Every finding on record at St Williams Living Center

Based on interview and document review, the facility failed to notify the physician for out-of-range blood sugars for 1 of 5 residents, (R1) reviewed for unnecessary medications.Findings include:R1's annual Minimum Data Set (MDS), 2/17/26, identified R1 was cognitively impaired and had diagnoses which included: diabetes mellitus (DM), Alzheimer's disease, Post Traumatic Stress Disorder (PTSD). R1's MDS identified R1 required Substantial/maximal assistance with bed mobility, transfers, bathing, and dressing, R1's care plan revised 1/11/26, identified R1 had DM and had interventions which included Accu- Checks (blood sugar checks) as ordered, diet as ordered, medications as ordered, monitor for signs of hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar), labs as ordered, updated provider prn (as needed). Review of R1's Progress Note dated 1/24/26, identified the following order. Blood sugar per Freestyle Libre. Fingerstick PRN two times a day. Update provider if less than or equal to 70 OR greater than or equal to 400. Review of R1's treatment administration record from 2/11/26 to 2/22/26, identified the following blood sugar readings below 70 mg/dl:-2/22/26 at 1:16 a.m., 64 milligram (mg )/deciliter (dl)-2/21/26 at 5:12 a.m., 69 mg/dl-2/19/26 at 3:36 a.m., 57 mg/dl-2/11/26 at 5:12 a.m., 62 mg/dl Review of R1 progress notes from 2/11/26, to 2/22/26, lacked documented notifications were made to the primary care provider for blood sugars under 70 as ordered. During an interview on 2/25/26 at 11:22 a.m., Registered Nurse Supervisor (RN)-A reported, It wouldn't be our standard practice to notify the provider if we can get blood sugar back up. RN-A reported the usual facility practice was to notify the primary care provider if a resident's blood sugar was unable to be controlled upon interventions. RN-A indicated that primary care provider was updated during rounding at facility and verified primary care provider was not notified at the time of the low blood sugars as the order was written. RN-A acknowledged R?'s order, as written, was to contact primary care provider if blood sugar was above 400 or below 70. During an interview 2/25/26 at 2:42 p.m., Nurse Practitioner (NP) verified the above order. NP stated, as the order was written, technically the providers should be notified in the moment. The Director of Nursing was not available for an interview. Review of facility policy Blood Glucose (sugar) Monitoring, reviewed 6/7/23, indicated, If blood glucose was above or below normal range, notify the physician if it was indicated by the resident's symptoms or specific orders in their chart.

Based on observation, interview and document review, the facility failed to report an allegation of potential abuse within 2 hours for 1 of 1 resident (R1) with an injury of unknown origin. Findings include: R1's annual Minimum Data Set (MDS) dated [DATE], identified entered facility on 10/31/24, from a skilled nursing facility (SNF). He had minimal difficulty with hearing and impaired vision (sees large print, not regular print in newspaper/books). He was severely cognitively impaired without behaviors. He required substantial/maximal assistance for all transfers. Diagnoses included atrial fibrillation (a common heart arrhythmia where the upper chambers (atria) quiver instead of contracting effectively, leading to an irregular and significantly increasing stroke risk) arthritis, Non-Alzhemier's dementia (a group of neurodegenerative disorders, like vascular dementia that affects cognition, behavior, and function often involving blood flow issues (vascular) or protein deposits (Lewy bodies), anxiety, depression, history of falling), anxiety, and depression. Currently taking an anticoagulant (blood thinner, reduces blood clotting, may bruise easily and take longer for bleeding to stop). R1's orders dated 11/5/25, Apixaban (a blood thinner used to prevent blood clots and stroke) tablet. Give 5mg (milligrams) by mouth two times a day related to paroxysmal Atrial Fibrillation. R1's electronic medication administration record (EMAR) from 11/8/25 through 11/17/25, identified: Tylenol 500 mg was administered three times from 11/8/25 through 1/10/25, for right hip pain ranged from two to four out of 10. Tylenol 1000 mg was administered six times from 11/11/25 through 11/17/25, for right hip pain ranged from three to eight out of 10. R1's care plan dated 12/17/25, identified: all transfers (started 10/9/25) sit to stand with assist of two and as needed (PRN) Hoyer lift for pain or difficulty standing/following directions, resolved on 12/17/25. Transfer (started on 12/17/25) Hoyer lift with 2 assist using the hourglass large sling for all transfers. Potential for falls related to weakness, history of falls, cognitive impairment with impaired safety awareness, visual deficit/blind in right eye, use of psychotropic medications, and impaired balance. Staff were directed to approach from front or left side, floor mat, hi/low bed, toileting schedule, provide a safe environment, gripper socks, anti-reverse brakes on wheelchair, and call don't fall sign place in room and bathroom. He had knee pain due to arthritis, right artificial knee joint and restless leg syndrome (RLS). Impaired cognition related to short term memory problem, time orientation difficulty, and difficulty hearing. Staff were directed to report changes in cognitive status. R1 was a vulnerable adult related to assistance needed for activities of daily living (ADLS), impaired communication and decision-making skills, and impaired mobility. Staff were directed to listen to his concerns and report any inappropriate or suspicious behaviors to the proper authorities. R1's progress notes from 11/10/24, through 11/17/25, identified: -On 11/10/25 at 4:24 a.m., noted during cares an approximate 4 centimeter (cm) scabbed scratch area noted on right hip located where the edge of the brief touches his skin. -On 11/10/25 at 7:41 p.m., gave 500 mg Tylenol po every six hours PRN for mild pain. R1 grimacing and with rolling and repositioning. Follow-up at 8:49 p.m. effective pain zero out of 10. -11/10/25 at 11:17 p.m., Weekly skin inspection has multiple scabbed area on right lower extremity and face. No bruising. -11/11/25 at 5:38 p.m., Gave 1000 mg Tylenol po (by mouth) every six hours PRN for moderate to severe pain. R1 jumpy in wheelchair seat at evening meal. Reporting hip pain. Follow-up at 7:57 p.m., effective pain zero out of 10. -11/12/25 at 11:12 a.m., Unable to stand today. -11/13/25 at 2:46 p.m., Bruise noted to right upper groin/hip area red/purple to center and yellowing around edges. He denied cause being from any suspicious or inappropriate behavior. Bruise does not appear suspicious. Denies pain. -11/13/25 at 2:49 p.m., Gave 1000 mg Tylenol po as needed for moderate to severe pain. Complained of right hip pain and facial grimacing. Follow-up at 4:28 p.m. effective pain zero out of 10. -11/14/25 at 12:33 a.m., gave 1000 mg Tylenol PRN for moderate to severe pain. Right hip pain. Follow up at 3:08 a.m., effective pain zero out of 10. -11/14/25 at 1:50 p.m., Gave Tylenol. Wiggling around in chair and swearing under his breath when he moved a certain way or when he tried to hold up his feet. Pain rated eight out of 10 using PAIN-AD scale (assesses pain in residents with cognitive impairment). Follow-up at 5:23 p.m., effective pain zero out of 10. -11/14/25 at 11:40 p.m., Gave Tylenol for moderate to severe pain. Right hip pain. Follow-up at 1:43 a.m., effective pain zero out of 10. -11/15/25 at 5:18 a.m., Bruising observed above posterior right knee and extended into upper posterior thigh. No pain with palpitation. -11/15/25 at 9:54 a.m., Gave Tylenol for moderate to severe pain. Right hip pain. Follow up at 12:00 p.m., effective pain two out of 10. -11/15/25 at 5:28 p.m., Gave Tylenol for complaints of increased right hip pain. Follow up at 7:26 p.m., ineffective. Pain six out of 10. Stated his pain was the same or worse since Tylenol administration. Facial grimacing. Has a yellowish brise with deep purple red marks across right hip. -11/15/25 at 9:38 p.m., Right hip bruise was yellowing with areas of dark purple. Appeared slight swollen. Tylenol administered at p.m. (evening) meal. Checked in with R1 twice and he stated it did not help much at all. Offered ice/heat, refused. Appeared to be in moderate pain. -11/16/25 at 3:58 p.m., Gave Tylenol for complaints of increased right hip pain. R1 grimacing, groaning. Rates pain at eight to nine out of 10. Noted to position self so he was lying on his left hip, offloading pressure on the right. Large ice pack applied. Follow-up at 6:47 p.m., continued to complain of increased right hip pain. Continuing with ice and repositioning. -11/16/25 at 8:39 p.m., R1 had a large amount of bruising noted to posterior right leg and right anterior hip area. Legs are equal in length. Right hip pain with movement and external rotation, no pain at rest. He did not remember hurting himself stated when you get old you just get fragile, I guess. Phoned daughter and updated, currently on her way to facility to assess if she would like him sent in or not. Per daughter request was sent to ER to have right hip assessed. Provider on-call approved transfer to ER. Left facility via ambulance at 9:20 p.m. -11/17/25 at 12:21 a.m., Returned to facility via ambulance. No [NAME] of pain, no grimacing or verbalization of pain. Received Tylenol at 10:23 p.m. -11/17/25 at 12:08 p.m., Daughter visited. Writer evaluated R1's bruising. Deep purple bruising remained to right posterior leg from behind knee to groin area, small scattered red bruising to lateral right thigh and softball sized deep purple bruise to right lower back. Faded bruising to right anterior hip. No c/o pain to back or lower leg. Complained of pain to right outer hip when palpated or pressure placed on area. Unable to lay on right side. No swelling or deformity noted to right hip. Daughter expressed concern that he had fallen and not reported she was unable to figure out how else the bruising occurred. Writer and daughter tried to brainstorm together but unable to determine definitive cause for bruising. He denied anyone hurting him. He will be a Hoyer lift for all transfers as EZ stand transfers are too unsafe. Requested MD be contacted for better pain control. -11/17/25 at 12:14 p.m., Fax sent to primary provider (MD) to update on ER visit from last evening and requested pain medication orders. R1's ER visit dated 11/16/25 at 9:43 p.m., identified presented with concerns about hip pain/bruising. Imaging result on 11/16/25, x-ray of right hip/pelvis. Impression: no definite fracture or dislocation was identified. Diagnoses: contusion (bruise) of right hip. R1's primary provider visit dated 11/19/25, identified the primary driver of the bruising suspected was the apixaban. Does not appear to be concerning for injury. Denied any staff injury, unable to identify how bruises occurred, and felt safe. Continue to monitor closely.Facility 5-day report submitted to the Minnesota Department of Health (MDH) dated 11/19/25 at 4:55 p.m., identified an incident report was submitted on 11/16/25 at 10:34 p.m., regarding an allegation of unexplained injury of unknown source occurred on 11/16/25 at 8:43 p.m. Bruising was noted to posterior right hip, leg and front of hip. Unknown source of origin. He did not know how bruising occurred, no recollection of any recent falls or events that could have caused significant bruising, has a poor memory, on Eliquis, and required assistance of two staff to transfer in an EZ stand lift. Initial bruising (4 to 5 smaller bruises that resulted in a larger bruise) was noted on 11/11/25. Between 11/15/25 p.m., shift and 11/16/25 at 0430 (4:30 a.m.) he remained in bed due to not needing incontinence cares until 0430. At that time the night NA went to assist with cares and noted the bruise went from the bottom of his buttocks to his knee on the right leg. Night nurse was notified, and bruising charting was initiated. On 11/16/25, prior to midnight the NA's noted old bruising on the right hip lighter in color. On 11/16/25, at approximately 8:30 p.m., registered nurse (RN) checked on R1 due to complaints of pain and found the bruising had expanded, darker in color than what was observed on 11/16/25. Some bruising was noted on upper back. Pain was managed by Tylenol 1000 mg hot/cold packs and repositioning. Family, director of nursing (DON), and administrator were notified, and he was sent to emergency room (ER) at 9:20 p.m., ER visit indicated no major injury, and diagnosis was hip bruise and constipation. During an observation on 12/12/25 at 1:06 p.m., nursing assistant (NA)-B and NA-A entered R1's room with an EZ total lift machine. R1 sat in WC. Loops from sling lift located underneath him were hooked up to the lift machine bar, lifted off wheelchair and transferred to the bed. Pulled down his pants, skin was observed. NA-A identified where the bruises used to be located on right hip, entire length of backside of right upper thigh, and the outer middle right side of his back. No bruises were seen during this observation. R1 stated it hurts when turned onto his right side. During an interview on 12/12/25 at 1:20 p.m., nursing assistant NA-A stated she identified a bruise on R1's backside of his mid-thigh on 11/13/25, looked like a thumb print red/purple and no yellow, looked fresh. She informed the nurse (unsure of which one) on the day shift. NA-A worked again on 11/15/25 and saw big dark purple bruises on his right middle lateral flank round, approximately six inches in diameter, and back of right thigh that covered the entire area from just above his knee to top of his thigh. NA-A had no idea how the bruises occurred. Staff were expected to report a bruise right away to the nurse. During an interview on 12/12/25 at 2:47 p.m., LPN-B stated R1 did not have the best memory but was able to respond appropriately to questions some of the time. R1 stated no one hurt him and she trusted what he said. LPN-B worked on 11/13/25, and learned during report he had a bruise on right hip. No documentation had been written in his chart prior to her assessment. R1 had a purple/red bruise with yellowing around the outside of it approximate size of a 50-cent piece. No open areas. LPN-B informed RN-D of the bruise and was informed weekly skin monitoring would be set up to assess the bruise. LPN-B worked on 11/14/25, and administered Tylenol for right hip pain, did not visually assess the hip. LPNB returned to work on 11/17/25, and was informed R1 had been sent to ER on [DATE]. LPN-B assessed the right hip and identified significant dark purple bruising located on right flank and back of right thigh. LPN-B stated the staff nurse would be expected to report the bruising and investigation started immediately for an unexplained bruise when identified to rule out if he was harmed by anyone to keep residents safe. During an interview on 12/12/25 at 2:11 p.m., licensed practical nurse (LPN)-A stated she identified LPN-B made the first documentation on 11/13/25, in R1's progress notes regarding his bruise and should have been reported right away. On 11/15/25, R1 complained of right hip pain, grimacing, staff indicated he was in pain with transfers, which was unusual for R1, he also had a scratch and a light in color bruise on the lateral side of the right hip. R1's bruises could have been considered suspicious and unknown as to how they occurred.During an interview 12/15/25 at 3:00 p.m. RN-C stated a bruise was documented on 11/13/25, in R1's progress notes located on right hip about four to five inches in diameter. RN-C saw the bruise on 11/15/25, and verified was located on his right hip area only, denied pain, and was not documented. R1's cognition was not intact to be reliable with his memory. Based off the documentation the bruise was not suspicious, R1 did not see an injury occurred. The bruise was from an unknown origin (did not know what caused it) and was reportable to the State Agency within two hours to make sure there was not neglect, or an injury caused by someone. RN-C stated the staff nurse should have notified the director of nursing (DON), administrator, family, and provider sooner. During an interview on 12/15/25 at 3:42 p.m. floor manager RN-D stated staff would have been expected to notify her when bruise was found and right hip pain without relief from interventions. RN-D was made aware of the bruises and right hip pain on 11/17/25, when assessed with his daughter. R1's cognition was severely impaired, and his memory varied. Progress notes on 11/13/25, identified R1 was asked what caused the bruise, and he was able to tell staff he was not hurt. On 11/15/25 at 5:18 a.m., the bruise was found with pain and should have been reported to the state; report was filed late. The investigation should have been initiated right away on 11/15/25, to figure out if he had an injury and which staff worked with him. RN-D was unable to identify what had caused the bruises. During an interview on 12/15/25 at 4:08 p.m., social service director (SSD) stated a resident with a brief interview for mental status (BIMS) rated at a three indicated severe cognitive impairment. R1 would have had difficulty making decisions, short term memory was impacted greatly and the recall after a couple of minutes would have been most likely impossible. R1 responded to questions regarding the bruises but was unable to identify who was involved and was not an accurate historian. Once R1's large bruises were identified they should have been reported to MDH. During an interview on 12/15/25, at 5:15 p.m., DON stated R1 had a severely impaired cognitive memory. DON was if he could have recalled what happened. R1 started having right hip pain on 11/8/25 and was not identified as new. DON found out later R1 was medicated with Tylenol and right hip pain up was up to six, eight, nine or over 10. The nurses reported discomfort in the right hip. The RN should have been notified on 11/13/25, when right hip pain was identified and contacted the provider sooner to make sure there was not anything more serious going such as an injury that would have caused more pain or discomfort. There was more bruising from unknown origin identified on 11/15/25, staff nurse should have notified DON that day, state report should have been filed, and investigation started to protect the residents from possible abuse/neglect and made sure needs were being met. DON was contacted the evening of 11/16/25, informed about additional bruising and unaware of the increase in right hip pain. Facility policy Neglect, and Exploitation dated 8/2/25, identified it was the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. The facility will have written procedures that include Reporting of all alleged violation to the Administrator, state agency, adult protective services, and to all other required agencies within specified time frames: immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury.

