Every finding on record at The Estates at Delano LLC

Based on observation, interview and document review, the facility failed to ensure there were orders and interventions in place for continuous positive airway pressure (CPAP) machine usage for 1 of 1 residents (R16) reviewed for CPAP therapy. Findings include: R16's quarterly Minimum Data Set (MDS) dated [DATE], identified R16 was cognitively intact and required assistance with all cares. Diagnoses included congestive heart failure (CHF), diabetes, atrial fibrillation, chronic kidney disease, end stage renal disease, obstructive sleep apnea, chronic respiratory failure and asthma. R16's care plan initiated 7/9/25, identified R16 had an alteration in oxygen/gas exchange, respiratory status related to sleep apnea and chronic respiratory failure. Interventions included CPAP at bedtime for sleep apnea. R16's physician orders dated 11/17/25 failed to indicate orders to wear CPAP machine at night, clean CPAP mask and tubing or to replace CPAP supplies. On 11/17/2025 at 11:12 a.m., R16's CPAP machine was observed on pole, the tubing was draped over the machine, the face mask was noted to have an unknown brown, crusty substance around the perimeter of the cushion. When interviewed on 11/17/25 at 4:55 p.m., R16 stated she wore her CPAP every night, needed assistance from staff to put the mask on. R16 was not sure when the mask and tubing were cleaned by staff. On 11/19/2025 at 11:23 a.m., observed R16's CPAP tubing was draped over the bottom rail of the bed with the CPAP mask facing the floor about six inches from the floor with the headgear resting on the floor under the bed. The CPAP mask was noted to have an unknown dried, white substance on the cushion. When interviewed on 11/19/2025 at 1:34 p.m., nursing assistant (NA)-A stated R16 wore the CPAP every night, needed assistance to put it on. NA-A stated the nurses took care of the CPAP machine. NA-A she R16 wore her CPAP every nightWhen interviewed on 11/18/2025 at 1:42 p.m., PM NA-B stated the nurses took care of the CPAP machine, but the nursing assistants helped her put the mask on when R16 went to bed. NA-B stated R16 wore the CPAP every night. When interviewed on 11/18/2025 at 1:45 p.m., registered nurse (RN)-A stated there should be orders in R16's electronic medical record (EMR) for R16 to wear the CPAP every night, cleaning the tubing and mask and replacing supplies. RN-A was not able to locate any orders regarding R16's CPAP in the EMR. RN-A was not sure when the CPAP tubing and mask were cleaned but knew another nurse had recently replaced the maskWhen interviewed on 11/18/2025 at 1:55 p.m., director of nursing (DON) stated there should be orders in the EMR for CPAP. DON was not certain why there were no orders located in R16's EMR. Facility policy regarding CPAP machines was requested, however, none was provided.

Based on document review and interview, the facility failed to ensure the Minnesota Ombudsman Office was informed of residents discharging against medical advice (AMA) for 2 of 3 residents (R37 and R38) who were reviewed for discharge from the facility.Findings include - R37: R37's electronic medical record (EMR) documented the following diagnoses: multiple fractures of ribs, left side subsequent to a motor vehicle accident, acute pain from trauma and muscle weakness. R37 was admitted to the facility on [DATE] and discharged against medical advice on 10/01/25, after not returning from an leave of absence (LOA). Review of R37's progress notes documented the following: > 9/30/2025 [9:45 p.m.] Writer was told in report resident was on LOA and will be back, around 9PM resident was not available, writer called resident phone and left a voicemail for resident to call facility> 10/01/2025 11:00 a.m., [business office manager] resident and left called a VM regarding his failure to return from LOA. Resident signed out and left the faciity on 9/30/25 at about 1:30pm stating that he would return in a couple hours. Resident still has not returned call. [business office manager -BOM] also called resident's friend who did not answer. BOM left VM and a return call has not yet been made.> 10/01/2025 11:28 a.m., [social services designee] called resident phone number and resident's friend, [Friend-A], phone number. No answer. [social services designee] requested resident/[Friend-A] call the facility to give an update on whereabouts> 10/01/2024 12:41 p.m., Administrator called resident's phone and left a voice message. Administrator called resident's [Friend-A], Friend-A returned call quickly and stated that resident is an adult and able to make his own decisions. [Friend-A] stated that he brought resident home and left. [Friend-A] stated that resident stated he was going to stay home and not return to the facility. [Friend-A] encouraged resident to call facility to let them know. Facility has not received a call back from resident. [Friend-A] stated that he was going to go to resident's house to check on him. [Friend-A] plans to update Administrator.> 10/01/2025 1:17 p.m., Administrator received return call from resident's friend [Friend-A]. [Friend-A] was able to get a hold of resident and instructed him to call The Estates at [NAME]. [Friend-A] confirmed that resident is at home and staying at home. Administrator was not able to speak with resident directly, so three additional calls were made to resident. Resident did not answer. Resident still has not made contact with facility.> 10/01/2025 4:44 p.m. At 2:20pm, Administrator and [social services designee] called 911 and requested a wellness check on resident at his personal address. 911 operated stated if resident was not found at address, a missing person's report will be filed. MAARC report was filed. Ombudsman notified. MAARC confirmation number: 1000244718.> 10/01/2025 at 5:12 p.m., [social services designee] attempted to call resident. No answer. [social services designee] left another voicemail.> 10/01/2025 6:25 p.m., Administrator called [NAME] County Sheriff's department for an update on wellness check. Sheriff stated that the officer that was on call during the wellness check was not able to make contact with resident. Sheriff stated that it was written in the notes, person working at business hasn't seen him in a month. Sheriff was unable to state what the business was or who the business person was. Sheriff reached out to the Sheriff on duty during the wellness check. The sheriff called administrator back and stated that the officer that was on duty stated it is an apartment building attached to a business. There is a person at front desk monitoring ins and outs, and they had stated that they have not seen this resident for a month. Administrator told sheriff that she would be filing a missing persons report. Sheriff agreed and instructed administrator to do so with [NAME] County.> 10/01/2025 6:53 p.m., Administrator filed missing person report #25027552 with [NAME] County Sheriff Department.> 10/01/2025 7:11 p.m., [Deputy-A ] arrived to facility and called Administrator for more information. [Deputy-A] stated he was going to try to find resident tonight and would update administrator with additional details.> 10/01/2025 8:20 p.m., [Deputy-A] called administrator stating that [R37] has been found safe at home. [R37] returned administrator's call stating he would like to be discharged AMA from The Estates at [NAME]. MAARC completed by SS 10/1/2025. Administrator discharged resident at 8:22pm. During interview on 11/18/2025 at 4:21 p.m., the facility assigned ombudsman (OMBUD)-A, after referencing her records, stated she had received an email from the social service designee (SSD) on 10/01/25 at 2:52 p.m., indicating R37 had left the facility yesterday with a friend and never returned. The email indicated they had involved the police to do a wellness check and had filed a MAARC (Minnesota Adult Abuse Reporting Center) report with the state of Minnesota. OMBUD-A stated she was uncertain if the facility had included R37 in their monthly report to the Office of Ombudsman but would check with the office's staff. On 10/01/2025 at 5:01 p.m., survey received a TEAMS Chat message indicating the facility had not included R37's AMA discharge to the Office of Ombudsman. R38: R38's electronic medical record (EMR) documented the following diagnoses: urinary tract infection, morbid obesity, muscle weakness, unsteady on feet and history of falling. R37 was admitted to the facility on [DATE] at approximately 4:00 p.m., and discharged against medical advice on 10/24/24 at approximately 12:00 p.m. (approximately 44 hours after admission) with family. A review of R38's Discharge Planning (dated 10/23/24) INDICATED: Resident would like to recover from his fall and return home with spouse. In review of R38's electronic medical record progress notes, the following was documented: > 10/24/2024 10:12 a.m. Behavior Note Text: Met with resident this morning after hearing that he was more confused during the night and was out in the hallway nude. [Director of nursing] confirmed with staff that they saw the Resident come out of his room nude. They immediately intervened and brought him back to his room and got him dressed. The resident stated that he is not sure how he became nude. He stated I found a door to go out of and then I was in a long hallway. People were in the hall. They found me these clothes. I don't know how they got on me or how they got here, but I recognize the pants. When asked if he slept in his bed or in the chair last night, the resident stated that he did sleep some in his bed but also got up into the chair. [Director of nursing] attempted to notify [(Fam)-A], with Resident's permission. Fam-A had called the facility concerned about her father's behaviors. DON left a voicemail for Fam-A to call back when she was able.> 10/24/24 at 12:02 p.m. Resident's [family] arrived at facility. DON, Administrator, and SSD spoke with family to update them on how resident was doing and to answer any questions. Family was concerned resident should go to hospital. Staff assured family resident was safe at facility and if staff noted any concerns, the facility would send resident to the hospital. Family did not agree and requested to discharge resident AMA. [Director of nursing] and Administrator educated family on the risks of discharging AMA. Family understood but decided to d/c AMA. Staff interviewed resident to ensure resident was okay. Resident stated he did not mind being at the facility but wanted to please his wife and daughter and do what they asked. Family signed AMA paperwork. Family stated they would be bringing resident to the hospital.> 10/24/24 at 12:55 p.m. MAAR report filed due to resident leaving AMA. Thu [DATE] 12:53:50 confirmation number: 1000204449 During interview on 11/18/2025 at 4:21 p.m., the facility assigned ombudsman (OMBUD)-A, after referencing her records, stated she had received an email from the social service designee (SSD) on 10/24/24 at 12:55 p.m., indicating R38 had left the facility AMA and the facility had filed a MAARC report. OMBUD-A stated she was uncertain if the facility had included R38 in their monthly report to the Office of Ombudsman but would check with the office's staff. During interview on 11/19/25 at 10:48 a.m., SSD stated she had contacted OMBUD-A on both R37 and R38 via email, which were provided. However, when SSD reviewed the monthly reports sent to the Office of Ombudsman (copies kept in a three ring binder), which should have included both residents names, dates of discharges and reason for the discharges, SSD not R37's and R38's names were not included. SSD stated the program they use requires her to trigger filters to gather the names and reasons for facility discharges. SSD stated the filter for AMA had not been selected, when the reports for R37 and R38 were run. In review of the requested facility policy for reporting discharges to the the Office of Ombudsman, the facility provided the policy entitled: Ombudsman Hospital Transfer Report (dated 08/2025). The policy documented the following: Purpose -Copies of notices for emergency transfers must be sent to the Ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis. Procedure - 1. This report is sent monthly, typically within the first 5 days of the month for the previous month.2. Run the report on [Point Click Care - PCC], using the following instructions: a. In PCC, go to Admin tab b. Reports c. Action Summary Report d. Ensure you date range is correct e. Action Code - Clear it all and then scroll to the bottom and click i. Transfer out to hospital ii. :discharge date iii. Discharge/Transfer New Facility f. Ensure all Payer Types are selected g. Click Show to / from description h. Run report3. Fax printed report to the Ombudsman at [PHONE NUMBER]\4.4. Once faxed, print and fax confirmation5. Keep the Fax Cover Sheet, Report and Fax Confirmation together in a file folder or binder.

Based on interview and document review, the facility failed to ensure there were orders in place for Dexcom sensor (a wearable Continuous Glucose Monitoring (CGM) system for people with diabetes) for 1 of 3 residents (R16) reviewed for Dexcom use. In addition the facility failed to ensure orders were in place to remove pressure dressing (bandage applied to stop bleeding) after dialysis (medical procedure filters and removes waste from blood) for 1 of 1 residents (R16) reviewed for dialysis. Findings include: R16's quarterly Minimum Data Set (MDS) dated [DATE], identified R16 was cognitively intact and required assistance with all cares. In addition the MDS indicated R16 received dialysis. Diagnoses included congestive heart failure (CHF), diabetes, atrial fibrillation, chronic kidney disease, end stage renal disease, obstructive sleep apnea, chronic respiratory failure and asthma. Review of R16's progress notes identified nurses had replaced R16's Dexcom sensor on 9/23/25, 10/4/25, 10/17/25 and 11/17/2025. R16's orders dated 11/17/25, directed nurses to monitor R16 for signs and symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) and to check blood sugars four times daily. However, R16's electronic medical record (EMR) failed to contain orders to change R16's Dexcom every 10 days. R16's orders directed staff to obtain vital signs after dialysis and monitor site every shift for bruit (listening for turbulent blood flow) and thrill (feel for vibration of blood flow) however, the R16's EMR failed to contain orders to remove the pressure dressing following dialysis. R16's care plan initiated 5/2/25, indicated R16 was at risk for complications related to dialysis with interventions which included dialysis per schedule and treatment and dressing protocol to dialysis site per order. When interviewed on 11/17/25 at 4:55 p.m., R16 stated the nurses check her blood sugars with the use of her Dexcom sensor. R16 further stated facility staff did not remove the pressure dressing from the dialysis fistula (dialysis access) site, she removed the dressing herself the day after receiving dialysis. When interviewed on 11/18/2025 at 1:45 p.m., registered nurse (RN)-A stated there should be orders in R16's EMR to have the Dexcom sensor replaced every 10 days. RN-A was not able to locate any orders regarding R16's Dexcom application in the EMR. When interviewed on 11/18/2025 at 1:55 p.m., director of nursing (DON) stated there should be orders in the EMR to change R16's Dexcom sensor, DON was unable to locate an order and was not sure how the nurses had changed the Dexcom when there was not order in the EMR for them to do so. When interviewed on 11/18/25 at 1:55 p.m., RN-B was not sure about an order to removed R16's pressure dressing after dialysis, has removed it at times but not on a regular basis. When interviewed on 11/18/25 at 2:30 p.m., DON stated there was an order to monitor every shift for bruit and thrill in R16's EMR, but was unable to locate an order to remove the pressure dressing and would have to check into that. During follow-up interview on 11/18/25 at 2:40 p.m., DON stated R16 had previously been admitted to the hospital, all orders had been discontinued at that time. The Dexcom order had not been re-started upon R16's return to the facility. DON stated checked on removal of dressing, should be removed four to six hours after dialysis. DON was not sure why R16 did not have an order to remove the dressing. Facility policy regarding Dexcom and/or CGM use was requested however, was not provided. Facility Hemodialysis policy dated 11/22/19 was provided, however, the policy does not address removal of pressure dressing after dialysis.

