Every finding on record at St John Lutheran Home

Based on observation, interview, and document review, the facility failed to ensure kitchen and walk-in cooler was clean and free of food-like debris. In addition, kitchen staff failed to consistently log dishwasher temps to ensure proper sanitation and failed to date meat when placed in the walk-in cooler to thaw. This had the potential to affect all 51 residents. Findings include: FOOD STORAGE/KITCHEN CLEANLINESSObservation on 6/1/26 at 10:55 a.m., in the kitchen identified:The stove-top had food crumbs and a dried liquid on and between the burners and the wall behind the stove had food debris splashed upon the wall. A utility box mounted on the wall to the right of the stove was covered with a heavy layer of dust, mixed with food particles.A food prep counter near the sink had a radio that was covered in dust and food debris splatter.The office area connected to the kitchen had a countertop with a microwave, toaster, open partially used container of peanut butter, a large partially used plastic container of butter, and half of a loaf of bread. The countertop also had phone chargers, staff personal drink tumblers, change, a stapler, magazines, clip boards, pens, and other postal mail laying on the counter and on top of the microwave. There was no indication this area was not used for resident food preparation or reheating.Inside the walk-in cooler there was shredded cheese, onion peels, crumbs, and other unknown debris scattered throughout onto the floor. The walls behind the shelving had splatters of an unknown substance and the floor below a shelf (approximately 1-2 feet up the wall from the floor) had a black, spotted, mildew-like substance. The walk-in cooler had a large beef roast on the second to bottom shelf that was contained in a sealed plastic wrap, was soft to the touch and appeared fully thawed. There was also 2 large boxes containing additional beef roasts that were placed in the cooler to thaw that had no date when it was placed into the cooler. The bottom shelf had a ham roast that was also thawing, again, with no date when it had been placed into the cooler. On the upper shelf above the thawing meat listed above, were several cooked chicken legs that were not covered or dated. Next to the chicken was a small steamtable tin left uncovered containing a white creamy substance, that was not labeled with its contents, nor was it dated. There were 4 free standing carts observed against the wall inside the cooler with large clear plastic cover over them. The carts had trays with a variety of items, such as single servings of desserts in small dishes, pureed bread, mixed fruit, glasses of white and chocolate milk, and glasses of juice. On the outside of the cover, the carts were labeled breakfast, lunch, supper. None of the food items on the carts were dated to identify when they had been removed from the original container or when they should be discarded if they were not used. Interview on 6/1/26 at 11:12 a.m., with dietary aid (DA)-A identified he agreed none of the previously mentioned food items had been dated. Dietary staff set up the carts for meal service and he identified some of the items on the carts that were set up yesterday and some of the items were set up today. He was not certain when the beef and ham roasts had been placed in the cooler to thaw and believed the chicken legs in the tin pan had been in the cooler for a couple days. He identified the white creamy substance in the small pan next to the chicken was pureed chicken and agreed the pan should have been covered and dated. Review of the cleaning logs for May of 2026, identified 3 different detailed list of kitchen areas to be cleaned and sanitized such as food prep counters, back splash, appliances, floors, coolers, and garbage. One of the lists noted staff had completed cleaning duties for 3 of 31 days, another list noted staff had completed cleaning duties for 8 of 31 days. Review of the undated General Food Preparation and Handling policy identified the kitchen was to be neat and orderly, kitchen surfaces and equipment would be cleaned and sanitized as appropriate. Food will be covered when in storage and cooked as soon as possible after thawing. Meats, fish and poultry will be defrosted using safe thawing practices. The policy made no mention of dating foods pulled from the freezer to be thawed. Review of the undated Cleaning and Sanitation of Dining and Food Service Areas Policy identified staff were to:Keep all food service areas clean, sanitary, free from litter, and rubbish.Tasks shall be designated to be the responsibility of specific positions in the department.A cleaning schedule would be posted for all cleaning tasks and staff would initial the task as completed.The director of food and nutrition services would perform inspections of the food service areas to ensure all cleaning and sanitation tasks are being completed.Sanitation inspections would be conducted daily by food service staff and weekly by the dietary manager to ensure the areas are clean and comply with sanitation and food service regulations. DISHWASHERInterview on 6/1/2026 at 11:20 a.m., with DA-B said she was one of the staff who washes dishes. She was not sure if the dishwasher sanitized by heat or chemical, but said that the monitor on the dishwasher says sanitizing and that was how she knew the sanitization was being completed. She said the dishwashing staff were to log the temperatures on the log sheet at each meal service but was not certain of the purpose of that process. She said she puts blue stuff she thought might be a sanitizer in a tub of water that she soaks the dishes in and if it isn't blue enough she adds more. Observation on 6/1/26 at 11:20 of the blue stuff DA-B was soaking the dishes in was not a sanitizer rather it was an enzymatic pre-soak commonly use as an aid to remove debris from dishes. Review of the May 2026 Dishwasher Temperature log identified the dishwasher sanitized through heat, and not chemical had a column for each meal service for staff to log dish wash and rinse temperatures for ensuring proper sanitization of the dishes. For the breakfast service, the temperatures were only logged for 4 of 31 days. for lunch service, the temperatures were logged for 3 of 31 days. The supper meal service, temperatures were logged for 26 of 31 days. Interview on 6/2/26 at 10:20 a.m., with the dietary manager (DM) identified she agreed with the above findings, she had no idea when the ham and beef roasts had been placed in the cooler to thaw and identified she would discard the meat as it was not safe to eat. It was her expectation that staff would date the meat when it was pulled from the freezer. She expected staff to complete cleaning in the kitchen daily and initial the cleaning logs as the duties were completed. The DM said the counter in the office where the microwave and toaster were located had been used to prepare and warm resident food and occasionally was used by staff to make toast for themselves. Interview on 6/2/26 at 10:27 a.m., with the registered dietitian (RD) identified, she comes to the facility every Tuesday. She had been in the kitchen today and agreed with the above findings. She identified she had not completed an audit or walk through of the kitchen since approximately December but had completed one earlier that day after being updated of the concerns noted above. The RD identified following her walk through I definitely need to start doing weekly audits again. In addition, she identified the kitchen needed some deep cleaning and staff would need to be re-educated. The RD said in the office area where the microwave and toaster were, it was not acceptable to be used for preparing food for residents in any area where staff personal supplies were used or stored. She was not aware this was happening until today. She further identified she had directed the DM to discard all the undated meat that was in the walk-in cooler for thawing and that this had been completed. A dishwasher policy and procedure or manufacturer's instructions for use on the dishwasher was requested but not provided by the end of the survey period.

Based on interview and document review, the facility failed to ensure data submitted to the Quality Assurance Program Improvement (QAPI) committee was analyzed and documented to ensure areas identified had oversight for their perspective outcomes brought forth. This had the potential to affect all 51 residents. Findings include: Review of the designated quarterly QAPI meetings from June 2025 through April 2026 identified facility departments were submitting data for review by the committee, but the minutes lacked evidence of measurable goals, discussion of the data submitted, and a plan of action for improvement. Examples included:The June 18, 2025, QAPI meeting minutes identified the facility monitored areas such as:Falls: 13 falls occurred, which was down from the previous month with 4 residents (unknown) having repeated falls. The goal was to decrease falls. There were no major injuries noted with actions to continue to review each fall and new intervention in place. There was no indication who the residents involved were, if the facility was monitoring those falls to ensure interventions were followed, if there was a need to alter interventions, if potential commonalities with residents and their falls (hours of day, shifts when they occurred, etc.) were reviewed, or how they intended to meet their goal or what the benchmark was.Alarms: Staff noted there was a decrease from the previous month and staff were to continue to attempt to decrease the number of alarms. There was no indication of what the goal was, how the facility would reach their goal, or how they were going to implement their action plan or monitor its progress.Skin: Staff noted they had 2 (residents) with pressure ulcers (PU). QAPI would continue to monitor. There was no documentation to identify what the benchmark and goals were, how the facility would reach their goal, or how they identified they would monitor the PU.Weights: The goal was to improve weight charting and monitor for accuracy. They had noted improvements occurred in charting and they had added a note to the electronic treatment record for the nurse to review and they would continue to monitor. There was no resident specific information noted to have been discussed as to whether or not the weights being monitored were high impact resident risk areas such as severe weight loss with specific residents, or if this was an overall problem with staff obtaining and documenting weights in the treatment record.Antipsychotics: 9 residents were noted to be on antipsychotics. 2 were on hospice. The facility noted they would continue to work on decreasing antipsychotics with the psychiatric provider. There was no indication if QAPI reviewed specific residents to determine if the antipsychotics were appropriately prescribed, if they were being appropriately monitored, and if non-pharmacological interventions had been tried and were appropriate.The July 25, 2025 meeting minutes identified each department area brought forth data to QAPI. Infection control, for example, had listed the number of infections, however there was no evaluation of that data, if the infections had commonalities in surveillance, what goals and benchmarks were, or how the facility was ensuring the infection preventionist was appropriately surveilling the facility. Skin areas were also discussed and were similar to the previous month's review with a lack of documented discussion or data analysis, and antipsychotics were noted with the same goal to decrease their use for residents', but there was no information as to how the facility would reach that goal, or if specifics for residents were discussed. The September 17, 2025, December 2025, March 2026, and April 2026 meeting minutes identified each area [NAME] forth data to QAPI were similar to those minutes above with missing goals, benchmarks for how the facility was performing with other facility's in the State or Nation, if they had reviewed specific residents' circumstances, how they would achieve their goals, if their limited documented actions had been successful from the previous months, if there was a need for change, or how long the facility needed to monitor each area brought forth. The Performance Improvement Project (PIP) for 2026 was moderate to severe pain in long stay residents. There was no data to identify the need for the project, discussion with rational for choosing the project, measurable goals, and development of a plan of action for the project. Overall, there was no documentation in the above-mentioned QAPI minutes to support the QAPI committee set benchmarks or measurable goals, thoroughly analyzed the data brought forward, how they were going to achieve their goals, if further education was needed, or if specific staff required retraining etc. Interview on 6/3/26 at 3:39 p.m. with the facility administrator and director of nursing regarding the QAPI program identified department heads provided data that was included in the meeting minutes, but there was no discussion, establishment of measurable goals, or plan of action developed and documented in the meeting minutes.The Administrator identified the QAPI committee had chosen moderate to severe pain in long stay residents as the 2026 project. She identified the QAPI minutes had no discussion, analysis of data, implementation of an action plan nor a measurable goal established in the five months since the beginning of 2026. Review of the January 2026, QAPI Plan identified the administrator as responsible to ensure the QAPI plan was reviewed at least annually. Revisions were to be implemented to identify and address issues identified in the organization. The facility provided services which impacted care and services to all residents living in the facility community. The committee was to utilize evidence-based practices and data to define goals and implement plans of action. The administrator and DON were designated as having responsibility for leading and directing the QAPI program. Performance Improvement Projects (PIPS) were to have a project charter developed at the beginning of the project that established goals, scope, timing, milestones, team roles, and responsibilities. Information was to be discussed during QAPI meetings with monitoring, analysis of the identified problem, and indication for changes. To promote improvement the organization was to develop actions to address the root cause and contributing factors that would affect the identified issue.

Based on interview and document review, the facility failed to follow physician orders to measure a pressure ulcer weekly and follow their policy and procedure on documenting pressure ulcer care for 1 of 1 sampled resident (R8).Findings include: R8's quarterly, Minimum Data Set (MDS) assessment, accepted on 5/19/26 identified R8's cognition was moderately impaired, and she required substantial assistance with care, bed mobility and transfers. R8 had a life expectancy of 6 months or less and was on hospice. R8 had pain and within the assessment period, had reported her pain was severe. R8 took scheduled pain medication and as-needed pain medication. R8 was identified as having a Stage 2 pressure ulcer with a pressure relieving device in her chair and on the bed. Observation and interview on 6/2/26 at 8:55 a.m., with registered nurse (RN)-A who performed a dressing change to R8's thoracic spine identified RN-A removed the old dressing and cleansed the area. The wound measured 0.7 centimeters (cm) x 0.4 cm. RN-A described the wound as superficial with a red wound bed and well-defined edges. RN-A reported she did not note any signs or symptoms of an infection and applied a new dressing. RN-A stated weekly wound documentation was completed in the progress notes. R8's 11/18/25, physician telephone order identified:Staff were to give Arginaid (wound healing supplement) and mix with a 4-ounce beverage twice a day until the wound resolved.Staff were to change R8'S dressing to her thoracic (upper middle area) spine Tuesday and Saturday morning after her bath and measure the wound on Tuesdays until healed. Review of nursing progress notes from 3/1/26 through 5/31/26 identified there were 5 weeks the facility did not follow the physician orders to measure weekly or document pressure ulcer assessments per policy. For the week of;3/22/26 through 3/28/26, there had been no wound documentation or measurement.4/12/26 through 4/18/26, a note identified on 4/18/26 R8's Mepilex dressing had been removed and a new one applied. The note lacked a description or measurement of the wound. 5/3/26 through 5/9/26, a note identified on 5/3/26, a treatment had been done to R8's mid back and a new foam dressing had been applied, with no drainage noted. The note lacked a description or measurement of the wound. On 5/9/26, a progress note identified a new foam dressing had been applied to bony prominence of mid back, with no signs or symptoms of infection. That note lacked a description or measurement of the wound.5/17/26 through 5/23/26, a note identified on 5/23/26, that no redness or edema was noted. A new foam dressing had been applied to R8'S mid back, showing no signs or symptoms of infection. The note lacked a description or measurement of the wound.5/24/26 through 5/30/26, there had been no wound documentation or measurement. Interview on 6/3/26 at 10:35 a.m., with RN-C identified, the nurse should be documenting and measuring a pressure ulcer weekly. Interview on 6/3/26 at 11:40 a.m., with RN-B identified the nurse was to assess and measure R8's wound weekly on her bath day and document that in the progress notes. Interview on 6/3/26 at 2:05 p.m., with director of nursing identified staff were to monitor R8's pressure ulcer weekly and notify the physician if the wound was not improving or was worsening. Her expectation was that R8's or any other resident's pressure ulcer would be assessed weekly with measurements to monitor any need to alter the treatment. Review of the November 2025, Pressure Ulcer/Skin Breakdown Clinical Protocol policy identified the nurse would monitor pressure ulcers weekly. The nurse was to describe and document the pressure ulcer location, stage, length, width, depth, surrounding tissue, and wound bed and document the residents' pain, mobility, current treatments and active diagnoses.

Based on interview and document review, the facility failed to perform antibiotic stewardship to include a system for monitoring and reducing antibiotic resistance. In addition, the facility failed to follow their policy on antibiotic stewardship and conduct an antibiotic timeout (ATO) for 1 of 3 sampled residents (R52). Findings include: Review of the current, undated, Centers for Disease Control (CDC): The Core Elements of Antibiotic Stewardship for Nursing Homes, Appendix A: Policy and Practice Actions to Improve Antibiotic Use, located at https://www.cdc.gov/antibiotic-use/core-elements/pdfs/core-elements-antibiotic-stewardship-appendix-a-508.pdf, identified facilities should evaluate the clinical signs and symptoms when a resident is first suspected of having an infection. Once the resident is placed on an antibiotic, they should be comprehensively reviewed within 48-72 hours after starting the medication to ensure they have been prescribed an effective medication. This is accomplished by reviewing the resident current symptoms and any laboratory results to identify medication effectiveness. The CDC identifies this process as an antibiotic time-out. Review of the Resident Antibiotic Tracking forms from February 2026 through May 2026 identified in the section Antibiotic Reassessment (Antibiotic Timeouts) preformed yes or no, was left blank each month. Review of February 2026, Antibiotic Tracking form identified R52 had symptoms of behaviors, incontinence, a fall, and cloudy urine with an onset date of 2/18/26. A urinalysis and culture were completed and R52 was identified as having a urinary tract infection (UTI). R52 started on Ciprofloxacin 500 milligrams (mg) orally twice a day for 7 days starting on 2/19/26 and finishing the antibiotic on 2/25/26 and symptoms resolved on 2/26/26. There was no indication that an ATO had been completed. R52's 2/19/26, physician order identified Cipro 500 mg by mouth for 7 days for UTI. Interview on 6/2/26 at 2:30 p.m., with registered nurse (RN)-D identified the facility kind of completed ATO's. The nurse was to notify the provider if the resident did not seem to be getting better and the nurse would make a note about that. The facility did not have a form or anything that they use, they would just make a progress note. Review of R52's progress notes from 2/15/26 through 2/27/26 identified on:2/15/26, multiple behaviors had been charted.2/19/26, R52 was found on floor at 0030 during routine rounds.2/19/26, at 4:45 p.m., a note identified an order for urinalysis and urine culture. 2/19/26, at 5:14 p.m., a note identified R52 had UTI and received an order for antibiotics.2/20/26, at 11:20 a.m., R52 was sleeping heavily, did not eat breakfast, was toileted and repositioned every 2 hours, sat in the recliner, and had not taken medications.2/20/26, at 1:04 p.m., R52 took bites for lunch and took some of her medications. 2/21/26, at 6:03 a.m., R52 was awake for bath and given last evening's antibiotic.2/22/26, at 6:02 a.m., R52 was awake and took last evenings antibiotic crushed and mixed with ice and grape juice.2/23/26, at 10:49 a.m., R52's culture was noted abnormal, and staff were to continue with current antibiotic, (5 days after starting the antibiotic). 2/27/26, at 8:45 a.m., the antibiotic course was completed for R52's UTI (on 2/25/26). Interview on 6/3/26 at 10:05 a.m., with RN-D confirmed the facility did have any type of form they used to document an antibiotic timeout. The facility did communicate to the physician about culture and sensitivity results. There should be a progress note, but the facility could do better on antibiotic stewardship and let the provider know how the resident was responding to an antibiotic. RN-D revealed the nurse practitioner came to the facility sometimes 3 times a week and could review the antibiotic timeout information on those days. RN-D confirmed that there was no consistent review of antibiotics. Interview on 6/3/26 at 11:00 with RN-C identified the facility did not do any type of ATO's after starting an antibiotic. Interview on 6/3/26 at 11:03 a.m., with RN-B identified as a nurse, she always followed up with the physician after a resident finished an antibiotic. She always tried to follow up with the provider to let them know if the resident symptoms resolved or continued after finishing the antibiotic and did not mention the need to perform an ATO between 48-72 hours after initiation. Interview on 6/3/26 at 2:05 p.m., with the director of nursing identified that she would expect staff would be following their antibiotic stewardship policy and completing ATO's. Review of the undated, Antibiotic Stewardship policy identified the facility had protocols and systems to monitor antibiotic use. Part of that system included an antibiotic timeout which the nurse would monitor the initiation of an antibiotic and conduct and ATO within 48-72 hours to monitor the response to the antibiotic. The nurse would also review laboratory results and consult with the physician to determine if the antibiotic was to continue or if any adjustments needed to be made. There was no indication the policy had been reviewed or revised annually to ensure it met current standards of practice.