Based on observation, interviews and document review the facility failed to thoroughly investigate an allegation of potential resident abuse for 1 of 1 residents (R1) who was found to have an injury of unknown origin. Findings include: R1's annual Minimum Data Set (MDS) dated [DATE], identified entered facility on 10/31/24, from a skilled nursing facility (SNF). He had minimal difficulty with hearing and impaired vision (sees large print, not regular print in newspaper/books). He was severely cognitively impaired without behaviors. He was dependent for toileting hygiene, required substantial/maximal assistance for all transfers, frequently incontinent of bladder, and occasionally incontinent of bowel. Diagnoses included atrial fibrillation (a common heart arrhythmia where the upper chambers (atria) quiver instead of contracting effectively, leading to an irregular and significantly increasing stroke risk) arthritis, Non-Alzhemier's dementia (a group of neurodegenerative disorders, like vascular dementia that affects cognition, behavior, and function often involving blood flow issues (vascular) or protein deposits (Lewy bodies), anxiety, depression, history of falling), anxiety, and depression. Currently taking an anticoagulant (blood thinner, reduces blood clotting, may bruise easily and take longer for bleeding to stop). R1's orders identified on 11/5/25, Apixaban (a blood thinner used to prevent blood clots and stroke) tablet. Give 5mg (milligrams) by mouth two times a day related to paroxysmal Atrial Fibrillation. R1's electronic medication administration record (EMAR) from 11/8/25 through 11/17/25, identified: Tylenol 500 mg was administered three times from 11/8/25 through 1/10/25, for right hip pain ranged from two to four out of 10. Tylenol 1000 mg was administered six times from 11/11/25 through 11/17/25, for right hip pain ranged from three to eight out of 10. R1's care plan dated 12/17/25, identified: all transfers (started 10/9/25) sit to stand with assist of two and as needed (PRN) Hoyer lift for pain or difficulty standing/following directions, resolved on 12/17/25. Transfer (started on 12/17/25) Hoyer lift with 2 assist using the hourglass large sling for all transfers. Potential for falls related to weakness, history of falls, cognitive impairment with impaired safety awareness, visual deficit/blind in right eye, use of psychotropic medications, and impaired balance. Staff were directed to approach from front or left side, floor mat, hi/low bed, toileting schedule, provide a safe environment, gripper socks, anti-reverse brakes on wheelchair, and call don't fall sign place in room and bathroom. He had knee pain due to arthritis, right artificial knee joint and restless leg syndrome (RLS). Impaired cognition related to short term memory problem, time orientation difficulty, and difficulty hearing. Staff were directed to report changes in cognitive status. R1 was a vulnerable adult related to assistance needed for activities of daily living (ADLS), impaired communication and decision-making skills, and impaired mobility. Staff were directed to listed to his concerns and report any inappropriate or suspicious behaviors to the proper authorities. R1's progress notes from 11/10/24, through 11/17/25, identified: -On 11/10/25 at 4:24 a.m., noted during cares an approximate four centimeter (cm) scabbed scratch area noted on right hip located where the edge of the brief touches his skin. -On 11/10/25 at 7:41 p.m., gave 500 mg Tylenol po every six hours PRN for mild pain. R1 grimacing and with rolling and repositioning. Follow-up at 8:49 p.m., effective pain zero out of 10. -11/10/25 at 11:17 p.m., Weekly skin inspection has multiple scabbed areas on right lower extremity and face. No bruising. -11/11/25 at 5:38 p.m., Gave 1000 mg Tylenol po every six hours PRN for moderate to severe pain. R1 jumpy in wheelchair seat at evening meal. Reporting hip pain. Follow-up at 7:57 p.m., effective pain zero out of 10. -11/12/25 at 11:12 a.m., Unable to stand today. -11/13/25 at 2:46 p.m., Bruise noted to right upper groin/hip area red/purple to center and yellowing around edges. He denied cause being from any suspicious or inappropriate behavior. Bruise does not appear suspicious. Denies pain. -11/13/25 at 2:49 p.m., Gave 1000 mg Tylenol po as needed for moderate to severe pain. Complained of right hip pain and facial grimacing. Follow-up at 4:28 p.m., effective pain rated zero out of 10. -11/14/25 at 12:33 a.m., gave 1000 mg Tylenol PRN for moderate to severe pain. Right hip pain. Follow up at 3:08 a.m., effective pain rated zero out of 10. -11/14/25 at 1:50 p.m., Gave Tylenol. Wiggling around in chair and swearing under his breath when he moved a certain way or when he tried to hold up his feet. Pain rated eight out of 10 using PAIN-AD scale (assesses pain in residents with cognitive impairment). Follow-up at 5:23 p.m., effective pain rated zero out of 10. -11/14/25 at 11:40 p.m., Gave Tylenol for moderate to severe pain. Right hip pain. Follow-up at 1:43 a.m., effective pain rated zero out of 10. -11/15/25 at 5:18 a.m., Bruising observed above posterior right knee and extended into upper posterior thigh. No pain with palpitation. -11/15/25 at 9:54 a.m., Gave Tylenol for moderate to severe pain. Right hip pain. Follow up at 12:00 p.m., effective pain rated two out of10. -11/15/25 at 5:28 p.m., Gave Tylenol for complaints of increased right hip pain. Follow up at 7:26 p.m., ineffective. Pain rated six out of 10. Stated his pain was the same or worse since Tylenol administration. Facial grimacing. Has a yellowish brise with deep purple red marks across right hip. -11/15/25 at 9:38 p.m., Right hip bruise was yellowing with areas of dark purple. Appeared slight swollen. Tylenol administered at p.m. meal. Checked in with R1 twice and he stated it did not help much at all. Offered ice/heat, refused. Appeared to be in moderate pain. -11/16/25 at 3:58 p.m., Gave Tylenol for complaints of increased right hip pain. R1 grimacing, groaning. Rates pain at eight to nine out of 10. Noted to position self so he was lying on his left hip, offloading pressure on the right. Large ice pack applied. Follow-up at 6:47 p.m., continued to complain of increased right hip pain. Continuing with ice and repositioning. -11/16/25 at 8:39 p.m., R1 had a large amount of bruising noted to posterior right leg and right anterior hip area. Legs are equal in length. Right hip pain with movement and external rotation, no pain at rest. He did not remember hurting himself stated when you get old you just get fragile, I guess. Phoned daughter and updated, currently on her way to facility to assess if she would like him sent in or not. Per daughter request was sent to ER to have right hip assessed. Provider on-call approved transfer to ER. Left facility via ambulance at 9:20 p.m. -11/17/25 at 12:21 a.m., Returned to facility via ambulance. No signs of pain, no grimacing or verbalization of pain. Received Tylenol at 10:23 p.m. -11/17/25 at 12:08 p.m., daughter visited. Writer evaluated R1's bruising. Deep purple bruising remained to right posterior leg from behind knee to groin area, small scattered red bruising to lateral right thigh and softball sized deep purple bruise to right lower back. Faded bruising to right anterior hip. No c/o pain to back or lower leg. Complained of pain to right outer hip when palpated or pressure placed on area. Unable to lay on right side. No swelling or deformity noted to right hip. Daughter expressed concern that he had fallen and not reported she was unable to figure out how else the bruising occurred. Writer and daughter tried to brainstorm together but unable to determine definitive cause for bruising. He denied anyone hurting him. He will be a Hoyer lift for all transfers as EZ stand transfers are too unsafe. Requested MD [doctor] be contacted for better pain control. -11/17/25 at 12:14 p.m., Fax sent to primary provider (MD) to update on ER visit from last evening and requested pain medication orders. R1's ER visit dated 11/16/25 at 9:43 p.m., identified [R1] presented with concerns about hip pain/bruising. Imaging result on 11/16/25, x-ray of right hip/pelvis. Impression: no definite fracture or dislocation was identified. Diagnoses: contusion (bruise) of right hip. R1's primary provider visit dated 11/19/25, identified the primary driver of the bruising suspected was the apixaban. Does not appear to be concerning for injury. Denied any staff injury, unable to identify how bruises occurred, and felt safe. Continue to monitor closely.Facility 5-day report submitted to the Minnesota Department of Health (MDH) dated 11/19/25 at 4:55 p.m., identified an incident report was submitted on 11/16/25 at 10:34 p.m., regarding an allegation of unexplained injury of unknown source occurred on 11/16/25 at 8:43 p.m. Bruising was noted to posterior right hip, leg and front of hip. Unknown source of origin. He did not know how bruising occurred, no recollection of any recent falls or events that could have caused significant bruising, has a poor memory, on Eliquis, and required assistance of two staff to transfer in an EZ stand lift. Initial bruising (4 to 5 smaller bruises that resulted in a larger bruise) was noted on 11/11/25. Between 11/15/25 p.m. [evening] shift and 11/16/25 at 0430 he remained in bed due to not needing incontinence cares until 0430. At that time the night NA went to assist with cares and noted the bruise went from the bottom of his buttocks to his knee on the right leg. Night nurse was notified, and bruising charting was initiated. On 11/16/25, prior to midnight the NA's noted old bruising on the right hip lighter in color. On 11/16/25, at approximately 8:30 p.m., registered nurse (RN) checked on R1 due to complaints of pain and found the bruising had expanded, darker in color than what was observed on 11/16/25. Some bruising was noted on upper back. Pain was managed by Tylenol 1000 mg, hot/cold packs and repositioning. Family, director of nursing (DON), and administrator were notified, and he was sent to emergency room (ER) at 9:20 p.m. ER visit indicated no major injury, and diagnosis was hip bruise and constipation. During an observation on 12/12/25 at 1:06 p.m., nursing assistant (NA)-B and NA-A entered R1's room with an EZ total lift machine. R1 sat in WC. Loops from sling lift located underneath him were hooked up to the lift machine bar, lifted off wheelchair and transferred to the bed. Pulled down his pants, skin was observed. NA-A identified where the bruises used to be located on right hip, entire length of backside of right upper thigh, and the outer middle right side of his back. No bruises were seen during this observation. R1 stated, it hurts, when turned onto his right side. During an interview on 12/12/25 at 1:20 p.m., NA-A stated she identified a bruise on R1's backside of his mid-thigh on 11/13/25, looked like a thumb print red/purple and no yellow, looked fresh. She informed the nurse (unsure of which one) on the day shift. She worked again on 11/15/25 and saw big dark purple bruises on his right middle lateral flank round, approximately six inches in diameter, and back of right thigh that covered the entire area from just above his knee to top of his thigh. She had no idea how the bruises occurred. Staff were expected to report a bruise right away to the nurse. During an interview on 12/12/25 at 2:47 p.m., licensed practical nurse (LPN)-B stated R1 did not have the best memory but was able to respond appropriately to questions some of the time. R1 stated no one hurt him and LPN-B trusted what he said. She had worked on 11/13/25 and learned during report he had a bruise on right hip. No documentation had been written in his chart prior to her assessment. R1 had a purple/red bruise with yellowing around the outside of it approximate size of a 50-cent piece. No open areas, asked if R1 was harmed and he replied, no. LPN-B informed RN-D of the bruise and was informed weekly skin monitoring would be set up to assess the bruise. LPN-B worked on 11/14/25, and medicated R1 with Tylenol for right hip pain. LPN-B did not visually assess the hip. LPN-B returned to work on 11/17/25 and was informed R1 had been sent to ER on [DATE]. LPN-B assessed the right hip and identified significant dark purple bruising located on right flank and back of right thigh. Staff nurse would be expected to report and start an investigation for an unexplained bruise when identified to rule out if he was harmed by anyone, to keep residents safe. During an interview on 12/15/25 at 2:09 p.m., medical director /primary provider (MD) stated R1's memory and cognition were poor due to dementia. He was able to answer questions about his bruises, denied anything happened, was believable and credible. He was taking Eliquis, would have not taken much trauma/injury and only a bump could have caused the bruising. MD did not have an explanation as to why R1 had bruises in the areas he did. R1 did not have right hip pain prior to the incident. The staff would have been expected to update him on a weekly visit or sooner. MD was not contacted when R1 was sent to ER on [DATE]. MD would have expected staff to notify him of any bruises or hip pain right away so that nothing was missed and concerns were evaluated as soon as possible. When MD arrived at the facility on 11/19/25, while rounds were being completed, he was told R1 needed a follow-up visit after the ER visit. That was the first time MD was informed of right hip pain and bruises. Upon assessment R1 had bruises located on the right hip, buttock, and superior (flank) to the right lateral abdominal wall mildly tender upon palpation. Color of the bruises were typical, purplish with some yellow, indicated maturing which made sense if they were identified around 11/13/25. No abuse suspected but unsure as to how he received the bruises. During an interview on 12/15/25 at 3:42 p.m., floor manager RN-D stated staff would have been expected to notify her when bruise was found and right hip pain without relief from interventions. She was made aware of the bruises and right hip pain on 11/17/25, when assessed with his daughter. R1's cognition was severely impaired, and his memory varied. A licensed practical nurse (LPN)-B documented on 11/13/25, R1 was asked what caused the bruise, and R1 was able to tell staff he was not hurt. The bruise was not measured and should have been. On 11/15/25 at 5:18 a.m., the bruise was found with pain and should have been reported to the state; report was filed late. The investigation should have been initiated right away on 11/15/25, to figure out if he had an injury and which staff worked with him. RN-D was unable to identify what had caused the bruises. R1's bruising with hip pain should have been reported to the provider right away to identify the underlying reason for the pain. During an interview on 12/15/25 at 4:08 p.m., social service director (SSD) stated a resident with a brief interview for mental status (BIMS) rated at a three indicated severe cognitive impairment. R1 would have had difficulty making decisions, short term memory was impacted greatly and the recall after a couple of minutes would have been most likely impossible. R1 responded to questions regarding the bruises but was unable to identify who was involved and was not an accurate historian. Once R1's large bruises were identified they should have been reported to MDH.During an interview on 12/15/25, at 5:15 p.m., DON stated R1 had a severely impaired cognitive memory. DON was if he could have recalled what happened. R1 started having right hip pain on 11/8/25 and was not identified as new. DON found out later R1 was medicated with Tylenol and right hip pain up was up to six, eight, nine or over 10. The nurses reported discomfort in the right hip. The RN should have been notified on 11/13/25, when right hip pain was identified and contacted the provider sooner to make sure there was not anything more serious going such as an injury that would have caused more pain or discomfort. There was more bruising from unknown origin identified on 11/15/25, staff nurse should have notified DON that day, state report should have been filed, and investigation started to protect the residents from possible abuse/neglect and made sure needs were being met. DON was contacted the evening of 11/16/25, informed about additional bruising and unaware of the increase in right hip pain. Facility policy Abuse, Neglect, and Exploitation dated 8/2/25, identified it was the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. An immediate investigation is warranted when suspicion or reports of abuse, neglect, or exploitation occur. Written procedures for investigation include identifying and interviewing all involved persons, including alleged victim, alleged perpetrator, witness es and others who might have knowledge of allegations. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and providing complete and thorough documentation of the investigation.

