Every finding on record at St Johns on Fountain Lake

Based on observation, interview and document review, the facility failed to ensure dishwasher water temperatures in 3 of 3 neighborhood kitchens were monitored to ensure proper sanitization of dishes. In addition, the facility failed to ensure metal pans in the main kitchen were dry before storing. This had the potential to affect all 77 resident who resided in the facility. Findings include:During the initial kitchen tour on 12/1/2025 at 10:55 a.m., dietary director (DD)-C, was asked to lift several metal pans and metal bowls of various sizes - all of which were stacked upside down on a wire shelving unit. Observed one wet 9 X 13-inch pan and three wet extra-large stainless bowls. DD-C stated staff were supposed to set wet dishes on a wire rack in clean side of the dish room to completely dry before storing. DD-C stated it was important to ensure no bacteria grew on the pans used to prepare and cook resident food. DD-C stated staff were trained to dry dishes completely before storing and did not know why that had not been done. During an observation and interview on 12/1/25 at 1:36 p.m., observed a dishwasher in operation in the neighborhood kitchen on third floor. Assistant cook (AC)-A and AC-B both stated there was no way to monitor the temperature of the water in the dishwasher - there was no temperature display on the outside of the dishwasher. During an interview and observation on 12/2/25 on 11:03 a.m., DD-C was in the neighborhood kitchen on third floor. DD-C stated the temperature of the water in the dishwasher was monitored by staff, who put an orange temperature strip in the dishwasher with each load. A small space on the orange strip turned from blue to orange when the water temperature reached 180 degrees. DD-C was informed some staff were not aware of that. DD-C provided a temperature log for November to show documentation of the results of the test strip. However, for November the temperature was documented 20 out of 60 potential times (morning and evening). Logs for September and October were blank. December had potential for logging the temperature on 12/1/25, but was blank.During an interview and observation on 12/2/25 at 11:07 a.m., with DD-C in the neighborhood kitchen on second floor, AC-C stated he was aware the orange strips should be used to verify temperature in the dishwasher and had a Ziploc bag of used strips, but strips were not dated to indicate verification. Neither AC-C nor DD-C could locate water temperature logs for September to December. During an observation and interview on 12/2/25 at 11:11 a.m., with DD-C in the neighborhood kitchen on first floor, AC-D provided a handwritten temperature log for November. Out of 60 possible temperature entries, only 23 temperatures were documented. For October, out of 62 possible temperature entries, 32 were documented. For September, out of 60 possible temperature entries, only 31 were documented. AC-D stated she utilized the orange strips and documented results on the log. At 11:15 a.m., DD-C stated she would need to re-educate staff, and that on 11/19/25, she had a training session with dietary staff called survey readiness and covered dishwasher temperatures. DD-C could not provide notes regarding specific training that had been covered (e.g., orange strips, documentation water temperatures, what do to if a strip doesn't change color). During an interview on 12/3/25 at 2:16, chief executive officer was informed of findings - wet pans and dish washer water temperatures not being monitored in the three neighborhood kitchens to ensure sanitization of dishes. No further information was offered or provided.Facility Cleaning Dishes/Dish Machine policy dated 2021, indicated all flatware, serving dishes, and cookware would be cleaned, rinsed and sanitized after each use. The dish machines would be checked prior to meals to assure proper function and appropriate temperatures for cleaning and sanitizing. Dishes should be air dried on the dish racks, not with towels. Inspect for cleanliness and dryness and put dishes away if clean. Dishes should not be nested unless completely dry. Facility Sanitation policy dated 2001, dishwashing machines were operated according to manufacturer's instructions. High temperature dishwashers wash temperature should be 150-160 degrees Fahrenheit (F), and rinse temperature 180 degrees F.

Based on observation, interview and document review, the facility failed to ensure 1 of 1 resident (R19) who was observed to have medications in her room, had been appropriately assessed and deemed safe to self-administer medications.Findings include:R19's face sheet provided on 12/3/25, included diagnoses of fibromyalgia (chronic condition that involves widespread body pain), chronic pain syndrome, dry eye syndrome (chronic condition where eyes don't produce enough tears), irritable bowel syndrome (chronic disorder causing cramping, gas, constipation, diarrhea) with diarrhea, osteoporosis, bursitis (inflammation) of hips, and anxiety. R19's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood. R19 was independent with eating and oral care after set-up help. R19 required substantial assistance for mobility-related activities of daily living and did not walk.R19's physician orders that correlated to the over the counter (OTC) medications observed in R19's room included: --Order dated 5/15/25: Artificial Tears Ophthalmic Solution 1.4 % (used for dry eyes). Instill 1 drop in both eyes every 8 hours as needed for dry eyes. --Order dated 6/10/25: Imodium A-D, oral tablet 2 mg (used to treat diarrhea). Give 1 tablet by mouth as needed for loose stools, after each loose stool; use sparingly, can cause problems.--Order dated 7/8/25: Tucks External Pad (used to relieve discomfort of hemorrhoids). Apply to hemorrhoids topically every 4 hours as needed for hemorrhoid irritation.--Ordered dated 7/8/25: Anusol-HC External Cream 2.5 % (relieves pain associated with hemorrhoids). Apply to rectum/hemorrhoids topically as needed for hemorrhoid irritation QID (four times a day). Insert 1 application into rectum.R19's care plan dated 6/3/25, indicated R19 was not appropriate to self-administer medication. Care plan with revised date of 8/11/25, indicated R19 had acute and chronic pain and chronic pain syndrome. Staff were to evaluate the effectiveness of pain interventions, alleviating of symptoms, dosing schedules and resident satisfaction with results. Monitor/record/report to nurse resident complaints of pain or requests for pain treatment.During an observation on 12/1/25 at 1:30 p.m., observed various OTC medications on R19's overbed table, including:--Aspercreme, 2.7 oz (ounce) used for minor aches and pains.--Lidocaine 4% cream, 2.7 oz used to temporarily numb skin to relieve pain.--Preparation H, 2 oz, used to relieve pain and soreness of hemorrhoids.--Family Care brand eye drops 0.5 oz, used to relieve dry eyes.--Neosporin ointment, used to prevent minor skin infections.During an observation and interview on 12/3/25 at 11:00 a.m., medications remained present on overbed table. R19 stated she ordered the medications from Amazon. In addition to the OTC medications observed on 12/1/25, observed two Imodium Softgels in a blister pack, two Claritin (used to relieve allergy symptoms) tablets in blister packs, and one unidentified, small two-toned capsule not in packaging. R19 stated she used the Aspercreme and Lidocaine for pain by rubbing it on her skin; applied Neosporin to her outer right ear where she had a skin biopsy; used the eye drops for dry eyes - rarely; used the Imodium for diarrhea and Preparation H for comfort. R19 was unaware of the Claritin -- did not know why she had that and was unaware of what the small two-toned capsule was. During an interview on 12/3/25, at 11:04 a.m., licensed practical nurse (LPN)-A stated some residents could self-administer medications, but would first have to go through an assessment for safety and have a physician order. LPN-A looked in the electronic medical record (EMR) and stated R19 did not have an order for self-administration. LPN-A stated, The big thing is, a resident can't have medications in their room without a physician order. LPN-A stated R19's boyfriend brought her medications, and R19 didn't let us know about them. LPN-A stated it was important to let the physician know because he/she might not want the resident to take it. LPN-A stated she was unaware of OTC medications in R19's room. During an interview on 12/3/25 at 12:49 p.m., registered nurse (RN)-A, who was also the nurse manager on the unit in which R19 resided, stated R19's significant other was known to bring items into the facility for R19 without staff knowing. RN-A stated she would need to inform the physician and let him/her decide if it was safe for R19 to self-administer medication, adding they would need to look at potential medication interactions and allergies. RN-A stated nursing would need to conduct a self-administration assessment. RN-A looked in the EMR and verified R19 did not have a self-administration order. RN-A stated she did not know why staff had not noticed the medications on the overbed table. During an interview on 12/3/25 at 1:37 p.m., the director nursing (DON) stated nursing staff had informed her of these findings. The DON stated staff may be uncertain about residents bringing in their own medications versus prescription medications and would follow up with nursing staff to re-educate. The DON was aware residents could not have any medications in their room without a self-administration order and safety assessment. Facility Self-Administration of Medications policy with revised date of 12/25, indicated; Those residents who seek to self-administer medications will be assessed by a nurse using the Self Administration Assessment form. At that time, it will be determined whether the resident is qualified to safely self-administer. Self-administration will be allowed only for those residents who have expressed an interest to self-medicate, have demonstrated minimal cognitive, visual, and physical abilities as determined by the nurse, have a written nurse practitioner or physician's order allowing self-medication, have a secure area for storage of medication so that other residents do not have access. These medications were to be stored in the resident's locked cubby. All floor personnel (nursing assistants and nurses) should alert the nurse when they see a resident self-administer medications.

Based on interview and document review, the facility failed to ensure the care plan included management of CPAP (continuous positive airway pressure) for 1 of 3 residents (R24) reviewed for respiratory care. In addition, the facility failed to ensure a care plan was initiated after a trauma assessment identified history of Post Traumatic Stress Disorder for 1 of 1 resident (R27) who was reviewed for mood and behavior. Findings include: R24's face sheet provided on 12/3/25, included diagnoses of obstructive sleep apnea and dementia. R24's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated severe cognitive impairment, clear speech, was understood and could usually understand. R24 was dependent upon staff for most all activities of daily living and did not walk. R24's orders dated 3/5/25, indicated okay to use home settings on his CPAP machine every shift. Orders dated 3/8/25, indicated CPAP cleaning wash mask, nasal pillows, tubing and headgear, wipe off. Flow generator every day shift every Sunday. R24's orders did not include if or when to apply CPAP. R24's care plan did not indicate use of CPAP. During an interview and observation on 12/1/25 1:23 p.m., family member (FM)-B stated R24 wore CPAP at night, but it did not always stay on. FM-B was not aware if mask was cleaned. Observed only a small amount of water in bottom of CPAP reservoir. During an interview on 12/2/25 at 8:18 a.m., nursing assistant (NA)-G stated she did not know if R24 used his CPAP. NA-G stated nurses cleaned CPAP masks and filled the water reservoir, adding sometimes NAs would fill the reservoir. NA-G didn't know how often either was done. During an interview on 12/2/25 at 12:47 p.m., NA-E stated she did not think R24 wore his CPAP, adding his wife had said he did not. During an interview on 12/2/25 at 1:03 p.m., licensed practical nurse (LPN)-A stated she didn't know if R24 wore his CPAP. LPN-A stated either a nurse, or a NA cleaned the CPAP mask with soap and water once a week on Saturdays, and a nurse filled the reservoir with distilled water. LPN-A looked at R24's care plan and verified use of CPAP was not included on his care plan. During an interview on 12/2/25 at 1:23 p.m., registered nurse (RN)-A who was also the clinical care manager for the unit on which R24 resided, stated she wasn't sure if R24 wore his CPAP, adding she had heard at report he took it off. Looking in the electronic medical record (EMR), RN-A acknowledged there was not an actual order to assist R24 with applying CPAP at bedtime. RN-A acknowledged it would be important in order for nursing staff to be prompted to apply it and to document if R24 refused it. RN-A also acknowledged CPAP was not included on R24's care plan, stating it absolutely should have been. RN-A stated she had been responsible for adding CPAP to R24's care plan, stating she overlooked it. RN-A stated CPAP should have been care planned because it was an important part of R24's care. RN-A acknowledged not having CPAP on R24's care plan could lead to improper use of CPAP and improper cleaning of the equipment as there was no direction or guidance for staff, which could result in a potential respiratory infection. During an observation on 12/3/25 at 7:00 a.m., R24 was supine in bed, eyes closed. Lights off. CPAP not on; mask and tubing draped over bedside table. During an observation and interview on 12/3/25 at 8:24 a.m., together with RN-A, went to R24's room and observed minimal water in bottom of both of the CPAP water reservoir. RN-A was not certain who was to monitor the level and add water. During an interview on 12/3/24, at 1:10 p.m., RN-A stated after doing some research, she learned CPAP masks should be cleaned daily (R24's was cleaned weekly), the remaining water in the reservoir should be emptied daily and the reservoir rinsed with warm water, which RN-A stated had not been done for R24. During an interview on 12/3/25 at 1:40 p.m., the director of nursing (DON) was informed CPAP had not been on R24's care plan, and while there had been some orders for maintaining the CPAP equipment, it did not cover all parts of the CPAP equipment. In addition, the DON was informed there had not been an actual order to apply CPAP to R24 at night. The DON was unaware of this, and unaware the CPAP mask was only being cleaned weekly. Facility Comprehensive Person-Centered Care Plan policy with revised date of March 2022, indicated a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident. Care plan interventions were chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. R27's face sheet received on 12/3/25, included diagnosis of dementia with other behavioral disturbance and agitation and repeated falls. R27's quarterly MDS assessment dated [DATE], indicated R27 understands and is understood. A Brief Interview for Mental Status (BIMS) indicated a score of 5 indicating severe cognitive impairment. R27 had behaviors that included verbal behavioral symptoms directed towards others 1 to 3 days, but less than daily. R27 had rejection of care 4 to 6 days. R27 required substantial/maximal assistance with transfers, toileting, bed mobility and transfers. R27 was taking antipsychotic and antidepressant medication. R27's Care Area Assessment (CAA) for cognitive loss/dementia dated 3/25/25, included psychiatric or mood disorder. The CAA for mood state included clinical issues that can cause or contribute to a mood problem including relapse of an underlying mental health problem, and psychiatric disorder. R27's care plan last revised 9/30/25, included R27 is/has potential to be verbally aggressive and has a history of threatening to hit staff and of striking staff. Interventions included: administer medications as ordered; analyze of key times, places, circumstances, triggers and what de-escalates behavior and document; assess and anticipate resident's needs for food, thirst toileting needs, comfort level, body positioning, pain etc ; assess R27's understanding of the situation. Allow time for the resident to express self and feelings towards the situation; give the resident as many choices as possible about care and activities; monitor behaviors every shift and document on observed behavior and attempted interventions; when the resident become agitated intervene before agitation escalates and guide away from source of distress. Engage calmly in conversation. If response is aggressive, staff to walk calmly away and approach later. R27's plan of care did not include a history of post traumatic stress disorder (PTSD). A Trauma Informed Care assessment dated [DATE], indicated R27 answered Yes to experiencing a traumatic event. A probable PTSD interview included R27 answered yes to having nightmares about events or thought about the events when he didn't want to. R27 answered yes to felt guilty or unable to stop blaming himself or others for the events or any problems the event(s) may have caused. On 12/1/25 at 3:10 p.m., R27 declined to speak with surveyor. On interview 12/2/25 at 1:42 p.m., social services (SS)-A indicated she had completed the Trauma Informed Assessment on R27 in February 2025. SS-A confirmed the plan of care did not include a plan to address potential PTSD but did include a behavioral plan of care addressing his refusals of care and behaviors. On interview 12/2/25 at 2:52 p.m., RN-C stated R27 sometimes talked about his time in war but has never stated he suffered from PTSD. RN-C indicated R27's family member had wondered if some of his behaviors are impacted from his history in the army. RN-C indicated a lot of his behaviors are during the night shift and could be related to nightmares but added R27 had never stated that to anyone. RN-C indicated R27 had a plan of care to address behaviors and mood but not for PTSD. On interview 12/2/25 at 3:27 p.m., NA-A stated R27 had verbal behaviors and on occasion will attempt to strike out. NA-A was unsure if R27 had a history of PTSD but did stated that sometimes if staff make too much noise he gets agitated and sometimes if they don't make enough noise when entering his room he will get startled. On interview 12/2/25 at 3:59 p.m., FM-A stated R27 was in army and when he returned home he struggled, was on edge and startled easily but thought that had resolved a few years after he returned. FM-A stated R27 does still get triggered by fireworks which can set off memories but otherwise does not show any signs of trauma. On interview 12/2/25 at 4:23 p.m., SS-B stated R27 had a terrible experience during war. SS-B stated R27 does have some triggers such as at night he doesn't want anyone in his room and will become verbally upset telling staff to get out of his room. SS-B was not aware of any other triggers except at night. SS-B confirmed there was no plan of care related to PTSD. On interview 12/3/25 at 10:01 a.m., the DON stated a further assessment should have been completed after the February 2025 assessment. The DON stated she would expect a plan of care to be initiated if confirmed PTSD history. Facility Trauma Informed Care and Culturally Competent Care policy dated 10/22, included: - Perform universal screening of residents, which includes a brief, non-specialized identification of possible exposure to traumatic events. - Use screening tools and methods that are facility-approved, competently delivered and culturally relevant and sensitive. - Use initial screening to identify the need for further assessment and care. - Develop individualized care plans that address past trauma in collaboration with the resident and family as appropriate - Identify and decrease exposure to triggers that may re-traumatize the resident.

Based on observation, interview and document review, the facility failed to ensure individualized activities were provided for 1 of 2 residents (R80) reviewed for activities. Findings include:R80's face sheet printed 12/3/25, indicated diagnoses of chronic kidney disease, adjustment disorder with depressed mood and anxiety, hearing loss, muscle weakness, and palliative care.R80's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R80 had no behaviors or rejection of care, intact cognition, considered it very important to have books, newspapers, and magazines to read, important to keep up with current news, and not important to do things with groups of people.R80's care plan dated 10/14/25, indicated R80 was alert and oriented and able to make needs known, enjoyed all types of music, reading, classic television shows and war movies. R80's care planned activity interventions included all staff conversing with the resident while providing cares, ensure activities are compatible with known interests and preferences, adapted as needed, compatible with individual needs, provide a program of activities that is of interest and empowers the resident, and a 1:1 activity program.During observation and interview on 12/1/25 at 3:48 p.m., R80 was awake in his bed and alone in his room. R80's television was on with no volume or captions. R80 stated he was not able to get out of bed anymore, was lonely in his room all day, bored, and wished more people would visit him throughout the day. R80 further stated his hearing was poor, and he couldn't read captions on his television, so could no longer enjoy that form of entertainment.During observation on 12/2/25 at 8:19 a.m., R80 was in bed in his room alone. R80's television was on with no volume, and he was staring at the ceiling. R80 stated he did not plan to attend any group activities today because he was unable to sit up in his wheelchair for more than 30 minutes due to back pain.During observation on 12/2/25 at 1:50 p.m., R80 remained in bed, was reading a book, and stated no activity staff had visited him so far that day.During observation on 12/3/25 at 8:53 a.m., R80 was in his bed, awake, starting to read a book. R80 stated he was bored in his room. R80 further stated activity staff bring him books and magazines but just drop them off and don't stay to visit with him or do an activity with him and he got very lonesome some days. R80 stated he would sure like to visit with activity staff sometime, but they are busy and can not spend the time with him.During interview on 12/2/25 at 8:30 a.m., nursing assistant (NA)-A stated R80 had declined over the last few weeks and did not get out of bed anymore. NA-A stated he stayed in his room all day, did not eat meals in the dining room, and did not attend any activities. NA-A was not aware of any individual activities for R80.During interview on 12/2/25 at 4:52 p.m., licensed practical nurse (LPN)-F stated R80 no longer got out of bed, and was in his room all the time. LPN-F stated he had declined and went on hospice, so he liked staying in bed.During interview on 12/3/25 at 8:19 a.m., activity assistant (AA)-A stated she was responsible for activity care plans and completing activities for R80. AA-A further stated she offered all group activities to R80 daily, delivered books and magazine to his room, and turned his television on to his preferred channel. AA-A stated she checked on R80 to make sure he had independent activities, but did not specifically do one-to-one activities with him because there was not enough time.During interview on 12/3/25 at 11:47 a.m., life enrichment director (O)-B stated she was not aware R80 was lonely and bored, and she was not sure if R80 had received individual one-to-one activities. O-B stated if R80's care plan indicated his program was for one-to one activity visits, then he should have been getting one-to-one visits. O-B further stated individual visits were for residents who did not attend group activities, and she would expect those visits to be completed. O-B stated dropping off books and magazines, and turning the television on did not qualify and individual activities.During interview on 12/3/25 at 2:05 p.m., administrator stated he would expect the activity care plan to be individualized and implemented as planned for each resident.A facility document titled The Woodlands Follow Up Question Report dated 11/1/25 through 11/30/25, indicated R80 was offered group activities and independent activities all days in November 2025 except for 11/2/25, 11/16/25, 11/23/25, and 11/27/25. It did not indicate R80 was offered any one-to-one activities.Facility Activity Programs policy dated 6/2018, indicated the activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. Activity programs consist of individual, small group, and large group activities that are designed to meet the needs and interests of each resident. All activities are documented in the resident's medical record.

Based on observation, interview and document review, the facility failed to ensure weekly comprehensive skin assessments (including measurements and characteristics) were completed for 1 of 3 residents (R1) reviewed for pressure ulcers. Findings include:R1's face sheet received on 12/3/25, included diagnoses of pressure ulcer of sacral region, stage four (the most severe type, involving full-thickness tissue loss); diabetes, chronic kidney disease, hemiplegia (paralysis affecting one side of the body) and hemiparesis (muscle weakness on one side of the body) following stroke.R1's admission Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech; R1 was understood and could understand. R1 required substantial assistance with toileting and bed mobility; was occasionally incontinent of bowel and bladder. R1 didn't walk and used an electric scooter. R1 was at risk for a pressure ulcer and had one, unhealed, stage four pressure ulcer present upon admission. R1's Skin CAA (care area assessment) dated 10/20/25, indicated R1 had been admitted with a stage four pressure ulcer to his sacrum. Treatments and interventions had been in place to promote healing and prevent further breakdown. R1's orders included:--10/16/25: Wound care coccyx: wash hands, remove old dressings, cleanse wound bases with Vashe (a solution used for cleaning, irrigating and debriding wounds), pack Vashe moistened dry gauze to wound base, cover with abdominal pad and secure with tape, every day shift and as needed for wound care.--10/29/25: Skin check on bath day. Document bruise, rash, open area. Complete N Adv.-Skin (Nurse Advantage; a skin assessment flow sheet in the electronic medical record [EMR]).R1's care plan dated 11/3/25, indicated R1 had potential/actual impairment to skin integrity of the coccyx related to stage four pressure injury. R1 was at risk related to fragile skin, type 2 diabetes, and impaired mobility. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations.R1's Braden score (standardized tool to assess risk of developing pressure ulcers) dated 10/14/25, indicated a score of 18 = mild or low risk for developing pressure ulcers.R1's skin assessments in the EMR indicated skin checks were documented each week on a flowsheet titled N Adv Skin Check, but not all of the skin checks included measurements of the coccyx wound or characteristics of the wound. Out of seven weekly skin checks since admission on [DATE], only one had all of the required documentation:10/15/25 (admission)***No staging. No characteristics such as tunneling, epithelial, granulation, slough, eschar, exudate amount and type, odor, condition of skin edges, surrounding tissue and induration had been documented.10/21/25*** All required documentation had been present.10/28/25 *** Required documentation had been present with the exception of characteristics. 11/4/25 ***No wound measurements or characteristics had been documented.11/11/25*** No characteristics had been documented. 11/19/25***No wound measurements or characteristics had been documented.11/25/25***No wound measurements or characteristics had been documented.12/2/25***No wound measurements or characteristics had been documented.R1's wound provider note dated 11/17/25, indicated a pressure ulcer on the coccyx, chronic, stage four measuring 2 cm x 2 cm x 1.5 cm. The pressure ulcer had moderate amount of drainage. The drainage was serous and serosanguineous. The pressure ulcer had exposed subcutaneous. Full thickness wound. No sign of epithelization. 50% granulation tissue. 50% nonviable material of slough/fibrin. R1's wound provider note dated 11/26/25, indicated sacral wound had reduced in size. There was healthy red granulation tissue to the wound base and no signs of infection. During an interview on 12/1/25 at 4:19 p.m., while in his room in his electric scooter, R1 stated he had one pressure ulcer on his coccyx, acquired in hospital before being admitted to the facility. R1 stated it was healing; nurses packed it and covered it. R1 stated he saw a wound provider at a clinic every four weeks. R1 stated he laid down frequently to get pressure off his bottom. During an interview on 12/2/25 at 12:53 p.m., licensed practice nurse (LPN)-A stated she had changed R1's coccyx dressing that morning but had not assessed the wound. LPN-A stated assessments were completed by the evening shift nurse on his bath day. Together looked in the EMR at the electronic flowsheet titled N Adv Skin Check. Weekly documentation. LPN-A acknowledged the documentation was inconsistent and lacked measurements and characteristics. During an observation on 12/3/25 at 8:30 a.m., with LPN-A and registered nurse (RN)-A, who was also the clinical care manager, observed R1's coccyx wound. The wound was center of buttocks, proximal to the intergluteal cleft. Wound was star-burst shape, with an estimated outside diameter of 1.5 to 2 inches. LPN-B measured depth with a cotton swab at 0.5 cm., then measured outside of wound - just the opening without spreading open the starburst, at 1 x 1 cm. Skin was dry, color normal, no redness, no exudate. Wound was flushed, packed and covered with pad and taped. During an interview on 12/3/25 at 8:38 a.m., RN-A looked in the EMR for each week of skin checks for R1 since admission. RN-A verified documentation was inconsistent and lacked elements of a comprehensive wound assessment. RN-A stated she would have expected nursing staff to complete all fields of the electronic skin check tool. It was important to determine if the wound had worsened or became infected. RN-A stated she had been monitoring documentation of the weekly skin checks but had not looked at each section of the documentation tool and therefore had not been aware measurements and characteristics had not been documented. RN-A stated R1 saw a wound care provider outside of the facility each month and recently saw a provider in-house who indicated the wound had reduced in size, had healthy looking skin and no sign of infection.During an interview on 12/3/25 at 1:35 p.m., the director of nursing (DON) was informed of the lack of comprehensive assessments of R1's coccyx wound to include measurements and characteristics. The DON stated she would have expected a complete assessment of R1's wounds in order to know if it was improving or worsening. Facility Pressure Injury policy with revision date of 11/24, indicated the purpose was to provide appropriate assessment and prevention of pressure injuries, ensure the necessary treatment and services to promote healing, prevent infection and prevent any new pressure injuries from developing. Complete a new skin check weekly. Document weekly and PRN (as needed) in the Interdisciplinary Nursing notes on the size, drainage, odor, pain, surrounding tissue, and current treatment.