Based on observation, interview, and document review the facility failed to ensure the kitchen ceiling tiles were kept in a clean and sanitary manner and free of dust and debris. This had the potential to affect all 46 residents residing in the facility. Findings include: On 5/13/25 at 9:08 a.m., two ceiling tiles located approximately six feet from the steam table were observed with gray, fuzzy material hanging from them. Directly beneath these ceiling tiles were two metal meal carts. At the time of observation, cook (C)-A was interviewed and confirmed the presence of the gray fuzzy material on the ceiling tiles, acknowledging the condition was unclean and unacceptable. C-A stated that kitchen staff were responsible for cleaning the ceiling tiles and further confirmed that plated food trays were placed on the metal carts located under the affected ceiling area before being delivered to residents. On 5/13/25 at 10:45 a.m., dietary aide (DA)-A was observed placing plated food onto meal trays located on metal carts situated directly beneath the ceiling tiles with visible gray material. On 5/13/25 at 11:09 a.m., maintenance director (MD)-A stated the kitchen staff were responsible to clean the kitchen ceiling tiles. On 5/13/25 at 12:17 p.m., the dietary director (DD)-C confirmed that the ceiling tiles were not included on the routine cleaning checklist. DD-C stated ceiling tiles above food preparation and tray assembly areas were expected to be clean and free of debris and would expect maintenance to clean the tiles when dirty. DD-C provided the kitchen cleaning schedule, which did not include ceiling tile cleaning. On 5/14/25 at 10:15 a.m., the administrator stated that kitchen ceiling tiles were expected to remain clean and free from debris. The administrator further stated that when debris is observed, both kitchen staff and maintenance are expected to coordinate to ensure cleanliness of the ceiling tiles Facility Cleaning and Sanitation of Dining and Food Service Area policy dated 2017, indicated: The nutrition and food services staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. The director of food and nutrition services will determine all cleaning and sanitation task needed for the departments. Staff will be trained on frequency of cleaning as necessary.

Based on observation, and interview the facility failed to ensure proper infection prevention practices was observed when transporting soiled linen when staff were observed to transport soiled linen unbagged and ungloved throughout the River Haven unit hallway. This had the potential to impact all 11 residents residing in the unit. Finding include: R35's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated severe cognitive impairment, required substantial/maximal assistance with personal hygiene, lower body dressing, and toileting hygiene and diagnoses included non-traumatic brain dysfunction and non-Alzheimer's dementia. R35's care plan dated 5/14/25, indicated ADL's (activity of daily living: alteration in self care r/t (related to) dementia, Parkinson's, poor balance, falls, weak with exertion, chronic disease process, arthritic changes substantial max to partial moderate assist with personal hygiene partial to moderate assist with dressing upper extremities and substantial max to dependent with lower extremities and footwear. On 5/13/25 8:15 a.m., nursing assistant (NA)-G exited R35's room and was observed carrying linen in her bare hands without placing the linen in a bag and without wearing gloves. NA-G proceeded through the hallway ungloved while carrying the unbagged linen and entered the tub room. In the tub room NA-G unwrapped the linen with her bare hands, revealing a brief mixed with the linens. NA-G separated the brief from the linen using her bare hands and placed the linen into the soiled linen hamper and the brief into a trash receptacle. NA-G stated she was not sure if the linen needed to be bagged when carried throughout the hallways and confirmed she did not wear gloves in the hallway while carrying the soiled linen. NA-G stated gloves were not allowed worn in the hallways. NA-G stated that the brief had been worn by the resident but was not visibly soiled with urine or feces and acknowledged the clothing was also worn. NA-G was observed washing her hands with soap and water for 21 seconds. 42073 During an interview on 5/13/25 at 1:11 p.m., on first floor, NA-A stated staff carried soiled laundry, including resident clothing, bed linens and towels, from resident rooms by hand, down the hallway to a hamper in the tub room if it was soiled resident clothing, or the utility room if it was soiled bed linens or towels. NA-A stated she would do this even if there were a small amount of BM (bowel movement) on the laundry. NA-A stated staff did not place soiled laundry in bags first before carrying it to the hampers. NA-A stated she was careful not to let soiled laundry touch her uniform. Further, NA-A stated she had done that as long as she had worked at the facility. Review of NA-A's orientation checklist dated 8/9/24, did not include instruction on transporting soiled laundry. During an interview on 5/13/25 at 1:29 p.m., on second floor, NA-F stated soiled laundry was carried by hand to either the utility room or tub room, such as resident clothing, towels, washcloths and bed linen. NA-F stated soiled laundry was not placed in a bag first before carrying it to the hampers. NA-F stated if something was heavily soiled and if there were extra bags in the residents wastebasket, she would place the soiled items in the bag. NA-F stated she was careful not to let the soiled items touch her uniform. During an interview on 5/13/25 at 2:45 p.m., registered nurse (RN)-A, who was also the infection preventionist, stated staff were to transport soiled laundry from resident rooms to the utility room or tub room hampers in a bag and away from their uniform. RN-A was informed of observation and interviews. During an interview on 5/14/25 at 12:29 p.m., the director of nursing (DON) was informed of observation and interviews regarding nursing staff carrying soiled laundry by hand, from resident rooms to the tub room or utility room to place in hampers. The DON stated staff could take the hampers to the resident rooms instead of carrying the laundry to the hampers. The DON acknowledged that still had the potential for staff to carry soiled items a distance. The DON stated if they (staff) did not do that, she would expect them to place soiled laundry in bags to carry to the hampers. The DON could not recall if nursing staff had received training on the expected way to transfer soiled laundry. Facility Infection Prevention and Control Program policy dated 2/2025, indicated the facility had established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Direct care staff would handle, store, process, and transport linens to prevent spread of infection. Soiled linen would be collected at the bedside and placed in a linen bag. When the task was complete, the bag would be closed securely and placed in the soiled utility room.

Based on observation, interview and document review the facility failed to ensure a comprehensive care plan was developed and implemented to include of post-traumatic stress disorder (PTSD) triggers and interventions for 2 of 2 residents (R10 and R23) who had a diagnosis of PTSD. Findings include: R23's face sheet printed 5/14/25, included diagnoses of Parkinson's disease (progressive neurodegenerative disorder that affects movement), psychological trauma, dementia, and major depressive disorder. R23's annual Minimum Data Set (MDS) dated [DATE], indicated R23 had moderate cognitive impairment, no behaviors and required moderate assist to stand, toileting substantial to maximal assist of 1 and was able to walk 150 feet with touching and standby by assist. PTSD was not checked as an active diagnosis. Medications included antipsychotic and antidepressant use. R23's plan of care dated 8/6/24, included a potential for mood deficit related to dementia, Parkinson's disease, depression and anxiety. Interventions included keep resident and family updated, encourage participation in activities of interest, support visits for mood and adjustment, mental health provider visits routinely, allow resident to verbalize and express feelings and frustrations. Medicate with Pristiq (antidepressant), Seroquel (antipsychotic), Remeron (antidepressant), Wellbutrin (antidepressant), Effexor (antidepressant, antianxiety), testosterone injection, olanzapine (antipsychotic) and melatonin (hormone that plays a role in sleep) per MD orders. R23's care plan failed to indicate PTSD triggers and interventions. On 5/13/25 at 12:51 p.m., registered nurse RN-C stated she was not aware of R23's history of trauma. RN-C stated R23 has a lot of anxiety and does not like being at the facility. RN-C is not aware of any triggers and confirmed there is no plan of care for PTSD. On 5/13/25 at 12:59 p.m., nursing assistant (NE)-E stated she was aware of R23's history of PTSD but was not aware of triggers. NA-E stated she felt R23 had more anxiousness than PTSD and when he is anxious she goes and gets the nurse. On 5/13/25 at 1:07 p.m., NA-F stated she was not aware of R23's history of PTSD but is aware he has a lot of anxiousness. NA-F could not state what triggers the PTSD or periods of anxiousness. NA-F stated we try to distract him by taking him outside or to an activity or we go get the nurse. On 5/13/25 at 12:06 p.m., the director of nursing (DON) confirmed she was aware of R23's history of PTSD but the comprehensive plan of care did not include PTSD including triggers and trauma informed care. 44630 R10's quarterly MDS assessment dated [DATE], indicated severe cognitive impairment, required substantial/maximal assistance with personal hygiene, utilized a walker and wheelchair, diagnoses included non-traumatic brain dysfunction, anxiety, depression, and post-traumatic stress disorder (PTSD), and antipsychotics were received on a routine basis. R10's care plan dated 5/10/25, indicated cognition: alteration in thought process r/t (related to) dementia in severe loss range, family kept updated and makes decisions on her behalf, family also consulted for history of needs and background information to assist with daily needs provide cues for her to participate with completing ADL (activity of daily living) needs with schedule she is comfortable with and supervision throughout the day to be sure any independent decisions are appropriate, observe for any changes with cognition or level of alertness and report if; activities: alteration in lifestyle r/t dementia in severe loss range, anxiety, chronic disease process, new environment needs assistance to, from and during activities of her preferences, shows signs of increased agitation, wanting to go home having things to do with difficulty in redirection, needs staff assistance to divert energy and attention to validate feelings, staff will encourage and assist to, from and during activities of her preference, in attempts to ward off onset of agitation, provide meaningful 1:1 visits of conversations, attempts at reminiscing, picture books, sensory, validate feelings to resident when she is agitated and attempt to find quiet, calming activities with safe items or materials. R10's care plan failed to indicate PTSD triggers and interventions. On 5/12/25 at 3:43 p.m., during a telephone interview family member (FM)-D stated R10 had a history of PTSD. On 5/13/25 at 8:51 a.m., NA-G stated she was uncertain if R10 had a history of trauma or PTSD and would need to look in R10's chart. NA-G stated, maybe the nurse would know. On 5/13/25 at 9:48 a.m., RN-B stated she was verbally informed of R10's PTSD history. RN-B stated the care plan was expected to include R10's PTSD and confirmed R10's care plan did not include or identify PTSD triggers or interventions. On 5/13/25 at 10:26 a.m. NA-H stated she was aware R10 had a history of PTSD, but was unsure of specific triggers and stated she would expect the triggers indicated on the care plan. NA-H stated she used the care plan located in the paper chart. NA-H was observed and looked at R10's paper chart and confirmed R10's record did not identify PTSD triggers or interventions. NA-H stated she was uncertain where to find R10's PTSD related information. On 5/13/25 at 12:06 p.m., during an interview with the DON and social services (SS)-A the DON confirmed R10's care plan did not include information related to PTSD as expected. Facility Trauma Informed Care policy dated 8/24, indicated : Trauma-specific care plan interventions will recognize the interrelation between trauma and symptoms of trauma such as substance abuse, eating disorders, depression, and anxiety. These interventions will also recognize the survivor's need to be respected, informed, connected, and hopeful regarding their own recovery. Facility Interdisciplinary Resident Care Plan policy dated 5/22, indicated: 1. The interdisciplinary team (IDT) in conjunction with the resident and his/her family or legal Representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 3. Assessment of residents are ongoing and care plans are revised as information about The residents and the residents' condition change. 4. The resident care plan is reviewed every 90 days by all member of the Interdisciplinary team. 5. Changes are made as needed on the care plan by all team members. 6. The resident, the resident's family and/or the resident's legal representative/guardian or surrogate is encouraged to participate in the development of and revisions of the resident's care plan.

Based on interview and document review, the facility failed to ensure accuracy of measured weights for 1 of 1 resident (R29) reviewed for nutrition. Findings include: R29's face sheet printed on 5/14/25, included diagnoses of diabetes, high blood pressure, and history of stroke. R29's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated severe cognitive impairment, clear speech, could understand and be understood. No weight loss and no difficulty swallowing. R29 required substantial assistance or was dependent upon staff for activities of daily living. R29's physician orders dated 12/12/23, indicated regular diet. R29 was not on a diuretic (a medication that increases urine output). R29's care plan dated 3/26/25, indicated R29 had an altered nutritional status related to diabetes and history of stroke. A goal for R29 dated 3/15/24, indicated R29 would have stable weights by estimated date of 6/24/25. Intervention dated 12/18/23, indicated to monitor weight and intake. (The frequency was not defined). Intervention dated 3/26/25, indicated R29 was independent with eating after meal set up and staff would encourage and assist. Nursing progress note dated 3/7/25, indicated family member (FM)-A was concerned about R29's eating; stated R29 ate slower and was easily distracted. Dietician progress note dated 3/24/25, indicated: 8# (pound) weight gain in past 6 months. Not significant. Continued regular diet, ate 50-75% for breakfast, and 75-100% of lunch and dinner. No chewing or swallowing difficulties. Cognitive status decreased further this quarter. Will continue to monitor intakes, weights, dehydration and nutrition risk. Continue with care plan. During record review noted potential discrepancies in measured weights. Twenty-two weights were reviewed for six months, from 11/5/24, through 5/6/25. Three incidences appeared potentially inaccurate: 12/17/24: 134# (pounds) 12/31/24: 142# (increase of 8#) 1/7/25: 135 # (decrease of 7#) 2/25/25: 148# 3/4/25: 129# (decrease of 19#) 3/7/25: 130# 3/11/25: 142# (increase of 12#) 3/18/13: 132# (decrease of 10#) During an interview on 5/13/25 at 8:52 a.m., nursing assistant (NA)-A stated residents were weighed on their bath day. While standing in the tub room on first floor, NA-A demonstrated how residents were weighed using the chair in the tub that slid out and onto an [NAME] Mobile Digital Scale. NA-A stated staff pressed the ON/ZERO button which displayed the residents weight. NA-A stated NA's recorded the weight in the electronic medical record (EMR). When entering a new weight, NA-A stated they did not see the previous weight, would need to go to a different part of the EMR. During an interview on 5/13/25 at 3:57 p.m., R29's weights for the past six months were reviewed with the director of nursing (DON). The DON acknowledged they were likely inaccurate. The DON stated she had posted the [NAME] Mobile Digital Scale Operations instructions in the nurses station on first floor for staff reference. The instructions indicated how to operate the scale. The DON provided a copy of the instructions which were page 51 of the operations manual dated November 2017. The DON stated if staff didn't zero out the scale, the reading of the weight could be inaccurate. Further, the DON stated the resident could not have their feet on the foot rests of scale or on the floor - they had to hold them off the floor to get an accurate weight. While the instructions indicated the residents feet could not be on the foot rests, it did not indicate the feet had to be off the floor. The DON stated NA's had not received formal training on the use of the scale and no competency had been conducted to ensure NA's knew how to use it properly. Further, the DON stated there was no auto-alert in the EMR when staff recorded a weight significantly higher or lower than the last recorded weight. The DON stated she would expect licensed nursing staff to be aware of weight fluctuations and to follow-up on them. During an interview on 5/14/25 at 7:31 a.m., licensed practical nurse (LPN)-A stated she was aware NA's had been having problems with the scale. LPN-A stated if she noted significant weight fluctuations, she would ask the NA to re-weigh the resident. LPN-A stated R29 had been having some issues eating - not remembering how to feed herself, and that it took her a long time to eat. LPN-A stated staff had started taking her to the dining room earlier, so she had more time to eat, and staff sat next to her to encourage and/or feed her. LPN-A looked in the EMR and verified the significant weight fluctuations and did not believe them to be accurate. LPN-A stated the EMR did not provide an auto-alert to indicate when a residents weight was significantly different from the previous weight so it could go unnoticed. During an interview on 5/14/25 at 8:12 a.m., NA-C stated she had training on the [NAME] scale when she was hired and knew a residents feet had to be off the foot rests of the scale and off the floor. NA-C stated they did not have to zero out the scale, just turn it on and it was ready to go. NA-C stated NA's entered the weight into the EMR but could not see the previous weight. During an interview on 5/14/25 at 9:02 a.m., NA-D stated she fed R29 breakfast and R29 ate everything. With NA-D and NA-C together, NA-C stated R29 could eat snacks in her room independently that her family brought in but was not able to feed herself with a fork -- she mainly played with her food and stacked cups on her plate. Registered nurse (RN)-A provided copies of orientation checklists for NA-A (dated 8/9/24), NA-B (dated 1/17/25), NA-C (dated 12/23/23). The checklists did not include orientation to the [NAME] mobile digital scale. For NA-D, RN-A provided a competency checklist from 2019-2020 which include how to weigh a resident accurately (balance the scale, feet off the floor). Facility Weight Monitoring policy dated 3/24/23, indicated weight could be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem. A weight monitoring schedule would be developed upon admission for all residents. Newly admitted residents - monitor weight weekly for 4 weeks. Residents with weight loss - monitor weight weekly. If clinically indicated - monitor weight daily. All others - monitor weight monthly.

