she saw NA-A's arm pull back and punch into R1's left knee. The facilities Witness Investigation Form dated 12/14/25 at 2:00 p.m. an interview with R1 indicated R1 stated he did not feel safe and the facility because a caregiver slugged him. He stated he wanted to transfer from his bed to his wheelchair and that NA-A slugged him and he slugged her back. RN-A then entered the room. R1 showed the interviewers how the interaction occurred by placing his hand at his side and moved it across the truck of his body with a closed fist. An untitled, facility form dated 12/15/25 indicated sixteen staff members were asked if they had ever physically mistreated any resident? Have they ever seen or heard other staff physically mistreat any resident? And what to do if they would see staff mistreat any resident? The form did not indicate any specific questions regarding R1 or NA-A. In addition, the questions asked not indicate what they would do if they heard allegations of abuse. The investigation did not include any resident interviews to ask if they were abused. Upon review of the facilities investigation dated 12/14/25 revealed fifteen residents on the 300 unit, the cognitive unit where R1 resided were given a skin and pain assessment. A progress notes on all fifteen residents indicated emotional and psychological state at baseline. The investigation failed to indicate any questions regarding safety, treatment, and/or abuse on the unit. In addition, no residents from other units who worked with NA-A were interviewed and no families were interviewed. Upon interview on 12/17/25 at 4:40 p.m. the director of nursing, DON stated NA-A was immediately pulled off the floor on 12/14/25 after RN-A witnessed her punch R1. All staff who worked the day shift on the 300 unit were interviewed about the incident. On 12/15/25 sixteen other staff members were asked if they had ever physically mistreated a resident, witnessed another staff member mistreat a resident, and what they would do if they did. She stated the facility did not interview residents on other units where NA-A had worked and was not certain of the reasons. The facility did not ask the residents on the 300 unit if they had ever been harmed because the 300 unit was a cognitive unit, and the residents may not be able to provide correct responses. Upon interview on 12/18/25 at 9:15 a.m. RN-B stated he worked on 12/14/25 training as a charge nurse. His role in the investigation was to conduct the skin and pain assessments on the fifteen residents on the 300 unit. He stated the documentation in the progress notes that indicated each resident was emotional and psychological state at baseline was his observation during the skin and pain assessments. He stated the reason the residents were not asked abuse was to not frighten the residents that abuse may have occurred. Upon interview on 12/18/25 at 11:09 a.m. the Administrator stated the facility kept residents safe during their investigation was by removing NA-A immediately from the floor. She stated the reason residents from other units were not interviewed was because she felt NA-A's witnessed punching of R1 was an isolated incident because NA-A had not had any prior allegations in the approximately two years she worked at the facility and her abuse education was up to date. The other residents on the 300 unit were assessed and not interviewed was because it was a cognitive unit, and they may not have been to recall accurate events. A facility policy titled Abuse Prevention Plan dated 2017 indicated the facility would identify and interview all who might have knowledge of the incident including the alleged victim, perpetrator, witnesses, or others who have had related contact with the alleged perpetrator, related to the incident in question.

Based on observation, interview, and record review the facility failed to implement the care plan for 1 of 3 residents (R1) reviewed for care plan interventions when R1 was to have cares in pairs (two staff with resident) and was to be transferred using a Sara Steady (a mechanical sit to stand machine) and was observed with staff transferring without the device. Findings include: R1's care plan dated 12/4/25 indicated R1 was to use the Sara Steady lift for transferring from the bed to the chair and to the toilet. R1 was not to ambulate, pivot transfers only. R1's care plan dated 12/8/25 indicated R1 was to receive care in pairs (two staff with resident) until further notice with the discipline of nursing assistants and nursing. No other guidance was documented with the intervention. R1's care plan dated 12/8/25 indicated R1 tended to make accusations and comments against staff of other ethnicities due to cognitive impairments, resident becomes forgetful and does not remember that he made these comments of accusations. Staff to continue to redirect resident when comments are made to continue to provide supportive care. This concern did not indicate cares in pairs as an intervention. R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1's Brief Inventory of Mental Status (BIMS) score was 13 indicating R1's was cognitively intact. R1 did not have any physical or verbal behavior symptoms toward others. R1 was dependent upon staff for eating, showing, lower body dressing and personal hygiene. He required maximal assistance with oral and toileting hygiene, upper body dressing, rolling in bed and transferring from lying to sitting and sitting to standing. R1's diagnoses were sepsis (life-threatening infection in the blood), alcohol-induced chronic pancreatitis (inflammation of the pancreas), lymphedema (swelling of lymphatic fluid in the arms or legs) and osteoarthritis of the right hip. Upon observation and interview on 12/17/25 at 10:20 a.m. R1 stated he was abused when a staff member slugged him, and he slugged her back. NA-A was in the process of transferring him from his bed to his wheelchair. NA-A and R1 began arguing about how she was lifting him. He stated she was not using that machine, and was lifting him under his arms. R1 stated he was not aware if was to have one or two staff caring for him. He stated it changed often, as sometimes staff would care for him alone and other times they would not. Upon interview on 12/17/25 at 2:03 p.m. RN-A stated on 12/14/25 she witnessed R1 seated on the edge of his bed, tilted to the right side as NA-A was supporting his body with her left hand. She closed the fist of her right hand and punched his left knee. RN-A with the assistance of the physical therapy assistant (PTA)-A completed R1's cares. RN-A asked for assistance with cares as R1 was to have all his cares completed in pairs. RN-A stated NA-A was caring for R1 alone and not using the lifting device. RN-A stated if a care plan only indicated care in pairs then all staff must have any cares they provide witnessed by another staff member including medication administration and feeding, RN-A fed R1 lunch in his doorway on 12/14/25 as R1 liked to eat in his room. Upon interview on 12/17/25 at 2:45 p.m. PTA-A stated she was not aware that R1 was on care in pairs and she was not sure if that pertained to therapy staff or just nursing staff. Upon interview on 12/17/25 at 3:27 p.m. NA-A stated she was caring for R1 on 12/14/25 and she answered his call light. He was requesting to get up and sit in his wheelchair. She stated she put R1's pants on up to his knees as he was lying in bed then she pivoted him to be seated on the side of the bed before standing him up, pulling up his pants and attempting to stand him. She stated she was in the room with R1 by herself and attempted to transfer him without the mechanical Sara Steady lift. She admitted she did not read his care plan before tending to his needs. Upon interview on 12/17/25 at 3:02 p.m. RN-C the ADON stated NA-A was not following the care plan when the abuse allegations occurred. She stated R1 was cares in pairs. She stated she thought cares in pairs were just for direct care and just for nursing and did not include feeding. R1 had behaviors as he voiced his opinion and he did not like people that were not the same ethnicity, therefore therapy would be able to go in alone because they did not have any therapists that were of a different ethnicity. Upon interview on 3/17/25 at 3:31 p.m. RN-D the clinical manager stated the reason R1 was on cares in pairs was on a prior admission to the facility R1 had made accusations against staff of a different ethnicity. She defined cares in pairs as you have to always have two people in the room unless otherwise indicated. She was certain if it was okay for therapy to be in there alone when they were dressing him. Upon observation on 12/18/25 at 8:28 a.m. NA-B was in R1's room and he asked to use the bathroom. NA-B told R1 that she needs to get the assistance of another staff member. NA-B got NA-C. They assisted R1 to sit on the side of the bed, put a gait belt around his waist, stood him up and him ambulate eight steps to his wheelchair. Upon observation and interview on 12/18/25 at 8:47 a.m. NA-B looked in a binder on the NA's desk. The physical therapy orders indicated R1 was to the use the Sara Steady with assistance of one staff member. NA-B stated she thought he was an assistance of two and a gait belt. Upon interview on 12/18/25 at 9:15 a.m. RN-B stated he just found out on 12/14/25 when he was investigating R1's abuse allegations that R1 was care in pairs. He was not certain as to why. He pulled up the care plan and read that R1 had made accusations against staff of different ethnicities. That was not on the treatment administration sheet (TAR) and therefore he would not see that unless he opened every resident's care plan every day, for which he stated he did not have time. Upon reviewing the care plan, he stated he noticed a bunch of stuff a floor nurse would not necessarily be looking at. He stated he followed the TAR and R1 making allegations and staff interventions should show on the TAR. RN-B deferred the question of how to define cares in pairs as it was written in R1's care plan. He stated the care plan should be more specific because now he did not know if he needed to be assisting the nursing assistants with their cares and if he needed to bring NA's in when he was giving medications. He stated pairs in cares is not feasible on the 300 unit as they staff one nurse and two nursing assistants for the fifteen residents.Upon interview on 12/18/25 at 10:46 a.m. the director of nursing, (DON) stated R1's cares in pairs was scheduled into the care plan for every shift and staff was expected to check it off. She stated the cares in pairs pertained to nursing staff only, as R1 had made accusations against the black staff. She stated she assumed staff were aware of that. For R1's transferring status he was to be a Sara Steady, and the staff should not have been transferring him against the care plan. The staff had the option of looking at the therapy binder on the NA's desk or the care plan to locate his transfer status. Upon interview on 12/18/25 at 11:13 a.m. the Administrator stated R1 was cares in pairs and she expected the staff to know their residents and read the care plans. A facility policy titled Comprehensive Assessment and Care planning dated 2017 indicated All person-centered care plan interventions will be implemented by qualified personnel. Interventions may be communicated through the electronic health record, resident profile, assignment sheets, and/or verbal communication.

Based on interview and document review, the facility failed to ensure the resident representative was notified in a timely manner of a deterioration in wound status for 1 of 3 residents (R1) reviewed for non-pressure skin impairments.Findings include: R1's admission Minimum Data Set (MDS), dated [DATE], identified R1 admitted to the care center on 6/23/25 from the acute care hospital. The MDS outlined R1 as having significant cognitive impairment, needing substantial assistance with most activities of daily living (ADLs), and having several medical conditions including a history of stroke, high blood pressure, thyroid disorder, and hemiparesis (i.e., muscle weakness or partial paralysis on one side of the body). The MDS identified R1 as having one un-healed stage II pressure injury present on admission, along with a subsequent section reading, M1040. Other Ulcers, Wounds and Skin Problems, which indicated R1 as having moisture-associated skin damage (i.e., MASD; a type of skin damage that occurs when skin is exposed to prolonged moisture, leading to inflammation and erosion).On 8/1/25 at 9:53 a.m., R1's family member (FM)-A was interviewed via telephone. FM-A explained R1 had admitted to the care center in June 2025 from the hospital after having a stroke and needing therapy services. FM-A stated R1 had a small sore on her coccyx when she admitted to the care center which the nurse identified on their initial skin check adding they had assumed the care center would address and prevent it from worsening. FM-A expressed several concerns about R1's care while at the facility and added aloud, The attention to her really lacked. FM-A explained R1 then contracted COVID-19 and suddenly, on 7/21/25, they were notified the wound had significantly changed and R1 needed to be hospitalized for it. FM-A stated nobody had ever mentioned or updated them on the wound since R1 admitted adding aloud, We were not updated at all on that wound. FM-A stated they were shocked to learn about how bad the wound had become when they learned of it from the hospital adding, It just floored me. FM-A added, We had no idea that is was that bad. R1's Weekly Skin Check, dated 6/23/25, identified a section to record current skin alterations upon R1's admission. This indicated R1 had a fluid-filled blister present along with another checkmark placed next to the option reading, Moisture Associated Skin Damage. The evaluation included a place to record the location of these which was answered with a radio-button next to the option, Other. The corresponding section to record dictation on, Other, had text which read, See note. R23's corresponding progress note, dated 6/23/25, identified R1 admitted to the care center on that same date. The note listed a section labeled, Skin:, which outlined R1 as having a blister on her right heel which the hospital reported as a stage II pressure injury along with an additional skin impairment recorded as, . 0.1 cm [centimeters] X [by] 0.1 cm X 0.1 cm and 0.2 cm X 0.3cm [sic] X 0.1 cm wounds noted on sacral region [which] hospital reported as moisture-associated [MASD]. R1's Wound Management Detail Report, printed 8/1/25, identified all the facility' wound tracking within the medical record and dated back to her admission on [DATE]. The report outlined R1's coccyx/sacral wound as, Other - moisture associated, and recorded it as being present upon admission with dictation on 6/23/25 reading, two small wounds . [measurements; see progress note] . both blanchable. However, the next recorded entry was dated 7/10/25 and outlined the wound as now being 10 cm X 5.5 cm with a healing status recorded, Declining, adding further, See the progress notes. R1's corresponding progress note, dated 7/10/25, identified R1 was evaluated by the registered nurse manager (RN)-B with dictation reading, . was assessed today following a reported change in condition related to a wound that was present upon admission . a boil-like lesion was observed near the anus in the coccyx/perianal region. Additionally, a coccyx wound was noted, measuring 10 cm (L) x 5.5 cm (W). The wound appears purple/red in color, with irregular edges, central necrosis, and blanchable red tissue surrounded by areas of white discoloration . odor was noted during the inspection . A dressing was applied to protect the compromised skin. However, R1's medical record was reviewed and lacked evidence R1's family member (FM) or responsible party had been notified of the change in condition and declining wound status despite R1 having severe cognitive impairment and the wound increasing in size with signs of necrosis, having an odor, and showing significant discoloration. When interviewed on 8/1/25 at 10:32 a.m., RN-A stated they recalled working with R1 and described her as being totally dependent for most ADLs. RN-A explained they had noticed the wound worsening towards the end of her stay at the care center and believed the nurse manager (RN-B) was aware and addressing it. However, RN-A stated they did not recall ever updating R1's family member about the wound adding, [Not] specifically. RN-A stated any conversations with family, including updates on wound conditions, should be recorded in the medical record. On 8/1/25 at 1:03 p.m., RN-B and the director of nursing (DON) were interviewed, and both verified they had a chance to review R1's medical record. RN-B explained the floor nurse had asked them to observe R1's coccyx wound on 7/10/25, which was the first time they had seen it. RN-B stated the area was purple and red in color and appeared more like a deep-tissue injury at that time so the DON was notified about it. DON verified the documented characteristics from admission to 7/10/25 and expressed, I would consider that a change. DON stated there was some conflicting charting from the hospital on the potential origin of the wound but reiterated there was care being done for it throughout her stay such as repositioning, nutritional supplements, and a dressing being applied. RN-B stated FM-A was R1's acting responsible party, and explained FM-A had been present in the room on 7/14/25 while R1's wound care was completed; however, RN-B verified they did not specifically mention or review the coccyx wound with them but rather discussed the heel ulcer which was healing. RN-B and DON both acknowledged the lack of documentation within the medical record to demonstrate R1's FM-A had been updated timely about the coccyx wound condition on 7/10/25 and RN-B expressed aloud, I feel like any change of condition should be notified to the family.A facility-provided Change In Condition policy, dated 10/2023, identified when a significant change is the resident's physical or mental status is identified, the provider and resident representative would be consulted. The policy listed a step-by-step procedure which included, 6. Notify the resident/resident representative.