Based on interview and document review, the facility failed to ensure an abuse protection plan was documented and all staff were educated on the plan for 2 of 3 residents (R1, R2) reviewed for sexual abuse. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated severe cognitive impairment with diagnoses including convulsions and Alzheimer's disease. R1's care plan dated 10/14/24 indicated R1 was a vulnerable adult with a goal of remaining free from abuse and/or neglect. An additional goal was added 1/7/24 directing R1 would be kept safe from other residents, and not be left alone with any other residents without staff supervision. R2's quarterly MDS dated [DATE] indicated severe cognitive impairment with diagnoses including dementia. R2's care plan indicated he was at risk for alteration in mood and behavior related to dementia. On 1/3/25 at 8:30 p.m., R1's incident note indicated R1 and R2 were sitting in their wheelchairs in the common area. At 8:30 p.m., another resident alerted staff R2 was lifting up R1's foot, then attempted to grope her. R2 put his hands up R1's shirt while asking her, You like that? Staff immediately separated R1 and R2. The administrator was notified. R1 was brought back to her room. She did not show any signs of anxiety, distress, or pain. No skin alterations were noted. R1's husband was notified. 15-minute checks and emotional distress monitoring were initiated. On 1/3/25 at 8:30 p.m., R2's incident note indicated R1 and R2 were sitting in their wheelchairs in the common area. At 8:30 p.m., another resident alerted staff R2 was lifting up R1's foot, then attempted to grope her. R2 put his hands up R1's shirt while asking her, You like that? Staff immediately separated R1 and R2. R2 was agitated and verbally aggressive towards staff. When asked about his behavior, R2 stated that he was trying to feel her breasts, I know she liked it because she wasn't stopping me. R2 was brought to his room with 1 to 1 supervision until he went to bed at 9:30 p.m., then 15 minutes checks were utilized. On 1/8/25 at 1:23 p.m., R2's social worker note indicated R2's wife was concerned his behaviors were getting worse. R2's provider note dated 1/8/25 indicated R2 was experiencing behavior issues lately. R2 had an episode where he placed his hands up the shirt of another resident, had tried to hit another resident, and was agitated and restless. No physical changes were noted. A new order was placed for Seroquel (a medication used to treat agitation in people with dementia) 12.5 milligrams (mg) two times a day for dementia with agitation. NA care sheet dated 12/24/24 lacked information about keeping R1 and R2 separate. NA care sheet dated 1/9/25 included new information for R2 included keep supervised around women and cannot be left alone with R1. New information for R1 included keep R1 away from R2. On 1/8/25 at 1:45 p.m., nursing assistant (NA)-A stated she worked with the float pool and had not worked at the facility recently. She gave R1 a bath the morning of 1/3/25, then took R1 to the common area to watch television with R2. Other staff members told her R1 could not be alone with R2, so NA-A moved R1. She did not receive information in report, nor was she educated before her shift, and there was no information on the nursing assistant care sheet about keeping R1 and R2 separated. As a person who did not work at the facility frequently, she relied on the NA care sheet for information. On 1/8/25 at 2:35 p.m., NA-B stated she worked with the float pool and had worked several shifts recently. She uses the NA care sheets for information about residents, and did not know where to look in the computer to find any resident specific interventions. She had not received any education about R2. On 1/8/25 at 4:23 p.m., trained medication aide (TMA)-A stated she worked with the float pool and had worked several shifts recently. She received information through report to keep R1 and R2 separate, but did not know if it was written down anywhere. She had not received any education about R1 and R2 in the last week. On 1/8/25 at 4:38 p.m., R1's significant other (SO) stated he had not had any concerns about R2 before this incident, but now he did not want R1 to be around R2. R1 was unable to communicate verbally, and did not have any purposeful movements. If R1 had the capability, she would have punched R2 for touching her. She would not have liked any man other than himself touching her. On 1/9/25 at 1:23 p.m., the director of nursing (DON) stated psychology services were declined by R1 and R2's decision makers due to their respective cognitive status. Psychology services was consulted about the situation and recommended staff-based interventions. These included staff to keep R1 and R2 separate at all times. This intervention was communicated to staff through education and shift to shift report. It was also on the NA care sheets and in both resident's care plans. The DON confirmed the intervention to keep R1 and R2 separate was not on the current NA care sheets, and the information in R2's care plan stated to not leave him alone with another resident. On 1/9/25 at 2:38 p.m., the administrator confirmed the intervention on the new NA care sheet and in R2's care plan instructed staff to not allow R2 to be alone with another resident. It would not be safe to place R1 next to R2 even when supervised. The intervention should instruct staff to not allow R1 and R2 to be close to each other. The administrator confirmed the intervention needed to be clarified. She verbally educated NA-A and NA-B. The facility Abuse Prohibition/Vulnerable Adult Policy dated 3/24 directed the purpose of the policy is to protect residents against abuse by anyone. The policy instructed staff will take necessary steps to protect residents from possible subsequent incidents of misconduct or injury while the matter is being investigated. Further instruction included the facility will provide proper follow up communication related to the incident across all shifts.

Based on interview and document review, the facility failed to report an allegation of sexual abuse to law enforcement as required for 1 of 1 residents (R1) reviewed for abuse. Findings include: R1's admission Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses which included bipolar disorder, anxiety disorder, and post traumatic stress disorder. Identified R1's cognition was intact. R1's care plan dated 10/23/24, revealed R1 required assistance of one to two staff members for activities of daily living (ADLs) such as dressing, personal hygiene, and toileting. Review of facility report number 358352 to the State Agency (SA) dated 10/21/24 at 12:40 p.m., revealed R1 reported nursing assistant (NA)-A came into her room to assist R1 with brief change and while wiping R1's bottom, R1 reported feeling NA-A place her hand in R1's vagina. R1 reported the incident shocked her and hurt her. R1's progress note dated 10/23/24 at 1:35 p.m., revealed R1 met with administrator and director of nursing (DON) and asked staff to call 911 so she can make a report about the incident brought to staff's attention on 10/21/24. 911 was called and R1 requested facility social services director attend the meeting with the police department when R1 would give a statement. 911 dispatcher confirmed someone would meet the resident in her room to complete a report. Further, handwritten on the progress note indicated police were called on 10/23/24 at 1:31 p.m. and the police arrived at the facility at 2:35 p.m. On 10/23/24 at 2:57 p.m., sheriff deputy (SD)-A entered the conference room and introduced self to SA. SD-A stated he was contacted through the dispatch at 1:44 p.m., to come to the facility and meet with R1 regarding the allegation. SD-A stated dispatch received a call from the facility at approximately 1:30 p.m. On 10/23/24 at 3:10 p.m., R1 observed sitting in a wheelchair in her room. R1 stated she had been residing in the facility for approximately three months and had received the best care until the incident on the morning of 10/20/24. R1 stated she was laying in her bed in her room and was utilizing the bed pan to have a bowel movement. R1 put on her call light for assistance with hygiene cares and NA-A entered her room, rolled R1 onto her side so she was facing the wall and NA-A had started wiping her bottom real hard and NA-A was wiping in the crevices of her butt and that was when NA-A went further into my legs and put her finger in my vagina and turned her finger so I could feel it and that hurt. Further, R1 stated she felt uncomfortable and NA-A then stormed out of R1's room and R1 laid there. On 10/25/24 at 10:11 a.m., social services director (SSD) stated R1's cognition was not impaired and R1 would report any concerns she had verbally to staff or would file a grievance, but R1 had never reported concerns related to abuse previously. SSD stated she was made aware of R1's allegation on 10/21/24, right before noon meal. SSD stated R1 had reported to her concerns regarding NA-A had inserted her hand into R1's vagina. Further, SSD stated the administrator and DON were notified. SSD stated the police were not notified at that time and SSD stated she was not aware of the facility's policy related reporting to law enforcement. In addition, SSD stated she wished she would have offered to call law enforcement then but was focused on helping R1 with her emotions. On 10/25/24 at 10:28 a.m., DON stated she was made aware of R1's allegation on 10/21/24, in the morning but was uncertain what time, by human resources. DON stated R1 had reported NA-A put their entire hand up R1's vagina. DON stated the allegation was reported to the SA on 10/21/24, within two hours and at that time R1 had also declined going to the hospital for an evaluation. Further, DON stated on 10/23/24, staff had asked R1 if she would like to file a police report which R1 had stated yes. DON stated she was not aware of the facility's police on when to report allegations to law enforcement and stated she would have to look at the policy, but on 10/21/24, when R1 reported the allegation it didn't dawn on us at that time. On 10/25/24 at 10:57 a.m., administrator stated she was made aware of R1's allegation on 10/21/24, at 11:20 a.m. DON stated the allegation was reported to the SA and staff had asked R1 if she wanted the facility to call or tell anyone else, which included the police, and R1 had said no. Administrator stated on 10/23/24, staff had asked R1 again if she would like the police to be notified and she stated yes, so that was when the facility notified law enforcement. Administrator stated she was unaware of the facility's policy for reporting to law enforcement, but in the past it has been up to the resident. In addition, administrator stated offering to notify law enforcement of an allegation of sexual abuse should be offered and if there was suspicion of any crime the facility should be reporting it to law enforcement. Review of facility policy titled Reporting Suspicion of a Crime revised on 2/2024, indicated the administrator, DON, or any other designated individual would report (within the required time frames) any reasonable suspicion of a crime against a resident to the State Agency and local law enforcement. Further, the policy revealed examples of crimes that would be reportable in any jurisdiction which included sexual abuse. The timing of reporting would be based on the events that cause suspicion would be as follows: if the event resulted in serious bodily injury which was defined as an injury involving serious physical pain, substantial risk of death, sexual abuse or aggravated sexual abuse, the suspicion would be reported immediately but not more than two hours after the individual first suspects that a crime had occurred.

F851 Based on interview and document review, the facility failed to submit accurate and/or complete data for staffing information at least quarterly based on payroll and other verifiable and auditable data during (2024) 1 of 1 quarter reviewed (Quarter three) in Federal Fiscal Year (2024), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. This has the potential to affect all 33 residents residing in the facility. Findings include: Review of the Payroll Based Journal Report (PBJ) [NAME] Report 1705 D identified the following dates triggered for review: 4/6/24, 4/20/24, 4/21/24, 5/19/24 and 6/15/24 for failure to have registered nurse (RN) coverage eight hours per day. Review of staffing schedules identified the facility had RN staff identified to have worked on 4/6/24, 4/20/24, 5/19/24 and 6/15/24 for at least 8 hours therefore the data submitted in the PBJ to CMS was inaccurate. When interviewed on 10/16/24 at 11:56 a.m., the administrator identified an RN was working for at least 8 hours on 4/6/24, 4/20/24, 5/19/24 and 6/15/24 and agreed RN staff had worked the above-mentioned days, therefore data submitted through PBJ per specifications established by CMS was inaccurate. There was no policy related to PBJ entries provided by the end of the survey.

