Every finding on record at The Emeralds at Grand Rapids LLC

Based on observation, interview and document review the facility failed to keep linen carts covered that were in the communal hallways. The facility also failed to offer hand hygiene to the residents prior to meal service. Lastly the facility failed to identify and investigate a foodborne pathogen that was diagnosed in a resident. This had the potential to affect all residents in the facility. Findings include: Linen: During an observation on 6/14/26 at 2:05 p.m., the hallway clean linen cart on 300 hallway was not covered. During an observation on 6/15/26 at 9:47 a.m., the 300 hallway extra linen cart was again not covered. the green flap that should cover the cart was flipped all the way backwards and was covered with Kleenex and gloves so the flap could not be flipped forward to a closed and covered position. During an interview on 6/15/26 at 9:50 a.m., nursing assistant (NA)-A stated all carts that hold clean linens for resident use should be covered unless staff are actively at the cart removing items to use for resident care. NA-A looked at the 300-hallway cart and confirmed it had been left uncovered and no staff had been around it for several minutes. During an observation on 6/16/26 at 1:12 p.m., the 300-hallway linen cart was again uncovered. During an interview on 6/17/26 at 9:48 a.m., the director of nursing/infection preventionist (DON/IP) stated clean linen carts in the resident hallways should be covered at all times to assist decreasing contamination and possible spread of infection that might be in the facility. Hand Hygiene: During an observation on 6/14/26 at 4:59 p.m., in the main dining room, several staff were lined up outside the kitchen and take the meals plate by plate to the residents seated at tables. Residents were observed being assisted to put on clothing covers, but there were no hand cleaning wipes being offered. During an observation on 6/15/26 at 11:39 a.m., in the main dining room with several staff assisting residents to cover their clothing, bring their lunch plates, and assist some of the residents to eat their meals. Hand hygiene was not offered to any of the residents. During a continuous observation on 6/16/26 beginning at 7:13 a.m., in the main dining room it was noted there were no hand sanitizing wipes or solutions located in the work area by the entrance of the kitchen or on the dining tables where residents ate. R5 wheeled themselves into the dining room and to a table. A kitchen staff member cleared dishes from the table R5 had selected, wiped the table down, and took R5's order. Hand sanitization was not offered to R5. -At 7:25 a.m., a staff member delivered R5's food. R5 was not offered hand sanitization at that time. -At 7:28 a.m., a female resident wheeled self into dining room and to a table. Dining staff removed dirty dishes from the table and wiped the surface down. The female resident was not offered hand sanitization on arrival or when food was delivered. -At 7:32 a.m., staff wheeled in a female resident and parked resident at a table. R35 wheeled themselves in from the outside smoking area and parked themselves at a table. The female resident and R35's breakfast was delivered at 7:36 a.m. Neither resident was offered hand sanitization prior to eating breakfast. -At 7:49 a.m., a male staff wheeled a male resident in a Broda chair up to a table in the back of the dining room. Two other residents who had wheeled themselves into the dining area were moved to a table by the resident in the Broda chair. The male staff then washed their hands at the sink in the dining area and placed clothing protectors on the 3 residents. No hand sanitization was provided to the three residents before they ate their breakfast. R4: R4's significant change Minimum Data Set (MDS) dated [DATE], indicated R4 was cognitively intact. R4's admission Record (also known as face sheet) dated 6/17/26, identified a diagnosis of Enteritis due to Yersinia Enterocolitica with onset date 6/2/26. Additional diagnoses included: neuromuscular dysfunction of bladder, enterocolitis due to clostridium difficile, congestive heart failure, stage IV pressure ulcer, osteomyelitis, and paraplegia. R4's care plan identified the review start date as 4/8/26. The care plan identified R4 was on contact precautions, had a foley catheter, an ostomy, and stage IV sacral pressure ulcer. R4's Grand Itasca emergency department note dated 6/1/26, identified R4's Enteric panel had tested positive for Yersinia enterocolitica. R4 had copious amounts of output from rectal stump with proctitis and sigmoid colitis that appeared infectious/inflammatory on CT imaging. The identified plan was to administer seven days of Bactrim. R4's Grand Itaska discharge documentation dated 6/2/26, indicated R4 had been hospitalized from [DATE] to 6/2/26, with the primary diagnosis of Colitis due to Yersinia enterocolitica. Follow-up appointments were scheduled for an ultrasound and surgeon visit. Additional recommendations included primary care follow-up at the facility and to ensure R4 had an infectious disease appointment. The CDC website Yersinia Infection Clinical Overview of Yersiniosis dated March 3, 2026, indicated yersinia enterocolitica was the most common form of yersiniosis with an incubation period of 4 to 6 days which could range from 1 to 14 days. Common clinical presentation included abdominal pain, diarrhea (can be bloody and persistent for several weeks), pain that mimics appendicitis, and sore throat. The Minnesota Department of Health Yersiniosis (Yersinia enterocolitica) fact sheet dated June 2007, indicated Yersinia enterocolitica was found in wild and domestic animals. Especially pigs, but it could also be found in birds, reptiles, rodents, rabbits, sheep, cattle, horses and dogs. Human infections usually resulted from: eating contaminated food, especially raw or under cooked pork products, contact with farm animals or pets, consuming unpasteurized milk or contaminated water, touching contaminated surfaces and then touching mouth, or eating food prepared by someone infected with yersinia who did not sanitize hands properly. The facility symptom tracking log provided by the facility IP included R4 and four other residents who did not have gastrointestinal symptoms. R4's documented symptoms included lethargy, malaise, increased BMs, and fever with an onset date of 5/29/26. R4 had stool sampled and received Sulfamethoxazole/trimethoprim for 7 days. The June log did not include any other residents with gastrointestinal symptoms or a positive Yersinia result for R4. The Bowel Movement report dated 5/15/26 to 5/30/26, included documentation of BM date, time, and consistency for all residents at the facility. The BM consistency of resident BM's was predominately documented as not required which made it difficult to ascertain accurate resident diarrhea rates. Other consistency descriptions included: formed/normal, putty like and loose/diarrhea-report to nurse ASAP! (as soon as possible). Report documentation identified the following residents as having had two or more loose/diarrhea stools during the report time period: R2, R11, R13, R14, R4, R15, R16, R5, R6, R21, R22, R26, R29, R33, R36, R37, and R3. During an observation on 6/14/26 at 5:10 p.m., R4's door had a contact isolation sign on the door. On 6/15/26 at 3:32 p.m., contact isolation signage remained on R4's door. On 6/16/26 at 1:24 p.m., contact isolation signage remained on R4's door. On 6/17/26 at 10:00 a.m., contact isolation signage remained on R4's door. During an interview on 6/15/26 at 2:41 p.m., the Minnesota Department of Health Infection Control Assessment and Response (ICAR) Program nurse specialist (PNS) stated Yersinia enterocolitica should be looked at as a foodborne illness. Illness often resulted from undercooked meat, or cross contamination during preparation of raw meat in the kitchen. Raw meat would be the most likely source, especially raw or improperly handled pork. However, there are other sources from outside of the facility that could have caused the yersinia. PNS stated they would expect the facilities infection prevention to work their review process when a resident was identified with a known foodborne illness. During an interview on 6/15/26 at 3:32 p.m., R4 stated they had been in the hospital so many times for different infections, that they couldn't recall what they had been told about what infection, they thought their significant other would know more. R4 stated they all just ran together. Contact was attempted, but R4's significant other was not available for interview on 6/16/26. On 6/16/26, and 6/17/26, R4's nurse manager was not available for interview. On 6/17/26 at 9:38 a.m., the director of nursing DON and infection preventionist stated the facility performed real time symptom tracking on staff and residents. In addition, the antibiotic stewardship program also tracked symptoms, diagnostic testing and treatments. Resident symptoms such as diarrhea should be reported to the nurse, and then to IP so systems and status changes can be tracked and reviewed. The goal is to identify and detect outbreaks or illnesses like c-diff early. The DON showed symptom mapping done in May and June, each symptom was color coded. Diarrhea fell into the category described as other. Two residents were coded as other. Any resident who has experienced two or more episodes of diarrhea, should be reported to IP along with associated symptoms. The May staff log showed one non-direct care staff member had experienced diarrhea and probable norovirus (based on confirmed norovirus in their household). The facility had performed contract tracing in response to the staff illness. Resident paperwork should be reviewed by the receiving nurse when a resident is admitted or has returned to the facility after an appointment, ER visit, or hospitalization. Any infection prevention/control concerns like assessment findings, new antibiotics, lab results, or diagnoses, should then be reported to the IP for further review and tracking. R4's yersinia diagnosis should have been reported to IP when R4 returned from the hospital. Had the yersinia been identified and reported, a comprehensive review would have been completed. The dietary area would have been reviewed to see if there were any opportunities for education, BM logs would have been reviewed for possible correlations. Any needed follow-up would have been reviewed and acted upon. During an interview on 6/17/26 at 11:11 a.m., the culinary director stated most facility foods, especially the proteins and meats were raw. Raw foods went directly into the freezer and did not get pulled out until 3 days prior to them being served to allow them to thaw the correct way. When raw meat is being prepared to cook, the meat is placed in a lipped container. Only the raw meat can be on the prep table when it is being prepared. A review of the facility menu cycles on 6/17/26, showed that the facility regularly served pork products. The facility Handwashing Policy dated 2/2024, instructed to prevent the spread of infection hand washing should occur before, during and after preparing food, before eating, and after caring for someone who is sick, after using the toilet, after changing incontinent products, after touching animal or animal waste, after handling pet food or treats and after handling garbage. The facility Infection Prevention and Control Program dated 11/2024, identified the program mission was to maintain an infection prevention and control program to ensure a safe, sanitary, environment and to help prevent the development and transmission of communicable diseases and infections. The program addressed residents and staff IP and control. Key components identified included: surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection and employee health. Coordination and oversight included committee review to ensure information about culture results or antibiotic resistance was transmitted accurately and in a timely fashion and whether there was appropriate follow-up of acute infections. Culture reports, sensitivity data, and antibiotic usage reviews were to be included in surveillance activities. Prevention of infection activities included identifying possible infections or potential complications of existing infections and instituting measures to avoid complications or spreading. Monitoring Employee health included policies and procedures that included reporting infections including, but not limited to draining wounds, respiratory infection/symptoms, and frequent loose stools. The Prevention of infection section identified the IP program included identifying possible infections, instituting measures to avoid complications, and enhancing screening for possible significant pathogens. Resident and staff symptom tracking policies were requested but not received. Resident symptom tracking for May and June were requested in addition to the antibiotic stewardship logs but not received.

Based on interview and document review, the facility failed to have a new order and a face-to-face provider visit every 14 days performed prior to renewing an as needed antipsychotic medication. This affected 1 of 5 (R34) residents reviewed for unnecessary medications.Findings include: R34's significant change Minimum Data Set, dated [DATE], indicated R34 had significant cognitive impairment. Diagnoses included dementia with agitation and anxiety disorder. R34's care plan dated 3/2/26, indicated an alteration in behavior due to severe dementia with agitation, major depressive disorder, and anxiety disorder. Interventions included administer medications as ordered, monitoring for potential side effects. R34's care plan dated 4/3/26, also indicated on hospice cares related to Alzheimer's dementia with interventions that included medications as needed. R34's Order Summary Report dated 5/5/26 through 6/17/26, indicated an order for Olanzapine (antipsychotic medication) 2.5 milligrams (mg) by mouth every 6 hours (hr) as needed (PRN) for 14 days. This order had been reordered every 14 days through the listed time frame. R34's electronic medical record (EMR) dated 5/5/26, indicated hospice wrote the last order for Olanzapine 2.5mg by mouth every 6 hr PRN for 90 days. R34's EMR lacked documentation related to new orders for Olanzapine PRN written every 14 days as entered into the Order Summary Report since 5/5/26. R34's EMR also lacked documentation the provider did a face-to-face visit with the resident and justified the continued need for the antipsychotic prior to a new order being entered.During an interview on 6/15/26 at 11:25 a.m., registered nurse (RN)-B stated when a resident is on hospice and has behavior concerns, the hospice organization will order prn antipsychotics for the facility to utilize to assist in keeping the client non-behavioral and comfortable. RN-B was not sure how long the prn antipsychotic orders were good for or who made sure all of the required information is gathered prior to a new order is received. During an interview on 6/15/26 at 3:44 p.m., RN-C-cares stated hospice took care of writing and monitoring the prn medications for comfort such as pain medications and antipsychotics like Olanzapine. When hospice would write the orders for prn antipsychotics, the orders would usually be written for at least 90 days so the provider did not have to write the orders so often. The provider would only come on site and do actual face to face visits every 90 days for recertification visits. The provider never comes to the facility just for a medication renewal. The medication renewals were based on what the hospice staff reported to the provider. RN-C reviewed R34's EMR and confirmed hospice was responsible for renewing the Olanzapine 2.5mg every 6 hrs as needed order and the last written order was on 5/5/26.During an interview on 6/15/26 at 4:19 p.m., the director of nursing (DON) stated PRN antipsychotic orders were only good for 14 days, then there had to be a request made for a new order. The DON stated she was not sure of what else was required prior to getting a new order for PRN antipsychotics. There was an expectation the staff followed the policies related to medications and medication orders.Facility policy Psychotropic Medication Use dated 5/25, indicated prn orders for antipsychotics would be limited to 14 days, and not be renewed unless the provider evaluated the resident for appropriateness of the medication. The policy lacked information explaining if the evaluated needed to occur face to face or not.

Based on observation, interview, and document review, the facility failed to ensure the use of thromboembolism-deterrent stockings (TEDs) as ordered for edema care. This affected 1 of 1 (R45) resident reviewed for edema.Findings include:R45's 5-day Minimum Data Set (MDS) dated [DATE], indicated R45 was moderately cognitively impaired. Diagnoses included left lower leg closed fracture, hypertension, and arthritis.R45's provider orders dated 6/10/26, included TEDs stockings right leg on in a.m., off in p.m. every morning and at bedtime.R45's care plan reviewed 6/15/26, did not include right pedal edema or the prescribed intervention of TEDs.R45's treatment administration record (TAR) dated 6/2026, included TEDs stockings to right leg on in a.m., off in p.m. every morning and at bedtime, start date 6/10/26.During an observation on 6/14/26 at 3:31 p.m., R45 was sitting in bed with legs elevated, right foot noted to be edematous with no TEDs stocking. R45 stated they were concerned about their swollen right foot, and their provider told them to keep it elevated.During an observation on 6/15/26 at 12:57 p.m., R45 was in their wheelchair with feet elevated on bed, non-slip sock on right foot, no TEDs stocking.During an observation on 6/16/26 at 10:46 a.m., R45 was in their wheelchair in the dining room. R45 stated their right leg felt tight and lifted their pant leg to rub on right shin and calf. Right leg noted to be edematous into calf, with a sock and shoe on the right foot, no TEDs stocking. R45 stated they were going to physical therapy. During an interview on 6/15/26 at 2:08 p.m., nursing assistant (NA)-B stated when TEDs are ordered, day shift puts them on the resident and evening shift removes them at bedtime. NA-B stated R45 had an ACE wrap on the left foot and stated they were not aware R45 was to wear TEDs on the right leg.During an interview on 6/15/26 at 2:09 p.m., licensed practical nurse (LPN)-A stated the aides put TEDs stockings on residents when ordered. LPN-A stated R45 was new to them. After reviewing R45's orders, LPN-A confirmed R45 had an order for TEDs to the right leg, and stated the TEDs were important for treating R45's edema.During an interview on 6/16/26 at 12:31 p.m., director of nursing (DON) confirmed R45 had orders for TEDs to the right leg. DON reviewed TAR documentation and stated the nursing staff charted the TEDs application and removal for the last few days.During an interview on 6/16/26 at 1:33 p.m., other staff (O)-C stated R45 came to their therapy appointment around 11 a.m., with a sock and shoe on the right foot, and O-C applied TEDs to R45's right leg during the therapy appointment. O-C stated R45 had right foot and lower leg edema.Medication and Treatment Orders policy dated 2/2024, instructed orders for medications and treatments will be transcribed accurately and in a timely manner.

Based on observation, interview and document review, the facility failed to provide monitoring to a dialysis site following a dialysis treatment for 1 of 1 resident (R9) reviewed for dialysis care.Findings include:R9's quarterly minimum data set (MDS) dated [DATE], identified intact cognition and diagnoses of end-stage renal failure, and anemia in chronic kidney disease. The MDS also reflected R9 had dialysis treatments while a resident.R9's provider orders dated 8/27/25, identified to offer rest and a snack after dialysis, to take and record vital signs after dialysis, to monitor fistula (a surgically created connection between an artery and a vein to provide access for dialysis treatment) for bruit (a whooshing sound heard with a stethoscope) and thrill (a powerful pulse felt at the top of the fistula) every shift and to notify provider if these were not found, and to monitor dialysis site every shift for bleeding and to call 911 if bleeding was noted.R9's care plan dated 9/25/24, identified a focus statement for alteration in blood formation and coagulation related to use of anticoagulant medication and included interventions to give anticoagulant medication as ordered, to monitor and notify provider of bleeding. On 6/18/25, a focus statement for risk for complications related to dialysis and included interventions to call 911 for uncontrolled bleeding at fistula, dialysis on Mondays, Wednesdays, and Fridays, to provide treatment and dressings to dialysis site per provider order, send communication folder to dialysis with each run, and fluid restrictions per provider order.During observations and interview on 6/15/26 at 4:04 p.m., R9 was sitting in her wheelchair at the counter in the activity area eating. R9 stated she had just returned from dialysis and the nurse had not seen her yet, normally they take her blood sugar and blood pressure. At 4:07 p.m., R9 was at the nurse's station and registered nurse (RN)-A was checking her vital signs, R9 was observed to be wearing a long-sleeve sweatshirt and RN-A asked her if the left arm was ok for blood pressures and R9 said yes. RN-A remarked her blood pressure was a little high and was recording the value on a clipboard. R9 headed to her room, then came back down the hall at 4:15 p.m. with some coloring materials and went outside to the smoking area. At 4:21 p.m. RN-A stated the first thing they should do was to check vitals, check the thing in their arm, and give them their meal. RN-A confirmed she had not looked at R9's fistula yet.During an interview on 6/17/26 at 8:25 a.m., dialysis clinical manager (CM)-A stated it was important they were checking her fistula site once a shift, but it should be visualized and monitored right after she returns from the dialysis run because the resident would be at risk for bleeding or complications. During an interview on 6/17/26 at 10:36 a.m., the director of nursing (DON) stated her expectation was after a dialysis run, making sure to check the site any excessive bleeding, doing the vitals and any follow up with the communication they send back and forth.A policy, Hemodialysis dated 11/22/19, identified the facility will ensure that residents who require dialysis, receive such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Ongoing assessment and evaluation of the resident's condition and monitoring for complications should occur before and after dialysis treatments (i.e. infection and patency of fistula or graft).

Based on observation, interview, and document review the facility failed to ensure daily staffing data was posted over the weekend. This deficient practice had the potential to affect any resident, family member, or visitor who wished to view the posting.Findings include: During an observation on 6/14/26 (Sunday) at 1:30 p.m., the facility staffing data sheet was posted in the main entrance. The documented read Day of week: Friday, Today's Date: 6/12/26.During an observation on 6/14/26 at 6:57 p.m., it was noted the 6/12/26 posted staffing data sheet had been taken down and replaced with a staffing data sheet for Sunday, 6/14/26. During an interview on 6/17/26 at 12:36 p.m., The administrator stated staffing sheets should be posted each morning and indicated it was the night staff's responsibility to review, make changes if needed, and then post. The administrator confirmed Saturday and Sunday staffing sheets had not been posted in the morning as expected.