Based on interview and document review, the facility failed to comprehensively assess the bowel and bladder status to determine what, if any, proactive interventions were needed to help promote healing of developed moisture-associated skin damage (MASD; a type of skin damage that occurs when skin is exposed to prolonged moisture, leading to inflammation and erosion) for 1 of 3 residents (R1) reviewed for non-pressure skin impairments. Findings include: R1's admission Minimum Data Set (MDS), dated [DATE], identified R1 admitted to the care center on 6/23/25 from the acute care hospital. The MDS outlined R1 as having significant cognitive impairment, needing substantial assistance with most activities of daily living (ADLs), and having several medical conditions including a history of stroke, high blood pressure, thyroid disorder, and hemiparesis (i.e., muscle weakness or partial paralysis on one side of the body). The MDS identified R1 as using no appliances for bowel and bladder (i.e., ostomy, catheter) and being frequently incontinent of both bowel and bladder. Further, the MDS identified R1 as having moisture-associated skin damage (i.e., MASD; a type of skin damage that occurs when skin is exposed to prolonged moisture, leading to inflammation and erosion).On 8/1/25 at 9:53 a.m., R1's family member (FM)-A was interviewed via telephone. FM-A explained R1 had admitted to the care center in June 2025 from the hospital after having a stroke and needing therapy services. FM-A stated R1 had a small sore on her coccyx when she admitted to the care center which the nurse identified on their initial skin check adding they had assumed the care center would address and prevent it from worsening. FM-A expressed several concerns about R1's care while at the facility and added aloud, The attention to her really lacked. FM-A explained they were unsure what all treatment(s) had been done for the coccyx wound as they hadn't been told about it again until 7/21/25, when R1 was re-hospitalized for it. FM-A stated R1 would often complain about soreness on her backside though adding they'd seen a small container of silly putty [looking] cream on her bedside table only a few times. FM-A stated they were unsure what it was. R1's corresponding Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 7/4/25, identified R1 had several factors which triggered the CAA to be completed including being frequently incontinent, dependent for mobility, and having MASD. The CAA outlined R1 had restricted mobility, a psychological or psychiatric problem, and urinary urgency. The CAA identified R1 consumed multiple psychotropic medications and listed a section labeled, Analysis of Findings, which identified, . is frequently incontinent of bladder [related to] impaired mobility and communication . Requires assist with toileting hygiene and transfer . I/O [intake/output] monitored per policy . All medications administered per orders and monitored for side effects and effectiveness . PRODUCT used to promote skin integrity and dignity. Resident does have MASD. This places resident at risk for falls and pressure injury. Goal is for resident to maintain current level of continence through review date. The CAA concluded with dictation directing to care plan and no referrals were needed. The CAA lacked information on what type of incontinence R1 demonstrated during the review period (i.e., functional, urge) or what other interventions were considered to promote continence despite R1 having MASD.R1's Skin Risk Observation with Braden Scale, dated 6/23/25, identified R1 had chronic incontinence, cardiovascular disease, and repeated hospitalizations. The evaluation outlined R1 required substantial assistance with most ADL(s) and had active skin problems including a stage II pressure injury and MASD. The corresponding Braden scale scored R1 as a 12.0 which had dictation, HIGH RISK. A section labeled, Interventions, was provided which identified staff would elevate R1's affected extremities and reposition her every 2 to 3 hours. The completed evaluation lacked what, if any, interventions would be done for R1's continence despite R1 having MASD and being recorded with, Chronic Incontinence. R23's progress note, dated 6/23/25, identified R1 admitted to the care center on that same date. The note listed a section labeled, Skin:, which outlined R1 as having a blister on her right heel which the hospital reported as a stage II pressure injury along with an additional skin impairment recorded as, . 0.1 cm [centimeters] X [by] 0.1 cm X 0.1 cm and 0.2 cm X 0.3cm [sic] X 0.1 cm wounds noted on sacral region [which] hospital reported as moisture-associated [MASD]. R1's Clinical Documentation (Admission) evaluation, dated 6/23/25, identified R1 demonstrated no behaviors and included a section labeled, BOWEL and BLADDER. This section had several questions to be answered by the staff member completing the evaluation, and it outlined R1 used no appliances for voiding, was frequently incontinent of bowel and bladder, and had no constipation present. The section continued and identified R1's last bowel movement as 6/23/25, and R1 as having active bowel sounds. The section concluded with a subsection reading, Comments .[;] however, this was left blank.R1's corresponding Bladder evaluation, dated 6/27/25, identified R1 used no appliances for voiding and was rated as, Always incontinent (no episodes of continent voiding). The evaluation outlined R1 did not recognize the appropriate time or place to void, did not feel the urge to urinate, and demonstrated one risk factor for incontinence which was recorded as, Impaired Mobility. The options to select other risk factors, including severe cognitive impairment, were left blank despite R1 being recorded as having such on the MDS. The evaluation listed several other sections to be completed with data including what, if any, potentially reversible causes of incontinence were present, contributing medical diagnoses which could be affecting continence, medications which could affect continence, an incontinence symptoms profile (i.e., type of incontinence), and a summary of the evaluation and decision-making for program placement. However, these sections were each left blank and not completed. The evaluation concluded with a section labeled, Section 9 - Bladder Assessment Summary, however, this also was left blank and not completed. R1's corresponding Bowel evaluation, dated 6/27/25, identified R1 did not use an appliance for defecation. The section labeled, Bowel Continence, was answered with a radio-button response, Not assessed. The entire remainder of the evaluation, including sections to review symptoms, medication use, risk factors, and treatment decisions, were left blank and not completed. The evaluation concluded with a section labeled, Section 7 - Bowel Summary, however, this was left blank and not completed. R1's Bowel & Bladder Function care plan, dated 7/11/25, identified R1 experiences bowel and bladder incontinence due to impaired mobility, hemiplegia, and impaired communication. A goal was listed which read, I will maintain current level of continence, along with interventions to help R1 meet this goal including assisting with toileting, initiating barrier cream in accordance with standing orders, reporting signs of a potential infection and, Provide individualized toileting interventions based on needs/patterns. These interventions were all initiated on, 07/11/2025.However, R1's medical record was reviewed and lacked evidence R1's bowel and bladder status had been comprehensively evaluated or assessed to determine what type(s) of incontinence R1 demonstrated; nor what, if any, interventions for voiding had been considered (i.e., fluid management, timed toileting program, potential appliance use) despite R1 being recorded as having active MASD on her coccyx upon admission [DATE]) which could worsen with ongoing exposure to incontinent urine or feces. When interviewed on 8/1/25 at 10:23 a.m., nursing assistant (NA)-A stated they recalled working with R1 while she was at the care center, and described her as total help for cares. NA-A stated R1 had a wound which just smelled so gross on the day R1 was sent back to the hospital for it adding, it wasn't always like that. NA-A stated R1 had been incontinent of bowel and bladder throughout her admission but verified R1 could use the toilet if helped. NA-A stated R1 had difficulty holding herself up though and used a mechanical lift for transfers so, as a result, she (R1) often just went [voided] in the bed. NA-A stated they did not recall ever using a barrier cream for R1 either, as most of the time her coccyx was covered with a dressing due to the wound. On 8/1/25 at 1:03 p.m., registered nurse manager (RN)-B and the director of nursing (DON) were interviewed, and both verified they had a chance to reviewed R1's medical record. RN-B stated the floor nurse had asked them to observe R1's coccyx wound on 7/10/25, which was the first time they had seen it. RN-B stated they then alerted the DON to the wound. DON stated there was some conflicting charting from the hospital on the potential origin of the wound but expressed cares had been done for it such as repositioning and nutritional supplements. RN-B verified R1 was able to use the toilet for voiding with assistance, and the DON explained a comprehensive review of R1's voiding and elimination would be done using the bowel and bladder observations in the medical record. DON reviewed R1's completed Bowel and Bladder evaluations, respectively, and verified they were not completed in their entirety adding, My expectation would be it's filled out. DON verified those evaluations would be the tools used to demonstrate what, if any, interventions for R1 had been considered for her voiding and elimination. DON stated continence and voiding were important to assess as incontinence does directly affect your skin adding further, We want to make sure we're toileting appropriately. A facility-provided Resident Examination and Assessment policy, dated 10/2023, identified each resident would have a thorough examination and assessment completed upon admission with three (3) parts being completed including a physical exam, reporting a refusal, and documenting a refusal in the medical record. However, the policy lacked information on how a comprehensive bowel and/or bladder evaluation would be completed.

Based on observation, interview, and record review the facility failed to report an injury of unknown origin to the State Agency (SA) immediately, but not later than two hours after the allegation is made for 1 of 3 residents assessed. Staff assisted R1 with a transfer using a sit-to-stand lift (a device that assists people with limited mobility to move from a seated position to a standing position) for toileting. R1's legs became weak, she needed to be sat down, and was lowered to the toilet. Approximately six hours later R1 woke-up in extreme pain, was sent to the emergency department (ED) and an x-ray revealed a fractured clavicle (one of the bones at the base of the neck, collar bone). Findings include: R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1's Brief Inventory of Mental Status (BIMs) score was a 15 indicating R1 was cognitively intact. R1 was dependent on staff for all transferring. R1's pertinent diagnoses were congestive heart failure, end stage renal disease, malnutrition, respiratory failure, and morbid obesity. R1's facility observation detail list report dated 11/6/24 at 12:45 a.m. indicated R1 had voluntarily transferred from the facility to the emergency department. The document indicated R1's transfer was necessary for R1's welfare and needs could not be met at the facility. R1 was transferred immediately for urgent medical needs. The document did not indicate R1's allegations of sliding in the mechanical lift, R1's pain level or location of pain. The document was unsigned. R1's nursing progress note dated 11/6/24 at 1:16 a.m. indicated R1 reported pain in her left shoulder. She reported her legs gave out early and she slide off the EZ sit-to-stand device and was seated on the toilet. Staff then used the ceiling lift to transfer R1 back from the toilet to the bed. R1's on-call provider was called, and an order was given for oxycodone (a narcotic medication for pain) and an x-ray of the shoulder/upper arm. No prior nursing notes were documented regarding any incident of R1 sliding in the in the lift or the use of a ceiling lift. R1's ED after visit summary dated 11/6/24 at 2:40 a.m. indicated R1 was seen for an arm injury and diagnosed with a displaced fracture of acromial end of left clavicle. R1 was given an arm sling to use and referred to Orthopedics. She was discharge back to the facility. Upon interview on 11/13/24 at 12:01 p.m. registered nurse (RN)-C stated she was on-call and received a call at approximately 2:00 a.m. from RN-B, the night nurse reporting R1 had been transferred to the emergency department due to excruciating pain. RN-B told her R1 had slid in the sit-to-stand lift earlier in the evening because her knees buckled. She stated RN-A the evening nurse told her R1 was having pain, weakness, and nausea all evening, and refused her p.m. mediations. RN-C stated she assumed something happened with the sling during the transfer, however, was not certain of a root cause. Upon observation and interview on 11/13/24 at 12:18 p.m. R1 was in the upright position in her bed, attempting to eat lunch. She had a sling on her left arm. She took many breaks while speaking due to pain. She stated on 11/5/24 in the early evening she was taken to the bathroom by NA-A and NA-B using the sit-to-stand lift. She stated when she got to the bathroom, she started screaming that her legs were weak, she was going to fall, they needed to sit her down. She stated she felt like she slipped in the lift. When she was seated on the toilet NA-A left to get the nurse because R1 requested the use of the ceiling lift to get her back to bed due to weakness, nausea, and fear of falling. R1 was transferred back to bed without difficulty. About an hour later around 7:30 p.m. RN-A came into give R1 her bedtime medications and R1 refused due to nausea. R1 could not recall her pain level at that time. She stated in the middle of the night, uncertain of time she woke-up in severe pain and called for a nurse stating she needed to go the hospital. R1 stated she did not recall bumping her arm in either of the transfers earlier in the evening nor did she recall any incidents in bed such as rolling over on her arm. Upon interview on 11/13/24 at 1:29 p.m. registered nurse (RN)-A stated on the evening on 11/5/24 (NA)-A asked RN-A if the staff could use the ceiling lift on R1 instead of the sit-to-stand because R1 was weak and not feeling well. RN-A stated she assessed R1 and allowed the use of the ceiling lift due to R1's fear of falling. A bit later checked on R1 and R1 denied any pain and refused her p.m. medications due to nausea. She stated she was still at work after 1:00 a.m. and was told by RN-B, the night nurse that R1 was having severe shoulder pain and wanted to go to the hospital. RN-A told RN-B that during the evening shift R1 was weak and requested the ceiling lift, however her vital signs were stable, and she was not complaining of any pain. Upon interview on 11/13/24 at 1:48 p.m. NA-B stated she was assisting NA-A on the evening of 11/5/24 at around 6 p.m. R1 was transferred to the toilet. She stated R1 looked weak, so the aides set her on the toilet. NA-B did not recall if R1 said anything during the transfer. She stated R1 was holding the sit-to-stand appropriately on the bar the entire time of the transfer and did not slide or bump her body during the transfer. She stated when R1 was seated on the toilet she told NA-A and NA-B she was too weak and nauseated to use the stand again and requested the ceiling lift be used. NA-B stayed with R1 until NA-A got permission from RN-B to use the ceiling lift. Another unidentified NA came to assist when the ceiling lift was used and R1 was safely transferred back to her bed. Upon interview on 11/13/24 at 2:27 p.m. RN-B stated she was the night nurse on 11/06/24 and around 1:30 a.m. R1 called her to her room crying saying she needed to go to the hospital because she was in excruciating pain. RN-B stated she attempted to assess R1 and all R1 could say was the pain was in her left shoulder and earlier that evening she slipped in the lift. RN-B called the on-call provider and sent R1 to the emergency department. Upon interview on 11/13/24 at 2:48 p.m. the assistant director nursing (ADON) stated she was aware of R1's incident. She heard during a transfer with the sit-to-stand lift R1's knee's buckled and she slid to the toilet. She stated the facility did not fill out a fall report upon interviews with the NA's R1 did not slide. She stated she assumed R1 had her arms up when she was being lowered and that jolted her arms and that is when the fracture occurred. She then stated the lift goes very slowly so there should not be any sort of force when the residents are seated. Upon interview on 11/13/24 at 3:09 p.m. NA-A stated on the evening of 11/5/24 at around 6:30 p.m. Her and NA-B transferred R1 from her bed to the bathroom using the sit-to-stand lift. She stated when they got to the bathroom R1 started screaming that her legs were giving out on her, and she needed to sit. The NA's lowered R1 to the toilet. R1 was breathing heavily, sat on the toilet a few minutes and told the NA's that she did not feel well and that she wanted to use the ceiling lift to go back to bed. NA-A left to get the nurse. When she came back R1 appeared to be fine, just continuing to refuse the sit-to-stand lift. NA-A stated with the assistance of another aid they transferred R1 back to bed without difficulty. She stated the rest of the shift R1 was on her telephone and then went to sleep. She stated R1 did not complain of pain the rest of the p.m. shift. Upon interview on 11/13/24 at 4:08 p.m. the facility's Medical Director stated due to R1's end stage renal disease she had severe osteoporosis leaving her vulnerable to fractures with even a slight movement of the arm. He stated she could have hit her arm on the sit-to-stand lift. Just lifting her arm over her head or a side-to-side motion could have enough pressure to cause a fracture in someone of her stature. In addition, due to her weight an attempt to move her body in bed or roll could have caused the fracture. He stated the cause of the injury was unknown. Upon interview on 11/13/24 at 4:15 p.m. the Administrator stated that to her knowledge R1 fractured her clavicle when she was lowered to the seat of the toilet because it took the aids about 15-30 seconds, and R1 could have had her arms up and caused the fracture. She stated upon her interviews with staff R1 was having minimal pain when the transfer began and was when she was lowered to the toilet with a complete proper transfer. R1 needed to catch her breath and was requesting the ceiling lift. R1 was not complaining of pain at that time. She stated it could reasonably be explained that R1 did fracture her clavicle during the transfer, however R1 always had pain so it was difficult to say exactly where the pain was coming from. The Administrator was not certain why R1 did not complain of pain from approximately 7 p.m. after she got back into bed following the transfers until about 2:00 a.m. when she woke-up in excruciating pain. The Administrator was aware that injury of unknown origin is to be reported to the SA within 24 hours, but she felt it was reasonable that R1 obtained the fracture during the lift. A facility policy titled Abuse Prevention Policy dated 2017 indicated the community is responsible for reporting serious bodily injury the individual is to report the event immediately, but no later than 2 hours. If the event does not involve abuse and does not result in bodily injury the individual is required to report no later than 24 hours. In addition, an injury should be classified as an injury of unknown source when both of the following conditions are met: The source of the injury was not observed by any person or the source of the injury could not be explained; and the injury is suspicious because the extent of the injury or the location of the injury or the number of injuries observed at one particular point in time or the incident of injuries over time.