Based on observation, interview and document review, the facility failed to ensure the physician and representative were notified of increased right hip pain and bruising for 1 of 1 resident (R1) reviewed for injury of unknown origin. Findings include: R1's annual Minimum Data Set (MDS) dated [DATE], identified R1 entered facility on 10/31/24, from a skilled nursing facility (SNF). He had minimal difficulty with hearing and impaired vision (sees large print, not regular print in newspaper/books). He was severely cognitively impaired without behaviors. He was dependent for toileting hygiene, required substantial/maximal assistance for all transfers, frequently incontinent of bladder, and occasionally incontinent of bowel. Diagnoses included atrial fibrillation (a common heart arrhythmia where the upper chambers (atria) quiver instead of contracting effectively, leading to an irregular and significantly increasing stroke risk) arthritis, Non-Alzhemier's dementia (a group of neurodegenerative disorders, like vascular dementia that affects cognition, behavior, and function often involving blood flow issues (vascular) or protein deposits (Lewy bodies), anxiety, depression, history of falling), anxiety, and depression. Currently taking an anticoagulant (blood thinner, reduces blood clotting, may bruise easily and take longer for bleeding to stop). R1's orders from 11/15/25 to 11/20/25, identified: -7/21/25, Acetaminophen (Tylenol) oral tablet. Give 1000 milligrams (mg) by mouth (po) every 6 hours as needed for moderate to severe pain. Do not exceed 3000 mg in 24 hours. Hold dates: 11/17/25 to 11/24/25. -7/21/25, Acetaminophen oral tablet. Give 500 mg by mouth every 6 hours as needed for mild pain. Do not exceed 3000 mg in 24 hours. Hold dates: 11/17/25 to 11/24/25. -11/5/25, Apixaban (a blood thinner used to prevent blood clots and stroke) tablet. Give 5mg by mouth two times a day related to paroxysmal Atrial Fibrillation. -11/15/25, bruise posterior right ( R ) upper leg into thigh. Right hip. Every shift until resolved. Discontinued on 12/17/25. -11/18/25, charting bruising R hip/leg: signs and symptoms (s/s) of improvement, pain, s/s of infection, interventions/treatments every day shift for 14 days. Discontinued on 12/19/25. -11/20/25, charting bruising to R hip/leg and R low back/flank s/s of improvement, pain, s/s of infection, interventions, and treatments every day shift for 14 days. Discontinued 12/4/25.R1's electronic medication administration record (EMAR) from 11/8/25 through 11/17/25, identified: Tylenol 500 mg was administered three times from 11/8/25 through 11/10/25, for right hip pain ranged from two to four on a scale of zero to 10. Tylenol 1000 mg was administered six times from 11/11/25 through 11/17/25, for right hip pain ranged from three to eight on a scale of zero to10. R1's care plan dated 12/17/25, identified: all transfers (started 10/9/25) sit to stand with assist of two and as needed (PRN) Hoyer lift (full body mechanical lift) for pain or difficulty standing/following directions, resolved on 12/17/25. Transfer (started on 12/17/25) Hoyer lift with two assist using the hourglass large sling for all transfers. Potential for falls related to weakness, history of falls, cognitive impairment with impaired safety awareness, visual deficit/blind in right eye, use of psychotropic medications, and impaired balance. Staff were directed to approach from front or left side, floor mat, hi/low bed, toileting schedule, provide a safe environment, gripper socks, anti-reverse brakes on wheelchair, and call don't fall sign place in room and bathroom. He had knee pain due to arthritis, right artificial knee joint and restless leg syndrome (RLS). Impaired cognition related to short term memory problem, time orientation difficulty, and difficulty hearing. Staff were directed to report changes in cognitive status. R1 was a vulnerable adult related to assistance needed for activities of daily living (ADLS), impaired communication and decision-making skills, and impaired mobility. Staff were directed to listed to his concerns and report any inappropriate or suspicious behaviors to the proper authorities. R1's progress notes from 11/10/24, through 11/17/25, identified: -On 11/10/25 at 4:24 a.m., noted during cares an approximate four centimeter (cm) scabbed scratch area noted on right hip located where the edge of the brief touches his skin. -On 11/10/25 at 7:41 p.m., gave 500 mg Tylenol po every six hours PRN for mild pain. R1 grimacing and with rolling and repositioning. Follow-up at 8:49 p.m., effective pain zero out of 10. -11/10/25 at 11:17 p.m., Weekly skin inspection has multiple scabbed areas on right lower extremity and face. No bruising. -11/11/25 at 5:38 p.m., Gave 1000 mg Tylenol po every six hours PRN for moderate to severe pain. R1 jumpy in wheelchair seat at evening meal. Reporting hip pain. Follow-up at 7:57 p.m., effective pain zero out of 10. -11/12/25 at 11:12 a.m., Unable to stand today. -11/13/25 at 2:46 p.m., Bruise noted to right upper groin/hip area red/purple to center and yellowing around edges. He denied cause being from any suspicious or inappropriate behavior. Bruise does not appear suspicious. Denies pain. -11/13/25 at 2:49 p.m., Gave 1000 mg Tylenol po as needed for moderate to severe pain. Complained of right hip pain and facial grimacing. Follow-up at 4:28 p.m., effective pain rated zero out of 10. -11/14/25 at 12:33 a.m., gave 1000 mg Tylenol PRN for moderate to severe pain. Right hip pain. Follow up at 3:08 a.m., effective pain rated zero out of 10. -11/14/25 at 1:50 p.m., Gave Tylenol. Wiggling around in chair and swearing under his breath when he moved a certain way or when he tried to hold up his feet. Pain rated eight out of 10 using PAIN-AD scale (assesses pain in residents with cognitive impairment). Follow-up at 5:23 p.m., effective pain rated zero out of 10. -11/14/25 at 11:40 p.m., Gave Tylenol for moderate to severe pain. Right hip pain. Follow-up at 1:43 a.m., effective pain rated zero out of 10. -11/15/25 at 5:18 a.m., Bruising observed above posterior right knee and extended into upper posterior thigh. No pain with palpitation. -11/15/25 at 9:54 a.m., Gave Tylenol for moderate to severe pain. Right hip pain. Follow up at 12:00 p.m., effective pain rated two out of10. -11/15/25 at 5:28 p.m., Gave Tylenol for complaints of increased right hip pain. Follow up at 7:26 p.m., ineffective. Pain rated six out of 10. Stated his pain was the same or worse since Tylenol administration. Facial grimacing. Has a yellowish brise with deep purple red marks across right hip. -11/15/25 at 9:38 p.m., Right hip bruise was yellowing with areas of dark purple. Appeared slight swollen. Tylenol administered at p.m. meal. Checked in with R1 twice and he stated it did not help much at all. Offered ice/heat, refused. Appeared to be in moderate pain. -11/16/25 at 3:58 p.m., Gave Tylenol for complaints of increased right hip pain. R1 grimacing, groaning. Rates pain at eight to nine out of 10. Noted to position self so he was lying on his left hip, offloading pressure on the right. Large ice pack applied. Follow-up at 6:47 p.m., continued to complain of increased right hip pain. Continuing with ice and repositioning. -11/16/25 at 8:39 p.m., R1 had a large amount of bruising noted to posterior right leg and right anterior hip area. Legs are equal in length. Right hip pain with movement and external rotation, no pain at rest. He did not remember hurting himself stated when you get old you just get fragile, I guess. Phoned daughter and updated, currently on her way to facility to assess if she would like him sent in or not. Per daughter request was sent to ER to have right hip assessed. Provider on-call approved transfer to ER. Left facility via ambulance at 9:20 p.m. -11/17/25 at 12:21 a.m., Returned to facility via ambulance. No signs of pain, no grimacing or verbalization of pain. Received Tylenol at 10:23 p.m. -11/17/25 at 12:08 p.m., daughter visited. Writer evaluated R1's bruising. Deep purple bruising remained to right posterior leg from behind knee to groin area, small scattered red bruising to lateral right thigh and softball sized deep purple bruise to right lower back. Faded bruising to right anterior hip. No c/o pain to back or lower leg. Complained of pain to right outer hip when palpated or pressure placed on area. Unable to lay on right side. No swelling or deformity noted to right hip. Daughter expressed concern that he had fallen and not reported she was unable to figure out how else the bruising occurred. Writer and daughter tried to brainstorm together but unable to determine definitive cause for bruising. He denied anyone hurting him. He will be a Hoyer lift for all transfers as EZ stand transfers are too unsafe. Requested MD [doctor] be contacted for better pain control. -11/17/25 at 12:14 p.m., Fax sent to primary provider (MD) to update on ER visit from last evening and requested pain medication orders. Physical therapy evaluation and plan for treatment dated 11/10/25, identified reason for referral: to evaluate if bed rails are necessary for mobility/transfers, and patient goal: decrease pain. Pain in right hip/deep rated at three out of 10 and skin integrity intact (per notes, had open area along right hip where brief attached). R1 reported increased right hip pain during today's session, limited his ability to complete transfers, and recent decline in functional mobility safety. Required maximum assistance with stand aid to transfer. R1's ER visit dated 11/16/25 at 9:43 p.m., identified presented with concerns about hip pain/bruising. Imaging result on 11/16/25, x-ray of right hip/pelvis. Impression: no definite fracture or dislocation was identified. Diagnoses: contusion (bruise) of right hip. R1's primary provider visit dated 11/19/25, identified the primary driver of the bruising suspected was the apixaban. Does not appear to be concerning for injury. Denied any staff injury, unable to identify how bruises occurred, and felt safe. Continue to monitor closely.Facility 5-day report submitted to the Minnesota Department of Health (MDH) dated 11/19/25 at 4:55 p.m., identified an incident report was submitted on 11/16/25 at 10:34 p.m., regarding an allegation of unexplained injury of unknown source occurred on 11/16/25 at 8:43 p.m. Bruising was noted to posterior right hip, leg and front of hip. Unknown source of origin. He did not know how bruising occurred, no recollection of any recent falls or events that could have caused significant bruising, has a poor memory, on Eliquis, and required assistance of two staff to transfer in an EZ stand lift. Initial bruising (4 to 5 smaller bruises that resulted in a larger bruise) was noted on 11/11/25. Between 11/15/25 p.m. [evening] shift and 11/16/25 at 0430 he remained in bed due to not needing incontinence cares until 0430. At that time the night NA went to assist with cares and noted the bruise went from the bottom of his buttocks to his knee on the right leg. Night nurse was notified, and bruising charting was initiated. On 11/16/25, prior to midnight the NA's noted old bruising on the right hip lighter in color. On 11/16/25, at approximately 8:30 p.m., registered nurse (RN) checked on R1 due to complaints of pain and found the bruising had expanded, darker in color than what was observed on 11/16/25. Some bruising was noted on upper back. Pain was managed by Tylenol 1000 mg, hot/cold packs and repositioning. Family, director of nursing (DON), and administrator were notified, and he was sent to emergency room (ER) at 9:20 p.m. ER visit indicated no major injury, and diagnosis was hip bruise and constipation. During an observation on 12/12/25 at 1:06 p.m., nursing assistant (NA)-B and NA-A entered R1's room with an EZ total lift machine. R1 sat in WC. Loops from sling lift located underneath him were hooked up to the lift machine bar, lifted off wheelchair and transferred to the bed. Pulled down his pants, skin was observed. NA-A identified where the bruises used to be located on right hip, entire length of backside of right upper thigh, and the outer middle right side of his back. No bruises were seen during this observation. R1 stated, it hurts, when turned onto his right side. During an interview on 12/12/25 at 1:20 p.m., NA-A stated she identified a bruise on R1's backside of his mid-thigh on 11/13/25, looked like a thumb print red/purple and no yellow, looked fresh. She informed the nurse (unsure of which one) on the day shift. She worked again on 11/15/25 and saw big dark purple bruises on his right middle lateral flank round, approximately six inches in diameter, and back of right thigh that covered the entire area from just above his knee to top of his thigh. She had no idea how the bruises occurred. Staff were expected to report a bruise right away to the nurse. During an interview on 12/12/25 at 2:47 p.m., licensed practical nurse (LPN)-B stated R1 did not have the best memory but was able to respond appropriately to questions some of the time. R1 stated no one hurt him and LPN-B trusted what he said. She had worked on 11/13/25 and learned during report he had a bruise on right hip. No documentation had been written in his chart prior to her assessment. R1 had a purple/red bruise with yellowing around the outside of it approximate size of a 50-cent piece. No open areas, asked if R1 was harmed and he replied, no. LPN-B informed RN-D of the bruise and was informed weekly skin monitoring would be set up to assess the bruise. LPN-B worked on 11/14/25, and medicated R1 with Tylenol for right hip pain. LPN-B did not visually assess the hip. LPN-B returned to work on 11/17/25 and was informed R1 had been sent to ER on [DATE]. LPN-B assessed the right hip and identified significant dark purple bruising located on right flank and back of right thigh. Staff nurse would be expected to report and start an investigation for an unexplained bruise when identified to rule out if he was harmed by anyone, to keep residents safe. During an interview on 12/12/25 at 2:11 p.m., LPN-A stated she identified LPN-B made the first documentation on 11/13/25, in R1's progress notes regarding his bruise and should have been reported right away. On 11/15/25, he complained of right hip pain, grimacing, staff indicated he was in pain with transfers, which was unusual for him, had a scratch and a light in color bruise on the lateral side of the right hip, and administered Tylenol. Follow-up pain score was two out of 10. R1's bruises could have been considered suspicious and unknown how they occurred. Staff were expected to and should have documented size of bruise, report when identified, and notified provider. He was sent to ER to be evaluated on 11/16/25. LPN-A came back to work on 11/18/25 and she saw a big bruise on R1's right flank side of back approximately 6 inches in diameter, round, the entire back side of the right thigh just above his knee to the top of the thigh, both were dark purple. During an interview on 12/15/25 at 10:40 a.m., family member (FM) stated R1's memory and strength were declining rapidly. When she visited R1 today, he was unable to recognize her partner. While she accompanied him in ER on [DATE], R1 stated he walked outside down the field road from our farm, tripped on the grass, fell and that was how it happened. He would not be able to remember if he fell due to his dementia. On 11/16/25, in the evening, the facility nurse contacted her and was the first time she was made aware R1 had right hip pain and bruises. FM expected staff to have notified her and the provider of right hip pain and multiple bruises prior to 11/16/25, when they were first seen, and hip pain started. FM would have requested he be sent in and checked out sooner. During an interview on 12/15/25 at 2:09 p.m., medical director /primary provider (MD) stated R1's memory and cognition were poor due to dementia. He was able to answer questions about his bruises, denied anything happened, was believable and credible. He was taking Eliquis, would have not taken much trauma/injury and only a bump could have caused the bruising. MD did not have an explanation as to why R1 had bruises in the areas he did. R1 did not have right hip pain prior to the incident. The staff would have been expected to update him on a weekly visit or sooner. MD was not contacted when R1 was sent to ER on [DATE]. MD would have expected staff to notify him of any bruises or hip pain right away so that nothing was missed and concerns were evaluated as soon as possible. When MD arrived at the facility on 11/19/25, while rounds were being completed, he was told R1 needed a follow-up visit after the ER visit. That was the first time MD was informed of right hip pain and bruises. Upon assessment R1 had bruises located on the right hip, buttock, and superior (flank) to the right lateral abdominal wall mildly tender upon palpation. Color of the bruises were typical, purplish with some yellow, indicated maturing which made sense if they were identified around 11/13/25. No abuse suspected but unsure as to how he received the bruises. During an interview 12/15/25 at 3:00 p.m., RN-C stated a bruise was documented on 11/13/25, in R1's progress notes located on right hip about four to five inches in diameter. She laid eyes on the bruise on 11/15/25, and verified bruise was located on his right hip area only, denied pain, and was not documented. His cognition was not intact to be reliable with his memory. Based off the documentation the bruise was not suspicious, RN-C did not see an injury occurred. The bruise was from an unknown origin (did not know what caused it) and was reportable within two hours to make sure there was not neglect, or an injury caused by someone. The staff nurse should have notified the DON, administrator, family, and provider sooner. The nurse would be expected to notify the provider if he had continued/increased pain not relieved by interventions. A fax should have been sent to provider to see if he wanted to do anything different such as interventions. During an interview on 12/15/25 at 3:42 p.m., floor manager RN-D stated staff would have been expected to notify her when bruise was found and right hip pain without relief from interventions. She was made aware of the bruises and right hip pain on 11/17/25, when assessed with his daughter. R1's cognition was severely impaired, and his memory varied. A licensed practical nurse (LPN)-B documented on 11/13/25, R1 was asked what caused the bruise, and R1 was able to tell staff he was not hurt. The bruise was not measured and should have been. On 11/15/25 at 5:18 a.m., the bruise was found with pain and should have been reported to the state; report was filed late. The investigation should have been initiated right away on 11/15/25, to figure out if he had an injury and which staff worked with him. RN-D was unable to identify what had caused the bruises. R1's bruising with hip pain should have been reported to the provider right away to identify the underlying reason for the pain. During an interview on 12/15/25 at 4:08 p.m., social service director (SSD) stated a resident with a brief interview for mental status (BIMS) rated at a three indicated severe cognitive impairment. R1 would have had difficulty making decisions, short term memory was impacted greatly and the recall after a couple of minutes would have been most likely impossible. R1 responded to questions regarding the bruises but was unable to identify who was involved and was not an accurate historian. Once R1's large bruises were identified they should have been reported to MDH.During an interview on 12/15/25, at 5:15 p.m., DON stated R1 had a severely impaired cognitive memory. DON was if he could have recalled what happened. R1 started having right hip pain on 11/8/25 and was not identified as new. DON found out later R1 was medicated with Tylenol and right hip pain up was up to six, eight, nine or over 10. The nurses reported discomfort in the right hip. The RN should have been notified on 11/13/25, when right hip pain was identified and contacted the provider sooner to make sure there was not anything more serious going such as an injury that would have caused more pain or discomfort. There was more bruising from unknown origin identified on 11/15/25, staff nurse should have notified DON that day, state report should have been filed, and investigation started to protect the residents from possible abuse/neglect and made sure needs were being met. DON was contacted the evening of 11/16/25, informed about additional bruising and unaware of the increase in right hip pain. Facility policy Change in Condition Monitoring dated 2/1/24, identified how to inform staff on how to set up monitoring for changes in condition. Procedure: if a resident has a change in condition that was considered abnormal for them such as change in skin condition daily monitoring will be set up. The doctor and family will be updated if appropriate. Facility policy Change in Condition Notification dated 2/1/24, identified direction for staff on when to notify the medical doctor (MD). Procedure: if the resident develops a bruise that cannot be explained, or the resident is on coumadin contact the MD to see if labs should be obtained. Anytime the resident experiences a change from baseline and complains of not feeling well complete an assessment, set up monitoring, and update the MD as indicated.

Based on observation, interview and document review the facility failed to ensure proper assessment of bed rails for 1 of 4 residents (R1) reviewed for siderails. Staff implemented a new mattress on a bed with side rails attached, resulting in R1's head becoming trapped between the mattress and the side rail of the bed. The immediate jeopardy (IJ) began on 4/10/25, at approximately 12:00 a.m., when facility staff replaced the mattress on R1's bed without checking the entrapment zones between the mattress and the side rail resulting in R1's head becoming trapped between the mattress and the siderail. The IJ was identified on 4/17/25, the administrator was notified of the IJ on 4/17/25, at 4:10 p.m. The immediate jeopardy was removed on 4/11/25, and the deficient practice was corrected prior to the start of the survey and was therefore issued at past noncompliance. Findings include: R1's Admission Record indicated he admitted to the facility on [DATE], with diagnosis that included wheezing, pneumonia, sleep apnea and weakness. R1's Safe Patient Handling assessment dated [DATE], identified the use of double half side rails. Initial Siderail/Entrapment assessment dated [DATE], identified the use of side rails for mobility and indicated R1 was able to demonstrate ability to grab side rail and assist in turning and repositioning. The assessment identified the seven potential entrapment zones and was signed as assessed by maintenance staff. R1's Functional Abilities assessment dated [DATE], indicted he required partial to moderate assistance to roll left and right. R1's care plan dated 4/10/25, identified physical limitations in bed mobility related to decreased strength and impaired mobility. The care plan indicated R1 required extensive assistance from one staff for bed mobility. A Fall Note dated 4/10/25, indicated R1 was found lying on his right side next to his bed. R1's head was between the mattress and the siderail facing downward with his continuous positive airway pressure (CPAP) machine on. R1's right hip was resting on the frame of the bed side table with his left knee on the floor. R1 sustained a skin tear on his right elbow and a skin tear on his left elbow and complained of right hip pain. R1's head was removed from between the mattress and the side rail. Staff was unable to assess hip/leg pain due to pain which R1 stated was different from back pain. On 4/16/25 at 11:14 a.m., the bed and mattress involved in the incident were observed with the administrator and maintenance staff (MS)-A. The mattress was an alternating pressure mattress with individual air chambers (baffles) which slid into individual sleeves to hold them in place. At least three of the baffles were not inside the sleeves. The administrator felt the mattress was faulty due to the baffles not being inserted into the sleeves. The administrator stated the facility had made the decision to discontinue using that brand of air mattress. The bed had half side rails attached on both sides of the frame. The observation was conducted in a separate area of the facility as the bed had been removed from R1's room following the incident. During interview on 4/16/25, at 4:14 p.m., R1 said he did not remember what happened and said, I think I got hung up in that bed. R1 said he could not get out of the bed, his legs were tied up, and he remembered his head being stuck between the side rail, and he could not get himself loose. R1 also could not get his CPAP loose from his face. R1 recalled being panicky. During interview on 4/17/25, at 6:34 a.m., registered nurse (RN)-A stated when she arrived for her shift on 4/9/25, two staff from the p.m. shift brought a pump and mattress to the unit and said R1's air mattress had not been holding air. At midnight, staff got R1 up to use the bathroom and RN-A and an unidentified nursing assistant (NA) swapped out the mattress on R1's bed. Around 4:00 a.m. RN-A said she went to give a medication to another resident and said when she returned to the medication cart, she heard a grunt or groan. RN-A walked down the hall and heard the noise again and when she entered R1's room she found him laying with his head between the air mattress and the side rail with his CPAP still on his head. RN- A said she called for help and while waiting tried to get R1's head loose but was initially unable to, it was tight, I could not move it. RN-A said she was going to remove the CPAP but noticed it had been pushed up away from his mouth so she hooked it back up so he could get air. RN-A said she had pushed and pulled and all of the sudden R1's head came loose. R1's leg had been resting on the tray table stand and he complained of pain. During a subsequent observation and interview on 4/17/25, at 10:25 a.m., MS-A performed a bed rail gap test using a bed system measurement device, which identified if the bed rail and mattress are at risk for entrapment, on the bed involved during the incident. The test did not pass at the head of the bed. MS-A said bed rails and entrapment zones were assessed upon implementation and quarterly by the maintenance department. The entrapment zones were not assessed when the mattress was swapped out 4/10/25. Facility policy Proper Use of Bed Rails dated 4/10/25, indicated if bed rails are used, the facility ensures correct installation, use, and maintenance of rails. Side rails will not be used with air mattresses due to the risk of entrapment. The facility will ensure the correct installation of bed rails to include ensuring the bed frame, bed rail and mattress do not leave a gap wide enough to entrap a residents head or body. The past noncompliance immediate jeopardy began on 4/10/25/25. The immediate jeopardy was removed 4/11/25, and the deficient practice corrected after the facility implemented a systemic plan that included the following actions: - Updated policy to include side rails will not be used with air mattresses - Licensed nurses were educated on the side rail policy, Side Rail Assessment, Bed Rail/Mattress Safety Assessment including how to measure for gaps that may cause entrapment. - Education was verified through interview and document review.