Based on observation, interview, and document review the facility failed to ensure staff were following manufacturer's guidelines with continuous positive airway pressure (CPAP) machine with daily maintenance and weekly cleaning for 1 of 1 resident (R23) reviewed for respiratory care and treatments. Findings include: R23's face sheet printed 5/14/25, included diagnoses of Parkinson's disease (progressive neurodegenerative disorder that affects movement), and obstructive sleep apnea (breathing repeatedly stops or become significantly reduced during sleep often due to collapse of the upper airway). R23's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R23 had moderate cognitive impairment, and required moderate assist to stand, toileting substantial to maximal assist of 1 and was able to walk 150 feet with touching and standby by assist. Special treatments included CPAP. R23's plan of care dated 3/11/24, did not include a respiratory plan of care or the use of a CPAP machine. R23's physician orders dated 1/24/25, included rinse CPAP mask and hose with gentle soap and water. Hang to dry, weekly on Friday's at noon. An order dated 2/29/24, included CPAP at bedtime. ResMed AirSense manual, undated, included empty the humidifier tub daily and wipe it thoroughly with a clean disposable cloth and allow to dry out of direct sunlight. Weekly included clean the humidifier tub, air tubing and outlet connector in warm water using household dishwashing liquid or wash the humidifier tub and outlet connector in a solution of 1 part vinegar and 9 parts water. Rinse each component thoroughly in water and allow to dry out of direct sunlight or heat. Wipe the exterior of the device with a dry cloth. During an observation and interview on 5/12/25 at 3:52 p.m., R23's [NAME] ResMed CPAP machine was on his bedside table, with the mask and tubing hooked around grab bar on his bed still hooked to the machine. A gallon jug of distilled water was present on bedside table. The water reservoir was 1/4 full of water. R23 stated staff don't ever clean the CPAP machine, face mask, tubing or empty out the water when he removes the CPAP mask in the mornings. R23 stated he has the So Clean machine, (on bedside table) but has never seen staff use it. On observation 5/13/25 at 1:38 p.m., water reservoir of CPAP machine was approximately 1/4 full of water. Tubing and mask was hooked around grab bar on bed. On interview 5/13/25 at 12:59 p.m., nursing assistant (NA)-E stated day shift staff don't do anything with the CPAP machine. That would be the night shift. On interview 5/13/25 at 1:07 p.m., NA-F stated she has never cleaned the mask or tubing for R23's CPAP machine and she has never emptied out the CPAP reservoirs. NA-F stated that is generally the night shift who does that. On interview 5/14/25 at 8:40 a.m., NA-G stated day shift does not do anything with R23's CPAP machine, mask or hose. NA-G stated she is unsure what night shift does. On interview and observation 5/14/25 at 9:11 a.m., R23 stated staff have never cleaned his machine since he has been at facility. R23 stated he has the So Clean machine (device to clean CPAP masks and hoses that kills 99.9% of microorganisms) on his bedside but staff haven't used it since he brought it here. R23 stated he has never seen staff disconnect the tubing and mask and wash it with soap and water. R23 stated staff never empty the water out of the machine and just fill it up when it needs more water. Mask and tubing were hooked onto the grab rail of the bed. On interview and observation 5/14/25 at 9:43 a.m., registered nurse (RN)-C stated she hasn't actually done anything with R23's CPAP machine and added the NA's would empty the water reservoir and clean the mask and tubing per orders. RN-C confirmed there was water in the reservoir and likely wasn't emptied this morning. RN-C stated she is unsure how the So Clean machine works. On interview 5/14/25 at 10:25 a.m., the director of nursing (DON) stated she would expect staff to use the So Clean machine weekly to clean the tubing and mask and added she wasn't aware staff were not using the machine. The DON stated she would expect whoever takes the mask off and turns off the machine would empty the water reservoir after each use. Facility CPAP-BIPAP cleaning policy dated 5/2025 included: - It is the policy of this facility to clean CPAP/BIPAP equipment in accordance with current CDC guidelines and manufacturer recommendations in order to prevent eh occurrence or spread of infection. -CPAP/BIPAP equipment may vary by manufacturer. Common equipment includes the machine, tubing, mask, headgear/straps, disposable/non-disposable filters, and humidifier chamber. -Respiratory therapy equipment can become colonized with infectious organisms and serve as a source of respiratory infections. -Staff shall perform hand hygiene and wear gloves whenever touching the CPAP/BIPAP equipment. -Dust the machine when needed, and wipe clean with a damp cloth and mild detergent. -If humidification is required, distilled or sterile water will be used to fill the humidifier chamber. Empty the chamber completely after each use and wipe dry. -Clean mask frame daily after use with CPAP cleaning wipe or soap and water. Dry well. Cover with plastic bag or completely enclosed in machine storage when not in use. -Weekly cleaning activities (specify day of week): Wash headgear/straps in warm, soapy water and air dry. Wash tubing with warm, soapy water and air dry.

Based on interview, observation, and record review the facility failed to identify and document the trauma-related history, post-traumatic stress disorder (PTSD), known triggers and lacked a system or process for completing trauma assessments for 2 of 2 residents (R10 and R23) with a known history of PTSD. Findings include: R23's face sheet printed 5/14/25, included diagnoses of Parkinson's disease (progressive neurodegenerative disorder that affects movement), psychological trauma, dementia, and major depressive disorder. R23's annual Minimum Data Set (MDS) dated [DATE], indicated R23 had moderate cognitive impairment, no behaviors and required moderate assist to stand, toileting substantial to maximal assist of 1 and was able to walk 150 feet with touching and standby by assist. PTSD was not checked as an active diagnosis. Medications included antipsychotic and antidepressant use. R23's plan of care dated 8/6/24, included a potential for mood deficit related to dementia, Parkinson's disease, depression and anxiety. Interventions included keep resident and family updated, encourage participation in activities of interest, support visits for mood and adjustment, mental health provider visits routinely, allow resident to verbalize and express his feelings and frustrations. Medicate with Pristiq (antidepressant), Seroquel (antipsychotic), Remeron (antidepressant), Wellbutrin (antidepressant), Effexor (antidepressant, antianxiety), testosterone injection, olanzapine (antipsychotic) and melatonin (hormone that plays a role in sleep) per MD orders. The plan of care did not include trauma informed care or interventions. R23's document review failed to include a trauma assessment or evaluation of R23's PTSD. On interview 5/13/25 at 12:06 p.m., the director of nursing (DON) confirmed she was aware of R23's history of PTSD. DON confirmed R23's plan of care lacked comprehensive trauma assessment and plan of care for triggers and trauma informed care. On interview 5/13/25 at 12:51 p.m., registered nurse RN-C stated she was not aware of R23's history of trauma. RN-C stated R23 has a lot of anxiety and does not like being at the facility. RN-C not aware of any triggers and confirmed there is no plan of care for PTSD. On interview 5/13/25 at 12:59 p.m., nursing assistant (NE)-E stated she was aware of R23's history of PTSD but was not aware of triggers. NA-E stated she felt R23 had more anxiousness than PTSD and when he is anxious she goes and gets the nurse. On interview, 5/13/25 at 1:07 p.m., NA-F stated she was not aware of R23's history of PTSD but is aware he has a lot of anxiousness. NA-F could not state what triggers R23's PTSD or periods of anxiousness. NA-F stated we try to distract him by taking him outside or to an activity or we go get the nurse. On interview and observation on 5/14/25 at 9:11 a.m., R23 was sitting in his chair in his room watching television. R23 stated he was in the military but doesn't feel he has PTSD. On interview 5/14/25 at 9:54 a.m., the DON stated during conversations, R23 has said he was shot at and people around him were killed when he was in Vietnam. The DON stated on memorial day during the last program at the facility, R23 was emotional and crying. The DON stated R23 likely didn't want to talk about his history when he stated he doesn't have PTSD. 44630 R10's quarterly MDS assessment dated [DATE], indicated severe cognitive impairment, required substantial/maximal assistance with personal hygiene, utilized a walker and wheelchair, diagnoses included non-traumatic brain dysfunction, anxiety, depression, and post-traumatic stress disorder (PTSD), and antipsychotics were received on a routine basis. R10's care plan dated 5/10/25, indicated cognition: alteration in thought process r/t (related to) dementia in severe loss range, family kept updated and makes decisions on her behalf, family, provide cues for her to participate with completing ADL (activity of daily living) needs with schedule she is comfortable with and supervision throughout the day to be sure any independent decisions are appropriate, observe for any changes with cognition or level of alertness and report if; activities: alteration in lifestyle r/t dementia in severe loss range, anxiety, chronic disease process, new environment needs assistance to, from and during activities of her preferences, shows signs of increased agitation, wanting to go home having things to do with difficulty in redirection, needs staff assistance to divert energy and attention to validate feelings, staff will encourage and assist to, from and during activities of her preference, in attempts to ward off onset of agitation, provide meaningful 1:1 visits of conversations, attempts at reminiscing, picture books, sensory, validate feelings to resident when she is agitated and attempt to find quiet, calming activities with safe items or materials. R10's document review failed to include a trauma assessment or evaluation of R10's PTSD. On 5/12/25 at 3:43 p.m., during a telephone interview family member (FM)-D stated R10 had a history of PTSD. On 5/12/25 at 6:15 p.m., R10 was observed seated in a wheelchair in the day area and completing a puzzle. On 5/13/25 at 8:07 a.m., R10 was seated in a wheelchair in the day area and was completing a puzzle. On 5/13/25 at 8:51 a.m., NA-G stated she was uncertain if R10 had a history of trauma or PTSD and would need to look in R10's chart. NA-G stated, maybe the nurse would know. NA-G stated education was not provided on R10's PTSD triggers or interventions and stated she utilized interventions for dementia and agitation which included distraction, puzzles, coloring and talking about family. On 5/13/25 at 9:48 a.m., RN-B stated she was verbally informed of R10's PTSD history. RN-B stated the care plan was expected to include R10's PTSD and confirmed R10's care plan did not include or identify PTSD triggers or interventions. RN-B stated she was not aware of trauma assessments completed for residents at the facility. On 5/13/25 at 10:26 a.m., NA-H stated she was aware R10 had a history of PTSD, but was unsure of specific triggers and stated she would expect the triggers indicated on the care plan. NA-H stated she used the care plan located in the paper chart. NA-H was observed and looked at R10's paper chart and confirmed R10's record did not identify PTSD triggers or interventions. NA-H stated she was uncertain where to find R10's PTSD related information. On 5/13/25 at 12:06 p.m., during an interview with the DON and social services (SS)-A, the DON confirmed awareness of the R10's PTSD and stated a trauma assessment was not done as expected. The DON and SS-A stated a trauma assessment was important to identify triggers and interventions and include that information on the care plan. The DON and SS-A confirmed there was no current process in place to for identifying or addressing trauma related needs including trauma related triggers and interventions. Facility Trauma Informed Care policy dated 8/24 included: - The facility will use a multi-disciplinary approach to identifying a resident ' s history of trauma, as well as his or her cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools such as the Resident Assessment Instrument (RAI), Admission Assessment, the history and physical, the social history/assessment, and others. - St [NAME] ' s will collaborate with resident trauma survivors, and as appropriate, the resident ' s family, friends, the primary care physician, and any other health care professionals (such as psychologists and mental health professionals) to develop and implement individualized care plan interventions. - In some cases, if the facility has more than one trauma survivor, social services will make a good faith effort at establishing a support group that is run by a qualified professional, or allow a support group to meet in the facility. If a group cannot be run/meet at facility, social services will assist the resident in locating a support group in the community as appropriate and feasible. -The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident ' s exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident, and will be added to the resident ' s care plan. While most triggers are highly individualized, some common triggers may include, but are not limited to: a. Experiencing a lack of privacy or confinement in a crowded or small space. b. Exposure to loud noises, or bright/flashing lights. c. Certain sights, such as objects that are associated with their abuser. d. Sounds, smells, and physical touch. -Trauma-specific care plan interventions will recognize the interrelation between trauma and symptoms of trauma such as substance abuse, eating disorders, depression, and anxiety. These interventions will also recognize the survivor's need to be respected, informed, connected, and hopeful regarding their own recovery. -The facility will evaluate whether the interventions have been able to mitigate (or reduce) the impact of identified triggers on the resident that may cause re-traumatization. The resident and/or his or her family or representative will be included in this evaluation to ensure clear and open discussion and better understand if interventions must be modified. - In situations where a trauma survivor is reluctant to share their history, the facility will still try to identify triggers which may re-traumatize the resident, and develop care plan interventions which minimize or eliminate the effect of the trigger on the resident.

Based on observation, interview and document review, the facility failed to follow manufacturer's instructions for cleaning and sanitizing 1 of 1 ice machines used for resident consumption. This had the potential to affect all 49 residents who resided in the facility. Findings include: During an observation on 4/16/24 at 10:39 a.m., noted a Manitowoc brand, counter-top style ice machine in the first floor resident ice machine. During an interview on 4/15/24 at 11:35 a.m., dietary supervisor (DS)-B stated dietary staff wiped down the outside of the ice machine located in the first-floor dining room but did not clean the inside. During an interview on 4/17/24 at 11:17 a.m., dietary aide (DA)-A stated she cleaned the ice machine using hot water and a long narrow brush to clean a long, narrow PVC pipe laying horizontal alongside the bottom of the ice machine. DA-A stated dietary staff did not clean the inside of the ice machine; didn't empty out the ice or do anything else to it. DA-A verified the ice machine was used for resident consumption. Reviewed Manitowoc ice machine Use & Care Manual, received from plant operations director (POD)-A. The manual identified three separate cleaning procedures: 1) Preventative Maintenance Cleaning Procedure - recommended monthly; 2) Cleaning/Sanitizing, recommended a minimum of once every six months; 3) Heavily Scaled Cleaning Procedure if the ice machine had certain symptoms. During an interview on 4/17/24 at 11:40 a.m., POD-A stated plant operations staff did not clean the ice machine; dietary staff took care of that. POD-A was informed dietary staff was not cleaning the ice machine according to manufacture instructions in order to prevent the growth of bacteria. POD-A acknowledged no one in the facility was cleaning the ice machine according to manufacture instructions. Manufacturer's instructions for Manitowoc RNS12 & RNS20 Model Nugget Ice Machines Installation, Use & Care Manual, dated 10/13. Cleaning and Sanitizing - the facility is responsible for maintaining the ice machine in accordance with the instructions in this manual. Clean and sanitize the ice machine every six months for efficient operation. The Manitowoc Ice Machine has three separate cleaning procedures: 1. Preventative Maintenance Cleaning Procedure. Perform this procedure as required for water conditions. Recommended monthly. Allows cleaning the ice machine without removing all the ice from the bin. Removes mineral deposits from areas or surfaces that are in direct contact with water during the freeze cycle (reservoir, evaporator, auger, drain lines). 2. Cleaning/Sanitizing Procedure. This procedure must be performed a minimum of once every six months. All ice must be removed from the bin. The ice machine and bin must be disassembled, cleaned, and sanitized. The ice machine produces ice with the cleaner and sanitizer solutions. All ice produced during the cleaning and sanitizing procedures must be discarded. 3. Heavily Scaled Cleaning Procedure. Perform this procedure if have some or all these symptoms: Grinding, popping or squealing noises from the evaporator. Grinding noise from gearbox. Ice machine stops on Safety Shutdown. Your water has a high concentration of minerals. The ice machine has not been on a regular maintenance schedule. Run a cleaning procedure as described above after this procedure is complete. NOTE: A Sanitizing Procedure must be performed after all cleaning procedures have been completed.