Based on observation, interview and document review the facility failed to assess for removal of an indwelling urinary catheter as soon as possible to restore urinary continence for 1 of 1 residents (R27), reviewed for catheter care. Findings include: R27's quarterly Minimum Data Set (MDS) dated [DATE], identified R27 was admitted to the facility on [DATE], had intact cognition, had an indwelling catheter and required substantial assistance with toileting and lower body dressing. The MDS documented R27 with diagnoses of polyneuropathy (nerve disease), enlarged prostate, obstructive (swelling) and reflux uropathy (urine flows back up into the kidneys), and urinary retention (incomplete emptying of the bladder). In addition, the facility did not attempt to implement a toileting program (e.g., schedule toileting, prompted voiding, or bladder training). R27's facility nurse practitioner admissions progress note (PN) dated 4/19/24, documented R27 had a fall at home resulting in an ankle fracture on 4/13/24, surgery on 4/14/24, and was hospitalized until 4/18/24. PN stated Foley catheter present since approximately last fall. PN plan stated, Foley catheter cares, follow-up with urology as directed. R27's physician orders (PO), care plan (CP), and progress notes (PN) lacked evidence of a urology consult and discussion with R27 and his spouse regarding a toileting program to determine appropriateness of continued catheter use or justification of continued use. During interview with R27 on 10/29/24 at 1:09 p.m., R27 stated his catheter was in place, off and on since last fall [2023] because I couldn't urinate properly. R27 stated he was admitted to facility in April [2024] and no one from the facility assessed him for removal of the catheter or tried alternatives to having the catheter in place. R27 stated the facility never offered to schedule a urology appointment during his stay. R27 stated, my long-term goal is to have it removed so I can go home. During interview with health unit coordinator (HUC)-A on 10/30/24 at 10:23 a.m., the HUC-A stated her role was to ensure all forms of provider orders including facsimile, voicemails, email, physical written forms, and electronic forms are placed in the resident electronic medical record (EMR) and consults are scheduled. HUC-A reviewed R27's electronic medical record (EMR) and hard chart and stated, I can't find the order for a urology consult. During interview with R27's legal representative/spouse/family member (FM)-A on 10/20/24 at 10:40 a.m., FM-A stated R27 has had a catheter since last fall [2023] due to retention of urine. FM-A stated, facility has not talked to us about setting up a urology consult or follow up and there was no discussion on how long it was to be in. FM-A stated, we do not think the catheter should be in forever and would appreciate a discussion or at least an appointment to get [to the urologist]. FM-A stated, nothing has been brought up by staff here at all and no one has discussed with us any other options or alternatives to having the catheter. During interview with director of nursing (DON) on 10/30/24 at 1:11 p.m., DON stated the facility failed to pursue a urology consult for R27 since his admission to the facility on [DATE]. In addition, DON stated the facility did not assess or evaluate R27 for a bladder rehabilitation program with R27's goal of removing the catheter as soon as possible. DON also stated R27's EMR failed to document a discussion and review with R27 and FM-A about how long the catheter was expected to be in place. An undated facility policy titled Prevention of Catheter-Associated Urinary Tract Infections (CAUTI) stated, indwelling urinary catheters are eliminated whenever possible. In addition, An indwelling catheter is used only after alternative methods have failed.

Based on interview and document review, the facility failed to ensure complaints of potential constipation were acted upon and assessed to determine what, if any, interventions were needed to promote appropriate bowel management and reduce the risk of complication (i.e., fecal impaction) for 1 of 2 residents (R59) reviewed for bowel management. Findings include: R59's Clinical Documentation (Admission), dated 4/19/24, identified R59 had a section to record R59's mental status with both long and short-term memory being marked, Memory OK. Further, the evaluation listed a section labeled, Bowel and Bladder, which outlined R59 as occasionally incontinent of bowel with a question reading, Constipation present? This was answered, Yes. In addition, R59's most recent quarterly Minimum Data Set (MDS), dated [DATE], identified R59 had moderate cognitive impairment but demonstrated no delusional thinking. Further, the MDS marked R59 as being frequently incontinent of bowel and not being on a bowel-related toileting program, but the question to answer if constipation present (i.e., H0600) was not answered. On 10/28/24 at 4:15 p.m., R59 was interviewed while in his room. R59 stated he had ongoing issues with constipation despite taking medications for it adding most of the time he ended up going three or four days between bowel movements. R59 stated he used to go more regularly and expressed staff had never asked him about what, if any, options were available for a more proactive bowel management program (i.e., increased fiber, medications) adding, Not really, I don't think so. R59 stated he had a history of colon polyps and expressed staff were aware of his concerns with constipation as he had reported it multiple times while staff provide medications adding, They know about it. R59's most recent Elimination - Bowel (evaluation), dated 6/21/24, identified R59 used no bowel-related appliances (i.e., ostomy) and was always continent of bowel. However, the remainder of the evaluation, which included sections to review R59's medication use, pertinent medical conditions and treatment options for bowel status, was left blank and not completed. R59's Medication Administration Record (MAR), dated 10/2024, identified R59's current physician-ordered medications and treatments with spaces for staff to record their administration or refusals, if needed. This identified R59 consumed multiple medications, including multiple bowel-related medications, such as Miralax (a laxative) 17 grams (gm) by mouth every day and Senna-S (a laxative) 8.6-50 milligrams (mg) two tablets by mouth daily. These each had a listed start date, 9/11/24 - Open Ended. The Miralax had four total listed refusals or non-administrations recorded on 10/5/24, 10/6/24, 10/8/24 and 10/20/24. The Senna had five total listed refusals or non-administrations recorded on 10/8/24, 10/12/24, 10/19/24, 10/22/24, and 10/26/24. In addition, an order was listed which read, Bowel Assessment (Review), which listed a one time frequency scheduled for 10/11/24. This was recorded as completed on 10/12/24 with dictation reading, Late Administration: Charted late. The note or order lacked further information on what, if any, actions were taken when it was completed despite the evaluation being left nearly blank; nor did the MAR outline any additional interventions or actions (i.e., as-needed medication) for bowel management during the month period. When interviewed on 10/29/24 at 12:59 p.m., nursing assistant (NA)-B stated they had worked with R59 multiple times and described him as needing staff help with toileting. NA-B stated they had heard R59 complain about constipation, including as recently as like last week, which NA-B reported to the nurse. NA-B added, I told the nurse about it. NA-B stated the nurses were responsible to then address it adding R59's stools were hard, like really hard and even, at times, needed to be broken up before they'd flush down the toilet. NA-B stated they chart residents' bowel movements in the computer and it should be done every shift. R59's medical record was reviewed and lacked evidence R59 had been comprehensively assessed for what, if any, proactive bowel management interventions were needed to promote more regular bowel movements despite R59 having a history of constipation as marked on the admission evaluation and having ongoing complaints to staff about the issue. On 10/29/24 at 1:44 p.m., registered nurse (RN)-B was interviewed and asked about the facility bowel assessment process. RN-A turned to the surveyor and made a slight sweeping motion away from their body with their hands adding aloud, This place needs to get their [explicative whispered] together [with them]. RN-A stated they were unable to answer those questions and directed the surveyor to licensed practical nurse unit manager (LPN)-B adding, I can't safely answer that question. LPN-B was present and interviewed. They explained each resident had standing orders which could be followed if the resident went so many days without a bowel movement. R59's were provided and listed multiple options which performing a rectal check to determine if impaction was present, encouraging fluid intake, consulting the dietician for recommendations and medications like a suppository or enema. LPN-B verified if a nurse did any of these actions, then they should be charted in the MAR. LPN-B stated residents' bowel movements were charted in the computer system and tracked with the night nurse printing a report for the oncoming shift to review and, if needed, act upon. The unit Resident Bowel Management Report, dated 10/23/24 to 10/29/24, identified R59's name along with corresponding bowel movements. This outlined R59 had a large bowel movement on 10/23/24, a small bowel movement on 10/25/24, and none recorded since then (four days prior). LPN-B verified R59 being on fourth day without a bowel movement and RN-B stated nobody had alerted them to R59 being on the fourth day, either. LPN-B stated the nurses were responsible to assess and, if needed, act on bowel status or potential constipation adding repeated episodes of going multiple days without stool could be a problem as well. LPN-B verified the Elimination-Bowel tool was used to demonstrate the assessment of a residents' bowel status and the MAR order, dated 10/11/24, was used to prompt the nurse working to review it and ensure it was accurate and updated. LPN-B reviewed R59's completed evaluation, dated 6/21/24, and verified it was nearly blank adding aloud, That's not good. LPN-B stated nobody had reported R59 as having ongoing issues with his bowel or potential constipation to them otherwise they would have visited with him and completed an evaluation. LPN-B added, Nobody's told me that though. LPN-B verified it should have been reported adding it was important to ensure residents' were not constipated saying aloud, Constipation is horrible, it's painful. On 10/30/24 at 2:22 p.m., the director of nursing (DON) was interviewed. DON verified they had reviewed R59's medical record and expressed R59 did end up having a large stool the day prior (10/29/24) after the surveyor interviewed staff. DON stated bowel status was evaluated upon admission and with the MDS cycle (i.e., quarterly) and verified the Elimination-Bowel tool was used to demonstrate this process in the medical record. DON verified the last completed evaluation, dated 6/21/24, was left nearly blank and stated they expected it to be completed accurately and fully. DON stated if staff were hearing concerns from R59 about his bowels, then a discussion and evaluation of his bowel sounds should have been done and recorded in the progress notes. DON verified the record lacked evidence this happened along with evidence the standing orders had been enacted or charted. DON verified it was important to ensure bowel complications were assessed and acted upon to reduce the risk of impaction. A facility policy on bowel management was requested, however, none was received.