Based on interview, and document review the facility failed to reduce the risk of falls for 1 of 3 residents (R1) reviewed when R1 was care planned to use two staff for transfers with a mechanical lift and nursing assistant (NA)-A attempted a mechanical lift transfer with one staff, R1 fell from the sling onto the floor sustaining a left femur fracture, head laceration and injury to left toes. The immediate jeopardy began on [DATE] when NA-A attempted a mechanical lift transfer with one staff, R1 fell from the sling onto the floor sustaining a left femur fracture, head laceration, and injury to left toes. R1 was care planned to use two staff for transfers with a mechanical lift and was identified on [DATE]. The administrator and director of nursing (DON) were notified of the IJ on [DATE] at 2:48 p.m. The immediate jeopardy was removed on [DATE] when the facility provided staff education and lift inspections, and the deficient practice corrected on [DATE], prior to the start of the survey and was therefore Past Noncompliance.Findings include: On [DATE] at 12:33 p.m., a tour was completed of the campus which identified seven mechanical EZ-Way lifts (Model L500PN) in the hallways for use. There were no slings present with the machines and each of them demonstrated no obvious defects when pushed, pulled, brakes locked/locked and inspected. R1's current care plan, initiated [DATE] indicated R1 was at risk for falls due to her impaired mobility and listed a goal [R1] will be safe and free from falls. The plan listed interventions to help R1 meet that goal including Hoyer lift with 2 staff for all transfers. The plan continued and identified R1 had deficits related to Transfer/Bed/Mobility/Ambulation and listed interventions Assist of two with Hoyer for all transfers. Resident prefers to have sling left on when in wheelchair. Resident is a M beige full body sling. R1's Lift/Mobility Status Form dated [DATE], identified R1 frail skin, and contractures, R1 required a full body mechanical lift with two staff assistance. In the comments/notes column it indicated R1 was to be an assistance of two staff with mechanical (Hoyer) lift. R1's quarterly Minimum Data Set (MDS), dated [DATE], identified R1, required assistance of two or more staff for all transfers. R1 had normal cognitive function with no or very minimal memory or thinking impairment. R1's progress note, dated [DATE] at 12:50 p.m., indicated R1 was found lying on the floor with blood on left side of her head and left toes. NA-A reported R1 slide out of the Hoyer sling during transfer onto the shower chair and that the transfer was done by one staff member. R1 was alert and oriented x 4 but in excruciating pain left lower extremity 10/10 and could not move left lower extremity. 911 was called and R1 was sent to the hospital emergency department (ED) for evaluation. R1's ED after visit summary note dated [DATE], indicated R1 sustained left femoral fracture. Orders included Morphine Sulfate (Concentrate) Solution 20 mg/ml, give 20 mg by mouth every 3 hours for pain, and brace to left leg. R1's Radiology Report, dated [DATE], identified acute mildly displaced and moderately angulated fracture of the distal femoral shaft. The report identified, [Shoulder] Results: Fracture of the surgical neck. No dislocation of the head . Conclusion: Acute appearing fracture of the surgical neck as noted. R1's progress note, dated [DATE] at 3:40 p.m., indicated R1 returned to facility from hospital new order received. Brace on at all times per her comfort. A provider note dated [DATE] at 9:06 a.m. indicated R1 fell from lift and sustained a left femoral fracture, laceration to scalp and cut to toe. Plan at this time after major discussion with family agreed on hospice consult. Given the fact that she does have a major bone fracture at this time, not going to be ambulatory, and is generally declining. Patient was agreed to having comfort cares at this time. On [DATE], at 10:18 a.m., during an interview NA-B stated staff used the mechanical lifts regularly during their shift to help transfer residents if they are care planned for the lift. NA-B explained use of the device while demonstrating the use of machine while transferring a resident with the assistance of NA-C. NA-B stated each resident had their own personal sling, the sling is placed underneath them and crossing the leg straps, securing it to the metal hanger bar using the colored loops. They need to make sure and check the sling for any rips or tears as well as that it is securely looped through and that the sling is centered prior to initiating the transfer. NA-B stated resident sling size was determined by the individual resident's weight which is noted on the resident's care plan sheet. Each machine also has the sling size label posted on the mechanical lift as well as a sling color chart located in linen closets on each unit for reference. NA-B stated they received education on use of the mechanical lifts when they started at the care center as well as annually. All staff recently had training on the along with additional education in the past few days as someone had fallen from the lift. On [DATE], at 1:19 p.m. during an interview NA-C stated two staff must always be assisting with mechanical lifts. Residents' care plan indicates for staff if the resident is one or two staff assistance for transfers, however for mechanical lifts there are always two staff needed for the transfer. NA-C stated there were enough staff for safe transfers and would use the radio/walkie talkie to call for staff assistance with a transfer. Recently we have had re-education for safe use of mechanical lifts. On [DATE] at 3:32 p.m. during interview, NA-A stated she made the decision to transfer R1 with the use of the mechanical lift by herself rather than ask another staff to come and assist. R1 was care planned for assistance with all transfers with the Hoyer and two staff at all times. She did not use her walkie to call for another staff member to assist but should have. NA-A stated if there had been another staff present for the transfer one staff could have been operating the lift remote and the other staff would have been with the resident guiding the resident in the sling. Facility training and policy was to follow the care plan which directed all transfers for R1 required assistance of two with the mechanical lift. When R1 fell she immediately yelled for assistance, R1 was on the floor in pain. She was suspended right after and then terminated for not following R1's care plan and facility policy. Received educated on using the mechanical lifts and importance of two staff assisting with the transfer prior to the incident on [DATE]. On [DATE] at 8:51 a.m. during an interview, director of nursing (DON) DON stated all nursing staff receive training on mechanical lifts upon hire as well as annually through competencies/training. Important and expectation was for all staff to follow individual residents' care plans to provide care in a safe setting. DON verified NA-A had not followed R1s care plan nor had she followed facility policy/procedure. R1 required assistance from two staff with the use of a mechanical lift for all transfers. As a result of NA-A not following R1's care plan, R1 sustained significant injuries which included left femur fracture, head laceration, and injury to left toes. Her expectation was all staff are following not only residents individual care plans but all facility policies and procedures to ensure care is being provided in a safe setting and in this case it was not. On [DATE], at 11:27 a.m. during an interview, facility administrator stated she arrived at the facility immediately after she was notified R1 had fallen from a mechanical lift. Facility DON arrived shortly after she had arrived. NA-A admitted to her at that time she did not follow R1's care plan and transferred R1 by herself. NA-A was suspended pending the investigation and terminated on [DATE]. NA-A did not follow R1's care plan by transferring R1 without a second staff member for transfer using a mechanical lift resulting in a fall from the Hoyer lift and substantial injury. All staff present at the time were interviewed and the incident was reported to the state agency. Education was started immediately with all staff members on mechanical lifts and following residents' care plans. We also educated all staff members on reporting immediately if they observe any staff, not following residents' care plans and our facility policy. The facility also interviewed residents who were cognitive and required the assistance of two staff members to ensure no other incident occurred. Maintenance staff inspected all mechanical lifts in the building to ensure all were in proper working order. All staff are trained to follow the individual resident care plan and facility policy/ procedure. This was not followed on [DATE], and as a result R1 was significantly injured. On [DATE], at 12:55 p.m., during interview R1's family member (FM)-A stated he had received a telephone call on [DATE] in the morning from R1 stating she had fallen out of the mechanical lift and was hurt. FM-A stated NA-A told him that she had attempted to transfer R1 with the mechanical lift by herself and she should have had another staff member assisting with the transfer. FM-A stated because of the fall R1 sustained a left hip fracture and laceration to the head. R1 returned to the facility that same day and quickly declined. R1 was placed on hospice and died on [DATE]. FM-A stated if there had been two staff members as required with the mechanical lift, maybe this would not have happened. The EZ Way Classic Lift Operator's Instructions, undated, provided by the facility identified directions for the lift devices used by the care center. This included a section labeled, Safety Notes, which directed multiple items including, The EZ Way Smart Lift(tm) was designed to be operated safely by one caregiver. However, depending on the situation, facility policy, and the patient's condition, two caregivers may be necessary. The facility Safe Resident Handling Program Policy, revision date 11/2025, directed all resident care will be provided in a safe, appropriate, and timely manner in accordance with the individual resident's care plan. A facility Care Planning policy, revision date 11/2024, directed the care plan shall be used in developing the resident's daily care routines and will be utilized by staff personnel for the purpose of providing care or services to the residents. A facility policy was requested specifically for Mechanical Lifts/Hoyer; however, the facility did not provide. The past noncompliance immediate jeopardy began on [DATE]. The immediate jeopardy was removed on [DATE] and the deficient practice corrected by [DATE], after the facility implemented a systemic plan that included the following actions: Education and competencies for all clinical staff on safe use of mechanical lifts, and safe resident handling policy, as well as vulnerable adult policy for all facility staff.

Based on interview and document review the facility failed to ensure controlled substances were accurately reconciled to prevent loss and diversion for 6 of 6 residents (R1, R2, R3, R4, R5, R6,) reviewed for narcotic diversion. A report to the State Agency (SA) dated 11/25/25, indicated a police report identified medications were found in possession of a former employee of the facility. The report identified the following medications and empty packages.Prescribed to R1:Hydrocodone/acetaminophen 5 milligrams (mg) -325mg, total prescribed 18.Prescribed to R2:Clonazepam 0.5 mg empty, total prescribed 29.Prescribed to R3:Gabapentin 100 mg, containing 4 tablets, total prescribed 30.Prescribed to R4:Lorazepam 1mg, total prescribed 30.Prescribed to R5:Oxycodone 5 mg empty, total prescribed 28.Oxycodone 5 mg empty, total prescribed 8.Prescribed to R6:Morphine 5 mg containing 11 tablets, total prescribed 30 of 60.Morphine 5 mg containing 19 tablets, total prescribed 30 of 60.Gabapentin 600 mg, containing 1 tablet, total prescribed 30 of 90.Lorazepam 0.5 mg empty, total prescribed 30 of 60.Gabapentin 600 mg empty, total prescribed 30 of 90.Gabapentin 600 mg empty, total prescribed 30 of 90.R1's admission Record indicated diagnosis of sepsis, hypertension, anxiety and depression. R1 discharged from the facility 1/10/25.R1's Physician order Summary printed 12/23/25, identified the following order:Hydrocodone-acetaminophen oral tablet 5 mg - 325 mg. Give one tablet twice daily by mouth as needed.R2's admission Record indicated diagnosis of Spondylosis, chronic pain, anxiety and depression. R2 discharged from the facility 8/27/25.R2's Physician order Summary printed 12/23/25, identified the following order: Clonazepam oral tablet 0.5 mg. Give .5 mg twice daily.R3's admission Record indicated diagnosis of fracture of left pubis, rib fractures, coccyx fracture and weakness. R3 discharged from the facility 10/23/25.R3's Physician order Summary printed 12/23/25, identified the following order:Gabapentin oral capsule 100 mg. Give one capsule by mouth at bedtime.R4's admission Record indicated diagnosis of heart failure, diabetes, hemiplegia and chronic kidney disease. R4 discharged from the facility 4/15/25.R4's Physician order Summary printed 12/23/25, identified the following order:Lorazepam 1 mg tablet. Give one tablet my mouth every eight hours as needed.R5's admission Record indicated diagnosis of pneumonia, heart failure, anxiety, depression and dementia. R5 discharged from the facility 3/19/25.R5's Physician order Summary printed 12/23/25, identified the following order:Oxycodone hydrochloride 5 mg. Give one tablet every six hours as needed.R6's admission Record indicated diagnosis of palliative care, anxiety, depression and dementia. R6 discharged from the facility 2/14/25.R6's Physician Order Summary printed 12/23/25, identified the following orders:Gabapentin oral tablet, 600 mg. One tab my mouth three times daily.Lorazepam oral tablet, 0.5 mg. Give by mouth every four hours as needed.Morphine Solutab, 5 mg. Give every four hours as needed.Facility Document's titled Record of Disposal identified the following:11/27/24, Medications destroyed.12/10/24, Medications destroyed.4/8/25, Medications destroyed.6/10/25, medications destroyed.6/13/25, medications destroyed.The disposal records lacked evidence of medication destruction from January 2025- March 2025 and May 2025. None of the destruction logs contained the names of the residents and correlating medications identified in the report.During interview on 12/18/25 at 11:31 a.m., the director of nursing stated the process for medication destruction was to perform a weekly inventory. The DON stated when she destroyed medications, she and another nurse brought the medications to the safe and destroyed them. The DON stated she kept a destruction log of all the medications destroyed. The DON stated the disposal system had a padlock and only herself and the pharmacy had keys.During interview on 12/18/25, at 11:35 a.m., the administrator stated the facility had received a call from the Sherrif on a Saturday that a former employee was in possession of medications from prior residents of the facility. The administrator stated the former employee had not worked at the facility since May of 2025. The administrator stated the facility had done an internal audit and were unable to locate destruction logs. The DON, present during the interview stated the pharmacy had to get the medications out of the safe but they did not reconcile the medications with facility staff. During interview on 12/18/25 at 1:03 p.m., trained medication aide (TMA)-A stated she had signed off on the narcotic log that medications had been destroyed and would go with the DON to place them in the box. TMA-A said there had been times when she was very busy and had signed off in the narcotic book without observing the destruction.During interview on 12/18/25 at 2:41 p.m., the DON said in order to pull the medication destruction box, both the facility and the pharmacy keys were required. The DON stated when she had destroyed medications with the former director of nursing, she had watched her place the medications into the box. The DON said there was no way the former DON could have gotten the medications back out of the box. Facility policy Disposal Medication and Medication Related Supplies dated May 2022, indicated Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal and state laws and regulations. The director of nursing, in collaboration with the consultant pharmacist, is responsible for the facility's compliance with federal and state laws and regulations in the handling of controlled medications. Only authorized licensed nursing and pharmacy personnel have access to controlled medications.When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It is destroyed in the presence of [two licensed nurses], and the disposal is documented on the accountability record/book on the line representing that dose. The same process applies to the disposal of unused partial tablets and unused portions of single dose ampules and doses of controlled substances wasted for any reason.All controlled substances remaining in the facility after a resident has been discharged , or the order isdiscontinued, are disposed of:1) In the facility by the [administrator], director of nursing and/or consultant pharmacist (or othersas allowed by state law); OR2) By returning to the Drug Enforcement Administration (DEA); OR3) By retaining for destruction by an agent of the DEA; OR4) By sending to the appropriate state agency or pharmacy as directed by state laws, regulations,and/or the DEA.When controlled medications are destroyed at the facility, licensed staff as allowed by state law willwitness the destruction and ensure that the following information is entered on the individual controlledsubstance accountability record/book:1) Date of destruction.2) Resident's name.3) Name and strength of medication.4) Prescription number.

Based on interview, and document review the facility failed to notify the provider as ordered for a weight increase of 3 pounds (lb.) or more in 24 hours for 1of 2 residents (R27). The facility also failed to follow fluid restrictions as ordered for 2 of 2 residents (R27, R28). The facility also failed to address elevated blood glucose levels for 1 of 1 resident (R16). The facility also failed to have a resident assessed for usage of a walker for 1 of 1 resident (R12) reviewed for provider orders. Findings include: R27: R27's annual Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition. Diagnoses included anemia, coronary artery disease and renal failure. R27's care plan dated 9/25/24, indicated a risk for complications related to dialysis. Interventions included fluid restriction per order. R27's Order Summary Report (OSR) dated 2/4/25, indicated R27 was on an IDDSI level 7 regular texture diet with a 1500 milliliter (ml) fluid restriction. R27's OSR as indicated on 12/7/24 R27 was placed on a 2000 ml fluid restriction. Review of R27's MAR from 2/25 and 3/25 indicated the following: - During 2/25 R27 received more than 1500ml of fluid 2 times and lacked documented fluid amounts for at least one shift 10 days. - During 3/25 R27 received more than 1500 ml of fluid 2 times and lacked documented amounts for at least one shift 7 days. R28's quarterly MDS assessment dated [DATE], indicated intact cognition. Diagnoses included heart failure, hypertension and post kidney transplant. R28's care plan dated 3/19/25 indicated a potential for altered nutrition status with interventions of weekly weights and offer adequate fluids at and between meals. The care plan lacked information related to daily weights or fluid restrictions. R28's OSR dated 1/27/25, indicated a heart healthy diet with a 2000 ml fluid restriction. The OSR also indicated on 12/20/24, orders were placed to weigh daily and notify the provider with a weight gain of 3 lbs in 24 hours or 5lbs in 1 week. Review of R28's MAR and Treatment Administration Record (TAR) from 1/25 through 3/25 indicated a lack documentation the fluid restriction was being monitored as ordered. Review of R28's MAR and TAR from 1/25 through 3/25, indicated the following: - A 24 hr 4 lb weight gain on 2/11/25, and a 4.6 lb weight gain on 2/13/25. Daily weights were missed 3 times. - A 24hr 6lb weight gain on 3/10/25. Daily weights were missed 6 times. R28's medical record for 1/25 through 3/25, lacked documentation the weights over 3lbs in 24 hrs or missed recieved a provider notification During an interview on 3/25/25 at 2:48 p.m., nurse assistant (NA)-C stated daily weight would be obtained by the NA's usually on day shift and then given to the nurse to enter into the medical record. For residents on a fluid restriction, the nursing staff would keep track how much fluid the resident took in during meals and throughout the day, minus fluids given with medications, and that would be given to the nurse to enter into the medical record and keep track of. During an interview on 3/27/25 at 12:48 p.m., registered nurse (RN)-B stated she was not sure how documentation would be done to show weights were called to provider or fluid restrictions were followed but did believe there was some documentation that went into the medical record to show it was completed. RN-B reviewed R27's and R28's medical record and indicated there was no documentation related to fluid restriction orders or weight orders being followed or that the provider was notified when needed. During an interview on 3/27/25 at 1:58 p.m., the director of Nursing (DON) stated staff should follow provider orders and follow the policy related to provider notifications. 47263 R16: R16's quarterly Minimum Data Set (MDS) dated [DATE], indicated R16 was cognitively intact and received insulin injections daily. R16's Diagnosis Report dated 3/27/25, included diagnoses of multiple myeloma, coronary artery bypass, diabetes type II with chronic kidney disease, diabetic neuropathy, heart failure, and hypertension. R16'a Careplan last reviewed on 3/19/25, included the following: Potential for alteration in blood sugar related to diagnosis of diabetes. Goal: resident will be free from hyper/hypo glycemic episodes with the following interventions: -Encourage diabetic HS snack. -Labs per MD order -Monitor resident for signs/symptoms of hyper and hypoglycemia. -Monitor residents blood sugar as ordered. -Administer scheduled and sliding scale insulin as ordered. -Administer medication as ordered. -Diet as ordered. Encourage resident to follow prescribed diet. R16's Order Summary Report for 2/1/25 to 2/28/25, included an order, dexamethasone oral tablet 4mg give 5 tablets by mouth one time a day every seven days for cancer treatment. Start date 3/2/25. R16's Order Summary Report Active orders as of 3/27/25, included the following orders: -consistent carbohydrate diet -blood sugar monitoring via finger stick 4 times a day -monitor for s/s of hyper/hypoglycemia including but not limited to lethargy, sweating, weakness, confusion, pale, vomiting, and excessive thirst every shift -Lantus subcutaneous solution pen-injector. Inject 12 units subcutaneously at bedtime related to diabetes type 2 -Lantus subcutaneous solution pen-injector. Starting 3/27/25, inject 15 units subcutaneously at bedtime related to type two diabetes. -Novolog flex pen solution pen-injector. Inject 4 units subcutaneously three times a day related to diabetes type 2 R16's careplan and current orders lacked parameters for provider notification and instruction on actions to be taken in the event R16 became hyperglycemic or hypoglycemic. R16's careplan did not identify R16 was receiving steroids, nor did it include a focus area with goals and interventions for steroid use/monitoring. Prior to 3/24/25, R16's most current in-person provider encounter at the facility was documented as 1/23/25. R16's nursing notes included the following: -A note on 3/23/25 indicated the on-call provider had been notified of a blood sugar reading of 485. The provider did not give any orders. -A note on 3/24/25, indicated the on-call provider had been notified of a blood sugar reading of 598. A one-time order for NovoLog 4 units was received and would be administered to R16. R16's medical record lacked evidence of provider notification for blood sugar values greater than 400 on 3/26/25, 3/21/25, 3/20/25, 3/13/25, or 3/6/25, In addition the chart lacked evidence a provider had been notified R16's blood sugars had been trending up. R16's Essentia Health Lab Report result for a hemoglobin A1C drawn on 1/14/25, showed that R16's A1C was 6.4 which meant that R16 had an estimated average blood glucose of 137mg/dl. The blood glucose values listed on the Weights and vitals Summary effective 1/1/25 to 3/31/25, were reviewed. Summarized documented blood glucose values between 3/1/25 and 3/27/25, showed R16 had had 8 blood glucose readings greater than 400 mg/dl, 20 readings greater than 300 mg/dl, 17 blood glucose readings below 200 mg/dl, with all other values falling between 200 and 299 mg/dl during the time period reviewed (R16 blood glucose testing was ordered four times a day). During an interview on 3/24/25 at 3:00 p.m., R16 stated they had had a high blood sugar, and the doctor never treated it with insulin. R16 stated they knew the high sugars were not good for them, but the nurse had said the doctor didn't want to treat it. R16 indicated they had requested to talk to a doctor about their high blood sugars. During an interview on 3/27/25 at 8:16 a.m., R16 stated they continued to worry about their blood sugar values, and explained they could go into a diabetic coma if their blood sugars got to high. R16 also worried about their eye sight getting worse because of their blood sugars. R16 stated they had told staff they were very concerned about their blood sugars and had also asked to be seen by a provider, but nobody had seem them since January. R16 indicated their blood sugars had been better before they started steroids, usually below 200 and rarely over 300, but now they were high all the time and they knew they needed more than a one time dose of insulin to take care of it. During an interview on 3/27/25 at 12:34 p.m., the director of nursing (DON) pulled up and reviewed R16's blood sugar record in the EMR. The DON confirmed R16's blood sugars had been consistently high and stated R16 frequently ate high carb take meals. R16's prescribed steroids would also elevate blood sugars. The DON stated they would expect nurses to notify the provider when blood sugars were in the 400-500s. In addition, they expected the provider would be notified if a resident was trending with high blood sugars. Registered nurse consultant (RNC-D) was present at the interview and stated they did not see a note that indicated R16 had been seen by a provider in February or March. Nor did they see nursing documentation that a provider had been notified of trending blood sugars or greater than 400 values other than on 3/23 and 3/24/25. RNC-D reviewed R16's A1C lab results and stated R16's A1C had been good in January. The DON stated R16 was medically complicated with several chronic diseases including cardiac issues which could be negatively impacted by higher blood sugars. R16's organs would have to work harder and R16 was at risk for hospitalization and DNK [diabetes ketoacidosis, a life threatening condition where the body does not have enough insulin, the body then makes ketones, which leads to the blood becoming too acidic] due to the high sugars. During an interview on 3/27/25 at 12:59 p.m., R16's nurse practitioner (NP-E) stated they had been contacted for a high blood sugar, and had ordered insulin coverage however, they had not been informed R16's blood sugars had been trending high. NP-E stated they would expect a call immediately for a blood sugar over 400 so the blood sugar(s) could be addressed. In addition, they expected it would be communicated to them if a resident's blood sugar started trending up averaging in the 200s to 300s. NP-E explained trending high blood sugars could result in further amputations, kidney issues, changes in vision, organ stress or complications like DNK for R16. If it had been communicated to them that R16's blood sugars were averaging greater than 200 with values around or greater than 400, R16's insulin would have been adjusted to address those values in addition to treatment of the reported high value. All polices and protocols related to blood glucose monitoring and management were requested. RN-D indicated the facility did not have a specific glucose management policy and indicated they would reference the Med and TX order policy for following provider orders. The Medication and Treatment Orders policy dated 2/2024, was reviewed. The policy did not address or instruct staff on diabetes management, nor did it provide actions/intervention to take or instruct when to notify the provider in the event a resident experienced hyper/hypoglycemia. 49877 R12: R12's annual minimum data set (MDS) dated [DATE], identified R12 was cognitively intact and diagnosed with arthritis, depression, schizophrenia, spondylosis in lower back (degenerative condition of spinal discs and joints causing pain and stiffness), and sciatica on the right side (pressure in the lumbar spine which causes radiating pain from the buttocks down the leg). MDS further identified R12 uses a wheelchair and requires partial to moderate assistance (worker does less than half of the effort) to transfer from a sitting to standing and standing to sitting position. R12's care plan reviewed on 3/25/25, identified R12 required the assist of 1 with toileting and used a bedpan. R12 had alteration in mobility related to increased weakness and the need for assistance with mobility. R12 will move safely within the environment, used a wheelchair for locomotion, and required moderate assist of 1 for wheelchair to toilet transfers. R12's active orders dated 3/5/25, identified physical therapy (PT) and occupational therapy (OT) to evaluate and treat for mobility. R12's progress note dated 3/16/25, identified R12 had requested to be seen again by PT. No additional progress notes were made from 3/16/25 to 3/25/25. R12's medical recorded lacked a risk versus benefit form related to the use of a walker completed prior to 3/25/25. During interview and observation on 3/24/25 at 3:36 p.m., R12 stated she would like to use a walker to assist with bathroom transfers instead of using a bedpan. R12 identified over the past several weeks she has reported this to nursing staff, requested to be provided with a walker, and to be seen by PT but no action had been taken. Approximately two weeks ago R12's father purchased her a walker and had it delivered to the facility. R12 stated after the walker was delivered, she was assured maintenance would assist with assembly, but no action had been taken. An unopened box identified as containing a 4-wheeled walker was noted in R12's closet. During interview and observation on 3/25/25 at 1:29 p.m., R12 reported a housekeeper put in a maintenance request to have her walker assembled. Maintenance worker was observed removing the box which contained the walker from the R12's room. During interview on 3/25/25 at 1:32 p.m., licensed practical nurse (LPN)-E confirmed R12 had requested to be seen by PT. LPN-E identified R12 made this request approximately 2 weeks ago. LPN-E reported the request to the director of nursing (DON) and documented it in R12's progress notes. During interview on 3/25/25 at 1:49 p.m., occupation therapist (OT)-B explained any resident who was provided with or obtained a walker must be assessed prior to its use to assure the walker was the correct type, height, and safe to use. Assessment prior to the use of a walker was a standard of care. (OT)-B reviewed R12's therapy documents and confirmed R12's did not have a current PT/OT referral and R12's medical record did not contain any therapy related documents (progress notes, screenings, or plan of care) which occurred in the past 30 days. During observation on 3/26/25 at 10:38 a.m., R12 had an assembled 4-wheeled walker at the foot of her bed. During interview on 3/27/25 at 9:45 a.m., R12 explained maintenance had returned the assembled 4-wheeled walker on 3/25/25. R12 reports she has been using the walker for the past 2 days and was not assessed or provided with education from nursing or PT/OT staff prior its use. R12 identified feeling a little scared and shaky while using the walker because it moves faster than she had expected. During interview on 3/27/25 at 10:42 a.m., DON expects nursing leadership be made aware of a resident's request for a walker. Nursing leadership will notify the provider who will, if warranted, order a PT/OT evaluation. PT/OT will be made aware of the order no later than the following day. The timeframe in which a resident will to be evaluated by PT/OT was in the facility policy. If a resident brings a walker into the facility DON identifed immediate action needs to be taken to evaluate the resident for safety. Depending on the resident this may include PT/OT evaluation, resident education, or the completion of a risk verse benefit form. A policy for PT/OT evaluation and treatment was requested but not provided.