Based on interview and document review, the facility failed to establish an on-going infection control program which included comprehensive surveillance of resident infections including, signs and symptoms of infections, an antibiotic timeout (timeframe used after an antibiotic was initiated to ensure appropriate use and effectiveness) was performed and start/stop dates of antibiotics to prevent the spread of communicable disease and infections. This deficient practice had the potential to affect all 46 residents who resided in the facility. Findings include: A review of the facility's infection control surveillance log monthly report dated September - December 2024, revealed the following: -Columns on the log included resident name, the station resident resided on, if symptoms were present on admission, if the patient was hospitalized , date of onset symptoms, diagnosis, site of infection, the results if a culture was obtained, if an antibiotic was ordered, if a culture was re-obtained, precaution to prevent spread of infection, and date the symptoms were resolved. - The facility's current surveillance log lacked tracking necessary data which included: signs and symptoms for each infection, dates cultures were obtained, when the antibiotic was completed, when the antibiotic was discontinued, and when symptoms resolved. -During the month of September 2024, the infection control surveillance log identified nine entries for infections. Five urinary tract infections (UTIs), three probable tooth infections, and one chronic obstructive pulmonary disease (lung condition) (COPD). No signs and symptoms were documented, no antibiotic time out was documented, no dates of when an antibiotic was started, no dates when the antibiotic was discontinued, and no room numbers were used. -During the month of October 2024, the infection control surveillance log identified that five antibiotics had been ordered. One for possible aspiration, one for diverticulitis (inflammation of the colon/anaplasmosis (illness caused by ticks), one for urinary tract infection, one for prophylaxis for nasal packing (prevent complications), and one for possible aspiration. There were no room numbers documented, no signs and symptoms documented, no dates when an antibiotic was started, no date when the antibiotic was discontinued, no antibiotic timeout documented, dates resolved were marked as not applicable (n/a) for a prophylaxis nasal packing and possible aspiration. During the month of November 2024, the infection control surveillance log identified that 12 antibiotics had been ordered. One for a toe infection, two for chronic obstructive pulmonary disease (COPD), two for respiratory infection, one for cystitis (inflammation of the bladder), two for cellulitis (bacterial skin infection), two for yeast infections, and two for urinary tract infection. No room numbers were used, no signs and symptoms were documented, no start dates for antibiotics, no stop dates for antibiotics and no antibiotic timeouts. The date resolved was left blank for the yeast infection. -During the month of December 2024 the infection control surveillance log identified one antibiotic was ordered, the date of onset was 12/2/24, the diagnosis was for respiratory symptoms, the site of infection was respiratory, no culture was documented, no start date for an antibiotic, no antibiotic stop date, no antibiotic timeout was documented and no room number was documented. The date resolved is blank. During an interview on 12/11/24 at 11:24 a.m., infection preventionist (IP) stated she was responsible for overseeing the facility's infection control program and maintaining the facility's infection control surveillance log. IP confirmed the facility's current surveillance log lacked necessary data which included; signs and symptoms for each infection, dates of cultures obtained, when an antibiotic was started, when an antibiotic was discontinued, if an antibiotic timeout was done, and when symptoms resolved. IP confirmed the date resolved was typically the time frame when the antibiotic regimen was completed not the time the symptoms or infections were resolved. During an interview on 12/11/24 at 1:10 p.m., director of nursing (DON) stated the IP was responsible for overseeing the facility infection control program and maintaining the facility's infection control surveillance log. DON confirmed the facility's current surveillance log lacked necessary data which included signs and symptoms for each infection, dates of cultures obtained, when the antibiotic was started, when the antibiotic was discontinued, if an antibiotic timeout was completed, and when symptoms resolved. The DON stated the expectation would be to have the surveillance log completed according to national standards to help prevent the spread of infectious diseases and infections A policy titled Infection Prevention and control manual dated 8/23/24, revealed essential elements of a surveillance system included: Standardized definitions and listing of the symptoms of infections based upon national standards of practice. Sources of relevant data that can be used for outcome surveillance for infections, antibiotic use and susceptibility may include: -monitoring a resident with a fever or other signs that may indicate an infection, -laboratory cultures or other diagnostic test results consistent with potential infections to detect clusters, -trends, or susceptibility patterns, -antibiotic orders, -laboratory antibiograms (antibiotic susceptibility profiles), -medication regimen review reports. -The infection preventionist collects and reviews data on an ongoing basis including: -elevations in temperatures/ presence of fever, -purulent drainage, -culture results or other diagnosis test results consistent with potential infections, -change in x-ray results consistent with possible infection, -increased falls, -change in mental status, -change in vital signs, -signs and symptoms of infection based upon nationally accepted surveillance definitions (i.e. CDC/[NAME] position statement: surveillance definitions of infections in long-term care facilities: revisiting the McGeer Criteria or NHSN). The infection preventionist would ensure data collection to complete a comprehensive monthly infection control log for surveillance activities on: -The infection site, -pathogen (if known), -signs and symptoms (which the surveillance log did not include) -resident location (room numbers not used, only what station they were on) -summary and analysis of number of residents and/or staff with infections, -observations of staff adherence to policies and procedures, -identification of outcomes that were unusual or unexpected that could potential lead to patterns, treads or outbreaks. The infection preventionist or designee would be able to identify any necessary interventions in order to identify trends or clusters for actions, the infection preventionist would keep an updated map of infections to identify any clusters or trends.

Based on observation, interview and document review, food was not served in a sanitary manner for 15 residents who dined in the north dining area, observed during dining services. In addition, the facility failed to maintain the ice machine in a sanitary manner to prevent potential illness for 15 residents who currently received ice from the ice machine in the north dining area. Further, the facility failed to maintain proper holding food temperatures for 13 of 17 residents observed to receive egg salad sandwiches. These deficient practices had the potential to cause foodborne illness. Findings include: FOOD SERVICE During an observation on 12/10/24 at 12:06 p.m., dietary aide (DA)-A washed her hands in the north kitchen, applied gloves to both hands, picked up an i-pad with resident dietary information on it and placed it on the counter next to the steam trays. DA-A opened a drawer with her left hand, removed utensils from the drawer with both hands and placed utensils into each food item on the steam tray area. DA-A proceeded to open a bag of buns, touched the i-pad with her left hand, picked up a baked potato with her right hand and placed the potato onto a plate. DA-A opened the potato with both hands and a knife and placed other food items on the plate with utensils and handed the plate to the server. DA-A touched the i-pad with her left hand, picked up a bun with her left hand and placed onto the plate. DA-A picked up a baked potato with her right hand, placed onto the plate, opened the potato with both hands and a knife, then placed other food items on the plate with utensils and handed the plate to the server. DA-A continued to touch the i-pad in between each resident served, picked up a bun and or a baked potato with her gloved hands for all residents who received a bun and or baked potato. DA-A then opened a kitchen cupboard with the same gloved hand, removed a salt shaker and handed it to the server. DA-A continued to touch the i-pad in between each resident's meal setup, placed a bun and or baked potato onto residents plates for the remaining of the lunch meal wearing the same pair of gloves. At no time during the observation did DA-A wash hands and re-apply new gloves. During an interview on 12/10/24 at 1:40 p.m., DA-A confirmed she touched the i-pad frequently throughout the meal service, touched the cupboard/drawer and then touched the buns and baked potatoes while wearing the same pair of gloves and without washing her hands. DA-A stated the i-pad was to be cleaned after each shift with an alcohol wipe and the i-pad had not been cleaned prior to meal service. DA-A stated other staff used the i-pad during the day to assist residents with deciding their meals for each day. DA-A stated the cupboards and drawers were not on a schedule to be cleaned. DA-A stated staff should not touch food with gloved hands if the gloves have touched other objects as germs could get onto the residents food. During an interview on 12/10/24 at 1:55 p.m., dietary manager (DM) verified the expectation of staff would be to wash hands and change gloves when the staff touched non-food items. DM confirmed it was important to prevent the spread of germs to the residents and could cause food-borne illness. ICE MACHINE During an observation of the north kitchen area on 12/10/24 at 11:27 a.m., the ice and water machine spouts on the ice machine had a white powder substance approximately one fourth to one half an inch in height around the entire inside and outside of both spouts. In addition, there was a white powder substance present expanding across the entire drain plate below the ice and water spouts. During an interview on 12/10/24 at 1:55 p.m., DM confirmed a white powder substance was present on the ice and water spouts of the ice machine. DM stated the facility had issues with the ice machine leaking. DM stated there was no cleaning process in place for the ice machine. DM stated the white powder substance had the potential to spread germs to the residents. During an interview on 12/11/24 at 8:56 a.m., maintenance staff stated the ice machine dripped when the ice melted and the machine was cleaned every three months. Maintenance staff stated the facility did not keep a log to verify cleaning of the ice machine. Maintenance staff stated the white powder substance could have bacteria present and residents could develop illness as a result. FOOD TEMPERATURE During an observation on 12/9/24 at 4:45 p.m., DA-B entered the north kitchen with a cart of food from the main kitchen. DA-B placed hot food items on the steam trays and proceeded to obtain beverages and fruit cups from the fridge and delivered to each resident table. DA-B placed a plastic tray with six egg salad sandwiches from the cart on the counter next to the steam tray and placed a small bowl of egg salad on the counter next to the sandwiches. During continued observation at 5:12 p.m., DA-B temped the egg salad in the bowl at 50 degrees. DA-B temped an egg salad sandwich at 55.7 degrees. DA-B started to place an egg salad sandwich onto a resident place when surveyor intervened and asked DA-B what the recommended temperature for cold food would be. DA-B looked at the facility food temp log to see what the recommended cold food holding temperature should be. DA-B then placed the egg salad bowl and sandwiches in the freezer. During an observation on 12/9/24 at 5:19 p.m., three and a half egg salad sandwiches were on the center counter on a plastic tray in the main kitchen. The cook temped the egg salad sandwich at 51.6 degrees. During an interview on 12/9/24 at 5:44 p.m., the cook stated the egg salad sandwiches were removed from the walk in fridge prior to food service and placed onto the center counter. The cook stated cold sandwiches were usually placed on a plastic tray and served from the center counter. The cook verified cold sandwiches were not put on ice. The cook stated cold food items holding temperature should be under 41 degrees to prevent residents from becoming ill. During an interview on 12/10/24 at 9:22 a.m., DM confirmed the expectation staff were to temp foods prior to serving and if a cold food was not in the recommended holding temperature, staff would place the food back in the fridge and re-temp prior to serving. DM stated the process was important to prevent foodborne illness. During an interview on 12/11/24 at 10:26 a.m., dietician confirmed the expectation staff would be to have cold foods on an ice-bath during food service. Dietician verified it was important to maintain holding temperatures, to prevent foodborne illness and bacteria growth, and to ensure quality of food for the residents. The Food and Drug Administration food code identified the danger zone refers to the range of temperatures at which bacteria can grow between 40 degrees Fahrenheit (F) and 140 degrees F. For food safety, keep food below or above the danger zone. A facility policy titled Food Safety Requirements dated 1/25/23, food service safety referred to handling, preparing, and storing food in ways that prevented foodborne illness. Staff would monitor food temperatures while holding for delivery to ensure proper hot and cold holding temperatures were maintained. Staff would refer to the current Food and Drug Administration (FDA) food code and facility policy for food temperatures. Foods and beverages would be distributed and served to residents in a manner to prevent contamination and maintain food at the proper temperature and out of the Danger Zone. Staff would not touch food with bare hands, exhibiting appropriate use of gloves. Gloves would be worn when directly touching ready-to-eat foods. A facility policy titled Sanitization of I-Pad Screen dated 10/3/23, identified staff were to clean the screen, sides, and back of the I-pad with an alcohol wipe before and after each meal and let air dry. A facility policy titled Ice Chests and Machines undated, identified the facility was to keep the ice machine clean and sanitary to prevent contamination. The ice machine would be drained, cleaned and sanitized according to manufacturer's specification. The tray would be run through a dishwasher or sterilized daily. A manufacturer form provided by the facility titled Scotsman Ice Systems dated September 2020, identified over time the drip tray and cup rest/spouts may become coated with scale or dirt. They could be removed and scrubbed in a sink. The spouts/chutes and drip tray were to be washed and to use ice machine scale remover if needed to dissolve scale. Recommended cleaning the ice machine every six months and more frequent cleanings may be required based on the mineral content of the water, run time and potential airborne contamination.

Based on interview and document review, the facility failed to ensure proper placement of a lift sling for the ceiling (overhead) mechanical lift for 1 of 3 residents (R1) reviewed for accidents. This resulted in harm for R1 when she fell from the mechanical lift and sustained a left rib fracture. This deficient practice is being cited at past non-compliance related to corrective action taken to ensure proper placement of the lift slings when using mechanical lifts prior to the survey. Findings include: R1's annual Minimum Data Set (MDS) dated [DATE] indicated R1 had a severe cognitive impairment, and was totally dependent on staff for all cares and transfers. The MDS indicated R1 had diagnoses of stroke, hemiplegia (one-sided paralysis), vascular dementia, and anxiety. R1's care plan indicated transferring required two staff with ceiling or Hoyer (mechanical) lift. Care plan indicated R1 had a fall on 1/28/24, requiring monitoring for 72 hours after the fall. A Fall Note dated 1/28/24, indicated R1 was being transferred from the bed to the wheelchair with the ceiling lift. While moving R1 in the lift and off of the bed and over to her wheelchair, she fell out of the sling to the left and onto the floor. A nursing assistant (NA) was holding R1's feet prior to the fall, and another NA was behind the wheelchair getting ready to position R1 into the wheelchair. After the fall it was noted the leg strap on the lift sling on the R1's right side was not hooked to the ceiling lift. On 1/28/24 a written statement by the administrator indicated registered nurse (RN)-C indicated the most likely scenario of how the accident happened was one of the employees did not hook one of the left sling straps to the ceiling lift. The employee likely was bearing some of the weight of R1's leg as the nursing assistants (NA) were transferring the resident. As the NA stopped bearing the weight of the leg during the transfer, R1 likely fell out of the sling. The nurses trying to recreate the accident stated had the NA not lifted the leg, the resident most likely would have slid out of the sling immediately. On 1/29/24 a written statement by RN-B indicated NA-B confirmed when R1 fell to the floor, the leg portion of the sling on the right was not in the hook. R1 was about 40 inches in the air before she fell . On 1/29/24 at 7:44 a.m., a progress note indicated R1 was complaining of pain. R1 was guarded with positioning and refused to roll to her side. R1 was sent to the emergency room (ER) to rule out injury. A Hospital ER Visit Summary note dated 1/29/24, indicated R1 presented to the ER after suffering an accidental fall out of a mechanical lift cradle yesterday (1/28/24). R1 was diagnosed with a closed fracture of one rib on her left side. R1 was discharged back to the facility on [DATE], with orders for Tylenol as needed for pain. On 1/30/24 at 3:18 a.m., a progress note indicated R1 had a headache and pain. R1 was administered Tylenol for pain, and an ice pack was placed on her ribs. The note continued to indicate R1 was having difficulty rolling side to side in bed due to pain. On 1/30/24 at 7:54 p.m., a progress note indicated R1 was very anxious with transfers using the ceiling lift. R1 complained of severe posterior, left-sided, mid-thoracic pain. When transferring and repositioning/rolling from side-to-side in bed R1 yelled, Don't touch me! On 1/31/24 at 3:11 p.m., a progress note indicated R1 had complained of pain to left rib area due to rib fracture. R1 was using Tylenol, ibuprofen, ice packs and repositioning for discomfort. These interventions provided some relief but R1 complain of pain and discomfort with repositioning and transfers. On 1/31/24 at 11:09 a.m., NA-A stated she and NA-B hooked the loops to the ceiling lift when transferring R1 on 1/28/24. NA-A stated NA-B assisted to lift R1's feet as they moved R1 in the direction of her wheelchair, and that was when R1 fell to the floor on her left side. NA-A stated she did not know how R1 fell . NA-A stated she could not recall if the loops for the sling were attached to the ceiling lift at the time of the incident. On 1/31/24 at 1:37 p.m., NA-B stated she and NA-A hooked the loops to the ceiling lift. NA-B stated as they were moving R1 in the lift to her wheelchair, R1 began to fall to the floor between the wheelchair and the bed. NA-B stated she was trying to hold R1's left leg as she began to fall. NA-B stated R1 fell to the ground landing on her left side. On 1/31/24 at 4:32 p.m., licensed practical nurse (LPN)-A stated she was called to R1's room on 1/28/24, following a fall from the ceiling lift. LPN-A stated R1 was on the floor when she arrived. LPN-A stated the sling was already unhooked from the ceiling lift when she entered the room, but NA-B explained the loop for the left leg had come off. LPN-A stated she worked with R1 on 1/29/24, and accompanied R1 to the ER due to increased pain. LPN-A stated R1 was diagnosed with a left rib fracture, advised to take Tylenol for pain, and returned to the facility on [DATE]. On 2/1/24 at 10:25 a.m., the DON stated R1 had not had a change in her level of dependency with activities of daily living (ADLs) following the incident. R1 continued to be dependent on two staff for all ADLs. A facility document EZ Lift (Hoyer) Operation dated 6/29/22, directed once there is tension on the loops (of the sling), double check to make sure that they are securely in the hooks. The facility implemented a systemic plan that included the following actions: Review of the EZ Lift (Hoyer) Operation policy for all staff who used these lifts. NA-A was retrained on the use of the ceiling lifts and competency was conducted on 1/28/24. NA-B was retrained on the use of ceiling lifts and competency was conducted on 1/29/24. Ceiling lift re-education and competency was completed with all direct care staff before they cared for any residents. This was verified through observation, interview and document review on 1/31/24.

Based on observation, interview, and document review, the facility failed to ensure grievances forms and procedures were posted in prominent locations throughout the facility for residents and resident representatives to file grievances anonymously if desired, for 5 of 5 residents (R17, R40, R37, R31, R5) reviewed for grievances. Findings include: On 1/9/24 at 2:00 p.m., a resident council meeting was held with five residents who attended. All five residents, R17, R40, R37, R31, and R5, confirmed they were not aware of how to file a grievance at the facility or how to file one anonymously. During an observation on 1/9/24 at 2:30 p.m., a walk-through of the facility was conducted. The walk-through revealed there were no grievances forms or procedures posted for residents or resident representatives to refer to. During an interview on 1/9/24 at 2:34 p.m., nursing assistant (NA)-C, indicated a resident would go to social services staff to have a grievance filed. During an interview on 1/9/24 at 3:43 p.m., licensed practical nurse (LPN)-A stated grievance forms were kept in both nurses' stations in the filing drawer and indicated residents could receive a grievance form to complete upon request. During an interview on 1/9/24 at 3:47 p.m., registered nurse (RN)-B stated grievance forms were kept in both nurses' stations in the filing cabinet. RN-B indicated residents could receive a grievance form upon request and indicated residents were not able to complete a grievance form anonymously. During an interview on 1/9/24 at 3:56 p.m., social worker (SW)-A indicated residents would have to verbally ask for a grievance form when they wanted to file a grievance. SW-A stated she was not aware of how a resident could file a grievance anonymously. During an interview on 1/10/24 at 11:15 p.m. activity director (AD)-A stated SW-A would assist residents in completing a grievance form when they wanted to file a grievance. AD-A stated residents would have to request a grievance form. AD-A stated she was not aware of how a resident could file a grievance anonymously. During an interview on 1/10/24 at 11:28 a.m., director of nursing (DON) stated that SW-A, or a nurse would provide a grievance form to a resident upon request. DON stated SW-A would follow up with the resident regarding a grievance. DON was not aware of how a resident could file a grievance anonymously. Facility policy titled grievance policy and procedure dated 3/7/23, identified forms were located in the social service office, nursing policy and procedure manual, and in the business office. The policy lacked identification of posting in prominent locations thought the facility, and instructions how to file a grievance anonymously.