Based on observation, interview and document review the facility failed to assess and determine what, if any, options were available to help facilitate bathing method preference (i.e., showers) for 1 of 1 resident (R33) who voiced feeling unsafe being transported for distance while seated in the shower chair. Findings include: R33's quarterly Minimum Data Set (MDS), dated [DATE], indicated R33 was admitted to the care facility on 11/23/22, had moderate cognitive impairment and required substantial to maximum assistance with most activities of daily living (ADLs) including bathing. R33's care plan, edited 4/8/24, indicated R33 had a self-care and mobility deficit with the following activities of daily living; bathing, grooming, oral cares, ambulation, transferring, mobility, vision, bowel and bladder. The care plan further indicated R33 required a mechanical lift for all transfers but did not indicate how or how often R33 preferred to bathe. R33's Preferences for Customary Routine and Activities, dated 1/23/23, indicated it was very important for R33 to choose between a tub bath, shower, or bed bath. R33's Preferences for Customary Routine and Activities, dated 1/10/24, lacked an assessment of how important it would be for R33 to choose his method for bathing. R33's Hospital Discharge Summary, dated 7/14/23, indicated R33 underwent a right below knee amputation on 3/2/23 and a left below knee amputation on 4/20/23. R33's electronic medical record (EMR) lacked evidence that post double amputation R33 was reassessed to determine what, if any, options were available to help facilitate R33 with continuing to get showers in the care facility. During an interview on 10/28/24 at 2:21 p.m., R33 stated he was receiving a bed bath weekly but would prefer a shower, however felt uncomfortable and unsafe in the shower chair the facility provided. R33 stated there was a communal shower room and in order to use the shower staff would transfer him to a shower chair in his room and transport him to the shower room through the public space of the unit in the shower chair. R33 stated he felt uncomfortable being wheeled unclothed through the public space despite being covered up and further felt unsafe being transported in the shower chair due to his bilateral amputee status. R33 further stated when he was first admitted to the care facility he would get showers and stated the transitional care unit, where he was first admitted to, had a shower in his room that he was able to use without having to transfer via a shower chair in a public space. During an interview on 10/30/24 at 10:36 a.m., nursing assistant (NA)-B stated he had offered R33 a shower a few times but R33 refused, stating he had never asked, and R33 had never shared, why he didn't want a shower. NA-B stated they usually transferred R33 via a ceiling lift in his room but the facility also had a stand-alone mechanical lift that could be used in the bathroom. During an interview on 10/30/24 at 12:13 p.m., unit manager and licensed practical nurse (LPN)-B stated when R33 was first admitted to the facility he was able to pivot transfer prior to his amputations, however since his second amputation R33 had stated he did not feel comfortable in the shower chair. LPN-B stated she did not assess why R33 felt uncomfortable in the shower chair to determine if there were any options for showering that would make R33 feel safe and stated, I didn't think it was my place to ask for more information. LPN-B stated there were a couple flooring changes from R33's room to the bathroom that could cause bumps and potentially make the shower chair feel unstable. LPN-B stated the facility did have mechanical lifts that could be used in the bathroom with a sling designed for residents with amputations. During an interview on 10/31/24 at 11:43 a.m., the director of nursing stated she would expect R33 be assessed on why he did not feel safe with showers in order to offer choices to help facilitate R33's bathing preference.

Based on interview and document review, the facility failed to ensure routine grooming was offered or provided to promote good hygiene for 2 of 2 residents (R1, R25) reviewed for activities of daily living (ADLs) and who were dependent on staff for their cares. Findings include: R1 R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 with impaired cognition, and diagnoses of heart disease, diabetes, anxiety, depression, and psychotic disorder. Also, the MDS documented R1 on hospice cares and dependent on staff for personal hygiene, bathing, dressing, and transfers from bed to chair. R1's care plan identified, Problem: I have a self deficit with the following activities of daily living; grooming, oral cares, ambulation, transferring, and mobility dated 12/13/21. During observation of R1 and interview with R1's emergency contact/son/family member (FM)-B on 10/28/24 at 2:01 p.m., R1 was observed with multiple white colored hairs on her lower chin. R1 was unable to answer questions. FM-B stated, she [R1] generally isn't OK with them [chin hairs]. FM-B stated the facility, should have them [razors]. During interview with nursing assistant (NA)-A on 10/30/24 at 10:07 a.m., NA-A stated, personal cares involve offering to shave, assisting as needed with dressing, oral care, and personal cares are offered twice per day and as needed. NA-A stated, I would feel like as a woman it should be addressed. During observation on 10/30/24 at 11:13 a.m., R1 was observed self-propelling wheelchair down hallway in front of nursing station. R1 was dressed and had multiple half inch white hairs visible on her chin. During interview with NA-C on 10/30/24 at 11:15 a.m., NA-C stated, no I haven't asked her [R1] to shave her. Every morning, we should be at least asking her when she is getting up and dressed. It takes no time to trim those chin hairs. Looks like those chin hairs [on R1] have not been trimmed for at least a couple weeks. We are all are responsible from trimming or shaving the residents. Also, Women don't like having chin or neck hairs. During interview with NA-B on 10/30/24 at 11:22 a.m., NA-B stated personal cares include, help with hygiene and shaving should be done or offered daily at least. NA-B stated, long chin hairs on a woman like two inches [sic] would be concerning to me [due to] a dignity concern. And I would hate it if my mom had hairs on her face. That is not something most women would like. NA-B stated, [R1's] chin hairs look like they have not been shaved or trimmed for at least a couple weeks. R25 R25's admission MDS dated [DATE], identified R25 with admission to facility on 7/23/24, had intact cognition and required partial to moderate assistance with personal hygiene. In addition, R25 was documented with diagnoses of diabetes, end stage renal disease requiring hemodialysis (procedure where a device filters wastes, salts and fluid from blood when kidneys are no longer healthy enough to do this work adequately), anemia (low red blood cell level), and a stroke resulting in partial paralysis of her upper body. R25's care plan dated 7/24/24 identified, Problem: ADLs Functional Status/Rehabilitation Potential. I have a self deficit with the following activities of daily living; bathing, grooming, transferring, mobility. Bowel and bladder. During observation and interview with R25 on 10/29/24 at 8:18 a.m., R25 was observed with multiple two-inch white hairs extending from throat. R25 stated, I want to shave it off. I want them gone. Last time I shaved it was when I was home before I was admitted here [7/23/24]. R25 stated no one from facility ever asked her about the hairs and offered to trim or shave them even on weekly shower days. I have never been asked about it. During observation and interview on 10/30/24 at 10:59 a.m., R25 was observed with multiple two-inch-long white hairs extending from throat. R25 stated facility had never offered to shave or trim her throat hairs and that, they bother me. During interview with FM-C on 10/31/24 at 7:40 a.m., FM-C stated, R25 always trimmed or shave the little hairs that grow out of her neck. In the past, it did bother her when she could notice the hairs. It is frustrating for a woman to have those pesky hairs. I don't know if the nursing home trims or shave her chin or neck hairs, but I totally expect them to offer to do it and to at least trim it. No woman that I know wants one-to-two-inch hairs growing from their face. During observation and interview with licensed practical nurse (LPN)-A on 10/30/24 at 12:54 p.m., LPN-A stated she was very familiar with residents on R25's unit. LPN-A stated, no one on this floor requires shaving. Then LPN-A walked with surveyor to R25's room and observed the throat hairs. LPN-A stated, I do see them. They should be shaved. They are really long. [sic] that looks like it has been missed. We should offer to take care of that for her. During interview with director of nursing (DON) on 10/30/24 at 1:05 p.m., DON stated personal hygiene care should be done at least twice per day and as needed. Shaving would done with personal cares. DON stated, women should be shaved or offered at least. Undated facility policy titled Activities of Daily Living (ADL) identify, Residents unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, personal hygiene, elimination, communication and mobility.

Based on observation, interview and document review, the facility failed to comprehensively assess, develop and implement safe smoking interventions to reduce the risk of avoidable injuries with tobacco products for 4 of 4 residents (R2, R4, R7 and R3), who smoked. These failures resulted in an immediate jeopardy (IJ) for R2 who was smoking unsupervised outside the doors of facility's attached assisted living (AL), caught fire, sustained burns to 90% of her body, and died as a result of her injuries. The IJ began on [DATE], when a recommendation from physical therapy identified R2 was not safe smoking independently unsupervised. The facility had not developed and implemented safe smoking interventions for R2 including but not limited to supervision. The administrator, director of nursing (DON), regional director of clinical services (RDCS)-A, [NAME] President of Clinical Services (VPCS)-A, Chief Operating Officer (COO)-A, and [NAME] President of Operations (VPO)-A were notified of the IJ for R2 on [DATE] at 12:41 p.m. The IJ was removed on [DATE] at 4:31 p.m. when an accepted removal plan was successfully implemented; however, non-compliance remained at an patterned scope with potential for more than minimal harm that is not immediate jeopardy (Level E). Findings include: Third degree burns penetrate the entire thickness of the skin and permanently destroy the tissue. These present a loss of layers, often painless (pain may be caused by patches of first- and second-degree burns surrounding the third-degree burns), and dry, leathery skin. Skin may appear charred or have patches that appear, white, brown, or black. The St. Louis University Mental Status Exam (SLUMS)-a brief screening assessment used to detect cognitive impairment in adults over age 60. The SLUMS identified that a score of 27 to 30 means, normal in a person with a high school education; 21 to 26 mild neurocognitive disorder and 0 to 20 indicates dementia. Nursing Home Incident Report (NHIR) dated [DATE], identified an incident that the charge nurse was notified R2 had caught on fire while smoking. EMS notified. Facility staff and passerby had extinguished the fire. R2 was transferred to the hospital for treatment. According to the facility census line (undated) R2 had been in room [ROOM NUMBER] on [DATE]. During a facility walk through observation on [DATE], at 10:52 a.m. a path was walked from the nursing home room [ROOM NUMBER] where R2 resided to the AL entrance (location of where R2 smoked and caught on fire). The total distance from R2's 400 room to the AL outside exit/entrance was approximately 155 steps. There was a AL receptionist desk located at the main entrance/exit of the AL. At 11:03 a.m. outside directly in front of the AL sliding glass double doors entrance/exit, approximately three feet from the door there was a scattered amount of black substance identified by the video footage viewed on [DATE] as the location of the fire for R2. There was not a cigarette receptacle in this area nor was one visible in the video footage on [DATE], the day of the fire. R2's Slums assessment dated [DATE], identified a score of 22 of 30 which indicated mild cognitive impairment. R2's admission Minimum Data Set (MDS) dated [DATE], identified R2 had intact cognition and diagnoses of left scapula fracture and essential tremor. R2 used a wheelchair for mobility; walking 10 feet from an uneven turf was not attempted due to medical condition or safety concern and did not identify if tobacco was used. R2's progress note dated [DATE] at 10:22 p.m., identified R2 as a current everyday cigarette smoker. R2's nurse practioner (NP) note dated [DATE] at 3:00 p.m., included a diagnosis of Tobacco abuse identifying R2 was a current one pack a day smoker and in the past had not been interested in quitting. Plan to add Nicotrol inhaler, counseled regarding smoking cessation. R2's progress note dated [DATE] at 1:48 p.m., identified R2 had tremors and to monitor when R2 was outside/ensure return due to cold weather. R2's Safe Smoking Evaluation dated [DATE], completed by RN-C identified the date recorded was [DATE] at 9:11 p.m. and the evaluation was completed at 9:12 p.m. (1 minute) The form was an electronic document that prompted staff to evaluate and click on the appropriate predefined response; most response options to choose were 'Yes' or 'No'. The reason for assessment was marked as Admission The form identified the following. -Resident has been given education and information about smoking cessation; Yes was selected -Resident demonstrates an understanding of the smoking standards and policy; Yes was selected -Resident demonstrates ability to make own decisions; Yes was selected. -Resident demonstrates ability to hold cigarette/cigar/pipe safely; No was selected -Resident demonstrates ability to light the smoking material safely with lighter/match; No was selected. -Resident uses or verbalizes a willingness to use a flame-retardant smoking apron; No was selected -Resident appropriately uses an ash receptacle and does not drop ashes on self; No was selected -Resident demonstrates the ability to control holding the smoking material if bumped or distracted; No was selected. -Resident can safely extinguish the smoking material: No was selected -Resident complies with storage requirements for smoking material; Yes was selected. -Resident verbalizes and consents with understanding about not sharing smoking privileges with other residents Yes was selected. -Interdisciplinary Team (IDT) recommended resident to receive the following smoking status; (choices of selection included: Independent, Must be supervised, Smoking material must be secured, and Other) The only response selected was Other-Resident is aware smoking is not prohibited on facility grounds. Resident chooses to decline nicotine patch and smoke in designated areas. The evaluation did not identify the reasons for the No selections, did not clearly identify if R2 was safe to smoke independently, and did not identify any education nor interventions provided for the boxes marked No. R2's care plan dated [DATE], did not identify if R2 was safe to smoke independently nor safe smoking interventions if R2 chose to smoke. R2's care plan identified R2 had the potential for injury related by R2's choice to smoke. Interventions included: Ascertain resident wishes about smoking and respect residents decision, Evaluate for safety prior to smoking and screen per facility protocol, Instruct resident about smoking health effects on themselves and others, educate on risks and hazards, and provide resources for smoking cessation aides that are available. R2's vulnerable adult care plan dated [DATE], included I am a vulnerable adult and need assistance to remain safe within the community. My admitting diagnosis is Laceration without foreign body of scalp, subsequent encounter. In review of R2's record it was not evident R2 was provided/educated on the risk and benefits of smoking off campus independently, and instructions/interventions on what to do in the event of an emergent situation that required assistance even though R2's care plan informed staff R2 was at risk for injury and was vulnerable because she required assistance. During an interview on [DATE] at 9:37 a.m., registered nurse (RN)-C stated residents have the right to smoke at the facility but there was not a designated area for residents to smoke because the facility was non-smoking. The residents must go off campus to smoke (outside the AL) and needed to be able to smoke independently; the facility did not provide supervision. When a resident who smoked was admitted to the facility nursing would complete a smoking evaluation to determine if the resident was safe to smoke independently. The evaluation questions were reviewed with the smoking resident. RN-C would then watch the resident smoke to determine if they were safe. If the resident was determined to be an unsafe smoker RN-C would notify the administrator and the DON of