Based on observation and interview, the facility failed to ensure basic infection control measures were followed when 1 of 1 resident (R41's) urinary drainage bag was observed resting on the floor. Findings include: R41's diagnosis list printed on 4/17/24, included history of pulmonary emboli (when arteries are blocked by a blood clot). R41's significant change Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment and dependency upon staff for most activities of daily living. R41's physician orders dated 9/8/23, indicated indwelling urinary catheter. R41's care plan dated 9/15/23, indicated Foley (describes the type of catheter) catheter management per MD (medical doctor) orders and facility protocol. During an observation on 4/15/24 at 1:39 p.m., observed R41's urinary drainage bag hooked to the side pocket of his cloth recliner, resulting in the bottom of the bag, including the urinary drainage valve, to rest on the floor. During an observation on 4/16/24 at 8:18 a.m., R41 was in his recliner eating breakfast. Observed R41's urinary drainage bag hooked to the side pocket of his recliner, resulting in the bottom of the bag, including the urinary drainage valve, to rest on the floor. During an interview and observation on 4/16/24 at 9:05 p.m., together with licensed practical nurse (LPN)-A looked at the location of R41's urinary drainage bag. LPN-A stated the bag was supposed to be kept off the floor to prevent the possibility of a urinary tract infection (UTI). LPN-A asked nursing assistant (NA)-A to obtain a pouch in which to put R41's bag. During an interview and observation on 4/16/24 at 9:07 a.m., together with NA-A, looked at the location of R41's urinary drainage bag. NA-A stated that was not where she would hang R41's bag and acknowledged the bag should not rest on the floor due to the possibility of bacteria entering the bag. NA-A placed the urinary drainage bag in a cloth pouch and set the pouch in the side pocket of the recliner. During an interview on 4/16/24 at 12:30 p.m., registered nurse (RN)-A who was also the infection preventionist, stated staff were trained to keep a urinary drainage bag off the floor and acknowledged the potential for bacterial growth if the bag was on the floor. During an interview on 4/17/24 at 11:24 a.m., the director of nursing (DON) was informed of observations of R41's urinary drainage bag resting on the floor. The DON stated she would expect staff to position the bag so that it would not rest on the floor or to place it in a cloth pouch or a plastic basin. The facility Catheter Care - Urinary policy dated 5/24/22, indicated the purpose of the procedure was to prevent catheter-associated urinary tract infection. The policy did not address how staff should position the urinary drainage bag when the resident was in bed, in a chair, or a wheelchair.

Based on interview and document review the facility failed to ensure written transfer notices were provided to the resident or resident representative following a facility-initiated transfer to the hospital for 2 of 2 residents (R25, R28) reviewed for hospitalization . This had the potential to affect all 49 residents residing in the facility. Findings include: R25's Record of Admission printed 4/17/24, included diagnoses of urinary tract infection, hydronephrosis (excess urine accumulation in kidney causing swelling the kidney) and hypertensive chronic kidney disease (high blood pressure causing kidney damage) R25's readmission Minimum data set (MDS) dated [DATE], indicated R25 had mild cognitive impairment but understands and is understood. During interview on 4/15/24 at 12:50 p.m., R25 indicated she was recently in the hospital and did not remember being given any paper work prior to her transfer there. R25 indicated she had a urinary tract infection prior to going to the hospital. A progress note dated 4/2/24 by registered nurse (RN)-B indicated R25 was sent to a local hospital via ambulance at 2:20 p.m. and returned to the facility on [DATE] at 3:15 p.m. R25's medical record lacked evidence written notice of the transfer had been provided to R25 or representative. R28's Record of Admission printed 4/17/24, included diagnoses of dementia, diabetes mellitus, atherosclerotic heart disease of native coronary artery (plaque build-up in artery) and arrythmia (abnormal heart rhythm). R28's quarterly MDS dated [DATE], indicated severe cognitive impairment but understands and is understood. During interview 4/15/24 at 2:28 p.m., R28's family member (FM)-C stated stated R28 was sent to the local hospital last fall where they found he had a blood clot in his lung. FM-C indicated he never received a written notice of transfer and R28's medical record lacked evidence a written notice of the transfer was provided to R28 or FM-C. A progress note dated 9/16/23 at 8:45 a.m. by RN-B indicated R28 was transferred via ambulance to local hospital. On 9/22/23 at 11:48 a.m., licensed practical nurse (LPN)-B's progress note indicated R28 was readmitted to the facility at 10:05 a.m R28's medical record lacked evidence written notice of the transfer had been provided to R28 or representative. During interview 4/16/24 at 2:18 p.m., LPN-A indicated a Transfer Form is filled out with the resident information present on it for the hospital but nothing is given in writing to the residents or family. During interview 4/16/24 at 2:25 p.m., the director of nursing (DON) confirmed they are not completing a transfer notice, nor giving a copy to the resident or family member. Requested a policy and procedure on transfer agreements and none was received. The admission packet dated 9/19/23, included a section on Transfer and Discharge that included in case of an emergency transfer, the facility will notify the resident or responsible person prior to the transfer, if possible. When time does not permit a prior notification, the facility will contact the responsible person as soon thereafter as possible.

Based on interview and document review, the facility failed to provide notification to the resident and/or resident representative of the facility's bed hold policy at the time of an emergency transfer for 2 of 2 residents (R25, R28) who were transferred to an acute care facility on an emergency basis. Findings include: R25's Record of Admission printed 4/17/24, included diagnoses of urinary tract infection, hydronephrosis (excess urine accumulation in kidney causing swelling the kidney) and hypertensive chronic kidney disease (high blood pressure causing kidney damage) R25's readmission Minimum data set (MDS) dated [DATE], indicated R25 had mild cognitive impairment but understands and is understood. A progress note, dated 4/2/24, by registered nurse (RN)-B indicated R25 was sent to a local hospital via ambulance at 2:20 p.m. and returned to the facility on [DATE] at 3:15 p.m. R25's medical record lacked evidence a Bed Hold policy was shared with R25 or her representative at the time of transfer. During interview on 4/15/24 at 12:50 p.m., R25 indicated she was recently in the hospital and did not remember being given any paper work or being asked about a bed hold prior to her transfer. R25 indicated she had a urinary tract infection prior to going to the hospital. A Bed Hold Notice for R25 was signed by RN-B, dated 4/2/24, stating I wish to reserve my room. A separate line signature line was present if not the resident that included title (if not the resident), which was blank. R28's Record of Admission printed 4/17/24, included diagnoses of dementia, diabetes mellitus, arteriosclerotic heart disease of native coronary artery (plaque build-up in artery) and arrhythmia (abnormal heart rhythm). R28's quarterly MDS dated [DATE], indicated severe cognitive impairment but understands and is understood. A progress note dated 9/16/23 at 8:45 a.m. by RN-B indicated R28 was transferred via ambulance to local hospital. On 9/22/23 at 11:48 a.m., licensed practical nurse (LPN)-B's progress note indicated R28 was readmitted to the facility at 10:05 a.m R28's medical record lacked evidence a Bed Hold policy was shared with R28 or his representative at the time of transfer. During interview 4/15/24 at 2:28 p.m., R28's family member (FM)-C stated stated R28 was sent to the local hospital last fall where they found he had a blood clot in his lung. FM-C indicated he was not asked about a bed hold nor was he given a copy of the policy. A Bed Hold Notice for R28 was signed by RN-B, dated 9/16/23, stating I wish to reserve my room. Title (if not the resident) was left blank. During interview 4/16/24 at 2:18 p.m., LPN-A indicated a Bed Hold Notice is completed prior to discharge and send to the hospital. LPN-A indicated families or the resident rarely sign the Bed Hold Notice form and a copy isn't shared with them unless they request a copy. During interview 4/16/24 at 2:25 p.m., the director of nursing (DON) indicated the facility used to send a copy of the Bed Hold Notice to the family if they weren't present at time of transfer, but does not believe that is currently happening due to turn over in staff. The DON indicated the staff should get verbal permission from the resident or family and document as verbal permission on the Bed Hold Notice form and not sign the form themselves. The facility Bed Hold policy dated 1/2019, included when the resident is absent for any reason, including hospitalization , the resident may continue to occupy the room if the resident pays the daily room rate authorized by law. For Medical Assistance residents the bed-hold limit for each hospitalization is 18 days and if leave exceeds the resident will be discharged from the facility. If Private Pay, any resident may hold his or her bed by paying the rate currently in effect. Residents of Medicare can not go on overnight visits without jeopardizing Medicare benefits.

Based on observation, interview, observation and document review, the facility failed to document and monitor weight status for 1 of 1 resident (R28) who has a history of edema and fluid retention. Findings include: R28's face sheet printed on 3/8/23, included diagnoses of chronic obstructive pulmonary disease (progressive lung disease with airflow limitations and variable respiratory symptoms), aortic valve stenosis (narrowing of heart valve that separates the pumping chamber of the heart to the rest of the body), and hypertensive heart failure (high blood pressure causing thickening of the heart muscle). R28's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R28 had moderate cognitive impairment, no weight loss or gain, uses oxygen therapy and takes a diuretic daily. R28 required extensive assist of 1 to 2 persons for activities of daily living. R28's care plan dated 8/11/22, indicated R28 had a potential for alteration in tissue perfusion related to heart failure, aortic stenosis, diabetes, and respiratory failure. Interventions included observe for changes in edema, weigh 2 times weekly and give medications including Lasix (diuretic) per physician orders. R28's physician orders dated 1/17/22, indicated R28's weight was to be obtained twice a week on Tuesday and Friday and to contact primary care provider for 2 pound increase in 2 days or 5 pound increase in a week. During observation on 3/7/23, at 12:39 p.m. R28 was sitting in recliner with legs elevated with elastic stockings on. R28 had minimal to no edema present on lower extremities. R28 had loose sounding cough. Review of R28's weights from 9/1/22 through 3/3/23 included opportunities for 70 weights with 19 not completed. Gaps in weights included: 9/19/22 to 9/26/22, one missed 9/26/22 to 10/3/22, one missed 10/3/22 to 10/19/22, four missed 10/25/22 to 11/4/22, two missed 11/11/22 to 11/18/22, one missed 11/22/22 to 12/2/22, two missed 12/16/22 to 12/23/22, one missed 12/23/22 to 12/30/22, one missed 12/30/22 to 1/6/23, one missed 1/20/23 to 1/27/23, one missed 2/10/23 to 2/17/23, one missed 2/17/23 to 3/3/23, three missed During interview on 3/8/23, at 1:36 p.m. nursing assistant (NA)-B indicated R28 is weighed on Tuesdays and Fridays. NA's report the weight to the nurse who documents it. NA-B provided an aide sheet that included weights to be completed on Tuesday and Friday. During interview on 3/8/23, at 1:50 p.m., registered nurse (RN)-A reviewed plan of care and indicated R28 is to be weighed Tuesday and Fridays. During interview on 3/08/23, at 1:53 p.m., the director of nursing (DON) evaluated weights and confirmed there were multiple missing weights. During interview on 3/8/23 at 2:15 p.m., the DON was able to locate 2 weights after 2/17/23 and added the unit was having difficulty with the scale around 2/24/23. Facility policy and procedure dated 10/28/22, for weight monitoring included: Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the residents clinical condition demonstrates this is not possible or resident preferences indicate otherwise -weights should be recorded at the time obtained if clinically indicated, monitor weight daily or as directed by medical provider.

Based on observation, interview and document review, the facility failed to ensure 1 of 2 residents (R24) received assistance with hand splints to prevent worsening of range of motion. Findings include: R24's Diagnosis Report printed 3/8/23, included diagnosis of hemiplegia and hemiparesis (total or nearly complete paralysis on one side of the body), speech and language deficits, and Alzheimer's disease. R24's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R24 had a Brief Interview for Mental Status (BIMS) score of 0 indicating severe cognitive impairment. The MDS further identified R24 required extensive to total assistance for activities of daily living (ADL's) and had no rejection of cares. Functional limitation in range of motion (ROM) of upper (shoulder, elbow, wrist, and hand) showed R24 had impairment on one side and and lower extremities (hip, knee, ankle, and foot) with impairment on both sides. R24's care plan dated 10/24/19, included R24 required total assist with ADL's and had an alteration in mobility. Interventions included passive range of motion to right upper extremity. R24 was last evaluated by occupational therapy on 5/3/22 for wheelchair positioning deficits related to sliding out of her chair. R24 was previously evaluated and treated 12/2/20 through 2/6/21 for joint mobility for range of motion deficits to right upper extremity (RUE). Goal included patient will trial various splints to determine most appropriate for day or night use to prevent further spasticity and contracture in RUE. Discharge plans and instructions included apply splint at appropriate times and if patient flings off no need to put it back on. During observation and interview on 3/6/23, at 4:23 p.m. R24 was lying in bed. Right arm was lying by her side and right thumb was tucked under her fingers which were curled in towards the palm of her hand. A family member (FM)-A indicated he doesn't believe R24 has ever had a splint for her right hand. During observation on 3/7/23, at 8:10 a.m. R24 was sitting in her Broda chair (positioning wheelchair) in dining room. No splint was present on her right hand and right fingers curled in towards palm. During observation and interview on 3/7/23, at 12:28 p.m. nursing assistant (NA)-A was assisting R24 with lunch. R24's right arm was on the armrest of the chair. R24 would move her arm which flopped down towards the side of the wheelchair. R24 did not move her right hand and no splint was present. NA-A indicated R24 frequently will move her right arm so it falls off the arm of the chair but has not seen her move her right hand or fingers at all. NA-A asked R24 to move her fingers with no movement noted. R24's thumb was tucked into her palm with fingers curled over the thumb but not touching the palm. NA-A indicated R24 does not have a splint for her right hand. During observation on 3/8/23, at 7:20 a.m., R24 was asleep in bed. No hand splint was present on right hand. During interview on 3/8/23, at 9:35 a.m., NA-B indicated it has been a few years since R24 last wore a splint. NA-B added they do range of motion (ROM) twice a day and are able to move her fingers, but R24 says owie the whole time. R24's right hand is paralyzed but she can move her right arm. During interview on 3/8/23, at 8:21 a.m., registered nurse (RN)-A indicated R24 does not have a hand splint. During observation on 3/8/23, at 1:27 p.m., R24 was asleep in bed with no hand splint on right hand. During interview on 3/8/23, at 8:28 a.m. occupational therapist (OT)-A indicated the last occupational therapy evaluation for R24 was for positioning in wheelchair and nothing was mentioned about her right hand. The last time R24 was seen for her right hand was February 2021 for hand splint use. OT-A indicated therapy should be notified if staff are going to stop using a hand splint so other options can be evaluated. Staff should not just discontinue use of a splint. During interview on 3/8/23, at 2:08 p.m., the director of nursing (DON) indicated she evaluated R24 and she was able to open her right hand without R24 saying ouch. After looking through R24's electronic medical record (EMR), the DON indicated the last notes she could locate were from January 2021 and R24 was to wear the splint at night but the resident would remove the right hand splint herself. The DON added she doesn't know what happened with the splint and would look for it in R24's room. A progress note dated 1/26/21, at 5:56 a.m. included staff reported that R24 had hand splint on approximately 2 hours, then removed it herself. A progress note dated 1/26/21, at 2:40 p.m. indicated R24 takes splint off a short time after putting it on. A progress note dated 1/31/21, at 5:07 a.m. included overnight staff reported R24 removed hand splint shortly after putting it on. Facility policy and procedure titled Functional Maintenance Policy, undated, included implement of a functional maintenance program may occur following a course of physical, occupational or speech therapy. In these cases, the therapist will provide resident specific training to the appropriate staff members, assist nursing in establishing initial goals and suggest interventions and approaches. The interdisciplinary team will determine when to discontinue the functional maintenance program and develop the follow-up interventions to be provided by general nursing staff.