Based on observation, interview and document review, the facility failed to ensure infection control practices such as hand hygiene, avoiding contamination of utensils during a water pass, and ensuring the personal laundry was transported in a manner that prevented risk of contamination for 2 of 5 hallways observed for linen transportation. In addition, the facility failed to ensure the spout of the coffee machine in that facility's kitchen was free of build up. Findings include: Review of Centers for Disease Control (CDC ) guidance, Appendix D - Linen and Laundry Management updated 5/4/23, identified linens must be sorted, packaged, transported, and stored in a manner that prevented risk of contamination by dust, debris, soiled linens or soiled items. In addition, CDC Handwashing in Communities: Clean Hands Save Lives updated 7/18/22, identified handwashing is the most important thing to prevent food poisoning. During an observation on 1/9/24 at 9:24 a.m., in the 400 hallway nursing assistant (NA)-A pushed a cart that contained glasses, water pitchers and an uncovered cooler with ice down the hallway. NA-A proceeded to use a scoop to place ice in five glasses. NA-A removed a water pitcher and glass of ice from the cart and placed the water pitcher and glass in R10's room. NA-A returned to the hallway,sanitized hands and removed another glass with ice and a water pitcher off the cart and placed the water pitcher and glass in R28's room. NA-A returned to the hallway, sanitized hands and removed a water pitcher and glass with ice from the cart and placed the water pitcher and glass in R 23's room. NA-A returned to the hallway, sanitized hands and removed a glass with ice and water pitcher off the cart and placed the water pitcher and glass in R8's room. During a continuous observation on 1/10/24 at 10:13 a.m., resident support staff (RS) pushed a cart down the 300 hallway that contained glasses, water pitchers, plastic spoons which were in one of the glasses and an uncovered cooler with ice. RS placed the cart with the uncovered cooler in the 400 hallway. RS did not perform hand hygiene and grabbed an uncovered plastic spoon from the glass. While holding the spoon by the bowl and the heel ( the concave part of the spoon that is used to eat from), RS proceeded to walk down the hallway to the dining room approximately 150 feet to obtain a packet of thickener. RS walked approximately 150 ft. back to the cart, emptied the thickener into a glass which contained water from the cart and used the spoon she had been holding in her hand to mix the thickener into the glass of water. RS delivered the glass of thickened water to R22. RS returned to the cart, used the scoop from the cart to place ice from the uncovered cooler into a glass, grabbed a water pitcher from the cart and placed the water pitcher and glass in R10's room. RS returned to the cart, used the scoop to place ice from the uncovered cooler into a glass, grabbed a water pitcher from the cart and placed the water pitcher and glass in R23's room. RS returned to the cart, used the scoop to place ice from the uncovered cooler into a glass, grabbed a water pitcher from the cart and placed the water pitcher and glass in R8's room. RS returned to the cart, used the scoop to place ice from the uncovered cooler into a glass, grabbed a water pitcher from the cart and placed the water pitcher and glass in R41's room. At 10:26 a.m., RS proceeded to move the cart with the uncovered cooler down the hallway as two visitors walked past the cart. RS placed the cart with the uncovered cooler in the 500 hallway. RS removed a glass from the cart, used the scoop to place ice from the uncovered cooler into the glass, grabbed a water pitcher from the cart and placed the water pitcher and glass in R6's room. RS returned to the cart, used the scoop to place ice from the uncovered cooler into a glass, grabbed a water pitcher from the cart and placed the water pitcher and glass in R26's room. RS pushed the cart with the uncovered cooler down the hall as a visitor walked past the cart. RS used the scoop to place ice from the uncovered cooler into a glass, grabbed a water pitcher from the cart and placed the water pitcher and glass in R42's room. RS returned to the cart, used the scoop to place ice from the uncovered cooler into a glass, grabbed a water pitcher from the cart and placed the water pitcher and glass in R16's room. RS returned to the cart, used the scoop to place ice from the uncovered cooler into a glass, grabbed a water pitcher from the cart and placed the water pitcher and glass in R39's room. At no time, did RS perform hand hygiene during the above observation. During an observation on 1/10/24 at 11:59 a.m., an uncovered cart which contained residents' personal laundry was present in the 300 hallway. Laundry aide (LA) exited R14's room, did not perform hand hygiene and proceeded to push the uncovered laundry cart down the hall as staff and residents walked past the cart. LA-A removed laundry from the uncovered cart and placed the laundry in R37's closet. LA-A pushed the uncovered laundry cart down the hallway past staff and residents. LA-A removed laundry from the uncovered cart and placed the laundry in R35's closet. LA-A did not perform hand hygiene and removed laundry from the uncovered cart and placed the laundry in R45's closet. At no time, during the observation did LA-A perform hand hygiene. During an interview on 1/10/24 at 10:41 a.m., nursing assistant (NA)-A stated while he was passing water to the residents on 1/9/24, the cooler which contained ice had not been closed. NA-A stated his usual practice was to place the cover on the cooler after obtaining ice however he had forgotten to place the cover on the cooler. During an interview on 1/10/24 at 10:32 a.m., RS verified she had touched the bowl and the heel of the spoon that was used to stir thickener in a glass of water for R22. RS confirmed she had not performed hand hygiene or placed the cover on the ice cooler while passing water on 1/10/24. RS stated her usual practice was to sanitize hands when she exited a resident room and to leave the ice uncovered so she was able to complete the water pass faster. RS indicated she should have only touched the handle of the spoon that she used to stir the thickener for R22. During an interview on 1/10/24 at 12:00 p.m., LA-A verified the laundry cart had been uncovered while she passed laundry. LA stated she had been told the laundry cart could remain open while she passed the laundry. LA indicated the expectation was that hand hygiene would have been performed after exiting each room. During an interview on 1/10/24 at 12:47 p.m., laundry supervisor (LS) indicated she was not aware laundry was being delivered in an uncovered cart. LS stated her expectation was laundry would have been covered while being delivered and staff would have performed hand hygiene before and after passing linen to resident rooms. During an interview on 1/10/24 at 12:51 p.m., infection preventionist (IP) stated infection control practices such as hand hygiene, holding utensils by the handles, covering the ice cooler and covering the laundry were important strategies to prevent the spread of infection and food borne- illness. IP indicated her expectation was that hand hygiene would have been performed, staff would hold utensils by the handles only and that the ice and laundry would have been covered. During an interview director of nursing (DON) stated staff were expected to perform hand hygiene when passing water or linen. DON stated staff should only be touching utensils by the handle. DON indicated staff were expected to cover the ice cooler and the linen cart when passing water and linen. A facility policy titled Food Safety Requirements dated 1/25/23, indicated food would be stored, prepared, distributed and served in accordance with professional standards for food safety. Identified staff would wash hands prior to handling clean dishes, and handle them by outside surfaces or touch only the handles of utensils and all food should be covered when traveling a distance such as down a hallway or to a different unit. A facility policy titled Clean Linen Handling undated, indicated all clean linen handling would be performed in a manner to minimize the potential for infection in residents, staff and visitors. Identified clean linen would be transported to the areas of use in a covered container. . . 49620 On 1/8/24 at 6:32 p.m., during the initial tour of the kitchen, the coffee machine was observed to have a white/green powdery substance build up on the right spout outlet. On 1/9/24 at 9:04 a.m., during a kitchen tour with the dietary manager (DM), the coffee machine in the kitchen was observed and the right spout outlet was covered with a white and green powder substance. The DM stated there were two spouts on the machine, the left spout was for coffee and the right spout was for hot water. On 1/10/24 at 7:42 a.m., cook-A stated the right spout of the coffee machine was for hot water only and it was drained every morning by the nursing assistant. The coffee machine was observed to have a white/green powdery substance build up on the right spout. During an interview on 1/10/24 at 7:46 a.m., the DM stated the coffee machine was wiped down weekly with a cloth and the water drained daily in the morning by the nursing assistant. When asked if the outlet spouts were cleaned, the DM stated the facility did not clean the spouts on the outside of the machine. The DM was unaware of a policy or procedure for cleaning the coffee machine. The DM was observed to touch the right spout on the coffee machine and scraped it with her fingernail. A white and green powdery looking substance flaked off some pieces onto the counter area and the rest of the white and green powder looking substance was adhered to the spout. During an interview on 1/10/24 at 3:05 p.m., the director of nursing (DON) verified her expectation was that staff would follow the manufacturer's recommendations for cleaning the coffee machine. The DON was unaware of a facility policy for cleaning the coffee machine. The DON indicated the unclean spout could result in an infection control issue and residents could develop a food borne illness as a result. Per the Cafitesse Quantum 11 Operator manual provided by the facility indicated the external parts of the coffee machine were to be cleaned daily with a damp, clean cloth and rinsed off with clear water. in addition, the manual recommended to clean and flush the drink outlets once a week. A facility policy was requested and one was not provided.

Based on interview and document review, the facility failed to help reduce unnecessary antibiotic use and reduce potential drug resistance for 1 of 2 residents (R16) reviewed for unnecessary medication. Findings include: The Center's for Disease Control and Prevention (CDC)'s Core Elements Of Antibiotic Stewardship For Nursing Homes, dated 2015, included recommendations to identify clinical situations which may be driving inappropriate use of antibiotics and implement specific interventions to improve use, as well as pharmacists could provide assistance in ensuring antibiotics were ordered appropriately. R16's quarterly Minimum Data Set (MDS) dated [DATE], identified R16 had moderate cognitive impairment and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R16's MDS indicated R16 required extensive assistance with bed mobility, transfers, toilet use, dressing and personal hygiene. R16's MDS identified R16 had received antibiotics seven of the last seven days. R16's care plan last revised 8/8/22, identified R16 required limited to extensive assistance of one staff for hygiene, dressing and bathing. R16's care plan lacked information related to the use of prophylactic antibiotics. Review of R16's Order Summary Report signed 10/5/22, identified R16's orders included: -[MEDICATION(S)] (antibiotic) tablet, give 100 milligram (mg) by mouth two times a day for prophylaxis (taken to prevent infection) per orthopedic physician (OP)-A (physician who specializes in musculoskeletal issues involving bones, muscles, joints, tendons and ligaments) with start date of 11/23/21, and no end date. Review of R16's Consultant Pharmacist Medication Review from 12/22/2021, to 9/26/22, identified the following: -12/22/21, no comments or recommendations related to R16's antimicrobial prophylaxis use of [MEDICATION(S)] -1/28/22, no comments or recommendations related to R16's antimicrobial prophylaxis use of [MEDICATION(S)] -2/25/22, no comments or recommendations related to R16's antimicrobial prophylaxis use of [MEDICATION(S)] -3/26/22, no comments or recommendations related to R16's antimicrobial prophylaxis use of [MEDICATION(S)] -4/27/22, no comments or recommendations related to R16's antimicrobial prophylaxis use of [MEDICATION(S)] -5/26/22, no comments or recommendations related to R16's antimicrobial prophylaxis use of [MEDICATION(S)] -6/13/22, no comments or recommendations related to R16's antimicrobial prophylaxis use of [MEDICATION(S)] -6/24/22, no comments or recommendations related to R16's antimicrobial prophylaxis use of [MEDICATION(S)] -7/29/22, no comments or recommendations related to R16's antimicrobial prophylaxis use of [MEDICATION(S)] -8/25/22, no comments or recommendations related to R16's antimicrobial prophylaxis use of [MEDICATION(S)] -9/26/22, no comments or recommendations related to R16's antimicrobial prophylaxis use of [MEDICATION(S)] R16's Consultant Pharmacist Medication Reviews lacked documentation of review of continued prophylactic antibiotic use. Review of R16's medication administration records (MARs) reviewed from 9/1/22, to 10/11/22, identified the following: -9/1/22, to 10/11/22, R16 received [MEDICATION(S)] two times a day. Review of R16's physician visit note dated 10/5/22, revealed R16's orders and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The notes lacked documentation the risks and benefits of continued long term antibiotic use had been reviewed and discussed. During a telephone interview on 10/12/22, at 10:10 a.m. R16's primary care physician (PCP)-A confirmed he served as the facility's medical director and was involved in the facility's antibiotic stewardship program. PCP-A stated the facility's goal was to decrease prophylactic antibiotic use. PCP-A indicated R16 had been receiving [MEDICATION(S)] when admitted to the facility and he was unsure why R16 continued to receive [MEDICATION(S)] prophylactically. PCP-A stated the antibiotic should have been discontinued as it was important to prevent R16 from developing resistance to antibiotics. During a telephone interview on 10/12/22, at 11:20 a.m. pharmacy consultant (PC)-A indicated R16 previously had an infection related to an orthopedic ( a branch of medicine, involving musculoskeletal issues which involve bones, muscles, joints, tendons and ligaments) procedure and R16 was placed on prophylactic [MEDICATION(S)] by OP-A at that time. PC-A confirmed pharmacy recommendations had not been made regarding R16's continued prophylactic antibiotic use of [MEDICATION(S)]. PC-A stated long term prophylactic use of antibiotics was not recommended as it has been known to cause antibiotic resistance. During an interview on 10/12/22, at 11:57 a.m. infection preventionist (IP)-A confirmed R16 had been admitted to the facility on [MEDICATION(S)] for prophylaxis. IP-A stated she tracked all antibiotics used in the facility and confirmed the facility had not reviewed the rationale for R16 to continue on the prophylactic antibiotic. During an interview on 10/12/22, at 1:00 p.m. director of nursing (DON) confirmed R16 was on a prophylactic antibiotic. DON stated her expectations were the facility would have reviewed the rationale for R16's continued prophylactic antibiotic use. The facility policy titled St. Williams Living Center Antibiotic Stewardship Policy, revised 9/15/22, identified the facility mission was to promote the appropriate use of antibiotics to treat infections and reduce possible adverse events associated with antibiotic use. The policy identified the physician, nursing and pharmacy leads were responsible for promoting and overseeing antibiotic stewardship activities. The policy identified the facility would monitor antibiotic use, stewardship actions and outcomes related to antibiotic use in order to guide practice change and track antibiotic stewardship program impact. The policy indicated antibiotic data would be tracked by infection preventionist (IP) and reviewed by the consulting pharmacist, then IP would interpret the monthly data, define any necessary action steps and compile the information for the monthly antibiotic stewardship program report. The policy identified the antibiotic stewardship team (AST) would identify actions to directly impact inappropriate antibiotic use including the use of antibiotics for prophylactic indications.

Based on observation, interview and document review, the facility failed to provide assistance to ensure hearing aids were available to maintain hearing/communication needs for 1 of 1 resident (R32) reviewed for hearing. Findings include: R32's quarterly Minimum Data Set (MDS) dated [DATE], indicated R32 was cognitively intact and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated R32 had no rejection to cares, and utilized hearing aids or other hearing appliances with no difficulty hearing when the hearing aid/appliance was used. Review of R32's Inventory of Personal Possession sheet dated 8/20/20, indicated R32 had hearing aids for his left and right ear. R32's care plan revised on 9/14/22, indicated R23 had hearing problems related to the aging process and directed staff to use bilateral hearing aids and to monitor for changes in hearing. R32's nursing assistant kardex dated 10/12/22, indicated under special needs: R32 had bilateral hearing aids and staff were to assist with them. During an observation and interview on 10/10/22, at 2:47 p.m. R32 was observed seated in his recliner with no hearing aids noted while visiting with his wife. R32's wife was observed to be repeating herself several times during the conversation she had with R32. R32's wife stated R32 had a difficult time hearing her. R32 stated he had been without hearing aids for over a year as he had lost one of his hearing aids and the other one was not functioning. R32 indicated he had made a request to several different staff members since last June to make an appointment for him with Veterans Affairs (VA) to be fitted for new hearing aids. R32 stated staff responded back to him an appointment had not been made due to the staff had been unable to reach anyone at the VA office to make an appointment for him. During an interview on 10/12/22, at 11:25 a.m. registered nurse (RN)-A stated R32 required staff assistance with his activities of daily living (ADL's) and was hard of hearing. RN-A confirmed R32's care plan identified he required the use of hearing aids. RN-A stated she was not aware R32 ever had hearing aids and indicated the inventory sheet which addressed his belongings identified he did have hearing aids before. RN-A stated she and R32 had discussed making an audiology appointment at the VA for new hearing aids and verified the appointment had not yet been made. During an interview on 10/12/22, at 11:48 a.m. NA-B stated R32 required staff assistance with ADL's. NA-B indicated R32 would often have his TV volume on a loud setting. NA-B stated she was not aware R32 ever had hearing aids. During an interview on 10/12/22, at 1:15 p.m the director of nursing (DON) confirmed R32's careplan and indicated R32 required the use of hearing aids. The DON verified staff had not followed up on R32's request for an appointment to obtain new hearing aids and confirmed he did not currently have hearing aids. The DON stated she expected staff to respond to the needs of the residents and ensure appointments were made in a timely manner according to facility policy. Review of facility policy titled, Hearing Aids revised on 4/18/21, indicated staff were to assist with cleaning and maintaining hearing aids.