the issue. Smoking supplies would be removed from the resident's possession with discussion and removal of supplies would be documented in the progress notes. A resident that would continue to smoke would be educated on a cessation program and the social worker and family would be included in those conversations. The clinical nurse manager would provide education to residents upon admission and when staff reported concerns of smokers who were not smoking in the right area. R2's smoking evaluation was done in January and the evaluation demonstrated that R2 was not safe to smoke. RN-C stated that R2 was not visualized smoking for the smoking assessment. RN-C had previously visualized R2 smoking prior to nursing home admission when R2 resided at the attached AL. RN-C stated R2's family was aware R2 smoked however, was not sure if the family was made aware R2 was deemed unsafe to smoke after the assessment was completed. Further not aware if it was communicated to family member (FM)-A that R2 would not be supervised while smoking because the facility was non-smoking. R2's progress note dated [DATE] at 11:20 a.m., identified R2 telling unknown nursing assistant I am going outside to smoke. At 11:25 a.m., identified R2 stating I was disoriented. Didn't know where I was or what I was doing., regarding a fall that occurred on [DATE]. At 12:55 p.m., R2 had tremors, and safety precautions to monitor when patient outside/ensure return due to cold weather. Subsequent notes on [DATE] between 3:07 p.m. and 3:14 p.m. indicated Nicotrol (a nicotine replacement medication used to stop smoking) was not available, and the NP was notified. R2's Occupational Therapy (OT) treatment encounter note dated [DATE], identified R2 was 15 minutes late to treatment due to being outside smoking. SLUMS score was a ,d+[DATE] indicating mild cognitive impairment. R2's NP note dated [DATE], identified R2 continued to smoke outside and was counseled regarding smoking cessation. Nicotrol inhaler ordered, supply has not arrived from pharmacy. R2 had used Chantix (medication used to stop smoking that does not contain nicotine) in the past was ineffective and caused nausea. Plan for Nicotrol inhaler (small hand-held inhalation device that contains nicotine cartridges) and R2 was counseled regarding smoking cessation, if Nicotrol inhaler ineffective would start Chantix along with Zofran for nausea. R2's progress note dated [DATE] at 3:54 p.m., identified R2 still smoked and would leave the unit without telling staff. R2's progress note dated [DATE] at 12:46 p.m., identified based on balance testing R2 was a high risk for falls and SLUMS ,d+[DATE]. R2's OT treatment encounter note dated [DATE] at 3:25 p.m., identified care conference were held with R2, R2's family members, facility director and assisted living manager. Discussed safety with activities of daily living (ADL's) and falls. Notes had no mention of smoking status addressed or concerns with R1 smoking. R2's Associated Clinic of Psychology (ACP) note with a service date of [DATE], identified R2 with adjustment disorders and mixed disturbance of emotions and conduct. Within the mental status exam identified that R2 presented with probable reduced insight and judgement along with SLUMS subtest which indicated moderate cognitive impairment. R2 presented with deficits in calculation, executive functioning, and short-term memory. R2 stated to be a current every day smoker and had been counseled to quit. R2's progress note dated [DATE] at 11:03 a.m., identified R2 was still smoking and started on Chantix. Does leave unit to go smoking and to AL apartment-during the daytime. R2's physical therapy (PT) treatment encounter note dated [DATE] at 1:15 p.m., identified R2 not in room at scheduled therapy time due to being outside smoking. R2's progress notes dated [DATE], identified R2 as a current smoker, was on Chantix medication-day three and R2 was planning to go outside to smoke after moving to new room (in the nursing home). Review of R2's January and February 2024 medication administration (MAR) identified the prescribed medications that had the potential to help R2 quit smoking were not administered as prescribed: - Chantix: According January/February MAR identified Chantix start date of [DATE]. R2 was administered Chantix 0.5 mg per physician order on [DATE], [DATE], and [DATE]. Starting on [DATE], R2 was supposed receive 0.5 mg twice a day. The MAR identified R2 did not receive evening doses on [DATE], [DATE], [DATE], and neither doses were administered on [DATE]. The dose on [DATE], note identified R2 did not want to take. -Nicotrol inhaler: January/February 2024 MAR identified Nicotrol (nicotine) cartridge; 10 milligrams (mg) give every two hours as needed; puff for 20 minutes per cartridge. Nicotrol inhaler was not administered between [DATE] to [DATE]. Corresponding nursing notes from [DATE] to [DATE] identified the medication was not given because the medication was not available. -Nicotrol nasal spray: January/February MAR identified Nicotrol nasal spray non-aerosol; 10 mg/milliliter (ml) give a spray to nostril every hour as needed may repeat one spray if not effective. The MAR identified Nicotrol spray was never administered. R2's OT treatment encounter note dated [DATE], identified OT attempted therapy three times that afternoon and each time R2 was out of the building smoking. Undated Facility eSource document indicated the administrator identified a concern on [DATE] at 4:20 p.m., R2 was smoking on facility grounds. Expectations/desired outcome as R2 was to not smoke on a non-smoking campus. R2's progress note dated [DATE] at 9:21 p.m., identified staff stated R2 was not safe to smoke outside by self. R2 replied that her mind was intact, and she can go outside and smoke on her own. R2's progress note dated [DATE] at 1:04 p.m., authored by the DON included Resident was outside smoking and self-propelling backwards in wheelchair into building. Resident indicated she has been smoking and not cutting back. Educated resident on smoking with Chantix and safe smoking practices/non-smoking campus. Resident verbalized understanding at the time of the conversation. (staff name) updated and indicated that family was bringing in cigarettes and was going to stop moving forward to assist in supporting resident with cessation. R2's record does not define/specify which safe smoking practices were provided. R2's PT discharge summary note dated [DATE], identified R2 as a smoker and would go outside in wheelchair very often to smoke. A recommendation for R2 to a LTC (long term care) placement that allows smoking somewhere right outside the door so R2 can be supervised and in a safe location. R2's OT discharge summary note dated [DATE] identified R2 has limitations due to safety and recommendation for higher level of care and monitoring, recommend assist with all ADLs. During an interview on [DATE] at 7:36 a.m., physical therapist (PT)-A indicated R2 had been on their patient load several times. PT-A identified R2 was an avid smoker, did not want to quit smoking, and continued to smoke throughout R2's stay. PT-A stated R2 was not safe to be in the community independently, this was why R2 was moved from her assisted living to long term care. R2 kept falling and hurting herself, this last time R2 had a huge laceration to the side of the head requiring several stitches. PT-A stated, [R2] was not necessarily demented, but made terrible choices, did not care about safety and was very impulsive. R2 was a danger to herself and needed more supervision, we tried to provide that. When R2's cigarette supplies were taken away, she somehow kept getting more. We have been trying to prevent [R2] from smoking because it was absolutely not safe for her to be doing it on her own. Physical therapy assistant (PTA)-A stated [R2] was at least a pack a day smoker. PTA-A further indicated R2 missed a few days of therapy due to smoking. PTA-A indicated visualizing cigarette burns on R2's clothing on several different occasions. Undated Facility eSource document indicated the administrator identified a concern on [DATE] at 1:00 p.m., R2 was smoking on a non-smoking campus. Assisted living clinical manager noted R2 to be smoking on facility grounds, was re-educated, and told R2 to not smoke. DON confiscated R2's smoking materials. During an interview on [DATE] at 2:06 p.m., trained medication aide (TMA)-A indicated if a resident smoked it would be on the care plan. Residents kept smoking materials on them and should sign out at the front desk by the AL entrance when they go out to smoke. Staff did not supervise residents who smoked nor check for burns on their body or clothing after the resident got done smoking. TMA-A was not able to articulate how residents would communicate or notify staff if they needed help outside without staff. During an interview on [DATE] at 2:12 p.m., nursing assistant (NA)-B stated staff did not check residents that smoked for holes burned into clothing or body parts after they were done smoking. Residents that smoke without supervision had no way to alert staff if they needed help. During an interview on [DATE] at 3:23 p.m., NA-A identified R2 was known to go out and smoke. NA-A would see R2 outside smoking, but staff did not have to go outside with her. During an observation on [DATE] at 3:25 p.m., R2 had two clear plastic bags labeled with name in a closet in the room where R2 resided. A size large blue [NAME] half zip fleece pullover with no hood was in the bag. The pullover contained a burn mark located by the left breast area zipper, two burn holes on the left sleeve and a burn hole on the cuff of the sleeve. During an interview on [DATE] at 3:33 p.m., licensed practical nurse (LPN)-B stated R2 was a smoker and used to see R2 outside smoking but never with any staff. LPN-B was unable to articulate safety interventions or protocols for residents who were determined unsafe to smoke but smoked without supervision. During an interview on [DATE] at 8:17 a.m., receptionist (R)-A stated [R2] smoked a lot since admission and would smoke at the front entrance without any staff supervision. R2 always wore a long dark jacket and had noticed burn holes in the fur hood of R2's jacket. During an interview on [DATE] at 8:23 a.m., RN-A indicated working the day shift on [DATE], R2 would usually smoke out of the transitional care unit (TCU) entrance and was not aware if R2 needed supervision to smoke. RN-A had never checked R2 for burns on her clothing or body after she came in from outside. Even though R2's record identified R2 was not safe to smoke, the record had multiple documented occurrences on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] of staff's awareness of R2's plan to go outside to smoke and/or was witnessed by staff outside smoking. There was not indication the facility identified any immediate safety interventions implemented for R2. Nor does the record identify documentation of assessments completed after smoking for burn holes on clothing. . During an interview on [DATE] at 3:25 p.m., NA-C stated on [DATE], at approximately 5:30 p.m. R2 was in her room standing near the bed putting her jacket on. NA-C reported no direction had ever been given to supervise R2 when smoking. NA-C stated unawareness of monitoring skin or clothing after smoking. R2's progress note dated [DATE] at 6:30 p.m., identified was updated that R2 noted to have an incident related to smoking causing burns. Nursing staff immediately responded, 911 was called by nursing staff. R2 was transferred to hospital emergency room (ER) via ambulance. NP and family updated. During a return phone interview on [DATE] at 1:50 p.m., NA-D who was working at the time of the incident stated that on [DATE], he was working on the 200 hallway and had been near the dining room when he saw and heard an unidentified visitor come around the corner yelling come, come, fire, fire!. The unidentified visitor told him the fire was outside. NA-D then went outside the AL door to find R2 on fire, the fire was huge. NA-D ran back inside passing two nurses who went outside. NA-D stated he then grabbed the fire extinguisher and handed it to someone else and let them put the fire out. During an interview on [DATE] at 3:40 p.m., LPN-A identified she worked the evening of [DATE] as the charge nurse of the building. LPN-A stated around 5:30 p.m. R2 had finished eating and was noted to be having urinary tract infection symptoms. R2 always wore a jacket with the furry hood that had a quarter sized burn hole on the lower part of her jacket and a dime sized burn whole near the front chest of the jacket. R2 was a known frequent smoker; she would go out and smoke at least twice a shift. LPN-A's recollection of events were, I heard a male voice yelling Fire, Fire, Fire! so I was walking near the fire doors, he said help help help she is on fire. I followed the sound of the man's voice and it was out the AL doors. LPN-A stated she saw R2 outside the doors about three feet from the building seated in the wheelchair and R2 was completely engulfed in flames. LPN-A looked for the fire extinguisher but could not see through all the smoke. LPN-A grabbed a half pitcher of water located on the medication cart, grabbed a blanket, and ran back outside. RN-B dumped the water on R2 and someone started hitting [R2] with the blanket and That's when the flames went way above R2's head. LPN-A stated she told an aide to call 911 and RN-B used the fire extinguisher to put the fire out. The paramedic asked R2 to state their name and R2 responded in a very soft voice, her name and answered yes to having pain. Review of the facility video footage of [DATE], identified at 6:00 p.m. R2 had wheeled self out of the automatic double doors of the AL entrance and stopped approximately three feet from the building and lit a cigarette, no cigarette receptacle was observed. R2 was not wearing oxygen nor was there an oxygen tank on or around her wheelchair. R2 wore a dark long jacket that was unzipped with a hood brimmed with long fur. Between 6:00 p.m and 6:07 p.m. R2 can be seen intermittently leaning forward in her wheelchair so that her head was half way to her knees while she continued to smoke. At 6:07 p.m. R2's jacket on the left side was visualized to be on fire (either the bottom of her coat or the cuff of her coat), R2 stood up, and attempted to remove jacket, R2 removed right jacket sleeve at 6:08 p.m. 15 seconds later R2's shirt caught on fire, about 20 seconds later R2 threw the jacket on the ground and R2's legs caught on fire, R2 fell back into the wheelchair. At 6:09 p.m. R2's left arm was also on fire, R2's head/shoulders were engulfed in flames by 6:10 p.m. An elderly unknown male came out of the facility at 6:10 p.m. and attempted to move R2's wheelchair without success and then went back into the facility. R2 stood up again, her feet were engulfed in flames. At 6:10 p.m. and 54 seconds an unknown facility male staff came out of the facility looked at R2 and went back in the facility. Then another unknown facility male staff came out of the door and tried to remove clothing off of R2, staff came out with a blanket and put the blanket around R2's left side without smothering the flames while the other male staff member vigorously and rapidly moved blanket up and down over in a fanning motion which seemed to increase the flames. Shortly after a pitcher of water was thrown on R2. At 6:12 p.m. a fire extinguisher was activated within two feet and sprayed directly at R2 (ABC fire extinguisher-an extinguisher that uses a powder chemical to extinguish a fire). The fire was extinguished at 6:12 p.m. and 27 seconds. Emergency medical services (EMS) attended to R2 at 6:15 p.m. R2 was engulfed in flames from 6:07 p.m. to 6:12 p.m. for almost a full 5 minutes. During a phone interview on [DATE] at 1:39 p.m., investigations sergeant (IS)-A indicated they reviewed the facility video from [DATE]. IS-A stated R2 was unsupervised had wheeled self out the doors and was smoking a cigarette when R2's clothing caught on fire. R2 was on fire for almost a full five minutes and was completely engulfed in flames, the whole facility could have gone up in flames. IS-A stated this was completely preventable, it would have been so easy to help R2, all the facility had to do was provide adequate supervision. The Shakopee Police Department Incident Report dated [DATE], identified officers arrived on the scene at 6:13 p.m., identified and recorded statements from six members of the police department that were on scene. Statements indicated that R2 was no longer on fire but appeared that R2 had been fully engulfed in flames at one point, a nurse was holding R2 in what remained of the frame of the wheelchair that the fire had disintegrated the padding. R2's legs were caught inside the chair. R2's clothing was all burnt off and personal items on the ground near R2 included shoes, glasses, keys, one blanket, one sheet, a cell phone, empty cigarette boxes and cigarettes. R2 was assisted out of the wheelchair and onto a blanket. Investigation showed that R2 was a smoker and often went outside in that area to smoke cigarettes. During a phone interview on [DATE] at 2:38 p.m., police officer (PO)-A indicated being called to the facility on [DATE] sometime after 6:00 p.m. R2 