Based on interview and document review, the facility failed to ensure pain management was provided consistent with professional standards of practice and the residents' goals and preferences for 2 of 2 residents (R131 and R14) reviewed for pain managment. This deficient practice caused actual harm for R131, who experienced unmanaged pain, disturbed sleep patterns and who had reports of pain. Findings include: R131's discharge Minimum Data Set (MDS) dated , 9/23/23, identified resident admitted to the facility 9/22/23 from an acute care hospital for aftercare following surgery on the nervous system and diagnoses of spondylolisthesis lumbar region (a spinal disorder in which a vertebra slips forward onto the bone below it), radiculopathy lumbar region (a pinched nerve), spinal stenosis (a narrowing of the spinal canal that can put pressure on the spinal cord and nerves within the spine), chronic pain and muscle weakness. R131 had clear speech, the ability to make herself understood and had clear comprehension. R131's hospital discharge summary dated 9/22/23, identified R131 admitted [DATE] and underwent surgical procedures including lumbar hemllaminectomy with [NAME] repair (a spine surgery that involves removing one of the two laiminae on a vertebra to relieve excess pressure on the spinal nerves) and was discharging to the facility on [DATE] for surgical aftercare for low back pain, skilled nursing services and therapy. The same discharge summary included a pain assessment dated [DATE], indicating resident was having aching, constant pain in the right buttocks and down the right leg. The same discharge summary included orders for ibuprofen (a pain medication) 800 milligrams (mg) every eight hours as needed (prn), oxycodone-acetaminophen (a pain medication) 5-325 mg every four hours prn, last received on 9/22/23 at 8:51 a.m., and diazepam (a medication for muscle spasms) 5 mg every six hours prn last received on 9/21/23 at 2:06 a.m. The hospital discharge summary identified these orders were sent to the facility contracted pharmacy. The same discharge summary was faxed to the facility 9/22/23 at 11:59:14 a.m., as identified on the fax cover sheet. The facility admissions notification form identified R131 as a confirmed admission 9/22/23 at 12:00 p.m. R131's 48-hour care plan dated 9/22/23 at 2:52 p.m., identified a section available for pain and comfort but lacked identification of focus, goal, and interventions. When interviewed on 1/3/24 at 9:48 a.m., R131's spouse stated resident was in the hospital for three days following a back surgery in which the dura (membrane that encases the spinal cord) had been cut by accident resulting in the need for skilled nursing care and therapy. R131's spouse stated resident admitted to the facility on [DATE] at approximately 1:30 p.m. and was told resident's medications had not been delivered yet. R131's spouse stated he left the facility then returned at approximately 5:00 p.m. and was told resident's medications were still unavailable. R131's spouse went home and returned at approximately 9:30 p.m. He stated he was again told resident's medications had not been delivered. R131's spouse stated he left resident with his cell phone and returned home. He received a call from R131 at approximately 10:30 p.m. because resident had used the call light to request help from staff to close the room blinds for privacy and no staff had come. R131's spouse stated he called the facility two times and no staff answered so he returned to the facility to close the blinds, spoke with staff regarding the lack of pain medication and told them he would be taking resident home in the morning. R131's spouse stated resident had asked for her ordered oxycodone-acetaminophen pain medication twice at approximately 3:30 p.m. and again at approximately 10:00 p.m. for pain she was rating at eight to nine out of 10. R131 was told the medication was unavailable because they were not delivered from pharmacy yet. R131's spouse stated he returned to the facility the next morning on 9/23/23 at approximately 7:30 a.m. and told staff he was checking her out because she wasn't getting adequate pain control. R131's spouse stated staff brought her breakfast and oxycodone-acetaminophen pain medication at approximately 8:15 a.m. before leaving. R131's progress note dated 9/22/23 at 10:30 p.m., indicated R131 had been turning on call light multiple times throughout shift for prn pain medications. Staff informed resident multiple times her medications had not yet arrived from pharmacy. Resident's husband came up to the nurse's desk and became upset with the nurse on shift because resident does not have any medication and staff did not know the exact time the medications would be delivered. The same progress notes also indicated a call was made to the pharmacy to determine when her medications would be delivered and the hospital discharge orders were again faxed, however lacked documentation of attempts to obtain a code to access medications from the facility cubex (emergency medication machine the facility had in place for ordered medications not yet delivered). R131's progress note dated 9/23/23 at 8:47 a.m., identified the resident's husband was upset with staff when staff came in because still had not yet received any prn pain medication all night from staff. The progress note also indicated R131 and her spouse communicated no one went in to check on her and resident stated she requested hot and cold packs and no one would take them in. Resident asked for an ice pack this morning and staff took it in right away. When nurse pulled meds from the cubex and took them into R131's room, her spouse stated they were leaving and wanted to discharge. R131's medical record indicated staff had documented her pain rating at 5 at on 9/23/23 at 4:38 a.m. and 8:27 a.m. R131's facility medication administration record (MAR) dated 9/1/23-9/30/23, identified orders for diazepam 5 mg every six hours as needed for pain with a start date and time of 9/22/23 at 2:00 p.m., but lacked evidence of the medication being administered. The same MAR identified an order for oxycodone-acetaminophen 5-325 mg every four hours as needed for pain, take one tablet for pain zero to five and two tabs for pain six to ten and was documented as being given one time on 9/23/23 at 8:27 a.m. R131's order for ibuprofen was not on the MAR indicating the order was not entered. When interviewed on 1/3/24 at 10:30 a.m., the facility pharmacy consultant (Pharm D)-A stated the facility has normal scheduled medication deliveries. The facility also has an emergency supply of medications in a dispensing machine referred to as a cubex or medbank. The Pham-D-A stated in the cubex are over 200 available medications that could be utilized per order prior to normal scheduled deliveries including pain medication such as oxycodone-acetaminophen. As long as the pharmacy had the prescription for R131's oxycodone-acetaminophen, staff could call the pharmacy to request a code to access the medication from the cubex onsite per facility protocol. Pharm-D -A stated the list of available medications in the cubex was usually posted right next to the machine. The facility staff were trained on the use of the machine when they were installed. The pharmacy Cubex medication inventory list dated 1/2021, indicated several available analgesics (pain medication) including oxycodone-acetaminophen 5-325 mg. When interviewed on 1/3/24 at 12:13 p.m., The Pharm-D-B stated R131's oxycodone-acetaminophen prescription order was received at the pharmacy from the hospital on 9/22/23 at 9:22 a.m The Pharm-D-B stated facility staff could have called to get a code to access the medication whenever R131 needed it. The Pharm-D-B verified no such request had been made. The Pharm-D-B confirmed the resident's demographic information had been entered into their system on 9/22/23 at 3:00 p.m., but the faxed hospital discharge orders from the facility were not received until 8:40 p.m. which would be the reason her medications were not delivered earlier. Despite this, staff could still access medications from the cubex unit if the facility had orders. The Pharm-D-B stated the reason facilitiy had the cubex in place was so medications could be provided between regular medication deliveries. The Pharm-D-B stated because R131 was rating her pain at eight to nine out of 10, he would consider the lack of provision of her ordered and available pain medication to be a significant error by the facility. When interviewed on 1/3/24 at 4:20 p.m., registered nurse (RN)-B confirmed he had worked at the facility approximately three years and was working the overnight shift on 9/22/23 to 9/23/23. RN-B stated if a resident was in pain, he would administer pain medication if ordered. RN-B stated if the medications had not come from the pharmacy, staff had the ability to pull medication from the cubex. RN-B stated if the medication was a narcotic or controlled substance like oxycodone-acetaminophen staff could call the pharmacy and get a code to pull it from the cubex. When asked if he had received a request from R131 for pain medication or ice packs, RN-B stated he did not remember. When interviewed on 1/4/24 at 11:45 a.m., R131 stated she last received her oxycodone-acetaminophen pain medication approximately 9:00 a.m. in the hospital before admitting to the facility and did not receive another dose from the facility until the morning of 9/23/23 at approximately 8:30 a.m. She started experiencing pain in her right buttocks and right leg approximately 3:00 p.m. after admitting to the facility and described it as severe, stabbing, aching in the nerve and rated it eight to nine out of ten. Her pain made it difficult to walk, sit on the toilet, get comfortable and sleep throughout her stay. R131 stated she asked facility staff for the pain medication prescribed for her in the hospital at least two to three times and was told it was unavailable. She asked staff for ice packs, but none were provided. When she left the facility the morning of 9/23/23, her son-in-law and husband had to carry her into their home because she was in too much pain to walk. Her husband got her ordered medications through their local pharmacy approximately 12:00 p.m. after returning home. R131 stated because she went nearly 24 hours without pain medication it took two days to feel any pain relief after resuming use of her ordered oxycodone-acetaminophen. R131 stated after approximately 12 days her pain began to diminish and she was able to gradually resume walking and regular activity. She believed, had she received the requested doses of her pain medication in the facility when she had asked, it would not have taken so long to get relief and recover normal function. When interviewed on 1/4/24 at 1:17 p.m., RN-A stated she worked for the facility approximately one year and four months. RN-A stated she was the nurse on duty 9/22/23 on the facility p.m. shift the day R131 arrived. She remembered the resident being very upset about her pain, asking for pain medications, and made racist comments about staff. R131's husband was upset because her medications had not been delivered. RN-A stated normally the facility pharmacy made medication deliveries around 5:30 p.m. and then again at 10:30 p.m. RN-A stated the facility has a cubex that staff could call the pharmacy to obtain a code to retrieve narcotics out of if needed but at that time she didn't think she could do that because when she called the pharmacy regarding the time of the next delivery they requested for the hospital discharge orders to be faxed again. She did not ask for a code for the cubex to obtain R131's hydrocodone-acetaminophen because she thought she had to wait for the pharmacy to deliver R131's medications. RN-A stated she communicated this information before leaving her p.m. shift to RN-B when he arrived for the night shift. RN-A stated this was the first time admitting a new resident and learned she could have called for a code and administered the medication because the facility already had the orders, and the pharmacy had the prescription. RN-A stated she returned the next morning for a day shift and by that time the resident's medications had been delivered so she administered her oxycodone-acetaminophen at that time. When interviewed on 1/4/24 at 2:58 p.m., the director of nursing (DON) stated through the facility referral process it had been determined the facility could admit and care for R131. The DON stated the facility received R131's orders approximately 12:30 p.m. and entered them approximately 2:00 p.m. into her EMR (electronic medical record) Normally the facility process for admissions is to receive the orders and send them to the pharmacy. If the orders were sent to the pharmacy before 3:00 p.m., then medications would be delivered approximately 5:00 p.m. and if the orders were sent to the pharmacy after that, the next delivery was approximately 10:00 p.m. Even if R131's medications had not been delivered the facility staff had the ability to pull medications from the cubex by calling the pharmacy and ensuring they had the prescription. The DON stated some of the staff trained on the use of the cubex machine in May of 2023. Any staff who missed that training were individually trained by himself. The DON stated he was made aware of R131 wanting to discharge when RN-A called him on the morning of 9/23/23. RN-A informed him of R131's racist comments and assumed this was the reason she wanted to leave as the facility employs African American staff. The DON stated he had not investigated R131's concerns regarding not receiving pain medication and did not know why RN-A and RN-B did not call the pharmacy to obtain an authorization code to administer it from the cubex. The DON stated it was important to ensure R131 received pain medications related to her diagnoses, recent surgery and reported pain because the facility agreed to provide her services including pain control and she didn't get that. The facility MedBank Training staff signature form dated 5/2/23 indicating training on use of the cubex was not signed by RN-A or RN-B and the DON did not provide other documentation the training had been provided to them. The facility policy and procedure Medication Ordering and Receiving from Pharmacy dated May 2022, identified Emergency pharmacy service is available on a 24-hour basis. Emergency needs for medication are met by using the facility's approved emergency medication supply or by special order from the provider pharmacy. The provider pharmacy supplies emergency medications including emergency drugs, antibiotics, controlled substances, products for infusion in limited quantities in portable containers, automatic dispensing systems incompliance with applicable state regulations. The Facilty Assessment Tool dated 2/28/23, identified pain management including assessment of pain, pharmocologic and nonpharmocological pain management as a service provided based on resident need. 48013 R14 R14's significant change Minimum Data Set (MDS) dated [DATE], indicated R14 was cognitively intact, was able to clearly communicate her needs and wishes and required extensive assistance with activities of daily living (ADL). R14's face sheet printed 1/4/24, noted diagnoses included idiopathic peripheral autonomic neuropathy (damage to the nerves that control automatic body functions), muscle weakness and hemiplegia (paralysis of one side of the body) following cerebral infarction affected left non-dominant side. R14's physician's orders printed 1/4/24, included the following orders: Oxycodone 5 mg as needed twice daily with a start date of 12/19/23; Gabapentin 300 mg twice daily with a start date of 12/14/23; Baclofen 10 mg three times daily with a start date of 12/13/23; and an order to monitor for pain every shift. During record review, records indicated R14 was previously on hospice services and was discharged from hospice on 12/6/23 due to R14 wanting to initiate therapy services. While R14 was on hospice, R14 utilized as needed morphine every four hours to help manage her pain. Upon discharge from hospice, as needed morphine was discontinued and new order was started for oxycodone as needed three times a day. On 12/19/23, oxycodone order was changed to as needed twice daily with the initiation of scheduled Gabapentin twice daily and scheduled Baclofen three times a day. R14's pain level results from 12/2023 thru 1/4/2024 indicated that R14 was having complaints of constant pain or discomfort which ranged from 6-10 out of 10 on the pain scale. During interview on 1/2/24 at 1:45 p.m., R14 stated she has pain in her left arm and down left leg that comes and goes but is pretty much constant. R14 stated her as needed pain medications were decreased from three times a day to two times a day and R14 was not happy about it as she stated she really needed them for her pain. R14 stated she was really worried about her pain when she started to do her physical therapy exercises more diligently as the pain was so horrible when doing the exercises to the point that R14 did not want to complete them. During interview on 1/4/24 at 9:51 a.m., R14's primary provider stated she did not recall being notified of the change in R14's increased pain levels anytime in December 2023 up until today 1/4/24. Provider stated she decreased R14's as needed oxycodone from three times daily to twice daily as she added scheduled gabapentin and baclofen to help manage R14's pain. Provider stated if she would have been notified of R14's increased pain levels, she would have seen R14 sooner to address pain. Provider stated she expected to be notified with any change in condition and relies on the facility staff to alert her on any changes or concerns so she could address or see the resident sooner. During interview on 1/4/24 at 11:41 a.m., director of nursing (DON) stated the nurse on the floor, who is obtaining vitals or performing assessment, notifies the provider of any changes. During interview on 1/4/24 at 1:47 p.m., physical therapist (PT) stated that R14 has pain but did try to participate in therapy as much as she could tolerate. PT stated he notified nursing of complaints of pain or discomfort. PT stated that R14's progress in therapy was slow as the increased pain or discomfort limited R14's participation. During interview on 1/4/24 at 1:50 p.m., nursing assistant (NA)-A stated R14 would call when R14 needed pain medication and NA-A would let nursing know of complaints of pain or discomfort. NA-A stated R14's pain has gotten worse and she noticed R14 had not gotten out of bed more due to her pain. During interview on 1/4/24 at 1:53 p.m., trained medication aide (TMA)-C stated when R14 was admitted to the facility she came on hospice services. TMA-C stated R14's complaints of pain have increased since discharging from hospice. TMA-C stated ice packs, repositioning or Tylenol were offered to help manage her pain and to help bridge the gap from the oxycodone coverage. TMA-C stated he would let the nurse or DON know of complaints of increased pain so that they could notify the provider. During interview on 1/4/24 at 4:32 p.m., DON stated he expected the provider should be notified with change in condition or anything out of the ordinary. DON stated he expected R14's increased complaints of pain or discomfort, should have been reported to the provider as it could potentially cause great harm. A facility Pain management policy was requested and was not received.