Based on interview and document review, the facility failed to assess safe smoking for 1 of 1 resident (R69) reviewed for smoking. In addition, the facility failed to provide a receptable for R69 to safely ash and dispose of cigarettes. Findings include:R69's face sheet provided on 12/3/25, included diagnoses of tobacco use and chronic obstructive pulmonary disease (a progressive lung disease that causes breathing difficulties).R69's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R69 was cognitively intact, had clear speech, could understand and be understood. R69 was independent with most activities of daily living and used a motorized wheelchair for mobility. R69's orders did not include smoking. R69's care plan dated 7/30/25, indicated R69 was a smoker, would not suffer injury from unsafe smoking practices. R69 would be instructed about smoking risks and hazards and facility policy on smoking including locations, times and safety concerns. Progress note dated 7/11/25, indicated R69 asked about having a cigarette and was educated on the rules of smoke free campus.Progress note dated 10/19/25, indicated R69 went outside multiple times to smoke. During interview and observations on 12/1/25 at 2:41 p.m., R69 was sitting in a recliner in her room. R69 stated she had been in the facility for six months and had smoked the entire time. R69 stated she smoked three to four times a day and didn't smoke a whole cigarette - maybe three or four puffs. R69 stated she kept cigarettes and lighter in her room and both were currently in her coat pocket on her motorized wheelchair. R69 stated she went onto the sidewalk in the parking lot to smoke. Since it's cold and snowy now, R69 stated she stayed closer to the building. R69 did not recall having had a safe smoking assessment. R69 stated she did not know if it was a no smoking campus - couldn't recall if she was told that or not. R69 stated when she was done smoking outside, she put the cigarette out with her fingers, rolled up what was left in the front of her t-shirt, brought it into the building, wrapped it in a tissue and threw it in the wastebasket. R69 stated she had not been given an ash receptable. Observed a partially used cigarette setting on a piece of paper on her overbed table. Tobacco spilling out. R69 stated she had been smoking for more than 50 years and had never had an incident, such as a burn or fire. During an observation and interview on 12/2/25 at 12:27 p.m., R69 signed herself out of the facility to go with her boyfriend to run errands and stated, I will be smoking. R69 stated she had been going out to smoke despite the cold and snowy weather. During an interview on 12/2/25 at 1:05 p.m., licensed practical nurse (NA)-B stated the facility was smoke-free and residents had to go off property to smoke. LPN-B was aware R69 smoked but did not know if a safe smoking assessment had been done, or if one needed to be done - social services might know. LPN-B stated she assumed R69 was safe to smoke as she had not had any problems. During an interview on 12/2/2025 at 1:13 p.m., LPN-B approached to report she had asked the director of nursing (DON) about a smoking assessment for R69 and was told one had been completed on 12/1/25, and now social services would be doing it quarterly. During an interview on 12/2/25 at 1:20 p.m., registered nurse (RN)-A who was also the clinical care manager for the unit R69 resided, stated the facility was smoke free and if a resident wanted to smoke, he/she had to go off campus and would not be escorted by staff. RN-A stated she was not aware the facility had a smoking risk assessment tool. Looking in the electronic medical record, RN-A stated she did not see a safe smoking assessment for R69.During an interview on 12/2/25 at 2:51 p.m., DON was asked how a smoking assessment happened to be completed for R69 on 12/1/25. The DON stated when their smoking policy had been requested, she reviewed it and realized they had not been following it, so therefore a safe smoking assessment had been completed on R69 on 12/1/25. The DON stated the facility was a smoke free campus but was aware R69 smoked in the parking lot. The DON was informed of interview with R69 on 12/1/25, specifically about R69 rolling up a used cigarette in her t-shirt, bringing it into the building, rolling it in a tissue and throwing it in the wastebasket. The DON was aware R69 had used a small can in the summer to ash her cigarettes but did not know how R69 had been disposing of ashes and cigarettes currently. The DON provided a copy of R69's smoking assessment dated [DATE], and signed by R69, the social worker and the DON which indicated R69 was safe to smoke independently. Facility Smoking policy dated 7/8/21, indicated the facility was a smoke free facility effective April 1, 2015. Residents admitted after July 1, 2011, would not be permitted to smoke on campus. All residents who wished to smoke (admitted prior to July 1, 2011) or use e-cigarettes, would be assessed at least quarterly to ensure the resident continued to be in compliance with the smoking policy. The use of e-cigarettes was only permitted outside the building on campus grounds. Social Services and nursing would assess quarterly at care conferences if a resident was safe to smoke/use e-cigarettes and keep smoking materials in their possession. Smoking materials included cigarettes, cigars, pipes, chewing tobacco, matches, lighters, and e-cigarettes.

Based on observation, interview and document review, the facility failed to ensure 1 of 1 resident (R8) reviewed for hydration and who was dependent upon staff for fluid intake, was offered water/fluids on a consistent basis.Findings include:R8's face sheet printed on 12/3/25, included diagnoses of Alzheimer's disease and severe dementia.R8's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated severe cognitive impairment, unclear speech, was usually understood, and sometimes was able to understand. R8 required substantial/maximal assistance with eating and drinking. R8 was dependent on staff for activities of daily living and did not walk. R8's orders dated 8/12/24, indicated regular diet, minced and moist texture, regular/thin consistency, required assist with all meals.R8's care plan dated 8/23/24, indicated R8 had the potential for hydration problems related to dementia and Alzheimer's disease.R8's Kardex (a quick reference tool used by nursing assistants summarizing essential resident cares) printed on 12/3/25, indicated staff were to offer fluids with all cares/meals and at least every three hours while awake. Assist with drinking.R8's fluid intake record indicated that for seven days (11/25/25, to 12/1/25), R8 averaged 660 milliliters (ml) of fluid each day.R8's urine output record indicated that for seven days (11/25/25, to 12/1/25), R8 averaged 787 ml of urine output each day. During a telephone interview on 12/1/25 at 4:56 p.m., family member (FM)-C stated staff didn't offer R8 anything to drink, adding it would be good if they were more in tune to giving him a drink every couple of hours or so. FM-C stated she had never seen staff offer R8 beverages unless it was at mealtime. FM-C stated, I think he gets dry and should be drinking more than he does. During a continuous observation on 12/2/25, from 8:28 a.m. to 10:59 a.m., R8 was not offered water:--8:28 a.m., lying in bed supine. Eyes open. Room dim.--9:14 a.m., no change. Observed arms in the air from time to time. -- 9:38 a.m., small navy thermal mug with straw on bedside table was full of water. R8 lacked ability to reach it and help himself. Urinary drainage bag appeared to have about 200 ml dark gold urine in bag.--9:54 a.m., no staff had been in R8's room.--10:13 a.m., nursing assistant (NA)-E entered room. NA-E emptied contents of the urinary drainage bag into a graduate. Urine was dark gold in color and had a pungent odor. NA-E stated the urine smelled strong and she would report that to the nurse and push fluids. A total of 150 ml of urine was emptied from the urinary drainage bag. NA-E stated R8 could not drink fluids on his own in bed. --10:38 a.m., up in wheelchair.--10:53 a.m., NA-E shaving R8. --10:59 a.m., in dining room. --11:21 a.m., eating scrambled eggs, yogurt and Carnation instant milk in a mug with straw with NA-F assisting. No water on the table.During an observation and interview on 12/3/25 at 9:58 a.m., R8 was at a table in the dining room being assisted with breakfast by NA-E, which included Carnation instant milk in a mug with straw. No water on the table. NA-E stated she offered R8 water when he was in his room, adding, We should before we lay him down. NA-E stated R8 was a good drinker. NA-E stated R8's urine output for the day shift yesterday 12/2/25, was only 200 milliliters (ml) and had a strong smell. NA-E stated she had informed licensed practical nurse (LPN)-A of this on 12/2/25. During an interview on 12/3/25 at 10:08 a.m., LPN-A acknowledged that NA-E had informed her yesterday that R8's urine was yellow and smelled strong. NA-E stated she would typically encourage fluids by offering a resident water and cranberry juice. LPN-A admitted she did not go to R8's room to assess skin turgor, mucous membranes, color, clarity and odor of urine. LPN-A stated she reported what NA-E had told her at shift change but admitted she had not communicated to NA staff to push fluids, nor did she document anything about characteristics of his urine, nor inform the clinical care manager. During an interview on 12/3/25 at 12:52 p.m., registered nurse (RN)-A, who was also the clinical care manager for the unit on which R8 resided, was informed of R8's urine - amount, color and odor and observations of R8 not being offered water. RN-A stated she would have expected LPN-A to lay eyes on R8 and report findings to her so they could determine if he was dehydrated, if he had possible urinary tract infection symptoms, notify the physician if necessary and to communicate to all NA staff to encourage fluids. RN-A stated she expected residents to receive fresh water and for staff to offer R8 fluids before laying him down and at mealtimes, adding it was especially important for residents who can't drink fluids without assistance. During an interview on 12/3/2025 at 1:46 p.m., the director of nursing (DON) was informed of R8 and potential for hydration concerns. The DON stated after being informed of the amount, color and odor of R8's urine, the nurse should have gone to look at R8 herself and reported it to RN-A so she could update the provider. Facility Resident Hydration and Prevention of Dehydration policy dated October 2017, indicated the facility would strive to provide adequate hydration and prevent and treat dehydration. Nurses' aides would provide and encourage intake of bedside, snack and meal fluids, on a daily and routine basis as part of daily care. If potential inadequate intake and/or signs and symptoms of dehydration were observed, intake and output monitoring would be initiated. The physician would be notified.

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 for 1 of 3 resident (R33) reviewed for respiratory care and treatments.Reviewed- LS-done Findings include: R33's face sheet received on 12/3/25, included diagnoses of epilepsy (seizures), cerebral infarction (stroke) and obstructive sleep apnea (breathing repeatedly stops or become significantly reduced during sleep often due to collapse of the upper airway). R33's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R33 had moderate cognitive impairment, and was dependent on staff for all activities of daily living. Special treatments included CPAP. R33's plan of care dated 10/28/25, included a sleep disturbance using a CPAP at baseline. Interventions included CPAP auto set at night pressure settings at auto set home settings. Wipe off mask, nasal pillows and tubing. CPAP cleaning included wash mask, nasal pillows, tubing and headgear. Wipe of flow generator. R33's physician order dated 10/11/25 included CPAP cleaning every shift every Saturday to clean and wash mask, nasal pillows tubing, headgear and wipe of flow generator. An order dated 10/30/25, included CPAP auto set at night. Pressure setting at auto set home settings; wipe off mask, nasal pillows and tubing every shift. ResMed AirSense 10 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. Mask cushion should be cleaned daily in a sink or tub using mild liquid detergent and warm, drinking-quality water. Weekly cleaning includes clean the humidifier tub, mask cushion and headgear, air tubing and outlet connector in warm water using mild liquid detergent and water. Rinse each component thoroughly in water and place on a flat surface, on top of a towel, to dry. Avoid placing them in direct sunlight. Wipe the exterior of the device with a dry cloth. On observation and interview on 12/2/25 at 8:32 a.m., R33 was lying in bed with his CPAP mask on and machine running. Nursing assistant (NA)-A turned off the CPAP machine, removed face mask and laid it over the machine. NA-A and NA-B stated the nurse is responsible for cleaning the mask, the CPAP machine and reservoir. On observation 12/2/25 at 10:48 a.m., R33's CPAP mask remained sitting on top of CPAP machine and moisture remained in the water reservoir. On observation 12/2/25 at 12:52 p.m., R33 was assisted to his bed by NA-A and NA-B. CPAP mask remained on bedside table on top of machine. Moisture was present in the water reservoir. On observation 12/2/25 at 3:36 p.m., R33 was assisted to his wheelchair. Water reservoir of CPAP machine remained with moisture present. CPAP tubing and mask remained sitting on top of CPAP machine. On observation and interview 12/3/25 at 7:30 a.m., R33 was lying in bed with his CPAP mask on, machine running with a noise coming from the CPAP mask. Licensed practical nurse (LPN)-C entered R33's room and readjusted his mask and the noise stopped briefly but then returned. LPN-C stated he hasn't noticed a face mask leak prior and thinks it is positional. On observation and interview 12/3/25 at 7:52 a.m., R33 was lying in bed with CPAP mask on which continued to make noise from around the mask. NA-A and NA-B entered R33's room, and NA-A turned off CPAP machine and removed the face mask. NA-A placed hose and mask over top of the machine. NA-A indicated they aren't responsible for cleaning the CPAP machine or supplies but are allowed to turn it off and remove the mask. NA-B stated LPN-C had told them R33's CPAP mask was leaking so it was time to get R33 up for the day. On observation and interview 12/3/25 at 8:24 a.m., LPN-C stated the CPAP machine, mask and tubing in cleaned once a week. LPN-C was unsure how often the mask is changed but stated they clean the mask, tubing, and water reservoir weekly with soap and water. LPN-B stated they refill the water chamber before applying the mask at bedtime and empty and clean it weekly. On interview 12/3/25 at 8:40 a.m., LPN-D stated the CPAP mask should be wiped every morning and evening using soap and water. LPN-D stated the water reservoir is cleaned every Saturday with soap and water along with the face mask and tubing. On interview 12/3/25 at 8:36 a.m., LPN-E stated the CPAP mask and tubing is cleaned weekly on Saturday's. The mask is wiped out daily. LPN-E stated the water reservoir is emptied and cleaned on Saturday's also using either vinegar with water or soap and water. On interview 12/3/25 at 8:37 a.m., registered nurse (RN)-C stated tubing, mask and reservoir should be cleaned weekly. RN-C stated a discussion was held with other team members this morning and it was noted the orders lack instructions on how to clean the machine, mask and reservoir and plan to review the templates so staff have more detailed instructions. On interview 12/3/25 at 9:56 a.m., the director of nursing (DON) confirmed the CPAP policy and instructions was lacking guidance on the cleaning of the CPAP machine, supplies and reservoir with how often and what to use to clean it with. The DON confirmed there was a variance in how the supplies were cleaned and how often. Facility CPAP-BIPAP cleaning policy last revised 3/15 included: General Guidelines for Cleaning: - These are general guidelines for cleaning. Specific cleaning instructions are obtained from the manufacturer/supplies of the CPAP device. - To clean machine wipe with warm, soapy water and rinse at least once a week and as needed. - Humidifier: Use clean, distilled water only in the humidifier chamber. Clean humidifier weekly and air dry. To disinfect, place vinegar-water solution (1:3) in clean humidifier. Soak for 30 minutes and rinse thoroughly. - Masks, nasal pillows and tubing cleaning is done daily by placing in warm, soapy water and soaking/agitating for 5 minutes. Mild dish detergent is recommended. Rinse with warm water and allow to air dry between uses. - Headgear strap is to be washed with warm water and mild detergent as needed. Allow to dry.

Based on observation, interview,, and document review, the facility failed to comprehensively assess and reassess past trauma and implement care plan interventions utilizing a trauma-informed approach for 1 of 1 resident (R27), reviewed who was evaluated for mood and behavior. Findings include: R27's face sheet received 12/3/25, included diagnosis of dementia with other behavioral disturbance and agitation and repeated falls. R27's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R27 understands and is understood. A Brief Interview for Mental Status (BIMS) indicated a score of 5 indicating severe cognitive impairment. R27 had behaviors that included verbal behavioral symptoms directed towards others 1 to 3 days, but less than daily. R27 had rejection of care 4 to 6 days. R27 required substantial/maximal assistance with transfers, toileting, bed mobility and transfers. R27 was taking antipsychotic and antidepressant medication. R27's Care Area Assessment (CAA) for cognitive loss/dementia dated 3/25/25, included psychiatric or mood disorder. The CAA for mood state included clinical issues that can cause or contribute to a mood problem including relapse of an underlying mental health problem, and psychiatric disorder. R27's care plan last revised 9/30/25, included R27 is/has potential to be verbally aggressive and has a history of threatening to hit staff and of striking staff. Interventions included: administer medications as ordered; analyze of key times, places, circumstances, triggers and what de-escalates behavior and document; assess and anticipate resident's needs for food, thirst toileting needs, comfort level, body positioning, pain etc ; assess R27's understanding of the situation. Allow time for the resident to express self and feelings towards the situation; give the resident as many choices as possible about care and activities; monitor behaviors every shift and document on observed behavior and attempted interventions; when the resident become agitated intervene before agitation escalates and guide away from source of distress. Engage calmly in conversation. If response is aggressive, staff to walk calmly away and approach later. R27's plan of care did not include a history of post-traumatic stress disorder (PTSD). A Trauma Informed Care assessment dated [DATE], indicated R27 answered Yes to experiencing a traumatic event. A probable PTSD interview included R27 answered yes to having nightmares about events or thought about the events when he didn't want to. R27 answered yes to felt guilty or unable to stop blaming himself or others for the events or any problems the event(s) may have caused. On 12/1/25 at 3:10 p.m., R27 declined to speak with surveyor. On interview 12/2/25 at 1:42 p.m., social services (SS)-A indicated she had completed the Trauma Informed Assessment on R27 in February 2025. SS-A does not believe the facility had a further Trauma assessment to complete if the initial assessment shows positive indicators possible of PTSD. SS-A reviewed the trauma assessment and indicated R27 would likely with his dementia answer the same assessment differently if completed, but confirmed another trauma assessment or further assessment had not been completed. SS-A confirmed the plan of care did not include a plan to address potential PTSD but did include a behavioral plan of care addressing his refusals of care and behaviors. On interview 12/2/25 at 2:52 p.m., registered nurse (RN)-C stated R27 sometimes talked about his time in war but has never stated he suffered from PTSD. RN-C indicated R27's family member had wondered if some of his behaviors are impacted from his history in the army. RN-C indicated a lot of his behaviors are during the night shift and could be related to nightmares but added R27 has never stated that to anyone. RN-C indicated R27 had a plan of care to address behaviors and mood but not for PTSD. On interview 12/2/25 at 2:53 p.m., licensed practical nurse (LPN)-F stated R27 occasionally talks about his time in the service but has never mentioned issues with PTSD. LPN-F stated he does have behaviors which increase at night with refusals of care and yelling at staff. On interview 12/2/25 at 3:27 p.m., nursing assistant (NA)-A stated R27 had verbal behaviors and on occasion will attempt to strike out. NA-A was unsure if R27 had a history of PTSD but did state sometimes if staff make to much noise he gets agitated and sometimes if we don't make enough noise when we enter his room he will get startled. On interview 12/2/25 at 3:59 p.m., family member (FM)-A stated R27 was in army and when he returned home he struggled, was on edge and startled easily but that had resolved a few years after he returned. FM-A stated R27 does still get triggered by fire works which can set off memories but otherwise does not show any signs of trauma. On interview 12/2/25 at 4:23 p.m., SS-B stated a brief assessment is completed for trauma informed care with the intent of filling out a more complete assessment on all residents. SS-B stated R27 had a terrible experience during war. SS-B stated R27 does have some triggers such as at night he doesn't want anyone in his room and will become verbally upset telling staff to get out of his room. SS-B was not aware of any other triggers except at night. SS-B confirmed there was no plan of care related to PTSD and indicated further assessment should have been completed after the initial assessment in February 2025. On interview 12/3/25 at 10:01 a.m., the director of nursing (DON) stated further assessment should have been completed after the February 2025 assessment. The DON stated she would expect a plan of care to be initiated if confirmed PTSD history. Facility Trauma Informed Care and Culturally Competent Care policy dated 10/22, included: - Perform universal screening of residents, which includes a brief, non-specialized identification of possible exposure to traumatic events. - Use screening tools and methods that are facility-approved, competently delivered and culturally relevant and sensitive. - Use initial screening to identify the need for further assessment and care. - Develop individualized care plans that address past trauma in collaboration with the resident and family as appropriate- Identify and decrease exposure to triggers that may re-traumatize the resident.

Based on interview and document review the facility failed to ensure medications were administered according to physician orders for 1 of 3 residents (R1) reviewed for medication administration. The facility's failures resulted in a significant medication error and an Immediate Jeopardy (IJ) situation for R1 who did not receive an increased dose of Torsemide (treat fluid overload related to heart or kidney disease) ordered by the physician. R1 was admitted to the hospital cardiac intensive care unit (ICU) for worsening congestive heart failure where she remained at the time of the survey. The IJ began on 7/9/25 when staff failed to administer an increased dose of Torsemide as ordered, due to not following the rights of medication administration. This resulted in 11 incorrect doses between 7/9/25 and 7/16/25. The Administrator and Director of Nursing were notified of the IJ on 8/6/25 at 1:22 p.m. The facility implemented corrective action prior to the survey on 7/21/25 to prevent reoccurrence, so the IJ was issued at past non-compliance.Findings include R1's face sheet date 8/6/25, identified diagnoses of hypertensive heart disease with heart failure (a condition where high blood pressure that causes the heart to weaken), atrial fibrillation (irregular, often rapid heart rate that causes poor blood flow), prosthetic (artificial) heart valve , presence of a defibrillator (a device that provides an electric shock to the heart to get out of abnormal rhythm), and chronic liver disease (progressive deterioration of the liver). R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 was taking a diuretic and had moderate cognitive impairment.R1's cardiac focus care plan revised on 3/28/25, identified R1 has congestive heart failure, atrial fibrillation, venous insufficiency, prosthetic heart valve, and a cardiac defibrillator. R1's goals included, will be free of cardiac complications. Corresponding interventions included, fluid restriction of 1500 ml, give cardiac medications as ordered, monitor intake and output, monitor vital signs (weekly and as needed), monitor and document sign and symptoms of congestive heart failure, and weight monitoring daily. R1's physician orders for cardiac management orders included:-Torsemide (diuretic medication) 40 milligram (mg) tablet give 1 tablet two times a day related to congestive heart failure. Hold if systolic blood pressure (top number in a blood pressure reading) was less than 100 mmHg (start date 5/19/25, stop date 7/9/25)-Torsemide 40 mg tablet give 1 1/2 tablets (total of 60 mg) two times per day for congestive heart failure. Hold if SBP less than 100 mmHg (start date of 7/9/25, stop date 7/17/25) -Spironolactone (diuretic medication) oral tablet 25 milligram give 1/2 tablet by mouth in the morning.R1's physician assistant note dated 7/9/25, identified R1 had been seen due to crackles (abnormal breath sounds described as popping, bubbling, or crackling) in lungs and increase weights. R1's Torsemide (diuretic) was increased from forty milligram (mg) twice daily to Torsemide sixty mg twice daily. R1's progress note dated 7/16/25, identified R1's face was edematous, had become short of breath, and oxygen level was 86% (normal range is typically between 95-100%) and needed supplemental oxygen. R1 was seen by in house physician and sent to the emergency department (ED) for evaluation. R1's nursing home physician note dated 7/16/25, identified R1 had been seen due to increased oxygen needs and swelling of the face. R1 had a history of congestive heart failure and had been taking Torsemide (a diuretic) at 40mg twice daily. R1 was seen on 7/8/25 due to an exacerbation of congestive heart failure and Torsemide dose was increased to 60mg twice daily. A chest X-Ray obtained showed pleural effusions and cardiomegaly consistent of congestive heart failure. Since that time, R1's dose had not been increased to 60mg, and had several doses of blood pressure medications held due to blood pressures less than 100 systolic. R1 had not had weights recorded since 7/9/25, but she has gained several pounds since admission in March. R1 was markedly edematous with significant pitting edema to mid back, tense and distended abdomen, facial edema, and increased oxygen needs. R1 had not been receiving increased diuretic doses as ordered on 7/9/25 and needed urgent evaluation in the emergency department. R1's emergency management services (EMS) note on 7/16/25, identified R1 had a new onset of shortness of breath and found to be hypoxic at 86% on oxygen at 2 liters/min (L/min). Nursing staff stated R1 had not been taking her diuretic as suspected to low blood pressure, but staff was unaware of how often R1 took the diuretic. R1 complained of shortness of breath and chest pain. R1 had reported the shortness of breath started the last day or so. R1 also had pitting edema (2+) located in upper legs and abdomen. R1's emergency department (ED) note dated 7/17/25, identified R1 presented to the ED due to increased shortness of breath and increased bilateral leg swelling. R1 was normally on 2 L/min of oxygen via nasal cannula and was increased to 3 L/min due to oxygen saturations at 86%. R1 had not been taking prescribed diuretics due soft blood pressures (hypotension). R1's physical exam revealed pitting edema noted on upper legs and abdomen, abdominal distention with abdominal pain rated 10/10 on a pain scale, and course (abnormal lung sounds characterized by gurgling or bubbling noises) breath sounds. ED laboratory tests identified NT-Pro BNP (blood test used to diagnose and manage heart failure) was significantly elevated, increased from prior test and venous pCO2 (measure of the amount of carbon dioxide dissolved in venous blood) increased from baseline. R1's computed tomography (CT) identified cardiomegaly (enlarged heart) with increased volume of ascites (excessive abdominal fluid), small bilateral pleural effusions, anasarca (generalized swelling), and interstitial pulmonary edema in lung bases. Findings suspicious for volume overload in the setting of congestive heart failure. R1's hospital note dated 7/20/25, identified R1 presented in the ED on 7/16/25 with shortness of breath and was admitted to the intensive care unit for critical care for acute for decompensated heart failure, pleural effusions, and ascites. R1 received diuresis with intravenous Lasix (diuretic), R1 was at high risk for life threatening deterioration in condition. During an interview on 8/5/25 at 10:06 a.m., physician (MD) stated on 7/16/25 she was asked by the nursing staff to evaluate R1 due to increased shortness of breath and having a puffy face. MD explained she examined R1, R1's edema was significant and recommended R1 be seen in the ED for evaluation. R1's swelling was significant and shocking that did not just happen overnight, she sent him to the ED for further evaluation. After R1 left with the ambulance she asked nursing staff to retrieve R1's Torsemide prescription cards to verify the dose she was receiving. MD discovered the prescription cards with the order date of 7/9/25 did not have any doses removed from the prescription cards and some older prescription cards of 40mg twice daily were still present in R1 medication storage area. MD notified the director of nursing (DON) immediately of the discovery and informed DON that R1 had not received any of the increased Torsemide order from the 7/9/25 increase, seven days. R1's medication administration record (MAR) for July 2025 identified the physician order that directed to administer 60 mg of Torsemide twice daily but hold if systolic blood pressure is below 100. Although the MD reported finding no 60 mg doses had been given after they were ordered, R1's MAR between 7/9/25 and 7/6/25, indicated 11 doses of 60 mg Torsemide had been administered and 4 doses were held due to low blood pressure for evening doses on 7/13/25, 7/14/25, and morning dose on 7/16/25. Facility pharmacy email dated 7/31/25, included medication delivery records of medications that the facility had returned for repackaging. The record identified on 5/22/25 the facility had returned195- 20 mg Torsemide tablets to have them repackaged to the Torsemide 40 mg twice daily which were returned to the facility later that day (accounting for 97 doses or 48 days of twice daily doses without doses held). During an interview on 7/31/25 at 3:14 p.m., licensed practical nurse (LPN)-B stated on 7/12/25 the trained medication aide had come to her to question R1's Torsemide 40 mg twice daily prescription card not matching the MAR, LPN-B looked at the card without looking at the physician order to verify the correct dose. LPN-B instructed the TMA to administer the wrong dose of Torsemide. Then on 7/16/25 MD had requested to see R1's prescription cards for her Torsemide orders and after observing the cards she identified some discrepancies on the cards verses what was ordered. R1's prescription card of the Torsemide 60 mg twice daily had no doses removed from it and R1 had not received any of the increase doses of Torsemide. During an interview on 8/1/25 at 1:28 p.m., registered nurse (RN)-E stated she had made two different medication errors for R1's Torsemide order on 7/11/25 and 7/15/25. RN-E reported to the DON she had administered the incorrect dose of 40 mg verses the ordered 60 mg for both errors. RN-E had made the error because the old prescriptions of R1's Torsemide had not been removed from the medication storage, she must have just grabbed the wrong ones and not completed the rights of medication administration prior to giving them to R1. RN-E had not identified the medication card was the incorrect dose in contrast to the physician order. RN-E was unaware she had made an error until the DON brought it to her attention. After the notification, RN-E did not fill out a medication error report nor was she directed to. During an interview on 8/1/25 at 8:17 a.m., registered nurse (RN)-C stated the causal analysis of R1's medication error was due to the previous prescription card not being removed from the medication storage and that the nurses did not perform the rights of medication administration to ensure the correct dose was being given to R1.During an interview on 8/5/25 at 12:41 p.m., physician assistant (PA) stated she had increased R1's diuretic on 7/8/25 due to increased weights and crackles in her lungs. The missed doses of the diuretic could have added to her worsening congestive heart failure causing her to be hospitalized . This type of error would be considered a significant error because people with her type of heart failure could die if not given the correct medication.During an interview on 8/5/25 at 10:06 a.m., medical doctor (MD) stated a resident with congestive heart failure even just missing few doses of a diuretic could put them at risk for serious harm or even death.During an interview on 8/25/25 at 3:32 p.m., consulting pharmacist (CPharm) stated even if there were only a few missed or incorrect doses of a diuretic for a person who was on the verge of worsening CHF exacerbation would be considered a significant error due to risk of being hospitalized or even causing poor outcomes for the resident. CPharm further stated if the rights of medication administration had been followed this error could have been caught sooner and the facility needed to re-educate nurses to ensure the rights of medication administration are being followed.Review of the facility's Medication Error Reports 7/9/25 through 7/15/25 did not identify R1's medication errors that had been made between 7/9/25 and 7/15/25. R1's Medication Error Report dated 7/16/25, identified R1 was given Torsemide 40 mg twice daily. Medication error made by several different staff member and reason for error was the order was misread. In review of the medication error documentation there was no indication of development and implementation of corrective measures to prevent and/or mitigate the risk of recurrent errors until after R1's medication error was identified on 7/16/25. During an interview on 7/31/25 at 3:59 p.m., DON stated she was informed of R1's Torsemide medication errors by MD on 7/16/25. Upon completing an investigation into the error, she believed some of the nurses had administered the correct doses of 60 mg from an April 2025 medication card that had not been appropriately dispositioned tabs had been returned and repackaged. However, DON did not have any documentation of the prescription numbers or the exact doses she believed were administered. DON identified the cause of the error was the previous medication card of 40 mg twice daily was not removed from the med cart and staff were not performing the rights of medication administration. During a follow up interview on 8/5/25 at 12:00p.m., DON stated a system change had not been made prior to R1's medication error on 7/16/25 even though there were errors regarding disposition of medication and the rights of medication administration. After identification of R1's medication errors, the facility began re-education nursing staff on the rights of medication administration/preventing errors and created a new order checklist to ensure that the medications disposition was being done with any new order. The facility also implemented medication pass audits weekly to ensure appropriate medication disposition and the rights of medication administration were followed. In addition, consulting pharmacist was scheduled to provide additional medication administration education to nursing staff. Review of the facility's Medication Administration Procedure Policy dated 5/2024, identified the purpose to ensure proper consistent medication administration. With the procedure as follows:-When in doubt about dosage or effect of medication, always refer to the original physician order, Drug Reference Book on nursing unit or to the Pharmacist. If there are any questions, HOLD the medication and consult the nurse in charge or attending physician.-Follow the Seven Rights when you are administering medication to the individuals you are caring for: Right Person; Right Medication; Right Dose; Right Time; Right Route; Right Reason; Right DocumentationThe Immediate jeopardy was issued at PNC (past non-compliance) after it was verified the facility implemented the following prior to the survey:-Re-educated all nursing staff on proper medication administration/preventing medication starting 7/17/25. -Order checklist had been created on 7/21/25 to ensure nurses remove old medication from the resident's medication storage. -Audits of medication passes and medication changes began on 7/21/25 to ensure the medication have been removed with no further errors identified. Plan for auditing will be done Monday-Friday for 4 weeks, and monthly thereafter and will report findings to QAPI.-Consulting pharmacist has an in-service scheduled for 8/11/25 to educate on medication administration/preventing medication errors.