was naked, body covered in burns seated in a wheelchair, the seat had melted away. PO-A stated RN-B reported to her R2 had been smoking for quite some time, R2 had snuck out of the building to smoke, and staff did not provide supervision to the residents that smoked. PO-A stated, R2 was helpless seated in the wheelchair and literally started on fire, someone should have noticed R2 went out, this would have been completely preventable. The hospital Health Emergency Medical Services (EMS) document dated [DATE], identified ambulance arrived on scene, [DATE] at 6:18 p.m., R2 had third degree burns over 70% of body, full thickness burns from mid thighs down to feet. R2 had soot and burns and the dry chemical from fire extinguisher in nares (nostrils) and mouth and arrived at the hospital at 6:43 p.m. R2's Healthcare Burn Unit Emergency Department (ED) provider note dated [DATE], identified R2 had deep third degree burns to 90% of the body with the only area spared being the right upper back. Injuries reported were suspected from R2 smoking at the time. Proximate cause of death was full thickness burns and immediate cardiopulmonary arrest (sudden loss of all heart activity). During a phone interview on [DATE] at 3:42 p.m., family member (FM)-A explained R2 was living at the AL building but was not safe to be there unsupervised and needed a nursing home. R2 had a long history of hand tremors that would cause her to occasionally drop lit cigarettes that would cause burns on her hands and clothing. R2 also had a history of falling asleep while smoking cigarettes and has had several falls. FM-A thought R2 would be much safer at the nursing home because she would have increased supervision. FM-A explained R2 had historically successfully quit smoking using a Nicotrol inhaler. Upon admit to the LTC facility R2 had been offered Nicotrol inhaler, but it never showed up. FM-A stated R2 called her during the day of [DATE], her words were slurred. FM-A thought something was not right. During the call R2 asked FM-A can I smoke if I get off the Chantix? FM-A stated she told R2 to not smoke because the facility did not want her smoking. FM-A was crying as she recalled the first call she received about the fire on [DATE]. FM-A stated the hospital called her before the facility. The hospital told FM-A that R2 had sustained burns that covered 85%-90% of her body and it was not survivable. When FM-A arrived at the hospital to say good-bye to R2. She was in the hospital elevator when she received a call from the DON and administrator. They told her R2 had gotten a hold of cigarettes and started a little fire, that was put out within 60 seconds, and R2 was sent to the hospital. They made it sound like no big deal! Had the hospital not called me I would have gone to bed and dealt with it in the morning. FM-A asked the facility for more details but no one would tell her. FM-A stated, I just want to know that [R2] didn't suffer! FM-A continued to cry as she identified what she saw when entering (R2's) hospital room. R2's hair was singed, her face was blackened. The doctor told her she did not want to see what was under the bandages, R2 died that night. FM-A stated R2's friend who smoked with (R2) over at the AL informed her that after R2's accident. R2 had been leaning to one side for a couple of days prior to the incident. FM-A thought in looking back, she questioned if R2 had a stroke. R2's friend also informed FM-A that she was offered a smoking apron. FM-A stated that was never offered to (R2), why didn't the facility offer [R2] a smoking apron!? FM-A stated the facility had never offered an apron to her and had never seen any residents with smoking aprons. A smoking apron would have saved [R2's] life, [R2] never should have died like that. During an interview on [DATE] at 4:07 p.m., Administrator and director of nursing (DON) both identified the facility as a non-smoking campus; residents who smoked, must smoke off-campus on the sidewalk in front of the building. DON further identified if a resident was deemed to be an unsafe smoker, then nicotine replacement was offered, resident's smoking material were removed, family would be involved to help the resident quit, and IDT involvement. DON indicated R2 was a smoker prior to admission and R2 continued to smoke during her stay, however R2 had never been observed smoking from start to finish as part of the smoking assessment to determine level of risk or necessary safety interventions. DON expected observations and a smoking evaluation to be completed with an active smoker on admission, quarterly and with a significant change as part of the smoking assessment. DON and administrator stated the facility's strategies to keep R2 safe included: the physician ordered nicotine replacement on [DATE], but was never available due to a pharmacy issue. On [DATE], physician ordered Chantix to help stop smoking. On [DATE], R2 was deemed unsafe to smoke outside due to R2 not physically able to wheel herself back into the facility. Additionally on [DATE], R2's smoking materials were taken away. On [DATE], and [DATE], R2's smoking materials were again removed when R2 was found smoking on facility ground. R2 was also re-educated of the smoke free campus, the physician was notified, and a discussion with family who agreed not to provide R2 with smoking materials. DON indicated after the incident on [DATE], she came to the facility to reassess R3, R4, and R7. DON stated she completed the assessments by watching the residents smoke from the doorway of the gardens inside the facility. This was approximately ,d+[DATE] yards away from the designated smoking area. DON stated based on the assessments all three residents were deemed safe to smoke. The DON offered them smoking aprons and were re-educated on the need to sign out in the book to go out and smoke off campus. The administrator stated, we are a non-smoking facility, and residents need to be off campus to smoke. If residents were deemed unsafe to smoke, education is provided, smoking supplies are removed, and a discussion with family. When a resident signs out to go off campus the resident was assuming responsibility we are not here to oversee and supervise them. Sign out sheets to go off campus for R2 were requested and never received. During an interview on [DATE] at 9:56 a.m., the administrator stated they had completed the investigation for R2. The administrator stated, the root cause of R2's accident was noncompliance with R2 making a poor decision. R4's undated face sheet identified R4 had diagnoses of nicotine dependence, epilepsy with status epilepticus , diabetes, difficulty in walking,

Based on interview and document review, the facility failed to perform timely comprehensive skin assessments, follow physician orders to provide treatment and services to heal and prevent pressure ulcer infection for 1 of 3 residents (R1) reviewed for pressure ulcers. The facility's failure resulted in harm to R1 who developed a stage 4 pressure ulcer with osteomyelitis and associated cellulitis requiring hospitalization . Findings include: Stage 2 Pressure Ulcer: Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink, or red, moist, and may also present as an intact or open/ruptured blister. Stage 3 Pressure Ulcer: Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. Stage 4 pressure ulcer: Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle tendon, ligament, cartilage, or bone in the ulcer. Slough and /or eschar may be visible on some parts of the wound bed. Unstageable pressure ulcer: Full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. If the slough or eschar is removed, a stage 3 or 4 pressure ulcer will be revealed. Osteomyelitis: an infection in a bone reached by traveling through the bloodstream or spreading from nearby tissue, treatment is usually surgery to remove portions of bone that have died , followed by strong antibiotics. R1's hospital discharge summary dated [DATE], identified R1 was hospitalized from [DATE] to [DATE] for right leg cellulitis (a serious bacterial infection of the skin) with discharge orders for treatment of cellulitis with antibiotics and has four wounds: right knee, right lower leg, left knee and left heel. Orders to clean each wound with wound cleanser, pat dry with sterile 4 x 4 gauze, apply a 4 x 4 border dressing to each wound and change every three days and as needed if dressing becomes soiled. Heel offloading boots to bilateral legs when in bed and wheelchair do not walk in boots. R1's Skin assessment dated [DATE], identified R1 was at risk for pressure ulcers. The assessment did not identify any current pressure ulcers. R1's nurse practioner (NP) progress note, dated [DATE], does not identify any pressure ulcer to R1's left heel. R1's progress note dated [DATE], identified a skin assessment identified wound on heels had small serosanguinous drainage (mix of red and yellow drainage) not open. Area surrounding very tender, wound cleansed and Mepilex dressing (foam dressing) applied. The assessment did not identify the wound type, a description of wound characteristics, measurements, signs and symptoms of healing, infection or if they had any pain. R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1's cognition was intact. R1 had diagnoses of cellulitis of lower right limb, hemiplegia (weakness on one side) and hemiparesis (paralysis on one side) following cerebral infarction (stroke) affecting left non-dominant side, dementia, bilateral hearing loss, and wound infection other than foot. R1 had impairment in range of motion (ROM) in all extremities, was dependent with lower body dressing, required maximal assist with transfers and used a manual wheelchair for mobility. R1 was at risk for pressure ulcers, had a stage 1 pressure ulcer, a pressure reducing device for bed and wheelchair, pressure ulcer care, and applications of dressings to feet. R1's Care Area Assessment (CAA) dated [DATE], indicated R1 was at risk for new or worsening pressure injury related to impaired mobility requiring assist with bed mobility, incontinence, and the use of psychotropic and diuretic medications. R1 had a stage 1 pressure injury, a pressure reducing mattress and wheelchair cushion, bilateral grab bars to assist with bed mobility, pillows utilized for positioning, heels floated in bed, staff to assess skin when providing cares and registered nurse (RN) to perform weekly body audit. R1's care plan dated [DATE], identified R1 was at risk for new or worsening skin impairments related to diagnosis of cellulitis in right leg. Prevention interventions dated [DATE], directed staff to observe pressure areas daily with cares and report any concerns to the nurse, wound nurse consultant as needed, wound care as ordered, offer turning and repositioning every two hours as needed. Care plan did not address R1's pressure ulcer to the left heel. R1's Skin assessment dated [DATE], identified R1 was at risk for pressure ulcers. The assessment did not identify any current pressure ulcers. R1's NP progress note dated [DATE], identified an unstageable pressure ulcer to R1's left heel, no complaints of pain, pressure relief measures in place. Plan-in-house wound MD (medical doctor) consult, heel protectors while in bed, and offload pressure. There was no description of the unstageable pressure ulcer including characteristics, measurements, infection, or drainage. R1's wound physician progress note dated [DATE], identified R1 to have a stage 3 pressure ulcer to the left heel, 2.9 centimeters (cm) x 4.7 cm x 0.1 cm, wound bed had 75% granulation tissue and 25% slough with light serous exudate. Treatment order use hydrocolloid sheet (provides a protective, translucent barrier that facilitates granulation and epithelialization. Smooth, satin backing is low friction for longer wear) apply every 3 days, recommend floating heels in bed. No debridement completed due to insignificant amount of necrotic tissue and no signs of infection, monitor closely. The best medical estimate of the wound to heal with continued physician evaluation and intervention is 56 days with 80 % certainty. R1's wound physician progress note dated [DATE], identified R1's stage 3 pressure ulcer to the left heel, 0.9 cm x 4.7 cm x 0.1 cm, wound bed had 60% granulation tissue and 40% slough with moderate serous exudate. Treatment order changed to apply foam border dressing (designed to absorb fluid (exudate), and to maintain a moist environment) apply every 3 days, recommend floating heels in bed. No debridement completed due to insignificant amount of necrotic tissue and no signs of infection, monitor closely. Follow up within 7 days. R1's wound physician progress note dated [DATE], identified R1's stage 3 pressure ulcer to the left heel, 2.5 cm x 3.0 cm x 0.2 cm, wound bed had 50% granulation tissue and 50% slough with moderate serous exudate. Treatment order changed to apply Medi honey (antimicrobial dressing used to draw fluid from deeper tissues to the wound surface to promote removal of devitalized tissue) with a foam border dressing apply every 3 days, also add skin prep daily, recommend floating heels in bed. No debridement completed due to non-infected heel necrosis, monitor closely. Follow up within 7 days. R1's nutritional progress note dated [DATE], identified skin with unspecified left heel ulcer being monitored by wound clinic and nursing, receiving a multivitamin which should help meet micronutrients needs for healing. R1's NP progress note dated [DATE], identified R1's left heel wound was covered with a dressing. R1 had unstageable pressure injury to left heel, followed by in house wound MD. Plan- Medi honey covered with Mepilex (absorbent foam dressing), change daily. There was no description of the unstageable pressure ulcer including characteristics, measurements, infection, or drainage. R1's wound physician progress note dated [DATE], identified R1's appointment was rescheduled due to being at an outside appointment. Review of record identified R1's left heel wound was not comprehensively assessed from [DATE] to [DATE] a total of 14 days. R1's NP progress note, dated [DATE], identified R1's left heel wound was covered with a dressing. R1 had no complaints of pain, pressure relief measures in place, facility wound MD following R1. Plan- weekly wound rounds, Medi-honey to left heel cover with Mepilex, daily dressing change, heel protectors while in bed, and offload pressure. There was no description of the pressure ulcer including characteristics, measurements, infection, or drainage. R1's [DATE] treatment administration record (TAR) identified on [DATE], R1's left heel dressing was not completed due to dressing was not saturated, even though the physician's order identified Medi-honey to left heel with Mepilex dressing daily. R1's wound physician progress note dated [DATE], identified R1's pressure ulcer to the left heel advanced to stage 4, measured 2.8 cm x 3.6 cm x 0.3 cm, wound bed had 50% granulation tissue and 30% slough and 20% thick adherent devitalized necrotic tissue, exacerbated due to infection, with a moderate amount of serous exudate. Concerned with worsening heel wound and superficial infection labs ordered. Treatment order changed to apply foam border with silver dressing (used to treat infected wounds due to antimicrobial properties) apply every 3 days, also add skin prep daily, recommend floating heels in bed. Debridement completed due to increased necrosis with removal of 4.26 cm of devitalized and necrotic muscle level tissues as a result the nonviable wound bed tissue decreased from 50% to 10%. Monitor closely. Follow up within 7 days. R1's physician orders [DATE], and [DATE] Treatment Assessment Record (TAR) did not identify the new treatment order to apply foam dressing with silver. The record identified R1's wound was treated with Medi honey dressing until [DATE], causing R1 to miss 10 days of physician ordered treatment of silver dressing. R1's progress note dated [DATE], identified R1's left heel pressure ulcer was not improving; wound care provider recommends - Ankle Brachial Index (ABI) test (a simple test that compares the blood pressure in the upper and lower limbs used to determine reduced blood flow) to test blood flow to the area. R1's TAR [DATE], included R1's left heel wound was not healing. The TAR on [DATE], included odor to wound noted. R1's NP progress note dated [DATE], identified left heel unstageable pressure ulcer being followed by facility wound MD, per report not healing, faint odor. Plan- ABI appointment pending, Registered Dietician (RD) consult, add Juven (a collagen supplement used to promote wound healing) twice a day, offload pressure and heel protectors. R1's nutritional progress note dated [DATE], identified stage 2 pressure ulcer to the left heel being monitored by wound specialist and nursing, recently noted to be declining, had been receiving a multivitamin but no additional nutritional support related to good intake and appetite. After discussion with NP and reported decline in wound will begin Juven 1 packet twice a day. R1's wound physician progress note dated [DATE], identified R1's stage 4 pressure ulcer to the left heel, 5 cm x 4 cm x 0.3 cm, wound bed had 70% granulation tissue and 30% slough with moderate serous exudate. Treatment order foam border dressing