Based on interview and document review, the facility failed to submit accurate and/or complete data for staffing information based on payroll and other verifiable and auditable data during 1 of 1 quarter reviewed (Quarter 4), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. Findings include: Payroll Based Journal (PBJ) [NAME] Report 1705 identified the following dates triggered: 7/1/23, 8/26/23, 8/27/23, 9/30/23 for failure to have licensed nurse coverage 24 hours per day and 8/5/23, 8/6/23, 8/19/23, 8/20/23, 9/2/23, 9/3/23, 9/30/23 for no registered nurse (RN) hours. Daily staff schedules on the above-mentioned dates identified licensed nursing staff including registered nurses had worked and therefore the data submitted in the PBJ to CMS was inaccurate. During interview on 1/4/23 at 3:02 p.m., administrator stated Human Resources submits the information for the PBJ reporting. Administrator stated the human resource staff who was responsible for submitting data was not available for interview on this date. Administrator confirmed that the information that was submitted for fiscal year Quarter 4 2023 was inaccurate. A facility policy titled Reporting Direct-Care Staffing Information (Payroll-Based Journal) with a date of 10/2017, identified direct-care staffing and census information will be reported electronically to CMS through the Payroll-Based Journal (PBJ) system. Direct-care staffing information includes staff directly hired by the facility, those hired through an agency, and contract employees. For auditing purposes, reported staffing information is based on payroll records, or other verifiable information. Information may be uploaded to the PBJ system manually, or through a payroll time and attendance system, or a combination of both. The PBJ system is accessed through the QIES system. Manual entries are made only by designated personnel with training on the PBJ user interface.

Based on observation, interview and document review, the facility failed to store and distribute food in accordance with professional standards for food safety. This had the potential to affect all 32 resident currently residing in the facility. Findings include: During observations and interview in the facility dining room on 1/2/24 at 11:15 a.m., in the resident dining room were two refrigerators side by side. One refrigerator referred to as the nurse refrigerator by the culinary services director (CSD), had latches on the bottom refrigerator door and on the upper freezer door but was not locked. There was a thermometer inside and temperature logs were kept. Inside the freezer were mighty shake supplements the CSD stated were used by nursing for the residents. On top of the mighty shakes were ice packs, some with resident names the CSD stated nursing used for the residents. The refrigerator had spills and stains inside. The CSD stated the dietary staff stocked the mighty shakes and assumed nursing was responsible to clean it. On the door of the refrigerator was a sign reminding staff to sanitize the ice packs before putting them in. The other refrigerator was referred to as the resident refrigerator and had a thermometer in it but no log kept. There were multiple dried stains/spills throughout. In this refrigerator there was 6 tubs of unopened squash not labeled, ice packs, two opened bottles of salad dressing with no open date or resident name, an unlabled package of sushi with a manufacture expiration date of 12/16/23, a salad with no label or date. The CSD stated the dietary department had nothing to do with this refrigerator and residents, families and staff used it. The CSD stated he was not aware of any food bourne illness in the building. When interviewed on 1/3/24 at 11:06 a.m., the day cook (cook)-A stated cleaning responsibilities were based on position. Cook-A stated the cooks cleaned the prep areas and prep pots and pans. There were no sign off sheets or cleaning schedules and cook-A was not aware of who was responsible for cleaning the two refrigerators in the dining room. When interviewed on 1/3/24 at approximately 11:15 a.m., CSD stated he learned the dietary department did have responsibility for the two refrigerators in the dining room and was previously unaware. CSD stated the ice packs in the freezer with the mighty shakes supplements was probably not a good idea as there was no sign off log to verify sanitization had been completed and the potential for cross contamination was there if the ice packs came in contact with resident skin or body fluids. CSD verified food brought in by residents and families should be labeled and dated to ensure proper disposal and staff should not be storing food in that refrigerator. CSD stated this was important because the refrigerator was accessible to residents. CSD stated weekly and monthly cleaning schedules were available and should have been in place but had not been utilized. The facility policy Food Receiving and Storage dated October 2017, identified All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date. All foods belonging to residents must be labeled with the resident's name, the item and the use by date. Refrigerators must have working thermometers and be monitored for temperature according to state- specific guidelines.

Based on observation, interview and document review, the facility failed to provide a safe and sanitary environment. This had the potential to affect all 32 residents. During observations and interview in the facility kitchen on 1/2/24 at 11:15 a.m., above the kitchen stove, the vent screens were noted have two-three inch wide areas thick with grease and imbedded dust. When interviewed the culinary services director (CSD) stated he agreed the vent screens looked bad. The CSD stated normally staff should be taking two panels down at a time and running them through the dish washer. The CSD stated this appeared to not have been done and normally all panels should be washed every two weeks. The CSD stated he had no cleaning logs to show when it had been done last. When interviewed on 1/3/24 at 11:06 a.m., the day cook (cook)-A stated cleaning responsibilities were based on position. Cook-A stated the cooks cleaned the prep areas and pots and pans. Cook-A stated the vent panels were run through the dishwasher by whoever had time and they had been missed for the past couple weeks. Cook-A stated there were no sign off sheets or cleaning schedules. When interviewed on 1/3/24 at approximately 11:15 a.m., CSD stated his expectation was the vent panels should be cleaned weekly because the build up of grease and dust could pose a fire risk and had the potential cause illness from dust falling into food during preparation. CSD stated weekly and monthly cleaning schedules were available and should have been in place but had not been utilized. The facility policy Hood Filters Over Stove policy dated September 2012, identified the cleaning procedure and instructed staff to Remove screens, run screens through dishwasher cycle, remove and let air dry, wipe off hood area with degrease, wash area with hot soapy water, rinse well, wipe or spray with sanitizing solution, let air dry and replace screens per schedule of facility.

Based on interview and document review, the facility failed to ensure 3 of 5 residents (R5, R8 and R17) reviewed for immunizations were offered and/or provided the pneumococcal vaccine series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s). Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R5's face sheet, dated 1/4/24, indicated she was [AGE] years old. The immunization record, dated 1/4/24, indicated she received a PCV13 on 12/2/2016 followed by the PPSV23 on 12/11/2017. The record lacked evidence of shared clinical decision making with the physician for PCV20 at least 5 years after the last pneumococcal dose. The record lacked evidence that R5 was offered or received PCV20. R8's face sheet, dated 1/4/24, indicated she was [AGE] years old. The immunization record, dated 1/4/24, indicated she received a PCV13 on 9/30/2016 followed by a PCV23 on 9/22/2018. The record lacked evidence of shared clinical decision making with the physician for PCV20 at least 5 years after the last pneumococcal dose. The record lacked evidence that R8 was offered or received PCV20. R17's face sheet, dated 1/4/24, indicated she was [AGE] years old. The immunization record, dated 1/4/24, indicated she received a PPSC23 on 12/20/2010 followed by a PCV13 on 6/23/2016. The record lacked evidence of shared clinical decision making with the physician for PCV20 at least 5 years after the last pneumococcal dose. The record lacked evidence that R17 was offered or received PCV20. During an interview with infection preventionist (IP), on 1/4/2024 at 4:32 p.m., IP indicated immunizations are reviewed upon admission through MIIC (Minnesota Immunization Information Connection). IP stated IP would ask residents and/or their families if they wanted the immunizations and consents are obtained if immunizations are needed. IP stated IP used the Centers of Disease Control and Prevention (CDC) pneumococcal vaccine recommendations, dated 4/2022 for eligibility of pneumococcal immunizations. IP verified R5, R8, and R17's pneumococcal immunizations as listed above. IP stated that IP was not aware of the recommendation of the PCV20. IP verified they had not been offered or provided education on PCV20. IP verified there had been no shared clinical decision making with the provider regarding pneumococcal immunizations for R5, R8 and R17. IP stated it was important to ensure residents are offered all available vaccinations to prevent the risk of developing symptoms to lead to acute illness. A facility policy titled Pneumococcal Policy with a review date of 4/6/22 was provided. Policy indicated: It is the practice of the Health Care Facility to offer all residents the pneumococcal vaccines to aid in the prevention of pneumococcal/pneumonia infections. To follow recommendations of the Advisory Committee on Immunization Practices (ACIP), Centers for Disease Control (CDC) and/or the state Department of Health for prevention of Pneumococcal disease by identifying those residents at risk for Pneumococcal disease and offering Pneumococcal vaccination. Prior to or upon admission not the facility (within 5 days), all residents will be assessed for current immunization status and eligibility to receive the pneumococcal vaccine. Within 30 days of admission, resident will be offered the vaccine, when indicated, unless the resident has already been vaccinated or the vaccine is medically contraindicated. If resident's immunization status is unknown, facility staff will contact resident's physician to determine record of immunization status from resident's permanent clinic record or verify using MIIC. Refer to the current CDC Recommended Adult Immunization Schedule to determine recommended vaccines i.e., Types, frequencies, intervals, and special considerations. The Infection Preventionist or designee will conduct periodic audits of resident medical records to determine compliance with the Pneumococcal-Disease Prevention Protocol.

Based on interview and document review, the facility to routinely assess residents who received antipsychotic medications for signs and symptoms of tardive dyskinesia (disorder that results in involuntary repetitive body movements) for 2 of 2 residents (R1 and R7) reviewed for unecessary medications. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 had severe cognitive impairment, had diagnoses of anxiety, depression, and schizophrenia. R1's physician orders print date of 1/4/24, indicated R1 had an order for Clozapine 200 milligrams (mg) once daily in the morning and Clozapine 400 mg once daily in the evening. In review of R1's electronic medical record, R1 had an AIMS (Abnormal Involuntary Movement Scale) assessment initiated on 11/17/23 but was not completed. R1's care plan indicated R1 had the potential for psychotropic drug adverse reactions related to daily use of psychotropic medication and included an intervention which directed an AIMS assessment needed to be done per protocol. R7's quarterly MDS dated [DATE] indicated R7 had intact cognition, had diagnoses of type 2 diabetes mellitus, chronic kidney disease stage 3 and bipolar disorder. R7's physician orders with print date of 1/4/24, indicated R7 had an order for Aripiprazole (antipsychotic) 10 mg once daily. In review of R7's electronic medical record, no baseline AIMS assessment was completed on admission (5/31/23) or semi-annually. R7's care plan indicated R7 had the potential for psychotropic drug adverse reactions related to daily use of psychotropic medication and included an intervention that stated an AIMS assessment needed to be done per protocol. On 1/4/24 at 11:41 a.m., director of nursing (DON) stated he was the person responsible for completing the AIMS assessments and they should be completed on admission and every six months if a resident is receiving an antipsychotic medication. DON confirmed R1's baseline AIMS assessment and R7's baseline and semi-annual AIMS assessments were not completed. DON stated it was important for the assessments to be completed due to being at risk for tardive dyskinesis. A facility policy titled Psychotropic Medication Use with a date of 7/8/21, identified Psychotropic medications may be considered for resident in which symptoms have been identified and the interdisciplinary team has deemed would benefit from us of these meds. Abnormal Involuntary Movement Scale (AIMS/Discus) will be performed on residents receiving antipsychotic medications to screen for tardive dyskinesia at baseline, semi-annually, and after discontinuation every month x 3.