Based on observation, interview, and document review the facility failed to comprehensively assess and monitor signs/symptoms of fluid overload and failed to implement interventions including notification of changes to the physician for 1 of 3 residents (R3) who had diagnosis of congestive heart failure (CHF) reviewed for change of condition. Findings include:R3's face sheet dated 8/6/25, identified diagnoses of chronic diastolic heart failure (a condition in which the heart does not pump as well as it should), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and chronic kidney disease (longstanding disease of the kidneys leading to failure).R3's significant change MDS dated [DATE], identified R3 was independent with transfers, had intact cognition, and received diuretic medication. R3's cardiac focus care plan dated 4/21/25, included the following interventions:-fluid restriction: 2000 milliliters (ml) within 24 hours.-give cardiac medications as ordered.-monitor vital signs (weekly and as needed). Notify physician of significant abnormalities.-monitor/document/report as needed any signs/symptoms of congestive heart failure: dependent edema of legs and feet, periorbital edema, shortness of breath (SOB) upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation of lungs, orthopnea, weakness and/or fatigue, increased heart rate, lethargy and disorientation. -weight monitoring daily. R3's physician orders were as followed: -compression stockings on in morning and off at bedtime-start date of 4/23/25.-Daily weights-start date of 4/3/25 .-Fluid restriction of 2000 milliliters (ml) within twenty-four hours-start date of 4/1/25.-Furosemide (diuretic) 20 mg, give two tablets once daily-start date of 4/2/25 with end date of 5/23/25. -Furosemide (diuretic) 40 mg, give one tablet two times per day-start date 5/24/25 with end date of 7/18/25. - Furosemide (diuretic) 20 mg tablets, give three tablets in the morning for congestive heart failure-start date of 7/19/25.-Ipratropium-Albuterol nebulizer (bronchodilators; opens airways to make breathing easier) four times per day for asthma-start date of 4/1/25.-Albuterol sulfate inhaler (bronchodilators; opens airways to make breathing easier)-give two puffs every 6 hours as needed for wheezing-start date of 4/1/25-Albuterol sulfate nebulizer (bronchodilators; opens airways to make breathing easier)-administer three ml every 6 hours as needed for wheezing-start date of 4/1/25. In review of R3's weights from 7/15/25 through 8/4/25, identified R3's weights were taken according to the physician's order except on 7/30/25 and 8/3/25 and identified the following:-7/27/25: 322 pounds-7/28/25: 321 pounds-7/29/25: 321.5 pounds-7/30/25: weight not obtained.-7/31/25: 321 pounds-8/1/25: 319.5 pound-8/2/25: 318.5 pounds-8/3/25: No weight obtained (refused).-8/4/25: 320 pounds Review of R3's record between 7/15/25 through 8/5/25 did not identify that edema monitoring was consistently documented. R3's progress note dated 8/1/25 at 11:41 a.m., identified R3's weight had been trending up over the last three days. R3's lung sounds had slight wheezes, although this is his baseline and does have three plus pitting edema to bilateral lower extremities-although it is his baseline. Today his weight is down two pounds. Will monitor his weight over the weekend and if his weight goes up with get him in for an acute visit and will continue to monitor. R3's record between 4/1/25 through 8/4/25 did not identify R3's goal weight nor baselines of lower extremity edema. Although R3's record dated 8/1/25 identified R3 had bilateral 3+ pitting edema, it did not identify the locations/extent of the edema other than lower extremities. Even though vital signs (heart rate, blood pressure, oxygen saturations) were obtained once and were within normal limits, there was no indication a comprehensive respiratory assessment was completed nor evident R3 was assessed and/or administered an as needed (PRN) breathing treatment for wheezing in accordance with physician orders. Further not evident R3's physician was notified, nor evident monitoring for edema and respiratory assessments were completed until 8/3/25.R3's progress note dated 8/3/25 at 5:45 a.m., identified R3 had three plus pitting edema to left foot as well as swelling to left thigh. R3's right foot had two plus pitting edema. Audible wheezing noted and crackles (abnormal breath sounds characterized by clicking, bubbling, or crackling noise) in bilateral lungs, complaining of feeling tired, breathing fast and unable to catch his breath. R3 was coughing throughout the night and was given an as needed cough syrup. Nurse suggested to R3 that he be sent to the ED for evaluation, however, R3 refused. R3 was educated on the importance of following fluid restriction, elevating legs, and using incentive spirometer. R3's progress note dated 8/3/25 at 11:35 p.m., identified R3 had worsening congestive heart failure symptoms of increased shortness of breath, coughing, bilateral crackles, and bilateral edema to lower extremities. R3 was unable to catch his breath after walking from bathroom to the recliner. R3 was given scheduled nebulizer, given as needed cough syrup, offered oxygen, however, R3 refused the application of oxygen. R3 was offered to be sent to the ED and/or have a telehealth visit, however, R3 refused. R3 stated, What are they going to do for me there, that you guys can't do for me here. R3 was provided education on the risk versus benefits of visiting ED and verbalized the understanding of the risks of worsening heart complications and worsening respiratory distress. Although R3's record dated 8/3/25 identified R3 had edema to specified location with the amount no further assessment was included even though there was an increase in edema in the left lower extremity with increased adventitious breath/lung sounds, coughing, rapid breathing with shortness of breath, and R3 complained of being tired, there was no indication the physician was notified. Additionally, there was no indication R3 was provided with as needed breathing treatments for wheezing and shortness of breath nor evaluation of the effectiveness of the education that was provided. Although, R3's vital signs were obtained twice and were within normal limits on 8/3/25, R3's record did not indicate any further monitoring and assessments of R3's congestive heart failure symptoms until 15 hours later on 8/4/25. Review of R3's medication administration record (MAR) from 8/1/25 through 8/4/25, identified R3 was administered as need cough syrup three times and did not identify any as needed albuterol inhaler and/or nebulizers were administered. R3's progress note on 8/4/25 at 2:30 p.m., identified a communication to physician was sent due to R3 having signs and symptoms of CHF: weight gain, bilateral lower extremity edema up to thighs, and increased shortness of breath. R3 had attempted to be sent to the emergency department (ED), but refused, therefore a telehealth (remote healthcare) visit was performed with a physician.R3's physician telehealth visit note dated 8/4/25, identified R3 has several months of increasing weight gain. Diuretic had been increased on 6/21/25, despite this R3 had gained three kilograms in the past two days (amount of weight. gain was not consistent with R3's weight record) with increasing shortness of breath and edema in lower extremities up to his thighs. At first discussed increasing R3's diuretic and having him seen by the nurse practitioner the next day, however, nursing was concerned about R3's symptoms and refusal for transfer to ED. R3 agreed to be sent to the ED for evaluation to receive IV diuretic and have blood work. R3's emergency department (ED) note dated 8/4/25, identified R3 had been seen due to concerns of increase weight and worsening shortness of breath. Vital signs in ED were notable for mild tachypnea (fast breathing) of twenty-nine breaths per minute, wheezes, and rhonchi (abnormal breath sound, often indicating presence of fluid or mucus in the airway). R3's chest X-Ray report dated 8/4/25, identified cardiogenic (something originating in or caused by the heart or a cardiac condition), pulmonary edema (a condition caused by excess fluid in the lungs) with associated small pleural effusion ( a buildup of fluid between the tissues that ling the lungs and the chest). R3's breathing showed signs of improvement after receiving IV Lasix (diuretic) suggesting R3 may benefit from up titration of his daily Lasix to help better manage his congestive heart failure and R3 was discharged back to the skilled nursing facility. During an interview on 8/5/25 at 2:33 p.m., licensed practical nurse (LPN)-C stated R3's weights had been trending up and she noted wheezing in his lungs. LPN-C informed registered nurse (RN)-F about R3's symptoms and was instructed to monitor R3's symptoms over the weekend, if he had worsening symptoms then she would have R3 seen for an acute physician visit on Monday. LPN-C was unsure of what exactly R3's baseline was for weights, lung sounds, and edema. LPN-C reviewed the progress note dated 8/1/25 that she wrote and was unable to articulate how she determined R3 was at his baseline for weights, edema, and lung sounds in the absence of information in the record. LPN-C stated when she came to work on 8/4/25, R3 was worse then when she had seen him on 8/1/25. R3 had worsening edema in his legs, cough, and shortness of breath. LPN-C felt R3 was very unstable and attempted to have R3 seen for an acute visit with a physician, but was unable to schedule, so had telehealth physician visit instead. During an interview on 8/5/25 at 2:23 p.m., LPN-G stated on 8/3/25 R3 was not doing well. R3 had crackles in lungs, worsening edema, cough, and shortness of breath that would indicate worsening CHF. LPN-G did not notify the physician of her findings, however, did recommended to R3 he be seen in the ED for evaluation, but R3 declined to be sent to the ED in fear of being hospitalized .During an interview on 8/5/25 at 2:51 p.m., RN-C stated R3' s change of condition began on 8/1/25, however, the physician had not been notified until 8/4/25 and should have been notified sooner. RN-C further stated R3 should have been monitored closely for worsening symptoms of CHF and updated the physician accordingly and was unable to identify in R3's medical record consistent documentation of a comprehensive assessment or timely physician notification. During an interview on 8/6/25 at 3:22 p.m., family member (FM)-F stated when she met R3 at the ED on 8/4/25, R3 was pale in color, extremely short of breath, she could hear rattling in his chest and was completely out of it. R3 had told the ED physician that this was his baseline, however, that was not R3's baseline. FM-F stated R3 had a fear of being sent to the ED because he did not want to be hospitalized , however, he was getting in trouble when she saw him. FM-F stated when R3 was at home she would know he was having worsening heart failure symptoms when he began to have noisy breathing and would notify the physician right away to see if they could keep on top of his symptoms to possible avoid a hospitalization. During an interview on 8/5/25 at 12:41 p.m., physician assistant (PA) stated residents with a diagnosis of congestive heart failure need to be monitored closely to be able to identify worsening CHF and notify the physician promptly of any changes in their health to prevent further decline of the resident. A follow up interview on 8/6/25 at 11:00 a.m., PA stated if she had been notified sooner of R3's worsening edema and shortness or breath, it would not have changed the outcome for R3 and he still may have eventually needed to get the IV diuretic. During an interview on 8/5/25 at 12:06 p.m., director of nursing (DON) stated her expectation would be for the provider to be notified immediately of any change in the residents' health status and to monitor the resident closely to possibly prevent decline. DON further stated she is in the process of training nursing staff on signs and symptoms of congestive heart failure and the correct procedures to perform in the event a resident has a change in condition. Review of the facility's Change of Condition-Resident Physician/Nurse Practitioner (NP) Policy dated 8/23, identified the attending physician or nurse practitioner will be notified of changes in resident's condition or health status.Definitions:-Short term change of condition: A change in the residents' health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition.-Significant change of condition: A major deviation from the most recent evaluation that may affect multiple areas of functioning of health that is not expected to be short term or imposes significant risk to the resident. -Examples, but not limited to, observations or changes of condition to be reported: Changes in behavior/mental health Cognitive &/or behavior changes Change in sleep pattern Pain /Fever Eating/appetite changes Change in ADL needs Change in O2/Oxygen sat/breathing Wounds/skin issues New medications Mobility changes Falls Change in hearing, vision, or speech Bowel/bladder changesThe facility identified a procedure with the following:-Seven days per week, attending physician/nurse practitioner (NP) or physician/NP on call is to be notified of condition or health changes via phone, fax, or NP board. Fax and phone numbers available in each nurse area.-Notify nurse on duty of any change of condition. Then nurse on duty will notify nurse manager or director of nursing (DON) if needed.-Notify family member of any change in condition.-Document time of call/fax to provider/NP, reason for call, and results/orders received.-Update resident care plan with new or additional changes in care.

Based on observation, interview, and document review the facility failed to maintain documentation of actual disposition of medications to include: residents name, medication name, strength, prescription number, quantity, date of disposition, and involved staff and method of destruction for 1 of 5 residents (R1) reviewed for medication disposition. Findings include:R1's face sheet date 8/6/25, identified diagnoses of hypertensive heart disease with heart failure (a condition where high blood pressure that causes the heart to weaken), atrial fibrillation (irregular, often rapid heart rate that causes poor blood flow), prosthetic (artificial) heart valve , presence of a defibrillator (a device that provides an electric shock to the heart to get out of abnormal rhythm), and chronic liver disease (progressive deterioration of the liver). R1's physician orders included:-Torsemide (diuretic) forty milligram (mg) tablet give 1 tablet two times a day related to congestive heart failure. Hold if systolic blood pressure (top number in a blood pressure reading) was less than 100 mmHg. (start date of 5/19/25 through 7/9/25).-Torsemide 40 mg tablet give 1 1/2 (60mg total) tablets two times per day for congestive heart failure. Hold if SBP less than 100 mmHg. (start date of 7/9/25 through 7/17/25). Facility pharmacy email dated 7/31/25, identified pharmacy record of a delivery on 7/9/25 of Torsemide prescription (RX) (# 2399736) containing 96 (20 mg) tablets. During an interview on 8/5/25 at 10:06 a.m., R1's physician (MD) on 7/16/25 discovered R1's 7/9/25 Torsemide prescription cards did not have any doses removed and a previously ordered Torsemide cards of 40mg twice daily were still present in R1's medication storage area. MD removed the cards and instructed nurse to give the cards to the director of nursing (DON) to assist in her investigation of a possible medication error. MD did take photos of the Torsemide cards and sent them to the DON on 7/16/25. Review of photo images of R1's Torsemide prescription that were taken on 7/16/25 identified the following: -Rx: 2369106-two cards of Torsemide 20 mg tablet with directions of take 2 tablets by mouth twice daily with 32 tablets remaining. (dispensed on 5/22/25)-Rx: 2399736 -two cards of Torsemide 20 mg tablets with directions to take 3 tablets by mouth twice daily with 96 tablets remaining. (dispensed on 7/9/25) R1's medication error report dated 7/16/25, identified R1 had been given Torsemide 40 mg instead of the prescribed Torsemide 60mg from 7/9/25 through 7/16/25.During an interview on 7/31/25 at 3:48 p.m., registered nurse (RN)-A stated when a medication is destroyed they complete a medication destruction log which contains the resident name, prescription numbers, quantity of medication destroyed. Once the form is filled out then the medications are place in the Med Safe (a medication disposal system) and then the completed log is scanned into the resident's chart. RN-A stated R1's medical record did not identify that R1's Torsemide was destroyed on the 7/23/25 log. During an interview on 7/31/25 at 3:59 p.m., DON stated after she completed an investigation into R1's Torsemide medication error, she proceeded to destroy four prescription cards into the medication destruction bin called Med Safe, however, did not document the prescription numbers, quantity, and date of the destruction. During a follow up interview on 8/5/25 at 5:06 p.m., DON stated after a discussion with the consulting pharmacist (CPharm) she will be creating a medication destruction log for R1's Torsemide that was wasted, however, will be only including an undetermined quantity she destroyed. R1's medication destruction record dated 7/23/25, included multiple of R1 medications that had been destroyed however, did not identify documentation of the destruction of Torsemide (RX: 2369106 and 2399736). During an interview on 8/6/25 at 4:01 p.m., consulting pharmacist (CPharm) stated all medications that are delivered to the facility are property of the resident. When any medication needs to be dispositioned in the medication destruction bin, a log must be completed to include the resident name, date, prescription number, quantity, signature of staff responsible for the disposition, and the documentation of the medication disposition must be maintained in the resident's record. CPharm stated the DON informed him that R1's torsemide had not been properly documented at the time of destruction and he recommended to document that an unknown amount of R1's torsemide had been destroyed and placed in R1's medical record. Review of the facility's Medication Destruction Policy/Procedure dated 8/25, identified the following:-Non-controlled medications should be recorded in the medical record. A licensed nurse should record the name of the medication, prescription number, amount of medication, and date in the medical record.-Medications that meet criteria will be appropriately disposed of using the MedSafe receptacle that is affixed and permanently placed.

Based on observation and interview, the facility failed to ensure proper infection control practices were followed for 1 of 1 resident (R54) when his urinary drainage bag was observed laying on the floor. Further, loose, and contaminated laundry was observed having been sent down the laundry chute without being secured in a laundry/plastic bag. This had the potential to affect all 68 residents who resided in the facility. Findings include: R54's facesheet printed on 11/6/24, included diagnoses of dementia, benign prostatic hyperplasia (an enlarged prostate gland that causes urinary difficulty), and retention of urine. R54's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R54's BIMS (brief interview for mental status) score was 99 indicating R54 could not complete the interview. R54 had clear speech, could usually understand, and be understood. R54 had an indwelling urinary catheter. R54 was dependent on staff for activities of daily living. R54's physician orders dated 8/22/24, included urinary catheter: 16F (French) 10 cc (cubic centimeter) balloon for BPH (benign prostatic hyperplasia) with obstruction and urinary retention. R54's care plan dated 8/22/24, indicated R54 had a foley (a type of urinary catheter) indwelling catheter related to BPH with obstruction, and to connect to leg bag during the day and gravity drainage bag at night. Position catheter bag and tubing below the level of the bladder and away from entrance room door. During an observation on 11/6/24 at 8:58 a.m., R54 was in bed with his eyes closed. His entire urinary catheter bag was laying on the carpeted floor next to his bed. During an observation and interview on 11/6/24 at 9:19 a.m., the catheter bag was still on floor after licensed practical nurse (LPN)-G exited room after giving R54 medications. Together with LPN-G, returned to R54's room. When asked if it was acceptable to have the catheter bag laying on the floor, LPN-G replied, I wondered that too and I don't think so. LPN-G donned gloves and hooked the catheter bag to the bed frame. LPN-G did not know who placed the bag on the floor and stated she found it in that location when she went into the room to give R54 his medications. LPN-G stated leaving the catheter bag on the floor could cause bacteria to get in the system and cause a UTI (urinary tract infection). During an interview on 11/6/24 at 10:03 a.m., registered nurse (RN)-F who was also the infection preventionist and staff development nurse, stated nursing staff were trained on orientation to make sure urinary catheter bags were not placed on the floor. RN-F stated the catheter bag could not rest on the floor or lay on the floor as bacteria could enter the port and migrate to the resident causing a UTI. During an interview on 11/6/24 at 11:14 a.m., RN-C who was also a nurse manager, stated staff were expected to hang the catheter bag on the bed frame and not allow it to rest on or lay on the floor; doing so could result in an infection. During an interview on 11/6/24, at 12:42 p.m., the director of nursing (DON) and the administrator were informed of findings. The DON stated catheter bags were never to be placed on the floor and staff had been trained to hang the bag on the bed frame or other surface to prevent that from occurring. The DON acknowledged a catheter bag laying on the floor could result in a UTI to the resident. Facility Catheter Care (Indwelling) policy with revised date of 3/22, indicated the purpose of the policy was to prevent infection. The policy did not include proper positioning of a urinary drainage bag and/or to keep the bag off the floor. LAUNDRY During an interview on 11/5/24 at 8:51 a.m., laundry aide (LA)-B stated resident linens were sent to the basement via a laundry chute located on each floor. Resident's personal clothing were done in unit laundry rooms. During an observation on 11/6/24 at 7:38 a.m., in the basement, the small room where laundry was deposited via laundry chutes from three floors was observed. The room had two yellow carts on wheels, positioned side by side. The carts were full of plastic bags of linen. In addition to the plastic bags, were loose towels and cloth gowns. On the floor were small pieces of maroon colored fabric resembling napkins. During a telephone interview on 11/6/24 at 8:06 a.m., facilitated by environmental services director (EVS)-H, laundry coordinator (LC)-H stated linens placed down the chute should be bagged. During an observation on 11/6/24 at 8:09 a.m., with EVS-H, together observed the laundry chute room. The cloth napkins had been picked up off the floor and were in one of the carts. EVS-H acknowledged the loose towels and gowns in the carts, along with the plastic bagged linens. During an interview on 11/6/24 at 8:21 a.m., LA-B admitted staff did not always bag the linen - they were supposed to but were probably in a hurry and just tossed them down the chute. LA-B stated she usually saw loose towels, gowns, and washcloths; blankets and sheets were usually bagged. During an observation on 11/6/24 at 8:26 a.m., observed linen and garbage chutes on third floor across from the service elevator. There was no signage to inform staff not to place loose laundry down the chute. During an interview on 11/6/24 at 8:30 a.m., community assistant (CA)-C stated she threw loose linen, like towels down the laundry chute, adding that linen only needed to be bagged if there was biohazard or fecal material on them. During an interview on 11/6/24 at 9:14 a.m., CA-D stated linen should be placed in a plastic bag first before putting it down the chute, adding she was aware that sometimes staff threw laundry down the chute that wasn't bagged. During an interview 11/6/24 at 10:02 a.m., RN-F, who was also the infection preventionist, was informed of findings and stated staff were not supposed to throw loose linen down the laundry chute in order to prevent the potential spread of infection. During an interview on 11/6/24 at 12:42 p.m., the director of nursing (DON) and administrator were informed of findings. The DON stated staff were aware to put linen in a plastic bag first before putting it down the chute; that it was an infection control concern if staff were carrying contaminated linen against their uniform. The DON stated laundry staff usually informed her when loose linens were being sent down the chute. Facility Soiled Linen Handling and Transportation policy dated 1/2020, indicated the purpose was to prevent contamination of laundry personnel, surfaces, and residents while handling soiled linens. Soiled linens were to be collected and transported in a sealed plastic bag to prevent spread of contaminants. The policy did not include procedure for placing soiled linen down the chute.