Based on observation, interview and document review, the facility failed to prepare food in accordance with resident needs for 1 of 2 residents (R28) who was identified as on a mechanically altered (cut up meats) diet. Findings include: R28's face sheet printed 3/8/23, included diagnosis of dysphagia (difficulty in swallowing food or liquid), pneumonia and diabetes mellitus. R28's signed physician orders dated 10/19/2022, indicated a diabetic diet, and cut meat into bite size pieces. R28's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R28 understands and is understood, has moderate cognitive impairment, requires supervision with eating, able to feed self and has no swallowing difficulties. R28's plan of care dated 2/5/23, included an alternation in nutritional status related to diabetes and history of cerebral infarction with right sided weakness and dysphagia. R28 requires adaptive eating utensils and staff to cut meat. Interventions included eats meals at nurses station, R28 to feed himself after meal is setup by staff and meat is cut up and resident will follow guidelines set up by speech therapy on 2/11/22. Black handled weighted silverware to aid with self feeding. A speech therapy discharge note dated 2/11/22, indicated R28 was discharged to continue with current diet, and cut up solids. Patient should continue to utilize cue card to help with recall and use of taught safe swallow strategies. During interview and observation on 3/6/23, at 3:22 p.m. R28 was sitting in his recliner in his room. A sign on the wall next to the recliner stated Safe Swallow Strategies which included small single sips of liquid, eat slow, cut up solids into small bites, alternate between food and liquid and was dated 1/21/22 from speech therapy. R28 indicated no one ever cuts up his food and denied any issues with chewing or swallowing. During observation on 3/7/23, at 12:09 p.m. R28 was eating lunch in the dining room. R28 had beef tips with gravy and mashed potatoes. Beef tips were not cut into bite size pieces. R28 ate without any choking incidents. There was no cue card present. During observation on 3/8/23, at 7:50 a.m. R28 was in the dining room with a round sausage whole patty and boiled egg on his plate. Neither were cut into bite size pieces. There was no cue card present on the table. During observation on 3/8/23, at 11:20 a.m. dietary aide (DA)-A was preparing meals for delivery to the residents on floor 2. DA-A placed a hamburger on a bun and potato wedges on R28's plate. Review of meal sheet indicated R28 was on diabetic diet with 1/2 dessert portions. During observation on 3/8/23, at 12:10 p.m. R28 was on floor 2 in dining area with a hamburger on a bun and potato wedges present. Food was not cut into bite size pieces. R28 ate 1/3 of his hamburger and 1/2 of potato wedges. There was no cue card present at R28's table. During interview on 3/8/23 at 12:15 p.m. nursing assistant (NA)-C indicated normally the kitchen cuts up R28's food. When questioned why R28's hamburger wasn't cut into bite size pieces, NA-C indicated R28 can eat sandwiches without being cut up, but meats like turkey need to be cut up. During interview on 12/8/23, at 12:18 p.m. registered nurse (RN)-A indicated R28 has a tendency to chew his food too fast and had been seen by speech therapy who told him to slow down when eating. RN-A indicated staff will ask R28 if he wants his food cut up or not. During interview on 3/8/23, at 12:20 p.m. R28 stated everything is supposed to be cut up but they never do it. R28 denied choking on his food. R28 further stated no one asks him if he wants his food cut up or not. During interview on 3/8/23 at 12:30 p.m. cook (C)-A indicated R28 is on a carbohydrate consistent, regular texture thin liquids diet with 1/2 portion of dessert. There was no mention of meat being cut up on the diet order the kitchen had but will discuss it with the registered dietician (RD). During interview on 3/8/23 at 1:27 p.m. RD indicated the kitchen did not receive notification to the change in diet order. Requested to see sign/recommendations speech therapy (ST) posted in R28's room, which she then reviewed. After reviewing sign and ST notes, the RD indicated somehow communication did not occur between ST, nursing and the kitchen. The RD added per current standards a Dysphagia easy to chew, level 7 diet would be appropriate which includes moistened tender meats, thin-sliced deli meats (cut up or chopped). During interview and observation on 3/8/23 at 1:35 p.m. NA-B approached the RD and indicated she found R28's swallowing strategies card on another table and will tape it to R28's table so it doesn't get moved again. During interview on 3/8/23 at 2:40 p.m. the director of nursing (DON) confirmed the diet order was missed. Facility policy and procedure titled Standard Diets dated 3/2018, included diet order terminology will be used to assure consistency and accuracy in providing the diets per physician order. Clarification will be requested by the dietician or charge nurse to the physician on diet orders noted in the standard terminology.

Based on interview and document review, the facility failed to ensure that 1 of 115 staff, laundry aide (LA)-A, were fully vaccinated for Covid-19 vaccinations, or had completed documentation of a medical or religious exemption or conducting bi-weekly Covid-19 testing. This resulted in a 99.1% vaccination rate. This practice created the potential for the spread of the Covid-19 virus to other staff and residents who resided in the facility. Findings include: During review of Section I of document titled Covid-19 Staff Vaccination Status for Providers, from the Centers for Medicare and Medicaid Services, which was completed at the request of the State Agency (SA), it was noted that one staff member was identified as not vaccinated without exemption/delay. Facility policy titled Exemption Policy and Procedure for Covid-19 Vaccination, dated 11/15/21, indicated all employees were required to receive the Covid-19 vaccination unless a reasonable accommodation was approved as an identified approved exemption. Employees who were approved for exemption would be required to do Covid-19 rapid testing twice a week prior to punching into work. Furthermore, employees who were not approved for an exemption, and/or had not received their first dose of a Covid-19 vaccine, or failed to comply with an exemption request would be removed from the schedule. During an interview on 3/23/22, at 2:10 p.m., the director of nursing (DON) was asked to identify the staff member who was not vaccinated without exemption/delay. The DON stated it was LA-A who started employment on 3/2/22, as a full-time laundry aide. The DON stated LA-A had initially tried to get an exemption, but it was denied. This was verified by review of a document titled Covid-19 Vaccination Form in which LA-A indicated she wished to refuse to receive the Covid-19 vaccination. This documented was signed and dated by LA-A on 3/1/22. After this denial, LA-A then agreed to receive the Covid-19 vaccine. On 3/7/22, a Covid-19 Vaccine Consent form giving consent to receive the vaccine was signed by LA-A, but she had not yet received a dose. The DON admitted that LA-A got missed for both Covid-19 vaccination and bi-weekly Covid-19 testing and had been working in the facility since 3/2/22. In addition, the DON stated it was her responsibility to ensure employees received the Covid-19 vaccination. The DON stated LA-A's Covid-19 vaccination consent form was with other papers on her desk and was overlooked. The DON stated her understanding of the facility policy was employees needed to be vaccinated or have an approved exemption, or would not be able to work. In addition, the DON stated the policy also required unvaccinated employees to test for Covid-19 twice a week. The DON admitted the policy wasn't followed in this case; that LA-A had not been vaccinated for Covid-19, had not received an approved exemption, nor had undergone bi-weekly Covid-19 testing. Review of timecards for LA-A which were provided by the DON, indicated LA-A worked a total of 71.5 hours between 3/2/22, through 3/23/22, and that LA-A's role required going into resident rooms. During the same interview, the DON stated there had been no problem getting the Covid-19 vaccination from the local pharmacy. Facility policy titled Exemption Policy and Procedure for Covid-19 Vaccination, dated 11/15/21, indicated all employees were required to receive the Covid-19 vaccination unless a reasonable accommodation was approved as an identified approved exemption. Employees who were approved for exemption would be required to do Covid-19 rapid testing twice a week prior to punching into work. Furthermore, employees who were not approved for an exemption, and/or had not received their first dose of a Covid-19 vaccine, or failed to comply with an exemption request would be removed from the schedule. By January 4, 2021 (sic), if not in compliance of policy, it would be considered a voluntary resignation.

Based on observation, interview and document review, the facility failed to comprehensively reassess and develop interventions to provide adequate supervision and safety with smoking for 1 of 1 resident (R4) identified to have cigarette [CONDITION(S)] on clothing and wheelchair. This resulted in an immediate jeopardy (IJ) situation, substandard quality of care, for R4 who remained at risk for [CONDITION(S)] and serious injury with unsupervised smoking. The IJ began on 9/23/21, when it was identified R4 had sustained incidents of cigarette [CONDITION(S)] to his clothing and wheelchair from unsupervised smoking. On 9/23/21, at 1:52 p.m., the director of nursing (DON), administrator, and social worker (SW) were notified of the IJ for R4. The IJ was removed on 9/24/21, at 11:10 a.m., however, non-compliance remained at an isolated scope and severity which indicated no actual harm with potential for more than minimal harm (Level D). Findings include: R4's annual Minimum Data Set (MDS) assessment dated [DATE], identified moderately impaired cognition, moderately impaired vision, and did not display any episodes of rejection of care. R4's medical diagnoses included [CONDITION(S)] and heart failure. R4 required extensive assistance with activities of daily living (ADLs), used a walker and wheelchair as mobility devices, and currently used tobacco products. R4's Medical Diagnosis listing printed 9/23/21, identified R4 had difficulty in walking, muscle weakness, abnormalities of gait and mobility, and repeated falls. On 9/20/21, at 4:16 p.m. R4 was observed seated in his wheelchair with cigarettes and lighter in shirt front pocket and 3 lighters on a TV stand in his room. R4 stated he keeps his cigarettes and lighter on himself and goes outside whenever he wants to smoke, and does not wear an apron. R4's plaid shirt had eraser size holes on the bottom of shirt; the holes edges were charred and brown/black in color. When asked, R4 stated when it was windy the ashes from his cigarette might blow on his clothes. On 9/21/21, at 12:40 p.m. R4 was observed wheeling himself out of his room in a wheelchair, down the hallway, exited the facility doors and remained directly outside the glass doors of the facility. R4 removed an opened package of cigarettes from the side pocket of his green jacket, removed a cigarette and standard lighter. R4 picked up the cigarette using his thumb and pointer finger and placed it into his mouth, R4 then used his hand to hold the cigarette with his thumb and first finger and used his opposite hand to hold the lighter. R4 lit the cigarette and used his left hand to bring it to his mouth. R4 finished the cigarette at 12:48 p.m. and tossed the remaining filter and butt into the cigarette receptacle by the facility doors. R4 lit another cigarette and finished smoking at 12:55 p.m. He tossed the remaining filter and butt into the cigarette receptacle by the facility doors, re-entered the facility and proceeded to his room. On 9/21/21, at 1:00 p.m. R4 stated none of the staff had spoken to him about his smoking, nor do they come outside with him while he smokes. When questioned, he stated he was not offered a smoking apron. R4's jacket was observed to have multiple holes through the jacket. The holes were burnt through the jacket and had brown/black edges. R4 confirmed the holes were most likely from ashes from his cigarette. R4 stated he smoked several times a day always going outside on his own to smoke. R4 stated the wind caused the ashes to fly and land on his shirt, pants, and jacket. R4 stated he had never sustained [CONDITION(S)]. In addition, R4 stated some of the holes were in his clothing prior to coming to the facility. An electronic progress note written by LPN-B dated 6/10/21, at 12:26 a.m. indicated at 0020 [12:20 a.m.] an aide reported resident had a burn hole in his gray sweat pants an approximate 2.5 cm burn hole was in the upper right thigh area, burned edges were brown in color. Will pass off on report to monitor resident, resident will need a skin check to rule out an injury to cigarette [CONDITION(S)] to upper right thigh and hands. The progress note did not identify if the burn hole occurred prior to the residents admission to the faility. An electronic progress note dated 6/10/21, at 7:55 a.m. RN- B identified a skin check was completed on R4 with his bath, no bruises, skin tears or pressure areas noted, no sign of burn on leg. No [CONDITION(S)] noted in extremities will continue with current plan of care. An electronic progress note dated 6/10/21, at 10:41 a.m. SW identified R4 was reassessed for smoking and went over the smoking policy and guidelines and provided resident re-education, resident was able to demonstrate safe and independent smoking. continues to be safe to smoke his cigarettes independently and hold them and the lighter at all times. The note lacked any observation, assessment or dictation to describe how the determination had been made of R4's unsupervised smoking abilities and even though R4 had several new burn holes identified on his clothing, on 6/10/21. R4's smoking evaluation dated 6/10/21, identified talked to resident about potentially wearing a smoking apron-resident is adamantly refusing to wear a smoking apron. Concerns of burn hole in his jacket-resident denied. The smoking evaluation lacked assessment information related to burn holes on clothing or wheelchair and interventions to provide safety while R4 smoked. R4's most recent Smoking Safety Evaluation dated 9/12/21, identified R4 currently used tobacco, independent to smoke, and refused to wear smoking apron (handwrote in the comments). The assessment did not identify R4's concerns related to burn holes in clothing or wheelchair, or any information on how the burn holes and refusal of smoking apron would be addressed. R4 displayed no physical limitations which would interfere with their ability to get outside or back in the facility. The assessment listed a section labeled, Resident smokes safely and Resident utilizes ashtray safely and properly, which identified R4 did not burn furniture, clothing, skin self or others, gets ashes into ashtray, does not cause/allow sparks or lit tobacco to fall anywhere but into the ashtray. The evaluation included a section with choices that included: resident has demonstrated ability to safely smoke without supervision, resident exhibits poor safety awareness when smoking, and a care plan must be in place to promote smoking safety, resident must wear smoking apron at all times, resident requires staff assistance to hold smoking material. The option for, resident has demonstrated ability to safely smoke without supervision, was checked and no other options were checked. R4's care plan printed 9/22/21, identified R4 was an active smoker, assessed to be a safe independent smoker, strengths: alert and orientated and interventions included: will smoke in designated areas. smoking assessment completed per policy, at least quarterly. On 9/21/21, at 2:34 p.m. an interview with social worker (SW) stated she completed R4's smoking evaluations quarterly. SW stated R4 smoking evaluation included an observation while he smoked, and she stated no concerns and deemed him safe to smoke independently. SW stated R4 was offered a smoking apron, as she offered to all residents, and he refused. SW stated she was not aware of the burn holes on his jacket or his clothing, and further stated if she was aware of clothing burn holes, he would need to wear an apron to keep his privileges to smoke. SW stated R4 has had no accidents with smoking. On 9/21/21, at 2:47 p.m. an interview with registered nurse (RN)-B and nursing assistant (NA)-A stated R4 was independent with his smoking and staff did not help him, nor did R4 wear or use any adaptive devices while he smoked. RN-B and NA-A stated they have offered R4 a smoking apron in the past and he refused, and family were aware. RN-B and NA-A stated approximately six months ago burn holes in R4's wheelchair and clothing were noticed. NA-A stated she was not sure if the [CONDITION(S)] in the clothing were old or new burn holes though as he came to the facility with the clothing. NA-A confirmed R4 did not come to the facility with his current wheelchair. NA-A stated the [CONDITION(S)] in the wheelchair would have been since R4 arrived at the facility. Further, RN-B and NA-A stated they had reported these [CONDITION(S)] to the nurse(s), however, was unable to recall anyone specific it had been reported to. On 9/22/21, at 10:17 a.m. an interview with the DON stated the SW does an assessment with smoking residents and determines if the residents were safe to smoke. The DON stated R4 smokes, a lot and stated approximately three months a NA reported a burn hole in R4's jacket, the DON was unable to recall the specific person who reported it. The DON stated the SW was notified and SW reassessed R4 and determined he was safe to smoke. The DON stated she did not document the incident. The DON stated she expected residents with clothing burn holes from smoking would be offered a smoking apron. The DON was unaware if R4 was offered a smoking apron as it was the responsibility of the SW. The DON stated she was not aware of R4 wheelchair burn holes. The DON confirmed burn holes in a wheelchair and/or clothing were a safety issues and stated she would expect the burn holes and smoking safety would be discussed in Interdisciplinary Team (IDT) meetings and care conferences. The DON discussed the facility policy was residents needed to be deemed independent to smoke as the facility does not provide supervision when residents smoke. The DON stated the facility was ultimately responsible to ensure R4 was safe. DON stated information related to R4's smoking were done as in passing conversations and not documented. On 9/22/21, at 10:31 a.m. an interview with RN-C stated she is the MDS coordinator and had not completed any smoking assessments with R4. RN-C stated she participated in R4 care conferences and stated in the past concerns were brought about R4's cognition. RN-C further indicated R4's burn holes on his wheelchair were brought up in either a care conference or IDT and was discussed that R4 should wear a smoking apron and stated she was not sure of the outcome of the concerns. RN-C stated she was not aware if the SW knew about R4 wheelchair burn holes. RN-C stated staff made her aware of the burn holes, but she did not see them and was unable to recall the specific staff who talked about R4's burn holes. On 9/22/21, at 10:54 a.m. and interview with RN-A stated she heard about burn holes in R4's pants from a NA on the day shift and was unable to recall the specific staff. RN-A stated staff were to monitor R4 for more smoking concerns, and stated she was unaware who was to monitor R4. RN-A stated the SW would be responsible for following up with smoking concerns. On 9/22/21, at 11:15 a.m. an interview with the SW stated within the last two months, she was made aware of R4's burn holes in his jacket and she reassessed R4 smoking and observed no safety concerns. R4 was offered a smoking apron and refused. SW indicated she was aware of the clothing burn holes and should have considered the burn holes as part of the assessment and verified she did not assess the wheelchair for burn holes. On 9/22/21, at 5:07 p.m. an interview with NA-D stated she had observed R4 outside smoking and would see him through the facility window. NA-D stated in the past she assisted R4 outside to smoke because it was the time of day the doors were locked. NA-D stated she had never seen the ashes fall on him. NA-D stated she had observed holes on R4's clothing and wheelchair and stated she had told a nurse about the holes a few months ago, and stated she was not able to remember the nurse's name. NA-D stated the holes on the wheelchair were from burn holes when R4 smokes but stated she did not witness the [CONDITION(S)] to the wheelchair occur. Further, NA-D stated R4 was independent with using his cigarettes and lighter, On 9/22/21, at 5:12 p.m. interview with trained medical assistant (TMA)-A stated she has observed R4 going outside to smoke but was not outside when he smokes and stated she has not closely watched him smoke. TMA-A stated about two months ago she saw a burn mark on his wheelchair and was not able to recall if she reported the burn. On 9/23/21, at 7:44 a.m. an interview with family member (FM)-A stated she was aware of the burn holes in R4's clothing and wheelchair. FM-A stated the burn holes in the wheelchair were not there prior to the resident admitted at the facility. FM-A stated R4 brought his clothes from home, so there could have been from holes in his clothes prior. FM-A stated someone from the facility had called in the past and stated R4 would be monitored more related to smoking, however FM-A could not remember more specific details. On 9/23/21, at 11:00 a.m. R4's wheelchair seat was observed with SW and confirmed an approximate 6-inch area, on the seat of the wheelchair, had multiple burn holes in varying depths on the vinyl which exposed the inner lining of the wheelchair seat. The holes had black and brown charred edges. SW further stated she suspected burn holes were related to R4's smoking. Further, the medical record lacked any reaassement of R4's unsupervised smoking abilities or recorded incident report(s) related to the cigarette [CONDITION(S)] sustained on his clothing and wheelchair, nor any evidence the facility had attempted to provide on-going collaboration with R4 to develop and implement interventions or therapies to promote safety related to his unsupervised smoking to keep him safe. The facility provided no additional notes or medical record entries regarding these items during the survey. Although the facility was aware R4 had multiple burn holes on his clothing and wheelchair, they had not included this as part of the assessment or determined how these [CONDITION(S)] hole occurred. The facility had not provided on-going collaboration with R4 to develop and implement interventions to keep him safe while smoking. Policy titled Resident Smoking Policy dated 12/2017, indicated: Policy: St John Lutheran Home has Established a safe smoking policy for residents. Residents that smoke can be admitted to the facility but must adhere to the policy and procedure of Saint John Lutheran home, as well as being evaluated to be safe and independent and smoking. The facility does not encourage or promote smoking but allows for individual choice by residents deemed to be safe and smoking. Policy interpretation and implementation 1. Prior to and upon admission resident shall be informed of the facility smoking policy, and the extent to which the facility can accommodate their smoking or non-smoking preferences by social services. 2. Residents that wish to smoke and who are evaluated as independent with smoking will be allowed to smoke in dependently 4. Metal containers, with self-closing covers, are readily available in smoking areas. 6. The resident will have a Smoking Evaluation conducted on admission to determine if he or she is a safe smoker. The Smoking Evaluation will be maintained in a medical record of the resident. if a smoker, the evaluation will include: d. Ability to smoke safely without supervision (per a completed Safe Smoking Evaluation) A smoking apron will be provided by the facility if determined required by the smoking evaluation. e. Residents must be evaluated as independent with smoking. The results of the smoking evaluation will be included in the resident care plan. Any resident evaluated as NOT independent with smoking will not be allowed to smoke according to facility policy. 7. A resident's ability to smoke safely will be reevaluated upon re admission, quarterly, upon significant change (physical or cognitive), annually and as determined by staff. a. if at any time of evaluation, the resident is NOT independent or smoking or ceases to be independent with smoking they will no longer have smoking privileges. A care plan for smoking cessation will be created by social services. 9. The facility may impose smoking restrictions on a resident at any time if it's determined the resident cannot smoke safely. 11. Resident smoking articles [cigarettes; E cigarettes; lighters; matches; smoking apron] are permitted to keep in their possession. Only the smoke disposable safety lighters are permitted. All other forms of lighters including matches are prohibited 13. This facility maintains their right to confiscate smoking articles found in violation of our smoking policies. Confiscated resident smoking materials will be documented. A meeting with the resident or representative and SW according regarding the circumstances that led to the confiscation will be held. The policy lacked any direction or procedure for staff to implement on how to address cigarette burn(s) on clothing and/or skin, should they occur. No further policies or procedures related to smoking safety or unsupervised smoking were provided. The IJ which began on 9/23/21 at 1:52 p.m., was removed on 9/24/21, at 11:10 a.m. after the facility successfully implemented a removal plan which included the following: - R4 was reassessed for smoking practices and observed prior burn holes in pants and multiple burn holes on the seat of his wheelchair. R4 can hold cigarette correctly, able to light cigarette safely with lighter, disposed ash in receptacle correctly and is able to extinguish his cigarette safely when finished in receptacle. Evaluation of smoking determined he was able to smoke safely with the donning of a smoking apron to catch any potential ash that would land on his lap. R4 smoking articles included apron, lighter and cigarettes and will be kept locked up at the 1sw nurses station medication room so staff can ensure R4 wears his smoking apron on. R4 will be given one cigarette at a time to ensure his compliance. R4 was given new wheelchair and the wheelchair will be monitored for burn holes. - On 9/23/21 and 9/24/21, nursing staff on station 1sw and TR staff educated on R4's smoking assessment, care plan and requirement to wear smoking apron and those smoking articles are to be kept at desk. If R4 refuses to wear apron, then forfeits his smoking privileges. - On 9/23/21 and 9/24/21, staff in all departments educated on Smoking Policy which was revised to include all staff to report any cigarette [CONDITION(S)] to charge nurse who will then report to social service and director of nursing. Removal plan information has been posted for all departments. Staff Development will track that all staff have been educated on the removal plan. Smoking reassessment will be completed with any report of [CONDITION(S)]. Smoking policy and procedure reviewed, and changes made on 9/23/21. -R4's care plan was updated to include smoking assessment, keeping cigarettes at 1sw nurses' station, one cigarette given at a time and apron usage. Family updated and has no concerns with his safety when smoking. On 9/24/21, from 10:11 a.m.-11:08 a.m. all working staff were interviewed to ensure the updated smoking policy was read and understood, and direct care staff education had been provided related to R4 required smoking apron at all times when smoking, staff to report any burn holes or safety issues with smoking to charge nurse, smoking articles included smoking protector, cigarettes and lighter to kept as nurses station, staff to give resident once cigarette at a time to ensure his compliance with smoking apron, and included ensuring R4's wheelchair and clothing were routinely monitored for potential burn injuries and R4 used a smoking apron. Care plan printed 9/24/21, indicated R4 required smoking apron at all times when smoking, staff to report any burn holes or safety issues with smoking to charge nurse who then notify social services and DON, involve family with compliance or concerns, smoking articles included smoking protector, cigarettes and lighter to kept as nurses station, staff to give resident once cigarette at a time to ensure his compliance with smoking apron, if resident refuses to return light, reapproach at a late time family intervention as need, social service intervention as need, chaplain intervention as needed The updated policy titled Resident Smoking Policy dated 9/23/21, included the addition: Staff are to report any burn holes in clothing or other safety concerns with smoking to charge nurse immediately who will notify social services director or director of nursing.