Based on interview and document review, the facility failed to to provide pharmaceutical services including administration of drugs to meet the needs of 1 of 1 (R131) residents reviewed for pain control. Findings include: R131's discharge Minimum Data Set (MDS) dated [DATE], identified R131 admitted to the facility 9/22/23 from an acute care hospital for aftercare following surgery on the nervous system and diagnoses of spondylolisthesis lumbar region (a spinal disorder in which a vertebra slips forward onto the bone below it), radiculopathy lumbar region (a pinched nerve), spinal stenosis (a narrowing of the spinal canal that can put pressure on the spinal cord and nerves within the spine), chronic pain and muscle weakness. R131 had clear speech, the ability to make herself understood and had clear comprehension. R131's hospital discharge summary dated 9/22/23, identified R131 admitted [DATE] and underwent surgical procedures including lumbar hemllaminectomy with [NAME] repair (a spine surgery that involves removing one of the two laiminae on a vertebra to relieve excess pressure on the spinal nerves) and was discharging to the facility on [DATE] for surgical aftercare for low back pain, skilled nursing services and therapy. The same discharge summary included a pain assessment dated [DATE], indicating resident was having aching, constant pain in the right buttocks and down the right leg. The same discharge summary included orders for ibuprofen (a pain medication) 800 milligrams (mg) every eight hours as needed (prn), oxycodone-acetaminophen (a pain medication) 5-325 mg every four hours prn, last received on 9/22/23 at 8:51 a.m., and diazepam (a medication for muscle spasms) 5 mg every six hours prn last received on 9/21/23 at 2:06 a.m. The hospital discharge summary identified these orders were sent to the facility contracted pharmacy. The same discharge summary was faxed to the facility 9/22/23 at 11:59:14 a.m., as identified on the fax cover sheet. The facility admissions notification form identified R131 as a confirmed admission 9/22/23 at 12:00 p.m. R131's 48-hour care plan dated 9/22/23 at 2:52 p.m., identified a section available for pain and comfort but lacked identification of focus, goal, and interventions. When interviewed on 1/3/24 at 9:48 a.m., R131's spouse stated R131 was in the hospital for three days following a back surgery in which the dura (membrane that encases the spinal cord) had been cut by accident resulting in the need for skilled nursing care and therapy. R131's spouse stated R131 admitted to the facility on [DATE] at approximately 1:30 p.m. and was told R131's medications had not been delivered yet. R131's spouse stated he left the facility then returned at approximately 5:00 p.m. and was told R131's medications were still unavailable. R131's spouse went home and returned at approximately 9:30 p.m. He stated he was again told R131's medications had not been delivered. R131's spouse stated he left R131 with his cell phone and returned home. He received a call from R131 at approximately 10:30 p.m. because R131 had used the call light to request help from staff to close the room blinds for privacy and no staff had come. R131's spouse stated he called the facility two times and no staff answered so he returned to the facility to close the blinds, spoke with staff regarding the lack of pain medication and told them he would be taking R131 home in the morning. R131's spouse stated R131 had asked for her ordered oxycodone-acetaminophen pain medication twice at approximately 3:30 p.m. and again at approximately 10:00 p.m. for pain she rated at eight to nine out of 10. R131 was told the medication was unavailable because they were not delivered from pharmacy yet. R131's spouse stated he returned to the facility the next morning on 9/23/23 at approximately 7:30 a.m. and told staff he was checking her out because R131 wasn't getting adequate pain control. R131's spouse stated staff brought R131 breakfast and oxycodone-acetaminophen pain medication at approximately 8:15 a.m. before leaving. R131's progress note dated 9/22/23 at 10:30 p.m., indicated R131 had been turning on call light multiple times throughout shift for prn pain medications. Staff informed resident multiple times her medications had not yet arrived from pharmacy. R131's husband came up to the nurse's desk and became upset with the nurse on shift because resident does not have any medication and staff did not know the exact time the medications would be delivered. The same progress notes also indicated a call was made to the pharmacy to determine when her medications would be delivered and the hospital discharge orders were again faxed, however lacked documentation of attempts to obtain a code to access medications from the facility cubex (emergency medication machine the facility had in place for ordered medications not yet delivered). R131's progress note dated 9/23/23 at 8:47 a.m., identified the resident's spouse was upset with staff when staff came in because R131 still had not yet received any prn pain medication from staff. The progress note also indicated R131 and her spouse communicated no one went in to check on her and R131 stated she requested hot and cold packs and no one brought them in. R131 asked for an ice pack this morning and staff took it in right away. When nurse pulled meds from the cubex and took them into R131's room, her spouse stated they were leaving and wanted to discharge. R131's medical record indicated staff had documented her pain rating at 5 at on 9/23/23 at 4:38 a.m. and 8:27 a.m. R131's facility medication administration record (MAR) dated 9/1/23-9/30/23, identified orders for diazepam 5 mg every six hours as needed for pain with a start date and time of 9/22/23 at 2:00 p.m., but lacked evidence of the medication being administered. The same MAR identified an order for oxycodone-acetaminophen 5-325 mg every four hours as needed for pain, take one tablet for pain zero to five and two tabs for pain six to ten and was documented as being given one time on 9/23/23 at 8:27 a.m. R131's order for ibuprofen was not on the MAR indicating the order was not entered. When interviewed on 1/3/24 at 10:30 a.m., the facility pharmacy consultant (Pharm D)-A stated the facility has normal scheduled medication deliveries. The facility also has an emergency supply of medications in a dispensing machine referred to as a cubex or medbank. The Pham D-A stated in the cubex are over 200 available medications that could be utilized per order prior to normal scheduled deliveries including pain medication such as oxycodone-acetaminophen. As long as the pharmacy had the prescription for R131's oxycodone-acetaminophen, staff could call the pharmacy to request a code to access the medication from the cubex onsite per facility protocol. Pharm D-A stated the list of available medications in the cubex was posted next to the machine. The facility staff were trained on the use of the machine when they were installed. The pharmacy Cubex medication inventory list dated 1/2021, indicated several available analgesics (pain medication) including oxycodone-acetaminophen 5-325 mg. When interviewed on 1/3/24 at 12:13 p.m., The Pharm D-B stated R131's oxycodone-acetaminophen prescription order was received at the pharmacy from the hospital on 9/22/23 at 9:22 a.m Pharm D-B stated facility staff could have called to get a code to access the medication whenever R131 needed it. The Pharm D-B verified no such request had been made. Pharm D-B confirmed the resident's demographic information had been entered into their system on 9/22/23 at 3:00 p.m., but the faxed hospital discharge orders from the facility were not received until 8:40 p.m. which would be the reason her medications were not delivered earlier. Despite this, staff could still access medications from the cubex unit if the facility had orders. The Pharm D-B stated the reason facilitiy had the cubex in place was so medications could be provided between regular medication deliveries. The Pharm D-B stated because R131 was rating her pain at eight to nine out of 10, he would consider the lack of provision of her ordered and available pain medication to be a error by the facility. When interviewed on 1/3/24 at 4:20 p.m., registered nurse (RN)-B confirmed he had worked at the facility approximately three years and was working the overnight shift on 9/22/23 to 9/23/23. RN-B stated if a resident was in pain, he would administer pain medication if ordered. RN-B stated if the medications had not come from the pharmacy, staff had the ability to pull medication from the cubex. RN-B stated if the medication was a narcotic or controlled substance like oxycodone-acetaminophen staff could call the pharmacy and get a code to pull it from the cubex. When asked if he had received a request from R131 for pain medication or ice packs, RN-B stated he did not remember. When interviewed on 1/4/24 at 11:45 a.m., R131 stated she last received her oxycodone-acetaminophen pain medication approximately 9:00 a.m. in the hospital before admitting to the facility and did not receive another dose from the facility until the morning of 9/23/23 at approximately 8:30 a.m. She started experiencing pain in her right buttocks and right leg approximately 3:00 p.m. after admitting to the facility and described it as severe, stabbing, aching in the nerve and rated it eight to nine out of ten. Her pain made it difficult to walk, sit on the toilet, get comfortable and sleep throughout her stay. R131 stated she asked facility staff for the pain medication prescribed for her in the hospital at least two to three times and was told it was unavailable. When interviewed on 1/4/24 at 1:17 p.m., RN-A stated she worked for the facility approximately one year and four months. RN-A stated she was the nurse on duty 9/22/23 on the facility p.m. shift the day R131 arrived. She remembered the resident being very upset about her pain, asking for pain medications, and made racist comments about staff. R131's spouse was upset because her medications had not been delivered. RN-A stated the facility pharmacy made medication deliveries around 5:30 p.m. and then again at 10:30 p.m. RN-A stated the facility has a cubex that staff could call the pharmacy to obtain a code to retrieve narcotics if needed but at that time she didn't think she could do that because when she called the pharmacy regarding the time of the next delivery they requested for the hospital discharge orders to be faxed again. She did not ask for a code for the cubex to obtain R131's hydrocodone-acetaminophen because she thought she had to wait for the pharmacy to deliver R131's medications. RN-A stated she communicated this information before leaving her p.m. shift to RN-B when he arrived for the night shift. RN-A stated this was the first time admitting a new resident and learned she could have called for a code and administered the medication because the facility already had the orders, and the pharmacy had the prescription. RN-A stated she returned the next morning for a day shift and by that time the resident's medications had been delivered so she administered her oxycodone-acetaminophen at that time. When interviewed on 1/4/24 at 2:58 p.m., the director of nursing (DON) stated through the facility referral process it had been determined the facility could admit and care for R131. The DON stated the facility received R131's orders approximately 12:30 p.m. and entered them approximately 2:00 p.m. into her EMR (electronic medical record) The facility process for admissions was to receive the orders and send them to the pharmacy. If the orders were sent to the pharmacy before 3:00 p.m., then medications would be delivered approximately 5:00 p.m. and if the orders were sent to the pharmacy after that, the next delivery was approximately 10:00 p.m. Even if R131's medications had not been delivered the facility staff had the ability to pull medications from the cubex by calling the pharmacy and ensuring they had the prescription. The DON stated some of the staff trained on the use of the cubex machine in May of 2023. Any staff who missed that training were individually trained by himself. The DON stated he was made aware of R131 wanting to discharge when RN-A called him on the morning of 9/23/23. RN-A informed him of R131's racist comments and assumed this was the reason she wanted to leave as the facility employs African American staff. The DON stated he had not investigated R131's concerns regarding not receiving pain medication and did not know why RN-A and RN-B did not call the pharmacy to obtain an authorization code to administer it from the cubex. The DON stated it was expected and important to ensure R131 received pain medications related to her diagnoses, recent surgery and reported pain because the facility agreed to provide her services including pain control and she didn't get that. The facility MedBank Training staff signature form dated 5/2/23 indicating training on use of the cubex was not signed by RN-A or RN-B and the DON did not provide other documentation the training had been provided to them. The facility policy and procedure Medication Ordering and Receiving from Pharmacy dated May 2022, identified Emergency pharmacy service is available on a 24-hour basis. Emergency needs for medication are met by using the facility's approved emergency medication supply or by special order from the provider pharmacy. The provider pharmacy supplies emergency medications including emergency drugs, antibiotics, controlled substances, products for infusion in limited quantities in portable containers, automatic dispensing systems incompliance with applicable state regulations. The Facilty Assessment Tool dated 2/28/23, identified pain management including assessment of pain, pharmocologic and nonpharmocological pain management as a service provided based on resident need.

Based on interview and document review, the facility failed to send notice of a hospital transfer to the office of the state long term care ombudsman for 1 of 1 residents (R15) reviewed for hospitalization . Findings include: R15's Minimum Data Set (MDS) dated [DATE], identified intact cognition. R15's progress note dated 10/17/23, indicated R15 had been sent to the emergency room for evaluation of increasing weakness and low blood pressure and was admitted to the hospital. The facility monthly ombudsman notification tracking form for October 2023, identified R15 was transfered to an acute care facility on 10/17/23 but lacked evidence the form was sent to the ombudsman. When interviewed on 1/3/24 at 4:19 p.m., the administrator stated the facility tracks all emergency acute care transfers and discharges on a monthly spreadsheet but verified they had not been sent to the ombudsman.