Based on observation and interview, the facility failed to maintain holding temperatures for hot foods of 135 degrees Fahrenheit or greater. In addition, the facility failed to ensure dietary staff followed appropriate infection control practices during food prep and meal service in the kitchen. This had the potential to affect 22 of 22 residents residing on the unit. Findings include: On 11/4/24 at 5:14 p.m., during observation, two baking sheets of cooked cheese quesadillas were sitting on the stove top, one tray completely covered, and one partially covered with aluminum foil. Surveyor asked cook (C)-A to re-temp the cheese quesadillas approximately five minutes after removing them from the oven and leaving one baking sheet partially uncovered. Cheese quesadillas were temped at 136 degrees Fahrenheit on initial removal from the oven and dropped to 127 degrees Fahrenheit on recheck. On 11/4/24 at 5:20 p.m., during interview with the culinary services manager (CSM) stated that she would not expect the quesadillas to be out of the oven and cooling down partially uncovered. The cheese quesadillas should have been in the oven on warm to hold the appropriate temperature for the resident's food. The culinary services manager stated the cheese quesadilla's will now need to be warmed up in the microwave before the residents receive their meal. On 11/4/24 at 5:22 p.m., during interview, C-A stated the quesadillas should have been kept in the oven on warm and recognized the potential for the quesadillas to cool down by leaving them on stove top partially uncovered. On 11/5/24 at 9:02 a.m., during observation, C-B prepared bacon for breakfast and placed it in a frying pan on top of the stove. The frying pan of bacon was kept on the warm burner via stove top without a lid/cover. On 11/5/24 at 9:05 a.m., during observation, C-B took the bacon temperature while it was on the warm burner (already cooked) and the holding temperature was 119.9 degrees Fahrenheit. On 11/6/24 at 11:40 a.m., during interview, the CSM stated foods that are hot need to be held at 165 degrees Fahrenheit and reheated to 165 degrees Fahrenheit. After looking on a cell phone, the CSM stated the quesadillas and bacon should have been held at 135 degrees Fahrenheit and acknowledged the foods prepared in the 3rd floor kitchen were not at adequate holding temperatures despite the food being cooked. Facility Food Temperatures policy undated, indicated all hot food items must be cooked to appropriate internal temperatures, held, and served at a temperature of at least 135 degrees Fahrenheit. Hot food items may not fall below 135 degrees Fahrenheit after cooking, unless it is an item which is to be rapidly cooled to below 41 degrees Fahrenheit and reheated to at least 165 degrees Fahrenheit prior to serving. Infection Control On 11/4/24 at 5:16 p.m., during observation, C-A was cutting a cheese quesadilla with a pizza cutter, initially C-A did not have gloves on. After touching the quesadillas with bare hands, C-A realized gloves were needed and stopped what C-A was doing to don gloves before continuing food preparation. The cheese quesadilla was not discarded. On 11/4/24 at 5:25 p.m., during observation, C-A placed fingers inside of a soup bowl, where food had the potential to be in contact with the same surface, removed a quesadilla from the microwave, and proceeded to cut the quesadilla without washing hands and/or donning gloves. On 11/4/24 at 5:29 p.m., C-A and another staff member collided in the kitchen. This incident caused C-A to drop a glass bowl of peaches. C-A proceeded to sweep up the broken glass bowel and peaches with a broom and dustpan, grabbed a cardboard box out of the garbage can in the kitchen and placed it on the floor, dumped the broken glass and peaches from the dustpan into a clear garbage bag and then placed the garbage bag in the cardboard box. Further, C-A placed the cardboard box (with broken glass and peaches) on the countertop next to the sink. C-A then proceeded to place hands on the serving counters and did not wash them or use alcohol-based hand sanitizer. Finally, C-A took the cardboard box of broken glass and peaches to the appropriate garbage. C-A did not wash hands after bringing the cardboard box to the garbage and proceeded to take a clean skillet pan out of the cupboard, put the aluminum foil back over the quesadillas, and placed the quesadillas back into the oven on warm. On 11/4/24 at 7:30 p.m., during interview C-A stated hands should have been washed after removing the garbage from the kitchen and before preparing food/removing pans. On 11/6/24 10:36 a.m., during interview the director of nursing (DON) stated staff need to re-educated on infection control immediately. The DON further stated infection control concerns have the potential to affect all residents living on that unit. On 11/6/24 11:44 a.m., during interview the CSM stated education has been started for the dietary staff. Facility Hand Hygiene policy undated, indicated hand hygiene is the most important single procedure for preventing the spread of infection. Hand hygiene is known to reduce patient morbidity and mortality from healthcare acquired infections. Hand washing with soap and water whenever hands are visibly dirty, before eating, and after using the restroom. The facility's hand hygiene policy also indicated general indications for alcohol-based hand sanitizer that include after touching a resident or resident's immediate environment, contaminated surfaced, and immediately after glove removal.

Based on interview and document review the facility failed to notify the physician of neck pain following a fall for 1 of 1 resident (R25) reviewed for accidents. Findings include: R25's facesheet printed 11/6/24, included diagnoses including Parkinsonism (condition that affects movement), pneumonia, atrial fibrillation (the heart's upper chambers beat chaotically and irregularly), displaced fracture of second cervical vertebra (broken bone in the neck region of the spine) and fracture of nasal bones. R25's significant change Minimum Data Set (MDS) assessment dated [DATE], included a brief interview for mental status score of 15 indicating intact cognition, uses walker and wheelchair and is dependent for toileting, dressing, and substantial/maximal help for transfers. R25 does not walk. R25 had one fall with major injury. R25's care plan undated, indicated the resident required extensive assistance assist of one and a gait belt to stand pivot transfer and wears a cervical (C)-collar related to neck fracture per physicians order. R25 is at risk for falls and injuries related to impaired balance and mobility, cognitive impairments and exhibits poor safety awareness and self transfers. Interventions for fall included administer medications, supplements as ordered, complete fall risk assessment on admission and as needed per facility policy, follow facility fall protocol, pharmacy consult to evaluate medications, sign in room reminding to ask for assistance, dycem (non slip material) to wheel chair, reacher, autolock brakes added to wheelchair, chair at bedside when in bed and wheelchair bag for storage. R25's current physician orders included: C-collar on at all times dated 8/14/24. On interview and observation 11/4/24 at 3:24 p.m., R25 was sitting in his wheelchair in his room. R25 had on a rigid C-collar on his neck. R25 stated it seems like a long time ago when he fell and broke neck but still has to wear C-collar. R25 indicated he was reaching for something and fell out of his chair. R25 denied any pain currently. A Post Fall Evaluation dated 8/3/24 at 11:43 a.m., no identifier present who completed the form, indicated R25 had an unwitnessed fall at 11:00 a.m. in his room reaching for an item. R25 had an abrasion to his mid forehead 4 centimeters (cm) by 2 cm and a skin tear to left back of hand. The provider was notified by fax. Wheelchair was unlocked and call light was on when resident found. R25 stated he was reaching for paper on the floor that was out of reach. R25 complained of some mild pain in his right foot. Communication was sent via fax to physician including fall with abrasion to mid forehead 4 cm by 2 cm left open to air. Skin tear to the back of left hand cleansed with normal saline and band aid applied. Resident was reaching for a piece of paper on the floor and fell forward out of wheelchair unwitnessed. Please note fall with head protocol being followed, abrasion to mid forehead left open to air, and is it okay to cleanse skin tear to back of left hand daily with normal saline and apply Band-Aid? R25's nursing progress note by licensed practical nurse (LPN)-H dated 8/3/24 at 3:36 p.m., indicated monitoring resident post fall with head abrasion frontal lobe (forehead). At 3:15 p.m., R25 is complaining of neck pain sitting in wheelchair at the time of examination. Declined tylenol for pain. Gently palpitated cervical spine; resident had no pain with palpitation. Resident unable/unwilling to elaborate on pain. Did confirm it was new since fall. Had no complaints of neck pain on prior vital sign checks or that was noted by the nursing assistants. Checked all four extremities for numbness and tingling and R25 denied. Demonstrated movement and strength; equal. Palpitated muscles on sides of neck and did not complain of pain. Offered cool pack and R25 declined. Offered two times very clearly to have him sent to the emergency room for evaluation of neck fracture due to hitting his head on floor. He said no both times. Stated I just want to lay down. Staff assisted him to lay down and he did complain of pain when doing this even when his head was put back up at 45 degrees. Continue to monitor and offer pain relief. R25's nursing progress note by LPN-H on 8/3/24 at 4:43 p.m., indicated cool packs were applied to cervical spine for complaints of pain post fall. See previous notes. R25's nursing progress note by LPN-H on 8/3/24 at 5:22 p.m., indicated resident continue to state his neck is hurting; explained it may be a muscle sprain from his fall. Has only been 45 minutes since Tylenol was given. Continue to monitor and treat pain with as needed treatments. R25's nursing progress note by LPN-H on 8/3/24 at 10:48 p.m., included following up on neck pain from fall at 11 a.m. today. Resident complaining of more severe pain when he is rolling in bed or with bed mobility. States minimal pain when still. Gave cool pack at 10:05 p.m. for 20 minutes to upper back/lower neck. Resident indicated it helped some. Tylenol last given at 4:40 p.m. Does not have any other as needed pain relieving treatments available. Still denies any pain/numbness/tingling in all externalities. Passed on to night shift to give as needed extra strength Tylenol when able to do so. R25's nursing progress note by registered nurse (RN)-G on 8/4/24 at 7:20 a.m., included resident slept poorly. States has worse pain to posterior (back) of neck, especially with repositioning/turning to sides when changing undergarments. Swelling and hematoma (collection of blood outside of blood vessels due to injury or trauma) to forehead/frontal lob 4 x 2 cm x 0.5 cm depth. Arouses easily and is alert and oriented to self and place. Hand grasps are equal, speech clear. Concern with need for imaging (X-rays) so notified on call physician at 3:10 a.m., who gave order to transfer resident to the emergency department (ER). Notified family member at 3:00 a.m., who gave permission to send. Ambulance called at 3:17 a.m. and transported at 3:35 a.m. An ED note 8/4/24 at 9:33 a.m., included diagnosis of fall with abrasion to scalp, fracture of second cervical vertebrae, fracture of orbit (upper face bone), nasal fracture, also with frontal bone fracture (forehead region of the skull). R25's nursing progress note 8/4/24 at 11:15 a.m., indicated R25 was sent to ER for evaluation due to complaints of neck pain on night shift. R25 just returned now, wearing C-collar to be kept on at all times for 14 days. R25 was started on Augmentin (antibiotic) for pneumonia. On interview 11/5/24 at 2:36 p.m., medical doctor (MD)-F, R25's doctor, indicated a fall with neck pain requires evaluation in the ED as soon as possible. Even if the neck pain onset was hours after the fall, the provider should have been notified immediately when he started complaining of neck pain. MD-F stated R25 could have lost mobility or even his life by delaying the immobilization of his neck. On interview 11/5/24 at 3:27 p.m., licensed practical nurse (LPN)-D indicated if someone started complaining of neck pain after hitting their head he would notify the provider immediately and transfer to the ER even if the neck pain wasn't initially present. On interview 11/5/24 at 3:33 p.m., LPN-E indicated the provider should be notified right away if a resident fell and then later complains of neck pain especially if the resident hit their head. On interview 11/5/24 at 3:44 p.m., LPN-F indicated any time a resident complains of neck pain after a fall, the physician should be notified and the resident sent to the ED. On interview 11/5/24 at 4:18 p.m., registered nurse (RN)-E, also identified as nurse manager, indicated the provider was initially contacted when R25 fell , but confirmed the nurse should have notified the physician again when R25 began complaining of neck pain. RN-E added LPN-H did offer to send him to the ED but he refused. On interview 11/6/24 at 10:40 a.m., the director of nursing (DON) after reviewing R25's medical record confirmed the provider should have been notified when R25 began having neck pain. A policy on notification to physician was requested but not received.

Based on observation, interview, and document review the facility failed to ensure weekly comprehensive skin assessments with measurements were completed for 1 of 3 residents (R59) reviewed for pressure ulcers. Findings include: R59's significant change in status Minimum Data Set (MDS) assessment dated [DATE], indicated cognitively intact, required substantial/maximal assistance with toileting, transfers, shower/bathe, dressing, personal hygiene, utilized a wheelchair, frequently incontinent of urine and bowel, diagnoses included: type one diabetes, cancer, hypertension (high blood pressure), renal insufficiency (poor function of the kidneys), chronic kidney disease; at risk for developing pressure ulcers, two unstageable pressure injuries presenting as deep tissue injury (full thickness skin and tissue loss), treatments included: pressure reducing device for chair and bed and pressure ulcer care. R59's care plan printed 11/6/24, indicated stage two pressure injury (partial-thickness skin loss) on both left and right heels, interventions included: follow facility protocols for treatment of injury, monitor/document location, size and treatment of skin injury, report abnormalities, failure to heal, s/sx (signs/symptoms)of infection, maceration etc. to MD (medical doctor), pressure relieving/reducing mattress, pressure relieving/reducing chair, cushion to protect the skin while in bed and sitting in chair, weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. R59's document titled skin only evaluation dated 9/12/24, did not indicate concerns or skin abnormatilities of R59's heels or feet. R59's document titled Braden Scale for Predicting Pressure Ulcer Risk Evaluation dated 10/3/24, indicated R59 was not at risk for developing pressure ulcers. R59's progress notes indicated : 10/10/24 at 4:12 p.m., licensed practical nurse (LPN)-A indicated R59 has pressure ulcers on both heels, sent for air mattress and pillow under both feet to elevate heels. 10/24/2024 at 2:59 p.m., LPN-C indicated open areas bilateral heels, diabetic, Rt (right) 2 cm (centimeters) x 4 cm, Lt (left) 4 cm x 3.5 cm, no drainage, Mepilex (absorbent foam dressing) applied, recommendations: to be assessed by wound nurse. 10/28/24 at 4:39 p.m., LPN-B indicated recommendations from nurse practitioner (NP)-A, known as the wound nurse, wound one and two: left posterior heel and right medial heel, cleanse wound, and peri wound with ns (normal saline), pat dry, apply collagen sheet, cover with dry bordered dressing, agreed, and signed by physician assistant (PA)-B. 11/05/2024 4:11 p.m., registered nurse (RN)-A indicated R59 and POA (power of attorney) requesting a wound clinic referral to her wound on the right heel. SBAR (situation, background, assessment, and recommendation/request communication) filled out for MD/NP (medical doctor/nurse practitioner) to advise/address R59's documents titled Skin Check indicated: 10/10/2024 at 4:00 p.m., LPN-A new skin issue left heel, pressure ulcer / injury, acquired in-house, not painful, length: 4 cm width 4.5 cm depth 0 cm; right heel issue type stage two pressure ulcer / injury - partial thickness skin loss with exposed dermis. wound acquired in-house, wound is new, no signs and symptoms of infection, not painful, length 3 cm width 2.5 cm depth 0 cm, additional care: heel suspension / protection device. 10/12/2024 at 1:14 a.m., RN-A indicated left heel pressure ulcer / injury, wound acquired in-house, not painful, length 4 cm width 4.5 cm depth 0 cm, right heel pressure ulcer / injury, stage two partial thickness skin loss with exposed dermis, wound acquired in-house, length 3 cm width 2.5 cm depth 0 cm, heel suspension / protection, additional care: air flow pad, skin loss with exposed dermis (middle layer of the skin), boggy, additional care: heel suspension/ protection device, air flow pad. 10/24/2024 at 2:41 p.m., LPN-C indicated left heel pressure ulcer / injury, unstageable pressure injuries presenting as deep tissue injury, wound acquired in-house, unknown how long the wound has been present, no signs and symptoms of infection, painful, 4 cm length, 3.5 cm width, 0.1 cm depth, granulation (development of new tissue): 20%, slough (shedding dead surface cells from the skin): 80%, surrounding tissue: dry / flaky, cool, dressing saturation: none, cleansing solution: normal saline, primary dressing: hydrocolloid (moisture-retentive dressings), right heel pressure ulcer / injury unstageable pressure injuries presenting as deep tissue injury, acquired in-house, unknown how long the wound has been present, no signs and symptoms of infection, painful: yes, medicate prior dressing change, 2 cm length, 4 cm width, 0.1 cm, cleansing solution: normal saline, primary dressing: foam, additional care: heel suspension / protection device. 11/05/2024 at 4:37 p.m., RN-C, known as the nurse manager, indicated skin is pale in color, skin is fragile, normal skin turgor, medial left heel, stage two pressure ulcer / injury, partial thickness skin loss with exposed dermis, wound acquired in-house on 10/10/2024, no signs and symptoms of infection, painful with dressing change, medicate prior dressing change, length 4.8 cm, width 4 cm, depth 0.2 cm, epithelial: 20%, slough: 20%, eschar: 60%, moderate sanguineous exudate, surrounding tissue: maceration; stage two right heel pressure ulcer / injury partial thickness skin loss with exposed dermis wound acquired in-house 10/10/2024, no signs and symptoms of infection, painful at dressing change, length 1.5 cm, width 1.5 cm, depth 0.2 cm, epithelial: 50%. granulation: 30%, slough: 20%, peri wound: rolled edge surrounding tissue: maceration. edema: no swelling or edema, skin issue education: change clothing / briefs, turn every two hours. R59's visit report document dated 10/25/24, RN-D, wound care nurse, indicated wound one: left, posterior heel is a stage two pressure injury/pressure ulcer acquired on 10/24/24, and has received a status of not healed, initial wound encounter measurements are 4 cm length x 3.5 cm width x 0.1 cm depth, with an area of 14 sq (square) cm and a volume of 1.4 cubic cm moderate amount of drainage, wound bed has 1-25 %, granulation, 76-100% epithelialization, no slough and no eschar present, DTI (deep tissue injury) present, autolytic debridement performed; wound two right, medial heel is a stage two pressure injury pressure ulcer acquired on 10/24/2024, and has received a status of not healed, wound encounter measurements are 2 cm length x 4 cm width x 0.1 cm depth, with an area of 8 sq cm and a volume of 0.8 cubic cm, moderate amount of drainage noted, wound bed has 26-50%, granulation, 26-50% slough, 1-25% epithelialization; wound #1 - left, posterior heel - pressure ulcer cover wound with bordered super absorbent 3.5 (inches) x 4 (inches) every day for 25 days; wound #2 - right, medial heel - pressure ulcer cover wound with bordered super absorbent 3.5 x 4 every day for 25 days apply wound with collagen sheet 2 x 2 every day for 25 days. R59's treatment administration record (TAR), dated 10/1/24-10/31/24, skin check on bath day: document any bruise, rash, or open area. On 10/17/24, the TAR documentation indicated a 5, which indicated hold/see progress notes. R59's progress notes failed to indicate a documented comprehensive skin check. R59's TAR dated 11/1/24-11/30/24, indicated weekly wound assessment B/L(bilateral lower heels every day shift every Saturday with a start date of 11/2/24. R59's TAR date 11/2/24, was blank and documentation in R59's chart of a weekly wound assessment was found for 11/2/24. On 11/5/24 at 8:34 a.m., R59 was lying on an air mattress in bed on and positioned on her back, with foam cushioned boots. R59 stated she was a diabetic and had ongoing problems with her feet, had an amputated toe, and recently broke her ankle prior to coming to the facility. R59 stated she had sores on her heels due to diabetes. R59 verified she wore cushioned boots in bed and while in the wheelchair, and staff repositioned her in bed. On 11/5/24 at 8:34 a.m., nursing assistant (NA)-A and NA-B stated R59 always wore cushioned boots. NA-A stated R59's heels were also floated while in bed. NA-A and NA-B were observed to provide morning cares for resident and removed boots and when morning cares were complete cushioned boots were replaced and R59 was transferred to the wheelchair. NA-A stated the NA's were responsible to inform the nurse when residents had changes in the skin. On 11/5/24 at 11:24 a.m., RN-C, known as the nurse manager, confirmed R59 had bilateral heel pressure ulcers acquired at the facility. RN-C stated the heel ulcers were discovered on 10/10/24, and further stated R59 had a decline in health prior to admission to the facility. RN-C stated R59 at times would refuse position changes, and R59 would not want to get out of bed some days. RN-C stated interventions included cushioned boots and floating heels. RN-C confirmed a comprehensive skin assessment was not completed weekly as expected after 10/10/24, and stated the next weekly assessment was 10/24/24. RN-C stated R59's wound had not worsened and were unavoidable due to her decline in health, and refusal for repositioning. On 11/5/24 at 1:38 p.m., RN-D, facility consulting wound nurse, stated she came to the facility and completed wound care on residents. RN-D stated weekly comprehensive skin checks were expected and documented by the facility. RN-D stated with R59's diagnoses, medications, and poor perfusion the pressure ulcers were most likely not avoidable. RN-D further stated without further diagnostic tests hard to determine if the wounds were pressure related or related to poor blood flow. RN-D stated due to comorbidities, decline in health and diet, put her at risk for skin breakdown. On 11/5/24 at 4:33 p.m., R59 was seated in a wheelchair at dining table with cushion boots on feet. On 11/6/24 at 9:26 a.m., the director of nursing (DON) and administrator stated weekly skin checks were expected and documented and confirmed the weekly skin check after 10/10/24, was not completed until 10/24/24. The DON stated pressure ulcers should be measurement weekly with a comprehensive assessment. The DON stated wounds were discussed during IDT (interdisciplinary team) meetings. The DON stated R59 was at risk for pressure related concerns due to her diagnoses. On 11/6/24 at 11:09 a.m., PA-C stated R59 was prone to skin break down due to comorbidities including diabetes, and stated the facility was expected to complete weekly comprehensive wound assessments that included measurements. On 11/06/24 at 11:38 a.m., LPN-B confirmed R59 had bilateral heel ulcers and confirmed weekly comprehensive skin assessments with measurements were expected weekly, and stated she was aware that R59 had skin assessments that were not documented to include the measurements and comprehensive description. The facility Pressure Injury policy dated 9/2019, indicated: To provide appropriate assessment and prevention of pressure injuries, as well as receive the necessary treatment and services to promote healing, prevent infection and prevent any new pressure injuries from developing. Based on the resident's Comprehensive Skin Assessment, St John's will utilize prevention and assessment interventions to assure that a resident entering the center without pressure injuries does not develop a pressure injury unless the resident's individual clinical condition demonstrates that this was unavoidable, and this information will be documented in the medical record. Upon noticing a pressure injury, complete a Wound Assessment and Braden Scale in the EMAR under assessments. Add an order to complete a Wound Assessment in the EMAR weekly. Start interventions as ordered/needed. Notify PCP or in-house NP of new pressure injury. Notify family of new pressure injury. Notify dietary of new pressure injury. Consult PCP, in-house NP, Nurse Manager, visiting wound nurse or Wound Clinic as needed for treatment. Complete a new Wound Assessment Weekly. Document weekly and PRN in the Interdisciplinary Nursing notes on the size, drainage, odor, pain, surrounding tissue, and treatment. Review at IDT meetings. When area is fully healed, update Plan of Care, PCP, and document in the Interdisciplinary Nursing notes

Based on interview and document review the facility failed to act upon the consultant pharmacist's recommendation for 2 of 5 residents (R55, R59) reviewed for unnecessary medications. Findings include: R59's significant change in status Minimum Data Set (MDS) assessment dated [DATE], indicated cognitively intact, required substantial/maximal assistance with toileting, transfers, shower/bathe, dressing, personal hygiene, utilized a wheelchair, frequently incontinent of urine and bowel, diagnoses included: type one diabetes cancer, hypertension (high blood pressure), renal insufficiency (poor function of the kidneys), and chronic kidney disease. R59's document title Medication Regimen Review Report dated 9/21/24, consulting pharmacist (CP)-A indicated potential medication need: R59 with diabetes mellitus type one and CKD3 (chronic kidney disease stage 3) does not receive ACEI/ARB (angiotensin converting enzyme inhibitor and angiotensin receptor blocker therapy is a combination of two types of prescription medications that are commonly used to treat a variety of conditions therapy including chronic kidney disease), presence of albuminuria (sign of kidney disease and means that you have too much albumin in your urine) is unknown from records, no allergy/intolerance to ACEI/ARB noted in records. Recommendation: please follow-up on whether ACEI/ARB therapy is indicated for this individual. Order clarification: order for ASA (aspirin) 81 upon admission of 8/12/24, no indication for use nor stop date if applicable. On 11/6/24 at 11:30 a.m. R59's paper chart was located in the nursing station and included the CP-A's recommendation dated 9/21/24. R59's provider and nursing orders were reviewed and lacked documentation the facility had addressed CP-A recommendations. On 11/6/24 at 11:48 a.m., registered nurse (RN)-C, known as the nurse manager stated CP-A emailed the director of nursing (DON) with resident pharmacy recommendations. RN-C stated she was not part of the pharmacy recommendations process, and confirmed R59's recommendation dated 9/21/24, was not addressed as expected. On 11/6/24 at 12:02 p.m., the director of nursing (DON) stated she received a monthly email from CP-A with resident's pharmacy and medication recommendations. The DON stated the email was forwarded to the health unit coordinator (HUC)-D who printed the recommendations and placed a hard copy of the pharmacy recommendation for the provider to address when next at the facility. The DON stated the provider was expected to address the pharmacy recommendations, and further stated she was responsible to ensure pharmacy recommendations were addressed. The DON confirmed R59's pharmacy recommendations dated 9/21/24, were not addressed as expected by the provider. 40614 R55's quarterly MDS assessment dated [DATE], indicated moderately impaired cognition, required maximal to moderate assistance with toileting, transfers and walking. Medications included anticoagulant, antidepressant, diuretic, anticonvulsant, and hypoglycemic. Active diagnoses included fractures, atrial fibrillation, heart failure, anemia, hypertension, renal insufficiency, diabetes, and chronic obstructive pulmonary disease. No psychiatric/mood disorder was indicated including anxiety or depression. R55's Medication Regimen Review Report dated 6/24/24, CP-A indicated potential medication need: R55 is taking duloxetine (antianxiety, antidepressant medication) with indication of cognitive impairment as diagnosis, is inappropriate. Please link to an appropriate indication, or clarify with a provider if no indication for use has been issued. A progress note from pharmacy consultant dated 7/30/24, indicated medical record reviewed (MRR) with no concerns reported. A progress note from 9/10/24, included indication for duloxetine requested previously and this is second notice due to non-response. Inappropriate indication of cognitive impairment is currently linked to this agent. A progress note dated 10/20/24, included duloxetine inappropriate indication for use. This is 3rd notice issued. Administrative nursing staff emailed to ensure this is resolved. R55's provider orders last signed 10/23/24, by medical doctor (MD)-F, included duloxetine delayed release particles 30 mg one capsule one time a day for cognitive impairment. Initial order date of 6/5/24. On interview 11/6/24 at 12:47 p.m., RN-C, known as the nurse manager stated she is not involved in pharmacy reviews and added the director of nursing and the health unit coordinator (HUC) is responsible for those. On interview 11/6/24 at 12:56 p.m., the DON indicated it is the responsibility of both nurse managers to get the pharmacy recommendations completed. The DON then clarified stating RN-C started her employment in August 2024 and hasn't been trained on pharmacy reviews yet. The DON stated the pharmacy recommendations are electronically mailed (email) to her. The DON stated she does remember getting an email about R55's duloxetine recommendations but had not acted on the recommendation at this time. On 11/6/24 at 12:05 p.m., a phone call was placed to CP-A and a voicemail was left and return phone call was not received from CP-A. Facility Medication Regimen Reviews policy dated 5/19, indicated: The consultant pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medication. The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. The MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities, for example: medications ordered in excessive doses or without clinical indication; medication regimens that appear inconsistent with the resident's stated preferences; duplicative therapies or omissions of ordered medications; inadequate monitoring for adverse consequences; potentially significant drug-drug or drug-food interactions; potentially significant medication-related adverse consequences or actual signs and symptoms that could represent adverse consequences; incorrect medications, administration times or dosage forms; or other medication errors, including those related to documentation. Within 24 hours of the MRR, the consultant pharmacist provides a written report to the attending physicians for each resident identified as having a non-life threatening medication irregularity. The report contains: the resident's name; the name of the medication; the identified irregularity; and the pharmacist's recommendation. An irregularity refers to the use of medication that is inconsistent with accepted pharmaceutical services standards of practice; is not supported by medical evidence; and/or impedes or interferes with achieving the intended outcomes of pharmaceutical services. It may also include the use of medication without indication, without adequate monitoring, in excessive doses, and or in the presence of adverse consequences.