Based on observation, interview, and document review, the facility failed to maintain proper food storage temperature in a unit refrigerator containing resident food. Furthermore, the facility failed to ensure refrigerated food items were properly labeled and dated. This deficient practices had the potential to affect all residents and visitors using unit refigerators to store food. Findings include: During observation on 3/26/25 at 10:41 a.m., unit refrigerator on wing 3 was reviewed. Refrigerator temperature read 50 degrees on both thermometers inside fridge. The following items were found: -french onion dip container with expiration date of November 11, 2024. -package of sliced cheese labeled with resident name without opened on date. -package of sliced deli meat labeled with resident name without opened on date. -large bottle of pedialyte beverage labelled with open date of 11/25/24 and name of resident that discharged in December of 2024. During followup observation on 3/26/25 at 3:32 p.m., unit refrigerator on wing 3 was reviewed. Refrigerator temperature read 50 degrees on both thermometers inside fridge. During interview on 3/26/25 at 3:34 p.m., nursing assistant (NA)-B verified both thermometers inside unit refrigerator on wing 3 read 50 degrees. During interview on 3/26/25 at 3:48 p.m., registered nurse (RN)-B verified contents of unit refrigerator on wing 3. RN-B further verified temperature on both internal thermometers read 50 degrees. RN-B stated 50 degrees was too warm for safe food storage and all perishable foods from the fridge would be thrown out. RN-B stated staff should have made a maintenance request to have the fridge looked at due to high temperaure. During observation on 3/27/25 at 7:23 a.m., unit refrigerator on wing 3 had been removed from the unit. During interview on 3/27/25 at 1:04 p.m., administrator stated unit refrigerator from wing 3 had been removed for resident safety. Administrator confirmed 50 degrees to be an unsafe temperature for food storage as it could increase the chances for food-borne illness and adverse effects. Administrator also stated expectation for staff to label resident food with date and resident name. Undated Refrigerators and Freezers policy identified 'acceptable temperature ranges are 35 degrees to 40 degrees for refrigerators.' Policy stated 'supervisor will take immediate action if temperatures are out of range.' Policy further identified 'all food shall be properly dated.'

Based observation, interview and record review the facility failed to ensure nebulizer equipment was properly washed, dried and stored for 2 of 2 residents (R29, R14); that equipment for tube feeding tube flushes was properly dated, rinsed, dried and stored for 1 of 1 residents (R16); and the facility failed to ensure proper PICC line cap placement occured for 1 of 1 resident (R200) who were reviewed for infection prevention and control. Findings include: R29: R29's quarterly MDS dated [DATE] indicate R29 was cognitively intact. Diagnoses included anxiety, depression and post-traumatic stress disorder. R29's Medication Admin Audit Report dated 3/27/25, indicated R29 had orders for Ipratopium-albuterol inhalation solution 0.5-2.5mg inhaled 4 times a day. On 3/26/25, a dose had been set up at 11:38 a.m. During an observation on 3/24/25 at 6:40 p.m., a nebulizer cannister was observed full of a liquid substance. During a second observation on 3/26/25 at 12:53 p.m., again a nebulizer cannister was observed full of liquid substance, not running, and no medical staff with him. At that time R29 turned on the nebulizer machine and started administering the liquid in the nebulizer cannister. During an interview on 3/26/25 at 12:56 p.m., LPN-B entered R29's room and confirmed R29 had a full canister of liquid in the cannister he was administering medication with. LPN-B reviewed R29's medication administration record (MAR) and stated the last documented administration of inhaled nebulizer medication was done at 11:38 a.m. and not at the current time. LPN-B stated based on the amount of liquid in the cannister R29 had just started the nebulizer at the current time and not at the 11:38 a.m, which meant fluid had sat in the nebulizer cannister for over an hour, not moving, which increased the risk of infectious disease. During an interview on 3/27/25 at 1:54 p.m., the director of nursing (DON) stated the facility staff should follow the infection control protocols related to nebulizer treatments and cleaning. The facility Oral Inhalation Administration policy dated 5/22, indicated medication should be given right after setup. After medication is given rinse and disinfect the nebulizer equipment according to manufacturer's recommendations, or wash pieces with warm water, rinse with hot water and allow to air dry. 47263 R14: R14's Minimum Data Set (MDS) dated [DATE], indicated R16 was moderately cognitively impaired with the diagnoses of heart failure, end stage renal disease with dialysis, diabetes and respiratory failure. R14's care plan last reviewed 2/19/25, indicated R14 was at risk for alteration in oxygen/gas exchange due to their respiratory status with the goal of adequate gas exchange: no cyanosis, freedom from shortness of breath, oxygen saturations greater than 90%, and normal respiratory pattern. Interventions included administration of Inhaler per MD order and notification of provider with respiratory changes. R14's Order Summary Report Active orders as of 3/27/25, included the following orders: -Ipratropium-albuterol inhalation solution 0.5-2.5 (3) 3mg/3ml, 3 ml inhale orally via nebulizer (neb) every 4 hours as needed for shortness of breath. -Ipratropium-albuterol inhalation solution 0.5-2.5 (3) 3mg/3ml, 3 ml inhale orally via nebulizer every 4 hours as needed for shortness of breath. Give before dialysis on Monday, Wednesday, and Friday. -Change oxygen tubing and mask weekly every Saturday. -Rinse and dry nebulizer cup after each nebulizer treatment During an observation on 3/24/25 at 3:28 p.m., R14's bed was unmade. R16 pointed to the foot of their bed where there was a nebulizer treatment unit sitting directly on the bed sheet and stated they received neb treatments for breathing. The Neb treatment unit and mask were directly on the bed and the neb cup had liquid and moisture droplets on the sides of the cup. The tubing unit was not dated. During an observation on 3/25/25 at 2:11 p.m., R14's nebulizer treatment unit cord could be seen, the rest of the unit was on the bed with bed covers and a pillow over it. During an observation on 3/25/25 at 3:31 p.m., R14's nebulizer treatment unit and tubing was still at the foot of R14's unmade bed. The medication cup had fluid in it. During an observation on 3/26/25 at 8:24 a.m., R14's nebulizer treatment machine power cord was visible at the foot of the bed, the rest of the unit was covered with bedding. During an interview at 3/26/25 on 11:19 a.m., R14 stated they had had a neb treatment early in the morning but not recently. R14 lifted up their bed coverings to show the neb treatment unit at the foot of the bed. The medication cup was dated 3/24, and there was liquid in the nebulizer cup. During an observation on 3/27/25 at 7:23 a.m., R14's nebulizer treatment machine was laying at the foot of R14's bed. The medication cup had been removed. There was a short tube connected to the machine and the other end was open to air and laying on R200's mattress at the foot of the bed. During an interview on 3/26/25 at 2:12 p.m., RN-A pulled up R14's MAR and stated R14 had had a nebulizer treatment last on 3/26/25 at 5:48 a.m. RN-A stated there was also an order on the medication administration record to sign off on for cleaning and letting the nebulizer treatment supplies air dry. RN-A went into R14's room and noted R14's nebulizer treatment had liquid in the administration cup. RN-A stated this should have been removed, cleaned and left to air dry and indicated they were going to take care of it. RN-A stated it was important to clean after each use because leaving moisture in the cup created a risk for respiratory infection. During an interview on 3/27/25 at 10:04 a.m., RN-B stated once a nebulizer treatment is done, staff should disconnect the tubing from the machine, rinse the medication cup, and then let it dry. RN-B stated it was important to do this after each use to prevent potential respiratory infections. In a perfect world the nebulizer unit should not be stored at the foot of a resident's bed. During an interview on 3/27/25 at 12:26 p.m., the DON stated after each nebulizer administration it should be rinsed and left to air dry. This was also one of R14's orders. The DON indicated there are lots of infection risks associated with nebulizer treatments. Lack of cleaning between uses could lead to bacteria growth in the tubing unit which could lead to thrush or growth of other forms of bacteria that could go directly into the lungs when used without cleaning. R14's unit should not be stored on the foot of R14's bed between uses. The facility policy Oral Inhalation Administration dated May 2022, directed staff to rinse and disinfect the nebulizer equipment according to manufacturer recommendation and once equipment was completely dry, store in plastic bag with the resident's name and date on it. R16: R16's quarterly Minimum Data Set (MDS) dated [DATE], indicated R16 was cognitively intact with the following diagnoses: multiple myeloma, diabetes with neuropathy, heart disease and end stage renal disease. R'16 careplan last updated 3/19/25, included the following interventions for R16's PEG tube maintenance: -fluid flushes per order -monitor PEG tube site for signs and symptoms of infection -PEG tube cares per protocol -change tube feeding bag and syringe every 24 hours. R16's Order Summary dated 3/27/25 included: -free water flushes 150 ml [milliliters] for a total of 600 ml of fluid via tube per day -GJ Tube-clean area and cover with split dressing every day. R16' electronic medical record lacked evidence to show the syringe and graduated cylinder used for R16's tube feeding water administration were/had been dated and replaced every 24 hours. During an interview on 3/24/25 at 6:22 p.m., R16 stated the nurses are supposed to change my dressing every day and flush my tube feeding tube a couple times a day. There was an undated graduated cylinder partially filled with water with an undated syringe sitting in it on R16 nightstand. R16 stated they usually had to ask for the dressing to be done unless registered nurse RN-A or licensed practical nurse (LPN-A) were working because they just did it. During an observation on 3/25/25 at 3:31 p.m., R16's graduated cylinder was dated 3/25/25. The cylinder contained water and an undated syringe. During an observation on 3/26/25 at 8:21 a.m., R16's graduated cylinder was dated 3/25/25. The cylinder contained water and an undated syringe. During an observation on 3/26/25 at 2:23 p.m., R16's graduated cylinder was still dated 3/25/25. The cylinder contained water and an undated syringe. During an observation on 3/27/25 at 7:27 a.m., R16's graduated cylinder was dated 3/25/25. The cylinder contained water and an undated syringe. During an interview on 3/27/25 at 8:27 a.m., R16 stated when staff were done putting water in their tube feeding tube staff didn't do anything special with the stuff, they just put the water holder (graduated cylinder) back on the nightstand with the syringe in it. During an interview on 3/27/25 at 10:07 a.m., RN-B stated the graduated cylinder, and syringe should be changed out per policy. RN-B stated they would have to review the policy to know how frequently staff should be exchanging the syringe and graduated cylinder, however, staff should not be leaving the syringe siting in water in the graduated cylinder. For infection prevention reasons, the cylinder and syringe should be left to air dry after use, and the policy should be followed. During an observation on 3/27/25 at 12:51 p.m., R16's graduated cylinder was dated 3/25/25. The cylinder contained water and an undated syringe. During an interview on 3/27/25 12:29 p.m., with the director of nursing (DON) and registered nurse consultants (RN-D) and RN-G. RN-D pulled up the facility policy and stated per policy the graduated cylinder should be left to air dry between uses and changed out daily. The DON stated the syringe should be pulled apart and left to air dry after use. It was an expectation staff would follow the policy for resident safety and infection prevention. During an observation on 3/27/25 at 1:50 p.m., R16's graduated cylinder was dated 3/25/25. The cylinder contained water and an undated syringe. The facility policy Enteral Feeding via Syringe (Bolus) dated 3/2024, instructed staff to make bolus syringe was labeled with the resident's name and marked with date and marked with date and time and if date and time were greater than 24 hours the syringe should be disposed of, and new supplies should be obtained. The syringe should be rinsed with hot water and dried and stored in designated area. R200: R200's admission Minimum Data Set (MDS) dated [DATE], indicated R200 was cognitively intact with the diagnoses of congestive heart failure, diabetes, and respiratory failure. R200's Order Summary Current Orders as of 3/24/25, included the following orders: -PICC/Midline-Change cap (needless access device) weekly with dressing change q wed in am -Vancomycin HCl Intravenous Solution (Vancomycin HCl) use 1500 mg intravenously every 24 hours related to methicillin resistant staphylococcus aureus infection as the cause of disease classified elsewhere (B95.62) for 20 Days. Inject 1500mg in NS over 90 minutes into the vein every 24 hours for 20 days. During an observation on 3/26/25 at 11:28 a.m., R200's PICC line was covered with a transparent dressing. The end or R200's PICC line did not have a lumen cap on it. R200 stated they had been told it was okay to not have the cap on the PICC line. R200 thought it had been that way for a couple of days. After an observation on 3/26/25 at 11:46 a.m., registered nurse RN-B confirmed R200's PICC line was missing the lumen cap attachment and indicated the missing cap was a concern for infection. RN-B opened the electronic medical record (EMR), and stated R200's cap was changed before R200's antibiotic was started on 3/25/25 at 1:15 p.m. RN-B indicated the cap would have likely been off sometime between the time the antibiotic was discontinued on 3/25/25, and now. During an interview on 3/26/25 at 2:51 p.m., the director of nursing (DON) stated they had a call out to infectious disease and had notified R200's provider that R200's lumen cap had been off. The DON indicated that it was possible the lumen could have been accidently removed during a flush or something and indicated R200's PICC like should have a lumen cap at the end of it at all times to prevent infection. During an interview on 3/26/25 at 3:08 p.m., R200 stated when they first got back from the hospital there was a green cap on the end of the PICC line but the facility didn't use that cap any longer. R200 stated they thought the clear cap (lumen cap) had been missing from their PICC line for a couple of days. R200 stated one day they sent a staff in that said they didn't know about PICC lines but they said they were told to do it anyway. R200 stated they had been worried about their PICC line. During an interview on 3/26/25 at 5:12 p.m., RN-A stated when they hooked up R200's antibiotic yesterday, the clear lumen had been attached to R200's PICC. The antibiotic didn't get done until after they had left for the day so another staff would have disconnected the antibiotic when it was done. During an interview on 3/26/25 at 5:59 p.m., RN consultant (RNC-A) stated once they had been made aware R200's PICC line was missing the lumen cap they consulted the nurse practitioner who advised the access area be cleansed and re-capped right away followed by a call to infectious disease. RNC-A stated they did as advised and had also successfully pulled back and flushed R200's PICC line after they had attached the new cap. During an interview on 3/27/25 at 9:39 a.m., licensed practical nurse (LPN-D) stated they never received picc line training or iv medication administration training, or had they ever completed a hands on or any other competency for PICC lines, but they did recall watching a PICC line demonstration. LPN-D confirmed as part of their job they administered iv medications and flushes through PICC lines. During an interview on 3/27/25 at 12:07 p.m., the DON stated they had contacted LPN-A who had disconnected R200's antibiotic on 3/26/25. The DON showed a written statement signed by LPN-A which indicated LPN-A could not say for sure if the lumen cap had been removed when they disconnected R200's antibiotic on 3/26/25, or if the cap was in place when they completed the task. The DON stated the LPN would receive follow-up education on PICC lines.

Based on observation, interview, and document review facility failed to perform a self-administration of medication assessment and obtain provider order to have medication left in room for 2 of 2 (R13 and R29) residents reviewed for self-administration of medication. R13's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R13 had intact cognition. Diagnoses included heart failure, hypertension and renal insufficiency. During an observation of R13's room on 3/24/25 at 3:17 p.m., a box with a tube of diclofenac cream was noted on the shelf to the right of the bed. During an interview on 3/24/25 at 3:17 p.m., R13 stated the staff utilize the diclofenac cream on her back and just leave it on the shelf so it would be available when they needed it. During a second observation of R13's room on 3/25/25 at 2:06 p.m., a box with a tube of diclofenac cream was again noted on the shelf to the right of the bed. R29's quarterly MDS dated [DATE], indicated R29 was cognitively intact. Diagnoses included anxiety, depression and post traumatic stress disorder. R29's Medication Admin Audit Report dated 3/27/25, indicated R29 had orders for Ipratopium-albuterol inhalation solution 0.5-2.5mg inhaled 4 times a day. On 3/26/25, a dose had been set up at 11:38 a.m. During an observation on 3/24/25 at 6:40 p.m., a nebulizer canister was observed full of a liquid substance, not running, and no medical staff were in the room with the resident. During a second observation on 3/26/25 at 12:53 p.m., again a nebulizer canister was observed full of liquid substance, not running, and no medical staff with him. At that time R29 turned on the nebulizer machine and started administering the liquid in the nebulizer canister. During an interview on 3/25/25 at 2:10 p.m. licensed practical nurse (LPN)-B stated prior to a medication left at bedside there must be a self-administration of medication (SAM) form completed, which showed resident was safe to leave medication at bedside and that resident wanted to have medication left at bedside. After that an order would be obtained from the provider to leave medication at bedside. LPN-B entered R13's room and confirmed a tube of Diclofenac cream had been left at R13's bedside shelf. LPN-B then reviewed R13's medical record and indicated there was no SAM or order to keep any medication at bedside. During a second interview on 3/26/25 at 12:56 p.m., LPN-B entered R29's room and confirmed R29 had a full canister of liquid in the canister he was administering medication with. LPN-B reviewed R29's medication administration record (MAR) and stated the last documented administration of inhaled nebulizer medication was done at 11:38 a.m., and not at the current time. LPN-B stated based on the amount of liquid in the canister R29 had just started the nebulizer at the current time and not at 11:38 a.m., as documented. R29 did not have a SAM or provider order to keep medication of any kind at bedside, so the staff member should have made sure the nebulizer had been utilized at 11:38 a.m., when documented as administered. During an interview on 3/27/25 at 1:54 p.m., the director of nursing (DON) stated if the resident did not have a SAM assessment or provider order to leave medication at bedside. Staff should not leave at bedside and should stay with the resident while they took the medication. The facility Self-Administration of Medications policy last revised 2/24 indicated the facility would deem if a resident was safe to self administer medication through assessment forms and provider orders.

Based on interview and document review, the facility failed to ensure advanced directives for emergency care and treatment were accurately reflected in all areas of the medical chart to ensure resident wishes would be implemented correctly in an emergent situation for 1 of 16 residents (R200) reviewed for advanced directives. Findings include: R200's admission Minimum Data Set (MDS) dated [DATE], indicated R200 was cognitively intact with the diagnoses of congestive heart failure, diabetes, and respiratory failure. R200's careplan initiated on [DATE], included the focus area Current Code Status: see current POLST [Physician Orders for Life Sustaining Treatment]. Interventions included review advanced directives per resident and or family request and arrange for MD consult as necessary. During record review on [DATE] at 4:48 p.m., R200's scanned in POLST dated [DATE], signed by the provider on [DATE], directed do not resuscitate (DNR). However, the order entered in the chart on [DATE], was for Cardiopulmonary resuscitation (CPR) and R200's banner also instructed CPR. During an interview on [DATE] at 6:27 p.m., R200 stated they had been asked if they had a living will when they returned to the facility. R200 stated they had told staff they didn't want CPR at the facility, they only wanted to die once. R200 indicated they had family members that had broken ribs and didn't do good after CPR. R200 stated they didn't want brain damage or to be worse off after. They would be a full code if they were having a procedure done at the hospital but otherwise they wanted to be DNR. During an interview on [DATE] at 6:04 p.m., RN-A stated for an un-responsive resident they would go to the electronic medical record and look at the code status there to know what to do. RN-A opened R200's EMR and stated R200's POLST was DNR, but the banner and order were for CPR. RN-A stated they would have done CPR on R200 based on the banner, so in that instance the wrong things would have happened because the order and the banner were entered incorrectly based on the POLST. During an interview on [DATE] at 6:11 p.m., LPN-A stated to determine a resident code status they would look at the facesheet and if it was not there they would look at the banner because it was quickest. LPN-A opened R200's chart and stated based on the banner they would start CPR on R200 if they found R200 unresponsive. LPN-A confirmed R200's banner and chart did not match and stated they would contact the provider or supervisor to determine what action to take when the POLST and banner did not match. During an interview on [DATE] at 6:02 p.m., LPN-C stated they always went to the main EMR screen to determine a resident's code status. LPN-C opened a EMR record and pointed to the banner and code status location. LPN-C stated they only went to the POLST to look at code status if the banner status was empty. During an interview on [DATE] at 6:03 p.m., LPN-B stated on admit the POLST reviewed with the resident and once the resident signed the POLST their status was entered on the EMR banner. It then went to the HUC so it could be signed by the provider and scanned in. The POLST and the order/banner should match. If a resident stopped breathing, staff can go to the banner for the code status. During an interview on [DATE] at 6:56 p.m., the director of nursing (DON) stated as a health care professional it is a number one priority to make sure residents are safe and that their wishes are respected and honored. The DON stated the facility had a process in place to honor resident's wishes and ensure their code status was correctly documented. The banner is a quick place for nurses to identify if CPR should be implemented. In R200's situation because the banner did not match the order, if R200 had coded and received CPR, R200's wishes would not have honored. CPR could have also resulted in negative consequences for R200. With CPR, R200's medical condition could have potentially been worsened after CPR resulting in a lower quality of life for R200 post CPR. During an interview on [DATE] at 7:17 p.m., RN-B stated they corrected R200's order and banner to reflect R200's POLST which showed R200 wanted to be a DNR. RN-B stated they expected staff to look at the EMR banner for a resident's code status. RN-B confirmed R200 would have likely received CPR if they had coded prior to the banner and order being corrected. RN-B explained performing CPR on a resident who did not want it could be bad for the resident depending on the outcome. CPR could result in pain, broken ribs, and possibly medical deficits that were not there prior to CPR. During an interview on [DATE] at 7:27 p.m., the administrator stated respecting the wishes of the resident was very important and indicated the team had corrected R200's code status as soon as they had been made aware of the error. The administrator indicated the facility had a process in place to get the resident's wishes regarding code status at the time of admission and then an order and banner status in place so that resident wishes could be honored as soon as they were known, while waiting for the final POLST to be completed. The administrator indicated that their HUC completed weekly audits on code status for all residents, however they had just completed an audit on all residents in the building due to the error on R200's code status. They had fixed R200's code status as soon as they were made aware of the discrepancy, had audited code status for the whole building, and had began staff education. On [DATE] at 7:38 p.m., R200's banner and orders were reviewed and indicated R200's code status was now listed as DNR. On [DATE] at 9:00 a.m., the HUC stated they were responsible for scanning the POLST into the chart, they did not update the banner, nurses did that. The HUC indicated they had started to do code status audits weekly at the facility on the second week of February 2025. Their process was to go through every resident. They started with review of the code status on the banner and then made sure the POLST was signed, correctly completed and matched the banner and order. The HUC's audit book showed several completed weekly audits. The audit completed on [DATE], listed R200 as being in the hospital. The HUC indicated they had not completed their audit for this week yet, but if there was a discrepancy it would be found during the audit. During a follow-up interview on [DATE] at 8:54 a.m., RN-A stated they had notified the social worker R200's code status and POLST did not match once they had been made aware of it. RN-A stated they had checked R200's chart at shift start this a.m. and R200's code status had been fixed. The facility policy POLST documentation dated ,d+[DATE], indicated the purpose of the POLST was to identify and document the code status consistent with the resident wishes so that staff know immediately what action to take or not take when an emergency arises. The policy identified a process for managing code status orders and the POLST and indicated routine audits of the POLST documentation should be conducted.