Based on interview and document review, the facility failed to immediately report to the State Agency (SA) and the facility administrator an allegation of abuse, no later than two (2) hours after knowledge of the allegation of abuse for 2 of 2 residents (R1 and R2) reviewed for timely reporting of abuse. Findings include: R2 R2's admission Minimum Data Set (MDS) dated [DATE], identified R2 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated R2 was cognitively intact and required extensive assistance with activities of daily living (ADL's) which included, bed mobility, transfers, and toileting. R2's care plan dated 5/19/22, revealed R2 had impaired cognition and had behaviors of hollering out for help instead of using call light and directed staff to acknowledge concerns, approach non-judging, listen to concerns and offer reassurance, and update MD/family of changes in behavior. The facility SA report dated 5/21/22, at 1:40 p.m. identified R2 hollered out and (NA)-A entered R2's room to see what R2 wanted. NA-A was overheard telling R2 to shut up and closed R2's room door. The report indicated R2 was interviewed and was unable to recall any incidents. During an interview on 5/31/22, at 2:43 p.m. NA-B indicated on 5/20/22, at 9:45 p.m. NA-B and NA-A were seated at the desk outside of R2's room when they heard R2 yelling out. NA-B stated NA-A entered R2's room, told R2 to shut up and closed the door to R2's room. NA-B indicated she reported the incident to licensed practical nurse (LPN)-A at 10:00 p.m. that same evening. LPN-A stated he would notify the DON and the administrator. During an interview on 5/31/22, at 3:29 p.m. LPN-A stated on 5/20/22, after 9:00 p.m. NA-B notified him of an allegation of abuse. LPN-A indicated he emailed the DON about the allegation of abuse and confirmed he had not contacted the DON directly regarding the incident. LPN-A stated the expectation was for staff to report any allegation of abuse within two hours to the DON. During a telephone interview on 5/31/22, at 3:40 p.m. NA-A indicated on 5/20/22, at 9:45 p.m. she and NA-B had a conversation while seated at the desk outside of R2's room. NA-A indicated R2 began repeating the conversation very loudly and NA-A entered R2's room and told her to be quiet. NA-A indicated she may have told R2 to be quiet however she did not tell R2 to shut up. During an interview on 6/1/22, at 8:58 a.m. administrator confirmed he was made aware of the allegation of abuse on 5/21/22, and the incident occurred on the evening of 5/20/22. Administrator stated he believed the supervisors were notified of the allegation and an email had been sent out on the evening of 5/20/22. Administrator confirmed the facility's policy was to notify the administrator immediately of any allegation of abuse however he felt it was appropriate to send an email since the incident occurred on the weekend. During an interview on 6/1/22, at 9:30 a.m. registered nurse RN-A verified she filed the report to the SA on 5/21/22, at 1:40 p.m. after the DON contacted her about the allegation of abuse. RN-A confirmed the report was filed late. During a telephone interview on 6/1/22, at 10:20 a.m. DON confirmed she had became aware of the allegation of abuse towards R2 on 5/21/22, in the morning when she reviewed her e-mails, and immediately contacted the administrator. DON stated she contacted (RN)-A and asked her to file the report to the SA. DON indicated her expectation was for staff to notify her and the administrator immediately and the report to the SA would be filed within 2 hours of an allegation of abuse. DON confirmed she and the administrator were notified late about the allegation of abuse. R1 R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had moderate cognitive impairment and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MDS indicated she required extensive assistance with bed mobility, transfers, dressing and grooming. R1's MDS identified R1 had verbal behaviors, other behaviors not directed at others and rejection of cares four to six days during the assessment period. R1's care plan revised 4/29/22, identified R1 required extensive assistance from staff with dressing, hygiene, and transfers. R1's care plan indicated R1 had episodes of hallucinations and delusions, and while hallucinating could become quite agitated with yelling and verbal aggression. The care plan listed the following interventions; acknowledge concerns, approach non-judging, listen to R1's concerns and offer reassurance. R1's care plan included a focus of vulnerability however lacked identification of a goal or interventions. R1's facility report to the State Agency (SA) submitted 5/21/22, at 9:36 a.m. indicated staff overheard nursing assistant (NA)-A tell R1 to shut up and to stop acting like a child when R1 was having behavioral outbursts. The report identified the incident occurred on 5/20/22, at 10:30 p.m. The report indicated staff notified the charge nurse, who e-mailed the director of nursing (DON) about the allegation. DON read the e-mail at 8:00 a.m. on 5/21/22, and notified administrator at that time. The administrator was notified 12.25 hours after the staff were aware of the allegation of abuse and the SA report was filed 13.75 hours after the staff became aware of the allegation of abuse. During an interview on 5/31/22, at 3:10 p.m. NA-B indicated on 5/20/22, around 8:15 p.m. NA-A informed her and NA-C she had told R1 to shut up and stop acting like a child when she had provided cares to her at around 8:00 p.m. that evening. NA-B stated she had informed licensed practical nurse (LPN)-A around 9:00 p.m. who asked them to write the details down, and LPN-A stated he would inform the director of nursing (DON) or administrator. NA-B indicated the next morning on 5/21/22, the DON called and interviewed her about the allegation. During an interview on 5/31/22, at 2:29 p.m. NA-C stated NA-A informed her and NA-B she had told R1 to shut up and she was acting like a little kid on 5/20/22, around 8:00 p.m. NA-C indicated shortly after they reported the incident to LPN-A. NA-C stated no one should speak to a resident in that manner. During an interview on 5/31/22, at 3:29 p.m. LPN-A indicated NA-B and NA-C brought to his attention the allegations of abuse toward R1 by NA-A on 5/20/22, between 8 and 9 p.m. LPN-A stated he asked NA-B and NA-C to write the details of the incident down. LPN-A stated he e-mailed the details of the allegation to the DON and confirmed he had not contacted the DON immediately. During a telephone interview on 5/31/22, at 3:39 p.m. NA-A indicated R1 was yelling on the evening of 5/20/22, while she provided cares and she was not certain why. NA-A stated she had not told R1 to shut up. NA-A indicated she had informed the nursing assistant staff she had told R1 to shut up however did not know why she told them that. NA-A stated she had felt stressed and vented frustrations to her teammates. NA-A indicated she was at fault for what she told her co-workers however stated she had provided R1 excellent care. During an interview on 6/1/22, at 8:58 p.m. the administrator confirmed he was made aware of the allegations of abuse to R1 on the morning of 5/21/22, and the incident occurred on the evening of 5/20/22. Administrator stated he believed the supervisors had been notified of the allegation and indicated an e-mail had been sent on the evening of 5/20/22. Administrator confirmed the expectation was to be notified of an abuse allegation immediately, as in their policy, however felt in this situation an e-mail was reasonable. During an interview on 6/1/22, at 9:30 a.m. registered nurse (RN)-A confirmed DON had called her on 5/21/22, and forwarded the note she had received from staff regarding the abuse allegation made towards R1. RN-A stated she had filed the SA report based on the information she had received. RN-A confirmed the report was filed late. During a telephone interview on 6/1/22, at 9:45 a.m. LPN-B confirmed she had worked the evening of 5/20/22, as charge nurse and had been informed of the allegations of abuse by LPN-A about 30 minutes before her shift ended. LPN-B stated she had read the note the nursing assistants had written for LPN-A. LPN-B indicated the note identified NA-A had told R1 to stop acting like a child. LPN-B indicated she was a new LPN and was not aware of the process for vulnerable adult reporting. LPN-B confirmed she scanned the note to be provided to DON and had not reported the allegation of abuse. During a telephone interview on 6/1/22, at 10:20 a.m. DON confirmed she had became aware of the allegation of abuse towards R1 on 5/21/22, when she reviewed her e-mails. DON stated she had contacted the administrator immediately and forwarded him the e-mail. DON indicated she had contacted RN-A who was at the facility and instructed her to file a vulnerable adult report to the SA. DON confirmed the administrator and herself were notified late of the incident and the SA report was submitted late. The facility policy Vulnerable Adult Act/Abuse Prevention revised 3/3/21, identified all suspected cases or allegations of abuse would be reported to the administrator immediately. The policy indicated the administrator, along with the DON would determine action needed. The policy identified if the events that caused allegation involved abuse, the alleged violation would be reported immediately, but not later than two hours after the allegation was made. The policy identified all alleged violations would be reported immediately to the administrator AND to other officials including the SA.

Based on interview, and document review, the facility failed to complete a thorough investigation to assure residents were safe, and prevent further potential abuse by allowing the alleged perpetrator (AP) to continue to have access to other vulnerable adults following an allegation of abuse, for 2 of 2 residents (R1 and R2) investigated for abuse. Findings include: R2 R2's admission Minimum Data Set (MDS) dated [DATE], identified R2 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated R2 was cognitively intact and required extensive assistance with activities of daily living (ADL's) which included, bed mobility, transfers, and toileting. R2's care plan dated 5/1922, revealed R2 had impaired cognition and had behaviors of hollering out for help instead of using call light and directed staff to acknowledge concerns, approach non-judging, listen to concerns and offer reassurance, and update MD/family of changes in behavior. Review of the facility incident report submitted to the State Agency (SA) dated 5/21/22, at 1:40 p.m. identified R2 was hollering out and (NA)-A entered R2's room to see what R2 wanted. NA-A was overheard telling R2 to shut up and closed R2's door. The report identified R2 was interviewed and was unable to recall the incident. The report indicated the director of nursing (DON) was updated via telephone and administrator was updated by DON immediately. Review of the facility investigation report to the SA submitted 5/26/22, identified NA-B overheard NA-A tell R2 to shut up and closed R2's door. The report indicated NA-A denied telling R2 to shut up however instead told her to be quiet. The report indicated NA-A was terminated on 5/24/22. R2's facility investigation report lacked documentation NA-A was suspended immediately after the allegation of abuse was reported to protect the residents. The report lacked documentation other residents were interviewed who had additionally received cares from NA-A. Further, the report lacked documentation education was provided to nursing staff to prevent further allegations of abuse from occurring in the facility. R1 R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had moderate cognitive impairment and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MDS indicated she required extensive assistance with bed mobility, transfers, dressing and grooming. The MDS identified R1 had verbal behaviors, other behaviors not directed at others and rejection of cares four to six days during the assessment period. R1's care plan revised 4/29/22, identified R1 required extensive assistance from staff with dressing, hygiene, and transfers. The care plan indicated R1 had episodes of hallucinations and delusions, and while hallucinating could become quite agitated with yelling and verbal aggression. The care plan listed the following interventions: acknowledge concerns, approach non-judging, listen to R1's concerns and offer reassurance. R1's care plan included a focus of vulnerability, however lacked a goal or intervention. The facility report to the State Agency (SA) submitted 5/21/22, at 9:36 a.m. indicated staff overheard nursing assistant (NA)-A tell R1 to shut up and to stop acting like a child when R1 was having behavioral outbursts. The report identified the incident occurred on 5/20/22, at 10:30 p.m. The report indicated staff notified the charge nurse, who e-mailed the director of nursing (DON) about the allegation. DON read the e-mail at 8:00 a.m. on 5/21/22, and notified Administrator at that time. The report identified staff member would be placed on suspension until outcome of investigation. The report indicated the resident interviewed had been interviewed and was unable to recall any incidents. The facility investigation report to the SA submitted 5/26/22, identified NA-A had informed multiple co-workers she told R1 to shut up, and she was acting like a child. The report identified NA-A admitted telling co-workers the statement, however denied she actually said it to R1. The report identified NA-C was terminated on 5/24/22. The report indicated during the investigation it was discovered a second incident occurred with another resident and NA-A, and a second vulnerable adult (VA) report was filed with the SA. -R1's facility investigation report lacked documentation NA-A was suspended immediately after the allegation of abuse was reported to protect the residents. The report lacked documentation other residents were interviewed who had received cares from NA-A. Further, the report lacked documentation education was provided to nursing staff to prevent further allegations of abuse in the facility. NA-A's facility time sheet identified NA-A worked 5/20/22, from 2:15 p.m. to 10:45 p.m. During an interview on 5/31/22, at 3:10 p.m. NA-B indicated on 5/20/22, around 8:15 p.m. NA-A informed her and NA-C she had told R1 to shut up and stop acting like a child when she had provided cares to her at around 8:00 p.m. that evening. NA-B stated she had informed licensed practical nurse (LPN)-A around 9:00 p.m. who asked them to write the details down, and LPN-A stated he would inform the director of nursing (DON) or administrator. NA-B indicated NA-A continued to work the rest of the shift and later that evening, NA-B stated R2 began yelling out again. NA-B observed NA-A enter R2's room, told her to shut up and closed the door. NA-B stated she reported this additional incident to LPN-A as well. NA-B indicated the next morning on 5/21/22, the DON contacted her to inquire about the allegation. During a telephone interview on 5/31/22, at 3:39 p.m. NA-A indicated R1 was yelling on the evening of 5/20/22, while she provided cares and she was not certain why. NA-A stated she had not told R1 to shut up. NA-A indicated she had informed the nursing assistant staff she had told R1 to shut up however did not know why she told them that. NA-A confirmed she had worked the rest of the shift and repeated the same statements regarding R1 to the night shift. During an interview on 6/1/22, at 8:58 a.m. administrator indicated DON completed the investigations for the allegations of abuse towards R1 and R2. Administrator confirmed DON contacted him the next morning on 5/21/22, and NA-A was suspended at that time. During a telephone interview on 6/1/22, at 9:30 a.m. registered nurse (RN)-A indicated she became aware of the allegations of abuse on the morning of 5/21/22, and was instructed by DON to file a VA report. RN-A indicated she had interviewed R1 and R2 on 5/21/22. RN-A confirmed NA-A continued to work until the end of her shift on 5/20/22. During an interview on 6/1/22, at 10:20 a.m. DON confirmed she became aware of the allegations of abuse which occurred on 5/20/22, on 5/21/22, when she reviewed her e-mail. DON indicated she had interviewed NA-A, NA-B, NA-C and LPN-A on 5/21/22. DON stated RN-A interviewed R1, R2 and another resident who NA-A had made a negative statement about. DON confirmed no other staff members or residents were interviewed during the investigation since they planned to terminate NA-A. DON indicated she had not been aware NA-A continued to work on 5/20/22, after LPN-A was notified of the allegation of abuse towards R1. DON stated she would expect the nurse to contact herself and the administrator immediately after an allegation of abuse and suspend the staff member involved. The facility policy Vulnerable Adult Act/Abuse Prevention revised 3/3/21, identified DON along with social services would thoroughly investigate complaints, determining whether they were true or false or not possible to substantiate, or disprove through interviews and examination with involved parties. The policy investigation process included; DON or designee would talk to the person reporting the incident, provide immediate intervention and corrective action if necessary, interview other residents to whom the accused employee provided care or services, and employees who had been accused for resident abuse would be reassigned to non-resident care duties or suspended from duty until the results of the investigation had been received by the administrator.

Based on interview and document review, the facility failed to complete a Significant Change in Status Assessment (SCSA) when two or more areas of change in resident status were noted on the Minimum Data Set (MDS) for 1 of 4 residents (R43) reviewed for activities of daily living (ADL's). Findings include: R43's annual Minimum Data Set (MDS) dated [DATE], identified R43 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified R43 was cognitively intact and was independent with ADL's of bed mobility and required supervision with transfers and toileting. The MDS identified R43 had occasional bladder incontinence and was not on a toileting program. R43's quarterly MDS dated [DATE], identified R43 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified R43 was cognitively intact and required extensive assistance with bed mobility, transfers and toileting. The MDS identified R43 had frequent bladder incontinence and was not on a toileting program. Review of the above assessments indicated R43 required an increased need in staff assistance with ADL's of bed mobility, transfers, toileting and experienced a decline in urinary incontinence. On 7/28/21, at 11:43 a.m. nursing assistant (NA)-I indicated R43 required an increased need for staff assistance with his ADL's On 7/28/21, at 12:36 p.m. NA-G indicated R43 required extensive assistance with his ADL's and had increased frequency of incontinence within the last few months. On 7/29/21, at 11:59 a.m. NA-H stated R43 required extensive assistance with most of his ADL's and had an increase in urinary incontinence within the past several weeks. NA-H indicated R43 had increased forgetfulness and confusion. On 7/29/21, at 12:34 p.m. the director of nursing (DON) stated she expected a SCSA to be completed when a resident experienced a decline of function in two or more areas. On 7/29/21, at 12:46 p.m. MDS coordinator confirmed R43's most recent quarterly MDS identified a significant decline in late loss ADL's of bed mobility, transfers, toileting and an increased frequency of incontinence. The MDS coordinator indicated she had not been aware of R43's decline and confirmed a SCSA should have been completed for R43 upon determining a decline without likely improvement. A facility policy St. Williams Living Center, Completion of the MDS dated [DATE], identified it was the policy of the facility to comply with the Resident Assessment Instrument (RAI) guidelines for MDS completion.

Based on observation, interview and document review the facility failed to provide assistance with routine grooming which included facial hair removal for 3 of 4 residents (R17, R26 and R43) who required assistance with grooming and personal hygiene. R17 Findings include: R17's quarterly Minimum Data Set (MDS) dated [DATE], identified R17 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified R17 had severe cognitive impairment and required extensive to total assistance with activities of daily living (ADL's ) of bed mobility, dressing, personal hygiene and bathing. R17's care plan updated 6/14/21, revealed R17 had impaired memory, right sided [CONDITION(S)] (paralysis), and required extensive assistance with grooming. R17's care plan revealed she did not wish to be shaved. On 7/26/21, at 1:20 p.m. R17 was observed seated in a tilt in space wheelchair, in her room with a neck pillow positioned behind her neck, had her eyes closed and was covered with a green blanket. R17 had dozens of three (3) to four (4) millimeter (mm) long, thick course white hair along her chin and upper lip. R17 also had several long wispy white hairs approximately ten mm long, on her jaw and chin line. On 7/26/21, at 6:13 p.m. during a telephone interview with R17's family member (FM)-B, indicated prior to R17's stroke and Alzheimer's disease she would routinely have her hair done and would make sure her facial hair was removed. FM-B indicated he felt it would bother R17 if she knew she had facial hair. On 7/26/21, at 7:12 p.m. R17 was observed seated in a wheelchair in her room, covered with a blanket. At that time nursing assistant (NA)-F entered her room, provided cares and exited. R17 continued to have dozens of 3-4 mm long, thick, course white hairs along her chin and upper lip. Additionally, R17 continued to have several 10 mm long wispy white hairs along her chin and jaw line. On 7/27/21, at 9:12 a.m. R17 was observed seated in a wheelchair in her room, covered with a blanket. R17 continued to have dozens of 3-4 mm long, thick, course white hairs along her chin with shaved patches along her lower, upper lip and neck. R17 continued to have a few ten mm long white wispy hairs along her jaw line. On 7/28/21, at 7:05 a.m. R17 was observed seated in a wheelchair in her room, eyes were closed, she wore a hospital gown and was covered with a blanket. R17 had several small patches of one (1) to two (2) mm long thick, course, white chin hairs. R17 continued to have a few ten mm long white wispy hairs along her jaw line. On 7/28/21, at 8:03 a.m. R17 was observed seated in a wheelchair, covered with a green blanket. NA-F approached R17, indicated she was bringing R17 to take a bath and proceeded to wheel R17 to the tub room. On 7/28/21, at 8:33 a.m. R17 was observed seated in a wheelchair, in the dining room at a table with four other residents and two other NA's. R17 continued to have several small patches of 1-2 mm long thick, course white chin hairs and a few ten mm long white wispy hairs along her jaw line. On 7/28/21, at 9:00 a.m. NA-F indicated R17 was totally dependent on staff for all of her ADL's and was not usually able to verbalize her needs. NA-F confirmed she had provided R17 with her weekly bath that morning, indicated she had not noticed any facial hair and stated she would have removed any facial hair. NA-F indicated R17 had an electric razor in her bedside table. On 7/28/21, at 12:45 p.m. NA-G stated R17 was totally dependent on staff for all of her ADL's and was not able to verbalize her needs. NA-G indicated she had assisted R17 with morning cares and had removed approximately 2-3 mm long chin, upper lip and neck hairs. On 7/29/21, at 11:55 a.m. NA-I indicated R17 was totally dependent on staff for all of her ADL's which included facial hair removal. NA-I stated R17 had an electric razor in her bedside table. On 7/29/21, at 12:38 p.m. the director of nursing (DON) stated she would expect R17's facial hair to be removed as needed. R26 R26's quarterly Minimum Data Set (MDS) dated [DATE], identified R26 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified R26 had moderate cognitive impairment and required extensive assistance with activities of daily living (ADL's) of bed mobility, dressing, personal hygiene and bathing. R26's care plan updated 6/17/21, revealed R26 had cognitive impairment, weakness and required extensive assistance of one staff with grooming/hygiene. R26's care plan identified he wanted to be shaved. R27's Bedside Kardex Report (nursing assistant care guide) dated 7/29/21, identified R26 wished to be shaved. On 7/26/21, at 2:30 p.m. R26 was observed seated in a high back wheelchair in his room, his eyes were closed and his chin was rested on his chest. R26 was observed to have approximately two (2) to three (3) millimeters (mm) of thick, course, white facial hair on his chin, both cheeks and neck. On 7/26/21, at 7:16 p.m. R26 was observed seated in a high back wheelchair in his room, he held a television remote control and faced the television. R26 continued to have approximately 2 to 3 mm of thick, course, white facial hair on his chin, both cheeks and neck. On 7/27/21, at 9:00 a.m. R26 was observed seated in a high back wheelchair in his room, faced the window. R26 continued to have facial hair along his chin, both cheeks, neck of thick, course, white facial hair on his chin, both cheeks and neck. and upper lip, approximately 2 to 3 mm long. On 7/28/21, at 7:06 am. R26 was observed seated in a high back wheelchair in his room, faced the window, with his eyes closed and was clean shaven. On 7/28/21, at 12:41 during an interview, nursing assistant (NA)-G indicated R26 was usually assisted with morning cares by the night shift staff. NA-G indicated R26 required extensive assistance with his ADL's which included dressing, personal hygiene and grooming. NA-G stated R26 was not always able to verbalize his needs and wishes. On 7/28/21, at 12:58 p.m. during an interview, NA-H stated R26 required extensive assistance with all of his ADL's except eating of which he required set up assistance. NA-H indicated R26 had impaired memory and was not always able to verbalize his needs and wishes. On 7/29/21, at 11:17 a.m. during a telephone interview with R26's FM-A indicated R26 preferred to be clean shaven daily. FM-A indicated she had observed R26 unshaven when she had visited and has shaved him herself, which occurred as most recently as the prior week. On 7/29/21, at 12:32 p.m. the director of nursing (DON) stated she would expect R26 to be shaved per his care plan. R43 R43's quarterly Minimum Data Set (MDS) dated [DATE], identified R43 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified R43 was cognitively intact and required extensive assistance with bed mobility, transfers and grooming tasks. R43's care plan revised 7/19/21, revealed R43 required extensive assistance with hygiene/grooming and preferred to be clean shaven. R43's Bedside Kardex Report (nursing assistant care guide) dated 7/29/21, identified R43 preferred to be clean shaven. On 7/26/21, at 1:36 p.m. R43 was observed seated in his room, in a wheelchair and faced the television with an over the bed table in front of him. R43 had approximately two (2) to three (3) millimeters (mm) of thick, course, white hairs along his jaw line, both cheeks, chin and neck. On 7/27/21, at 9:03 a.m. R43 was observed seated in his room, in a wheelchair and faced the television with an over the bed table in front of him. R43 continued to have approximately 2 to 3 mm of thick, course, white hairs along his jaw line, both cheeks, chin and neck. On 7/28/21, at 7:33 a.m. R43 was observed lying in his bed on his right side and faced the window of his room. R43 continued to have approximately 2 to 3 mm of thick, course, white hairs along his jaw line, both cheeks, chin and neck. On 7/28/21, at 7:55 a.m. R43 was observed seated in a wheelchair at a table in the dining area. R43 continued to have approximately 2 to 3 mm of thick, course, white hairs along his jaw line, both cheeks, chin and neck. On 7/28/21, at 8:44 a.m. R43 was observed seated in a wheelchair in his room, faced the television with an over the bed, rolling table in front of him. On 7/28/21, at 12:36 p.m. nursing assistant (NA)-G indicated R43 required extensive assistance with his ADL's, which included reminding him to shave. NA-G stated she felt R43's memory had been declining within the last few months and he needed more reminders and assistance. NA-G indicated R43 was able to propel himself in a wheelchair and would often take his shaver from the bathroom and shave himself. On 7/29/21, at 11:43 a.m. NA-I indicated R43 required extensive assistance with his ADL's, which included personal hygiene and grooming. NA-I stated she felt R43 had been declining in his cognition and his ability to do things on his own within the past few months. NA-I indicated R43 used to shave himself everyday and was unsure when he last shaved himself. On 7/29/21, at 11:59 a.m. during an interview, NA-H stated she felt R43's memory had declined and he needed increased assistance with his ADL's, which included shaving. NA-H indicated R43 used to shave himself daily and felt he would if he was reminded. On 7/29/21, at 12:34 p.m. the director of nursing (DON) stated she would expect R43's care plan to be followed and for R43 to be shaved daily with cares. A facility policy titled, St. Williams Living Center Shaving Policy revised 4/20/21, identified residents would be asked their preference for shaving upon admission and quarterly.