Based on observation, interview, and record review the facility failed to utilize enhanced barrier precautions (EBP) for 2 of 5 residents (R1, R2) observed with personal cares. Findings include: Per the Centers for Disease Control (CDC) dated 6/28/24: EBP are indicated during high contact care activities for residents with infection or colonization with a CDC targeted multi-drug resistant organisms (MDRO) (when contact precautions do not apply) or for any resident who has a chronic wound and/or indwelling medical device. High-contact resident care activities include dressing, bathing/showering, transferring, toileting, providing hygiene, changing linens or briefs, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, or wound care: generally, for residents with a chronic wound(s), not skin breaks or tears covered with an adhesive bandage (e.g., Band-Aid) or similar dressing. R1's face sheet dated 9/24/24, identified diagnoses of bullous pemphigoid (rare skin condition that causes large, fluid-filled blisters). R1's significant change Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment. R1 required assist (A) of one person for dressing, bathing, and hygiene. R1's wound care visit dated 9/17/24, identified R1 had left first and second toe ulceration in the setting of bullous pemphigoid. R1 had wound debridement (removal of dead or infected tissue from wound to promote healing) performed. R1's care plan dated revised 9/20/24, identified wound management to left foot. A second area focused on enhanced barrier precautions revised on 9/17/24, identified staff to follow standard precautions, including proper handwashing techniques, to minimize microorganism transmission enhanced barrier precautions will be used in addition to standard precautions during high contact care activities. During an observation and interview on 9/24/24 at 11:36 a.m., clinical manager (CM)-A applied gait belt to R1, transferred R1 from recliner to wheelchair, and wheelchair to toilet without EBP. CM-A assisted with pulling brief down. CM-A washed hands and put gloves on. CM-A stated direction for using EBP would be located on the computer. CM-A verified she should be wearing EBP as she was performing high contact cares. CM-A put gown on, assisted R1 with toilet hygiene. CM-A removed gown and gloves and assisted R1 from wheelchair to recliner. During an observation on 9/20/24 at 12:12 p.m., nursing assistant (NA)-A observed putting gait belt around R1, transferred R1 from recliner to wheelchair, wheelchair to toilet, and toilet to wheelchair after performing toilet hygiene. NA-A did not use EBP for high contact care. During an interview on 9/20/24 at 2:37 p.m., NA-C stated EBP instructions for residents could be found on the inside of the residents' cabinet door and in the care plan. R2's face sheet dated 9/24/24, identified malignant neoplasm of bladder (bladder cancer), hydronephrosis (urine unable to drain from a kidney properly causing the kidney to swell), absence of other parts of the urinary tract. R2's significant change MDS dated [DATE], identified severe cognitive impairment. R2 required two staff with transfers, assist of one staff with cares. R2's care plan revised 6/4/24, identified R2 had a urostomy. A second area focused on enhanced barrier precautions revised on 9/17/24, identified staff to follow standard precautions, including proper handwashing techniques, to minimize microorganism transmission enhanced barrier precautions will be used in addition to standard precautions during high contact care activities. During an observation on 9/20/24 at 1:12 p.m., NA-A and NA-B transferred R2 from wheelchair to recliner. NA-A and NA-B did not wear EBP for high contact care. During an interview on 9/24/24 at 1:45 p.m., infection preventionist (IP)-A stated education on EBP was provided at every meeting to nursing staff along with audits of staff. IP-A stated management staff are working on processes to ensure residents on EBP have the processes in place. During an interview on 9/24/24 at 2:10 p.m., Director of Nursing (DON) stated it was her expectation that EBP would be followed and that it was in easy to locate places. The facility EBP policy and procedure dated 4/1/24, identified EBP was used to reduce the transmission of MDRO. 3.Nursing staff will implement EBPs for residents who have a wound or indwelling medical device. a.Wounds: include chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers, c. Indwelling medical devices include central line catheters, peripherally inserted central line catheters (PICC), feeding tubes, and tracheostomies, d. Indwelling medical devices do not include peripheral IV lines, healed ostomies, dialysis shunts that do not have access to the outside of the body, or port-a-caths. 4. High-contact resident care activities include dressing, bathing, showering, transferring, changing linens, changing briefs, or assisting with toileting, device care or use, and wound care. PROCEDURE: 1. Enhanced Barrier Precautions (EBP) requires staff to use gloves and gowns during close contact resident care for residents who have a history of or colonization with a CDC-targeted MDRO. 4. If the resident is colonized with or has a history of infection of a MDRO, nursing staff will implement EBP. 5. If the resident has a wound or indwelling medical device, nursing staff will implement EBP. 6. If nursing staff becomes aware of the resident's history of or colonization with a MDRO, nursing staff will implement EBP. 7. Post appropriate signate for type of precautions, signage is located inside bottom cubby of resident's room. 8. Gowns, gloves, and hand sanitizer will be readily accessible for use outside the resident's room. 9. The IP/Designee will provide staff, residents and/or resident representatives with education regarding the purpose of EBP. 10. When EBP is initiated for a resident, this will be communicated to staff in the Special Instructions section on Point Click Care and on EMAR. 14. EBPs are in the resident's Kardex

Based on interview and document review the facility failed to safely use a full body mechanical lift per manufacturer's recommendations for 1 of 3 residents (R1) reviewed who used a mechanical lift. This resulted in harm when R1 fell from a full body mechanical lift causing ongoing pain in shoulders and neck region. In addition the facility failed to ensure comprehensive assessments were completed to determine proper sling size for 3 of 3 residents (R1, R2, and R3) who required transfers with a mechanical lift. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was alert and with diagnosis of quadriplegia, bilateral range of motion impairment to both upper and lower extremities. R1 was dependent with all activities of daily living (ADLs) except for eating, which required set up only and used a electric wheelchair independently. R1's Nursing Assessment for Total Mechanical lift dated 4/13/24 indicated R1 was deemed unsafe to use standing lift. The assessment directed staff to use the Hoyer lift (brand of full body mechanical lift) with two staff assist. The assessment did not address sling size and type. R1's care plan dated 7/10/24, directed staff to transfer R1 with a Hoyer lift with two staff, but did not identify size or type of sling to use during transfers. R1's progress notes dated 7/5/24 at 11:45 p.m., indicated at 11:10 p.m. R1 fell from Hoyer sling during transfer. R1 reported he had hit his head and his upper back. R1 rated his pain at 7/10 and was given Tylenol. Nurse discussed with R1 option of going into the emergency room (ER) to be further evaluated for any injuries, R1 declined further ER evaluation multiple times. No visible injuries noted. No swelling, redness or bruising noted anywhere at this time. Director of nursing (DON) notified by phone. Fall protocol worksheet initiated and continue to monitor. R1's Post Fall Evaluation dated 7/6/24 at 7:46 a.m., indicated R1 vocalized a pain rating of 7/10 and was a new issue. No further documentation noted. R1's situation background assessment, and recommendation (SBAR) progress note dated 7/9/24 at 10:44 a.m. identified R1 had a fall on 7/5/24, within the last week has had an increase in pain in the back and neck, recommendation to be seen at the clinic and have a CT scan completed to rule out fractures. R1's progress note dated 7/9/24 at 11:47 a.m., indicated R1 left the facility at 11:00 a.m. and returned at 2:45 p.m. R1's hospital After Visit Summary dated 7/9/24 indicated R1 was seen in the emergency room for back pain. R1 was administered an injection of Ketoralac 15 milligrams (mg) (non-steroidal anti-inflammatory medication to relieve pain). Imagining tests were completed with no new findings or fractures. New orders included: Tylenol 1000 milligrams (mg) every 6 hours for pain, could also take 600 mg of ibuprofen every 6 hours, and use topical over the counter patches such as lidocaine or Salonpas and over the counter ointments/creams Voltaren gel or Asper to assist with pain control. Apply ice and/or heat for 20 minutes at a time multiple times per day and can alternate ice and heat. R1's medication administration record (MAR) was reviewed for June and July 2024. The June MAR included a physician order for Acetaminophen (Tylenol) hydrocodone (narcotic pain medication) 325/5 milligrams (mg) three times a day; R1's average pain rating was marked 4 and 5 out of 10 scale (10 being the most severe). June's MAR also identified an order for as needed (PRN) Tylenol 1000 mg every two hours; MAR identified one administration on 6/22/24 for pain level of 8 out of 10. July's MAR identified the aforementioned orders. The pain rating for the scheduled Acetaminophen/hydrocodone identified increased pain ratings between 7/5/24 and 7/11/24 after the fall. R1 reported pain 6/10 on five occasions and 7/10 pain on 4 occasions. July's MAR also identified R1 was administered PRN Tylenol on 10 occasions between 7/5/25 through 7/11/24; R1 reported pain rated 6/10 prior to one administration, pain rated 7/10 prior to eight administrations, and pain rated 8/10 prior to one administration. R1's Nursing Assessment for Total Mechanical lift dated 7/25/24 indicated R1 was deemed unsafe to use standing lift; R1 could follow commands but not always cooperative. The summary included: Hoyer lift was appropriate and effective in transfers using two assist due to medical diagnoses. The assessment did not address the sling size or type. During an interview on 7/25/24 at 11:22, R1 recalled his fall from the lift on 7/5/24. R1 stated nursing assistant (NA)-B and NA-H were transferring him from his wheelchair to his bed with a mechanical lift when the right shoulder sling loop/strap came off the lift causing him to fall to the floor. R1's voice became rigid and abrasive as he explained his frustration that he had to go the hospital several days later on 7/9/24 to make sure nothing was broke even though he continued to have pain currently from this fall. During an interview on 7/25/24 at 4:00 p.m., NA-B indicated on 7/5/24 at approximately 11:00 p.m. NA-H was helping him transfer R1 from his wheelchair to his bed. NA-B explained R1 was raised into the air and while the lift was pushed toward the bed, the right upper lift strap came off the lift hook causing R1 to fall approximately 3 feet to the floor. NA-B indicated they connected the sling to the lift the normal way, NA-B connected his side and NA-H connected her side. NA-B was not able to articulate why the strap came off of the lift and did not identify tension was checked prior to moving the lift away from the wheelchair. The NA's called for the nurse over the radio. RN-H arrived to the room and they used the same lift to get R1 off the floor and into bed after RN-H did an assessment. NA-B stated R1 was complaining of pain in his neck and back. NA-B indicated staff used whatever sling was in the room and was not able to articulate how sling sizes were determined. NA-B indicated the lift was not removed from operation per for a safety inspection immediately following the fall. During an interview on 7/25/24 at 4:07 p.m., NA-H indicated on 7/5/24 she was assisting NA-B with R1's bedtime cares. We (NA-H and NA-B) were transferring R1 from his chair to his bed. They moved the lift away from the chair and that is when the right upper sling strap, which was on NA-B's side of the lift, came off causing R1 to fall backwards to the floor. Initially NA-H thought the sling broke, but everything was fine. NA-H indicated the loop must not have been all the way around the hook and more resting on top of the hook, indicating they had not checked for the tension prior to moving. NA-H stated they called for the nurse immediately. RN-H responded, she checked R1 for injury and checked the lift to make sure it worked. After that was done, a different sling was used to get R1 off the floor into bed. R1 was complaining of pain in his upper back and shoulder area. NA-H indicated staff used whatever sling was in the room and was not able to articulate how sling sizes was determined. NA-H further stated the lift was not removed from the floor for inspection after the incident. The facility's fall investigation was reviewed; the investigation did not address and/or identify if the appropriate sling size and type that was used at the time of R1's transfer. The facility's Vulnerable Adult Investigation Form for NA-H dated 7/6/24 at 10:30 a.m. signed by DON indicated NA-H, reported We were putting resident to bed and hook up sling to the hoyer, we made sure the sling was attached. We lifted resident up and one of the straps snapped off, and resident rolled out the right side onto the floor The investigation form for NA-B dated 7/6/24 at 9:00 signed by DON indicated NA-B reported We were putting [resident room number] to bed like we always do. We made sure all the straps were hooked up. Resident [was] also checking to make sure he wasn't caught on anything and we started to lift him up and the strap on the right back snapped off and resident rolled out the right side onto his back .He was 2-3 feet up and it happened so fast there was nothing we could do. Both NA-H and NA-B's forms included Re-Education: discussed and educated CNA on the importance of checking and double checking the straps are properly hooked to hoyer. NOC [night] nurse on duty at the time of the fall educated staff on importance of checking straps during transfer. Nurse also observed res [resident] transfer in the a.m. with staff and hoyer. During an interview on 7/25/24 at 2:27 p.m., RN-H stated she was called to R1's room around 11:00 p.m. on 7/5/24, because R1 had fallen from a mechanical lift. RN-H entered the room, R1 was on the floor beside the bed on his back. R1 was alert and oriented, she did not observe any obvious injuries, however, R1 complained of pain in his upper back and neck area but refused to go the ED. RN-H inspected both the lift and the sling. She did not see anything wrong with either but used a different sling to get R1 off the floor. RN-H stated she thought a large size sling was used for both transfers however could not say for sure. RN-H indicated the facility did not have an assessment or system for determining sling sizes however she would make sure the sling covered the shoulders to upper thighs. RN-H indicated the lift was not removed from the floor because she had found it was in working order. RN-H had not asked maintenance to inspect the lift, nor was the transfer sling inspected. RN-H further indicated that R1 was continuing to have on going pain and had gone to the emergency roiagnom on [DATE] and was found to not have any injuries. Review of the facility's maintenance logs for the Hoyer mechanical lifts for the months of June and July indicated all lifts were checked on 6/5/24, one lift was checked on 7/8/24, three days after R1's fall. The records indicated the remaining lifts were inspected on 7/25/24. The facility was using EZ-Way brand lifts rather than Hoyer brand lifts. R3's quarterly MDS dated [DATE], indicated R3 did not have cognitive impairment. R3 had no impairment of upper or lower extremities. R3 was dependent with all transfers and did not walk. R3's Nursing Assessment for Total Mechanical lift dated 6/21/22, indicated R3 required a Hoyer lift with two staff assistance. The assessment did not address size and type of sling. R3's ADL care plan 6/21/24 directed staff to transfer R3 with Hoyer lift with two staff. The care plan did not include the sling size and type that R3 required. R3's Nursing Assessment for Total Mechanical dated 7/25/24, indicated R3 required a Hoyer lift with two staff assistance. The summary included: Hoyer lift is appropriate and effective for transfers and two assist due to resident's decline in mobility. This assessment also did not address sling size and type. During an observation on 7/25/24 at 12:56 p.m., R3 sat in her recliner with a green sling underneath her. This sling size was extra-large per manufactures sizing guide on mechanical lift outside of room. During an observation on 7/25/24 at 1:11 p.m., nurse manager (NM)-A entered R3's room and verified that the sling R3 was sitting on was extra large in size. NM-A was not aware of how to measure for the appropriate sling size and type and indicated there was no process in place for completing sling assessments. During an interview on 7/25/24 at 3:20 p.m., EZ-Way lift representative (LR)- A stated the sling R3 was sitting on, was not the correct sling size. LR-A stated R3 should be a large sling size and not extra large. R2's quarterly MDS dated [DATE], R2 had severe cognitive impairment. R2's diagnoses included hip fracture, Alzheimer's disease, and dementia. R2 was dependent for ADLs except required moderate assistance with eating. R2 had impairment on one side of her lower extremities and used a manual wheelchair. R2's Nursing Assessment for Total Mechanical lift dated 6/20/24, indicated R2 required a Hoyer lift with two staff assistance. The assessment did not address size and type of sling. R2's ADL care plan 6/20/24, for transfers directed staff to use a Hoyer lift with two staff. The care plan did not identify sling size and type that R2 required. R2's Nursing Assessment for Total Mechanical lift dated 7/25/24, indicated R2 required a Hoyer lift with two staff assistance. The assessment continued to lack mention of size and type of sling. During an interview on 7/25/24 at 10:25 a.m., NA-A stated an unawareness of how to properly determine sling size and would use the sling that was in the resident's rooms. NA-A thought nursing or therapy decided the sling size. During an interview on 7/25/24 at 10:51 a.m., NA-M indicated the sling size was dependent on the size and weight of the person. NA-M would check the sling size chart on the lift against the resident's weight. She would use whatever sling was in the room unless she questioned the fit. During an interview on 7/25/24 at 5:50 p.m., Administrator and DON both indicated if there was not anything wrong with the lift and the sling the cause of the fall would be operator error. DON and Administrator expected staff to follow the manufacturers recommendations for safety. Stated there had not previously been a process in place to determine proper sling size and staff were expected to follow the manufacturer's instructions. During an interview on 7/25/24 at 3:20 p.m., EZ-Way lift representative (LR)-A explained staff needed to check the tension of the sling loops/straps by touching each one to make sure they were secured onto the lift. This check is completed while the resident is being lifted and still on/over the surface that they are being raised off of. LR-A stated the correct sling sizes were important to prevent falls and injuries to both residents and staff. Additionally, with the correct sling size, the staff can obtain better resident placement in chair and bed without pushing or pulling on resident. EZ-Way Smart Lift Operator Manual included the following: WARNING: For safe operation of the EZ Way Lifts, the lift must be used by trained personnel in accordance with operators manual, video, and training checklist to avoid injury to patient. -do not modify the sling design in any way, make the accessories used with each lift are appropriate for both the patient and the transferring situation, -the sling size is calculated using the resident weight, height, and girth, a proper fir will involve judgement of the caregiver, - proper sling placement include top of sling at the shoulder level and the base of the sling two inches below the tail bone, -while lifting the patient upward, continue until there is tension on the sling legs, making sure all the loops on the sling are securely hooked on the hanger bars before moving resident from over the surface transferring from, -all EZ Way equipment must be maintained regularly by competent staff according to the maintenance checklist provided.

Based on interview and document review, the facility failed to ensure a comprehensive care plan was developed, and maintained to ensure appropriate level care was provided to 1 of 3 residents (R1) reviewed for activities of daily living. Findings include: R1's admission Minimum Data set (MDS) dated [DATE], identified R1 had moderately impaired cognition, was able to understand others and be understood, did not have any behaviors or rejections of cares in the assessment period. R1 also had a condition or disease with a life expectancy of less than 6 months. R1's care plan, dated 2/28/24, indicated impaired physical mobility related to weakness, impaired balance, history of falls, terminal illness. R1's goals included will participate in transfers and ambulation as able. Interventions included R1 was 1 assist with transfers and transfer belt and walker, was able to walk in room and hall with 1 assist and transfer belt; revision on 3/18/24 added to include second staff to follow with wheelchair when walking. R1's progress note dated 3/22/24 at 12:43 p.m., stated new therapy recommendation from hospice for nursing to continue to transfer with front wheeled walker and gait belt for all mobility and assist second staff to follow with wheelchair. Distance as tolerated. R1's progress note dated 3/29/24 at 6:43 p.m., indicated, [R1] had a significant change of condition within the last 24 hours. [R1] was unable to express wants and needs and unable to verbally communicate, drooling noted on left side of mouth and was staring in one direction. Unable to walk decline in mobility from baseline. [family member] updated and [R1] was sent to emergency room [ER] for evaluation and treatment. R1's progress note dated 3/29/24 at 11:09 a.m., included resident returned from ER and was unable to communicate R1 started on Cefdinir 300 mg (antibiotic) for urinary tract infection. R1's Kardex summary printed 4/16/24 at 7:14 p.m., indicated resident was dependent with 1 assist for transfers and walker. Resident could be up as tolerated with assistance. R1's record did not include an assessment or development and implementation of care plan goals and interventions that identified R1's needs after the facility identified a decline in overall health status. During an interview on 4/17/24 at 10:25 a.m., clinical manager (CM)-A stated R1 was up and walking with one assist until revised on 3/18/24 with fall intervention to have a second staff follow with wheelchair when walking R1. CM-A stated she was familiar with R1 and identified R1 was unable to walk or verbalize needs when she had the change of condition and was sent to the hospital on 3/29/24. CM-A stated R1 had returned to the facility on [DATE] and still had not returned to her previous baseline after her change in condition that caused her to go to the hospital. CM-A stated she was unable to locate a comprehensive assessment completed on R1 after the change of condition and her return to the facility. R1 would not have been a one assist for transfers and or mobility after 3/29/24 and could not find changes in R1's care plan or documentation that would have accurately reflected the assistance R1 would have needed for mobility. CM-A stated it is an expectation that nursing staff follow the care plan of the residents but a mobility assessment had not been completed for R1 and R1's care plan was not accurate for her level of care related to mobility and activities of daily living (ADL's) on or after 3/29/24. During an interview on 4/17/24 at 1:37 p.m., director of nursing (DON) stated, R1 would not have been assist of one or been able to walk after her last hospital visit. DON stated there should have been a comprehensive assessment completed on residents who return from hospital visits to re-establish baselines with changes of condition or changes in mobility. DON recognized the need to complete assessments and the facility was already working on a plan for improvement. During an interview on 4/17/24 at 2:23 p.m., administrator stated she recognized the facility needed to work on creating better care plans for residents and had a current performance improvement plan (PIP) in place for care planning in the facility. Administrator stated the reason a PIP was in place for care plans was the management team had already recognized the need for improvement. Administrator stated she would expect nurses to complete a comprehensive assessment when a resident has a change in condition and would expect the care plan to reflect those changes. A facility policy titled Care Planning-Interdisciplinary Team, revision date 3/2022, was provided. The policy indicated the interdisciplinary team was responsible for the development of resident care plans. Implementation and interpretation on the policy included: 1. Resident care plans are developed according to the timeframes and criteria established by S483.21. 2. Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT). 3. The IDT includes but is not limited to: a. the resident's attending physician. b. a registered nurse with responsibility for the resident. c. a nursing assistant with responsibility for the resident. d. a member of the food and nutrition services staff. e. to the extent practicable, the resident and/or the resident's representative; and f. other staff as appropriate or necessary to meet the needs of the resident, or as requested by the resident. 4. The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. 5. Care plan meetings are scheduled at the best time of the day for the resident and family when possible. 6. If it is determined that participation of the resident or representative is not practicable for development of the care plan, an explanation is documented in the medical record.