with silver dressing apply every 3 days, add skin prep daily, and recommend float heels in bed. No debridement completed due to non-infected heel necrosis, monitor closely. Follow up within 7 days. R1's progress note dated [DATE], identified R1 was seen by wound provider left heel odor has decreased, doppler showed blood flow to the area, has been using Prevalon heel boots, will attempt to float heels using two pillows when in bed and chair instead of heel boots. R1's progress note dated [DATE], identified meeting with R1 and family to discuss left heel healing status, family wondered if a culture of the wound could be completed to see if R1 would need an antibiotic. R1's TAR dated [DATE], included wound culture to left heel performed. Per interview on [DATE] at 4:16 p.m. the wound doctor reported the wound culture showed proteus mirabilis. R1's NP progress note dated [DATE], identified R1's left heel wound edges to be macerated (skin softening and breaking down due to prolonged contact with moisture), center of wound slough, moderate drainage. Followed by in house wound MD, wound culture obtained, white blood count (WBC) 11.2 (anything above 11 can be related to infection). Plan-vascular appointment [DATE], RD following, Juven twice a day, weights two times weekly, offload pressure and heel protectors. R1's wound physician progress note dated [DATE], identified R1's stage 4 pressure ulcer to the left heel, 5.6 cm x 7.3 cm x 0.4 cm, wound bed had 50% granulation tissue and 50% slough with heavy serous exudate. Wound was exacerbated and treatment order changed to apply Medi honey with foam border dressing with apply daily with skin prep, recommend float heels in bed. Debridement completed due to the need to remove necrotic tissue and establish viable margins of viable tissue, 16.35 cm of devitalized tissue including slough, biofilm and non-viable tissue in the wound bed decreased from 50% to 10 %. Monitor closely and follow up within 7 days. R1's progress notes dated [DATE], wound provider rounds family present and educated on wound status and recommendations, stated R1's heel was making slight improvement. X-ray ordered to rule out osteomyelitis. R1's progress note dated [DATE], identified left heel X-ray results impression was a large posterior heel ulcer and underlying posterior calcaneal osteomyelitis (inflammatory condition of the bone secondary to infection). Nurse practitioner (NP) was paged with results and gave orders to send to the hospital with the new diagnosis of osteomyelitis. R1's emergency department (ED) to hospitalization progress notes dated [DATE] to [DATE], identified R1 was admitted for treatment of left heel osteomyelitis with associated cellulitis. As of [DATE], R1 was still hospitalized . During an interview on [DATE] at 1:07 p.m., family member (FM)-B stated R1 admitted to facility with a left heel blister and was planning to move to an Assisted Living facility (ALF) and ALF staff came to evaluate R1. R1 was admitted to hospital on [DATE] with an unstageable pressure ulcer with osteomyelitis and was on three different antibiotics and would not return to the facility after hospitalization . FM-B stated It took our family being aggressive for the facility to do anything about R1's infected left heel. During an interview on [DATE], at 3:06 p.m., DON indicated the admission floor nurse was responsible to remove dressings, assess and measure wounds during an admission. DON identified R1's pressure ulcer to left heel was not comprehensively assessed from admitted [DATE], until the wound doctor came onboard on [DATE]. Additionally missed a comprehensive assessment on [DATE] and verified the pressure ulcer went from a stage 3 to a stage 4. The assessment should include wound bed and peri wound description, measurements, signs and symptoms of infection, and drainage and to document this weekly. DON identified being wound certified and would expect a wound to be larger when Medi-honey was used. Skin assessments should be done on admission, weekly for the first four weeks, quarterly and with all significant changes. R1 had weekly wound rounds by the wound physician, if the wound physician was not available it would be the responsibility of the floor nurse to assess the wound and document it. During a phone interview on [DATE] at 4:16 p.m., wound doctor (WD)-A indicated a comprehensive wound assessment should be completed weekly to identify changes to help with the treatment plan for healing. WD-A stated that an addendum was made to R1's chart after a phone conversation with the DON. WD-A stated that an odor was present in the wound on [DATE] and discussed the need for topical antibiotics and the next week on [DATE] the odor was less prominent, acknowledged that R1 was hospitalized with osteomyelitis to the left heel on [DATE]. WD-A indicated he was under the impression that nursing assistants or licensed nursing staff were completing dressing changes. WD-A did feel that the wound was getting worse on the last visit ([DATE]) but that wound measurements were not always completed and WD-A admitted to sometimes eyeballing the wounds instead of measuring. WD-A stated that the only reason he ordered the x-ray was because the family was insistent on further testing. During an interview on [DATE] at 12:39 p.m., medical director (MD)-A stated, I expect wound assessments to be done on a weekly basis to determine an appropriate treatment for healing or maintaining a pressure ulcer. MD-A indicated the facility had completed some weekly assessments and missed some others. MD-A stated the facility began working with a contracted wound care company in [DATE] as facility wounds had not been properly managed and had thought things were getting better. Facility policy, Prevention and Treatment of Skin Breakdown/Pressure Injury, dated 2018 identified a Purpose: Maintaining intact skin is integral to resident health and wellness. Care and service are delivered to maintain skin integrity and promote skin healing if skin breakdown should occur. Policy: Resident skin integrity is assessed upon admission and weekly thereafter. A skin risk assessment is completed upon admission, weekly for 4 weeks, upon significant change and quarterly thereafter. Those residents at an increased risk for impaired skin integrity are provided preventative measures to reducing the potential for skin breakdown. Those residents' who experience a break in skin integrity or wounds are provided care and service to heal the skin according to professional standards of care. 3. Skin integrity is monitored, and abnormal findings are documented: o Skin is observed daily with cares. If any skin concerns are noted, they are reported to the licensed nurse. o Weekly skin audits are performed by a licensed nurse. 4. A therapy evaluation is requested as appropriate. 5. Education is provided to the resident/resident representative as indicated. II. Treatment of impaired pressure injury and lower extremity ulcers (arterial, venous, neuropathy/diabetic, or mixed). If a resident is admitted with impaired skin integrity or new pressure injury or a lower extremity ulcer develops, the licensed nurse implements the follow items: 1. Documentation of the skin impairment is completed in the medical record. Staging is completed as necessary by trained licensed nursing associates. 2. Standing orders/protocol for skin impairment are initiated. 3. Notify attending provider, resident, and resident representative. Attending provider determines wound type and may provide additional orders. 4. Notify Supervisor/designee. 5. Evaluate current pressure reduction interventions and revise resident centered care plan. 6. Notify dietitian for nutritional interventions. 7. Notify therapy associates and other members of the care team as appropriate for possible additional treatment interventions. 8. Educate resident/resident representative on skin impairment and care plan interventions. 9. When pressure injury is present, the dressing and/or wound as appropriate are monitored daily. 10. Weekly the licensed nurse will stage, measure, and examine the wound bed and surrounding skin. If wound bed has deteriorated; notify attending provider. 11. Notify the attending provider, resident/resident representative, and supervisor if the skin injury has not shown progress in 2 weeks and/or is deteriorating unexpectedly. Re-evaluate plan of care as appropriate.

Based on observation, interview and document review, the facility failed to comprehensively assess and develop interventions within the resident' environment to ensure safety and reduce the risk of avoidable injuries for 1 of 1 resident (R11) reviewed who demonstrated repeated behavior of placing their legs off the bedside and whose bed was placed next to an active heating element. These findings constituted an immediate jeopardy (IJ) situation, and substandard quality of care, for R11 when their feet were found directly on the heating element after an extended period of time resulting in multiple, full thickness burns and subsequent hospitalization . The IJ began on 12/13/23, when it was identified R11 had sustained multiple burns to their feet because their bed had been placed adjacent to an active, wall-mounted heating element. R11 had a known behavior of placing their feet off the bedside (i.e., in attempt to get up or reposition) which had not been reported by direct care staff to the nursing leadership team and, subsequently, was not acted upon or assessed to ensure safety within the environment given R11's bed placement near an active heating element. R11's feet were subsequently found directly touching the heating element which resulted in multiple, full thickness burns and subsequent hospitalization . The campus administrator and director of nursing (DON) were notified of the IJ for R11 on 12/14/23 at 2:38 p.m. The IJ was removed on 12/14/23, when an accepted removal plan was successfully implemented; however, non-compliance remained at an isolated scope with potential for more than minimal harm that is not immediate jeopardy (Level D). Findings include: A National Library of Medicine, National Institute of Health (NIH) Burn Classification article, dated 9/2023, identified burns can occur when skin is exposed to heat sources such as flames, hot objects, and electricity, with a patient's clinical comorbidities being able to influence the clinical outcome of such sustained burn(s). The article provided several classifications, and subsequent treatment options, for various burns which could be sustained. This included a section labeled, Full-Thickness Burns, which outlined, A third-degree burn, also known as a full-thickness burn, is more severe and affects the epidermis and dermis skin layers . These burns result in a leathery, stiff, and dry appearance . the affected area does not blanch under pressure due to compromised blood supply . nerves at this depth are also damaged, resulting in the patient experiencing no sensation or pain . burns [like these] take more than 8 weeks to heal . Further, a Antiscald Burn Exposure Chart, dated 2016, identified a chart with various temperature' skin exposure time to receive a severe burn. This outlined a 120 degree (F) temperature could cause a 2nd degree burn at eight (8) minutes and a 3rd degree burn at 10 minutes time. A facility' submitted incident report (FRI), dated 12/13/23, identified an allegation of neglect for R11. The FRI identified R11 had been transported to the hospital (i.e., Hennepin County Medical Center [HCMC]) and outlined, On the last rounds of night shift . [R11] was noted to have feet off the edge of her bed and on the heater in her room . toe and foot noted to have a burn. First aid was applied . order given to send resident to HCMC ER [emergency room ] for further evaluation. R11's quarterly Minimum Data Set (MDS), dated [DATE], identified R11 had severe cognitive impairment, required extensive assistance with transfers and bed mobility, and had several medical conditions including diabetes mellitus and Alzheimer's Disease. Further, the MDS outlined R11 had no current wounds or burns present on their skin. R11's most recent Fall Risk (Acuity) and Functional Limitation ROM (range of motion) evaluation, dated 10/3/23, identified R11 demonstrated intermittent confusion and safety awareness; and was listed as having impaired hearing or vision, neuromuscular limitations (i.e., loss of limb movement, decline in functional status), and cognitive conditions (i.e., Alzheimer's). These factors considered, R11 was determined to be at high risk for falls with an assigned score of, 16.0000. The evaluation continued and outlined R11 had no ROM limitations on their lower extremities which placed them at risk of injury. The evaluation concluded with a radio-button answered, Continue Current Plan of Care. However, the completed evaluation lacked any evidence R11's immediate environment (i.e., bedroom), or subsequent hazards within, had been evaluated to determine what, if any, risks were present which could place R11 at risk of injury (i.e., falls, burns). On 12/13/23 at 1:22 p.m., R11's room was observed. The room was a double-bed room (i.e., shared room) and was located at the end of a hallway in the long-term care unit. The room opened from a single door into a space which was separated down the middle using a privacy curtain, and R11's bed was positioned against the wall adjacent to the window. The wall adjacent had a large picture window with an off-white-colored heater vent below near the floor which extended across the room. The cover was on with a visible dent in the register at this time, and the unit was not hot to touch. Further, the room had several signs posted which read, CALL Don't Fall, but no other visible safety instructions posted (i.e., keep bed away from heater). R11 was not present at this time (i.e., hospitalized ). R11's progress note, dated 12/10/23, identified R11 had a shower completed and nursing identified, . scabs on 2 toes on the right foot and some red areas on top of both feet. Appears to be from her shoes. The note lacked any evidence R11 had multiple burns or areas of black, discolored skin present on her feet. However, R11's electronic medical record (EMR) Wound Management section, printed 12/14/23, outlined R11 had no active or healed wounds or skin issues on their body with dictation, There were no wounds that match your search criteria. Further, the entire medical record was reviewed and lacked evidence R11 had any burn or burn-type injuries present prior to 12/13/23. When interviewed on 12/13/23 at 1:46 p.m., nursing assistant (NA)-E stated they had worked with R11 multiple times prior and described R11 as needing pretty much total assist with most cares adding R11 was not with it cognitively. NA-E stated they were aware of the incident with R11 on 12/13/23, as they had just arrived to work the day shift after it happened when the nurse voiced something happened. NA-E stated they walked into R11's room and saw staff members present taking photographs of R11's feet who voiced they found her feet on the heater pipe along the bottom of the wall. NA-E stated R11 used a high-low bed for safety as she often tried to get up from bed on her own and staff would find her with her legs outside of the bed on a daily basis almost. At 1:50 p.m., NA-E observed R11's room with the surveyor present. NA-E verified the bed was now moved to the opposite wall from where it had been when the incident happened adding R11's bed used to be kept parallel with the wall which had the window and heating element present. When the incident happened on 12/13/23, NA-E verified R11's leg had been found touching the heating element while the bed was in low position. NA-E stated the bed was, typically, only kept like a foot away from the wall and heating element in the past from their observations. NA-E stated they had never been told or directed to monitor R11's bed placement or ensure it was kept a certain distance from the wall prior to the incident on 12/13/23, and added such action was not the responsibility of the nursing staff but rather this was maintenance' responsibility. NA-E reiterated R11 did, at times, place her legs over the bedside in attempt to get up and, as a result, the staff try to get her up quickly in the mornings to prevent falls. However, NA-E added they don't know if the nurses' were aware of it or not adding they had never reported it to anyone as they were typically doing TMA (trained medication aide) work instead. NA-E explained some other rooms had wooden brackets or markings installed on the beds to prevent them from contacting the wall but R11's bed did not have anything like such installed to their recall. NA-E then walked the surveyor to the room located across the hallway from R11's room and showed the bed which had a visible wooden bracket installed along the bottom which prevented the bed frame from touching the wall. NA-E stated R11's bed now moved to the opposite wall, and away from the heating element, was the best idea to help prevent more burns on the heating element; however, reiterated there had been no direction or instructions to check R11's bed placement for safety despite being placed next to a heating element prior to the incident on 12/13/23. When interviewed on 12/14/23 at 6:03 a.m., NA-F