Based on interview and document review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN; CMS-10055) to 1 of 3 residents (R54) reviewed whose Medicare Part A coverage ended while in the facility. Findings included: R54's Notice of Medicare Non-Coverage (CMS-10123) dated 10/15/24, indicated R54's last day of skilled services was on 10/15/24 due to going on hospice services. The form was signed by R54 and dated 10/15/24. In addition, R54's medical record lacked evidence the required CMS-10055 had been reviewed and/or provided to R54 prior to their Medicare Part A coverage ending. R54's Census List indicated a payer change occurred on 10/16/24, to hospice private pay. R54's progress notes from 10/9/24 to 10/17/24, indicated R54 was a resident of the facility until discharge on [DATE]. During an interview on 3/27/25 at 8:01 a.m., the business office manager (BOM) stated she was responsible to give the residents the CMS 10123 and 10055 forms to the residents 3 days prior to discharge from Medicare-A services. The CMS-10055 was also known as the daily rate form so the resident would be aware of the approximate daily rate bill if they had to pay out of pocket. The BOM reviewed R54's record and acknowledged the 10055 had not been issued to R54, but R54 had remained in the facility after the last day of Medicare A coverage stopped. The BOM stated even though R54 was only in the facility for 1 day after the discontinuation of Medicare A coverage, a 10055 form should have been issued so R54 was aware of what each day of stay would cost. During an interview on 3/27/25 at 8:14 a.m., the administrator stated any resident that stayed at the facility after Medicare part A coverage stopped coverage needed to have the 10055 form given to them so they were aware of what a daily rate might be for their stay. The facility's policy titled ABN/NOMNC Policy and Procedure dated 2/20/23, indicated any resident that stayed in the facility after Medicare part A coverage ended would be issued a SNFABN: CMS-10055.

Based on interview and document review the facility failed to perform prescribed dressing changes to a pressure ulcer as ordered for 1 of 3 residents (R27) reviewed for pressure ulcers. Findings include: R27's annual Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition. Diagnoses included anemia, coronary artery disease and renal failure. R27 was at risk for pressure ulcers and had an unhealed unstageable pressure ulcer. R27's Medication Administration Record (MAR) dated 3/25, indicated orders were present from 3/7/25 to 3/20/25 to cleanse pressure ulcer with vashe. Loosely fill wound with vashe damped packing strip, ensure filling in tunnel and undermining. Leave out tail for easy removal. Cover with bordered foam dressing. Change twice daily and as needed. R27's MAR dated 3/25 lacked documentation dressing changes were completed on the following days: - Day shift 3/9/25, 3/13/25, 3/14/25, 3/16/25 through 3/18/25, and 3/20/25 - Evening shift 3/8/25 through 3/10/25, 3/14/25 through 3/16/25 R/27's progress notes were reviewed from 3/8/25 through 3/20/25. Progress notes lacked documentation as to why scheduled dressing changes were missed or passed on to the next shift to make sure they were done. During an interview on 3/24/25 at 7:05 p.m., R27 stated there was a pressure ulcer on her coccyx region that nursing was doing dressing changes on. The staff would miss several of the dressing changes since the wound appeared. During an interview on 3/26/25 at 5:08 p.m., trained mediation aide (TMA)-B stated that either the nurse manager or a nurse from 200 hallway would do all of the dressing changes for 100 hallway when a nurse was not assigned. I know everybody is really busy, so I never know when they are done or not done. During an interview on 3/26/25 at 5:19 p.m., licensed practical nurse (LPN)-C stated the nurse on either 200 or 300 hallways would assist 100 hallway with dressing changes when there was not a nurse assigned to 100 hallway. We usually find time to run over to 100 hallway to get the dressing changes done. I can't think of any specific times, but I know there have been times when evening shift has not been able to get 100 hallway dressing changes done. When that would happen, we would report off to the next shift to get the dressing changes done and document in progress report why it was not done. After the next shift completed the dressing change, they would go into the MAR and document the completed dressing change. During an interview on 3/27/25 at 12:48 p.m., registered nurse (RN)-B reviewed R27's MAR and acknowledge several dressing changes were not documented on. Based on the documentation, there is no way to know if the dressing changes were completed. During an interview on 3/27/25 at 1:58 p.m. the director of nursing (DON) stated dressing changes needed to be done as ordered and documented on in the MAR. Facility policy Skin Assessment and Wound Management last revised 2/25 indicated ongoing treatments would be followed as ordered by the provider.

Based on interview and record review, the facility failed to consistently monitor dialysis access site for 1 of 1 resident (R27) reviewed for dialysis care. Findings include: R27's annual Minimum Data Set (MDS) dated [DATE], indicated intact cognition. Diagnoses included anemia, end stage renal disease and diabetes. The MDS indicated R27 was on dialysis. R27's care plan dated 9/25/24, indicated R27 had a dialysis port to the right chest. The care plan lacked information related to R27's arteriovenous dialysis fistula in the right arm. R27's Order Summary report dated 2/6/24, indicated orders which included dialysis-monitor chest port post dialysis, dialysis-no IV. Blood draws, blood pressures on right arm. Fistula incision care and monitor dialysis site for bleeding. The order summary lacked to monitor the fistula bruit and thrill (swish sound coming from fistula indicating normal function) from fistula. Provider progress note dated 2/18/25, indicated R27 had right upper extremity fistula placed for dialysis on 2/13/25. During an interview on 11/16/25 at 1:24 p.m., licensed practical nurse (LPN)-E stated R32's access site got assessed for bruit, bleeding, and infection on the day shift but often not on dialysis days because R32 left the facility during the night shift at 5:30 a.m., and often did not return until later in the evening shift. During an interview on 3/27/25 at 9:41 a.m., the dialysis clinical manager (DCM) confirmed R27 had a AV fistula placed on 2/13/25, and was used by the dialysis team for dialysis treatments. The DCM stated the facility should start monitoring the fistula for the bruit and thrill at least daily right after the fistula is placed. Monitoring was important because there would be early warning signs of a potential bigger issue. During an interview on 3/27/25 at 9:57 a.m. trained medication aide (TMA)-A indicated R27 had a new fistula that the dialysis center just started using. TMA-A did not believe the nurse would evaluate the fistula at all. During an interview on 3/27/25 at 12:48 p.m. registered nurse (RN)-B stated staff had not started monitoring R27's fistula for bruit and thrill since the fistula was placed. RN-B was unsure how often the fistula should be monitored. During an interview on 3/27/25 at 1:58 p.m. the director of nursing indicated the bruit and thrill should be monitored per facility policy. The facility dialysis policy was not received.

Based on observation, interview, and record review the facility failed to ensure licensed staff were educated and competent in the administration of intravenous medications (IV) and/or the management and care of peripherally inserted central catheters (PICC) [a long thin tube inserted into a vein on the inside of the upper arm that extends into a larger vein leading to the heart for medication, blood, and nutrition administration] for 1 of 1 residents (R200) reviewed for PICC line care and management. This deficient practice had the potential to impact all residents at the facility who had IV/PICC access and/or received medications through IV/PICC access. Findings include: R200's admission Minimum Data Set (MDS) dated [DATE], indicated R200 was cognitively intact with the diagnoses of congestive heart failure, diabetes, and respiratory failure. R200's careplan initiated on 2/18/25, did not include R200's PICC line nor did it include goals and interventions for care of R200's PICC line. The Order Summary Current Orders as of 3/24/25, included the following orders: -PICC/Midline-Change cap (needless access device) weekly with dressing change q wed in am -Vancomycin HCl Intravenous Solution (Vancomycin HCl) use 1500 mg intravenously every 24 hours related to methicillin resistant staphylococcus aureus infection as the cause of disease classified elsewhere (B95.62) for 20 Days. Inject 1500mg in NS over 90 minutes into the vein every 24 hours for 20 days. -PICC/Midline Change dressing location______(blank) using sterile technique weekly and as needed. Document in progress notes description of care and resident's response to procedure every Wed -PICC/Midline-Measure arm circumference 3 inches above insertion site weekly with dressing change in the morning every Wed -PICC/Midline-Measure total catheter length on dressing change. Location_____(blank) in morning. -PICC Line monitor for complaints of unusual sounds near the neck ear or the affected site every shift -PICC/Midline monitor site location_______(blank) every shift for s/s of infection and infiltration every shift During an observation on 3/26/25 at 11:28 a.m., R200's PICC line was covered with a transparent dressing. The end or R200's PICC line did not have a lumen cap on it. R200 stated they had been told it was okay to not have the cap on the PICC line. R200 thought it had been that way for a couple of days. R200 also stated she had had a blood draw yesterday and the nurse had removed about 6 big syringes of air from their PICC line and they were afraid something bad might happen because of all that air. After an observation on 3/26/25 at 11:46 a.m., registered nurse RN-B confirmed R200's PICC line was missing the lumen cap attachment and indicated the missing cap was a concern for infection. RN-B opened the electronic medical record (EMR), and stated R200's cap was changed before R200's antibiotic was started on 3/25/25 at 1:15 p.m. RN-B indicated the cap would have likely been off sometime between the time the antibiotic was discontinued on 3/25/25, and now. During an interview on 3/26/25 at 11:51 a.m., the director of nursing (DON) stated the PICC line should have the lumen cap on the end of the PICC line as it is an infection prevention issue for it to be capless. The DON confirmed R200 was correct, five 10cc syringes of air had been pulled off of R200 PICC line during R200's blood draw completed on 3/25/25. The PICC line gets clamped so they were not sure how the air got in R200's line. The DON indicated the order instructed to flush, and didn't say anything to pull back before the flush, and indicated air could have entered the PICC line with flushing. The DON stated they thought they may need to do some PICC line education with staff. The DON confirmed the air had not been documented or a note made to indicate the provider had been notified of the air in R200's PICC line on 3/26/25. During an interview on 3/26/25 at 2:51 p.m., the DON stated they had a call out to infectious disease and had notified R200's provider that R200's lumen cap had been off. The DON indicated that it was possible the lumen could have been accidently removed during a flush or something and indicated R200's PICC like should have a lumen cap at the end of it at all times to prevent infection. The DON stated another resident had told the them that R200 was concerned about dying because of the air in their PICC line. They were also concerned about the air as well because of the risk for air embolism. The DON indicated they had updated the provider about the air in R200 line on 3/25/25 and indicated R200 had a follow-up appointment tomorrow, so R200 would see the provider then. During an interview on 3/26/25 at 3:08 p.m., R200 stated when they first got back from the hospital there was a green cap on the end of the PICC line but the facility didn't use that cap any longer. R200 stated they thought the clear cap (lumen cap) had been missing from their PICC line for a couple of days. R200 stated one day they sent a staff in that said they didn't know about PICC lines but they said they were told to do it anyway. R200 stated they were afraid they were going to get killed here with all that air in their line. During an interview on 3/26/25 at 5:12 p.m., RN-A stated when they hooked up R200's antibiotic yesterday, the clear lumen had been attached to R200's PICC. The antibiotic didn't get done until after they had left for the day so another staff would have disconnected the antibiotic when it was done. RN-A stated today when they went to hook up R200's antibiotic, the PICC line would flush, but there was no blood return so R200 was being sent to the emergency room for evaluation of their PICC line. RN-A stated they would definitely contact the provider for any air pulled back from a PICC line that was greater than 4cc because there should not be any air in the PICC line. RN-A stated they had not received any hand off report of R200 having had air in their PICC line on 3/25/25. During an interview on 3/26/25 at 5:37 p.m., RN-B stated RN-A had reported R200's PICC line was not properly functioning. RN-B stated they had talked to R200 to see if they would like to go into to have it assessed or if they would like the nurse at the facility to try Cathflo. R200 had chosen to go to the hospital to have it addressed. During an interview on 3/26/25 at 5:59 p.m., RN consultant (RN-G) stated once they had been made aware R200's PICC line was missing the lumen cap they consulted the nurse practitioner who advised the access area be cleansed and re-capped right away followed by a call to infectious disease. RN-G stated they did as advised and had also successfully pulled back and flushed R200's PICC line after they had attached the new cap. During an interview on 3/27/25 at 9:39 a.m., licensed practical nurse (LPN-D) stated they never received PICC line training or IV medication administration training, or had they ever completed a hands on or any other competency for PICC lines. They did recall watching a PICC line demonstration at one time. LPN-D confirmed as part of their job they administered IV medications and flushes through PICC lines. During an interview on 3/27/25 at 12:07 p.m., the DON stated they had contacted LPN-A who had disconnected R200's antibiotic on 3/26/25. The DON showed a written statement signed by LPN-A which indicated LPN-A could not say for sure if the lumen cap had been removed when they disconnected R200's antibiotic on 3/26/25, or if the cap was in place when they completed the task. The DON stated the LPN would receive follow-up education on PICC lines. The DON stated air pulled from a PICC line was a serious concern because it could mean a resident was at risk for an air embolism. They would expect any nurse that encountered air in a PICC line to notify the provider and document the event in the progress notes. RNC-D and RNC-G were also present. RNC-D stated the facility did not do a competency for intravenous medication administration or IV and PICC line management when RN's or LPN's were hired, nor was there any education specific to PICC lines, however they had done PICC line review at their skills day with a dummy arm. The facility did not have specific education for PICC lines or competencies for blood draws or PICC line dressing changes. The DON confirmed the facility did not have a competency in place to ensure PICC line management competency or IV medication competency for RN's or LPNs. The DON indicated they did not have a process to make sure that LPN's were competent to administer IV medications through an IV or PICC line. The DON indicated when a nurse was hired, they were asked what they knew how to do. The DON felt the facility did on the spot training if a nurse did not know how to do a skill related to IV or PICC lines they would be taught on the spot. A list of licensed staff who had performed PICC line care and medication administration to R200's PICC line and their PICC line competencies for PICC line management, dressing changes, blood draws and IV mediation competencies specific to LPNs was requested. The facility identified three LPNs including LPN-A and LPN-D. Five RNs were identified. Information provided included: - The New hire LPN/RN Competency Check List provided by the facility did not include intravenous medication administration nor did it include PICC lines. -The Temporary Agency Staff Orientation Checklist dated 2/12/24, was provided for RN-A. The checklist did not include PICC lines or -The Nurse Annual Skill Fair Competency Checklist listed several areas including IV/PICC line and medication administration however no additional documents were included to indicate what nurses were competent to do regarding IV/PICCs and medication administration. A completed check list dated 6/5/24, was provided for LPN-A, and one RN. -Education and or competency documentation was not provided for the other staff who worked with R200's PICC line. The facility policy Flushing Midline and Central Line IV Catheters dated May 2022, directed staff to aspirate the CVAD catheter for blood return to confirm patency prior to administration of medication and solutions. The section Complications gave instruction if there is resistance or lack of blood return during flushing stop the flush and consult the IV nurse specialist or provider. The documentation and reporting section both instruct staff to notify the provider if there are any complications. The facility policy Obtaining Blood Specimens From a Venous Catheter dated May 2022, directed staff to notify physician, supervisor, and oncoming shift of any problems or inability to get blood sample. Facility Policies Central Venous Catheter Dressing changes dated May 2022, directed staff to document date and time of dressing change, location and description of site, complications and interventions done, and if flushed: positive blood return and whether needleless connection device or extension tubing was changed. None of the facility policies provided specifically addressed cap changes or how to address air in a PICC line.

Based on interview and document review the facility failed to make sure pharmacy recommendations were addressed timely for 2 of 5 residents (R28, R33) reviewed for unnecessary medications. Findings include R28's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition, and diagnoses included heart failure, hypertension, and renal failure. R28's order summary report dated 12/12/24, indicated R28 was started on Quetiapine Fumarate oral tablet 25 milligrams (mg) one time daily by mouth for a diagnosis of other specified anxiety disorders. R28's Consultant Pharmacist Medication Regimen (PMR) Review dated 2/13/25, recommended the facility address the diagnosis for Quetiapine Fumarate. The PMR indicated CMS guidance for antipsychotic utilization in nursing facilities required an FDA approved diagnosis in chart to use the medication which other specified anxiety was not. The form had not been addressed or signed as completed. During interview on 3/27/25 at 10:43 a.m., the consultant pharmacist (CP) explained monthly medication regimen reviews were done monthly on all residents. CP stated medication regimen reviews were tracked over time and provider responses of accepting or rejecting recommendations were noted. CP stated providers had a month to respond and if there was no response from the provider then the recommendation would be sent again. During interview on 3/27/25 at 12:49 p.m., the director of nursing (DON) stated an expectation for provider to respond to pharmacist medication regimen review recommendations with the next visit, but at least within 30 days. 49878 R33's quarterly MDS dated [DATE], identified intact cognition, and diagnoses including sequelae of cerebral infarction (aftereffects of a stroke), dyspnea (shortness of breath), post-traumatic stress disorder (PTSD), rib fracture, chronic kidney disease, protein-calorie malnutrition, depression, and psychosis. R33's order summary report dated 3/27/25, included the following order: -polyvinyl alcohol ophthalmic solution 1.4%- instill one drop in both eyes as needed for dry eyes. Order was written 1/15/25. R33's Consultant Pharmacist Medication Regimen Review dated 2/13/25, recommended the provider to please add frequency (e.g 4 times a day prn dry eyes) to complete order for polyvinyl alcohol ophthalmic solution. R33's medical record did not contain a provider response to this recommendation. R33's Consultant Pharmacist Medication Regimen Review dated 3/12/25, recommended the provider to please add frequency (e.g 4 times a day prn dry eyes) to complete order (repeat) for polyvinyl alcohol ophthalmic solution. R33's medical record did not contain a provider response to this recommendation. During interview on 3/27/25 at 10:43 a.m., consultant pharmacist (CP) explained monthly medication regimen reviews were done monthly on all residents. CP stated medication regimen reviews were tracked over time and provider responses of accepting or rejecting recommendations were noted. CP stated providers had a month to respond and if there was no response from the provider then the recommendation would be sent again. During interview on 3/27/25 at 12:49 p.m., director of nursing (DON) stated expectation for provider to respond to pharmacist medication regimen review recommendations. Facility policy Consultant Pharmacist Services Provider Requirements policy was requested but not provided.

Based on interview and document review the facility failed to have an appropriate diagnosis for use of medication for 1 of 5 residents (R28) reviewed for unnecessary medications. Findings include R28's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition, and diagnoses included heart failure, hypertension, renal failure and post kidney transplant. R28's order summary report dated 12/12/24, indicated R28 was on Tacrolimus Oral 1mg capsule, take one by mouth every 12 hours for health maintenance. During interview on 3/27/25 at 10:43 a.m., the consultant pharmacist (CP) stated medications appropriate for a diagnoses of health maintenance included several different vitamins and minerals that a resident took as a preventative or maintenance dosing program. The CP stated Tacrolimus was an antirejection drug for patients who have received a transplant. The CP reviewed R28's chart and indicated R28 had a history of post kidney transplant and post kidney transplant would have been the appropriate diagnoses for that medication. During interview on 3/27/25 at 12:49 p.m., the director of nursing (DON) stated all medications ordered by providers would have appropriate diagnoses assigned to them. Facility medication policy was not provided.

Based on interview and document review the facility failed to have an appropriate diagnosis for use of an antipsychotic for 1 of 5 residents (R28) reviewed for unnecessary medications. In addition, the facility failed to complete orthostatic blood pressure (series of blood pressures taken while lying, sitting, and standing) monitoring for an antipsychotic medication for 1 of 1 residents (R33). Findings include R28's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition, and diagnoses included heart failure, hypertension, and renal failure. R28's order summary report dated 12/12/24, indicated R28 was started on Quetiapine Fumarate oral tablet 25 milligrams (mg) one time daily by mouth for a diagnosis of other specified anxiety disorders. R28's Consultant Pharmacist Medication Regimen (PMR) Review dated 2/13/25, recommended the facility address the diagnosis for Quetiapine Fumarate. The PMR indicated CMS guidance for antipsychotic utilization in nursing facilities required an FDA approved diagnosis in chart to use the medication which other specified anxiety disorder was not. During interview on 3/27/25 at 10:43 a.m., the consultant pharmacist (CP) stated appropriate Food and Drug Administration approved diagnoses included behaviors and disorders that included specific negative behaviors such as delirium, Schizophrenia or anxiety with psychosis. During interview on 3/27/25 at 12:49 p.m., the director of nursing (DON) stated all medications ordered by providers would have appropriate diagnoses assigned to them. R33's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition, and diagnoses including sequelae of cerebral infarction (aftereffects of a stroke), dyspnea (shortness of breath), post-traumatic stress disorder (PTSD), rib fracture, chronic kidney disease, protein-calorie malnutrition, depression, delirium, and psychosis. MDS also indicated R33 received antipsychotic medication on a routine basis. R33's Order Summary Report dated 3/27/25, identified order for haloperidol tablet 5 milligrams (mg) to be given by mouth twice a day for delirium and psychosis. Report also identified order to monitor orthostatic blood pressure monthly on the 4th and 5th of the month while resident is receiving antipsychotic medications. R33's treatment administration records (TAR) reviewed for October 2024 to March 2025, did not have orthostatic blood pressure readings on the 4th or the 5th of any month. During interview on 3/27/25 at 12:49pm, director of nursing (DON) stated expectation for staff to follow provider's orders. DON also stated expectation for orthostatic blood pressures to be completed monthly for residents taking an antipsychotic. Facility policy Consultant Pharmacist Services policy was requested but not provided.