Based on observation, interview and document review, the facility failed to assess, monitor and implement pressure relieving interventions for 2 of 2 resident (R71, R68) who developed pressure ulcers. The facility failure resulted in R71 sustaining harm when the resident developed an unstageable pressure ulcer to left gluteus (butt cheek) along with three additional stage II pressure ulcers on gluteus. Findings include: Pressure Ulcer stages defined by the Minimum Data Set (MDS) per Center Medicare/Medicaid Services: Stage II pressure ulcers (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ ruptured blister.) Unstageable pressure ulcer: (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar.) R71's Record of Admission, printed 1/10/24, indicated admission to the facility on [DATE], with diagnoses per the Diagnosis Report Sheet including: end stage renal disease with dependence on renal dialysis, orthopedic aftercare after acquired absence of right great toe and other right toe (1st and 2nd toes), reduced mobility, diabetes mellitus, heart failure, anemia (deficiency of health red blood cells in blood), morbid obesity (excessive body fat), and urgency of urination. R71's Admission Nursing Comprehensive Skin assessment dated [DATE], indicated Braden Risk score (a scale that measures the risk of developing pressure ulcers) of 13 which indicated a mild risk. Other risk factors included assistance with activities of daily living, non-compliance with diet, fluids, mobility, head of bed elevated majority of the day and psychotropic drug use. Skin conditions and treatments included bruises, and surgical wound. Assessment of potential problem areas was blank. Areas found on assessment included abrasion on left gluteal fold 4 centimeter (cm) x 1.2 cm, bruises and incision from amputation on right foot. No additional comprehensive skin assessments were completed per electronic medical record. R71's Wound Assessment completed by licensed practical nurse (LPN)-D on 11/17/23 at 12:21 p.m., included a left gluteal fold wound present on admission and identified as other non-pressure wound. Contributing factors included resident is incontinent. Wound is 4 cm x 1.2 cm with no tunneling or infection present. Nursing interventions included other and under treatment identified R71 was placed on the nurse practitioner board for orders. There was no indication the provider was notified of the new wound and change in skin condition R71's admission Minimum Data Set (MDS) dated [DATE], indicated R71 had intact cognition, understood and understands, requires partial to moderate assistance with rolling left and right and lying to sitting on the side of bed and dependent with ability move from sitting on side of bed to lying flat on the bed. R71 was depend on all transfers. R71 was occasionally incontinent of stool and was continent of urine. R71 is at risk of developing PU and currently has no PU's but does have a surgical wound. Skin and ulcer treatments included a pressure reducing device for the bed and surgical wound care. A progress note 11/21/23 at 2:54 p.m., by dietary manager (DM) included appetite was not good at times and has chewing, swallowing, taste changes and mouth pain. R71 is not on a supplement at this time. R71's Braden Scale (standardized assessment tool used to assess and document risk for developing pressure injuries) was completed on 11/23/23, with a score of 15 indicating mild risk for skin breakdown. Although the Braden Scale assessment indicated mild risk, the skin assessment indicated risk factors of impaired mobility, cardiovascular disease, end stage renal disease, obesity, diabetes and requires assistance with ADLS. R71 also had a gluteal abrasion on admission. In addition, there were other discrepancies between the assessments. The MDS indicated resident was continent of urine, progress notes indicated R71 required assist of one changing incontinent pads and was incontinent of loose stools. R71's plan of care dated 12/4/23, included R71 was at risk for alteration in skin integrity bruising, skin tears related to impaired mobility, multiple medication problems, diabetes, dialysis, obesity, occasional incontinence, anticoagulant therapy and requires assistance with ADL's. The care plan also included alteration in skin integrity related to surgical wound from right 1st and 2nd toe amputations on 11/2/23, and dialysis access site of right upper arm. Interventions included: Monitor for breakdown with cares and bath. Mobility per care plan. Use pressure reducing measures as needed. Lower head of bed, and keep bedding wrinkle free. Toilet per care plan, lotion to dry skin with cares. Dietician to evaluate nutrition status as needed and encourage adequate fluid and food. Treatment to surgical wound per medical doctor (MD) orders. Update provider if concerns noted. Monitor for bruising and bleeding. On 1/3/24 an alternating air mattress and pressure reducing wheelchair cushion was added. The care plan failed to direct staff on the frequency for R71's repositioning, transferring or toileting plan to reduce the risk of pressure ulcers. On 12/6/23, Butt paste (topical medication for diaper rash and skin irritations) was ordered four times a day as needed to irritated peri rectal area and inner thighs from nurse practitioner (NP)-D. On 12/10/23 at 11:16 p.m., a progress note by LPN-C indicated wound open area of right inner thigh, and on left medial buttock measure 2.5 x 2 cm and wound on right medical buttock measuring 1.5 cm by 1 cm and 0.8 cm depth. Also has an unstageable ulcer on lateral left buttock measuring 2.5 cm x 3 cm. Hydrocolloid dressing was applied to areas on buttocks and zinc oxide (butt paste) applied to area on inner thigh. Review of the medical record lacked notification to the provider regarding the development of PU and no new interventions were initiated . A Wound assessment dated [DATE] at 11:24 p.m. by LPN-C included: an unstageable PU on left lateral buttock, not present on admission. Eschar (dry, hard, leathery tissue that is not part of wound healing process and must be removed to support healing) present over 90% of wound bed and full thickness. Contributing factors included non-compliance, personal habits, non weight bearing, in bed most of the day with limited offloading (technique used to protect wounds from getting worse due to added weight on the area). Wound is 2.5 x 3 cm with no tunneling and 90% eschar present with pink wound edges. Nurse interventions included chair cushion. Current wound treatment indicated R71 was placed on nurse practitioner board to be addressed at next visit. On 12/14/23 at 1:47 p.m., a progress note by NA-B, also identified as health unit coordinator, included a wound unstagable pressure ulcer to left lateral buttock 2.5 x 3 cm with 90% eschar. Also has open areas bilateral medial buttock with left 2.5 cm x 2 cm and right 1.5 cm x 1 cm and 1.5 and 0.8 cm. and hydrocolloid dressing applied. Recommendations included dressing order please. Physician orders were okay for Mepilex to areas and to change every 3 days and as needed and to be discontinued to when healed. On 12/23/23 at 1:05 a.m., a Wound Assessment by registered nurse (RN)-F indicated right gluteal fold, pressure ulcer stage 2. Appearance of wound indicated area difficult to measure, reddened friable tissue with some open macerated areas on right gluteal fold. A second wound on left gluteal fold identified as PU, stage 2 with measurements of 1 cm x 0.5 cm with 100% slough present and some maceration and friable tissue noted surrounding the wound. A 3rd wound on left lateral buttock identified as PU, not staged and documented as not applicable (NA). Wound is 0.5 cm x 0.75 cm with no tunneling present. A fourth wound identified on left center buttock indicated PU and unstageable related to eschar, slough. Wound is 4 cm x 4 cm x 0.3 depth. Unable to determine if tunneling is present without debridement. Slough was 85% with eschar present for 15% of wound around edge. Nursing comments included frequent incontinent loose stools. Resident placed on nurse practitioner list for review of possibly adding pressure reducing mattress for resident. Although an additional wound was identified, no additional interventions were added at this time. The director of nursing (DON) reviewed and signed wound assessment on 12/28/23. On 12/29/23 a Braden scale was completed with a score of 14 which indicated moderate risk for skin breakdown. No additional interventions were added. A Wound assessment dated [DATE] at 12:40 p.m. by LPN-D included right buttock PU stage 3 not present on admission. Wound was 1 cm x 1 cm with depth 0.3 cm. Drainage was present and surrounding tissue was red. A second wound included left buttock which was not present on admission and was PU stage 3. Medical provider was checked as being notified, but there was no indication the medical provider had made any changes or comments about R71's PU. A progress note dated 1/4/24 at 3:01 p.m., by NA-B indicated right wound was 4 cm x 4 cm, granulation with slough covering wound bed with moderate drainage. Bloody and odorous. Severe pain present and current treatment not effective. Wound clinic appointment not until January 24th this month. Nurse Practitioner (NP)-D ordered collagen, Zeroform and Mepilex to be completed every other day and as needed. A progress note 1/5/24 at 3:35 p.m., indicated registered dietician (RD) was consulted due to R71's skin breakdown on buttock region. R71 continued on therapeutic diet, a new weight was requested due to fair to poor appetitive at times. Nutritional supplement provided at dialysis when available. RD recommend a high protein healing supplement to support wound healing and protein levels. Although a progress note on 11/21/23 at 2:54 p.m., by dietary manager (DM) identified poor appetite and concerns of chewing, swallowing, taste changes and mouth pain. There was no indication any nutritional changes were completed even though she was admitted to the facility with a pressure ulcer on 11/23. R71's significant change MDS dated [DATE], indicated R71 has 1 unhealed PU, and 2 stage 3 PU's not present on admission. A pressure reducing device for chair and bed is present and turning and repositioning program. R71's Care Area Assessment (CAA) dated 1/5/23, indicated R71 is at risk for PU's and requires staff assistance to move sufficiently to relieve pressure over any one site. R71 is confined to bed or chair all or most of the time. R71 needs special mattress or seat cushion to reduce of relieve pressure and requires regular schedule of turning. Observation and interview 1/8/24 at 1:42 p.m., R71 stated she has a PU from laying on the bars of the bed. R71 added she could feel the bars on her buttock, in the area of sores. She could feel the bars through the mattress. R71 stated she didn't have a wound when she came here and at the hospital they were putting a protective heart shaped dressing on her bottom but they didn't do that here. She has a dressing on it now that she has an open area and has an appointment on 1/24/24 to see wound care. R71 stated I don't think it is very deep but deep enough. R71 was laying on her back in the bed with head of bed (HOB) at 30 degrees. R71 indicated she turns herself in the bed without assistance from staff but sometimes has to call for help to get a pillow tucked behind her to keep her on her side. R71 has an alternating air mattress present on her bed. Observation and interview 1/8/24 at 5:38 p.m., LPN-B indicated R71 had a loose bowel movement (BM) and her dressings came off her buttocks. At 5:51 p.m., R71 rolled to her left side with partial assistance from LPN-B and used the grab bar to keep herself in position. One dressing on mid left gluteal area remained intact. Wounds without dressings were measured and described by LPN-B and included: -Right gluteal area measured 0.5 centimeter (cm) by 0.5 cm. Slough (non-viable tissue) was present on wound bed. -Left lateral gluteal area 0.75 cm by 1 cm with slough present. -Left gluteal fold measured 1 cm by 0.75 cm with slough present. -Left mid gluteal area dressing was removed by LPN-B who described a moderate amount of white with brown tinged drainage present, which had a slight odor. LPN-B cleansed the wound with saline and 4x4 gauze pad and indicated the skin was red around the wound bed area. Measurements were completed and were 6 cm by 5 cm with a 1 cm hole in upper left portion of the wound. LPN-B indicated there is tunneling present but did not attempt to measure the tunneling. LPN-B indicated this was an unstageable PU due to wound bed being covered with slough. Collagen powder (healing gel that keeps out bacteria) was applied to all 4 wounds, Zeroform (non adhering dressing) placed then Mepelix (highly absorbent form dressing) covering. LPN-B was unsure if the wounds were improved or worsened as this is her first time changing the dressings. R71 indicated there was some discomfort with changing of the dressings but otherwise she tries to position herself so she is comfortable. Observation and interview 1/9/24 at 3:28 p.m., with R71 indicated she had just returned from dialysis and was sitting in her wheelchair with her head in her hands. R71 indicated she is always tired after dialysis and her blood pressure was low again during dialysis. R71 indicated she had diarrhea this morning so took Immodium (medication used to treat sudden diarrhea), and only passed gas during her dialysis today. R71 indicated when she is at dialysis if she has a loose stool, she will just wait until she gets back to the facility to be changed because she can see how busy the staff are and doesn't want to bother them. R71 indicated at dialysis she can lay down in the chair or can sit up and controls that herself. R71 indicated no one has educated her to try to stay off her buttock or not to sit for long periods of time and generally will try to find a position that is the most comfortable. At 3:50 p.m., NA-A and NA-E entered the room and using a lift assisted R71 to her bed. R71 was then lying on her back with HOB at 20 degrees. Interview 1/9/24 at 4:00 p.m., nursing assistant (NA)-A indicated R71 is capable of turning herself so is not on a turning program but sometimes will call for assistance if incontinent. NA-A indicated they use a lift to transfer her to her wheelchair for dialysis and upon return but she rarely gets into a chair per her request. During interview on 1/9/24 at 3:55 p.m., LPN-A indicated she was not aware R71 had PU's but it should all be documented in her medical record. LPN-A was not aware of any offloading program or of the wound care treatment but indicated she could look that up in the medical record if needed. During observation on 1/10/24 at 7:11 a.m., R71 was lying in bed and appears to be lying on her back with HOB flat. During interview on 1/10/24 at 9:20 a.m., NA-I indicated R71 is able to turn and reposition herself independently and will call for assistance if needed. NA-I indicated staff use a lift when she needs to get out of bed, otherwise she uses a bed pan. During interview on 1/10/24 at 10:44 a.m., medical doctor (MD)-B indicated she wasn't aware that R71 was so immobile and believed she was able to bear weight on her good leg and should have been more active. MD-B indicated R71's immobility put her at a higher risk for developing pressure ulcers along with incontinent liquid stool. MD-B stated the skin breakdown isn't unexpected, but the severity was preventable. MD-B added interventions should have been put into place once a PU was identified to prevent further breakdown not just wound treatment. MD-B indicated she had not seen R71's PU's. During interview on 1/10/24 at 11:05 a.m., R71 again indicated she repositions herself and staff do not come in to assist unless she calls for help. R71 indicated initially on admission she layed on her back a lot because her surgical wound on her foot had to be elevated. R71 indicated the first time she actually stood up was 2 days ago when therapy assisted her. R71 stated she rarely sits in the chair due to being incontinent of diarrhea and finds it easier to, with assist from staff, to use the bed pan if she is in the bed. R71 denied every refusing to reposition in the bed. R71 added she hasn't had a shower or bath since she was admitted due to her surgical wound needing to be closed with scab off prior to any bathing. R71 did indicated she has had all bed baths. During interview on 1/10/24 at 11:25 a.m., NP-D indicated skin breakdown wasn't completely unexpected but the severity should have been prevented by off loading pressure. NP-D indicated once one wound was identified the facility should have done more to prevent the other three from developing. NP-D indicated the facility has to make sure R71 is truly offloading if they aren't doing that currently and not just rely on R71 to turn herself. NP-D added he was aware of the wounds, but not the severity or of any tunneling and added he has not seen the wounds. During interview on 1/10/24 at 10:00 a.m., the DON confirmed R71 should have been put on an off loading schedule and the staff are responsible to ensure offloading is being completed. The DON confirmed education with R71 should have occurred with importance of offloading and repositioning. The DON confirmed R71 was on a regular facility mattress, which are supposed to prevent skin breakdown, until the air mattress arrived on 1/4/24. The DON added the plan of care did not include a repositioning program and no new interventions were put in place prior to or after initial PU's were identified. 42073 R68's Diagnosis Report printed on 1/11/24, included hemiplegia (partial paralysis on one side of the body) following a stroke, protein-calorie malnutrition, anemia, and end-stage renal disease requiring dialysis. A PU was not included in the admission diagnoses from 8/11/23. A PU of sacral region, stage II, was added on 12/20/23. R68's comprehensive skin assessment dated [DATE], was completed upon admission. The assessment indicated R68 had a Braden risk score of 15, indicating mild risk for PU development. The skin assessment indicated R68 had a red coccyx; no open lesions and no current PU. The form indicated weekly, and PRN skin assessments were to be completed, to notify the provider of concerns, and to remind and assist R68 to off-load buttocks. Weekly skin assessments and off-loading had not been added to R68's care plan or orders. R68's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R68 was cognitively intact; could understand and be understood. R68 was at risk for PU development, but had no unhealed PU's. R68 was dependent upon staff for most activities of daily living (ADL's). R68's care plan dated 8/22/23, indicated R68 was at risk for alterations in skin integrity due to impaired mobility, incontinence, and multiple medical issues. Interventions included monitoring [skin] for breakdown with cares/bath. Lower head of bed to decrease friction/shearing, wrinkle free bedding. In addition, R68's care plan indicated R68 had impaired physical mobility related to weakness. Staff were to reposition R68 every two hours when in bed or chair. Further, staff were to assist R68 per her request for transferring, wiping, and pericare after incontinence. Progress note dated 9/24/23, indicated R68 had an open area to coccyx measuring 2.3 x 1.5 cm (centimeters). Abd (abdominal) pad applied for protection; resident off-loading with pillows while in bed. During document review, the next time a skin assessment was documented was on 9/24/23, six weeks after admission and when R68 returned from a seven-day hospitalization . The skin assessment indicated R68 had an open area to the coccyx measuring 2.3 x 1.5 cm, and the open area had been acquired before admission. This conflicted with the admission skin assessment conducted on 8/11/23, which indicated a red coccyx -- no open skin. The skin assessment form indicated staff would continue weekly and PRN skin assessments, weekly wound assessments, and would update the provider with any changes. The weekly skin assessments had not been added to the care plan or orders. R68's physician orders dated 10/3/23, indicated wound care: Mepilex foam dressing, every shift change, every three days or PRN (as needed) for open area to coccyx. Documentation of skin assessments varied regarding whether R68 had a PU to the coccyx at the time of admission or if it was acquired after admission: --An admission comprehensive skin assessment dated [DATE], indicated a red coccyx. No open lesions, no current PU. --The admission MDS dated [DATE], indicated no unhealed PU's. --A comprehensive skin assessment dated [DATE], indicated the open area on coccyx was acquired before admission. --Wound assessment flowsheets dated 9/26/23, 10/23/23, 11/2/23 and 1/10/24, indicated the wound was present upon admission. --Wound assessment flowsheets dated 11/15/23 and 1/8/24, indicated the wound was not present upon admission. A total of eight skin assessments had been documented from admission on 8/11/23 to 1/10/24, and conducted by five different nurses. During an observation and interview on 1/8/24 at 3:57 p.m., R68 was lying in bed with the head of the bed elevated approximately 30-45 degrees. R68 had a naso-gastric (NG) tube in place, not attached to a supplemental feeding. An alternating air pressure mattress was observed on the bed. R68 stated she had a PU on her bottom which was acquired after she moved into the facility on [DATE]. R68 admitted she usually rested in bed in her current position - supine with head of the bed elevated. During an observation on 1/10/24 at 8:41 a.m., with registered nurse (RN)-B, observed R68's PU to coccyx. The PU was a pink circular wound, approximately the size of a quarter on the coccyx. The skin appeared in intact, no exudate, no odor. RN-B measured the PU to be 2 x 2 cm and stated it was healing well. During an interview on 11/10/24 at 8:57 a.m., RN-B stated R68 had been admitted to the facility on [DATE], and arrived with a red coccyx but did not have open areas on her coccyx. RN-B, while looking in the electronic medical record (EMR) stated the first time an open area to R68's coccyx was documented was on 9/24/23. The first note by a provider regarding the open area was on 10/3/23, nine days after it was observed by nursing staff. During an interview on 1/10/24 at 10:57 a.m., medical doctor (MD)-B, who was familiar with R68, stated R68 would be at risk for PU development due to co-morbidities and that she would expect regular skin monitoring and repositioning for any resident who had mobility issues. MD-B was not able to say if R68's PU had been preventable. During an interview on 1/10/24 at 11:05 a.m., the director of nursing (DON) stated since R68 had a red coccyx upon admission, she would have been at risk for skin breakdown. The DON stated once staff identified the red coccyx, staff should have put an order in the EMR for weekly skin monitoring, and a provider should have been informed of any skin concerns. The DON admitted these actions had not been taken. The DON admitted no skin monitoring or assessments had been documented between R68's admission on 8/11/23 and 9/24/23, when the PU was discovered. The DON stated the care plan should have included something about monitoring bony prominence's, education on importance of repositioning. The first progress note identifying a provider was aware of skin concerns was on 10/3/23, and treatment orders were received. It was possible the PU was acquired during hospitalization from [DATE] to 9/24/23, however, not able to determine this since the only documentation of R68's skin on 8/11/23, indicated a red coccyx, no open skin. An After Visit Summary from the hospital dated 9/24/23, did not mention skin concerns or PU's. The facility Skin Assessment protocol dated 2/17/20, included: -Weekly full head to toe skin assessment must be completed on the resdient's bath day indicted on the bath schedule. Skin assessment should be charted under bath/skin note in the progress notes. - Skin assessment needs to include: - Color of the skin and any redness. Redness over a bony prominence is present indicate whether it is blanchable or not -Skin integrity/any breakdown -All bony prominence's scapula, sacrum, heels, elbows, occiput, ankles, knees, hips and ears -Wounds and bruising new and existing. Include location, measurements, color, how the resident thinks the got it, any intervention and if there is any pain or swelling. Follow-up on wounds and bruising noted in previous skin assessment. A Pressure Injury policy and procedure last revised 9/19, included: - Upon noticing a pressure injury, complete a Wound Assessment and Braden scale. - Add an order to complete a Wound Assessment in the EMAR weekly -Start interventions as ordered/needed -Notify MD or in house NP of new pressure injury -Noisy family of new PU -Notify dietary of new pressure injury -Consult MD or in house NP, nurse manager, visiting wound nurse or wound clinic as needed for treatment -Complete a new Wound Assessment weekly -Document weekly and as needed in the nursing notes on size, drainage, odor, pain, surrounding tissue and current treatment -Review at interdisciplinary team meetings

Based on interview and document review, the facility failed to provide basic life support, including cardiopulmonary resuscitation (CPR) in accordance with resident wishes and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice resulted in an immediate jeopardy (IJ) situation when R3 was found with absent pulse and respirations, and timely CPR was not initiated. The immediate jeopardy began on [DATE], at 4:40 a.m. when R3 had no respirations or pulse and CPR was not initiated. The administrator and director of nursing (DON) were notified of the immediate jeopardy at 6:30 p.m. on [DATE]. The immediate jeopardy was removed, and the facility implemented correction action on [DATE], prior to the start of the survey and was therefore issued at past non-compliance. Findings include: R3's Admission Record printed [DATE], indicated R3 was admitted to the facility on [DATE], for rehab and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's admission Minimum Data Set (MDS) dated [DATE], indicated resident was cognitively intact and required partial assistance with activities of daily living. R3's care plan dated [DATE], indicated R3 was a full code. R3's Provider Orders for Life-Sustaining Treatment (POLST) dated [DATE], indicated if R3 had no pulse and was not breathing, staff were directed to attempt resuscitation/CPR including the provision of full life sustaining treatment including intubation, advanced airway interventions, and mechanical ventilation as indicated. Transfer to hospital and/or intensive care unit if indicated. The POLST was signed on [DATE], by R3, a facility representative, and physician. R3's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Progress note dated [DATE], at 6:45 a.m. by licensed practical nurse (LPN)-A indicated R3 was found deceased in bed at 4:40 a.m. and death was verified by registered nurse (RN)-A. At 5:00 a.m. family member (FM)-A was notified R3 was deceased . R3's clinical record lacked documentation as to when R3 was last checked or provided care by the nursing staff and lacked documented evidence that CPR had been initiated per R3's identified wishes. On [DATE], at 12:57 p.m. during a phone interview with nursing assistant (NA)-A stated during her shift on [DATE], at approximately 4:45 a.m. LPN-A indicated R3 passed away and requested her to confirm. NA-A stated she went into R3's room and R3's chest was not rising up and down and indicated R3 was not breathing, however NA-A stated she had never witnessed a resident that was not breathing. NA-A stated LPN-A then alerted RN-A. RN-A went to R3's room and RN-A and LPN-A indicated they did not feel comfortable with CPR due the unknown time R3 stopped breathing. On [DATE], at 1:13 p.m. during a phone interview with RN-A stated she was the nurse on the third floor on [DATE] and was not R3's nurse and indicated R3's room was on second floor. RN-A indicated on [DATE], at approximately 5:00 a.m. she received a phone call from LPN-A to confirm a death on second floor, RN-A indicated she proceeded to second floor and found LPN-A at the nurse station. RN-A asked LPN-A if R3 had an order to perform CPR or if she was on hospice and LPN-A responded, she didn't know. RN-A indicated R3's computer record indicated CPR, and at that time she informed LPN-A we needed to get to R3's room . RN-A stated when her and LPN-A entered R3's room, R3's arms, upper torso and face were white, and she was cold to the touch. RN-A indicated to LPN-A CPR needed to be started, and then LPN-A indicated about twenty minutes of time had elapsed when R3 was found without a pulse. RN-A stated the facility policy at the time was ,d+[DATE] minutes after finding a resident pulseless don't start CPR. RN-A stated she called FM-A and told him R3 was breathless and pulseless, and RN-A to indicated to FM-A staff could start CPR, however FM-A requested CPR not started and to let her [R3] rest. RN-A stated after the incident she received re-education about the policy and refresher course on CPR and stated she would start CPR, if a resident was a full code. On [DATE], at 2:55 p.m. during an interview with the DON stated her investigation into the incident began on [DATE], when RN-B notified her R3 was a full code and had not received CPR on [DATE], and the DON stated she immediately begun an investigation and filed a vulnerable adult report. The DON investigation indicated: - 3:00 a.m. R3 call light was on and licensed practical nurse (LPN)-A went into R3's room and sat with her until she fell asleep - 3:45 a.m.- 4:00 a.m. nursing assistant (NA)-A checked on resident and found her sleeping. - 4:46 a.m. LPN-A went to R3's room to bring her medications and found R3 pulseless and unresponsive, and LPN-A went and found NA-A assistant and returned to R3's room and assessed R3 again and R3 was unsuccessful for signs of life. There was no indication that CPR was initiated at this time. - 5:00 a.m. registered nurse (RN)-A stated she received a phone call from LPN-A to confirm a death on second floor, RN-A, and asked LPN-A if R3 had an order to perform CPR or if she was on hospice. LPN-A responded that she didn't know. RN-A found a POLST in R3's chart that indicated an order to perform CPR. -The DON identified R3 was a full code and CPR was not initiated when she was found without a pulse. The DON indicated LPN-A should have called for help and should have initiated CPR after determining R3 had no pulse or respirations per R3's CPR order. On [DATE], at 4:27 p.m. the DON indicated all active working nursing were provided staff education that started on [DATE], and was completed by [DATE], education was provided on the CPR policy and procedure and included staff would call for assistance during a medical emergency, initiate CPR when indicated, review of the updated CPR standing orders, and competency quiz. The DON provided a spreadsheet and indicated active working staff completed the education as of [DATE]. The DON indicated active working staff were educated by their next scheduled shift, causal or leave of absence staff had been contacted to receive training before they next scheduled shift. On [DATE], at 3:36 p.m. during a phone interview with FM-A, stated the facility called him on [DATE], at 5:00 a.m. and stated when nursing staff woke her [R3] for her pills she was unresponsive, and staff asked if FM-A wanted CPR and he refused CPR for R3. On [DATE], at 7:52 a.m. an interview via telephone with LPN-A stated on [DATE], whom was the nurse responsible for R3 when found unresponsive. LPN-A stated on [DATE], she started her shift around 10:45 p.m. and received nurse report, including R3 had increased weakness. LPN indicated at about 12:00 a.m. R3's call light was on and LPN-A entered R3's room and R3 indicated she said she didn't need anything. LPN-A stated she sat with R3 until she fell asleep. LPN-A stated she was on break from approximately 4:00 a.m. to 4:40 a.m. and entered R3's room after her break with R3's scheduled pain medication. LPN-A stated at that time R3 was in found laying bed, pale in color, and she called R3's name with no response, shook her [R3] with no response, and used two fingers on the neck and wrist and checked R3's pulse and no pulse was felt. LPN-A stated at that time she alerted NA-A she thought R3 had passed away and called RN-A on her Walkie and told RN-A, that R3 was unresponsive. LPN-A stated then she went to the nursing station to check the code status and confirmed the code was CPR. LPN-A indicated she went with RN-A to R3's room to start CPR and she observed RN-A use a stethoscope to check a pulse at the heart location and felt and observed R3's with stiff arm joints and muscles and discoloration of skin of the lower legs with, reddish, bluish, purplish color, skin was not warm, and cool to touch. LPN-A indicated with the observations RN-A and herself made of R3, they decided CPR was not advisable . RN-A called FM-A, and he refused CPR. LPN-A stated she provided information to her nurse manger on the morning of [DATE], of the incident. LPN-A verified 911 was not called, and confirmed CPR was not initiated. LPN-A further indicated R3 was a new resident at the facility, and was not aware of R3's code status prior to her shift. LPN-A stated she received education after the incident regarding call 911 right away and would confirm code and would start CPR. LPN-A stated with the facility education she recently received she would have performed CPR on the resident and verbalized understanding of the facility education provided on CPR and code status. Review of the facility memo dated [DATE], indicated the facility requested licensed nursing staff were expected to complete education on the CPR Policy and Procedure and the skills assessment questionnaire by [DATE], and prior to working on the units; the memo further indicated upon completion staff signature showed understanding. Review of the sign in sheet titled, What If a Resident is Found Unresponsive dated [DATE], and [DATE], indicated staff signatures acknowledged review of the education. On [DATE], at 9:26 a.m. NA-B stated she would call for the nurse if she found a resident unresponsive and the nurse would direct actions to be taken and indicated the code status would be determined by the resident's chart. On [DATE] , at 9:40 a.m. NA-C stated if a resident was found unresponsive would call for a nurse right away and then look in their chart for code status and take direction from the nurse. On [DATE], at 1:40 p.m. LPN-B stated in the event of a medical emergency, she would call for help, look in the chart for the resident code status, if CPR would send NA for defibrillator, call 911, and would start CPR. LPN-B reiterated that if a resident status was CPR, she would start CPR right away. On [DATE], at 1:47 p.m. RN-D indicated a resident's code status was in the chart, and if she found a resident unresponsive, she would assess patient, check code status, and if not breathing and full code she would start CPR. On [DATE] at 2:46 p.m. LPN-C stated in the event a resident was found unresponsive, the nurse was supposed to assess the resident, and if a full code, start chest compressions, start CPR. RN-B stated the code status information was in the resident chart, and indicated if he couldn't determine how long resident without pulse/breathing at time of assessment CPR would be initiated Policy titled St John's Lutheran Community CPR Policy dated ,d+[DATE], indicated: -It is the policy that this facility will provide basic life support including CPR- cardiopulmonary resuscitation, when a resident requires such emergency care, prior to the arrival of the emergency medical services, subject physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Procedure: 1. CPR certified staff will be available at all times and maintain current CPR certification for health care providers 2. Upon admission, all residents/families will be notified the facilities unwitnessed CPR policy 3. Staff will obtain signature on the POLST form. 4. Resuscitation (CPR) will be provided to residents that have indicated they want CPR or have not chosen an advance directive. 5. Staff present will notify the charge nurse. Resuscitation efforts will be immediately be started by the CPR certified staff unless obvious signs of clinical irreversible death are president such as rigor mortis, dependent lividity, decapitation , transaction, decomposition if initiating CPR could cause injury or peril to the rescuer 6. 911 will be called 7. The resident's family will be notified 8. The physician will be notified Policy titled St John's Lutheran Community CPR procedure, dated ,d+[DATE] indicated Procedure: 2. Check for resident response 3. Assess the resident for breathing and pulse for 10 seconds 4. Shout for nearby help or use the call light system for assistance activate the emergency response system, staff are immediately instructed to retrieve AED in emergency equipment. 5. Either the staff member who found the resident or responding staff member is to notify residents nurse of event and verify CPR or DNR status ASAP. If resident has a valid advance directive or do not resuscitate order do not perform CPR 6. If DNR order or advanced directive exists and if the advance directive does not indicate do not resuscitate began CPR The past noncompliance immediate jeopardy began on [DATE]. The immediate jeopardy was removed and the deficient practice corrected by [DATE], after the facility implemented a systemic plan that included the following actions: education provided to nursing staff on all floors of CPR policy and procedures, review and nursing staff education of nurse job description, revised the CPR policy and procedure, review of CMS Clarifies CPR Policy for Nursing homes, staff education on revised standing orders, education where to access resident code status, steps to take for an unresponsive resident, and staff competency quiz regarding procedure when finding a resident unresponsive and where to locate resident code status forms, Additionally, the facility removed the statement in the policy that stated and not on those known to have been clinically dead for more than four to six minutes.