stated they typically worked on the night shift and verified they were the NA assigned to care for R11 on 12/13/23, when the incident happened resulting in R11 being burned. NA-F explained they had worked with R11 multiple times in the past and described her as pretty much a check and change during the overnight hours adding R11's bed was usually kept in the down (i.e., low) position due to her risk for falls. NA-F stated R11 was physically capable of rolling side to side while in bed and, at times, would swing her legs off the bedside while repositioning herself or if attempting to get up for some reason adding they had observed a couple of times when R11 would be found with her legs off the bed on the window side (i.e., next to the heating element). NA-F stated R11 was not on any formal safety checks (i.e., her position in bed or bed position in room) while in bed during the overnight hours but rather just on the routine rounds (i.e., every 2-3 hours) all patients were on. NA-F stated they believed the nurses were aware of R11's behavior of placing her legs and feet off the bedside as that's why the bed have [has] to be lower all the time, and expressed staff just put her feet back into bed when found in such manner. At 6:07 a.m., NA-F observed R11's room with the surveyor present and verified the bed had been moved to the adjacent wall since the incident happened. NA-F explained R11's bed had been positioned parallel with the wall which had the window and, directly below that, the heating element which ran the length of the room. NA-F stated R11's bed, while in the low position, was usually only kept about 10 inches or so from the wall and heating element while using their hands to show the physical space. NA-F recalled the incident on 12/13/23 and explained they had been doing last rounds for the shift and were behind schedule due to being the only NA working. NA-F entered the room and found R11 lying in bed on her left side facing the window and covered with blankets. NA-F stated R11 had not been crying or making any noise when they entered the room, however, upon removing R11's blankets then saw the blood[like] substance dried to her feet which were directly touching the heating element. NA-F stated they could see areas on the skin (i.e., burns) which had not been there on the prior rounds and, as a result, called for the nurse to come down and check on R11. NA-F stated the skin impairments were cause of the heat from the heating element and described them as smooth, discolored, and shiny areas. NA-F stated they had never been told or directed to check the bed position, in proximity to the heating element, prior to the incident on 12/13/23. However, R11's medical record was reviewed and lacked evidence this behavior had been comprehensively assessed to determine what, if any, safety interventions needed to be placed to promote a safe environment with R11's bed kept near an active heating element. In addition, R11's care plan, last revised 10/9/23, identified R11 had a communication deficit and directed staff to, Anticipate my needs. The care plan outlined R11 had a self-care deficit, required assist of one with bed mobility, and had socially inappropriate or disruptive behavioral symptoms due to hearing loss evidenced by, at times, yelling out for her family member. The care plan identified R11 was at risk for falls due to impaired mobility and Alzheimer's Disease and directed to ensure R11's bed was kept in a low position when in use. However, the care plan lacked evidence R11 had any behaviors or patterns of placing her feet or legs off the bedside, nor any subsequent interventions to address such including interventions to ensure safety within her environment, despite direct care staff members witnessing this behavior multiple times prior to 12/13/23. On 12/14/23 at 6:15 a.m., licensed practical nurse (LPN)-A was interviewed and verified they were the nurse who had been working when R11 had sustained the burns on 12/13/23. LPN-A explained R11's room was the last one down the hallway and, to their knowledge, she had typically slept well during the overnight hours. LPN-A stated R11 was a fall risk and, at times, would try to get up from bed so, as a result, they tried to keep her bed in the low-position when occupied. LPN-A recalled the incident from 12/13/23 and explained they had been in R11's room between 4:45 a.m. and 5:00 a.m. to give R11's roommate some medication. At that time, R11 appeared to be sleeping in bed on her left side facing the window. LPN-A stated R11 seemed comfortable, however, verified they did not physically move any of the bedding to check her adding they didn't see or smell anything of concern. LPN-A then left the room and finished the early morning medication pass until later when the NA came down and reported R11 had something on her leg and needed to be seen. LPN-A stated they entered the room and there was a little blood on R11's feet and the wall adding, upon inspection, her feet had black spots on the skin and toes which had not been there prior. The charge nurse was notified and responded who then measured the areas and took photographs of them. LPN-A verified R11's bed was in the low position and parallel with the heating element when they responded to the NA' request adding R11 had not ever been on any formal safety checks while in bed (i.e., placement away from heater) to their knowledge. LPN-A stated now, since the incident, staff were going around to all the rooms and checking bed placement to ensure none are kept too close to the heating elements adding burns from them had never happened before to their knowledge. LPN-A explained they were aware R11 was able to turn herself back-and-forth (i.e., side to side) in bed, however, they were unsure what, if any, interventions were done for that or to ensure safety within R11's environment as a result adding any evaluations of such would be the care managers' responsibility to do. LPN-A added, Check with the manager. R11's progress note, dated 12/13/23 at 7:10 a.m. (recorded as late entry), identified LPN-A was notified by the nursing assistant (NA) to come and check R11. The note outlined, Burn wounds were noted on the L [left] leg/foot and some burns also on R [right] foot. The charge nurse was notified . took some measurement. On call provider [named] was called and updated . gave orders to send patient to ER . paramedics were called and they came and transported resident to HCMC . R11's subsequent progress note, dated 12/13/23 at 7:19 a.m., identified registered nurse unit manager (RN)-A recorded, Resident was observed having burn wounds on bilateral feet. Left outer great toe, 2.5 cm [centimeters] X 1.5 cm undetermined depth wound bed black not bleeding. Left outer foot outer aspect just below 5th digit, 4 cm X 4 cm undetermined depth wound bed black not bleeding . Right foot inner aspect 2.5 cm X 2 cm undetermined depth wound bed black not bleeding . did not have any S&S [signs and symptoms] of discomfort at the time . has Alzheimer's/dementia and DM2 [diabetes] . Unable to verbalize how the burns happened . has decreased safety and space awareness . left around 6:50 [a.m.] on a stretcher accompanied with paramedics. A corresponding Skin Integrity Events -- Burn Event, dated 12/13/23, identified R11 had sustained burns of feet and listed the same measurements as the recorded progress note. A section labeled, Etiology of Burn, identified these as, Contact Burn: Hot surface ., and listed a classification of them as, Full Thickness . The event report outlined R11 was sent to the ED and R11's physician was notified of the incident. R11's Hennepin Healthcare ED Triage Note, dated 12/13/23 at 7:29 a.m., identified R11 was brought in via ambulance from the care center. The note outlined, Staff found her this morning with her feet over the edge of the bed between bed/wall and feet resting on the baseboard heater. Sustaining Full thickness burn to bilateral feet - worse on left. R11's corresponding ED Provider Note, dated 12/13/23, identified R11 presented to the ED with . severe burns to the bilateral feet. R11 was recorded as having Alzheimer's Disease and was unable to provide any history when asked. The note outlined, Apparently she was attempting to move out of her bed and her feet were placed on a heater. They were placed there for multiple hours. She does not have apparent pain, however likely due to her diabetes. The burn team was consulted and recommended outpatient follow-up, however, due to family concerns for safety, R11 was admitted to the hospital adding, There were concerns for elder abuse as the burns did not match the history given from the nursing home. R11's subsequent Hospitalist Admission - Staff note, dated 12/14/23, identified a section labeled, Assessment, which outlined, 3rd Degree Burns to Right and Left Feet ., with no surgical intervention being required. The note outlined the burns were being treated with proper hygiene, dressing changes, and silver sulfadiazine (a topical antibiotic used with burns to prevent infection) and included several photographs of the resulted burns. When interviewed on 12/13/23 at 8:07 a.m., the environmental services director (ESD) explained they had been notified via telephone of the incident with R11 on 12/13/23. ESD explained the heating element inside R11's room, positioned underneath the window, was a glycol and water mixture which passed through a tube and radiated heat from the wall-mounted unit. ESD stated when the zone valve calls for heat (i.e., activated) then the unit can get warm, adding the maintenance staff did check surface temperatures of these heating elements; however, they were not routinely documented. ESD stated the water inside the heating element was approximately 168 degrees (F) when it left the boiler and, by the time it reached the room or element, was likely in the 138-141F range with a unit' surface temperature of about 120 [F]. ESD explained R11's bed had been the only one which, to their knowledge, had been positioned near a heater like that due to family preference. ESD stated none of the staff had ever reported any potential safety concerns to him with the bed' position, however, explained just two weeks prior the maintenance department had been called to replace the heating element cover which had been displaced due to the high-low bed tearing it from the wall (i.e., due to being placed so close) when it was being either raised or lowered. When asked if that had been reported as a possible safety issue, ESD stated resident' bed placement within the room was not maintenance' responsibility but rather they just checked to ensure the bed worked correctly adding, [We're] not one to tell how they [nursing or resident] orient the room. ESD verified they had never been asked to mark R11's room, bed or floor with any safety markings or instructions (i.e., keep bed away from heater) prior to the incident on 12/13/23, and reiterated nobody had presented any potential safety concerns to their department with the bed being placed close to the heater despite R11 having a known behavior of placing her legs over the side. A corresponding Work Order #9715, undated, outlined a header which read, Heater Cover, and listed R11's room number. The work order had been requested by the nursing department with notes which read, Heat cover to base board heater has been damaged and needs to be repaired. A due date was listed which read, Dec. 13, 2023. A subsequent section labeled, Comments, outlined, Straighten out the cover and reattached cover to base boards. The completed work order lacked evidence the room or immediate placement of R11's bed had been evaluated for safety given the proximity to the heating element and the bed physically damaging the cover. On 12/14/23 at 9:58 a.m., the director of nursing (DON) and RN-A were interviewed. DON explained they had just returned from a leave of absence the week prior, and RN-A stated they had just started working at the nursing home about three weeks prior. DON verified they had reviewed R11's medical record and described R11 as having severe cognitive impairment and diabetes mellitus and who required extensive assist with most cares. However, DON and RN-A both expressed they were unaware the direct care staff had observed, multiple times, R11 to place her legs off the bedside in attempts to either reposition or get up adding, Not that I am [was] aware of. DON stated they believed R11 needed assistance with bed mobility as had been reflected in the NA charting on a consistent basis, and RN-A expressed if staff had witnessed behaviors such as those they should have been reported to the nurses or directly to me so it could be reviewed and addressed by the interdisciplinary team (IDT) for intervention. RN-A verified they had seen R11's injuries on the morning of the incident and stated the heating element caused three sites of burn with two of them being black and discolored adding R11 did not, to their knowledge, have any skin issues on their feet prior to these burns. DON reviewed R11's medical record and care plan, and they verified it lacked evidence the identified behavior had been evaluated or acted upon to review what, if any, safety interventions were needed to keep R11 safe while in bed with the bed positioned next to an active heating element and her displaying repeated behaviors of placing her feet outside of the bed and over the edge. RN-A stated if they had been told of such behavior, they would have evaluated R11 for potential risks and included therapy (i.e., PT, OT) to screen her for bed mobility and any needed safety interventions, then care planned those for staff awareness and guidance. DON stated R11's bed was kept parallel to the window at family request due to television placement and viewing in the room, however, expressed such knowledge was just hearsay after the incident with nothing about room layout being care planned. DON verified R11 was not on any specialized safety rounding or formal safety checks (i.e., safe in environment) while in bed prior to the incident and expressed the facility had just audited the other resident rooms with R11's bed being the only one found to be placed in close proximity to the wall-mounted heating elements. DON explained, since the incident on 12/13/23, they were working to verbally educate staff on bed placement but verified a resident' bed should not be kept near an active heating source to help reduce the risk of burns or fire. When interviewed on 12/14/23 at 1:24 p.m., the campus administrator explained they had started to begin education with all staff on resident' safety with the heating elements. The administrator stated they expected resident' beds to be kept an appropriate distance from the wall-mounted elements and nothing should be placed next to or on the heaters. However, not all staff had been educated yet. The administrator stated they were also going to develop and review a four-point quality project to help them better identify the root cause of the incident and what, if any, actions needed to be done. The written education with staff, thus far, was provided and reviewed. This included a single page titled, Resident Bed Proximity to Room Heater, and included a photograph of the type of heating element which had caused the burns to R11 on 12/13/23. The education included several statements which directed, Staff to ensure resident beds are an appropriate distance (at least 3 feet) aware from heaters in resident room during all rounding and resident interactions, and, No items can be on a heater. If personal items or items of any kind are on heater, please educate the resident on the need to remove them due to a safety risk. There were several attached signature pages which had various staff' signatures, however, the provided education lacked evidence the facility had identified or started education on ensuring resident' behaviors, such as placing feet off the bedside, are promptly reported and acted upon to ensure safety within the environment. A provided Change in Condition policy, undated, outlined a procedure which included, Assess significant change in the resident's condition noted through direct observation, interview or report from other staff. The policy directed to notify the resident' physician and . appropriate members of the IDT team, and, Update the care plan as appropriate. A facility' policy on resident safety within the environment was requested, however, none was received. The IJ which began on 12/13/23 was removed on 12/14/23, when the facility successfully implemented a removal plan which included evaluating all resident' rooms with heating elements to ensure appropriate bed placement away from the devices, completing a root-cause analysis of the incident to help better determine what, if any, interventions or education was needed to prevent recurrence, and educating staff members on how to identify and report potential behaviors or resident' changes to ensure their evaluated to reduce safety hazards within the environment and associated resident harm. These interventions were verified as having been implemented on 12/15/23 evidenced by a review of available documentation and multiple interviews with various staff members who verified education had been completed as outlined.