Based on observation, interview, and document review the facility failed to ensure medications were properly labeled with direction for use for 1 of 1 resident (R13). Findings include: R13's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R13 had intact cognition. Diagnoses included heart failure, hypertension, and renal insufficiency. R13's Order Summary Report dated 3/29/24, indicated R13 had ordered Diclofenac sodium topical gel, apply 2gms topically to shoulders, upper and mid back 4 times a day. During an observation of R13's room on 3/24/25 at 3:17 p.m., a box with a tube of diclofenac cream was noted on the shelf to the right of the bed. The box and the tube lacked any kind of label with resident name, medication dosage or times to administer. During an interview on 3/24/25 at 3:17 p.m., R13 stated the staff utilize the diclofenac cream on her back and just leave it on the shelf so it would be available when they needed it. During a second observation of R13's room on 3/25/25 at 2:06 p.m., a box with a tube of diclofenac cream was again noted on the shelf to the right of the bed. The box and the tube lacked any kind of label with resident name, medication dosage or times to administer. During an interview on 3/25/25 at 2:10 p.m., licensed practical nurse (LPN)-B stated any medication left at the resident's bedside needed to have a label with the resident's name, dosage of medication to administer, and frequency to administer so everybody was aware of the correct order. LPN-B entered R13's room and observed the box and tube of diclofenac cream in R13's room. She confirmed there was no label on the box or the tube. Since there was no label on the box or the tube, nobody would know the appropriate dosage or if the resident should have the medication. There was an increased risk of a resident getting a medication not ordered or the incorrect dosage. During an interview on 3/27/25 at 1:54 p.m., the director of nursing (DON) stated any medication left at a resident bedside should have at least the name of the resident, the dosage of medication to give and the frequency the medication should be administered. Facility policy Medication and Treatment Orders last revised 2/24, indicated all ordered medications and treatments would include: a. Name and strength of the drug b. Number of doses, start and stop date, and/or specific duration of therapy. c. Dosage and frequency of administration d. Route of administration e. Clinical condition or symptoms for which the medication is prescribed.

Based on interview and document review the facility failed to provide the physician ordered textured diet for 1 of 3 residents (R1) who subsequently choked and required the Heimlich Maneuver. This was an Immediate Jeopardy (IJ) for R1 who required hospitalization following the choking incident where she was determined to have aspirated and required mechanically assisted ventilation. The IJ began on 3/9/24, at approximately 6:30 p.m. when R1 was found by nursing assistant (NA)-A in the common area of the unit observed as pale, lips blue and unable to speak. R1 was administered the Heimlich Maneuver, suction and was sent to the hospital where she subsequently required mechanically assisted ventilation. The IJ was identified on 3/22/24, and the administrator was notified of the IJ on 3/22/24, at 1:00 p.m. The immediate jeopardy was removed on 3/13/24, and the deficient practice was corrected prior to the start of the survey and was therefore issued at past noncompliance. R1's Admission Record indicated she admitted to the facility on [DATE], with diagnosis that included dysphagia (difficulty swallowing). R1's physician orders dated 12/29/23, identified regular diet, mechanical soft texture, nectar consistency, no straws. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment. The MDS indicated R1 required supervision or touching assistance to eat and identified a mechanically altered diet. R1's care plan dated 1/23/24, indicated Diet: mechanical soft diet, nectar thick liquids. No straws. The care plan was updated to NPO (nothing by mouth) on 3/15/24. Facility Diet Spreadsheet dated 3/9/24, indicated chicken strips were on the menu the evening of 3/9/24. R1's Progress Note dated 3/9/24, indicated as registered nurse (RN) came onto the floor, R1 had just been discovered by NA (nursing assistant) to be very pale with blue lips and unable to speak. LPN (licensed practical nurse) on shift attempted abdominal thrust which was effective to open the airway partially, but wheezing persisted. Additional thrust ineffective. RN directed LPN to initiate oral suction. Emergency services called and R1 left the facility to the hospital. Hospital staff reported R1 required intubation and was air lifted to a Duluth hospital. R1's hospital History and Physical (H and P) dated 3/10/24, indicated she admitted to the hospital on 3/9/24, with acute respiratory failure and required mechanical ventilation after she aspirated (when food, liquid, or other material enters a person's airway and eventually the lungs by accident) while eating at her nursing home. R1's hospital Discharge Diagnosis included: Aspiration into airway, on mechanical assisted ventilation. Hospital course indicated admission to the hospital due to respiratory failure due to aspiration event requiring intubation. Facility Diet Spreadsheet dated 3/9/24, indicated chicken strips were served for the evening meal. The spreadsheet indicated for a mechanical soft diet, the chicken strips should have been ground. A facility internal plan of correction document, dated 3/11/24, indicated an identified opportunity for improvement: Diet extension accuracy when serving meals to residents with different textured diets. Potential contributing factors: chopped chicken strips given to resident instead of ground. During interview on 3/21/24, NA-A stated on 3/9/24, she had been supervising R1 and another resident while they ate in the common area of the unit. NA-A stated she kept an eye on both of them during the meal. NA-A said after dinner, the other resident wheeled R1 over in front of the television and said she was about to go on her break and heard the other (severely cognitively impaired) resident stating the boy, the boys, the boys over and over. Upon hearing this, NA-A stated she went to remove R1 from the area and saw her gasping for air. During interview on 3/20/24 at 1:08 p.m., the culinary director (CD) described the diet extension as a spread sheet that explained what food was to be prepared for each diet type. The CD stated on the evening of 3/9/24, when R1 choked on her meal, her diet slip had been correct. The CD stated the cook who prepared the meal told her he did not grind the chicken strips as directed on the diet extension but had chopped them with a knife instead. The administrator and director of nursing (DON) were interviewed on 3/20/24, at 2:27 p.m. the administrator stated upon investigation into the incident that led to R1's hospitalization , it was determined staff had served R1 chopped chicken strips instead of ground as directed by her diet order. The administrator stated the culinary staff were educated regarding the diet extensions and following the orders. The DON stated she had educated the nursing staff to ensure the correct diets were being followed prior to delivering a meal to a resident. A facility policy related to preparation of modified diets was requested but not received. Per administrator, refer to diet extensions. The past noncompliance immediate jeopardy began on 3/9/23. The immediate jeopardy was removed, and the deficient practice corrected by 3/13/23 , after the facility implemented a systemic plan that included the following actions: - Training was implemented to all culinary staff to ensure diets were prepared and served according the the diet extensions and physicians orders. - Training was implemented for all nursing staff to ensure the proper diets were sent from the kitchen prior to distributing meals to residents. - Diet extension audits were implemented. The education and audits were verified through interview and document review.

Based on observation, interview and document review the facility failed to ensure an environment free from hazards. This resulted in actual harm to R1 who sustained a second degree burn when his knee rested against the baseboard heater and he was unable to move his knee or call for help. 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 encephalopathy (disease in which the functioning of the brain is affected), Diabetes, transient ischemic attack (a short period of symptoms similar to those of a stroke) and a tracheostomy (a direct airway through an incision in the trachea). R1's annual Minimum Data Set, dated dated dated [DATE], indicated he was rarely/never understood, had upper and lower extremity impairments and was dependent on staff for all activities of daily living. R1's care plan dated 2/2/24, indicated he was non-verbal and unable to make his needs known. The care plan further identified a self care deficit related to R1 being dependent on nursing staff for all cares. R1's Progress Note dated 2/27/24, indicated at approximately 7:10 p.m. nursing assistant on duty called nurse to R1's room. R1's bed was close to the heater and R1 sustained a burn to his knee. R1's Skin and Wound Evaluation dated 2/28/24, identified a second degree burn 3.9 centimeter (cm) x 3.3 cm described as a ruptured blister. Facility's internal investigation dated 2/29/24 indicated, based on interview with unidentified NA, R1's bed was believed to have been moved closer to the wall unintentionally when the EMT staff transferred R1 to the gurney for his unrelated hospital visit. During observation on 3/7/24 at 10:13 a.m., registered nurse (RN)-A was performing wound care on R1's knee. Each time RN-A applied the prescribed cream to R1's knee, R1 displayed discomfort by flinching. During that same observation at 10:13 a.m., R1's bed was observed to be a 18-24 inches from the baseboard heater (RN-A was standing between baseboard and R1's bed as she performed resident care). The baseboard was not hot to touch by surveyor; surveyor was able to keep hand on baseboard for over a minute comfortably. During interview on 3/7/24 at 11:10 a.m., RN-A stated she had been working the day R1 was burned and said she had assessed R1 around 12:45 p.m. after he returned from an unrelated hospital visit and the burn had not been present. RN-A stated staff came to her around 7:00 p.m. and showed her the burn. During interview on 3/7/24 at approximately 11:00 a.m., the maintenance director (MD) stated the heating system was a hot water baseboard system and said he did not have a manual for the system. The MD stated there was a weekly temperature check on the all the baseboards in the facility but said he did not have records dating prior to the incident because it had just recently been implemented. The MD said weekly temperature checks were not being completed prior to R1 sustaining the burn because they had not been set up in the maintenance system but this was corrected immediately follow R1's incident. On 3/7/24 at 11:16 a.m. the administrator confirmed the weekly temperature checks on the baseboards had been implemented after R1 had been burned. The Regional Maintenance Consultant (RMC) was interview on 3/7/24 at 12:20 p.m., and said according to the policy, surface temperatures of the heaters should not be over 120 degrees to avoid injury. The RMC stated the baseboard heat registers should be checked during weekly room audit inspections and said the facility should have been checking the temperatures during the heating months which were typically September 1st through May 1st. During interview on 3/7/24 at 12:47 p.m., nursing assistant (NA)-A stated she was working the day R1 was burned on the heat register. NA-A said R1 had returned from the hospital and the nurse had been in his room around 3:30 p.m NA-A stated she had left at 6:00 p.m. and had not repositioned R1 on her shift. NA-A said R1 was unable to make even slight adjustments independently and relied on staff for positioning. During interview on 3/7/24 at 2:00 p.m., the director of nursing (DON) stated her understanding was R1 had come back from the hospital the day he was burned and said his bed was up against the heat register. The DON stated the wound care nurse practioner who assessed the knee indicated R1 had sustained a second degree burn. During interview on 3/7/24 at 2:13 p.m., NA-C said R1's bed had been too close to the wall and he ended up with the burn on his knee. Facility policy Baseboard Heat Register Surface Temperature dated 1/9/17, and updated 2/28/24, indicated facility maintenance director will check baseboard heating register surface temperatures and make immediate corrections to the thermostats if any temperatures are above 120 degrees Fahrenheit. Notification of the administrator will occur immediately if any temperatures are above 120 degrees in any resident room. Prior to the start of the survey the facility initiated immediate temperature checks on all baseboard heaters facility wide and bed placement checks. Additionally, the facility maintenance R1's baseboard heater in an attempt to determine reason for overheating and continued daily checks with no temperatures over 120. Lastly the facility developed and implemented a system to perform weekly checks of the heat register temperatures, developed and implemented bed placement audits throughout the facility and educated staff regarding implementation of the procedures. The education and audits were verified through interview and document review.

Based on interview and document review the facility failed to maintain resident safety when a resident (R1) who was assessed to be at risk for elopement verbalized his intent to leave the facility, left without staff knowledge and was returned to the facility by two strangers. Further, R1 was allowed to discharge home against medical advice from the facility even though he had been assessed to have cognitive impairment and admitted due to recurrent falls. This resulted in an immediate Jeopardy (IJ) situation for R1. The IJ began on 9/30/23, when R1 left the facility without staff knowledge. R1 was found by two strangers on a highly-trafficked four lane highway with a cut on his nose. Additionally, within two hours of R1' s return to the facility, R1 wanted to return home. The facility did not implement interventions to keep him safe and assisted R1 leave on his own even though the facility assessed him unsafe in the community alone. The administrator and senior nurse consultant (SNC) were notified of the IJ on 10/12/23, at 3:33 p.m The IJ was removed on 10/13/23, at 2:35 p.m., but noncompliance remained at the lower scope and severity level D, with no actual harm with potential for more than minimal harm that was not immediate jeopardy. Findings include: R1's Admission Record indicated he admitted to the facility on [DATE]. R1's diagnosis included: Syncope, epilepsy, history of traumatic brain injury (TBI) and repeated falls. R1's hospital History and Physical dated 9/27/23, identified a past medical history of diabetes mellitus type 2, hypertension, chronic kidney disease, memory deficit/dementia, seizure disorder and multiple other medical issues and was was brought to the emergency room after he went to get the mail and passed out. R1's Admission/ Initial Data Collection Form dated 9/28/23, indicated he admitted to the facility on [DATE], at 1:00 p.m. The form indicated R1 used a walker for ambulation and required supervision. R1's fall history, pain, skin and communication were not assessed. R1's Elopement Risk Evaluation dated 9/28/23, identified a habit/history of wandering or attempts to leave the unit or building, pacing or agitated behavior, and indicated he was ambulatory. The evaluation indicated R1 was at risk for elopement and identified the use of a Wanderguard. R1's Brief Interview for Mental Status dated 9/30/23, identified a score of six which indicated severe cognitive impairment. R1's facility Progress Notes identified the following: Note written 9/29/23, at 8:09 a.m. indicated R1 was unaware of his own name and asked writer is that me? Writer told resident yes, that's your name. R1 had been busy in the morning and had been wandering around wing one, entering other resident rooms, trying to go out emergency exit and trying to go to the wing onse courtyard. Resident had required a 1:1 in the morning. Note written 9/29/23, at 8:33 a.m. indicated R1 had been exit seeking in the evening and wanting to walk home. R1 thought his his house is nearby. R1 said he would just walk out the door and a Wanderguard was placed on his left ankle. R1 was restless during the night, going into other resident rooms, opening doors, looking to go home, looking for his boots, digging around in drawers in room and into his roommate's belongings. R1 had been exit seeking into the morning and came out of the of unit looking for a way to get out. When attempting to redirect, R1 began yelling at staff and appeared he was going to push right past staff. R1 started yelling for staff to call the police and let them take him out of here. R1 walked down the hallway toward the staff entrance and oncoming staff was able to redirect him back onto the unit. R1 had been a 1:1 with staff member since. Note written 9/29/23, at 8:55 a.m. indicated R1 was sent to the emergency department (ED) due to hypotension. R1 was offered bed hold and refused and stated he wanted to look elsewhere. A second note written at 9:15 a.m. indicated R1 discharged . At 7:40 p.m. Progress Note indicated R1 returned from the ED in a pleasant mood. 9/30/23, at 2:19 a.m. note indicated from 10:15 p.m. to 11:15 p.m. R1 was pleasant and calm, sitting in a chair and eating snacks in a common area. R1 then began wandering and exit seeking, requesting a bus to come pick him up. R1 was easily redirectable and continued to wander around wing one and wing two common area. At 11:40 p.m. nursing assistant (NA) assisted R1 into bed as he appeared tired and agreed to lying down. At midnight NA and writer happened to be in the wing one hall and heard commotion and yelling coming from R1's room. When staff entered, R1 was on roommate's side of curtain and was pulling on roommate's walker. Roommate was yelling and had his foot hooked on walker handle, in an attempt to prevent R1 from taking it. Writer was able to verbally redirect R1 into letting go of walker and coming back onto door side of room. R1 then began to yell that the walker belonged to him. The NA was standing near the doorway and asked R1 to calm down. R1 then lunged at NA with both fists and struck NA in the upper chest. Writer called 911 and R1 went into the hall where he was provided a wheel chair. R1 was calm at that time and accepted the chair. Police officer arrived first and was familiar with R1. When officer was interviewing R1 he stated that he would beat down that worker again if he had to. R1 was pleasant and calm throughout emergency responders assisting him. R1 was sent back to the ED but was discharged back to the facility as he was calm and pleasant at the ED. 9/30/23, at 1:35 p.m. note indicated R1 was very pleasant with staff all of shift. R1 was exhibiting some confusion of place and time. No other concerns or behaviors at this time. 9/30/23, at 2:01 p.m. note indicated per registered nurse (RN), staff to apply Wanderguard. Wanderguard placed on left ankle. 2:33 p.m. documentation indicated R1 was found on the side of the highway headed south. A younger guy and his female friend brought resident back to the facility. R1 did not have a Wanderguard due to not being able to get an order for one. Hospital stated that he does not pose a risk to self or others. R1 had a cut on the right side of his nose and no other obvious signs of injury. R1 was very adamant that he wanted to leave. 9/30/23, 2:58 p.m. notes indicated Resident signed AMA (against medical advice) discharge paperwork. Administrator and two nurses spoke with resident about risks. 9/30/23, late entry note indicated R1 had expressed the want to leave the facility and return home to his house. Writer was notified of this via phone call by facility staff. Writer spoke to resident via phone call with two nurses present in room. Resident was explained the AMA discharge process - that the facility could not help him if he left and no medication could be sent with. R1 gave a verbal understanding of this and wanted to leave. Resident signed AMA discharge paperwork. Writer notified resident case worker and Grand Rapids Police department of resident leaving AMA. Case worker stated she would be up the next day to check on R1. She did have a chance to talk to R1 via phone call and get information from him. During interview on 10/11/23, at 2:22 p.m. RN-A stated she was on call when R1 eloped and subsequently discharged from the facility. RN-A said R1 got to the facility on [DATE], and said they did some assessments but he wanted to leave so he was sent to the ED on Friday. RN-A stated an elopement assessment was done and because he wanted to leave a Wanderguard was placed. RN-A stated the next day she spoke with the hospital nurse and learned R1 had some sundowning and he needed to be watched. RN-A said the Wanderguard was removed when R1 went to the ED because he said he was not coming back. RN-A stated the ED sent R1 back to the facility and was told the hospital said R1 was his own person and was not an elopement risk. RN-A said at the time of the progress note dated 9/30/23, at 2:01 p.m. she had asked why the Wanderguard had not been on when R1 eloped. RN-A said staff told her the administrator and director of nursing (DON) said he was his own person and did not need one. RN-A said the Wanderguard had been replaced following the elopement. RN-A further stated she had no idea how R1 ended up out on the highway and confirmed the Wanderguard was not put back on until he had returned to the facility following the elopement. On 10/11/23, at approximately 3:00 p.m. the administrator stated R1 admitted to the facility on Thursday 9/28/23, and left AMA 3 days later. The administrator said R1 had been sent to the hospital due to behaviors and hospital staff said R1 was his own decision maker and could leave if he wanted to so a Wanderguard had not been replaced after R1 had been sent to the ED. The administrator said R1 ended up leaving on Saturday and was found on the highway by people passing by and was brought back. The administrator stated she had received a call from staff reporting what had happened and staff had told her the DON said R1 did not need a Wanderguard even though the facility had assessed R1 to be at risk for elopement. The administrator said she had spoken to R1 on the phone and he was adamant he wanted to go home and check on his cat and check his mail. The administrator said she had called R1's case worker to let her know and called the police who told her to call 211 (United Way 211 Hotline connects Central Minnesotans to local resources 24/7) to get him a ride home. At 3:16 p.m. the DON stated a Wanderguard was not placed on R1 after he returned from the hospital because he had not signed a bed hold and the hospital said he was his own decision maker. The DON said she understood there had been some confusion about wether or not R1 was appropriate for a Wanderguard. The DON said the corporate nurse was involved and said if R1 began exit seeking and could not be redirected they would look at placing the wanderguard again. The DON said she had not heard anything more and then found out R1 had eloped and was found out on the highway. The administrator who was present during the interview said they did not feel any education or training was necessary because R1 had discharged . On 10/11/23, at 4:11 p.m. the administrator said on 10/30/23, at 2:22 p.m. she had sent a text message to the DON asking her to complete education with staff related to completing an elopement assessment, facility assessment verses hospital assessment and asked her to complete audits but it had not been followed through on. On 10/12/23, at 10:03 a.m. R1's case worker (CW) stated she had spoken to several staff over the course of R1's stay at the facility. The CW stated the last conversation she had with the facility they said R1 was distressed and wanted to go home and they could not keep him there because he was his own decision maker and said they were trying to find resources to get him home. The CW said the facility told her they called the police who said they were not a taxi service so the facility called 211. The CW said she spoke to R1 on the phone about going home and said she would check in with him later in the day. She said she spoke with R1 about his panic button and R1 also said someone who lived with him would be home. The CW said when she called R1 later that evening he told her he had to walk to a church near his home to get an extra set of keys and said he had fallen and someone from the church brought him home. The CW said R1 also said he did not have any food at home and she went and picked him up to go get some food. The CW stated R1 had been a client of their agency for a while and said he also received home health services. The CW said from a safety standpoint she did not think R1 was physically safe to be discharged home. The CW said when she had spoken to the hospital staff while R1 was in the ED she told them her recommendation was he go back to the facility. She said R1 had a history of a TBI and did not have a dementia diagnosis but had memory issues and said she felt he was medically fragile. During interview on 10/12/23, at 11:07 a.m. the administrator said she had not been part of the discussion with hospital staff who reported R1 was able to decide if he wanted to leave the facility. The administrator said the regional director of operations (RDO) and the corporate social service consultant had been in contact with the hospital. The administrator said when R1 left AMA she had not contacted a physician or R1's home health agency, only the case worker and the police who said they were not a taxi. On 10/12/23, at 11:20 a.m. the RDO and administrator were interviewed. The RDO said her understanding was R1 had demonstrated to the facility staff he did not want to be at the facility. The RDO said her conversation with the hospital staff was that R1 did not want to be there and was showing signs of agitation and combativeness. The RDO said hospital staff told her R1 did not need to be in the hospital and the facility needed to take him back. She said the hospital staff said R1 had agreed to come back however, when he was at the facility he was trying to leave. The RDO said hospital staff told her R1 was his own person and the physicians said he was able to make his own decisions. The administrator said the facility referred to the physician to determine if R1 was safe to go home. The SNC, also present said she felt they should be able to trust the physician that R1 was alert and oriented. The SNC said she did not talk to the physician. The SNC said they felt R1 was clinically stable to go home because he had been stable enough to return to the facility. The SNC said they had concerns initially that maybe R1 was not cognitively intact and couldn't sign the admission agreement. She said hospital staff said he was fine and was his own person and that he was just anxious. During interview on 10/13/23, at 1:59 p.m. NA-A stated she had worked with R1 on the day he admitted to the facility and said he seemed fine. NA-A stated she worked with R1 again a day later and said he had been in and out of rooms and said when she opened the linen closet R1 had been in there and had cabinets open and items were rearranged. NA-A said R1 had also rearranged his room. She said R1 had been restless and walking around so she sat with him most the the shift. NA-A stated R1 was unsteady at his baseline when ambulating. NA-A said R1's wanderguard had been cut off when he went to the hospital but she did not know why. At 2:01 p.m. NA-B stated she had worked the weekend R1 was at the facility. NA-B said she was aware he had been combative and had been going in and out of rooms. NA-B said she had assisted the ambulance staff on one of R1's hospital returns and said he had not been combative, angry or aggressive and been joking around. At 2:16 p.m. licensed practical nurse (LPN)-A said when R1 was at the facility he was very confused and followed her around. LPN-A said she had to have R1 sit with her because he was very unsteady. LPN-A said she was there when R1 returned from the ED and said she didn't notice any behaviors and said he was easily re-directed but said he thought she was his ex-girlfriend. Facility Elopement Policy dated 6/2023, indicated Monarch Healthcare Management is committed to provide a safe environment for all residents. Assure that each resident is assessed on an ongoing basis and has appropriate safety precautions in place. Facility Discharge Planning Policy dated 11/2016, indicated the purpose of a discharge plan is to provide the resident with needed care and services, and to work out an acceptable solution for all concerned. Discharge planning is done to assure continuity of care to meet the needs of a resident returning to independent living in the community or discharged to another facility or institution when and if possible. The IJ was removed on 10/13/23, at 2:35 p.m. when it was verified through interview and document review the facility reassessed all residents at risk for elopement and provided education related to elopement to all facility staff including a plan to educate oncoming staff prior to the next shift worked. Elopement education included the facilities responsibility to perform their own assessment of residents and not utilize information passed on by outside agencies. The facility further educated all management staff on procedures to implement prior to allowing a resident to discharge AMA including involvement of outside support services and physician notification.