Based on observation, interview and document review, the facility failed to properly prepare food to the appropriate temperature to ensure food safety and prevent foodborne illness. This deficient practice resulted in an immediate jeopardy (IJ) for 5 of 7 residents (R29, R60, R47, R23, R48) who ate undercooked food prepared and served from one of five facility satellite kitchens (kitchen 2B). Furthermore, the facility failed to ensure staff completed proper cleaning and sanitization of items and equipment, date when food items were opened, and monitor food storage temperatures to prevent foodborne illness. This deficient practice had the potential to affect all 58 residents receiving food from the kitchenettes. The IJ began on 5/27/21, at 5:15 p.m. when the facility failed to serve food to residents at an appropriate temperature to prevent foodborne illness. The administrator and dietary director (DD)-A were notified of the immediate jeopardy at 5/28/21, at 1:44 p.m. The immediate jeopardy was removed on 5/30/21, but noncompliance remained at a lower scope and severity level of E - pattern, scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: During an observation on 5/27/21, at 5:15 p.m. R58 was dining in her room and reported to surveyor her pork patty was cold to the touch. The burger was taken back to the unit kitchen by surveyor and temperature was taken by DD-A at 92 degrees Fahrenheit (F). The pork patty was observed to be pale gray/tan in color and had no char marks. On 5/27/21, at 5:20 p.m., a pork patty that homemaker (HM)-A had removed from the frying pan, placed on a bun, put on a plate, and covered with foil, was temped by DD-A at 89 degrees F. Furthermore, at 5:25 p.m., a pork burger that was prepared, plated, and set on a tray for room service for R55 was temped by DD-A at 87.6 degrees F. It was not known how long the pork burger had been sitting on the tray. DD-A stated the pork patties should have been cooked to 160 degrees F. R48 who had returned to his room after eating supper in the 2B dining room, left half of his uneaten pork burger on his plate. The middle of the pork patty was pale pink. DD-A was asked if the pork patty appeared fully cooked and replied, it doesn't look appetizing. On 5/27/21, at 5:35 p.m., HM-A admitted in the presence of DD-A, that she had not temped any of the pork patties she made for the 7 of 13 residents (R29, R60, R47, R58, R23, R48, R55) on unit 2B who requested a pork burger for their evening meal. Five of the seven residents consumed part of a pork burger before it was identified as being undercooked: Of the seven residents who requested and received pork burgers for dinner on 5/27/21, five residents ate part of it: 1) R29: quarterly Minimum Data Set (MDS) dated [DATE], indicated a brief interview for mental status (BIMS) of 14, indicating intact cognition. MDS also indicated R29 could eat independently. R29 who dined in the 2B dining room, stated she took a couple of bites of the pork burger, but didn't like it so didn't eat more. 2) R60: quarterly MDS dated [DATE], indicated BIMS of 99, indicating R60 was not able to complete the BIMS interview. MDS also indicated she could eat independently. R60 who dined in her room consumed a portion of the pork burger. 3) R47: quarterly MDS dated [DATE], indicated BIMS of 14, indicating intact cognition. MDS also indicated she could eat independently. R47 was in her room with family members present. Noted a half eaten pork burger on her plate. When asked how the burger was, R47 stated she didn't care for it so didn't finish it. 4) R23: quarterly MDS dated [DATE], indicated BIMS of 09, indicating moderate impaired cognition. MDS also indicated she could eat independently. R23 who dine in her room consumed a portion of the pork burger. 5) R48: quarterly MDS dated [DATE], indicated BIMS of 11, indicating moderate impaired cognition. MDS also indicated he could eat independently. R48 who dined in the 2B dining room was observed to have eaten half of the pork burger. Review of the pork patty vendor cooking instructions indicated the pork patties were raw and frozen when delivered and required cooking to an internal temperature of 155 degrees F and to hold at a temperature of 135 degrees or above. During unit 2B satellite kitchen observation and interview on 5/24/21, at 4:35 p.m., HM-A stated she had been employed as a homemaker at the facility for about two weeks, adding she had five days of training with three different homemakers before starting on her own. In her position, she was responsible for preparing and serving meals to 13 residents currently residing on second floor, unit 2B. During an interview on 5/26/21, at 8:13 a.m., DD-A stated the main kitchen in the basement supplied five satellite kitchens on three floors with uncooked food for lunch and dinner. Homemakers were responsible for cooking the food and serving it to residents on their unit. During an interview on 5/26/21, at 10:12 a.m., DD-A stated there was no orientation training checklist for HM-A who started working at the facility on 5/13/21. DD-A stated, to be honest, I don't think they are using the orientation checklists. According to DD-A, of the 23 homemakers employed, only two had a training checklist on file. The training checklist included hands-on skills such as how to take and record food temperatures. In addition, 12 out of 23 homemakers had not completed their online training modules related to culinary topics such as food safety temperatures. According to DD-A, HM-A was first scheduled for online culinary training modules on 5/27/21, after concerns were identified with her temping food. DD-A verified her responsibility as dietary director to ensure homemakers were trained properly before working on their own, which included temping food and serving it at proper temperatures. During interview on 5/27/21, at 1:30 p.m. with infection preventionist, reviewed the facility electronic infection surveillance log. No trends were identified and no symptoms related to foodborne illness were noted. During an interview on 5/28/21, at 11:14 a.m., the administrator stated he was aware undercooked pork patties were served to residents on 5/27/21, and provided a document from the facility associated trade organization, titled Food Safety Requirements Policy and Procedure, dated 2017, which he stated the facility would be adopting for food safety guidance. During separate interviews on 5/28/21, starting at 12:05 p.m., five residents (R29, R60, R47, R23, R48) who ate part or all of an undercooked pork burger on 5/27/21, were interviewed for signs and symptoms of foodborne illness. One resident, R47, stated I filled my pants this morning but denied other symptoms. During an interview at 12:20 p.m., nursing assistant (NA)-A stated R47 had a bowel movement (BM) blow out with stool running down her legs, but did not have a fever or other gastrointestinal symptoms. During an interview on 5/28/21, at 12:25 p.m. registered nurse (RN)-A confirmed she was aware of residents being served undercooked pork patties the evening of 5/27/21. RN-A was not aware of any residents with signs or symptoms of foodborne illness and was not aware R47 had experienced loose stools. Review of R47's medication administration record indicated medication to treat constipation that had been given daily since 5/22/21, was held on 5/28/21, due to loose stools. RN-A stated that was unusual for R47. Review of R47's BM log indicated she had an XXL (extra, extra-large) BM on the 7 a.m. to 3 p.m. shift on 5/28/21. RN-A stated nurses and nursing assistants were monitoring these residents for signs and symptoms of foodborne illness. During an interview on 5/28/21 at 1:45 p.m., the administrator stated he was unaware of homemakers on satellite kitchens not temping food and/or not temping food properly. The administrator admitted this could result in residents acquiring a foodborne illness. Administrator was not aware that some homemakers did not complete orientation checklists or culinary training modules before starting shifts on their own. Further, the administrator stated he would be working with DD-A to improve this process to ensure dietary staff have training to properly temp foods for resident consumption. The immediate jeopardy that began on 5/28/21, was removed on 5/30/21, at 11:30 a.m. when the facility developed and implemented interventions to ensure food was prepared to appropriate temperature. All dietary staff and homemakers who prepared and served food to residents were trained on performing temperature checks and on proper food serving temperatures. In addition, management staff verified competency of food temperature compliance by observing dietary staff and homemakers temp food prior to serving it to residents. Visual references with instruction how to use a food thermometer and appropriate end cooking temperatures were posted in each household kitchen. It was verified through interviews that prior to their first shift of work following the identification of the IJ, dietary staff and homemakers completed online training modules related to temping food. In addition, dietary staff and homemakers completed a competency with a facility director on calibration of food thermometers, properly temping food, and documenting food temperatures. Observations and interviews of homemakers was conducted on each of the five-household kitchens to ensure competency. However, non-compliance remained at the lower scope and severity level of E - pattern, scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Surveyor: [NAME], [NAME] On 5/24/21, at 1:50 p.m. the initial observation and tour of the main kitchen with the dietary manager (DM) revealed: - A cupboard with a bag of white sugar and brown sugar not dated or sealed, and white sugar particles visible on the lower shelf of the cupboard. - A metal sauce pan located in a lower cabinet had hard, brown substance around the inside of the cooking put. -A box of lasagna noodles opened was found located on a metal shelf not dated and a clear bag which reassembled pasta shells dated 12/20 and not labeled. -The clean area where the clean dishes were located, had metal baking dishes on the counter and were stacked and placed on the counter to dry. -A metal shelf located in the walk in freezer had and a bag of stator tots opened and not dated and clear plastic bag was filled with white string like food material located on a metal shelf, not dated and labeled lunch -Ice fragments were located on the floor of the walk in freezer and multiple ice chunks were stacked on the floor and under the shelves near the door. The boxes to the left of the door on the metal shelf were covered with frost on the outside of the boxes, visible frost was located on the metal shelves and frost was built up on both of the doors frames of the walk in freezer. On 5/24/21, at 2:15 p.m. an interview with the DM confirmed the pot was not clean. DM indicated the bags of sugar were expected to be sealed, dated, and the spilled sugar wiped and removed. The DM indicated dishes removed from the dish machine were not to be stacked until fully air dried. The DM indicated a nursing assistant was helping with the dishwashing due to no staff available, and stated she was not trained in dishwashing. DM discussed the freezer has always had frost and ice built-up and maintenance was aware. When asked when and what repairs were done for freezer the DM was not sure. The DM stated she was aware the refrigerator temperatures were not always checked daily. On 5/24/21, at 3:00 p.m. the initial tour of the first floor kitchenette revealed: - Refrigerator temperature was at 50 degrees Fahrenheit (F) - Plastic container of strawberries located in the refrigerator was not dated - Small refrigerator with cardboard container with liquid egg whites opened and not dated - Plastic covered container with unknown contents not labeled or dated was found in the refrigerator - Refrigerator and freezer temperatures had blank areas for the dates of 5/15-5/21 On 5/24/21, at 3:15 p.m. the initial tour of the second floor kitchenette A revealed: - Oven inside had burnt, black layers of debris and food particles - Microwave on the inside was found to have food particles and inside walls of the microwave were found to have hard and dried food particles built up - Cupboard drawers were observed and found with food particles and crumbs - Clear plastic bag was on the counter and contained shredded wheat cereal and was not sealed, labeled or dated On 5/24/21, at 3:25 p.m. an interview with the DM indicated the cleanliness of the kitchen on 2A was not acceptable and indicated she expected the kitchen cleaned daily and stated it [kitchen] looks like a week or two without being cleaned. On 5/24/21, at 3:30 p.m. the initial tour of the second floor kitchenette B revealed: -Hairbrush was located on the counter by the microwave -Cupboards throughout the kitchen included : chicken flavor mix, beef gravy mix, powdered sugar and were opened and not dated -Small fridge contained liquid eggs in a cardboard container opened not dated -Top handle of the small refrigerator felt greasy and sticky and visibly had greasy substance -Food crumbs and food particles observed in all cupboard drawers -Bread in a kitchen drawer was found opened not dated -Food particles were dried onto the floor and food crumbs/particles were built up in the corners of the floor. The 2B refrigerator was found top shelf with 3 plates stacked on top of each other covered with aluminum foil not labeled or dated - All food on refrigerator top shelf was not dated - Drawer in the refrigerator had a clear plastic bag of brown wilted lettuce, not opened and not dated and further observed the DM to discard -Milk, juice, cake, and hard boiled (located in a plastic bag) were opened not dated -A staff member was observed to take plastic cups out of the dishwasher, steam were on the cups and wetness was observed on the plastic cups, the staff member used a red rag and wiped inside and outside of the glasses dry On 5/24/21, at 3:45 p.m. an interview with the DM stated the drinking glasses should not be wiped with a rag and the staff member was a nursing assistant who was not trained in the kitchen and the DM further indicated the refrigerators were expected to have dates of the food opened needed to be cleaned. On 5/25/21, at 9:37 a.m. observed homemaker (HM)-G exited the 3B kitchen and failed to wash her hands when she reentered the kitchen. Further, HM-G removed oatmeal from the microwave, removed two drinking glasses from the cupboard, poured a glass of juice and glass of milk, and exited the kitchen. HM-G provided the glass of juice and milk to the resident in the dining area, and failed to wash or sanitize her hands. HM-G was further observed to reenter the kitchen and removed bacon from a pan on the stove top. HM-G provided the bacon to a resident and failed to check the temperature of bacon. On 5/27/2, at 9:44 a.m. observed HM-G in kitchen and placed her un-gloved bare hand in a bag of shredded cheese and placed the shredded cheese on eggs. The eggs with cheese was served to the resident. When asked, HM-G confirmed gloves should be worn when handling food and indicated she failed to do so. On 5/25/21, at 9:00 a.m. the DM manager provided a written list of the items she discarded from the second floor refrigerators and cupboards on 5/25/21 between 7:00 a.m. and 7:30 a.m. The written listed indicated the following were opened and not dated, and therefore the DM indicated she discarded the following foods: hard boiled eggs, milk, juice, deli meats, cream cheese, grated cheese, lettuce, leftovers (not identified), bacon, bread, peanut butter, brown sugar, syrup, pancake mix, oatmeal. On 5/25/21, at 10:23 a.m. observed unidentified homemaker in the kitchen with no gloves, used cooking utensil to stir food, then touched a walkie talkie, drank water out of water bottle, and further observed to continue to prepare food and stir food on the stove top and failed to wash hands. On 5/25/21, at 1:55 p.m. HM-D was located in kitchen 2A, and stated she did not record the freezer temperatures today, because she could not find the thermometer and further indicated the freezer temp need to be at 32 degrees or less. HM-D failed to state and understand the correct freezer temperature food was stored. On 5/25/21, at 2:00 p.m. observed second floor B kitchen the self cleaning oven was in use. HM-E discussed the oven should be cleaned once a week, and further stated she was not aware when it was cleaned last. HM-E stated the fridge temps need to be at 37-47 degrees and freezer less then 0. When asked, to see the prepared food temperatures, HM-E stated she had not wrote down the food she temped today, because she does it at the end of her shift and remembers the food and the temperatures. On 5/25/21, 03:07 p.m. interview with the DM stated she could not find documentation of maintenance repairs since 2018, for the main kitchen walk-in freezer. On 5/26/21, at 9:00 a.m. HM-H was observed working on the 3B kitchen and stated the pancakes for breakfast were temped at 172 degrees F. HM-H further indicated she failed to temp the bacon and sausage served to the residents for breakfast. HM-H confirmed food should be temped when served to the residents. On 5/27/21, at 1:30 p.m. interview with the DM indicated she was new to the manager role and also has many new dietary staff who needed to be trained about labeling and dating food items before putting them back in dry food storage, the refrigerator and the freezer, and further indicated was ultimately responsible to assure all foods were labeled and dated. Interview with the administrator on 5/28/21 at 1:45 p.m. stated-he was unaware the kitchen had items in dry food storage, refrigerator and freezer were not labeled and dated and the residents food was not temped prior to being served. Facility policy titled Dietary Policies, dated October 2017, indicated: 1. Each resident received, and the facility provided: --Food prepared by methods that conserved nutritive value, flavor, and appearance. Food and drink were palatable, attractive, and served at a safe and appetizing temperature. --Food would have taste, aroma, and appearance that encouraged resident consumption of food. 2. Potentially hazardous food would be maintained at 40 degrees Fahrenheit (F) or below, or 150 degrees (F) or above including periods when it was being transported. 3. Potentially hazardous food meant any food subject to continuous time and temperature controls in order to prevent the rapid and progressive growth of infectious or toxigenic microorganisms. Facility memo titled Policy on Food Temperatures, dated 11/1/08, indicated: Food temperatures would be taken before food was served to residents. Minimum temperature was 150 degrees. If temp was below 150, food was to be microwaved or sent back to the kitchen for replacement. Facility policy titled Employee Education and dated 3/1/21, indicated: --All employees were assigned online orientation education at hire and were to complete the education prior to job/floor training beginning. The policy titled St. John's Lutheran Community Position Description Homemaker date 5/2017, indicated: Regulatory compliance 1. Review, understand and follow residents written plan of care. Education: - Must be trained in serve safe practices. - Must be capable of reading and following residents care plans. The policy titled St. John's Lutheran Community Position Description Certified Dietary Manger/Culinary Manager dated 9/2017, indicated: Operations Management: -Interview, hire, train, coach, evaluate, discipline, employees and when necessary work with HR to fire employees. -Develop job duties. Facility policy titled Employee Education and dated 3/1/21, indicated: --All employees were assigned online orientation education at hire and were to complete the education prior to job/floor training beginning. Document titled Use of plastic gloves (not rated) indicated: Policy: Plastic gloves will be worn when handling food directly with hands to ensure that bacteria are not transferred from the food handlers hands to the food product being served. Procedure: 1. If used, single use gloves shall be used for only one task such as working with ready to eat food or raw animal food, used for no other purpose, and discarded when damaged or soiled , or with interruptions occur in the operation. 2. Hands are to be washed when entering the kitchen before putting on the plastic gloves. 3. Plastic gloves are to be worn whenever handling the food directly with hands when handling ready to eat foods, anytime you touch food directly. 4. Remember gloves are just like hands they get soiled anytime a contaminated surface is touched the glove must be changed. During food preparations as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks, after using the restroom. Document titled Reminders dated 4/14/14 indicated, Make sure you're taking temps of the food you are making and recording it on the sheet and initial them when you're done. When you're done cleaning make sure you're signing the cleaning sheet if you don't sign it, it's not done. Before you put away your dish make sure they are dry bacteria grows in dark wet places Document titled policy and food temperatures dated 11/1/2008, indicated: Food temperatures will be taken before food is served to residents. Minimum temperature is 165 degrees. If temp is below 165, food is to be microwaved or sent back to the kitchen for replacement. Document titled dietary policies dated October 2017, indicated: Air drying dishes and utensils must be air dried before being stored or must be stored in a self-driving position. Properly racked sanitized dishes and utensils may complete air drying in proper storage places, if available Document titled storing leftovers dated 9/22/12, indicated. All leftovers are to be dated and labeled. They are to be covered. Can be help for three days then discarded. Dry storage items such as Jell-O and noodles are to be placed in a sealed container labeled and dated. No food item is to be left in original bag and sealed with the twisty no food items should be stored on the floor everything needs to be in a shelf or rack. All food past expiration date is to be thrown. Policy titled refrigeration policy dated 8/22/2012, indicated. All refrigerators are to be kept clean and in good working condition at all times. Temperatures for a refrigerator should be between 36 through 40 degrees if above please let supervisor know shut off light and keep door closed as much as possible. Every refrigerator should be equipped with an internal thermometer. each nursing unit with the refrigerator/freezer unit will be supplied with thermometers and monitored for appropriate temperatures. Cooked foods must be stored above raw food to prevent contamination. All food should be covered and labeled and dated. All foods should be allowed to allow air circulation. Document titled freezer and walk in policy dated 11/1/2008, indicated Temperatures will be checked twice daily. Cook will check the walk in another refrigerator at the start of the shift cook will check between 3:00 and 4:00 o'clock, the temp should be between 33 and 40 degrees. Freezers will be checked by the CA when getting supplies temperatures should be at zero degrees or below if temperatures are not correct report to maintenance.

Based on interview and document review, the facility failed to protect 1 of 3 residents (R1) from verbal abuse. Verbal abuse occurred when a staff person screamed at R1 and called her a liar and the facility failed to take immediate action to protect R1 from further abuse. This finding constituted an immediate jeopardy (IJ) situation which had potential to affect all 26 residents residing on the second floor, as nursing assistant (NA)-A continued to work despite an allegation of verbal abuse towards R1. The IJ began on 12/30/20, when the facility failed to take action when R1 informed social worker (SW)-A that a staff member screamed in her face and called her a liar. The facility failed to protect R1 and other residents from continued verbal abuse from NA-A. The administrator, director of nursing (DON) and director of social services (SW)-B were informed of the IJ on 1/6/21, at 4:53 p.m. The facility implemented corrective action and the IJ was removed on 1/7/21, at 2:56 p.m. However, non-compliance remained at the lower scope and severity of D, isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's facesheet with admission date of [DATE], included a [DIAGNOSES REDACTED]. R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R1 was cognitively intact; had adequate vision and hearing, clear speech, was able to make herself understood and could understand others. R1 depended upon staff for bed mobility, transfers, locomotion on the unit, dressing, toileting and hygiene. R1's plan of care, dated 7/28/20, indicated R1 had alterations in mood related to changes in a new environment. Staff were to monitor mood and report changes such as withdrawal, tearfulness and sadness. During an interview on 1/5/21, at 11:51 a.m., SW-A stated she completed R1's quarterly MDS update on 12/30/20. At the end of the interview SW-A asked R1 how staff treat her; were they gentle and respectful? R1 responded, stating she loved all the girls except one who she did not get along with. R1 told SW-A a staff member had screamed in her face and called her a liar. R1 went on to tell SW-A that she did not want her to do anything about it for fear of retaliation, adding that if she said too much, the staff person might yell at her more. R1 could not remember the staff person's name, but described her as an older woman who worked the evening shift. Following this allegation, SW-A spoke to SW-B and registered nurse (RN)-B about the allegation. No further action was taken. During an interview on 1/5/21, at 2:21 p.m., SW-A stated as part of an abuse allegation, staff and residents were supposed to be interviewed. SW-A admitted no residents had been interviewed since R1's allegation of verbal abuse. SW-A stated 12/31/20, was crazy they were giving COVID-19 vaccinations and she was helping with that. SW-A stated she had wanted to talk to R1 again to get more information, but by the time she did and interviewed NA-B and (NA)-D, that was as far as she got. SW-A added more would have been done had it not been a holiday. SW-A stated she had asked NA-B, who was scheduled to work New Years Day with NA-A, to leave her a note if any concerns came up with NA-A. An email from RN-B to the DON and administrator dated 12/31/20, at 11:29 a.m. indicated R1 made an allegation of mistreatment when she was being interviewed by SW-A for her MDS and that SW-A was doing the report and investigation. SW-A notes from an interview with NA-D, dated 12/31/20, at 2:15 p.m. indicated NA-A would get a tone. If a resident was giving attitude, NA-A would get snarky. SW-A notes from interview with NA-B, dated 12/31/20, at 2:30 p.m. indicated on Christmas Eve R1 was crying because NA-A was rude and mean, and R1 got off bed pan and still had to go. NA-A said, I'm not dealing with her. NA-B answered R1's call light and R1 said she had an accident because NA-A wouldn't bring her the bed pan. NA-B has reported this behavior before to RN-A, but nothing was done. NA-A would make residents do things they don't want to do. NA-A would refuse to answer R1's call light saying I don't care what your son owns; your name means nothing to me. At the end of the interview SW-A asked NA-B to leave her a note if anything came up over the weekend in regards to NA-A. An email from RN-A to the DON, SW-A and SW-B, dated 12/31/20, at 7:06 p.m. indicated NA-C told RN-A that R1 does not want NA-A in her room. R1 did not tell NA-C or RN-A why. An email from SW-B to the DON, dated 1/1/21, at 10:22 a.m. indicated SW-A filed an OHFC (Office of Health Facility Complaints) report on allegations against a staff member on evening shift. The email indicated the facility was not sure who the staff was other than R1 stated it was an older lady who worked from 3 p.m. to 10 p.m. A handwritten note from NA-B to SW-A, dated 1/1/21, and received by SW-A on 1/4/21, indicated NA-B was working on New Years day, on A-side, and around 5 PM after R1 got her supper tray dropped off by NA-A. R1 then put her call light on and before NA-B could go to 207 (R1's room), NA-A stopped NA-B and told her to go into R1's room, stating, I can't deal with her tonight. I just brought her her tray and I'm definitely not dealing with it. When NA-B entered R1's room, R1 was worked up and crying, saying, I try so hard to get along with that woman, but she is just horrible and full of hate. R1 then started crying because all she wanted was her pillows fixed and NA-A told her she could deal with how they were. R1 went on the whole night about how upset she was because she just tries so hard to get along with NA-A but NA-A was so mean. R1 asked NA-B many times to please never let NA-A in her room again. This same thing happened on 12/31/20, when NA-C was working both days, and reported to RN-A as she was the nurse both nights. During an interview on 1/5/21, at 10:53 a.m., when asked how she was treated by staff, R1 stated, I talked to someone about it and that just causes trouble and I'm not going to cause trouble. When asked if a staff person got in her face and yelled at her, R1 stated, I will not answer that; I've prayed that she finds happiness and completeness. My condemning her is my fault. I'm not saying more. R1 stated she did not know the staff person's name. During the interview on 1/5/21, at 11:51 a.m., SW-A stated she confirmed with R1 on 1/4/21, at 2:30 p.m., that the staff member she had been referring to was NA-A. SW-A stated she had been standing outside R1's room when NA-A went into the room to answer the call light. After NA-A left R1's room, SW-A went in and asked R1 if NA-A was the staff person who screamed at her and called her a liar. R1 confirmed it was. SW-A informed the DON of this finding immediately following the interview with R1. During an interview on 1/5/21, at 12:55 p.m., the DON stated it was not until 1/4/21, that she learned who the resident and the staff person were, and also became aware R1 no longer wanted NA-A in her room. DON stated she talked to NA-A on 1/4/21, at 3:30 p.m. about the allegation of abuse and informed her not to go into R1's room during the investigation. During an interview on 1/5/21, at 1:54 p.m., the DON stated NA-A was one of their stronger employees who advocated for residents, therefore it was decided they would offer her the Employee Assistance Program in order to find out what was causing her to be more short than normal. The DON stated NA-A would not be suspended during the investigation. During an interview on 1/5/21, at 3:20 p.m., the DON stated the chain of command when she was on vacation generally starts with the NA, who tells the nurse, who tells the nurse manager, who tells me. The DON stated a nurse was responsible to take action for something like this and that RN-A should have told NA-A not to go into R1's room anymore. During an interview on 1/6/21, at 9:52 a.m., SW-B presented the facility PowerPoint used for staff training in 2020, titled, Freedom from Abuse, Neglect, Misappropriation and Exploitation for Direct Caregivers. SW-B stated she taught the training and that the training indicated they did not have to take an employee off the schedule - it depended upon the allegation. SW-B went on to say that it was automatic to remove an employee from the schedule if there was bodily harm. SW-B added, they would take into consideration if the employee was good staff; if complimented by other residents, family and staff -- even if staff say she's snippy. Further, SW-B stated staff should have told them what was going on as they are responsible to inform someone when they see abusive behaviors by a coworker. During an interview on 1/6/21, at 12:08 p.m., the administrator stated he first learned of the allegation of verbal abuse on 1/4/21, when SW-B sent him an email message. The administrator stated he was in the facility on 12/30/20, and 12/31/20, but had not been informed of the allegation of abuse. The administrator was handed an email dated 12/31/20, time of 11:29 a.m. which included him, and which read: R1 made an allegation of mistreatment when she was being interviewed by (SW-A) for her MDS. (SW-A) is doing the report and investigation. The administrator stated he did not recall seeing this email, adding, I completely missed it; I was here that day. The administrator stated they would normally take an employee off the schedule or at least not have them working with that resident. The administrator said they would honor the resident's wishes. The administrator stated if he had seen the email, he would have taken NA-A off the schedule or at a minimum, would not have allowed NA-A to go into R1's room. During an interview on 1/6/21, at 3:35 p.m. NA-A stated SW-A informed her of R1's allegation on 1/4/21, adding, I was taken aback by that. NA-A stated she never called R1 a liar or yelled at her. NA-A did not know why R1 would say that. NA-A went on to say, I speak loudly, so does she think I'm yelling? NA-A thought maybe R1 called her a liar when R1 requested something for supper, then said she did not request it. When NA-A pointed that out to R1, R1 asked if NA-A was calling her a liar. NA-A denied feeling frustrated or short on temper when caring for residents, adding, I come across as harsh or stern, I am matter of fact. R1 denied having asked coworkers to answer R1's call lights for her when she cannot deal with R1 anymore. NA-A stated the DON informed her of the allegation of abuse against her on 1/4/21, at about 3:30 p.m., and to not to go into R1's room. NA-A stated she had already been in there two or three times as she did not know. During an interview on 1/6/21, at 5:59 p.m., RN-A stated she emailed the DON, SW-A and SW-B on 12/31/20, that (NA)-D said R1 did not want NA-A in her room, but R1 did not say why, and RN-A admitted she did not ask R1 why. RN-A stated that NA-B told her the same thing on New Years Day, and she informed NA-B she had already reported it. RN-A stated they were not able to keep NA-A out of R1's room completely, as she was needed to help with two-person cares. RN-A did not feel it was her responsibility to tell NA-A that she should not go into R1's room, stating that should come from a social worker. SW-A notes from interview with NA-C, dated 1/4/21, indicated: NA-A was pretty mean to R1; NA-A would not jump up to answer her call light. R1 told NA-C she does not want NA-A in her room. NA-A has voiced to NA-C that she does not like R1 because NA-A believes R1 expects special treatment. Staff schedules were reviewed and the DON confirmed NA-A worked on the following shifts: 12/30/20, 12/31/20, 1/1/21, 1/4/21, 1/5/21, 1/6/21; all 2 p.m. to 10 p.m. shifts. During a telephone interview on 1/8/21, at 14:42 p.m., family member (FM)-A stated R1's care was really good, except for an older gal whose name FM-A did not know. FM-A stated it was likely a personality clash, adding the staff person was a hard worker, but did not have a tender bedside manner. Further, FM-A stated the tone of her voice was not as sweet as other staff and she was not as patient, but had never detected anything malicious or mean. FM-A stated a couple of weeks prior to Christmas, that would be the first thing R1 said when they called her -- that she dreaded when this staff person worked. FM-A stated they did not report it to the facility, but were at the point where they were going to because R1 kept telling them the same thing every time they talked to her. The facility policy titled, Reportable Incidents Policy, revised date 8/27/20, indicated the following definitions: --Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including care taker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Willful means the individual's act was deliberate -- not inadvertent or accidental -- regardless of whether or not the individual intended to inflict injury or harm. --Verbal abuse: may be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gesture communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. Examples of mental and verbal abuse include, but are not limited to: harassing a resident, mocking, insulting, ridiculing, yelling or hovering over a resident, with the intent to intimidated, threatening residents, including but limited to, depriving a resident of care or withholding a resident from contact with family and friends, and isolating a resident from social interaction or activities. The facility's undated PowerPoint slide deck used in 2020, for staff training on abuse titled: Freedom from Abuse, Neglect, Misappropriation and Exploitation indicated: 1. Objectives: to protect residents from abuse and identifying abuse. 2. Regulations: residents have the right to be free from abuse. The facility must promote resident rights. 3. Role and responsibilities of staff to step in to assist others who may be frustrated or angry. 4. Definition of abuse, including verbal abuse. 5. Examples of abuse, including verbal abuse. 6. If you witness or are informed of abuse, you must first protect the resident, intervene and stop the abuse. 7. Preventing further abuse: the facility must protect the residents from further abuse while the investigation is being completed. 8. Direct care givers are required to follow nursing home regulations. 9. Healthcare workers are required to identify and report alleged abuse. The immediate jeopardy that began on 12/30/20, was removed on 1/7/21, at 2:56 p.m., when the facility developed and implemented interventions to ensure all allegations of abuse or neglect were verbally communicated to the administrator and DON immediately. Licensed nurses and social workers were re-educated on this, and were reminded that the administrator and DON are available 24/7 and their cell phone numbers were posted at every nurses station. Five residents were interviewed on 1/6/21, and findings were reported to the administrator, DON, and social workers. The facility VA policy and procedure was reviewed with department managers, lead personnel and front line staff. The administrator, DON, social services and nurse managers conducted a table top exercise on 1/7/21, to review the VA policies and procedures. Going forward, two or more members of the leadership team (administrator, DON, social workers and nurse managers) will convene a meeting immediately upon report of alleged abuse or neglect. The purpose of the meeting is to assure the residents(s) are protected and that facility policies, procedures, State and Federal requirements are being followed. This practice was added to the facility VA policy and procedure document. The Quality Assurance Committee will review all reported cases of abuse and neglect. However, non-compliance remained at the lower scope and severity of D, isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy.