Based on interview and document review, the facility failed to notify a provider of low blood glucose readings for 1 of 1 residents (R7) as well as complaints of increased pain for 1 of 1 residents (R14) reviewed for changes in condition. Findings include: R7's quarterly MDS dated [DATE] indicated R7 had intact cognition, had diagnoses of type 2 diabetes mellitus, chronic kidney disease stage 3 and bipolar disorder. R7's physician's orders printed 1/4/24, included an order to check blood glucose every morning before meal and put results in vitals in the morning. The order failed to provide instructions for updating the physician. Review of R7's blood glucose results 12/2023-1/2024 were as follows: - 1/3/24 - blood glucose of 45 - 1/2/24 - blood glucose of 80 - 1/1/24 - blood glucose of 78 - 12/31/23 - blood glucose of 57 - 12/30/23 - blood glucose of 67 - 12/27/23 - blood glucose of 54 - 12/26/23 - blood glucose of 80 - 12/19/23 - blood glucose of 69 - 12/17/23 - blood glucose of 77 - 12/14/23 - blood glucose of 61 During record review, R7's progress notes for 12/2023 thru 1/4/2024 failed to note changes in R7's blood glucose or action taken as a result. R7's insulin order was previously reduced by the provider on 11/13/23 due to low blood glucose readings. R7's progress notes failed to identify follow-up after the order change. During interview on 1/4/24 at 9:46 a.m., R7's primary provider stated she did not recall being notified of the change in R7's blood glucose readings anytime in December 2023 up until today 1/4/24. Provider stated if she would have been notified of the low blood glucose readings, she would have made a dose reduction to R7's insulin. She expected to be notified with any change in condition, including blood glucose levels that are consistently under 80. During interview on 1/4/24 at 11:53 a.m., R7 stated he can feel when his blood sugar gets low, he gets shakey and confused. This has happened several times in the past couple of weeks. R7 stated after the nurse checked his blood glucose, if it is low, he or she got him some orange juice and/or a snack. R14's significant change Minimum Data Set (MDS) dated [DATE], indicated R14 was cognitively intact, was able to clearly communicate her needs and wishes and had diagnoses of idiopathic peripheral autonomic neuropathy (damage to the nerves that control automatic body functions), muscle weakness and hemiplegia (paralysis of one side of the body) following cerebral infarction affected left non-dominant side.required extensive assistance with activities of daily living (ADL). R14's physician's orders printed 1/4/24, included an order to monitor for pain. The order failed to provide instructions for updating the physician. Review of R14's pain level results 10/2023-12/2023 were as follows: - 1/4/24 - pain level rating of 6 out of 10 on pain scale. - 1/3/24 - pain level rating of 7 out of 10 on pain scale. - 1/2/24 - pain level rating of 10 out of 10 on pain scale. - 1/1/24 - pain level rating of 8 out of 10 on pain scale. - 12/31/23 - pain level rating of 8 out of 10 on pain scale. - 12/30/23 - pain level rating of 9 out of 10 on pain scale. - 12/29/23 - pain level rating of 8 out of 10 on pain scale. - 12/28/23 - pain level rating of 8 out of 10 on pain scale. - 12/27/23 - pain level rating of 7 out of 10 on pain scale. - 12/26/23 - pain level rating of 9 out of 10 on pain scale. - 12/25/23 - pain level rating of 10 out of 10 on pain scale. - 12/24/23 - pain level rating of 10 out of 10 on pain scale. During record review, R14's progress notes for 12/2023 thru 1/4/24 failed to note notification to the provider of changes in R14's increased pain levels or action taken as a result. During interview on 1/2/24 at 1:45 p.m., R14 stated she has pain in her left arm and down left leg that comes and goes but is pretty much constant. R14 stated her as needed pain medications were decreased from three times a day to two times a day and R14 was not happy about it as she stated she really needed them for her pain. R14 stated she was really worried about her pain when she started to do her physical therapy exercises more diligently as the pain was so horrible when doing the exercises to the point that R14 did not want to complete them. During interview on 1/4/24 at 9:51 a.m., R14's primary provider stated she did not recall being notified of the change in R14's increased pain levels anytime in December 2023 up until today 1/4/24. Provider stated if she would have been notified of R14's increased pain levels, she would have seen R14 sooner to address pain. Provider stated she expected to be notified with any change in condition and relied on the facility staff to alert her on any changes or concerns so she can address or see the resident sooner. During interview on 1/4/24 at 11:41 a.m., director of nursing (DON) stated the nurse on the floor, who is obtaining vitals or performing assessment, notifies the provider of any changes. During interview on 1/4/24 at 1:50 p.m., nursing assistant (NA)-A stated R14 would call when needing pain medication and NA-A would let nursing know of any complaints of pain/discomfort. During interview on 1/4/24 at 1:53 p.m., trained medication aide (TMA)-C stated if he obtains a low blood glucose reading on a resident, he will recheck it to ensure that it is a correct reading. TMA-C stated if it continues to be low, he would notify the nurse or the DON who would then notify the provider if needed. TMA-C stated he would let the nurse or DON know of any complaints of increased pain so that they could notify the provider. During interview on 1/4/24 at 4:32 p.m., DON stated he expected the provider was notified with any change in condition or anything out of the ordinary. DON stated he expected R7's low blood glucose readings and R14's increased complaints of pain or discomfort, should have been reported to the provider as it could potentially cause great harm. A facility policy titled Change in a Resident's Condition or Status undated, identified the facility will promptly notify the resident, the physician/healthcare provider, and the resident representative of changes in the resident's medical/mental condition and/or status.

Based on interviews and document review, the facility failed to thoroughly investigate an allegation of misappropriation of property for 1 of 1 resident (R19). Findings include: R19's quarterly Minimal Data Set (MDS) dated [DATE], indicated R19 was cognitively intact, without hallucinations or delusions noted and no behaviors were identified. Review of facility report to the State Agency (SA) dated 10/17/23, identified R19 had reported missing money from his wallet on 10/16/23. Facility staff searched R19's room for the missing money with no success of locating money. Review of facility 5-day investigation submitted to the SA dated 10/19/23, the facility investigation lacked evidence of staff interviews and other residents being interviewed or assessed to ensure safety of personal property. During interview on 1/2/24 at 12:41 p.m., R19 stated that he was missing $210.00 from his wallet that was located in his nightstand. R19 stated he went out to have a cigarette and when he came back the money was missing from his wallet. R19 stated the facility looked all over his room, when reported, but has not notified him of the investigation process or determination of allegation and stated that he wants the money reimbursed. During record review, form titled Exploitation Cheat Sheet indicated a checklist of tasks to be completed for investigation. Checklist included Interview & Document all staff involved on the date that the item was reported missing, with it marked off as completed with a checkmark. Review of form Facility Investigation indicated detailed sections for each step of the investigation such as Description of the event or allegation; Resident Initial Interview; Assessment of Resident; Notifications/Describe the Immediate Resident Protection Initiate; Event/Allegation First Reported By, Name/Title the Event/Allegation was reported to; Casual and/or Contributing Factors to Event/Allegation, Summary of the Event/Allegation, Investigation and Outcome; Notifications made regarding this event/allegation; and Name of Person Completing Investigation. Bottom of last page in bold indicated See Witness Statements and Supporting Documentation Attached. No documentation was attached to Investigation. During interview on 1/4/23 at 2:46 p.m., administrator stated when there is a reported allegation of misappropriation of property, he interviews the resident to obtain information to help determine if property is missing or stolen. Administrator stated R19 consented to have his room searched for the missing money to see if money was misplaced with no success finding money. The administrator stated he interviewed the director of nursing (DON) due to DON working as a floor nurse the night that R19 stated money was missing. Administrator stated that standard procedure was to interview any staff and residents that were working or around during the time period in question. Administrator stated he interviewed the DON and R6 but confirmed that no additional interviews of staff or residents was completed. Administrator confirmed the investigation was not thorough and additional interviews would have helped with the investigation process. Administrator stated he was not aware of any follow up communication to R19. A facility policy titled Abuse Prohibition/Vulnerable Adult Policy with a date of 8/23, identified the facility's Investigation Team will review all incidents reports regarding residents including those that indicate an injury of unknown origin, abuse, neglect, misappropriation of resident property, or involuntary seclusion no later than the next working day following the incident. The investigation team will determine if further investigation is needed. The investigation team will continue the investigation. Investigation includes interviewing staff, residents, or other witnesses to the incident. Corrective action based on the investigation will be completed (e.g., change of procedure, training, discipline, or discharge of staff, etc.). All documentation will be kept in a confidential file in the facility in accordance with State Law. Social Services and other staff, as appropriate, will provide ongoing support and counseling to the resident and family as needed. The facility will provide proper follow up communication related to the incident across all shifts and to practitioners and resident representatives as applicable.

Based of observation, interview and document review, the facility failed to ensure self-administration of medication was clinically appropriate for 1 of 1 residents (R5) reviewed. Findings include: R5's Minimum Data Set (MDS) dated [DATE], identified intact cognition and R5 had a diagnosis of asthma. R5's clinical order set dated 1/3/24, identified resident as having the following medication orders: - albuterol sulfate (an asthma medication) inhaler and to take two puffs, inhale orally every four hours as needed (prn) for wheezing and shortness of breath - fluticosone propionate (an asthma medication) inhaler to take two times a day for mild intermittent asthma - artificial tears ophthalmic ointment to instill into right eye four times per day for dryness R5's medical record lacked an order to self administer the above medications as well as an order for saline eye drops. R5's medication administration record (MAR) for December and January 2023, indicated staff were documenting use of her fluiticosone inhaler twice a day and her arificial tears eye ointment four times a day. There was no documentation resident had used her prn albuterol inhaler or the saline eye drops she kept in her room. R5's self administration of medication evaluations dated 6/16/2023 and 1/3/24 , both identified R5 was assessed and capable of self use of ophthalmic medications but not inhalation medications. R5's care plan dated 10/22/22, indicated resident had alteration in oxygen/gas exchange- respiratory status and instructed staff to monitor and document on respiratory status and communicate changes to the doctor. R5's care plan also identified resident will administer eye medications as ordered and instructed staff to assure that medications resident self administers have been done. During observation and interview on 1/2/24 at 5:35 p.m., two inhaler medications were observed on R5's bed and two other medications; one an artificial tears eye gel and one a saline eye drop, were observed on R5's night stand and were visible from the hall. R5 identified the two inhalers to be fluticosone and albuterol and the medications on her night stand to be over the counter (OTC) artificial tears eye ointment and OTC eye saline drops. R5 stated she has her son pick up the eye drops and ointment from the store, the facility assisted to re-ordering her inhalers when she ran out. R5 stated she used red inhaler in the morning and at bed time and the blue inhaler when she felt short of breath. R5 stated she used the saline eye drops approximately two-three times a day and her prn albuterol inhaler maybe one to two times a day on average. R5 stated she had never let staff know when or how often she used these medications and that they had never asked. R5 denied experiencing other residents coming in her room and was not concerned with anyone taking her medications. During observation and interview on 1/3/24 at 10:26 a.m., the fluticosone and albuterol inhalers were observed on R5's bed and the artificial tears eye gel and saline eye drops were on her night stand and visible from the hall. R5 stated she preferred for her inhalers to be on her bed and and the eye medications on her night stand so she could more easily find them and remember to use them. During observation on 1/3/24 at 2:17 p.m., the fluticosone and albuterol inhalers were observed on her bed and the OTC eye gel and drops were observed on her night stand and visible from the hall. R5 was not in her room at this time. During observation 1/4/24 at 7:44 a.m., the fluticosone and albuterol inhalers were observed on her bed and the OTC artificial tears eye gel and saline eye drops were observed on her night stand and visible from the hall. R5 was not in her room. During interview 1/4/24 at 10:07 a.m., R5 stated she used the artificial tears eye ointment and saline eye drops because she had previously had her right eye removed. These helped with the dryness with her prosthetic eye. She stated she used the artificial tears eye ointment four times a day and the saline eye drops when she needed. When asked about her inhalers, R5 stated she knew which one she needed to use regularly two times a day by their color because her eyesight was poor and couldn't read the labels. R5 stated she used the inhaler with the red chamber two times a day. R5 picked it up and verified it was the scheduled fluticosone inhaler. R5 then picked up the inhaler with the blue chamber and verified it was an albuterol inhaler which she used when needed for shortness of breath. When asked if she communicated how often she was using the prn inhaler to the staff and the eye drops R5 stated, no. She only told them when she needed another inhaler ordered. When interviewed on 1/3/24 at 5:04 p.m., trained medication aide (TMA)-A stated she didn't know if R5 had an order to self-administer her own medications and could not find one in R5's orders. TMA-A stated there was no order for the saline eye drops. TMA-A stated she never asked or documented how often she used her prn albuterol inhaler or the saline eye drops. TMA-A stated she only documented the scheduled fluticosone and artificial tears eye ointment because she knew R5 always administered that on her own. When interviewed on 1/4/24 at 8:31 a.m., TMA-B stated she never documented or asked how often R5 used her prn albuterol inhaler or the saline eye drops. When interviewed on 1/4/24 at 1:17 p.m., registered nurse (RN)-A stated R5 self-administered her fluticosone and her albuterol inhalers as well as her artificial tears eye ointment and saline eye drops. RN-A stated she was not aware how often R5 used her prn albuterol or the saline eye drops and they had never asked her or documented use. RN-A stated staff documented use of her scheduled fluiticosone inhaler and her scheduled artificial tears eye ointment but never asked if she had actually used the medications. RN-A stated she assumed R5 had been using them because she told staff when they needed to be reordered. RN-A stated she was unaware of an order for R5 to self-administer these medications. When interviewed on 1/4/24 at 1:17 p.m., the director of nursing (DON) stated the self-administration assessments were filled out incorrectly and had not accounted for the inhaler medications. There was no order in place for the saline eye drops. The DON stated there was no order in place for self -administration for any of these medications. The DON also acknowledged facility staff had not been documenting on or asking resident regarding how often she had been using the prn albuterol inhaler or the saline eye drops. The DON stated he was unaware of how the resdient stored these medications. The DON stated this is important in order to determine if the resident was using her medications safely and to ensure other resident's can't get to them. The facility policy Self-Administration of Medications dated December 2016, identified for self-administering residents, the nursing staff will determine who will be responsible (the resident or the nursing staff) for documenting that medications were taken. Self -administered medications must be stored in a safe and secure place, which is not accessible by other residents. Staff shall identify and give to the charge nurse any medications found at the bedside that are not authorized for self-administration, for return to the family or responsible party. Nursing staff will review the self-administered medication record on each nursing shift, and they will transfer pertinent information to the medication administration record appropriately noting that the doses were self-administered.