Based on observation, interview and document review, the facility failed to follow Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control (CDC) guidelines by appropriately implementing measures to prevent the spread of COVID-19 when the facility failed to ensure personal protective equipment (PPE) including masks, were worn correctly. This had the potential to affect all 58 residents who resided in the facility. Finding include: On 9/20/21 through 9/22/21, the following mask observations were made: of staff in the facility who were not appropriately wearing face masks. Upon entrance to the facility on [DATE], at approximately 2:45 p.m., several of the facility leadership team greeted surveyors in the conference room including the administrator whose mask was below his nose. During observation on 9/21/21: 9:29 a.m.: Nursing assistant (NA)-F was at the 2nd floor nurses station talking to several unidentified co-workers with her mask below her nose. 11:47 a.m.: Social worker (SW)-A was walking in the main hallway past a section of resident rooms with her mask below her nose. 12:56 p.m.: Dietary aide (DA)-A was in first floor empty dining room with her mask below nose, wiping tables. 2:25 p.m.: While standing within a foot of R33's s face, NA-F spoke directly into R33's face with her mask below her chin. R33 was not masked. During observations on 9/22/21: 9:34 a.m.: (NA)-G was sitting at a table in the dining room area across from the nursing station with her mask below her nose. Residents were nearby in wheelchairs. 9:42 a.m.: While in the 2nd floor nurses station, standing next to registered nurse (RN)-D and talking to her, ward clerk (WC)-E had her mask below nose. 10:35 a.m.: (WC)-F was sitting in 1st floor nurses station with mask hanging from one ear. During an interview on 9/22/21, at 10:40 a.m., the director of nursing stated the expectation for all staff was to wear masks properly, with the mask covering both the nose and mouth. The DON stated she had told staff this, but there was still lack of compliance, adding, they get hot, or take a drink and pull it down. DON was informed of multiple observations of masks worn below nose and mouth, none of when an employee was taking a drink. DON acknowledged she was aware of this and stated she has addressed it with staff when she observed this. Facility policy on masking was requested and policy titled Policy for Suspected or Confirmed Coronavirus, undated, was received. Policy indicated staff would use appropriate PPE when interacting with residents per CDC (Center for Disease Control) guidance. All facility staff were required to wear a face mask while in the facility.

Based on observation, interview and document review, the facility failed to immediately implement assessments and interventions to prevent elopement for 1 of 3 residents (R1) reviewed for elopement. This resulted in an immediate jeopardy (IJ) for R1 who eloped on 10/6/20, at 3:30 a.m. out of the building and went undetected for approximately 30 minutes. R1 was found outside, approximately 62 yards from the building with scrapes to her elbows, knees, toes, fingers and temple. The facility immediately implemented interventions and corrected the deficient practice on 10/6/20. This is issued as past noncompliance at Immediate Jeopardy (IJ). The IJ that began on 10/6/20, was corrected on 10/7/20, when the facility implemented interventions to prevent reoccurrence. The administrator and director of nursing (DON) were notified of the IJ past noncompliance on 10/13/20, at 6:35 p.m. as a result of the immediate corrective action taken by the facility. Findings include: R1's [DIAGNOSES REDACTED]. R1's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R1 had moderate cognitive impairment, adequate vision and hearing, clear speech, understands and was understood. R1 required extensive assistance of one staff for bed mobility, transfers and toileting and could walk in her room with limited assistance of one staff. Following elopement on 10/6/20, R1's care plan was revised on 10/6/20 and 10/7/20, to indicate R1 was an elopement risk and staff were to observe whereabouts as R1 had periods of confusion and a tendency to wander. The care plan indicated R1 was moved to a different room and an alarm was added to her bed and chair, as well as the exit door near R1's room. During record review, a progress noted dated 10/1/20, at 11:16 p.m. indicated staff observed R1 on the security camera unsuccessfully trying to exit the building by her room. R1 told staff she was looking for her room and got mixed up. R1 denied she was trying to leave the building. The progress note indicated R1 was having an increase in confusion around supper time since admission, and the evening prior told her daughter she had to go home. During record review, a progress note dated 10/6/20, at 4:31 a.m. indicated R1 had been checked on at midnight and 2:00 a.m. and was asleep. At 4:00 a.m. rounds, R1 was not in her room. A search for R1 ensued and she was found outside the building, lying on the ground, with her walker at the bottom of the hill. When found, staff noted resident was in good spirits and prayed for help to arrive. R1 was assisted to a standing position, found to have scrapes to her elbows, knees, toes, fingers and temple, but denied pain. Wounds were bandaged and R1 was assisted back to bed. According to the five-day investigative report dated 10/8/20, R1 had been sleeping in bed on 10/6/20, at 2:00 a.m. At approximately 3:30 a.m., nursing assistant (NA)-B stated she heard the alarm go off for the exit door near R1's room. NA-B looked down the hallway and did not seen any activity, but failed to investigate further. Fifteen minutes later, NA-B discovered R1 was not in her room. During an interview on 10/12/20, at 11:03 a.m., licensed practical nurse (LPN)-A stated she was on duty the night R1 eloped. LPN-A stated NA-B and (NA)-C were doing rounds and observed R1 in her bed at midnight and 2:00 a.m. LPN-A recalls at approximately 4:00 a.m., NA-B radioed that R1 was missing. LPN-A was near the front entrance at that time, and went out the front door to look for R1 while NA-C went out the south exit, and eventually found R1. LPN-A thought the temperature outside was in the 60's and R1's arms were chilled when brought back inside. LPN-A stated nursing staff on the evening shift were responsible to activate door alarms on the control panel at the nurses station at 9:00 p.m. each day and the night shift nurse was responsible to turn them off at 4:00 a.m. LPN-A stated she recalled seeing the lights on the alarm panel when she arrived to work, indicating they were activated. During an interview on 10/12/20, at 11:15 a.m., R1 recalled the night she went outside, stating I think I was dreaming and it wasn't a good experience. R1 further stated once she fell , she was not able to get up on her own. R1 recalled feeling chilly and added that she was trying to get back home (to her assisted living residence on the same campus). During an interview on 10/12/20, at 11:40 a.m. social worker (SW)-A, who completed the Vulnerable Adult report for this incident, stated on the night of the elopement R1 exited the building at 3:30 a.m. The south exit door alarm sounded and NA-B looked down hallways, adding NA-B could not fully see R1's door due to a partition in the hallway that blocked the view. When NA-B saw no movement at the south exit door, she did not investigate further. At 3:45 a.m., R1 was discovered missing from her room. NA-C went outside to look for R1. Following the incident, R1 was moved to a different room two doors from the south exit door; staff re-education was completed, an alarm was placed on R1's bed and on the inside exit door, weekly audits of door alarm was implemented, and a verbal coaching was provided to NA-B for not for investigating why the door alarm sounded. During a telephone interview on 10/12/20, at 12:08 p.m., NA-B stated R1 was sleeping soundly at 2 a.m. when she rounded on her. When NA-B checked on her before 4 a.m. rounds, R1 was not in her room. NA-B radioed NA-C that R1 was not in her room, and notified LPN-A. All three started searching for for R1. NA-B stated when the alarm had gone off prior to noticing R1 was not in her room (around 3:45 a.m.), she had looked down the hallway and did not see anyone. At that point NA-B shut the door alarm off to silence it, then reset it. During a telephone interview on 10/12/20, at 12:35 p.m. family member (FM)-E stated she was informed of R1's elopement that morning. They told me they were doing 4:00 a.m. rounds and R1 was not in her room and they found her outside. FM-E stated R1 had no prior history of wandering, but R1 had been in the hospital for six days prior to admission with a urinary tract infection and fractured ribs from a fall at home. She wasn't herself at that point. FM-E stated the facility informed her they added a second alarm to the exit door and an alarm to R1's bed and chair to prevent reoccurrence. During a telephone interview on 10/12/20, at 1:39 p.m., NA-C stated that night NA-B radioed her to ask if she had seen R1. NA-C said she had not heard the door alarm go off, but may have been on the second floor of the facility at that time. After NA-C checked R1's room and an empty room next to it, NA-C went out the south exit door by R1's room. NA-C did not see R1 until she went around to the back of the building and found R1 laying on the private road on the east side of the facility. R1's walker was at the bottom of the hill. NA-C stated she did not know what time R1 left the building but found R1 at approximately 4:10 a.m. During an interview on 10/13/20, at 11:20 a.m. maintenance worker (MW)-A measured the distance from the south exit to the approximate location on the private road on the east side of the facility where NA-B found R1. This measured 62 yards. During an interview on 10/13/20, at 11:38 a.m., the director of nursing (DON) indicated the following actions were taken after R1 eloped on 10/6/20: an alarm was added to the inside door of the south exit, a note was placed on the alarm panel indicating this door alarm was to remain on at all times, staff received education on use of alarms and responding to alarms, and NA-B received a disciplinary coaching. After the first elopement attempt on 10/1/20, DON stated they did not move R1 to a room further away from exit door, but removed R1's purse and keys from her procession, thinking it would make R1 not think about going home since she lives across the street. DON added I guess the only other thing we could have done was to start the tab alarms sooner. DON stated a resident's elopement risk was not reassessed after an elopement or an elopement attempt; it's only reassessed quarterly and is not currently being done if there is a new attempt to leave or elopement. DON reiterated that NA-B did not physically look for R1 on 10/6/20 and turned the alarm off to silence it, then immediately turned it back on to reset it, which was why other staff did not hear the alarm. DON stated it was her expectation all staff take door alarms seriously and fully investigate when an alarm sounds, stating it was required in order to ensure safety of the residents and staff. During an interview on 10/13/20, at 12:16 p.m., administrative support (AS)-D played the security camera footage from 10/6/20: --3:28 a.m.: R1 is observed walking with her walker, leaving through both sets of exit doors on the south side of the building, disappearing into the dark. --4:06 a.m.: Staff are seen coming in through the employee entrance with R1 in a wheelchair. In addition, R1's attempt to exit the building on 10/1/20 was viewed on security camera footage: --6:59 p.m.: R1 is seen walking with her walker, opening the first exit door. The door opens momentarily, then closes. --7:05 p.m.: R1 is seen again attempting to push walker through exit door. The door closed, pushing R1 back into the hallway. R1 had gotten about a foot into the vestibule with her walker before the door pushed her back. During an interview on 10/13/20, at 1:40 p.m. DON verified an elopement risk assessment completed on admission and dated 9/29/20, failed to identify whether or not R1 was an elopement risk. DON stated when a nurse completes an elopement risk assessment form, they were to document their analysis by describing and summarizing the overall risk. During an interview on 10/13/20, at 3:00 p.m., health information manager (HIM)-C stated she was responsible for updating the document titled high risk elopement which included color photos, names and room numbers of residents deemed high risk for elopement. According to HIM-C, R1's photo was added on 10/6/20. This document was routed to all departments, and staff were to contact nursing staff if any of the residents were seen outside of their corridor without supervision. Facility policy titled Wandering Resident/Elopement, dated 5/2016, indicated the following: 1. The entire staff at the facility has the responsibility to provide security and safety for their resident population. 2. Nursing or social services will do an initial screening for wandering/elopement risk when gathering initial intake information. 3. During admission process each potential resident will be screened for potential of elopement risk to evaluate appropriate placement. 4. Any resident identified as at risk for wandering or elopement will have their picture taken on admission and share/posted with all other departments. 5. Any elopement risk assessment will be performed and care plan will be developed/reviewed/revised to ensure safety. 6. Nursing and/or social services will complete an elopement risk assessment on admission and the resident's risk will be reviewed quarterly and as needed with any significant changes. Information will be obtained from admission assessment, family, resident interviews, staff observations and social history. 7. A care plan identifying wandering and elopement risks will be implemented on admission with quarterly review as needed. 8. If a resident leaves the building without informing the staff, measures will be taken to locate and return the resident to the facility. 9. Appropriate delegation will be made to engage in the search procedures. 10. All areas will proceed to conduct a thorough search. 11. An Elopement Investigation Report will be completed. Results will be shared at Quality Assurance. Facility policy titled Door Alarms, dated 10/6/20, indicated the following: 1. It is the policy of the facility to ensure the safety of residents and staff with the use of door alarms. This policy will ensure proper procedure when a door alarm sounds. 2. Door alarm panel is located behind the nurses station. 3. Charge nurse is responsible for turning alarms on in the evening and off in the morning. 4. Certain doors alarms are to remain on at all times. These are posted on the alarm panel. 5. If door alarm sounds, staff are to check the panel for which door. Staff are then to check the door for any activity outside of the door. 6. Do a resident check on the hallway if no activity noted outside. The past non-compliance IJ that began on 10/6/20, was verified during the 10/12/20 - 10/14/20, onsite visit to have been corrected by the facility on 10/7/20. The verification of corrective action was confirmed by staff interviews, observations and record review. New alarms put in place were observed (door and bed), the panel alarm at the nurses' station was observed, alarm audits were reviewed. R1's photo was added to the facility high risk elopement tool. R1's care plan was updated to include new elopement interventions; staff re-education was completed and NA-B received a disciplinary coaching.