Based on interview and document review, the facility failed to ensure a thorough investigation was completed and adequate protection provided to ensure freedom from abuse for 1 of 3 residents (R1). These findings constituted an immediate jeopardy (IJ) situation which had potential to affect all 26 residents residing on the second floor, as nursing assistant (NA)-A continued to work despite an allegation of verbal abuse. The IJ began on 12/30/20, when the facility failed to take action when R1 reported an allegation of verbal abuse to social worker (SW)-A that a staff member screamed in her face and called her a liar. The facility failed to report and investigate this allegation, and to protect R1 and other residents from continued verbal abuse from NA-A. The administrator, director of nursing (DON) and director of social services (SW)-B were informed of the IJ on 1/6/21, at 4:53 p.m. The facility implemented corrective action and the IJ was removed on 1/7/21, at 2:56 p.m. However, non-compliance remained at the lower scope and severity of a D, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's facesheet with admission date of [DATE], included a [DIAGNOSES REDACTED]. R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R1 was cognitively intact; had adequate vision and hearing, clear speech, was able to make herself understood and could understand others. R1 depended upon staff for bed mobility, transfers, locomotion on the unit, dressing, toileting and hygiene. R1's plan of care, dated 7/28/20, indicated R1 had alterations in mood related to changes in a new environment. Staff were to monitor mood and report changes such as withdrawal, tearfulness and sadness. During an interview on 1/5/21, at 11:51 a.m., SW-A stated that when she completed R1's quarterly MDS update on 12/30/20, she asked R1 how staff treat her; if staff were gentle and respectful. R1 stated she loved all the girls except one who she didn't get along with. R1 told SW-A a staff member had screamed in her face and called her a liar. R1 went on to tell SW-A that she did not want her to do anything about it for fear of retaliation, adding that if she said too much, the staff person might yell at her more. R1 couldn't remember the staff person's name, but described her as an older woman who worked the evening shift. Following this allegation, SW-A spoke to SW-B and registered nurse (RN)-B about it. SW-A also talked to the staff scheduler and obtained names of staff who worked on second floor in order to determine which staff worked with R1. No further action was taken. In a handwritten note from nursing assistant (NA)-B to SW-A, dated 1/1/21, NA-B wrote that on 1/1/21, she worked with NA-A. During the shift, NA-B entered R1's room and found R1 crying. R1 told NA-A, I try so hard to get along with NA-A, but she is just horrible and full of hate. NA-B stated R1 was upset the entire night, telling NA-B she tried to get along with NA-A, but NA-A was so mean. R1 asked NA-B multiple times to not let NA-A in her room again. NA-B reported this to registered nurse (RN)-A. During an interview on 1/5/21, at 10:53 a.m., when asked how she was treated by staff, R1 stated I talked to someone about it and that just causes trouble and I'm not going to cause trouble. When asked if a staff person got in her face and yelled at her, R1 stated I will not answer that; I've prayed that she finds happiness and completeness. My condemning her is my fault. I'm not saying more. R1 stated she did not know the staff persons name. During the interview on 1/5/21, at 11:51 a.m., SW-A stated she confirmed with R1 on 1/4/21, at 2:30 p.m., that the staff member she had been referring to was NA-A. SW-A stated she had been standing outside R1's room when NA-A went into the room to answer the call light. After NA-A left R1's room, SW-A went in and asked R1 if NA-A was the staff person who screamed at her and called her a liar. R1 confirmed it was. SW-A informed the DON of this finding immediately following the interview with R1. During an interview on 1/5/21, at 12:55 p.m., when asked what she knew about R1's allegation of abuse, the DON stated she was on vacation at the time the allegation was made, and while she did not know the details, was aware a staff member had yelled at a resident. The DON first learned the facility filed a report with the State Agency (SA) on 12/31/20, when she came to the facility for a Covid-19 vaccination. The DON stated RN-B told her a resident was not happy, but did not know who the involved staff member was at that time. The DON stated it was not until 1/4/21, that she learned who the resident and the staff person were, and also became aware R1 no longer wanted NA-A in her room. The DON stated she and the administrator planned to meet with SW-A to discuss an action plan, adding she did not want to make harsh decisions without further information. The DON stated they assumed the alleged perpetrator was NA-A, and NA-A was aware of the allegation against her. DON stated she talked to NA-A on 1/4/21, at 3:30 p.m. about not going into R1's room during the investigation, adding that NA-A did not seem too surprised. During an interview on 1/5/21, at 1:54 p.m., the DON stated NA-A was one of their stronger employees who advocated for residents, therefore it was decided they would offer her the Employee Assistance Program in order to find out what was causing her to be more short than normal. The DON stated NA-A would not be suspended during the investigation, but would avoid working with R1. Furthermore, the DON stated they determined RN-A would receive a disciplinary warning for sending an email to the DON on 12/31/20, who was on vacation, rather than calling the administrator to inform him that R1 did not want NA-A in her room anymore. The DON stated other residents had not been interviewed to determine if there were additional concerns of verbal abuse. During an interview on 1/5/21, at 2:21 p.m., SW-A stated as part of an abuse allegation, staff and residents were supposed to be interviewed. SW-A admitted no residents had been interviewed since R1's allegation of verbal abuse. SW-A stated 12/31/20, was crazy they were giving COVID-19 vaccinations and she was helping with that. SW-A stated she had wanted to talk to R1 again to get more information, but by the time she did and interviewed NA-B and (NA)-D, that was as far as she got. SW-A added more would have been done had it not been a holiday. SW-A stated she had asked NA-B, who was scheduled to work New Years Day with NA-A, to leave her a note if any concerns came up with NA-A. During an interview on 1/6/21, at 9:52 a.m., SW-B stated it was imperative to ask other residents if they encountered the same thing R1 experienced. SW-B confirmed no resident interviews had been conducted since R1's allegation of abuse on 12/30/20. SW-B stated staff would be removed from the schedule for an allegation of bodily injury, but since there was no bodily injury in this incidence, NA-A was left on the schedule and told not to go into R1's room. When asked how other residents were protected during the investigation, SW-B stated, we didn't talk about it -- it was a holiday and no one was here. SW-B stated they should have had a discussion about removing NA-A from the schedule but did not talk about it until the morning of 1/4/21. When asked if the administrator was present in the facility on 12/30/20, SW-B verified that he was and should have been notified as soon as possible about the allegation of verbal abuse, adding, it was my bad. During the same interview, SW-B presented the facility PowerPoint used for staff training in 2020, titled Freedom from Abuse, Neglect, Misappropriation and Exploitation for Direct Caregivers. SW-B stated she taught the training and that the training indicated they didn't have to take an employee off the schedule - it depended upon the allegation. SW-B stated as they got more into the investigation, they obtained information from other staff about NA-A, adding, there may have been other residents NA-A had done things to. During a telephone interview on 1/6/21, at 11:15 a.m., former RN-B stated she was made aware of the abuse allegation on 12/30/20, at approximately 9:30 a.m. by SW-A. The plan of action was discussed, and SW-A stated she would write the report, send it to the SA and do the investigation. RN-B stated she did not report or discuss the concern with anyone else. RN-B stated that on 12/31/20, she sent an email to the DON and administrator about the allegation, but admitted she didn't speak to either one directly. During an interview on 1/6/21, at 11:45 a.m., the DON stated she thought the facility followed their abuse prevention policy appropriately in this case, however had she been at the facility, would have continued the investigation on 12/31/20. The DON added that SW-A was new and did not have a lot of support for the investigation. The DON admitted she did not know if resident interviews had been done. During an interview on 1/6/21, at 12:08 p.m., the administrator stated he first learned of the allegation of verbal abuse on 1/4/21, when SW-B sent him an email message. The administrator stated he was in the facility on 12/30/20 and 12/31/20, but had not been informed of the allegation of abuse. The administrator was handed an email dated 12/31/20, time of 11:29 a.m. which included him, and which read: R1 made an allegation of mistreatment when she was being interviewed by SW-A for her MDS. SW-A was doing the report and investigation. The administrator stated he did not recall seeing this email, adding, I completely missed it; I was here that day. An email from RN-B to the DON and administrator on 12/31/20, at 11:29 a.m. indicated R1 made an allegation of mistreatment when she was being interviewed by SW-A for her MDS. SW-A would be doing the report and investigation. An email from RN-A to the DON, SW-A and SW-B, dated 12/31/20, at 7:06 p.m. indicated NA-C passed onto RN-A that R1 did not want NA-A in her room. She did not tell NA-C or me why. An an email from SW-B to the DON, dated 1/1/21, at 10:22 a.m. indicated SW-A filed an OHFC (Office of Health Facility Complaints) report on allegations against a staff member on evening shift but they were not sure who the staff is other than R1 states it is an older lady who works from 3 p.m. to 10 p.m. Staff schedules indicated, and DON confirmed, that NA-A worked on the following shifts: 12/30/20, 12/31/20, 1/1/21, 1/4/21, 1/5/21, 1/6/21; all 2 p.m. to 10 p.m. shifts. The facility policy titled Reportable Incidents Policy, revised date 8/27/20, indicated the following definitions: --Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including care taker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Willful means the individual's act was deliberate -- not inadvertent or accidental -- regardless of whether or not the individual intended to inflict injury or harm. --Verbal abuse: may be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gesture communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. Examples of mental and verbal abuse include, but are not limited to: harassing a resident, mocking, insulting, ridiculing, yelling or hovering over a resident, with the intent to intimidated, threatening residents, including but limited to, depriving a resident of care or withholding a resident from contact with family and friends, and isolating a resident from social interaction or activities. The facility's Appendix C: Abuse Prevention Policy & Plan, dated 8/13/15, indicated investigations would begin with the supervising staff on duty at the time of the report and includes the nurse manager, social worker, director of nursing, the administrator and human resource director as needed. If an alleged perpetrator was identified as an employee, immediate action must be taken by the supervisor on duty to protect the resident. This may include suspension of the employee pending the results of the investigation. When a complaint was substantiated, the facility shall identify corrective actions to be taken along with a plan to minimize the risk of abuse. The facility's Appendix J: Internal Investigation Form, dated 8/13/15, indicated the following information was to be obtained: --Written summary of incident as described by the mandated reporter --Written summary of incident as described by the witness(es) --Written summary of incident as described by the resident --Written summery of incident described by the residents family or visitors --Summary of interview with resident roommate if applicable --Relevant polices and procedures reviewed --Alleged perpetrators personnel file reviewed The facility's undated PowerPoint slide deck used in 2020, for staff training on abuse titled: Freedom from Abuse, Neglect, Misappropriation and Exploitation indicated: 1. Every allegation of abuse must be thoroughly investigated. Residents, employees, family members, visitors, and others may be interviewed about their knowledge of events. 2. The facility must protect the residents from further abuse while the investigation is being completed. 3. Direct care givers are required to follow nursing home regulations. The immediate jeopardy that began on 12/30/20, was removed on 1/7/21, at 2:56 p.m., when the facility suspended the alleged perpetrator effective 1/6/21, pending further investigation, developed and implemented interventions to ensure all allegations of abuse or neglect were verbally communicated to the administrator and DON immediately. Licensed nurses and social workers were re-educated, and reminded the administrator and DON are available 24/7 and their cell phone numbers were posted at every nurses station. Five residents were interviewed on 1/6/21, and findings were reported to the administrator, DON, and social workers. The facility VA policy and procedure was reviewed with department managers, lead personnel and front line staff. The administrator, DON, social services and nurse managers conducted a table top exercise on 1/7/21, to review the VA policies and procedures. Going forward, two or more members of the leadership team (administrator, DON, social workers and nurse managers) will convene a meeting immediately upon report of alleged abuse or neglect. The purpose of the meeting is to assure the residents(s) are protected and that facility policies, procedures, State and Federal requirements are being followed. This practice was added to the facility VA policy and procedure document. The Quality Assurance Committee will review all reported cases of abuse and neglect. However, non-compliance remained at the lower scope and severity of a D, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy.

Based on interview and document review the facility failed to ensure residents were free from abuse for 1 of 3 residents (R11) reviewed. R11 suffered emotional harm when nursing assistant (NA)-F taunted the resident using disparaging, derogatory, and humiliating language and used both hands to gesture resident's face. Although the abuse was determined to have occurred, the facility had implemented corrective action 6/17/19 to correct the deficiency so this finding is being issued at past non-compliance. The findings include: R11's care plan, updated 6/5/19, indicated R11 was vulnerable due to cognitive deficits, impaired communication, and impaired physical mobility related to a [MEDICAL CONDITION]. Furthermore, the care plan indicated R11 was totally dependent on staff for all activities of daily living, including hygiene, grooming, toileting, and transfers with a mechanical lift. The care plan also indicated R11 had [DIAGNOSES REDACTED]. An initial report submitted to the State Agency 6/17/19, indicated a nursing assistant (NA) had reported to the nursing director she'd overheard another NA call R11 names during evening cares on 6/13/19. The reporter stated the incident happened during provision of cares for R11 while he was in bed. The reported stated the resident could be both verbally and physically aggressive during cares, so the other NA (the AP-alleged perpetrator) had started making rude comments to R11 while performing pericares. The reporter stated the AP had stated to R11, I'm gonna start calling you a pussy. You little puss nugget. You little [***] nugget. In addition, the reporter stated the AP taunted R11 when she kept asking R11, Why, why? over and over, and then the AP asked R11 if he had a hole in his brain. Further, the reported stated the AP had placed both of her hands over resident's face, one hand on each cheek/temple area and was tapping back and forth, right to left, trying to antagonize him. During an interview with the Director of Nursing (DON) on 6/19/18 at 12:15 p.m., the DON verified she had first received an initial report of the incident described above, on 6/17/19 in the morning. The DON stated NA-B, who reported the incident, had expressed feeling intimidated and afraid so had not reported the incident immediately. The DON stated an investigation was immediately initiated and revealed the incident had happened on 6/13/19 at 7:05 p.m., during cares being provided by NA-B and NA-A (AP). The DON stated the incident was an example of verbal abuse, and lack of respect and dignity. As such, the DON stated she had immediately removed NA-A from the schedule and the administrator was immediately notified. The DON also verified the delay in reporting resulted in NA-A working till 10 p.m. on 6/13/19, and another shift 2-10 p.m. on 6/14/19. The DON stated she was unaware of any adverse effects related to the incident with R11, and stated once they'd become aware of the situation on 6/17/19, they'd removed NA-A from the schedule, and had initiated corrective immediately. During an interview on 6/20/19 at 3:15 p.m., NA-B verified she had reported on 6/17/19, what she'd witnessed from 6/13/19. NA-B stated she had never witnessed a resident treated so disrespectfully. NA-B also verified she'd never witnessed NA-A abuse any residents before. The nurse manager, registered nurse (RN)-A, was interviewed on 6/20/19 at approximately 3:30 p.m. She stated she'd first been made aware of the incident regarding R11 on 6/17/19. RN-A also reported the DON had initiated an investigation interviewing all staff and residents from the two units where NA-A had worked. There had been no other reports of abuse identified. RN-A stated all staff working had been required to review the facility's Abuse policies, and all staff had been expected to completed an education packet prior to working their next shift. During an interview on 6/20/19 at 4 p.m., family member (FM)-A reported the facility had called her on 6/17/19 to report the incident. FM-A stated she visited R11 daily, and knew NA-A. FM-A said she'd only every witnessed respectful interactions between R11 and NA-A who she'd felt was non-threatening. However, FM-A stated after the reported incident, FM-A had noticed R11 had not eaten well the following 2 days but was back to himself today. FM-A also stated, since the incident she has reassured (R11) during every visit that he is safe here and the nurses will take good care of him. FM-A indicated satisfaction with R11's routine care and stated, This is a wonderful place and the staff are very very good. FM-A indicated she had asked R11 since the incident about the care of each aide, and he had indicated to her he liked them as she named each name, however when she named NA-A, R11 stopped talking. FM-A stated she felt the issue had been resolved now, and R11 was eating and smiling more again now. The facility's (YEAR) policy Vulnerable Adult Law, included: The purpose of St. [NAME]'s Policy for reporting the maltreatment of [REDACTED]. [NAME]s from abuse, neglect and financial exploitation because of their physical and or mental disability. The policy further indicated, A mandated reporter is any employee providing services at St. [NAME]s .report the incident to your supervisor immediately. If your supervisor has caused the maltreatment, report to the Director of Social services or Administrator. If your supervisor is not in the building, report the incident to a nurse. Corrective action for the past non-compliance that began on 6/13/19, was verified during the onsite visit 6/19 and 6/20/19, as having been implemented 6/17/19. Verification of the corrective action was accomplished by interview, chart review and review of educational documents completed. Residents had been interviewed, nursing staff had been interviewed, and nursing staff were re-educated to the facility's abuse/neglect policies including responsibilities for reporting.

Based on interview and document review, the facility failed to implement their Water Management Plan to Reduce Legionella Growth and Spread resulting in harm to 1 of 3 residents (R1) reviewed for respiratory infections who developed legionella pneumonia, became very ill and was hospitalized . Findings Include: Review of face sheet, with run date of 4/25/19, indicated R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R1's care plan included problem areas of: impaired physical mobility requiring assist of one for transfers and ambulation; alteration in bathing/grooming/dressing requiring assist of one to dress; request for physical and occupational therapy to evaluate and treat beginning 4/15/19. On 4/16/19, a [DIAGNOSES REDACTED]. Interventions included: observe for signs and symptoms of distress, fever, coughing up blood, vomiting, shortness of breath and provide medication's as ordered. Review of R1's progress notes indicated: 4/2/19, R1 was seen by her physician for routine visit with changes to her insulin doses. 4/3/19, resident exhibited periods of confusion and a temperature of 100.0 degrees Fahrenheit (°) at 8:00 a.m. treated with Tylenol. Temperature at 9:30 a.m. was 99.5°. 4/4/19, resident did not eat supper and had temperature of 101.6° at 6:15 p.m Extra strength Tylenol was given at this time and at 8:30 p.m., R1's temperature was 99.8°. 4/5/19, at 8:59 a.m., resident had weakness and felt tired requiring more assist than usual with transfers and had a cough. R1's certified nurse practitioner (CNP) was notified and updated on temperature, confusion and pale color. The CNP stated to monitor morning and call back with any changes. Vital signs were blood pressure 118/60, oxygen saturation (SPO2) 95%, respirations 16 and temperature 101.6°. At 11:37 a.m., R1's temperature was 98.9° and R1's daughter was updated on her condition and indicated she was okay with continued monitoring. 4/6/19, at 5:46 a.m., a progress note indicated R1 had a temperature of 100.3° at 4:30 a.m., and was given extra strength Tylenol. R1's temperature at 5:30 a.m. was 100.8°. Temperature at 8:02 p.m. was 99.7° and resident ate fair for supper. 4/7/19 at 5:46 a.m., the progress note indicated at 2:30 a.m., R1's temperature was 100.3° and the resident received extra strength Tylenol and at 5:30 a.m., had a temperature of 100.1°. The note indicated Will monitor. At 6:35 a.m., documentation indicated R1 had an occasional dry, non-productive cough during the night. At 1:45 p.m., R1's temperature was 99.4° with increased confusion and poor appetite. At 6:09 p.m., the note indicated vital signs were completed at 3:30 p.m. with a temperature of 100.6°, oxygen saturation of 93%, respirations 18 breaths per minute. At that time, R1 had indicated she was feeling weak and having a poor appetite. When asked if she wanted to go the emergency department, R1 was adamant she didn't want to go. Family was notified and also requested she continue to be monitored at the facility. 4/8/19, R1 had dry heaves. 4/9/19, at 6:35 a.m., R1's temperature was 100.2°, she was very weak, unable to hold her self up in a seated position. At 1:51 p.m., R1's temperature continued to be low grade from 99.2° to 100.2°, R1 had a poor appetite, and oxygen saturation of 88 - 91%. The note indicated R'1s physician had been notified and examined R1 noting crackles in her lung fields, and diagnosed her with pneumonia. Orders included [MEDICATION NAME] 750 milligrams by mouth daily for five days and oxygen at two to four liters per nasal cannula (NC) to keep saturation above 90%. 4/10/19, at 8:08 p.m., R1 ate poor for supper. Temperature was 97.3° and indicated she was feeling a little better. 4/11/19, at 1:47 p.m., R1 had increased confusion, reported feeling weak with difficult transfers at times and a temperature of 98°. 4/12/19, at 6:28 a.m., R1 had respirations of 18 breaths per minute (BPM), lung sounds were clear, no cough, congestion or sputum. Her oxygen saturation at rest was 95% and R1 was afebrile. At 11:09 a.m., provider was notified R1 was lethargic and hard to arouse that morning. An order to send to emergency department was received. Family was notified and arrived at bedside. Vitals were stable, skin turgor poor, not wanting to eat or drink anything with a lot of encouragement. R1 did wake up enough to finally agree to go to the hospital for evaluation. Left with van driver at 11:15 a.m., for the emergency room . At 2:23 p.m., the facility was notified R1 was being admitted for pneumonia. 4/15/19, at 2:34 p.m., R1 returned to the facility at 12:40 p.m R1 stated she was feeling better. 4/16/19, at 1:30 p.m., R1 went to scheduled appointment at the laboratory and vomited three times with some blood. R1 was sent to the emergency department for evaluation and was discharged back to the facility with an order for [REDACTED]. indicating R1's urine test was positive for Legionella and to send R1 to the emergency department if she started coughing out blood, having fever, vomiting, or complaints of shortness of breath. From 4/17/19 to 4/25/19, R1 continued to require assist of 2 for tranfers, complained of feeling tired and had a poor appetite. R1's Medication Administration Record [REDACTED]. During interview on 4/25/19, at 9:15 a.m., the adminsitrator stated they'd had a contracted agency, Innovational Concepts (IC) onsite the day prior to treat the water lines with a chemical, and were flushing the lines today. The adminsitrator stated every water source was being treated and flushed for a complete sterilization of the entire building. Further, the administrator stated these process had also been done nine months ago due to a previous outbreak of Legionnaire's disease. The administrator stated the facility's water management team consisted of himself, the director of nursing (DON), director of environmental services (DES), maintenance director (MD), housing director and housing manager. Review of the facility's undated Water Management Plan, identified as having been implemented as a result of a Legionella outbreak in (MONTH) (YEAR), indicated the goal of the Water Management Plan was to assure that all potable water is safe for use by residents and tenants that live at St. [NAME]'s, staff, and visitors. In addition, the plan indicated areas at high risk for legionella growth would include: Water maings, Hot Water Heaters, Hot Water Distribution, Cooling Towers, Air Handling Units, Dead Legs and Stagnated Water, Water Softeners, Cold Water Distribution and the Irrigation System. The plan indicated the facility would conduct routine monitoring including: Twice a year water samples will be taken at all water heaters and tested for legionella by Minnesota Valley Testing Lab, a CDC Elite Certified Lab; In addition, the plan indicated water samples would be taken twice a year: at each water main and, at each hot water heater and would be tested for legionella by Minnesota Valley Testing Lab, a CDC Elite Certified Lab. Review of the facility's documented monitoring revealed no water samples had been obtained for these areas of the building from (MONTH) of (YEAR) until after a resident was diagnosed with [REDACTED].