Based on interview and document review, the facility failed to ensure the actual hours and number of staff were posted per each shift. This had the potential to affect all residents residing in the facility, staff and/or visitors who may wish to view the information. Findings include: The facilities daily staff postings and the actual working schedules were reviewed for the month of 12/2023. The posting Report of Nursing Staff Hours directly Responsible for Resident Care contained the following information: census, date, start of day shift, start of evening shift, start of night shift, number of registered nurses (RN) with a total hours and number of staff for each shift, number of licensed practical nurses (LPN) with a total hours and number of staff for each shift, number of trained medication aides (TMA) with a total hours and number of staff for each shift and number of nursing assistants with a total hours and number of staff for each shift, and then an accumulated total of nursing staff and nursing hours for each 24-hour day. The schedule and nurse postings were compared and identified the following: The staff postings dated 12/1/23 thru 12/31/23, contained the following information and was unchanged from one day to next: - identified a census of 31; total nursing hours for today: 61.5 hours; Total nursing staff working for today: eight staff; Start time day shift of 6:00 a.m., start time of evening shift at 2:00 p.m. and start time of night shift of 10:00 p.m. - The number of RN's identified for the day shift were eight hours with one staff, evening shift eight hours with one staff and night shift of eight hours with one staff. - The number of LPN's identified for the day shift were 0 hours with 0 staff, evening shift 0 hours with 0 staff and night shift with 0 hours and 0 staff. - The number of TMA's identified for the day shift were eight hours with one staff, evening shift eight hours with one staff and night shift of 0 hours with 0 staff. - The numbers of assistants identified for the day shift were 23 hours with three staff, evening shift 23 hours with three staff and night shift seven and a half hours with one staff. During interview on 1/4/24, at 3:02 p.m. the administrator confirmed that the daily staff postings from the month of December does not reflect the working schedule and therefore is inaccurate. A facility policy titled Posting Direct Care Daily Staffing Numbers dated 7/2016, identified facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents.

Based on interview and document review, the facility failed to ensure allegations of abuse were reported immediately, within two hours, to the State Agency (SA) for 1 of 1 residents (R1) reviewed for allegations of abuse. Finding include: A Facility Reported Incident (FRI) submitted to the SA on 11/22/23 at 5:10 p.m. indicated R1 reported physical abuse by a facility employee. R1's Diagnosis List included diagnoses of nontraumatic intracerebral hemorrhage (stroke), hemiplegia and hemiparesis (paralysis on one side of the body) left non-dominant side. R1's admission Minimum Data Set (MDS) indicated R1 had moderate cognitive impairment. On 11/29/23, at 10:38 a.m. R1 stated she woke up on the floor. R1 stated the only thing that made sense was one of the nursing assistants (NA) or nurses must have pulled her out of bed. R1 stated she wasn't getting along with NA-A prior to ending up on the floor. R1 stated NA-A broke her arm and it hurt bad. On 11/29/23, at 11:42 a.m. NA-A stated she assisted R1 to boost up in her bed on 11/21/23, around 10:00 p.m. NA-A stated there was no fall that she was aware of. NA-A stated at the time she boosted R1 up in bed, R1 did complain of arm pain. On 11/29/23, at 2:06 p.m. the director of nursing (DON) stated R1 told LPN-A she was abused by NA-A on 11/22/23 around 3:00 a.m., with the alleged abuse occurring on 11/21/23 around 10:00 p.m. The DON stated he was notified of the alleged abuse on 11/22/23 at 9:00 a.m. The DON stated he should have been notified of the alleged abuse right away. On 11/29/23, at 2:57 p.m. the administrator stated he became aware of the alleged abuse on 11/22/23 around 10:00 a.m., when he reviewed his emails. The administrator stated he should have been notified of the alleged abuse within two hours. The administrator stated he filed the report with the SA at 3:36 p.m. on 11/22/23. The facility's Abuse Prohibition/Vulnerable Adult Policy revised 8/23 directed facility staff to promptly report, document and investigate all incidents of alleged or suspected abuse/neglect. The abuse policy indicated a supervisor will be notified immediately and will assess the situation to determine if any emergency treatment or action is required. The abuse policy indicated notification to the facility administrator will occur immediately for any incidents of resident abuse, alleged or suspected abuse, injury of unknown origin, neglect, financial exploitation, or involuntary seclusion. The abuse policy indicated suspected abuse shall be reported to OHFC (Office for Health Facility Complaints) only reporting not later than two hours of forming the suspicion of abuse.

Based on observation, interview, and document review, the facility failed to monitor orthostatic blood pressures with the use of an antipsychotic medication for 4 of 5 residents (R15, R21, R22, and R4) reviewed for unnecessary meds. Findings include: R15's admission Minimum Data Set (MDS) dated [DATE], indicated R15 had severe cognitive impairment and received extensive assistance with activities of daily living (ADLs).The MDS also indicated R15 took and antipsychotic medication. R15's care plan revised 1/16/23, indicated R15 was at risk for psychotropic drug adverse drug reaction (ADR's) related to daily use of psychotropic medications, and included an intervention to monitor monthly orthostatic blood pressure (measuring difference in blood pressures from lying, sitting, standing). R15's physician orders included orders for Risperdal (antipsychotic) 1 milligram (MG) by mouth two times daily for vascular dementia with psychotic disturbance. R15's treatment administration record (TAR) from December 2322 through February 8, 2023, directed nursing staff to Monitor orthostatic blood pressures monthly on the fifth: Resident Lying for 2 minutes, sitting for 2 minutes, Standing for 2 minutes. Although no orthstatic blood pressures were documented. R15's medical record was reviewed and lacked any evidence orthostatic blood pressures had ever been obtained for R15. During observation on 2/8/23, at 7:23 a.m. R15 was sitting in his wheelchair watching television. R21's admission MDS dated [DATE], indicated R21 was cognitively intact and required extensive assistance with ADLs, R21 was independent with ambulation with a walker. R21's care plan dated 1/10/23, indicated R21 had a potential for psychotropic drug adverse drug reaction (ADR's) related to daily use of psychotropic medications, and included an intervention to monitor monthly orthostatic blood pressure. R21's medical record was reviewed and lacked any evidence orthostatic blood pressures had ever been obtained for R21. R21's TAR was reviewed from January 2023 through February 2023, TAR did not contain an order to obtain orthostatic blood pressures. During observation on 2/7/23, at 4:04 p.m. R21 was ambulating with walker from back patio to her room with no difficulty. R22's quarterly MDS dated [DATE], indicated R22 was cognitively intact and required extensive assistance with ADL's R22's care plan revised 1/24/23, indicated R22 had a potential for psychotropic drug adverse drug reaction (ADR's) related to daily use of psychotropic medications, and included an intervention to monitor monthly orthostatic blood pressure. A Consultant Pharmacist's Medication Regimen Review dated 9/22/22 indicated R22 was on the following psychotropic medications: duloxetine, melatonin and quetiapine, with recommendation to monitor orthostatic blood pressure. R22's medical record was reviewed and lacked any evidence orthostatic blood pressures had ever been obtained for R22. R22's TAR was reviewed from September 2022 through February 2023, TAR did not contain an order to obtain orthostatic blood pressures. During observation on 2/7/23, at 3:49 p.m R22 was in therapy department participating in physical therapy. When interviewed on 2/8/23, at 12:42 p.m. director of nursing (DON) stated orthostatic blood pressures were monitored routinely on residents admitted with syncope (fainting or passing out), orthostatic hypotension ( form of low blood pressure that happens when standing after sitting or lying) and for residents on any medication that requires orthostatic blood pressures. DON reviewed records for R15, R21 and R22 stated they do not have orthostatic blood pressures in their medical records. A facility Psychotropic Medication use policy undated indicated residents who do not require use of a mechanical hoyer lift will have an orthostatic blood pressure performed on a monthly basis. 46943 R4's quarterly MDS dated [DATE], identified daily use of antipsychotic, antidepressant and antanxiety medications. R4's psychotropic drug use CAA dated 10/19/22, indicated she was, At risk for negative side effects of meds to manage her anxiety and depression. R4's care plan dated 7/24/22, indicated a potential for psychotropic drug adverse drug reactions related to daily use of psychotropic medication and to monitor monthly orthostatic blood pressure. R4's careplan dated 7/24/22 indicated she was able to ambulate with assist of one staff and rolling walker. R4's order summary report dated 2/8/23, indicated the following medications: Alprazolam two times daily for anxiety with a start date of 7/22/22, Aripiprazole (an atypical antipsychotic, approved for schizophrenia and bipolar disorder and as an add-0n treatment for major depressive disorder) one time daily for major depressive disorder with a start date of 7/22/22, Duloxetine one time daily for pain and moods related to major depressive disorder with a start date of 7/22/22, Hydroxyzine hydrochloride as needed for anxiety/insomnia with a start date of 1/31/23, melatonin for insomnia every 24 hours with a start date of 1/26/23 and Mirtazapine at bedtime for major depressive disorder with a start date of 7/21/22. R4's order summary also included direction to complete orthostatic blood pressure checks due to antipsychotic med use on evening shift on the first of every month with a start date of 9/1/22. R4's Consultant Pharmacist's Medication Regimen Review (MRR) dated 7/27/22 indicated her as taking the psychotropic medications Alprazolam, Abilify (Aripiprazol), Duloxetine, Mirtazapine, Melatonin and prn (as needed) Hydroxyzine and to monitor orthostatic blood pressure unless she was unable to stand. R4's MMR dated 9/22/22, indicated she was taking the psychotropic medications Alprazolam, Abilify, Duloxetine, Mirtazipine and Melatonin and to monitor orthostatic blood pressure unless she was unable to stand. R4's blood pressure summary report lacked documentation of orthostatic blood pressure values on 9/1/22, 10/1/2022, 11/1/22, 12/1/23, or 2/1/23. R4's vital signs record failed to identify any orthostatic blood pressures on any dates. When interviewed on 2/8/23, at 1:04 p.m. registered nurse (RN)-A stated, blood pressures including orthostatic would be documented under the vitals tab of the resident chart if required. RN-A stated, R4 didn't require orthostatic blood pressures. When interviewed on 2/8/23, at 2:54 p.m. the director of nursing (DON) stated ordered orthostatic blood pressure checks would be scheduled on the resident treatment administration record (TAR) for staff to complete and the blood pressure values would be documented in the vitals tab of the resident chart. The DON acknowledged orthostatic blood pressure values were missing for R4.