Based on observation, interview, and document review, the facility failed to ensure safety interventions were in-place, prior to a resident leave of absence (LOA), and additional interventions were developed for subsequent unapproved outings and/or intoxication for 1 of 3 residents (R1) reviewed for accidents. This resulted in actual harm for R1 who left the facility for four hours, was sent to the emergency department (ED) when he returned, received intravenous (IV) fluids, and was diagnosed with [REDACTED]. Findings include: R1's Admission Record printed 3/4/21, indicated R1's [DIAGNOSES REDACTED]. R1's quarterly Minimum Data Set ((MDS) dated [DATE], identified R1 had intact cognition. R1 was totally dependent upon staff for transfers, did not walk, and required supervision with locomotion. R1 used a wheelchair and had an indwelling urinary catheter. A Guardianship/Conservatorship document dated 5/2/18, indicated family member (FM)-A was R1's court appointed guardian/conservator as R1 was impaired to the extent of lacking sufficient understanding or capacity to make or communicate responsible decisions concerning Respondent's personal needs for medical care, nutrition, clothing, shelter or safety. Further, The Respondent (R1) is requesting a guardian and conservator due to his lack of capacity in regards to safety and decision making. R1's care plan undated, identified R1 went into the community when FM-A approved. R1's care plan further identified R1 had a history of [REDACTED]. The care plan identified staff educated R1 related to the risks of leaving the facility for extended periods of time in the cold. Interventions included educating R1 on facility LOA policies and his individual LOA plan, educating R1 on the risks of going into the community independently, notifying staff of his whereabouts, and notifying staff of his expected return time. R1's next-of-kin, the charge nurse, R1's physician, and police were to be notified if his whereabouts were unknown or did not return at the expected time, education was provided regarding signing the resident sign-out book and how to contact the facility in-case of an emergency; and FM-A approval was required prior to R1 leaving the facility. R1's group sheet undated, directed, If wanted to go out of the facility, (FM-A) must be called prior to every outing to get approval and must be accompanied by his mother or designee. On 10/23/20, at 5:44 p.m. a progress note indicated FM-A had called the facility and voiced concerns regarding R1 going shopping or anywhere else in his wheelchair. If R1 attempted to leave the facility, FM-A wanted a manual wheelchair given to him. On 11/9/20, at 1:34 p.m. a progress note indicated FM-A wanted to keep R1 in the facility, and not go to the store, due to the COVID-19 pandemic. On 12/1/20, at 8:00 p.m. a progress note indicated the facility received a telephone call at approximately 7:45 p.m. from FM-A. FM-A was informed R1 was quarantined in his room due to a trip to a store the previous day. FM-A questioned why R1 was allowed to leave the facility, due to COVID-19. The progress note further indicated FM-A had been contacted by the day shift nurse, and FM-A agreed to allow the outing. On 12/4/20, at 9:24 a.m. a progress note indicated FM-A was contacted regarding R1 requesting to go to a store. FM-A was okay if R1 went to the store when it was daylight, however, requested he was back before dark. On 12/8/20, at 4:11 p.m. a progress note indicated three 50 milliliter bottles of alcohol were found in R1's room. R1 stated, I wish those bottles were mine. The bottles were removed from R1's room. On 12/19/20, at 11:22 p.m. a progress note indicated R1 left the facility at 4:40 p.m. against writer advise (sic). R1 was instructed it was getting dark and his mother did not want him to be out in this kind of weather. R1 replied it was not dark and he wanted to go get something to eat. R1 returned to the facility at 8:40 p.m. with slurred speech, thrashing arms, and stated he wanted to die. R1 was noted to be half way out of his wheelchair and was partially undressed. R1's pants were half off, and his coat was noted to be unzipped with his abdomen exposed. R1 had a small abrasion to the third toe on his right foot. R1's catheter was frozen and his body was severely cold. R1 was sent to the emergency department (ED) at 9:30 p.m., and FM-A was notified. The progress notes further indicated FM-A stated, She encouraged her son to not go out in the cold or after dark but she says that her son will do the things he is not suppose to do. Accuweather indicated the temperature in Grand Rapids, MN on 12/19/20, was between -5 degrees Fahrenheit (F) and 21 degrees F. A document titled Resident Sign Out indicated R1 signed out of the facility at 4:40 p.m. on 12/19/20. ED Provider Notes dated 12/19/20, indicated R1 was evaluated with a concern for hypothermia and altered mental status. R1 felt warm-to-touch, however, had cold knees, was slurring words, and was belligerent. R1 had no witnessed or suspected trauma, but was assumed he had slid out of his wheelchair. R1 was agitated, and required a sedation protocol. Intravenous fluids were given in addition to external warming measures. R1 was noted to have superficial frostbite on both of his knees. R1's blood alcohol level was 0.2 and consistent with intoxication. A Urinalysis (urine sample) was collected and was expected to be dirty (urinary tract infection) due to freezing. R1 was prescribed an antibiotic and discharged back to the facility. On 12/20/20, at 4:13 a.m. a progress note indicated R1 returned to the facility at 4:00 a.m. R1 returned with an antibiotic prescription to prevent a urinary tract infection and for the areas of frostbite. On 12/21/20, at 1:00 p.m. a progress note indicated risk versus (vs.) benefit information related to alcohol use and unaccompanied LOAs were presented to R1. R1 stated he would continue to leave the facility if he so chooses. On 12/21/20, at 1:35 p.m. a progress note indicated a social worker, director of nursing (DON), and the administrator had a care conference with FM-A. A conversation related to risk vs. benefits were reviewed with FM-A. On 1/1/21, at 9:00 p.m. a progress note indicated R1 showed a nurse a video in which someone had taken of him spinning in circles on the icy/snowy walkway of the smoking patio. R1 was educated he could be hurt by doing so. On 2/1/21, at 10:28 p.m. indicated R1 had been out of the facility with his roommate until approximately 6:00 p.m. The progress notes further indicated He appears to be in a very pleasant mood and not quite himself. He is very friendly and giggly. A progress note dated 2/18/21, at 2:33 p.m., indicated R1 talked about going to a store with another resident. On 3/1/21, at 12:18 p.m. R1 was observed to exit his room in an electric wheelchair and approached the nurses' station. R1 was wearing a jacket, hat, and boots. A backpack was hanging on the back of R1's wheelchair. R1 was administered medications at 12:23 p.m., and returned to his room at 12:24 p.m. On 3/2/21, at 10:24 a.m. R1 wheeled towards the smoking entrance. R1 was wearing a jacket, hat, and boots. Staff opened a door and R1 proceeded to the smoking area. On 3/2/21, at 10:26 a.m. an interview was conducted with NA-B. NA-B stated residents who were cognitively intact were allowed to leave for outings. NA-B stated she notified a nurse, or nurse manager, if a resident wanted to go on an outing. NA-B stated if she saw a resident leave the facility without approval, she would stay with a resident until she knew if it was approved. NA-B stated residents filled out a sign-out log when they wanted to leave the facility. NA-B stated R1 liked to go to the store, but was not sure how he got there. NA-B stated she believed R1 asked staff when he wanted to leave. NA-B stated R1 was cognitively intact, but had a [MEDICAL CONDITION]. On 3/2/21, at 10:39 a.m. an interview was conducted with licensed practical nurse (LPN)-A. LPN-A stated R1 often went on outings. LPN-A stated R1 did tell staff when he was leaving and where he was going. LPN-A stated on 12/19/20, R1 stated he was going to the store, and returned to the facility intoxicated, and his roommate was with him. LPN-A stated she was unsure what the temperature was when R1 left the facility. LPN-A stated she did not recall what time R1 had left or returned to the facility. LPN-A stated she believed R1 was gone for a couple of hours. LPN-A stated when R1 had returned, it appeared like he had fallen out of his wheelchair, and his roommate had put him back in. LPN-A stated R1 was half out of his wheelchair and his jacket was unzipped. LPN-A stated R1's catheter was frozen, and his belly was showing. LPN-A stated R1 was so cold. LPN-A stated NA-C brought R1 to his room and he kept saying that he wanted to die. LPN-A stated staff put R1 in his bed, warmed him up with heated blankets, and called 911. LPN-A stated since the incident, FM-A expected to know when R1 requested to leave the facility, and what time he will return. LPN-A stated she did not recall if she contacted FM-A for approval for R1 to leave the facility on 12/19/20. LPN-A stated the facility started communicating with FM-A after the incident occurred. LPN-A stated she believed R1 had previously been intoxicated and had history of intoxication since being admitted to the facility. LPN-A stated she did not recall when R1 had been intoxicated before the incident on 12/19/20. On 3/2/21, at 10:59 a.m. an interview was conducted with NA-C. NA-C stated R1 liked to go on outings, and was hanging around another male resident who was half his age. NA-C stated she was unsure if R1 normally informed staff when he went on outings, but believed he did not sign in and out. NA-C stated R1 had intact cognition and knew what he was doing. NA-C stated facility staff caught R1's roommate intoxicated on a couple of occasions. NA-C stated there was two incidents in which R1 was intoxicated. NA-C stated she was unable to recall when the first incident occurred. NA-C stated R1 and his roommate came back from the store, was unsure of the date, and she suspected both residents were intoxicated. NA-C stated LPN-B called the administrator and DON. NA-C stated staff were instructed in the future to call 911 if the residents came back to the facility intoxicated. NA-C stated the second incident happened on 12/19/20. NA-C stated she arrived to work at 6:00 p.m. and R1 returned to the facility well after dinner. NA-C stated staff found R1 in the Unit 4 dining room near the smoking door. NA-C stated R1 was half way out of his wheelchair and did not verbally make sense. NA-C stated R1's belly was red, his legs were ice cold, and his catheter was frozen. NA-C stated R1 had no idea where he was or what he was doing. NA-C stated R1 was so disoriented he could not operate his electric wheelchair. NA-C stated staff brought R1 to his room, minor scrapes were noted on his back side, and his belly was red and purple. NA-C stated R1's right big toe was bloody, and R1 accused staff of trying to kill him. NA-C stated staff removed R1's pants and placed heated blankets on him. NA-C stated R1 was sent to the hospital. NA-C stated the facility did not have interventions in-place when R1 left for a LOA, prior to the incident on 12/19/20. On 3/2/21, at 12:24 p.m. an interview was conducted with NA-D. NA-D stated R1 notified staff when he wished to leave the facility. NA-D stated R1 used the sign-out book, and staff were supposed to let the nurse know when he wanted to leave. NA-D stated she was not aware of any time where R1 tried to leave without signing out or was intoxicated. On 3/2/21, at 12:29 p.m. an interview was conducted with R1. R1 stated he did not have frostbite from the time he left the faciity on [DATE]. R1 stated it was like when a child had a red nose. R1 stated if he wanted to go to the store, he called for the bus and notified staff. R1 stated the incident (on 12/19/20) was not a big deal. R1 stated FM-A made sure the facility called her when he wished to go on an outing. R1 stated he would usually call FM-A and bring his phone to nursing staff. On 3/2/21, at 12:54 p.m. an interview was conducted with registered nurse (RN)-A. RN-A stated R1 liked to go on outings quite often. RN-A stated R1 typically went to a store or restaurant across the highway. RN-A stated R1 also went to the hardware store on a couple of occasions. RN-A stated when R1 wanted to leave the facility it was a special case. RN-A stated staff needed to contact FM-A, and FM-A made decisions for him. RN-A stated R1 usually handed her the phone with FM-A already on the line when he wished to leave. RN-A stated R1 informed staff of when he was leaving and when he was expected to return. RN-A stated staff had R1 also use the sign-out book. RN-A stated she had not seen R1 intoxicated, however, verbalized there was one occasion when R1 was known to get intoxicated and was sent to the hospital. RN-A stated R1 had suffered from frostbite when he was sent to the hospital. RN-A stated R1 never disappeared without telling anyone, and staff needed to call the police if he left without permission. On 3/3/21, at 9:40 a.m. an interview was conducted with FM-A. FM-A stated she was told R1 was intoxicated and suffered from frostbite on 12/19/20. FM-A stated she was R1's guardian, and sometimes they call me about his outings, sometimes they don't. FM-A stated she did not recall if facility requested approval for R1 to leave the facility on 12/19/20. FM-A stated the facility put interventions in-place after the incident occurred. FM-A stated she was comfortable with the plan as long as it was enforced. FM-A stated the facility was now reliably calling her when R1 wished to leave the facility. FM-A stated she did not believe R1 should consume alcohol, but that was a doctor's decision. On 3/3/21, at 9:56 a.m. an interview was conducted with social worker (SW)-A. SW-A stated R1 was cognitively intact, however, had a deficit in making good choices. SW-A stated R1 had a history of [REDACTED]. SW-A stated R1 lacked consequential thinking, and required FM-A's approval prior to leaving the facility. SW-A stated on 12/19/20, R1 and his roommate went to the store and returned to the facility between 7:00 p.m. to 7:30 p.m. SW-A stated R1's shirt was pulled up and his pants were half-way down. SW-A stated R1 was sent to the hospital, and possibly was diagnosed with [REDACTED]. benefit document was completed with R1 and his roommate. SW-A stated the facility wanted both residents to be more cognizant when they went on an outing. SW-A stated she was unable to recall if R1 had become intoxicated prior to the incident on 12/19/20, but thought R1 may have had one other occurrence of intoxication prior to 12/19/20. SW-A stated nothing like the incident on 12/19/20, had happened before. SW-A stated the facility now made sure FM-A's approval was obtained prior to R1 leaving for an outing. SW-A stated facility staff were to call law enforcement if he left without approval. SW-A stated she was unsure if facility staff obtained FM-A's approval prior to leaving the facility on 12/19/20. On 3/3/21, at 10:23 a.m. an interview was conducted with RN-C. RN-C stated R1 needed to call FM-A for approval, and use the sign-out book prior to leaving for an outing. RN-A stated she was only aware of one occasion in which R1 was intoxicated. RN-C stated she was not aware of R1 being intoxicated since the incident on 12/19/20, however, suspected his roommate of consuming alcohol. RN-C stated an incident occurred two weeks ago in which R1 and his roommate left the facility without telling anyone. RN-C stated R1's roommate got his stimulus check and went to the store. RN-C stated staff called her and stated they were unable to find R1. RN-C stated she instructed staff to call law enforcement. RN-C stated staff contacted the DON, however, R1 had since been tracked down. RN-C stated she spoke to R1 and he told her FM-A gave SW-A permission for him to leave the facility. RN-C stated SW-A told her she did not speak to FM-A. RN-C stated she did not know if any new interventions were put into place since R1 left the facility without permission from R1. On 3/3/21, at 10:32 a.m. an interview was conducted with the DON and administrator. The administrator stated staff called R1's cell phone because he was gone longer than expected on 12/19/20. The administrator stated R1 stated he and his roommate were heading back to the facility. The DON stated R1 and his roommate got drunk and were intoxicated when they returned to the facility. The administrator stated staff put R1 in bed, performed a skin assessment, and covered him with blankets. The administrator stated the ambulance was called and R1 was sent to the hospital. The administrator stated R1 was noted to have frostbite to his toes and stomach. The administrator stated after the incident occurred a risk vs. benefit was completed with R1. The administrator stated the facility also added an intervention of contacting FM-A prior to R1 leaving the facility. The DON stated she was not sure if there were any interventions in-place prior to the incident on 12/19/20, because R1 was alert and oriented. The administrator stated FM-A was historically wishy washy about R1 leaving the facility. The administrator stated staff spoke to R1 about obtaining an order for [REDACTED]. The administrator stated he did not believe there had been any incidents since 12/19/20, in which R1 had been intoxicated. The DON stated R1 needed FM-A's permission prior to leaving the facility, and staff were to call the police if he left without permission. The DON stated she was not aware of any occurrence in which R1 had left the facility without FM-A's permission. The administrator stated a full-house assessment was completed for all residents who took LOAs. The administrator stated he was unsure if any staff-education was conducted. On 3/4/21, at 11:25 a.m. a follow-up interview was conducted with SW-A. SW-A stated R1 had left the facility a couple of weeks ago with his roommate. SW-A stated she is unsure if facility staff called FM-A. SW-A stated she asked if R1 had permission to leave the facility, and when he was coming back. SW-A stated she instructed staff to call FM-A an additional time to ensure the leave was approved. SW-A stated she felt staff should enter a note in R1's medical record so the facility knew if FM-A was notified. The facility policy Safety and Supervision of Residents dated 7/17, directed, Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. Further, The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents.

Based on observation, interview and document review, the facility failed to provide the necessary care and services to monitor and evaluate weight gain which caused R1 harm when she had +3 [MEDICAL CONDITION] resulting in hospitalization for [MEDICAL CONDITION]. Although noncompliance was present at the time of the events, the facility had implemented appropriate corrective action prior to the survey, resulting in a finding of past-noncompliance for R1. Findings include: R1's Face Sheet dated 5/6/19, indicated R1 was admitted from the hospital to the facility on [DATE], with [DIAGNOSES REDACTED]. R1's admission orders [REDACTED] -[MEDICATION NAME] (antibiotic) 300 milligrams (mg) two times daily for 14 days for pneumonia of both lungs, [MEDICATION NAME] (insulin) 5 units at bedtime for Type 2 diabetes mellitus, [MEDICATION NAME] (diabetic medication) 25 mg tab one time daily, atorvastatin (blood pressure medication) 20 mg tab one time daily, [MEDICATION NAME] (antidepressant)10 mg tab one time daily and orders for a Diabetic, sodium controlled, 1500 milliliters (mls) fluid restriction. R1's care plan initiated 4/9/19, indicated R1 had the following focuses and interventions: -R1 utilized antidepressant medication and to monitor for side effects including changes in weight. -R1 had a [DIAGNOSES REDACTED]. -R1 had [MEDICAL CONDITION] and was at risk for skin breakdown. Nursing to assess resident's skin every week. -R1 nutritional status indicated a 1500 ML fluid restriction and needed to be weighed weekly. -R1 has shortness of breath on exertion. Keep physician informed of changes. On 5/7/19 at 8:00 a.m. R1's clinical record was reviewed and lacked evidence of monitoring for [MEDICAL CONDITION], or reporting significant weight gain to dietician or physician. R1's progress note dated 4/28/19, at 2:01 p.m. indicated the following: resident has facial [MEDICAL CONDITION], family is here and concerned about her. This started a few days ago. (No prior information in clinical record). Resident has +3 [MEDICAL CONDITION] to lower extremities, facial [MEDICAL CONDITION] -resident's right eye is shut due to [MEDICAL CONDITION]. Crackles in lung sounds, R1 reports cough, but has not coughed anything up. R1 denies shortness of breath, does report feeling fluid in her abdomen. On call medical doctor contacted and gave orders to send to the emergency room for evaluation. Ambulance contacted and here at 8:40 a.m. The clinical record progress notes lacked any further documentation related to R1's [MEDICAL CONDITION] or weight gain. On 4/28/19, at 2:47 p.m. R1 was admitted to the hospital for [MEDICAL CONDITIONS] and [DIAGNOSES REDACTED] (Inflammation of the colon caused by the bacteria [MEDICAL CONDITION]). R1 was readmitted to the nursing facility on 5/4/19, following a 6 day hospital stay. R1's Medication Administration Record [REDACTED] -4/9/19- 209.4# Admission -4/15/19, 236.6# (weight gain of 27.2 # in 6 days) -4/22/19 244.0# (an additional 7.4# weight gain in one week, for a total weight gain of 34.6# over 13 days) The facility's Weight Assessment policy dated 3/16, indicated assessment information should be analyzed by the multidisciplinary team with conclusions made regarding the resident's target weight range. On 5/7/19, at 9:20 a.m. nursing assistant (NA)-A stated she documented R1's weight of 209.4 # on admission, and 236.6 # the following week for a weight gain of 27.2#. The NA-A stated she was suppose to report 3 to 5 pound weight gains to the nurse however, stated she must not have reported R1's weight gain. On 5/7/19 at 9:25 a.m., NA-B stated she had worked with R1. NA-B stated she had not reviewed the previous weights. NA-B confirmed she had not reported any of R1's weight changes to the nurse. On 5/7/19 at 9:35 a.m., licensed practical nurse (LPN)-A confirmed she had looked at R1's weight but had not reviewed the admit weight, I focused more on her [MEDICAL CONDITION] and [MEDICAL CONDITION]. LPN-A confirmed R1's weight had not been monitored properly and the physician had not been notified of a weight gain of over 35 pounds in three weeks. LPN-A added, We dropped the ball on this one and confirmed R1's weight should have been monitored more closely. LPN-A stated the facility had implemented a change to their weight monitoring system following R1's hospitalization . On 5/8/19 at 9:00 a.m. the director of nursing (DON) confirmed R1's weight gain should have been addressed in a more timely manner. On 5/8/19, at 8:36 a.m. during an interview with registered nurse (RN)-A, she stated, I was on duty when (R1) arrived at the emergency room (ER), the family had requested to have the resident seen in the ER due to overall poor health condition and [MEDICAL CONDITION]. The family was adamant about (R1's) lack of care and interventions by the nursing staff. (R1) had gained 35 pounds over a 3 week period of time, I absolutely believe the hospitalization could have been avoided if (R1's) weight gain had been followed up on immediately. I do not believe (R1) was provided with appropriate nursing procedures/cares to monitor her and help prevent this illness and hospitalization . RN-A stated the facility should have provided more timely interventions. On 5/9/19, at 8:20 a.m. the nurse practitioner (NP) stated her expectation would have been for the facility to contact herself, the resident's primary care provider, or the hospital, when they identified the initial weight gain of twenty seven pounds. On 5/7/19, at 9:25 A.M. LPN-A confirmed R1's weight gain was not reported or followed up on and should have been. LPN-A stated, I would have expected staff to report a jump in weight like that. LPN-A confirmed R1's weight gain resulted in a hospitalization for [MEDICAL CONDITION]. LPN-A confirmed R1's weight gain should have been addressed immediately. LPN-A confirmed she had reviewed R1's weights and missed R1's weight gain of over 35 pounds over a three week period of time. However, LPN-A stated the facility had recognized the problem and implemented a corrective action plan. The Corrective action plan implemented in full by 4/30/19, at 9:00 a.m. included: 1. Immediate intervention: To ensure all new admissions have weekly weights completed and to notify the physician of any weight gain or loss of 5% or greater. Individuals assigned to monitor are nurse managers and the Dietary Manager. 2. Immediate actions to identify all residents potentially affected: Review all new admissions in last four weeks to ensure weekly weights are done. Ensure adequate documentation is complete. All new admission weights to be completed one time per week. Nurse Manager assigned to monitor. 3. Actions taken for future residents potentially affected: Nurse Managers and Dietary manager to review weights and chart progress notes weekly. Notify MD if weight gain or loss of 5% or greater. 4. System changes made: Education of notifying the physician of 5% or greater weight gain or loss in one week. Nurse manager/director responsible for education. 5. Continued Quality Assurance audits implemented to ensure enhanced system compliance: New admission weekly weight audits; director of nursing (DON)/director responsible for follow up. 6. 4/30/19- staff education/review completed of plan. 7. A weight summary report was generated for all residents in the facility which identified weights from 180 days prior to current date. This report will continue to be generated for all residents so weight gain/loss can be identified easily. 8. All facility residents were reviewed at the weekly Nutrition at Risk committee. Residents were reviewed for weight loss/gain and interventions were identified and implemented as needed. These weekly meetings will continue to be ongoing. The past non-compliance that began on 4/28/19, was verified during the 5/6/19, onsite visit and reviewed to be corrected by 4/30/19. Verification of corrective action was confirmed by interview with a variety of nursing and dietary staff, observation and document review. Audits conducted verified interventions were being completed. Nursing and dietary manager were educated to the facility policy and revisions were made to on-going monitoring of resident weights to prevent future incidents.