Based on interview and document review, the facility failed to promptly notify the physician for 1 of 10 residents (R78) in the sample who was reviewed as a death record. The facility's failure to promptly notify the physician resulted in harm to R78. Findings include: R78's physician was not informed of a significant change in her condition related to low oxygen (O2) saturation rates and elevated pulse rates. The resident expired at the facility. R78 was admitted to the facility at 12: 40 p.m. on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's hospital discharge summary dated [DATE], indicated R78 had been admitted to the hospital on [DATE] from her home, with [DIAGNOSES REDACTED]. R78's medications had been adjusted during her hospital stay and she had subsequently been discharged to the nursing home in stable condition on [DATE]. The discharge summary indicated the resident's pulse rate was 104 and her O2 saturation levels had measured 95% at the time of hospital discharge. (A normal blood oxygen saturation reading is between 95 to 100 percent, as measured by a pulse oximeter.) Review of the facility's admission notes for R78 dated [DATE] at 5:00 p.m., indicated the resident had increased anxiety and SOB (shortness of breath). The notes further indicated that the resident's O2 saturation levels had dropped to the upper 60%s. The notes described that R78 utilized accessory muscles and pursed lip breathing with shoulder heaving. The nurse's entry further stated that R78 was anxious about her medication changes on admission and wanted to take the ambulance to the hospital. The Interdisciplinary Progress Note (IDT) revealed that the resident did not think she would live through the night. The on-call physician had been notified at that time and had modified the resident's medication orders [REDACTED]. At 11:30 p.m. on [DATE], the IDT notes indicated that the resident was calmer and less anxious. Oxygen saturations were documented as "52% to 67%" with the resident using pursed lip breathing. The resident's pulse was recorded as a range, "128 and 135". The IDT notes on [DATE] at 2:00 p.m., stated R78 was laying on her bed in a fetal (knees curled up to chest) position. The notes described the resident as being short of breath, with diminished lung sounds but no wheezing. The note also indicated R78 had requested the physician be called, and that the resident had been told by staff that she had physician orders [REDACTED]. The notes further revealed that at 3:00 p.m. R78 again was requesting the physician to be called and wished to be transferred to the hospital. The nurse had documented that after checking regulations they were unable to transfer the resident directly to her hospital of choice. The resident would have to be stabilized at the local hospital before they could transfer her to her hospital of choice, which was 30 miles away. The resident therefore declined because she did not want to go to the local hospital. [MEDICATION NAME] was administered and the resident then became less anxious. The IDT notes on [DATE] at 2:50 p.m, stated R78 had increased anxiety and that her O2 saturations were at 63%. The notes indicated the resident's appetite was poor and the resident had eaten only bites at breakfast and dinner. Further review of the notes revealed that at 4:45 p.m. the resident's family had expressed concern about the resident's low O2 saturation levels. At 4:50 p.m. on [DATE], R78's O2 saturation level was recorded at 62% and her pulse was recorded as 121. Additional nurse's notes indicated the resident had utilized the [MEDICATION NAME] inhaler at 5:15 p.m. and had received prn [MEDICATION NAME] at 10:00 p.m. The notes then indicated the resident had become quiet with no further complaints. The IDT notes on [DATE] at 9:00 a.m, indicated R78's O2 saturation levels measured 72% with the supplemental oxygen running at 3 liters. The note further included that the resident was harder to understand due to her increased weakness and continued SOB. An entry at 10:00 a.m, indicated the resident was somewhat anxious and had received a prn [MEDICATION NAME] at 7:00 a.m. The notes identified the resident as having little effect from the [MEDICATION NAME]. Further review of the IDT notes revealed an entry at 11:30 a.m. that indicated the resident was not responding to conversation and her family had decided that they wanted her hospitalized . The hospital had been notified and an ambulance summoned. According to the notes, by the time the ambulance had arrived at 11:45 a.m. and applied an O2 nonrebreather, the resident had been gasping for air. R78 expired at 11:50 a.m. Although the resident's physician had been notified shortly after admission of her initial anxiety and decreased oxygen saturation levels, R78 continued to decline, without further notification of the physician. During interview with RN (registered nurse)-D at 8: 26 a.m. on [DATE], she stated that she'd thought R78 was supposed to receive "comfort care" because of her end stage [MEDICAL CONDITION]. She further stated she felt there was not much more to do for the resident. However, RN-D stated that she had not expected the resident to die so soon after admission. She stated that she did not expect the physician to be notified when the resident's O2 saturations had declined, because they had [MEDICATION NAME] to give the resident. In addition, RN-D stated that she felt the resident had a lot of fear because she had a hard time breathing and that made her more anxious. She also stated that if they had notified the physician over the weekend they may not have gotten a response, because it is difficult to get a response from physicians on weekends. RN-D stated she would have faxed the physician on Monday if the resident had not expired. RN-C, who had cared for R78 on ,[DATE] and [DATE] was interviewed at 9:51 a.m. on [DATE]. RN-C also stated that she thought the resident had been admitted for comfort care and that she hadn't thought she should call the physician when the resident's O2 saturation declined. She stated she felt the [MEDICATION NAME] was enough to keep the resident comfortable. During interview with the DON (director of nursing) at 1:00 p.m. on [DATE], she stated she would have expected the nurses to call the physician when R78's O2 saturation levels dropped to 54% with a pulse rate of 135 on [DATE]. However, the DON clarified at 12:06 p.m. on [DATE], that she had not been aware of the resident's decline in condition, nor the way the nursing staff had handled the situation, until the surveyor had brought it to her attention. LPN (licensed practical nurse)-E, who had cared for R78 on ,[DATE], ,[DATE] and [DATE], was interviewed at 11:27 a.m. on [DATE]. She stated she could not remember R78's history very well, however she stated she had thought R78 was supposed to receive comfort cares. The surveyor reviewed LPN-E's IDT notes with her from an entry 11:30 p.m. on [DATE]. The LPN's notes had indicated that R78's O2 saturations were at 52% and her pulse had been 135. LPN-E stated she could not recall the resident's condition from that evening. LPN-E stated that if she had concerns regarding a resident's condition, she would report those concerns to the RN working that shift. LPN-E stated she could not recall whether she had reported the resident's condition to the RN. RN-W (in charge the evening of [DATE]) was interviewed at 4:00 p.m. on [DATE]. She stated she had not been informed of R78's condition changes on [DATE]. RN-W further indicated that if she would have been made aware of the resident's decline in her O2 saturations, she would have assessed the resident and contacted the physician for further direction. Attempts to reach the resident's physician were made several times during the survey. The physician responded post survey by telephone at 5:30 p.m. on [DATE]. The physician stated she had not been made aware of the R78's decline in O2 saturation levels nor increase in pulse rate. She said she would have expected to have been notified when the resident's oxygen levels started to decline along with her overall condition. She stated that if she had been notified, she could have discussed the resident's wishes for hospitalization , comfort measures or even hospice care with the resident, her family and staff. Review of the facility's policy: Change of Condition Notification dated ,[DATE], indicated that timely notification of the physician regarding a resident's acute illness, serious accident or death was expected. The procedure included for the staff to notify the physician regarding a significant change in the resident's physical, mental, psychosocial status, a decision to transfer or discharge the resident from the facility, or expected or unexpected resident death. The policy further indicated that the physician must be notified in a timely manner of a significant change as soon as an assessment was completed. "...Including the overall expected decline of health, keep the physician updated every ,[DATE] days unless specified by the physician. Mental or Psychosocial status change in life threatening conditions or clinical complications. Contact Physician by fax and follow up by a phone call if condition warrants faster action. If an incident of a Chronic Condition occurs care plan the possibility of incident and discuss with the doctor what his/her wishes are regarding notifications."