Based on observation, interview and document review the facility failed to ensure resident Care Area Assessments (CAA) included a comprehensive analysis to reflect the current health status for 1 of 1 residents (R34) with an unstageable pressure ulcer (Full thickness tissue loss in which actual depth of the ulcer was completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed). Findings include: R34's annual Minimum Data Set, dated dated dated [DATE], identified R34 had severe cognitive impairment and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated R34 required one staff assistance with bed mobility, transfers, dressing, toileting and personal hygiene. The MDS identified R34 was not at risk for developing pressure ulcers and had no unhealed ulcers. The MDS indicated R34 had no venous/arterial ulcers and no other wounds or skin problems. The MDS identified R34 had a pressure reducing device in her wheel chair and she had been receiving an application of dressing to her feet. R34's annual CAA dated 6/30/21, identified eight care areas that had triggered from the data entered into the MDS dated [DATE]. The following areas were triggered: Cognitive Loss/Dementia, Visual function, Urinary Incontinence, Behavioral Symptoms, Falls, Nutritional status, Pressure Ulcer/injury and [CONDITION(S)] Drug Use. The Pressure Ulcer/Injury CAA revealed the care area was a potential problem for R34 and indicated her skin was intact. The CAA identified R34 had the potential for skin breakdown due to needing staff assistance with bed mobility at times. The CAA revealed pre-populated check marked areas which identified factors which affected R34's risk for pressure ulcers. The CAA revealed the following check marked areas: assess location, size, stage, presence of, type of drainage, presence of odor and the condition surrounding skin. The CAA had checked the extrinsic risk factors of pressure were: altered mental status, cognitive loss, incontinence, anti-psychotics, antianxiety agents, [CONDITION(S)], dementia, depression and chronic or end stage renal, liver or heart disease. The CAA indicated R34's care plan would have been considered to avoid complications and indicated R34 had the potential for skin breakdown related to urinary incontinence. The CAA identified R34's skin was currently intact with no areas of concern. The CAA indicated R34 wore a pull up for incontinence and was able to manage the incontinence on her own. The CAA identified R34 was able to make position changes independently, staff were to monitor skin daily with cares and on her weekly bath day. The CAA indicated staff continued to monitor and make changes as needed. The CAA lacked information related to an accurate assessment of R34's current skin condition during her annual assessment. During observation on 7/28/21, at 10:40 a.m. R34 was seated in her wheel chair in the hallway out side of her room. Registered nurse (RN)-C had supplies in her hand to change R34's dressing to her left foot, approached R34 and wheeled her back to her room. RN-C assisted R34 to pivot transfer into her recliner, raised her foot rest and asked R34 how her foot felt. R34 responded by saying it did not hurt unless he stepped on it. RN-C proceeded to glove her hands, removed R34's red grippy sock and cotton sock which revealed a dressing on the back of her left heel. RN-C removed the dressing from R34's left heel and the dressing had a scant amount of serosanguinous (combination of blood and serous fluids) yellow/red drainage present with no odor. RN-C removed her gloves, sanitized her hands and measured the wound bed. The wound measured 1.8 centimeters (cm) in width x 1.6 cm length. The center of the wound bed was 75 percent (%) yellow/white slough and the outer edge was 25% pink/red granulation tissue. The outer edges surrounding the wound bed were hard and had dry scaly skin around it. RN-C gloved her hands, cleaned the wound bed and applied skin prep to the outer edges of wound. RN-C wrote a date on the new dressing and applied the dressing to R34's left heel area. RN-C removed her gloves, sanitized her hands and applied R34's cotton sock and her red grippy sock to her left foot. RN-C cleaned up her supplies, sanitized her hands and left R34's room. On 7/28/21, at 1:55 p.m. RN-C confirmed the above findings and indicated R34 had an unstageable pressure ulcer on her left heel due to not being able to see the wound bed. RN-C indicated she did not think it was caused by pressure and believed it was caused by friction. RN-C stated staff had not staged the ulcer when it developed because they had been told by their consultant not to stage ulcers until the resident had been seen by the doctor. RN-C indicated the nursing staff were told by the consultant staging an ulcer would mean the nursing staff were diagnosing the ulcer and it was not within their scope of practice to diagnose a resident's condition. RN-C stated staging an ulcer was part of the nursing assessment process. On 7/29/21, at 11:45 a.m. the MDS coordinator (MDSC)-A confirmed the above findings and indicated R34 had an open area on her left heel. The MDSC-A indicated she did not think it was pressure related and it could of been caused by friction from her shoe. The MDSC-A stated MDS's were completed on admission, quarterly, significant changes, discharges and the CAA's were done annually. The MDSC-A confirmed she had completed R34's annual MDS and CAA indicating R34 did not have an open area on her heel as pressure. MDSC-A thought she had coded it as an open area and confirmed she had missed it. The MDSC-A confirmed R34's skin was not intact as indicated on her annual CAA and once the ulcer was identified, it should have been staged. The MDSC-A confirmed she was qualified to stage pressure ulcers and was told not to stage pressure ulcers by the consultant. The MDSC-A indicated she used the resident assessment instrument (RAI) manual as a reference when completing MDS's and CAA's. On 7/29/21, at 12:49 p.m. The director of nursing (DON) confirmed the above findings and indicated she did not know how the area on R34's left heel developed. The DON stated she was told the ulcer was not related to pressure and she was not sure who assessed it. The DON confirmed R34 had a stage two pressure ulcer that became unstageable after not being able to see the wound bed. The DON indicated she expected nursing staff to use the RAI manual when completing MDS's and CAA's. The DON stated nursing staff should have documented the presence of the ulcer to her left heel on R34's CAA. The DON confirmed R34's MDS and CAA were incorrect and did not understand how it had been missed by the staff. Review of facility policy titled, Completion Policy for MDS Assessment reviewed on 4/18/21, indicated the MDS would have been in compliance with RAI guidelines and the RN assessment coordinator was responsible for making sure all sections were completed. Review of facility policy titled, MDS assessment dated [DATE], indicated the RAI process was completed as the basis for care plan decisions and the triggered areas would have been noted. The policy further indicated a determination made regarding whether to trigger condition does or does not affect the resident function or well being and should have been addressed on the care plan.

Based on interview, observation and document review, the facility failed to ensure medications were available to be administered as prescribed by the physician, for 1 of 5 residents (R35) reviewed for medication administration. Findings include: R35's quarterly Minimum Data Set (MDS) dated [DATE], identified R35 had intact cognition and identified R35 was independent with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. R35's diagnoses list printed 7/29/21, identified low back pain, intervertebral disc degeneration, pain in right hip, [CONDITION(S)] (RA), spinal stenosis (narrowing), and malignant neoplasm (abnormal growth of tissue) of bladder and [MEDICATION(S)] colon. R35's order summary report printed on 7/29/21, identified an order for [MEDICATION(S)] Pen-injector Kit 40 milligrams (mg)/0.4 milliliters (ml) inject 40 mg subcutaneously one time a day every 14 day(s) related to [CONDITION(S)]. R35's current care plan dated 2/6/20, identified R35 was on hospice/terminal care for malignant neoplasm of the [MEDICATION(S)] colon. R35's care plan indicated the following interventions: collaborate with hospice for patient care, medications per hospice/medical doctor (MD) order and pain management. The care plan identified R35 had pain related to (r/t) cancer diagnosis, chronic low back pain, and [CONDITION(S)] and listed the following interventions: to administer pain medications as ordered, and update hospice/MD as needed (PRN). R35's doctor visit dated 3/10/20, identified he had recently seen rheumatology in regards to his [CONDITION(S)]. He had been on [MEDICATION(S)] for [AGE] years, since around 2000. The report indicated that rheumatology recommended he remain on it and identified when trying to discontinue it in the past he developed significant swelling in his wrists and hands. R35's electronic medication administration record (EMAR) and progress notes identified for the months of April 2021, through July 2021, the order for administration of [MEDICATION(S)] Pen injector kit 40 mg/0.8 ml inject 1 dose subcutaneously one time a day every 14 day(s) for [CONDITION(S)]: -On 4/7/21, at 11:00 a.m. medication was given. -On 4/21/21, at 11:00 a.m. medication was given. -On 5/5/21, at 11:00 a.m. other/see progress note. Progress note dated 5/5/21, at 12:21 p.m. identified [MEDICATION(S)] Pen-injector kit 40 mg/0.8 mL inject 1 dose subcutaneously one time a day every 14 day(s) for [CONDITION(S)]. Resident did not want to take insulin with him to his appointment and said he would take it when he got back. R35's EMAR and progress notes dated 5/5/21, did not identify the [MEDICATION(S)] was given or if the medical doctor was contacted. -On 5/19/21, at 11:00 a.m. medication was given. -On 6/5/21, at 11:00 a.m. medication was given. -On 6/30/21, at 4:00 p.m. medication was given. -On 7/14/21, at 4:00 p.m. other/see progress note. Progress note dated 7/14/21, at 4:16 p.m. identified [MEDICATION(S)] Pen-injector Kit 40 mg/0.8 mL medication unavailable, medication on order through Veteran's Administration (VA). Progress notes dated 7/22/21, at 10:28 a.m. identified resident requested that writer checked to be sure his [MEDICATION(S)] pens were in the fridge due to them being out of stock last week. Writer looked, found none, reordered from the VA pharmacy and told resident they were reordered. Resident became very upset and stated you guys said they were reordered last week and now I wont get them this week either. Writer stated they were sorry that it is not here but it is reordered now. Resident stated sorry is not good enough, have you ever take care of someone with RA? Its bad. Writer explained the facility had trouble reordering before and writer had personally reordered three different times for the same dose medication and it finally arrived. Resident did not believe writer and stated he was going to talk to his hospice nurse about keeping the [MEDICATION(S)] in his fridge and self-administering the medication. Progress note entered late dated 7/27/21, at 3:21 p.m. identified on 7/14/21, Staff registered nurse came to writer and stated there was no [MEDICATION(S)] to give resident. The box was empty. Writer called VA pharmacy to order and was told (via automated system) that [MEDICATION(S)] was refillable and that it would arrive in 3-5 days. Resident was informed and seemed satisfied. Telephone call placed to Dr. Kietzman's office to inform him that [MEDICATION(S)] was not available and to ask for direction. Message left for him to return call. -On 7/27/21, at 4:00 p.m. medication was given. During an interview on 7/27/21, at 11:36 a.m. hospice registered nurse (HRN) stated the [MEDICATION(S)] medication had always been ordered through the VA for R35. The [MEDICATION(S)] medication was supposed to be sent out to facility and received on 7/14/21. HRN also stated she called the VA and they verified no record of it being ordered. HRN indicated she called the VA and reordered the [MEDICATION(S)] on 7/23/21, and was due to be sent out today 7/27/21. HRN stated any missed medication was the facility's responsibility. During an interview on 7/28/21, at 12:42 p.m. R35 stated he received a dose of [MEDICATION(S)] last night. R35 indicated staff forgot to order it when the supply ran out and had happened three times. R35 indicated he received the [MEDICATION(S)] from the VA and it had taken only three or four days to get it once it was ordered however the facility staff told him it took up to ten days. R35 stated he was to receive a dose of the [MEDICATION(S)] every two weeks and the last time prior to last night 7/27/21, he had received it was on 6/30/21. R35 indicated the facility staff informed him they forgot to reorder the [MEDICATION(S)] for the 7/14/21,dose. R35 identified the longest he had gone without a dose was one month and he had not noticed any increased swelling or pain however, he realized it had taken a while to work once he had missed a dose and felt that was not a good thing. R35 stated he really wanted to receive his [MEDICATION(S)] as ordered. During an interview on 7/28/21, at 1:50 p.m. RN-A stated R35's order identified R35 was to receive [MEDICATION(S)] every 14 days and four doses were sent at a time. RN-A verified the 4/17/21, dose of [MEDICATION(S)] was not given and was unavailable to be administered. RN-A stated it was the nurse's responsibility to re-order the [MEDICATION(S)] prior to running out of the medication. RN-A stated when [MEDICATION(S)] had been reordered the staff were expected to place an X on the box. RN-A indicated R35 did not want to take the [MEDICATION(S)] with him to his appointment on 5/5/21, and indicated he would take it when he returned. RN-A verified on 6/19/21, and 7/14/21, the [MEDICATION(S)] was unavailable to administer and on order from the VA. During an interview on 7/29/21, at 10:56 a.m. RN-B verified on 4/17/21, the hospice nurse was notified by the facility the [MEDICATION(S)] was unavailable to be administered and a hold order was placed by hospice until it was refilled. RN-B stated the physician was not notified of the missed dose of [MEDICATION(S)] and no progress note was present that indicated the [MEDICATION(S)] was ordered on that date. RN-B stated on 5/5/21, R35 had requested the [MEDICATION(S)] be given to him once he returned from his appointment. RN-B stated she would have expected the [MEDICATION(S)] be administered to R35 once he returned however it was not documented as given and the doctor was not notified. RN-B indicated on 7/15/21, an order to hold [MEDICATION(S)] until the supply arrived (unless it would take longer than two weeks) then call primary care physician (PCP) had been placed by an on call physician. RN-B stated staff were expected to notify the PCP when a dose was missed or not available. RN-B stated both hospice and the provider were expected to be notified when a medication supply ran out or when unable to administer the medication. During an interview on 7/29/21, at 1:15 p.m. director of nursing (DON) stated the facility nurse administering the [MEDICATION(S)] for R35 was responsible to reorder it and make sure it was available. DON indicated the night shift nurse went through the medication carts to ensure medications were reordered and available. DON stated the VA medications had been a real challenge to maintain an adequate supply due to reordering issues with the VA. DON identified the staff placed an X on the medication box which indicated it had been ordered once the order had been placed. DON stated when ordered medications did not arrive timely the staff were expected to inform the doctor and receive direction from them. DON stated hospice should have been contacted too. On 7/29/21, a medication administration policy and notification of missed medication was requested and was not provided by facility.