Based on interview and document review, the facility failed to comprehensively assess pressure ulcer risk, reassess the efficacy of interventions, educate on the risk and benefits of routine repositioning, and/or consistently implement interventions to promote healing and prevent the development of new pressure ulcers for 1 of 1 resident (R2) reviewed for pressure ulcers. These failures resulted in actual harm when R2's facility acquired pressure ulcers worsened to stage 3 (full thickness tissue loss) pressure ulcers on the buttocks. Findings include: R2's [DIAGNOSES REDACTED]. Pressure ulcers on the left and right buttocks were indicated as acquired during a stay on 3/19/19. R2's Resident Record printed 5/6/19, indicated R2 had been admitted to the facility on [DATE]. R2's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R2 had intact cognition, did not demonstrate any behaviors or rejection of care, required extensive to total assistance for bed mobility, transfers, locomotion on unit, and toilet use. In addition, the MDS indicated R2 was at risk for development of pressure ulcers and had 3 documented Stage 3 (full thickness tissue loss) pressure ulcers on feet upon admission. Treatments included pressure relieving devices for chair/bed, pressure ulcer care, application of ointments/medications, and application of dressings to feet. R2's Care Area Assessment (CAA) for pressure ulcers dated 2/22/19, indicated R2 required extensive assistance with bed mobility, was always incontinent of bowel, was at risk and had a Stage 3 pressure ulcer and an unstageable wound. R2 was to wear boots in bed for protection, was followed on weekly wound rounds in addition to wound care orders, followed a bowel protocol to reduce incidences of bowel incontinence, and was checked/changed/repositioned every two hours with assistance from one to two staff. R2's Order Summary Report provided 5/6/19, identified the following orders: Start date 3/3/19: Left & right buttocks: cleanse with soap and water to open area and redness. Pat dry. Apply foam dressing. Change every 3 days and as needed. Start date 3/9/19: Left & right buttocks: cleanse with soap and water to open area and redness. Pat dry. Apply [MEDICATION NAME] and foam dressing. Change everyday and as needed. Change positions during sleep every two hours. Start date 3/23/19: Left buttocks: cleanse with soap and water to open area and redness. Pat dry. Apply foam dressing. Change everyday and as needed. On 5/9/19, at 10:25 a.m. the director of nursing (DON) was interviewed and stated the facility had not completed an assessment regarding the ability of R2's skin and it's supporting structures to endure the effects of pressure, without adverse reaction. The DON further stated the facility did not complete tissue tolerance assessments on their residents. R2's Braden Scale assessment (tool to identify pressure ulcer risk) was not completed upon admission. The first assessment completed was dated 3/8/19 (date that areas on buttocks were first identified), and indicated R2's sensory perception was slightly limited, with some sensory impairment which limited the ability to feel pain or discomfort in 1 or 2 extremities, skin was moist, R2 was chairfast, had very limited ability to change or control body position, had adequate nutritional intake, had a potential friction and shearing problem, and was at moderate risk for the development of pressure related ulcers. The assessment further indicated R2 had been admitted with pressure ulcers on the top of his feet, and indicated R2 had pressure ulcers on his right and left ischial area (lower and back part of the hip bone). The record revealed R2 was paraplegic and did not have feeling in the lower half of his body. Staff were using the Hoyer (full body mechanical lift) for transfers. In addition, assessment revealed R2 allowed staff to put him to bed, then raised the head so he was sitting on his ischial area again. R2's care plan dated 2/22/19, indicated R2 had impaired mobility related to [MEDICAL CONDITION] due to motor vehicle accident and directed the staff to transfer with assist of two staff and mechanical lift. Staff were to turn and reposition every 2 hours in bed and chair. The care plan also indicated R2 had two Stage 3 pressure ulcers (did not indicate the location) and was at risk of developing more. The plan directed staff to provide the following: -follow facility policies/protocols for the prevention/treatment of [REDACTED].>-nurse manager to assess/record/monitor wound healing weekly and as needed. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to medical doctor (MD). -resident had a pressure redistributing mattress -resident had a pressure-redistributing pad on chair -resident needs assist of one or two to turn/reposition at least every 2 hours, more often as needs or requested -resident requires boots on in bed for protection R2's Weekly Pressure Wound Evaluations indicate the following: On 3/13/19, area identified on 3/3/19, right buttocks measured 1.4 centimeter (cm) x 2 cm x 0.2 cm. Stage 2 (partial thickness tissue loss). No changes to progress. R2 has no feeling in lower extremities, reposition every 2 hours. On 3/13/19, area identified on 3/3/19, left buttocks measured 1.5 cm x 2 cm x 0.2 cm. Stage 2. No changes to progress. R2 is hoyer lift, unable to move legs without assistance. On 3/21/19, right gluteal fold measured 2 cm x 4 cm x unable to determine depth. Stage 3. Declined in progress. R2 unable to feel buttocks, staff to reposition every 2 hours and as needed. Encourage to not sit in wheelchair for long periods. On 3/21/19, left gluteal fold measured 2.5 cm x 4 cm x 0,2 cm. Stage 2. Declined in Progress. R2 is paraplegic and has no feeling in buttocks. On 4/9/19, right buttocks measured 3 cm x 1.2 cm x unable to determine depth. Stage 3. Declined in progress. R2 is paraplegic with no feeling in lower body and staff to reposition every 2 hours. On 4/9/19, left buttocks measured 2 cm x 3.5 cm x >0.2 cm. Stage 2. No changes in progress. Wound has not changed in depth. Unable to reposition due to [MEDICAL CONDITION], hoyer lift (full body mechanical lift) all transfers. On 4/12/19, right buttocks measured 4 cm x 3.5 cm x >0.2 cm. Stage 2. No changes in progress. R2 using sliding board transfers, paraplegic and needs assistance to turn and reposition in bed. On 4/12/19, left buttocks measured 3.5 cm x 4 cm x unable to determine depth. Stage 3. No changes in progress. R2 transferred with sliding board, needed staff assistance for repositioning and did d not like to be in bed often during the day. Review of R2's physician notes indicated the following: 3/18/19 NP (nurse practitioner) note indicated R2 had pressure ulcers on bilateral buttocks that he (R2) wanted to have looked at. The note included, R2 does have Stage III pressure ulcers on each buttocks. These were evaluated, all measurements per nursing. 3/27/19 primary MD (medical doctor) saw at office visit. (R2) was frustrated with his care at current facility.(R2) had some pressure [MEDICAL CONDITION] and ulcerations on his buttocks regions and had pictures on his phone of those that he shared with me as well as during a recent visit on 3/18/19 with our NP. (R2) reported the Hoyer lift likely contributes to these and has asked staff to use sliding board for transfers and cares which the nursing staff tend to refuse. Orders written to use sliding board as much as possible for transfers and cares to avoid pressure in ulcers on buttocks. 3/27/19 notes from Grand Itasca Hospital: (R2) had stage III open ulcerations on buttocks ranging in size from 1 x 2 cm to 2 x 3 cm. 3/30/19 History and Physical: (R2) states that he had been doing fairly well but then started to have decubitus sores and (R2) stated that they had been leaving him sit on the Hoyer lift straps after they put him in the chair and he states that's where the open sores came from. 4/8/19 wound consult from St. [NAME]'s hospital Duluth: (R2) seen for x 5 pressure ulcers on admission, ischial bilateral one necrotic, top of both feet, left heel. Left ischial 4 x 3 cm small amount serous drainage noted, mild odor. Right ischial 3.2 x 3.5 small amount drainage mild odor noted. 4/8/19 NP note from nursing facilty: (R2) did have decubitus ulcers on both buttocks. These had been healing at time he was admitted to the hospital. Recommend continue with border foam and change daily. Offload pressure at all times. (However notes and measurements prior did not indicate healing.) On 5/6/19 at 12:47, R2, who had discharged from the facility, was interviewed by telephone. R2 expressed concerns related to having the Hoyer lift straps left under him in wheelchair with subsequent development of pressure ulcers from not being repositioned timely, in addition to having feces to exposed areas. R2 stated at times he would put call light on, wait 20-30 minutes, staff would come in turn off light and say they would be right back and another 15 minutes would go by. R2 stated there were times he had waited 3-4 hours to be re-positioned and stated after discharge to home, within 3-4 days the home care agency sent him to hospital for infected pressure ulcers on buttocks. He is now residing in another care facilty. R2 stated he had spoken to the facility's administrator about his concerns but they just continued to happen. He stated when he entered the nursing home he'd only had ulcerated areas on his feet. R2 further stated the facility had experienced problems finding a wheelchair that would work for him and that he felt like Goldilocks; 1st chair was too small, 2nd chair was too big and 3rd chair was hitting my mudpack causing sore areas. R2 stated, finally the facility's Social Worker brought in her father's chair which is the chair I still have because they did not send in the paperwork to get me the customized chair the physician ordered. R2 stated he went to therapy everyday to regain strength and the ability to self-transfer. Review of the manufacturer's guidelines for the EZ Way Smart Lift indicated on pages 7 & 9, under Step 7, the sling was to be removed from under patient after being placed into the wheelchair or bed. Review of a competency checklist for use of the mechanical lift, #29 indicates to remove sling from under and between legs, grasp at both sides, shoulder level and with a gentle pull remove sling. #30 indicated resident may keep sling under then while in chair if it is the resident choice and had been care planned. On 5/7/19, at 8:08 a.m. the clinical manager (CM)-A stated the cross slings can be removed from a resident's chair. The CM stated with R2, the straps were usually slid to the side from underneath R2 and tied behind the wheelchair, so the sling was not removed from the chair. During interview with the occupational therapist (OT) on 5/7/19 at 8:36 a.m., the OT stated the recommendation was that slings be removed from under residents when in a wheelchair as the straps can work their way down, causing pressure. The OT stated, Especially when an individual is a paraplegic who cannot tell you if it is uncomfortable or causing pain. The director of nursing (DON) stated during interview 5/7/19 at 11:24 a.m., Residents who have skin issues should have the sling removed from the chair. The DON could not confirm if this was done for R2. On 5/8/19, at 1:40 p.m. the DON verified the ulcerated areas on R2's buttocks were identified on 3/3/19. The DON could not verify whether the NP was notified of the new ulcerations, but stated she would expect the NP to be notified the day of identification with new areas of concern. The DON further verified the NP did not see the resident until 3/18/19, and confirmed no documentation was available to indicate whether R2 chose to keep the sling underneath him in the chair, or if education regarding the risks and benefits of leaving the sling underneath him had been provided. On 5/9/19, at 8:22 a.m. the NP interview stated she would expect to be notified of a new ulcer area within a week. The NP could not recall when she'd been notified of R2's new pressure ulcers to his buttocks, but verified she'd first seen them on 3/18/19, even though the ulcers had been identified by nursing staff 3/3/19. Regarding R2 refusing to be repositioned as recommended note indicated: On 5/8/19, at 9:51 a.m. licensed practical nurse (LPN)-A stated she did not recall staff reporting any refusals to get out of bed, chair or reposition. At 10:57 a.m. on 5/8/19, the administrator provided documentation on their Quality Conference form that R2 was documented as refusing to be repositioned during the first 5 days at the facility. They administrator stated they'd stopped adding this to their morning meeting notes when CM-A stated she had completed a risk vs. benefit with R2. Administrator indicated there was no documentation of these refusals in R2's clinical record or any documentation that risk vs benefit was completed. On 5/8/19 at 1:15 p.m., the DON confirmed no documentation could be located regarding repositioning of R2 every 2 hours. She stated it would be hard to tell if repositioning actually occurred. The DON verified that repositioning was included on the care plan, but could only provide one progress note from R2's stay that indicated he refused to be repositioned. Further, the DON stated a root cause analysis (RCA) was completed when a resident develops new pressure areas however, verified this had not been completed for R2. During interview with LPN-B on 5/8/19 at 2:30 p.m., LPN-B stated she did not recall discussing risk vs. benefits of repositioning with R2. LPN-B expressed feeling R2 was repositioned according to schedule although could not confirm this. LPN-B stated the nursing assistants (NA) would document when residents were repositioned on their repositioning sheets. On 5/9/19, at 8:40 p.m. the facility's Regional Nurse Consultant stated repositioning/toileting sheets are not kept as part of the permanent record. Review of the 24 Hour Nursing Report sheets during R1's stay did not include any comments regarding refusal of cares. Instead, the 24 Hour Nursing Report sheets indicated R2 was quiet, pleasant and without behaviors. Review of progress notes included one notation on 2/10/19, indicating the resident refused repositioning that shift before supper x2. Review of OT progress note dated 2/12/19, indicated R2 was currently using a wheelchair that was not giving him the best support. The note indicated, Patient given wheelchair with deeper seat for better weight displacement. Continued assessment of wheelchair needed for a wider wheelchair but unable to supply patient with one at this time. Discussed with OT plan for new wheelchair for patient. On 2/21/19 R2 was seen by his physician face to face for assessment of wheelchair need. The physican documented order indicated need for a specialized wheelchair would be forwarded to an appropriate supplier. OT progress note dated 3/5/19, completed set up of lightweight manual wheelchair for patient to progress comfort and mobility. Administered Roho cushion for increased pressure relief and decreased risk of skin breakdown as patient has noted redness on bilateral ischium. On 5/7/19, at 8:36 a.m. OT stated during interview, We tried a few different chairs with (R2) but we have a very limited supply of chairs available for residents. A donated chair was brought in which fit (R2) well and he discharged with that chair. OT further stated, It generally takes a couple weeks to provide a note to the supplier for a wheelchair once the physician's orders [REDACTED]. The OT further confirmed R2 had discharged from the nursing facility to home on 4/14/19. In addition, the OT stated R2 was always compliant with working with therapy. The facility's Repositioning Policy revised 6/2017, provided guidelines for evaluation of resident repositioning needs to prevent skin breakdown, promote circulation and provide pressure relief for residents. The policy included: Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. The resident's assistance required, number of staff to assist and timelines for repositioning will be entered into the resident's Care Plan. For residents with a Stage I or above pressure ulcer, an every two hour repositioning schedule is inadequate. Residents who are in a chair should be repositioned every hour. Staff were directed to notify the supervisor if the resident refuses the procedure. If the resident refuses care, an evaluation of the basis of refusal, and the identification and evaluation of potential alternatives is indicated.

Based on observation, interview and document review, the facility failed to prevent the development of and worsening of, document the presence of, and monitor and treat an unstageable pressure ulcer on the bridge of the nose for 1 of 3 residents (R17) reviewed for pressure ulcers. R17 experienced actual harm due to the development of a new pressure ulcer that worsened. Findings include: R17 was observed on 8/1/16, at 5:42 p.m. to have a pressure ulcer on the bridge of her nose. R17 stated it was from her [MEDICAL CONDITION] (continuous positive airway pressure) mask. At 4:57 p.m. registered nurse (RN)-A stated R17 did not have a pressure ulcer. R17's Order Recap Report printed 8/4/16, indicated R17 had [DIAGNOSES REDACTED]. A physician order [REDACTED]. R17's admission Minimum Data Set ((MDS) dated [DATE], indicated R17 had moderately impaired cognition, and required extensive assistance with bed mobility, transfer, toileting, dressing and personal hygiene. The MDS also indicated R17 was short of breath, reported frequent severe pain, was at risk of developing pressure ulcers, and had no unhealed pressure ulcers. The MDS further indicated R17 received anticoagulants, insulin and diuretics. In addition, the MDS indicated R17 received both oxygen and [MEDICAL CONDITION] treatments. R17's Care Area Assessment (CAA) worksheet dated 7/20/16, indicated R17 was on antidepressants and antianxiety medications, which increased the risk for pressure ulcer development. The CAA also identified R17 used a device that can cause pressure ulcers, such as oxygen tubing. A CAA progress note, dated 7/26/16, indicated R17 was at risk for the development of pressure ulcers, had no current pressure ulcers, and to proceed to the care plan with a goal of preventing skin breakdown. R17's care plan dated 7/26/16, indicated R17 had multiple skin tears on her upper extremities and her skin was very fragile and tears easily. Nursing staff were directed to be extremely careful with R17's skin as it was very fragile, to turn and reposition R17 every two hours in bed and in the wheelchair, and observe R17's skin at least weekly on bath day. The care plan also directed nursing staff to set up R17 ' s [MEDICAL CONDITION] machine every night before bed, and have R17 wear the [MEDICAL CONDITION] for 6-8 hours a night. The care plan lacked identification of, or interventions for the pressure ulcer on the bridge of the nose. R17's Pocket Care Plan indicated R17 had skin tears, fragile skin and used oxygen, however, it lacked identification of, or interventions for R17's pressure ulcer. R17's Initial Nursing Evaluation and Vitals dated 7/14/16, indicated the appearance of R17's nose was ok and no abnormalities were noted. R17's Braden Scale Assessment for Predicting Pressure Score Risk dated 7/13/16, identified a score of 18, which indicated moderate risk for developing pressure ulcers. R17's Comprehensive Evaluation of Skin and Risk Factors, dated 7/13/16, 7/20/16, 7/27/16, and 8/3/16, all lacked indications of any skin concerns to R17's nose. On 8/3/16, at 12:57 p.m. RN-A stated R17 had 3 skin tears along her arm and R17 is on [MEDICATION NAME] (a medication that can treat and prevent blood clots) which affects her healing. On 8/4/16, at 8:37 a.m. R17 was again observed to have a pressure ulcer on the bridge of her nose. On 8/4/16, at 8:47 a.m. RN-A stated R17 did not have the pressure ulcer on her nose when she was admitted on [DATE]. RN-A stated the wound hadn't been measured and there were no notes, assessments or measurements of R17's pressure ulcer. RN-A did not know when the pressure ulcer developed. RN-A stated she was aware of the scab on R17's nose, but had not assessed or measured the pressure ulcer. RN-A stated she would describe the pressure ulcer as an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) or eschar (tan, brown or black) in the wound bed). RN-A stated the pressure ulcer was not being treated, and was left open to air during the day. RN-A further stated the pressure ulcer on R17's nose was from her [MEDICAL CONDITION] machine. RN-A stated R17 has always had a spot on her nose, but not open. RN-A also stated staff would pad the mask with a cotton ball at night. RN-A reiterated R17 did not have the nose wound on admission, R17 developed it while a resident at the facility. R17 brought the [MEDICAL CONDITION] mask from home and has used this mask for over a year. RN-A stated the pressure ulcer was never open, it had only been black eschar. RN-A stated she had verbally notified the nurse practitioner (NP) last week, but RN-A did not document the concern or the communication to the NP. R17's progress notes from 7/13/16, to 8/3/16, revealed only one mention of her pressure ulcer: On 7/17/16, at 4:02 a.m. it was noted that R17 had a scant amount of blood on her nose. R17 stated it was from her [MEDICAL CONDITION] mask. The NP's Nursing Home Note dated 7/28/16, identified a 0.75 cm scabbed lesion to the top of the nose. The note further indicated R17 told the NP it was from the [MEDICAL CONDITION], and she was using a cotton ball under the mask at night. A Physician Appointment Note dated 8/2/16, lacked identification of the pressure ulcer, but indicated it was okay to use any device from home to decrease rubbing on R17's nose from [MEDICAL CONDITION]. On 8/4/16, at 9:17 a.m. RN-A measured R17's pressure ulcer as 1.3 centimeters (cm) long by 1.7 cm wide. RN-A described the area as a black spot, covered with eschar surrounded by redness. RN-A stated the pressure ulcer was all eschar, and it would be classified as unstageable. On 8/4/16, at 9:20 a.m. R17 stated she continued to wear the [MEDICAL CONDITION] mask every night. On 8/8/16, at 2:30 p.m. the director of nursing (DON) stated nurse managers are responsible for identifying pressure ulcers. The DON stated weekly wound rounds are done on Wednesdays or Thursdays. The DON stated nurse managers, the MDS nurse and sometimes the quality nurse attended the weekly rounds. The DON stated she has not attended for some time. The DON stated she had just found out about the pressure ulcer on R17's nose. The DON stated she thought the staff had noted it as a scab, and they were not looking at it as a pressure ulcer. The DON stated the MD should have been notified and treatment initiated. The DON further stated staff should have documented if they saw a scab and the [MEDICAL CONDITION] that she uses. The DON stated she would expect documentation to include initial weekly documentation of the pressure ulcer, the resident's risk for development of a pressure, notification of the MD, and interventions added to the care plan. The facility policy Prevention of Pressure Ulcers revised February 2014, indicated pressure ulcers are often made worse by continual pressure on the resident's skin and directed staff to report any signs of a developing pressure ulcer to the supervisor. The facility policy Pressure Ulcer Risk Assessment revised April 2016, directed staff to routinely assess and document the condition of the residents' skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown and to immediately report any signs of a developing pressure ulcer to the supervisor. The facility policy Pressure Ulcers/Skin Breakdown revised in February 2016, directed the nurse to assess and document a full assessment of a pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue.