Based on observation, interview and document review, the facility failed to provide the necessary care and services, to attain or maintain the highest practicable physical well-being for 1 of 10 residents (R78) in the sample whose death was reviewed; 1 of 3 residents (R44) reviewed for non-pressure related skin conditions (bruising); and 1 of 3 residents (R39) reviewed for pain. The failure to provide adequate care resulted in harm for R78. Findings include: R78 had a decline in her condition following admission, including low oxygen (O2) saturation rates and elevated pulse rates. The resident died 3 days after admission. R78 was admitted to the facility at 12: 40 p.m. on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's hospital discharge summary dated [DATE], indicated R78 had been admitted to the hospital on [DATE] from her home, with [DIAGNOSES REDACTED]. R78's medications had been adjusted during her hospital stay and she had subsequently been discharged to the nursing home in stable condition on [DATE]. The discharge summary indicated the resident's pulse rate was 104 and her O2 saturation levels had measured 95% at the time of hospital discharge. (A normal blood oxygen saturation reading is between 95 to 100 percent, as measured by a pulse oximeter.) The preliminary plan of care (temporary care plan) developed for R78 on [DATE], indicated the resident should have oxygen on at ,[DATE] liters continuously to maintain O2 saturations at ,[DATE]%. Review of the facility's admission notes for R78 dated [DATE] at 5:00 p.m., indicated the resident had increased anxiety and SOB (shortness of breath). The notes further indicated that the resident's O2 saturation levels had dropped to the upper 60%s. Although the Vital Sign (VS) flow sheet identified an O2 saturation levle of 54%. The notes described that R78 utilized accessory muscles and pursed lip breathing with shoulder heaving. The nurse's entry further stated that R78 was anxious about her medication changes on admission and wanted to take the ambulance to the hospital. The Interdisciplinary Progress Note (IDT) revealed that the resident did not think she would live through the night. The on-call physician had been notified at that time and had modified the resident's medication orders [REDACTED]. At 11:30 p.m. on [DATE], the IDT notes indicated that the resident was calmer and less anxious. Oxygen saturations were documented as "52% to 67%" with the resident using pursed lip breathing. The resident's pulse was recorded as "128 and 135". The VS flow sheet entry from 9:00 p.m. indicated the resident had an O2 Saturation of 54%. The VS flow sheet included oxygen saturation and pulse rate monitoring documented on [DATE] to include: 1:00 a.m. (O2 Sats 68%, Pulse 114); 5:00 a.m. (O2 Sats 70%, Pulse 121); 9:00 a.m. (O2 Sats 65%, Pulse 130); 1:00 p.m. (O2 Sats 74%, Pulse 106). The IDT notes from 2:00 p.m. [DATE], indicated R78 was laying on her bed in a fetal (knees curled up to chest) position. The notes described the resident as being short of breath, with diminished lung sounds but no wheezing. The notes also indicated R78 had requested the physician be called, and that the resident had been told by staff that she had physician orders [REDACTED]. An entry at 2:15 p.m. on the VS flow sheet indicated an O2 saturation of 68% with a pulse rate of 124. The IDT notes revealed that at 3:00 p.m. R78 again was requesting the physician to be called and wished to be transferred to the hospital. The nurse had documented that after checking regulations they were unable to transfer the resident directly to the hospital of R78's choice. The resident would have to be stabilized at the local hospital before they could transfer her to her hospital of choice, which was 30 miles away. The resident therefore declined because she did not want to go to the local hospital. [MEDICATION NAME] was administered and the resident became less anxious. The VS flowsheet documentation included a 10:00 a.m O2 saturation of 72% with a pulse rate of 113 on [DATE]. The IDT notes from 2:50 p.m. [DATE], indicated R78 had increased anxiety and that her O2 saturations were at 63%. The notes indicated the resident's appetite was poor and the resident had eaten only bites at breakfast and dinner. Further review of the notes revealed that at 4:45 p.m. the resident's family had expressed concern about the resident's low O2 saturation levels. At 4:50 p.m. on [DATE], R78's O2 saturation level was recorded at 62% and her pulse was recorded as 121. Additional nurse's notes indicated the resident had utilized the [MEDICATION NAME] inhaler at 5:15 p.m. and had received prn [MEDICATION NAME] at 10:00 p.m. The notes then indicated the resident had become quiet with no further complaints. The IDT notes from 9:00 a.m. [DATE], indicated R78's O2 saturation levels measured 72% with the supplemental oxygen running at 3 liters. The notes further included that the resident was harder to understand due to her increased weakness and continued SOB. An entry at 10:00 a.m. on [DATE], indicated the resident was somewhat anxious and had received a prn [MEDICATION NAME] at 7:00 a.m. The notes indicated the resident had received little effect from the [MEDICATION NAME]. Further review of the IDT notes revealed an entry from 11:30 a.m. on [DATE] that indicated the resident was not responding to conversation and her family had decided that they wanted her hospitalized . The hospital had been notified and an ambulance summoned. According to the notes, by the time the ambulance had arrived at 11:45 a.m. and applied an O2 nonrebreather, the resident had been gasping for air. R78 expired at 11:50 a.m. Although guidelines for the resident's oxygen saturation levels had been identified in a temporary plan of care, the levels had dropped below the recommendation on several occassions and the resident's physician had not been been kept informed. During interview with RN (registered nurse)-D at 8: 26 a.m. on [DATE], she stated that she'd thought R78 was supposed to receive "comfort care" because of her end stage [MEDICAL CONDITION]. She further stated she felt there was not much more to do for the resident. However, RN-D stated that she had not expected the resident to die so soon after admission. She stated that she did not expect the physician to be notified when the resident's O2 saturations had declined, because they had [MEDICATION NAME] to give the resident. In addition, RN-D stated that she felt the resident had a lot of fear because she had a hard time breathing and that made her more anxious. She also stated that if they had notified the physician over the weekend they may not have gotten a response, because it is difficult to get a response from physicians on weekends. RN-D stated she would have faxed the physician on Monday if the resident had not expired. RN-C, who had cared for R78 on ,[DATE] and [DATE] was interviewed at 9:51 a.m. on [DATE]. RN-C also stated that she thought the resident had been admitted for comfort care and that she hadn't thought she should call the physician when the resident's O2 saturation declined. She stated she felt the [MEDICATION NAME] was enough to keep the resident comfortable. During interview with the DON (director of nursing) at 1:00 p.m. on [DATE], she stated she would have expected the nurses to call the physician when R78's O2 saturation levels dropped to 54% with a pulse rate of 135 on [DATE]. However, the DON clarified at 12:06 p.m. on [DATE], that she had not been aware of the resident's decline in condition, nor the way the nursing staff had handled the situation, until the surveyor had brought it to her attention. LPN (licensed practical nurse)-E, who had cared for R78 on ,[DATE], ,[DATE] and [DATE], was interviewed at 11:27 a.m. on [DATE]. She stated she could not remember R78's history very well, however she stated she had thought R78 was supposed to receive comfort cares. The surveyor reviewed LPN-E's IDT notes with her from an entry 11:30 p.m. on [DATE]. The LPN's notes had indicated that R78's O2 saturations were at 52% and her pulse had been 135. LPN-E stated she could not recall the resident's condition from that evening. LPN-E stated that if she had concerns regarding a resident's condition, she would report those concerns to the RN working that shift. LPN-E stated she could not recall whether she had reported the resident's condition to the RN. RN-W (in charge the evening of [DATE]) was interviewed at 4:00 p.m. on [DATE]. She stated she had not been informed of R78's condition changes on [DATE]. RN-W further indicated that if she would have been made aware of the resident's decline in her O2 saturations, she would have assessed the resident and contacted the physician for further direction. Attempts to reach the resident's physician were made several times during the survey. The physician responded post survey by telephone at 5:30 p.m. on [DATE]. The physician stated she had not been made aware of the R78's decline in O2 saturation levels nor increase in pulse rate on [DATE]. She said she would have expected to have been notified when the resident's oxygen levels started to decline along with her overall condition. She stated that if she had been notified, she could have discussed the resident's wishes for hospitalization , comfort measures or even hospice care with the resident, her family and staff. R39 had been identified as having pain daily. Nursing staff failed to utilize interventions to effectively control and relieve the resident's pain. R39 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Since admission to the facility, R39 had experienced an alteration to her mobility related to arthritic changes, pain indicators, upper extremity stiffness and tight fists. During observations of R39 at 1:30 p.m. on [DATE], she was sitting in a recliner in the lounge muttering loudly. The resident's was observed to be making a grimacing facial expression. R39 also appeared restless as she was moving her arms and legs up and down. During an observation of R39 at 2:22 p.m. on [DATE], she was laying in the recliner in the lounge with her eyes closed. The resident was heard to be moaning out occasionally and was observed to move her head back and forth. During an observation of R39 at 11:00 a.m. on [DATE], she was observed to be assisted by two staff to the toilet. R39 was observed to moan out during the transfer and appeared to be guarding her body. R39's record was reviewed. The resident had physician orders [REDACTED]. These orders have remained unchanged over the past year. Review of the medication administration records (MARs) for the months of September, October and [DATE], indicated R39 had received the [MEDICATION NAME] and [MEDICATION NAME] as prescribed. She had only utilized the [MEDICATION NAME] to her teeth on [DATE], and had not utilized any prn Tylenol. The resident's most recent annual Minimum Data Set ((MDS) dated [DATE], revealed the resident had indicators of pain that were observed daily. The MDS indicated the resident expressed non-verbal sounds such as whining, moaning, groaning and facial grimaces. In addition, R39 also displayed body movements of bracing and guarding. The assessment further indicated that R39 had not received prn pain medication during the assessment period and also had not utilized non-medication interventions for pain. Further review of the assessment notes dated [DATE], indicated R39 had non-verbal indicators of pain with movement, especially with the upper extremities, hands, and occasionally of her gums and teeth. The MDS indicated R39 would occassionally holler out with cares and identified the resident as having obvious or likely cavities or broken natural teeth. The corresponding Geriatric Pain Record completed on [DATE], indicated that R39 had daily observed pain. The record indicated that the resident exhibited non-verbal indicators of pain by calling out, grimacing and guarding and protecting her body parts. It further identified the potential locations and related [DIAGNOSES REDACTED]. The interventions for relieving the pain were identified as rest, mild exercise, [MEDICATION NAME], [MEDICATION NAME], prn tylenol and prn [MEDICATION NAME]. Although the resident had been identified as having uncontrolled pain, review of the medication administration records indicated neither the PRN tylenol or [MEDICATION NAME] had been utilized since the assessment had been completed. R39's current plan of care was reviewed. There was a problem statement for the resident indicating an alteration in comfort, related to a history of right knee discomfort, [MEDICAL CONDITION] right hip, contracture of the left hand, stiff shoulders and poor dentition. Interventions included: 1) medicate with [MEDICATION NAME], [MEDICATION NAME], prn tylenol and prn [MEDICATION NAME] for breakthrough pain that is not relieved by non pharmacy interventions. 2) Report to charge nurse any indications of changes with usual comfort, especially when at rest. 3) Rest periods between meals or mild exercise. 4) Reassure with transfers, proceed slowly. Review of the nurses' notes revealed no regular documentation of monitoring the resident's pain. During interview with NA-O at 7:00 p.m. on [DATE], she stated that R39 does become resistive and would occassionally yell out when staff move her or provide cares. During interview with RN-B at 10: 52 a.m. on [DATE], she confirmed that R39 had been identified as having daily observed pain. She also confirmed that since the completion of the assessment in October there had been no new interventions tried to promote comfort and relief for the resident's pain. RN-B stated she felt the resident would not get relief regardless of what was tried. She stated the resident mostly had pain with movement. When questioning RN-B about why the PRN Tylenol had not been tried before transfers, range of motion to hands, and/or activities of daily living, she stated again that the medication probably would not relieve the resident's pain anyway. RN-B also stated that R39 may be having oral pain due to her poor dentition, but she could not explain why the [MEDICATION NAME] had not been used since September of 2011. During interview with R39's daughter at 11:00 a.m. on [DATE], she stated she visited her mom routinely and was aware of her pain. R39's daughter further stated that she felt her mother also had pain in her joints. She said when she would move her mother's hands or shoulder, her mother would holler out and pull away from her. During interview with NA-M at 2:20 p.m. on [DATE], she stated that R39 had pain mostly with movement of her upper extremities. NA-M further indicated that the resident would pull away or yell out with pain during care. The DON was interviewed at 11:40 a.m. on [DATE]. She stated that based on the resident's status, and recent assessment, she would have expected staff to utilize the prn medications to promote comfort for the resident. Review of the facility's 'Pain Policy' dated ,[DATE], revealed that the facility's goal is to assure that all residents are assessed for pain. The policy indicated the facility would provide for optimal pain control through appropriate and timely data collection, treatments, documentation and monitoring of each resident's pain status. In addition, the policy indicated that cognitively impaired residents were to be observe for vocalizations, calling out, facial grimaces upon movement, increased restlessness, irritability, aggressive behaviors or resistance to personal cares. According to the policy, it might be necessary to "trial" a pain medication to determine if indicators of pain could be lessened for someone who cannot express themselves. The facility failed to comprehensively assess R44's risk factors for bruising, and failed to develop interventions for prevention. During initial observations of R44 at 1:48 p.m. on [DATE], he was noted to have two dime sized bruises on his left middle finger and was observed to be wearing protective arm sleeves. At 7:00 p.m. on [DATE], RN (registered nurse)-D was interviewed about the bruising observed on R44's left hand. RN-D stated R44 frequently had bruising. RN-D further stated R44 often seemed to sustain bruises from the use of the mechanical lift he utilized for transfers. RN-D stated the mechanical lift had been padded. R44's current care plan dated ,[DATE], indicated R44 was at risk for alteration in skin integrity related to a history of actinic [DIAGNOSES REDACTED] of left ear, immobility, incontinence and decreased nutrition. The care plan failed to identify the resident's history of bruising, risk factors or interventions necessary for prevention. R44's medical record was reviewed and included the following notations about bruising: On [DATE], R44 was identified with a 4 cm (centimeter) x 3 cm hematoma (bruise) on his right hand. The note indicated R44 had stated he'd bumped his hand on the table. On [DATE], R44 was identified with a bruise on top of his right hand which measured 5 cm x 3 cm. On [DATE], R44 was identified with bruised areas to his left thumb (2 cm), top of left arm (1 cm), right thumb (2 cm), top of right arm (2 cm), and left inner arm (5 cm x 2 cm). The note indicated staff had reported the findings following provision of care. A 'Head to Toe Skin Check' had been documented on [DATE]. The RN who had documented the skin check had noted that R44's skin was "within normal limits and free of bruising or purpura." A review of the 'Nurses' Notes' from [DATE] to [DATE] failed to identify any skin issues including bruising. At 9:03 a.m. on [DATE], nursing assistant (NA)-P was interviewed about R44's bruising. She stated the resident often had bruising on his hands and arms related to leaning and throwing his hands out and striking them against items. She stated he would throw his arms out while being wheeled in his chair and strike the wall, wheel chairs, or lifts. At 9:05 a.m. on [DATE], R44 was observed seated in the second floor's North dining room in a reclined wheel chair. During the observation, R44 was noted to have multiple bruised areas over both arms, hands, and fingers. The bruising was noted to be at different stages of healing ranging from yellow in color to dark purple. R44 was not wearing sleeve protectors. At 10:40 a.m. on [DATE], NA-S was interviewed. She stated she'd put R44's sleeve protectors on his arms late because he had a bath. She stated R44 often swung his arms out and struck them against things. She verified he had numerous bruises on his hands and arms. At 11:00 a.m. on [DATE], the Director of Nurses (DON) was interviewed. The DON stated staff should have documented incident reports for the current bruising. She further confirmed the care plan should have addressed the resident's bruising. The DON also stated she was unable to locate an assessment related to R44's risk factors for bruising in his medical record. During interview with RN-C at 11:05 a.m. on [DATE], she verified R44 had multiple bruises and stated he had not had the bruising when she'd checked his skin at 7:00 p.m. on [DATE]. She verified R44 frequently had bruising and stated the staff conducted a weekly skin audit on bath days. She verified R44's last skin check from [DATE], indicated he had no bruising.

Based on observation, interview and record review, the facility failed to provide adequate supervision to minimize the risk of falls for 2 of 6 residents in the sample (R9 and R127). The lack of supervision resulted in harm to R9. The findings include: R9 was not supervised adequately while using the bathroom, attempted to stand independently and fell , sustaining a laceration to the back of her head which required emergency medical treatment. She required 4 staples to the injury. R9 had been admitted to the facility's memory care unit in 2005. Her [DIAGNOSES REDACTED]. Review of the medical record revealed R9 had experienced 4 falls in the past 6 months. The resident's most recent fall had occurred on 1/24/11. The record indicated R9 had been left alone on the toilet at 9:30 a.m. on 1/24/11 when the nursing assistant (NA) caring for her had stepped out of the room to retrieve an incontinent product. The nurses' notes from the incident indicated the resident had attempted to independently stand, and had fallen. R9 had sustained a one and three quarter inch laceration to the back of her head. The resident had been sent by ambulance to the local hospital where the laceration required 4 staples. The other falls R9 had experienced in the past 6 months included: 1) 7/27/10- the resident fell when attempting to get out of bed independently. 2) 9/6/10- the resident fell out of her wheelchair. 3) 10/16/10- the resident had attempted to get up from the recliner to sit in another chair and had fallen. An assessment dated [DATE], indicated the resident had a history of [REDACTED]. The assessment indicated the resident had physical performance limitations, balance problems during transitions requiring staff assist to balance, and an unsteady shuffling gait. The assessment also indicated the resident needed extensive assistance with transferring and indicated the resident would transfer self unsafely. "Resident is at risk for falls and history of attempting to transfer self. Will proceed to care plan as resident is at risk for falls." The resident's care plan, last revised 12/14/10, included a problem statement of: "High risk for falls and impaired mobility related to history of falls, unsteady gait, attempts to self transfer independently unsafely, [DIAGNOSES REDACTED]." Other problems identified on the care plan included: "Impaired cognition related to multi infarct dementia, history of confusion, and wandering manifested by short and long term memory loss and moderately impaired decision making, " and "Extensive physical assist of 1-2 with toileting at all times, wears briefs at al times, staff assist to change." The care plan included the following fall prevention interventions: chair pad alarm, automatic brake locks on the wheelchair, perimeter mattress the bed, use of a low bed, restorative nursing daily, and for staff to ask if she would like to sit in a different chair after meals. R9 was observed at a table with staff observing a card game at 5:15 p.m. on 1/25/11. The resident was observed to sit quietly, under direct supervision of staff. R9 was observed to have a clip alarm fastened to her clothes, and the wheelchair was observed to have brakes that would automatically lock if the resident was to remove pressure from the seat of the wheelchair. NA-V was interviewed at 9:45 a.m. on 1/27/11. She stated that in addition to the clip alarm and the automatic brakes, the resident had a pressure sensitive alarm pad on the seat of her wheelchair that would sound if the resident attempted to stand. Registered nurse (RN)-A was interviewed at 10:15 a.m. on 1/26/11. She confirmed that R9 needed extensive assist with toileting and transfers. RN-A stated that R9 had fallen from the seated position in the past and now had a chair pressure alarm and automatic locking brakes on her wheelchair. When asked, she verified that R9 had impaired judgement and memory loss. RN-A confirmed that the care plan had not specified that R9 needed someone to stay with her while on the toilet until. When asked about the resident's safety with transfers, she confirmed that the resident had difficulty with transitions as stated in the assessment information. Interview with the SW (social worker)-Y at 10:55 a.m. on 1/27/11, confirmed that if a resident's care plan stated extensive assist with transfers and toileting, she would expect someone to stay with the resident when they were on the toilet as part of their vulnerable adult risk prevention plan. R127 experienced falls on 1/23/11 and 1/24/11. The facility failed to provide adequate supervision or assistance to prevent further falls. R127 had been admitted to the facility's memory care unit on 12/30/10. His [DIAGNOSES REDACTED]. Record review revealed that R127 had been found on the floor in the dining area on 1/23/11 at 7:30 p.m. The resident had stated that he had tripped over the leg pedals on the wheelchair that had been used to transfer him to the toilet. The resident had sustained a skin tear to the left elbow. No further injuries had been noted. An incident report completed on that date revealed steps taken to prevent recurrence: "remove leg pedals from the wheelchair." Review of the repeat post-fall report related to the incident identified as the cause of the fall: "unsafe condition, tripped over wheelchair pedals." Further record review revealed nurse's notes from 1/24/11 that R127 was not feeling well, was more confused, complained of a sore throat and had a low grade temperature. The nurses' notes stated that the resident had spit out Tylenol when the nurse had attempted to give it, and indicated that the resident had been seated in a wheelchair after supper due to unsteady gait and poor balance. At 8:30 p.m. on 1/24/11, R127 had been found on the floor next to his wheelchair. The incident report of the same date included: "appears attempted to get up from w/c (wheelchair) and fell ." R127 was observed at 7:30 a.m. on 1/26/11 walking independently about the unit. He asked the staff where he could go to use the "can." Staff was observed to lead him by the hand to the bathroom. At 8:10 a.m. R127 was observed to have spilled water on his pants while sitting in a stationary chair across from the nurses' desk. Staff was then observed to have assisted R127 into a wheelchair and to take him to his room to change his pants. At 8:20 a.m. R127 was wheeled back to the dining area and left in the wheelchair with foot pedals attached and in the up position. At 9:00 a.m. R127 was observed asleep in the wheelchair in the dining room. One staff was present in the area. Staff had then moved R127 more to the edge of the room. At approximately 9:20 a.m., R127 was observed leaning over and trying to move the foot pedals that were in the up position. At 9:25 a.m. the resident stood from the wheelchair without locking the brakes. A dietary staff in the area noticed his unsteady stance as he tried to stand and maneuver around the foot pedals on the wheelchair. The dietary staff watched R127 and supervised him until NA-B was able to assist the resident. The NA-B instructed R127 to sit back down. She placed his feet onto the foot pedals and wheeled him to the bathroom. The staff wheeled R127 back to the dining area and up to the table to participate in an activity, leaving the resident's feet on his foot pedals. R127's record was reviewed. An initial MDS (minimum data set) with an assessment reference date of 1/8/11, revealed that the resident had problems with being inattentive, had trouble with sleep, poor appetite, and was easily annoyed. The MDS also indicated that the resident had experienced a fall prior to admission. An assessment completed in conjunction with the initial MDS indicated that the resident had fallen at home prior to admission and that the resident currently had a potential for falls. The assessment also included, "takes lisinopril for hypertension, Seroquel (an antipsychotic medication), and Haldol (also an antipsychotic medication) as needed which can increase risk for falls. Internal risk factors include incontinent of urine, wanders, agitation, cognitive impairment and Alzheimer disease. He did fall ..prior..to admission. Proceed to care plan." Review of the resident's current plan of care revealed interventions for fall prevention including: supervision with transfers and locomotion on unit. The care plan indicated the resident ambulated independently but needed supervision to specific locations. Orthostatic blood pressures were to be monitored monthly. During interview with RN-A at 10:05 a.m. on 1/26/11, she confirmed that R127 was at a greater risk of falling when left to sit in the wheelchair. RN-A stated that 1/26/11 was her first day to work since the 2 incidents had occurred. She stated that she had not yet reviewed the reports. She confirmed that staff should transfer R127 to a stationary chair when he was in the common area to prevent further falls. She confirmed that staff could use the wheelchair to transport the resident to the bathroom since he was not feeling well and was unsteady with ambulation. When asked who was responsible to review the incidents and make changes to the plan of care in her absence, RN-A stated that the director of nursing or the assistant director of nursing should have reviewed the reports, updated the plan of care, and informed the staff of any changes to the plan of care.