Based on observation, interview, and document review, the facility failed to ensure staff implemented pressure ulcer and hand contracture interventions for 1 of 1 residents (R10) reviewed for pressure ulcers. Findings include: R10's quarterly Minimum Data Set (MDS) dated [DATE], identified R10 had severely impaired cognition and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated R10 required total assistance with bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. The MDS identified R10 was always incontinent of bowel and bladder and was at high risk for developing pressure ulcers. R10's care area assessment (CAA) dated 5/20/21, identified R10 had the potential for skin breakdown due to bowel and bladder incontinence and required staff assistance. The CAA identified extrinsic variables (variables that may contribute to pressure ulcers) which included the need for a special mattress or seat cushion to reduce or relieve pressure. The CAA indicated R43's Braden scale score was nine and identified R10 was at severe risk for developing a pressure ulcer. R10's care plan printed 7/29/21, identified R10 was at high risk for skin breakdown related to (r/t) immobility, incontinence, and a history of skin breakdown. The care plan indicated the following interventions: air mattress on bed, [MEDICATION(S)] to buttocks every shift after each incontinent episode, keep skin clean and dry, lotion dry, flaky skin, monitor skin condition every day, pressure reducing cushion in wheel chair (w/c), reposition every two hours, Spenco booties, tilt in space w/c reclined at all times except at meals, and washable pool noodles applied to the metal of both leg and foot rests on w/c to pad against injury. R10's care plan did not include the order written 7/1/21, to keep a rolled wash cloth in R10's left hand to prevent contractures. The care plan instructed staff to change out R10's rolled wash cloth every morning and evening shift. R10's most recent comprehensive skin assessment dated [DATE], identified R10's ability to respond to pressure-related discomfort was very limited, skin was exposed to moisture often, degree of physical activity was severely limited or non-existent, unable to change and control body position without assistance, very poor food intake, and unable to transfer independently. R10's medical diseases and comorbidities (two or more medical conditions existing simultaneously) identified [CONDITION(S)] (PVD), Alzheimer's disease, history of pressure ulcers, cognitive impairment, incontinence of bowel and bladder and impaired mobility. R10's current interventions identified pressure reducing cushion, Spenco boots, skin barrier cream ointment, toileting program and turning and re-positioning. R10's orders identified the following written on 7/1/21, to keep a rolled wash cloth in left hand to prevent contractures. The orders indicated staff were to change out every morning (AM) and at bed time (HS) every shift. Facility treatment administration record (TAR) printed on 7/29/21, for the month of July 2021, identified keep a rolled wash cloth in R10's left hand to prevent contractures. The TAR instructed staff to change out every morning and at bedtime. The TAR identified staff documented on day shift, evening shift, and night shift the rolled wash cloth was placed on 7/27/21, 7/28/21, and 7/29/21. Facility document printed 7/29/21, titled Visual/Bedside Kardex Report posted inside R10's closet door identified special needs: Spenco booties (designed to float the heel off the surface of the mattress to minimize pressure injury risk). R10's kardex report identified Mobility: required total assist of two staff for bed mobility. This document did not include an order written [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 7/28/21, at 7:43 a.m. R10 laid in a low bed on her back with a pillow behind her slightly turned towards the door on her left side. R10 did not have a rolled wash cloth in her hand. Two blue foot/heel protectors were noted to be on R10's recliner and none were noted on R10's heels. During an observation on 7/28/21, at 8:11 a.m. activity director (AD) and nursing assistant (NA)-A entered R10's room with a total lift machine. R10 laid in bed on her back. NA-A uncovered R1 and both heels rested on the bed mattress with no heel protectors or booties on them. NA-A placed the lift sheet underneath her and attached the loops of the lift sheet to the total lift machine. NA-A lifted R10 out of the bed with the lift machine and placed her in the wheel chair. AD combed R10's hair, sanitized her hands, and then pushed R10 out of the room in her wheel chair. R10's left hand was closed in a fist. R10 did not have a rolled wash cloth in her hand during this observation nor did she have the booties applied to her heels. Two blue foot protectors were noted on the recliner. During an observation on 7/28/21, at 8:33 a.m. and 9:20 a.m. R10 sat in dining room in her wheel chair. R10's left hand was closed in a fist and rested on her lap. R10 did not have a rolled wash cloth in her hand. During an observation on 7/28/21, at 9:50 a.m. NA-B and NA-C entered R10's room with a total lift machine. R10 sat in her wheel chair. Both NA-B and NA-C sanitized their hands and attached the loops to the lift sheet located under R10. NA-B lifted R10 off out of the wheel chair, lowered her onto the bed and completed a check and change. R10 laid on her back and NA-B elevated the head of the bed approximately 20 degrees and her legs slightly elevated also. R10 had socks on her feet and her heels rested on the mattress with no booties on her heels. Blue foot protectors were located on the recliner. R10's left hand remained in a closed fist without a rolled wash cloth in it. During an observation on 7/28/21, at 10:58 a.m. R10 laid in bed on her back and eyes were closed. R10 did not have a rolled wash cloth in her left hand and the blue boot protectors were not placed on her feet. R10's heels rested on the mattress. During an observation on 7/29/21, at 9:01 a.m. R10 sat in the dining room in her wheel chair at a 90 degree angle. NA-D and NA-E entered R10's room, changed her oxygen tubing and exited the room. R10's left hand was positioned in a fist and laid on her lap. R10 did not have a rolled wash cloth in her left hand. Two blue foot protectors were on the recliner and her heels did not have heel protectors on. During an observation on 7/29/21, at 9:47 a.m. NA-C and NA-E entered R10's room with a total lift machine. R10 sat in a wheel chair. NA-C and NA-E transferred R10 from the wheel chair onto the bed with the total lift machine. R10's left hand was noted to be open, rested on her abdomen and did not have a rolled wash cloth present. NA-C and NA-E repositioned R10 onto her right side slightly with a wedge placed against her back, stretched out her legs, placed a folded blanket between her knees and her heels rested on the mattress. R10's head of the bed was raised to approximately 45 degrees. The blue boot foot protectors were not on R10's heels. During an interview and observation on 7/29/21, at 10:00 a.m. NA-E and NA-C remained in R10's room. NA-E verified the Spenco blue boots were to be used on R10 anytime she laid in bed. During this interview, NA-E uncovered R10, removed her socks and verified her heels were not red. NA-E then applied R10's socks and grabbed the blue boot foot protectors and applied them to her feet. NA-C verified R10's kardex was located inside her closet on the door, the blue boots are listed on there however was not indicated when they should have been used. NA-C stated the facility nurse was in charge of the placement of the rolled towel in R10's left hand and made sure it had been placed. NA-C indicated she had been off for two weeks and had never seen a rolled wash cloth prior to that in R10's hand. NA-C verified the rolled wash cloth for the left hand was not identified on R10's kardex located in her room. NA-C stated the blue boot foot protectors should have been applied anytime R10 laid in bed and most of all during the night to help relieve pressure to her heels. Both NA-E and NA-C verified they had not seen a rolled wash cloth placed in R10's left hand and were not aware it was part of R10's care plan. During an interview on 7/29/21, at 12:00 p.m. licensed practical nurse (LPN)-A stated she signed off the left hand rolled wash cloth for the day shift 7/29/21, indicating it had been placed in R10's hand however had not checked to see if was placed. LPN-A stated the nurse was responsible for that task and indicated the NAs had placed it in the past too. LPN-A stated it should have been placed in R10's hand to prevent contractures. During an interview on 7/29/21, at 1:15 p.m. director of nursing (DON) stated R10's order for the rolled wash cloth should have been placed on the care plan and the kardex when the nurse received the order. DON indicated the staff nurse was responsible to place the rolled wash cloth in R10's hand to prevent contractures. DON stated it was expected staff followed the care plan for interventions of applying the blue heel protectors and the rolled wash cloth to prevent pressure ulcers and contractures. Facility policy reviewed 4/18/21, titled Skin Breakdown identified it was the policy of St. Williams Living Center (SWLC) to properly identify and assess residents whose clinical conditions increased the risk of impaired skin integrity, and pressure ulcers. The purpose of this policy was to implement preventive measures and to provide appropriate treatment modalities for ulcers according to industry standards of care. The facility policy identified activity, mobility, and positioning: protect elbows and needed with the use of sheepskin, heel and elbow protectors to reduce shear and friction and to provide for comfort. The policy identified the need to elevate heels off bed as indicated unless contraindicated due to medical condition.

Based on interview and document review, the facility failed to ensure the resident bill of rights (BOR) were provided verbally for residents of the facility. This deficient practice had the potential to affect all 47 residents residing in the facility. Findings include; On 7/28/21, at 1:30 p.m. seven residents were present at a resident council meeting held by surveyor. When questioned if the residents' (BOR) had been reviewed, all seven residents present stated the rights had not been reviewed and they were not aware of where to find them in the facility. On 7/29/21, at 9:32 a.m. the facility activity director confirmed the resident (BOR) had not been reviewed with residents. The activity director indicated the facility social worker used to review them in resident council meetings several months ago. On 7/29/21, at 12:09 p.m. the licensed social worker confirmed the resident (BOR) had not been reviewed with the residents. She indicated residents were provided with the residents' (BOR) upon admission and indicated the facility had the residents' (BOR) posted in the facility. Review of monthly resident council meeting minutes from December 30, 2020, to July 21 2021, lacked any evidence the residents' (BOR) had been reviewed with residents. A facility policy titled, St. William's Living Center, Resident Rights, dated 2/21, identified each resident would be fully informed of all residents rights outlined in the Bill of Rights upon admission, with any changes.

Based on interview and document review, the facility failed to ensure ordered follow up with specialty service physicians and implementation of discharge orders for notification of the surgeon were completed for 1 of 1 residents (R1) following an acute hospitalization for [CONDITION(S)] (heart attack) and post operative coronary artery bypass grafting (CABG). The deficient practice caused actual harm for R1, who required emergent readmission to the hospital and was subsequently diagnosed with shortness of breath, extreme fluid overload, and [CONDITION(S)] (CHF). Findings included: R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified R1 had intact cognition, required extensive assistance of 2 staff for bed mobility, transfers, toileting, and ambulation in her room and used a walker and wheel chair (wc) for mobility. The MDS also identified R1 had shortness of breath on room air upon exertion and lying flat in bed. R1's admission Care Area Assessment (CAA) dated 12/17/20, identified extensive assist with ADL's, recent hospitalization for [CONDITION(S)] (MI), renal disease, CHF, and hypertension ([CONDITION(S)]). R1's care plan dated 12/24/20, identified extensive assistance needed for ADL's for bed mobility, bowel and bladder, dressing, hygiene and grooming, transferring, ambulation and wc mobility, and one person assist for bathing. R1's care plan also revealed she had an open area to midline gluteal fold proximal to coccyx bone. R1's surgery discharge summary dated 12/10/20, at 10:40 a.m. indicated R1 had a CABG x (times)] 3, post operative ileus (blockage of intestine), left main CAD (coronary artery disease), [CONDITION(S)] (MI), post op AKI (acute kidney injury) on CKD (chronic kidney disease) stage 3, pulmonary [CONDITION(S)] - improved, history EVAR (endovasuclar aneurysm repair), [CONDITION(S)] ischemia (heart attack), and LV (Left ventricle) dysfunction post infarction (obstruction of blood supply to an organ or region of tissue). The summary indicated R1's past medical history included aneurysm of abdominal aorta, chronic kidney failure stage 3, GERD ([CONDITION(S)]), [CONDITION(S)] (high blood pressure), Lupus (systemic [CONDITION(S)] disease which causes the body's immune system to attack tissues and organs), [CONDITION(S)] of right hip, Renal artery stenosis (narrowing), and vitamin D deficiency. Postoperatively, R1's Creatinine(measures kidney function) levels increased from baseline of 1.7 to above 2.5 and had trended down to 1.9 before discharge. The discharge summary listed for R1 to follow up with nephrology as outpatient. R1's discharge instructions included follow up with PCP (primary care physician) 1 to 2 weeks, CT (cardiothoracic) surgery in 1 week and in 4-5 weeks, cardiology in 4-5 weeks. Nephrology in 1 week. R1's discharge summary directed to call your surgeon's office if any of the following symptoms appear: If you develop shortness of breath or activity intolerance. Further, R1's summary directed please keep scheduled appointments with cardiology and primary care provider as scheduled. R1's Interagency Referral Form dated 12/10/20, identified R1 was to have follow-up appointments in one week, with cardiac surgeon in one week, with a chest x-ray just prior to the appointment, the nephrologist, and the family practice physician. Review of R1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The visit started at 9:55 a.m. and ended at 10:00 a.m. R1 was in for therapy following non-ST segment elevation [CONDITION(S)] (NSTEMI) and indicated she was doing fairly well. R1's physician note identified general appearance appears well and is pleasant and conversant today, no nursing concerns, well groomed, good eye contact, affect appropriate. The note did not address R1's SOB, emesis or any follow up appointments with surgeon or nephrologist. Review of R1's progress notes dated 12/11/20, -12/29/20, revealed the following: -12/15/20, R1 placed in isolation after c/o [complaints of] SOB. Called [NAME] in [NAME] updated MD [medical doctor]. States she has had some anxiety in the past and this is similar to the past experience, but she does not feel anxious at this time. [MEDICATION(S)] test completed and was negative. -12/15/20, lung sounds clear in upper lobes, diminished in bases -12/16/20, No SOB with activity. A note later that day indicated R1 had emesis, poor appetite and had stated the food was good but it was hard for her to swallow. -12/17/20, lung sounds clear upper lobes, diminished lower lobes, appetite good -12/18/20, Lung sounds were clear in all lobes posterior, R1 had 2+ pitting [CONDITION(S)] noted to her bilateral lower extremities from mid shin to feet and listed R1's weight that day was 169.0 pounds and was eating less than 25% of her meal. -12/19/20, 2+ pitting [CONDITION(S)] noted to her bilateral lower legs/feet, lung sounds were clear in all lobes, no complaints of SOB weight is down 1.2 pounds. Later notes indicated R1 had poor appetite and only ate 50% of evening meal. -12/20/20, R1 had trace to 1+ pitting [CONDITION(S)] noted to her bilateral lower legs and feet. She had legs elevated much of the shift. Lung sounds are clear in all lobes. A second note indicated R1 reported she had no appetite and the thought of food made her want to vomit. -12/21/20, R1 feeling weaker and not drinking well and had been nauseated and had small emesis after breakfast. Fax sent to doctor to discuss medications, her nausea and depression. -12/22/20, lung sounds clear appetite fair -12/24/20, appetite remains poor,she reports swallowing pills is painful on her throat and takes a couple of hours to take her morning pills, No response from MD for request for antidepressant, re-faxed to MD. -12/25/20, lung sounds diminished throughout, appetitive fair -12/26/20, extensive assist to bedside with weakness and SOB that happens sometimes. Very poor air movement bilateral bases and fine crackles mid lobes bilateral -12/29/20, R1 not eating well and not drinking and concerns with dehydration and abnormal labs. Discussed with R1 and family and requested transfer. The notes indicated R1 was transferred to the local hospital due to increased weakness, fatigue and not eating or drinking well. R1's progress notes did not address any follow up appointments with the cardiac surgeon or nephrologist and lacked documentation of notification of shortness of breath or activity intolerance. R1's ED (emergency department) Alomere Health in [NAME] report dated 12/29/20, at 11:20 a.m. the doctor suspected R1's persistent nausea and vomiting may have had a least some cardiac etiology. R1 would be transferred back to Essentia Health in Fargo where R1 had recent bypass surgery. The report listed R1's lab testing for Creatinine, glomerular filtration rate were elevated and BNP (a peptide which indicates heart failure) was 3588.9 pg/mL (picograms per milliliter) (reference range 0.0-100.0 pg/ml) which indicated moderate to severe CHF. R1's ambulance transfer report dated 12/29/30, at 1:37 p.m. indicated emergency department physician determined pt (patient) was having a NSTEMI and advised her that she needed to be transported by ambulance to a higher level of care for further evaluation by a cardiologist. R1's admission report to the hospital dated 12/29/20, at 5:46 p.m. physical exam identified R1 looked anasarca (a general swelling of the whole body that can occur when the tissues of the body retain too much fluid) and eccymotic all over, extremities had 3+ [CONDITION(S)]. R1's admission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Neurology consult report dated 1/2/21, at 3:42 p.m. indicated R1 was admitted to the hospital for decompensated [CONDITION(S)] and fluid overload. R1 currently feels short of breath even while sitting up. Physical examination of R1 identified significant shortness of breath all the time with bilateral crackers heard in lower lung field and 1+ pitting [CONDITION(S)] to lower extremities. R1's admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview on 1/5/21, at 2:16 p.m. FM-A indicated she had been very concerned R1 did not have any follow up visits completed, with at least the cardiologist. FM-A indicated she had contacted the facility and talked to the nurse and inquired about follow up visits. The nurse confirmed with FM-A she had failed to see the follow up visits with the cardiologist and the nephrologist and R1 had missed both appointments. During an interview on 1/5/21, at 2:44 p.m. RN-B stated the new admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-B indicated doctor appointments and transportation are expected to be scheduled and placed on a calendar by the admitting nurse located at the nurse's station. RN-B indicated staff are expected each day to check the calendar, and the list of residents with appointments, the daily outlook on the computer, and ensure transportation and appointments are arranged. RN-B verified R1 had been admitted from the hospital after having a coronary bypass and R1's orders indicated to set up appointment in 1 week after hospital discharge with her cardiologist and nephrologist. She confirmed the one weekly follow up appointments with cardiologist and nephrologist had not been scheduled and confirmed the only appointments that had been made were for the 4 week follow up. RN-B stated the follow up appointment should have been set up for the 12/21/20, I think. She confirmed R1's daughter had questioned follow up appointments and was concerned. RN-B indicated she was unsure of how the directions for follow appointments in one week with the cardiologist and nephrologist had gotten missed. During a follow up interview on 1/7/21, at 11:25 a.m. RN-B indicated on 12/29/20, prior to R1's transfer to the hospital by ambulance R1 was weak and needed assistance, no breathing problems or chest pain was noted. RN-B indicated she did not remember if R1 had [CONDITION(S)]. During review of R1's progress notes, RN-B stated she was not notified when R1 had 2+ pitting [CONDITION(S)] on 12/18/20, another nurse had been but was unaware of any follow up. RN-B confirmed when R1 had pitting [CONDITION(S)] on 12/19/20 and 12/20/20 no one had been notified. RN-B confirmed the findings noted on 12/26/20, but was not aware if the physician had been notified at that time. RN-B indicated the usual facility practice when a resident with a change in a baseline assessment and seemed concerning a doctor should have been contacted. On 1/5/21, at 4:30 p.m. during an telephone interview with family medicine physician (FMP)-A indicated he had seen R1 by Telemedicine on 12/16/20, no nursing concerns reported and doing fairly well. During an interview on 1/6/21, at 11:30 a.m. RN-C verified on 12/26/20, R1 was short of breath (SOB), very poor air movement bilateral bases, and with fine crackles in the lungs. RC-C also indicted R1 was very weak when she got her up to go to the bathroom. RN-C indicated she did not report these findings to anyone and a doctor was not notified. RN-C identified R1's primary physician had been updated with R1's poor intake, trouble swallowing and depression and indicated she did not even think about cardiac issues. RN-C indicated staff would be expected to notify and update the doctor immediately when crackles in the lungs and 2+ [CONDITION(S)] where noted. RN-C indicated when R1 became SOB and it was identified her condition was a big change the doctor should had been notified in the morning at least. RN-C indicated there were 2 appointments R1 was to be scheduled for in 1 week and verified the facility failed to schedule the appointments with cardiology and nephrology. During an interview on 1/6/21, at 1:10 p.m. director of nursing (DON) stated she was aware R1 missed only 1 cardiologist appointment and was unsure about the missed nephrology appointment. DON indicated the usual facility practice for admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . DON stated I was not aware of R1's 2+ [CONDITION(S)] and indicted if R1 had new [CONDITION(S)], with other symptoms and it was continuous the doctor should have been contacted. DON also indicated the staff did not feel like it was cardiac when R1 had been transferred to the hospital. During a phone interview on 1/6/21, at 3:10 p.m. physician assistant (PA)-A who worked with R1's cardiothoracic surgeon, indicated she saw R1 in the emergency room when she arrived by ambulance prior to being readmitted to the hospital. Her assessment included 3 + pitting [CONDITION(S)], shortness of breath, and lung sounds had rales. R1 was in heart failure and volume overload. The hospital pulled off a lot of fluid during this admission and indicated there was also a need to consult the nephrologist since R1's kidneys did not respond well to the process of removing all the fluid with diuretics and Creatinine levels increased dramatically. PA-A indicated with timely appointments with the cardiothoracic surgeon and Nephrology, the doctors could have evaluated R1's clinical status and admitted her to the hospital at that time to get things under control. PA-A stated she felt the one week follow up appointments were pretty important and adjustments of diuretics were done during those appointments. Review of facility document received on 1/5/21, titled Hospital Return Checklist with no date identified listed a check list to be completed by staff upon admission. Number 2 on checklist requested orders updated in PCC including appointments and labs per hospital return order. Have a second nurse check for accuracy. Number 8 on checklist indicated add to calendar if any new appointments. On 1/6/21 DON was unable to provide a copy of the facility admission policy and indicated the facility did not have one. DON verified the staff were expected to use the a document titled Hospital Return Checklist instead. Review of facility policy Change in Condition Monitoring revised 1/6/21, identified if a resident has a change in condition noted in respiratory status, circulatory status, mood, GI (gastrointestinal) condition, skin condition, mobility, change in sleep pattern, change in CHF that involves an increase in [CONDITION(S)] or weight gain, SOB (shortness of breath), or any other conation that is abnormal for the resident, monitoring will be set up. Change of condition will be added to the care plan. The doctor and family will be updated if appropriate. Review of facility policy Admission Vital Signs revised 2/24/16, identified the first set of vital signs will be taken when the resident enters the facility during the admission data gathering by nursing. If there is any concern regarding the vital sign readings they will be monitored at least one every four hours for the the first 24 hours following admission time at the discretion of the nurse. Healthcare provider will be notified if vital signs are not within normal limits at the discretion of the nurse, as ordered by the MD and/or as listed in Nursing Home Standing Orders.