Based on observation, interview, and document review, the facility failed to provide ambulation services to prevent loss of function for 2 of 9 residents (R20 and R48) who required physical assistance with ambulation, and were not reassessed upon a decline in ambulation. The decline in ability to ambulate resulted in actual harm for R20 and R48. Findings include: R20's quarterly Minimum Data Set ((MDS) dated [DATE], indicated he had [MEDICAL CONDITION], Alzheimer's, dementia, severe cognitive impairment, ambulated once or twice in his room or corridor with assist of two, received scheduled pain medication and had no presence of pain. R20's quarterly MDS dated [DATE], indicated he had severe cognitive impairment, did not walk in his room or corridor, received scheduled pain medication and had no presence of pain. The Care Area Assessment (CAA) dated 1/24/14, indicated R20 triggered for activities of daily living (ADLs) due to needing supervision with dressing, hygiene, bathing, not being steady and needs a wheelchair or walker. During interview 9/17/14, at 8:00 a.m. with nursing assistant (NA)-E and NA-D both stated they have not been able to ambulate R20 and other residents due to their work load assignments for the past several months. During observation 9/18/14, at 9:30 a.m. R20 was sitting in his room in a wheelchair, a walker was not observed in his room to assist with ambulation. During interview 9/18/14, at 9:44 a.m. nursing assistant (NA)-D who cared for R20 stated R20 has stopped ambulating over a month ago and that he has becoming more combative with cares. She also stated, "We have no time to ambulate our residents," which had been occurring for the past several months. Review of a Hospital Discharge Summary dated 1/5/14, indicated R20 was admitted for [MEDICAL CONDITION]ly secondary to osteo[DIAGNOSES REDACTED], an amputation of the right second toe was completed on 1/3/14 without difficulty. R20's care plan dated 2/12/14, indicated he cannot ambulate independently due to recent toe amputation and decline in cognition. The care plan indicated R20's balance while standing was unsteady and that R20 was to participate in a functional maintenance program (FMP) to ambulate with supervision 75-100 feet (ft.) up and down the hallway times two, when able. Review of R20's Pain Assessment 3.0 which was updated on 6/20/14, indicated when asked he had no pain presence, rarely has pain and staff assessment for pain using numeric scale from 00-10 (00 being no pain to 10 being the worst pain experienced) R20 identified their pain as a "1" mild discomfort. The assessment identified R20 received Tylenol 500 milligrams (mg) ([MEDICATION NAME]) three times a day. The Pain Assessment 3.0 dated 7/3/14, indicated R20 had no pain presence, rarely has pain and his numeric rating was 00. The assessment identified R20 denied pain, and the Tylenol 500 mg three times a day on 6/20/14, and seems effective for pain relief. The Pain Assessment 3.0 dated 8/21/14, and 9/21/14, remained unchanged from the 7/3/14, assessment indicating resident denied pain and Tylenol extra strength seems effective for pain relief. Review of R20's progress notes from 7/1/14 thru 9/22/14, did not indicate R20 was having any pain or discomfort from his toe amputation in January 2014. The facility's nursing assistant care sheet undated, directed staff to ambulate R20 75-100 ft. with a front wheeled walker (FWW) and gait belt two times daily. A Walking/Ambulation Program Guidelines Restorative Nursing/Functional Maintenance Recommendations authorized by physical therapy (PT) dated 4/9/14, indicated R20 walked with a FWW and a gait belt 75-100 ft. with two self-performance and two support. Review of the progress notes, physician notes and facility assessment from June 20, 2014 to September 18, 2014 did not identify R20 was being ambulated 75-100 ft. with a front wheeled walker (FWW), and gait belt two times daily, as directed by the Walking/Ambulation Program Guidelines Restorative Nursing/Functional Maintenance Recommendations which PT recommended for R20. During interview 9/18/14, at 9:01 a.m. physical therapist (PT)-A stated she hadn't been informed that R20 was not ambulating, and confirmed that he had not been seen by physical therapy since 4/9/14, when he'd started on his walking/ambulation program. PT-A then stated she would reassess his ability to ambulate. During interview 9/18/14, at 9:20 a.m. the director of nursing (DON) stated in November 2013, the facility started documenting the FMP's in a new computer system and stated she was unable to find any documentation that staff were providing R20 with his FMP that started on 4/9/14. The DON further stated the staff development nurse who left in March 2014, was supposed to be documenting quarterly on his progress with his FMP but she had not completed this. During interview on 9/17/14 at 2:13 p.m. certified occupational therapy assistant (COTA)-A stated the facility has a functional maintenance program which was to be completed by their restorative aides. But, at this time they do not have any staff that are implementing the restorative program, and have not had any for at least three weeks or longer. COTA-A stated, "If we don't have any staff to do the programs, the programs have not been implemented for any of the residents." Review of the Physical Therapy Plan of Care dated 9/17/14, identified reason for referral was, "(functional decline) Patient is a [AGE] year old male who presents with a decline in transfers and ambulation due to patient not participating in current FMP for ambulation and decreased bilateral ankle ROM (range of motion). This since resulted in the patient now requiring significantly more assistance for the completion of transfers and ambulation." The referral indicated under initial assessment that his prior level was that he walked 100 ft. with his front wheeled walker. The current level of his assessment indicated he needs "moderate assist x 2 persons (Routinely requires 50 % physical assistance of 2 persons to transfer)." The referral under gait distance indicated his prior level was "100 feet" and his current level is "0 feet." The evaluation also indicated "Therapy is necessary for improving bilateral ankle ROM, transfers, and ambulation along with updating current FMP to make it appropriate for the patient due to his dementia with behavior disturbances. Without therapy patient is at risk for further functional decline." The referral indicated R20 received [MEDICATION NAME] for pain but did not indicate R20 was currently having any pain. During interview 9/18/14, at 9:01 a.m. PT-A stated that R20 started on a FMP on 4/19/14, and that he was able to ambulate 75-100 ft. with his front wheeled walker. The PT-A stated she had attempted to ambulate R20 yesterday (9/17/14), and R20 would not ambulate with her. She had spoken to the staff and they informed her he (R20) was no longer ambulating. PT-A stated staff are supposed to inform her if a resident is declining or is no longer is able to complete their FMP, but stated she had never been informed that R20 was not ambulating anymore. PT-A stated she was going to try and get approval to pick him back up again for therapy. During a phone interview 9/22/14, at 11:40 a.m. PT-A stated that if a resident was observed during her evaluation to have pain she would document that on the evaluation. Although R20 had a FMP to assist with ambulation, the facility failed to ambulate R20, which resulted in a decline in ambulation which was not reassessed, and resulted in actual harm for R20. R48's quarterly MDS dated [DATE], indicated he had a [DIAGNOSES REDACTED]. He ambulated in his room with extensive assist of one and did not ambulate in the corridor. R48's care plan dated 3/14/14, indicated on 5/23/13 he was placed on a FMP to ambulate 100 ft. twice daily with walker. The nursing assistant care sheet undated, indicated R48 was to ambulate 100 ft. twice daily with a walker. R48's FMP documentation dated May 2013 indicated under comments section of the FMP identified "(R48) to ambulation 100 ft. twice a day with walker and assist of one staff. he will demonstrate benefits from his program by his ability to stand & transfer with assist of one staff." During interview 9/17/14, at 8:00 a.m. with NA-E and NA-D both stated they have not been able to ambulate R48 or their other residents due to their work load assignments for the past several months. During interview and observation on 9/17/14, at 8:20 a.m. R48 stated he does not ambulate and the staff do not offer to ambulate him. He further stated if staff would offer to ambulate with him he would not refuse. There was no walker observed in his room. During interview on 9/17/14 at 2:13 p.m. COTA-A stated the facility has a FMP which was to be completed by their restorative aides. But, at this time they do not have any staff that are implementing the restorative program, and have not had any for at least three weeks or longer. COTA-A stated, "If we don't have any staff to do the programs, the programs have not been implemented for any of the residents." Review of the progress notes, and FMPs from June 2014 to September 8, 2014, did not identify R48 had been ambulated 100 ft. twice a day with a walker, as identified by the 5/23/13 FMP. During interview 9/18/14, at 9:01 a.m. PT-A stated she would be reassessing R48's ability to ambulate. Review of the Physical Therapy Plan of Care Evaluation dated 9/18/14 (during survey), indicated he was re-evaluated for ambulation to check for a decline. The evaluation indicated he was able to ambulate 100 ft and now was only able to ambulate 20 ft, but wanted to continue his FMP. During phone interview 9/25/14, at 10:30 a.m. PT-A stated that when she had evaluated R48 for a decline he was only able to ambulate 20 feet, and the program initially started May 2013. PT-A stated she had recommend the facility to ambulate R48 up to 100 feet with front wheeled walker and assistance of two staff. A request was made to the facility for the May 2013 FMP and none was provided. During interview 9/17/14, at 11:30 a.m. the DON stated they have an issue with their FMP and restorative nursing and indicated the staff member who was in charge of the program had walked off of the job the last week of August and they currently have no one in charge of the program. Although R48 had a FMP to assist with ambulation, the facility failed to ambulate R48, which resulted in a decline in ambulation which was not reassessed, and resulted in actual harm for R48. A Restorative Nursing Program policy revised March 2013, indicated the policy to, "promote each residents ability to adapt to or attain his or her maximum functional potential. To promote each resident's highest practicable level of physical, mental and psychosocial functioning." The policy further indicated all restorative nursing programs must be reviewed by a registered nurse and need to address how they are working and if changes are made, why the changes were made. This needs to be done quarterly. They must be individualized and address how they are maintaining or improving ambulation, range of motion (ROM), continence etc. and be specific about how this is happening for each resident. The policy also indicated the notes need to assess progress or lack of progress, changes made, why programs needed to continue (or discontinue in some cases), and why program is maintaining or restoring a function that affects the residents activity of daily living skills (ADL'S).

Based on observation, interview, and document review, the facility failed to provide care in accordance with an established care plan and physician orders, to promote healing and prevent infection for 2 of 3 residents (R77, R36) with current pressure ulcer(s). This resulted in actual harm for R77 evidenced by worsening pressure ulcer characteristics. Findings include: R77's quarterly Minimum Data Set (MDS), dated [DATE], indicated R77 had moderate cognitive impairment, had a [DIAGNOSES REDACTED]. R77 had a stage III pressure ulcer (full thickness tissue loss, slough may be present but does note obscure the depth of tissue loss) with dimensions of 1.5 cm (centimeter) X (by) 1.5 cm X 0.2 cm, with granulation tissue (pink or red tissue with shiny, moist, granular appearance). R77's care plan, revised on 8/5/14, indicated R77 had a stage III pressure ulcer on his right outer ankle. The care plan indicated a goal of care to be free of skin breakdown, and further identified interventions of, "Treatment as ordered," "Float heels while in bed," and "I have Rooke boots to wear in bed." R77's Order Summary Report, dated 9/4/14, indicated R77 should have his right outer ankle wound (pressure ulcer) cleansed with normal saline, dressed with calcium alginate (a dressing used for wounds with significant drainage), and covered with [MEDICATION NAME] (a dressing used to absorb wound drainage). The Order Summary Report, signed by the medical doctor on 9/4/14, indicated R77 should have this dressing changed daily. During observation on 9/17/14, at 7:05 a.m. R77 was lying in bed with his eyes closed and had blankets pulled up over his face, with his heels lying directly on the bed. R77 did not have any protective boots (Rooke boots) on to reduce the pressure on his heels or ankles as identified in the care plan. When interviewed on 9/17/14, at 2:20 p.m. nursing assistant (NA)-F stated R77 used to wear white boots when he was lying in bed, however, she was unsure if he should still have them now or not. NA-F stated the resident had worn protective boots in bed when he was in a different room, however, had not seen them used since R77 changed rooms a few months prior. During interview on 9/17/14, at 2:38 p.m., NA-G stated R77 has not used the protective boots in bed since moving to a different room a few months ago. When interviewed on 9/18/14, at 9:41 a.m., registered nurse (RN)-A stated R77 was supposed to be wearing protective Rooke boots while in bed to reduce the pressure to his heels and ankles. During observation of pressure ulcer care on 9/18/14 at 10:05 a.m. RN-C stated the current treatment for [REDACTED]. RN-C removed R77's cotton sock from his foot revealing a foam dressing to his right ankle. There was writing on the foam dressing which read, "9-19" (the following day). Further, the dressing had an illegible name written underneath the date. RN-D came into the resident's room at 10:15 a.m. to observe the ulcer with RN-C. RN-D stated it appeared as if the dressing had been placed on the ankle days prior, and the date on the dressing had been changed. However, stated it appeared the actual dressing on R77's ankle had not been changed. RN-D stated the writing on the dressing appeared to be 9/15 versus 9/19. RN-A came into the room to observe the pressure ulcer at 10:19 a.m. with RN-C, and RN-D. RN-A stated she had seen the wound earlier that same week, and it that it appeared the dressing had not been changed since 9/15 according to writing on the dressing. RN-A stated the ulcer should be viewed, and the dressing changed everyday. RN-C removed the foam dressing from R77, and the pressure ulcer wound was observed by RN-A and the surveyor. RN-A measured the pressure ulcer at 1.0 cm X 1.0 cm X 0.1 cm, however stated the ulcer now had purulent drainage (primarily pus), foul odor, and the wound bed no longer had 100% granulation tissue, but now contained some slough (non-viable tissue that requires debridement (removal)). RN-A further stated the wound appeared to have increased redness around the wound edges from when she had previously viewed earlier in the week. RN-C completed the pressure ulcer treatment, and applied a new [MEDICATION NAME] dressing and dated it 9/18/14. When interviewed immediately following the wound care observation, at approximately 10:45 a.m., RN-C stated the pressure ulcer dressing had not been consistently changed on a daily basis, as the physician ordered. RN-C further stated the ulcer seems to be larger than she previously had seen. Review of R77 record identified the following: A fax communication to the physician on 8/13/14, identified R77 developed a "fluid filled blister on (R right) outer ankle. Area measures 1.4 X 2.5 cm." R77's Weekly Wound Documentation Form, dated 8/27/14, indicated R77 had a stage III pressure ulcer on his right outer ankle. The form indicated the ulcer to be 1.9 cm X 1.2 cm X 0.2 cm in size, have 100% granulation tissue in the wound base, moderate serosanguinous drainage, no odor or pain associated with the ulcer. In addition, the form indicated the pressure ulcer was stable in condition with a plan to continue the current treatment of [REDACTED]. R77's Weekly Wound Documentation Form, dated 9/2/14, indicated R77 had a stage III pressure ulcer on his right outer ankle. The form indicated the ulcer to be 1.0 cm X 0.8 cm X 0.2 cm in size, have 100% granulation tissue in the wound base, scant serosanguinous drainage, no odor or pain associated with the ulcer. Further, the form indicated the pressure ulcer was improved in overall condition with a plan to continue the current treatment. R77's most recently completed Weekly Wound Documentation Form, dated 9/9/14, indicated R77 had a stage III pressure ulcer on his right outer ankle. The form indicated the wound to be 1.0 cm X 1.0 cm X 0.2 cm in size, have 100% granulation tissue in the wound base, scant serosanguinous drainage (containing both blood and serous fluid), no odor, and no pain associated with the pressure ulcer. Further, the form indicated the pressure ulcer was stable in condition, and the plan was to continue the current treatment. R77's Braden Scale for Predicting Pressure Sore Risk, dated 8/21/14, indicated R77 had no sensory perception impairments, was occasionally exposed to moisture, walked occasionally, had very limited mobility, excellent nutrition, and was potentially exposed to friction and shear. Further, the document indicated R77 had an open area (pressure ulcer) on his ankle, and a history of skin breakdown. R77's Care Area Assessment (CAA) progress note, dated 9/18/14, indicated R77 had a stage III pressure ulcer on his right outer ankle, and remained at risk for further skin breakdown related to R77's impaired mobility, being incontinent of urine, and cognitive impairments. Further, the note indicated, "staff are monitoring healing of stage 3 ulcer on right ankle daily with dressing changes and documenting weekly." During interview on 9/18/14, at 10:59 a.m. the director of nursing (DON) stated the physician orders [REDACTED]. The DON stated R77's dressing changes should be completed per the physician orders, documented accordingly, and the care plan interventions should have been followed. R77 had a current stage III pressure ulcer, was assessed at risk for further pressure ulcer development, and had physician orders [REDACTED]. The facility did not implement daily dressing changes as ordered by the physician for R77's stage III pressure ulcer. The facility also did not implement pressure relieving boots while in bed to prevent additional ulcer development or worsening of the current ulcer. As a result, R77's stage III pressure ulcer on his right ankle went from 100% granulation tissue in the wound bed on 9/9/14, to having slough tissue present, developed a foul odor when none had been present before, and developed purulent drainage indicative of infection on 9/18/14. A facility Prevention of Pressure Ulcers policy, dated 2/2014, indicated pressure ulcers were a serious skin condition for the resident, and the facility should have a system or procedure to assure assessments are timely, appropriate, and for changes in condition to be recognized, evaluated, and reported. Further, the policy indicated the date and time skin care was given should be recorded in the medical record. R36's diagnoses, as identified on the care plan (CP), dated 8/1/2014, included dementia, [MEDICAL CONDITION] with [MEDICAL TREATMENT], and fracture of scapula and multiple ribs. The admission MDS, dated [DATE], indicated R36 was cognitively impaired, and required extensive, physical assistance for ADLs, including two-person assist with bed mobility, transfers and ambulation. A Braden Pressure Sore risk assessment, dated 8/18/2014, indicated R36 was at low risk for development of pressure sores, and further, that R36 repositioned himself. The CAA for pressure ulcers, dated 5/29/2014, indicated R36 was at risk to develop pressure ulcers related to [MEDICAL CONDITION], and needing extensive assistance with bed mobility and weakness. A nursing progress note dated 7/31/2014, indicated R36 had an open area on left buttocks, which measured 3 centimeters (cm) by 2 cm by less than 0.2 cm in depth. During observation on 9/17/2014, R36 was seated in his wheel chair from 10:30 a.m. to 1:19 p.m., a total of 2 hours and 49 minutes, without any off-loading (removing pressure to allow tissue perfusion) or repositioning. At 10:30 a.m., R36 was seated in his wheel chair at a table in the dining area prior to the noon meal, visiting with other residents. At 11:37 a.m., R36 was assisted by staff, and relocated to his usual table in the dining area, and subsequently ate the noon meal. At 12:57 p.m., licensed practical nurse (LPN)-F removed R36, still seated in his wheel chair, from the dining area, and pushed him to his room. Inside the room, LPN-F took R36's vital signs, and continued to remain seated. LPN-F told R36 he was to attend a care conference meeting in a few minutes, and a staff member would help him to the meeting room. At 1:05 p.m., LPN-F then exited R36's room. LPN-F neither offered nor repositioned or off-loaded R36 while in his room. At 1:09 p.m., R36, still seated in his wheel chair, propelled himself from his room into the adjacent day room, positioning his wheel chair at a table. At 1:19 p.m., NA-A entered the day room, approached R36, and told him it was time to get up and stretch. NA-A offered R36 to assist him to stand, and encouraged him to ambulate and stretch. NA-D also asked R36 to use the toilet in his room but R36 refused all of NA-A offers to move, reposition, or off load. During an interview on 9/17/2014, at 1:22 p.m. NA-A stated R36 had been last repositioned "...at 10:30 this morning," it had been "almost three hours" since R36 had been repositioned out of his wheel chair. NA-A acknowledged that R36 had been seated in his wheelchair, without repositioning or off-loading, for nearly 2 hours and 50 minutes. NA-A stated that of late, R36 had been refusing more and more "to stand up, or repo, or do other things suggested, like brushing teeth." NA-A also said when R36 was was there during the day, it was "very difficult" to get him to comply. A review of a weekly wound documentation progress noted on 8/13/2014, indicated presence of a stage 2 pressure ulcer on R36's left buttock, measuring 0.8 cm x 0.5 cm x < (less than) 0.2 cm. The ulcer was 100% granulation tissue, with scant, serous drainage, surrounding area pink, with no signs or symptoms of infection. The note also indicated R36 exhibited mild pain during treatment. A review of the weekly wound notes from 8/13/2014, to 9/10/2014, indicated the pressure ulcer was healing, and subsequently, had resolved. During observation on 9/18/2014, at 10:27 a.m. LPN-A had assisted R36 with toileting. R36's buttocks was slightly pink and had no open areas. LPN-A applied a barrier cream to R36's previously open area, during which time R36 denied any sensation of pain. During an interview on 9/18/2014, at 9:00 a.m. RN-D stated, "We usually do our repos (repositioning) at least every two hours." RN-D said that although (R36's) pressure area had resolved, he remained at risk for future pressure sores, and further, that (R36) "...should have been repositioned at 2 hours." RN-D said, "We need to be more aggressive in follow through." In a subsequent interview at 11:10 a.m., RN-D said she did not know if R36 was routinely repositioned or off loaded when off site receiving [MEDICAL TREATMENT], and noted those runs can last "more than three hours." RN-D also said that recently, R36 was refusing to follow staff direction, especially on the days he does not leave the building. RN-D said R36's refusal to reposition, or get up out of the wheel chair "should be part of his assessment and care plan." RN-D said she was unaware of any repositioning schedule while R36 attended [MEDICAL TREATMENT]. Although R36's assessments indicated he was at risk to develop pressure ulcers, the assessment did not identify R36's refusal of cares, including repositioning or off loading. The assessment did not identify if R36 was repositioned while at [MEDICAL TREATMENT], even though he was gone for several hours three days a week. R36's CP identified pressure ulcers, and included various interventions to maintain intact skin, among which required (R36) "... to be turned and repositioned every 2 hours." The CP lacked further direction, or action, staff were to take either, when R36 was off-site, such as when attending [MEDICAL TREATMENT], or when R36 refused repositioning or off-loading, regardless of location. During an interview on 9/18/2014, at 11:48 a.m. the DON stated the plan of care "should be followed" for any resident who needs timely repositioning. The DON agreed a resident's refusals of care also needed to be assessed, and that risks and benefits of refusal "needed to be identified."