Based on interview and document review, the facility failed to ensure assistance was provided with repositioning and applied medical devices were removed timely to prevent pressure ulcer formation and associated complications for 1 of 3 residents (R13) reviewed for pressure ulcer care. This resulted in actual harm for R13 when they developed multiple unstageable pressure injuries to their buttocks and sacrum after they were left on a bedpan for an extended period of time. Findings include: A State agency (SA) submitted Incident Report Summary, dated [DATE], identified the nursing home reported an allegation of potential neglect when R13 was found to have a bed pan underneath of her which caused redness. R13's admission Minimum Data Set (MDS), dated [DATE], identified R13 had both long and short-term memory impairment, demonstrated no rejection of care behavior(s), and required extensive assistance to completed bed mobility and toileting. Further, the MDS identified R13 was at risk for developing pressure injuries; and had developed two unstageable pressure ulcers (described as full thickness loss where the base of the ulcer is covered by slough and/or eschar) which were not present on her admission to the nursing home. R13's MHM (Monarch Health Management) Admission/Initial Data Collection V-3 assessment, dated [DATE], identified R13 had poor cognition and both short and long-term memory recall impairment. R13 was listed as needing two person physical assistance to complete transfers and had sustained a fall prior to admission which resulted in a femur fracture. The assessment identified R13 had an indwelling Foley catheter in place and had occasional bowel incontinence, and a subsequent section labeled, Skin, provided several options for the assessor to check R13's current skin condition including clear, mottled, pale, or dry. However, none of these were selected. Further, the section contained a body map image to select parts on the body where skin impairments were identified; however, the assessment had no recorded skin impairments recorded for R13 upon her admission to the nursing home with only dictation reading, Multiple scattered bruises on left arm . Bruising in inner left thigh (related to) fracture of femur. R13's MHM Braden Scale, dated [DATE], identified R13 was assessed to be at Moderate Risk for skin breakdown with dictation reading, Client is not able to reposition self in bed and needs frequent help by staff to be repositioned. R13's corresponding initial MHM Tissue Tolerance Observation Lying assessment, dated [DATE], identified R13 had a left femur fracture with no redness noted to her bony prominence's after a one, two or three hour interval of time along with bolded font which read, If no redness noted to bony prominences after 3 hour interval further evaluation may be indicated. Further, the assessment outlined a section labeled, Results, which identified R13 was to turned and repositioned every one hour while sitting with dictation reading, Client needs help with bed repositioning frequently, ambulating and toileting. There was no clarification recorded which described or identified R13's frequency of repositioning when in bed despite the assessment instructions dictating that was the purpose of the assessment; nor did the assessment identify R13 to have any current skin impairments or pressure injuries. R13's MHM 48 Hour Baseline Care Plan, dated [DATE], identified several sections to be completed to help drive R13's initial care. A section labeled, Self Care, had options to select to record R13's assistance needs with bathing, dressing and personal hygiene. However, this section was left blank and not completed. Further, a subsequent section labeled, Skin, was listed which had several options to provided to record any identified goals or interventions for R13; however, this section was also left blank and not completed. The completed care plan lacked any identified problems, goals or interventions to help ensure R13's skin remained intact and free of pressure-related injuries despite being identified as needing assistance with repositioning, potentially as often as every one hour, on the completed Tissue Tolerance Observation. R13's progress note, dated [DATE], identified R13 admitted to the nursing home and required assist of four to be transferred from the stretcher into bed. The note identified R13 was disorientated to the year and place, however, denied pain or discomfort. A subsequent progress note, dated [DATE], identified R13 had been . in bed sleeping all shift (night shift) . and lacked any information on how often, or if at all, R13 had been assisted with repositioning while she remained in bed. R13's progress note, dated [DATE], identified R13 as bed bound and completely dependent on staff for bed mobility and (activities of daily living). The note continued, Due to femur fracture, has poor bed mobility to BLE (bilateral lower extremities) . take [MEDICATION NAME] (sic) for ([MEDICAL CONDITION]). However, a subsequent progress note, dated [DATE], identified a comprehensive skin assessment was completed . due to report of resident having redness from being on the bed pan for a BM (bowel movement). Resident has non-blanchable redness to bilateral buttock and back of right thigh . left thigh (has) one intact blister and 1 open blister. MD notified and request for barrier cream sent. Air mattress placed on her bed. Reposition schedule for every 2 hours side-to-side initiated. An additional progress note, dated [DATE], identified R13's specifically witnessed skin concern(s) which included, (R)ight buttock 18 x (by) 5 dark red and non blanchable . Left buttock 27 x 3 cm (centimeters) dark red, non-blanchable area 0.8 intact blister, 0.8 cm from bottom an open blister 4 x 5 cm . right thigh: inner right thigh 7 x 2 non-blanchable dark red . Left thigh: inner thigh 10 x 5 purple and green bruise . The note outlined several interventions which were being placed which included, Added to check on every 5 minuets (sic) while on bed pan. R13's corresponding MHM Weekly Skin Inspection, dated [DATE], identified a section labeled, Skin Evaluation, which outlined R13 as having a skin impairment which read, Large ring sized non-blanchable redness surrounding buttocks. R13's later progress note, dated [DATE], identified R13 as having . two open areas on her buttocks. She had two intact blisters over bruising on her buttocks. Blisters are no longer intact and now has a superficial open area on both buttocks. (Left) buttock measures 2x2, (Right) buttock 3X2. Order in place to apply [MEDICATION NAME] cream (twice a day) and with each toileting. She is being re-positioned every ,[DATE] hours. Further, R13's completed, untitled wound tracking sheet, dated [DATE], listed R13 as having two unstageable pressure ulcers, with one to each buttock. The ulcer on the left buttock was recorded as, 7 (cm) X 1.5 (cm) 100% closed eschar. No drainage periwound red. The right buttock was recorded as, 5.5 (cm) X 2.0 (cm) 100% eschar No drainage periwound red. The sentence of additional dictation was present which read, * Redness around entire buttocks due to bed pan - non open - continue skin prep and calmo(septine). A later progress note, dated [DATE], identified R13 had expired. When interviewed on [DATE], at 10:00 a.m. nursing assistant (NA)-A recalled R13 as someone who needed quite a bit of help to complete her ADL's and repositioning. NA-A then voiced she was one of the staff working when R13 had been found on the bedpan on [DATE]. NA-A explained she entered R13's room to help her with morning cares when they found and removed a bedpan from her bottom. NA-A described the bedpan as being suctioned to R13's skin when it was removed and proceeded to describe R13's skin when the bedpan was removed as really red and bruised while being full of poop. NA-A expressed R13 had voiced pain when the bedpan was removed. NA-A then explained they had been helping R13 reposition just a few times a shift to her recall prior to finding R13 on the bedpan, and added she was unsure how long the bedpan had been left underneath of R13 prior to it being found; however, NA-A felt it was likely placed by the evening shift the day prior. Further, NA-A voiced R13 did not have any skin issues on her bottom prior to the bedpan being left underneath of her and added since the incident, the management had talked to her and pretty much said to make sure you're careful when someone is placed on a bedpan. NA-A could not recall any education on pressure ulcers or timely repositioning being provided. On [DATE], at 10:30 a.m. the administrator, director of nursing (DON) and regional nurse consultant (RNC)-A were interviewed. R13 admitted on [DATE], from the hospital where she had been diagnosed with [REDACTED]. R13 came to the nursing home to have rehabilitation therapy and they verified R13 was not considered to be in a terminal condition when she admitted . They recalled R13 as needing extensive assistance to complete most of her activities of daily living and expressed she admitted with an indwelling catheter, however, used a bedpan for her bowel movements due to extensive pain. They verified R13 had been assessed upon admission to require repositioning every (1) hour; and they acknowledged R13's temporary care plan (used when someone admits until their comprehensive care plan can be developed) lacked any identified goals or interventions demonstrating what had been in place prior to the incident where R13 was left on the bedpan. RNC-A explained, at the time, there was no system in place to track and record when residents were repositioned or toileted and expressed there still was not a systemic process in place to do such; however, they were working on trying to get it on a task so it could be tracked and recorded by the NA(s) electronically. RNC-A then verified there was no way to demonstrate when R13 had been placed on the bedpan prior to being found with it underneath of her the morning of [DATE], due to the lack of a process to track and record such. The interview continued and the DON explained on the morning of [DATE], the NA's had reported R13 was found on a bedpan which left redness on her skin. R13's skin was observed and the resulted pressure injuries were initially pink and blanchable, however, they quickly evolved and got worse by the following day. The administrator voiced they immediately placed interventions to mitigate any further harm and had the wound nurse observe R13's skin. They started an investigation into the incident, however, still to this day had not been able to substantiate anyone specifically who placed and forgot to remove the bedpan under R13 and, due to the lack of charting in the medical record, the investigation did not have much information to work off of. The DON voiced the last time they were aware she had been toileted or repositioned was on the evening shift of [DATE], and as a result, the bedpan could have been placed then and left underneath of her until it was found the morning afterwards (approximately nine to 17 hours later). They voiced a floor nurse, registered nurse (RN)-B, was the first person to observe R13's skin when the bedpan was removed. At 10:51 a.m. RN-B joined the interview and verified she was the nurse working when R13 had been found with a bedpan underneath of her on [DATE]. The staff removed the bedpan and RN-B explained R13's skin appeared inflamed which was in the shape of the bedpan. They proceeded to clean R13, apply a barrier cream to her skin and then reported it to the management team and physician. The administrator explained they had discovered through their investigation that the overnight shift had left her (R13) for the entirety of the night without any repositioning or assitance with toileting as, They didn't want to wake her up, and the staff thought she would call for help, if needed. The administrator then explained since the incident happened, they completed some education with the floor staff and provided the education roster and objectives for review which identified: An Education Topic sheet, dated [DATE], identified four bulleted points of information which were reviewed. These included R13's specific scenario; the initial admission assessment process and handoff; bed pan and/or urinal use including offering / removal of the device and communicating with the team members so they're aware of such; and, documentation and monitoring to include order entry and ensuring progress notes and incident reports are completed for skin concerns. The roster was signed by 15 staff members between [DATE] and [DATE]. However, the provided education lacked evidence employees had been trained on implementing assessed needs (i.e. one-hour repositioning), implementing the care plan, or any education on pressure ulcers including risk and interventions when medical devices are applied or used or someone is not repositioned in a timely manner. The interview continued and the administrator voiced the covered topics were done to help ensure clear communication amongst the floor staff; however, he verified they had not yet completed any education or guidance with staff on pressure ulcers, including the risk of them with use of other various medical devices (i.e. nasal cannula's, braces), or timely repositioning reinforcement. They all reiterated the focus was to immediately prevent R13's wounds from getting worse after they learned of the incident. When questioned on current monitoring to help ensure compliance with repositioning and toileting needs, the DON voiced the facility had been cited on their previous recertification survey, exited [DATE], for a lack of timely assistance with toileting and improper use of a medical device and, as a result, audits were still being completed. These were provided and reviewed which identified a total of five (5) audits were completed for timely repositioning on only three (3) different residents since R13's incident (on [DATE]) to present. On [DATE], at 1:01 p.m. wound nurse practitioner (NP)-A was interviewed and recalled R13 as being pretty dependent on staff for care. NP-A explained she had been asked to observe R13's skin after a bedpan was left underneath of her too long when the care staff kind of forgot about her on there. NP-A had observed R13's skin and voiced she recalled you could see the ring where the bedpan had been placed and expressed R13 developed the recorded pressure injuries to her sacral area as a result. NP-A estimated R13 had been left on the bedpan for a likely period of at least six to eight hours given the wounds which developed and verified the wound(s) were likely pressure induced and not related to R13's poor health (i.e. Kennedy Ulcer (a dark sore that develops rapidly during the final stages of life)). Further, NP-A explained despite R13 being at risk for skin breakdown the extent of the developed pressure injuries was likely very preventable had R13 been repositioned and not been left on a bedpan for such a long period. A provided Prevention of Pressure Ulcers/Injuries policy, dated [DATE], identified a purpose which read, . to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. The policy outlined the assessment process along with various methods to help prevent pressure injuries from forming; however, lacked any direction or guidance on the application of medical devices and how the facility would ensure placed devices are assessed and handled to prevent pressure injuries. However, a provided Bedpan/Urinal, Offering/Removing policy, dated ,[DATE], identified a General Guideline(s) which included, Do not allow the resident to sit on a bedpan for extended periods. This is not only uncomfortable to the resident, it also causes skin breakdown. The policy outlined a procedure on how to use such device, and an additional section outlined information which should be recorded in the medical record including date and time the device was offered, the amount of output, and how the resident tolerated the procedure. However, the policy lacked any direction or guidance on how to ensure placed bedpans were removed timely when used on cognitively impaired residents.

Based on observation, interview and document review, the facility failed to follow existing fall interventions and comprehensively assess falls to identify the root cause of the fall to assist in implementing appropriate, timely interventions for 1 of 2 residents (R24) reviewed for falls. This practice resulted in actual harm to R24. In addition, the facility failed to ensure a Wanderguard (personal tracking alarm) was functional for 1 of 1 residents (R75) reviewed for wandering and ensure smoking aprons were worn as assessed for 2 of 2 residents (R75, R27) reviewed for smoking. Findings include: FALLS: R24's annual Minimum Data Set ((MDS) dated [DATE], indicated R24 had severe cognitive impairment. The MDS identified R24 needed extensive assistance for bed mobility, transfers and ambulation. The MDS also identified [DIAGNOSES REDACTED]. The MDS indicated R24 had two or more falls without injury since the last assessment dated [DATE]. R24's fall Care Area Assessment (CAA) dated 4/28/17, identified R24 was at risk for falls due to being unsteady and not able to stabilize himself moving from seated to standing position, walking, turning around and facing the opposite direction while walking, moving on and off the toilet, and surface to surface transfer. The CAA also indicated R24 had falls since the last assessment and was also taking antianxiety medication. The CAA identified R24 was at risk for further falls and fall related injuries. A care plan was developed to avoid complications and minimize risks. R24's Fall Risk Evaluation dated 4/18/17, indicated R24 had multiple falls over the last 6 months and indicated R24 was a moderate risk for falls. R24's care plan revised on 3/8/17, identified R24 had a potential for falls/ accidents. Risk factors included the use of medications, pain, a fall in 6/14, which resulted in an intracranial hemorrhage, resulting in impaired mobility/cognition, impulsivity, and placing him at higher risk for falls. The care plan identified R24 had fallen several more times since the initial fall. Interventions included: bed in low position, fall mat on floor bedside, mobility monitors on R24's bed and chair, ensure they are on and working, anticipate needs, provide rest periods, keep call light within reach when in room, keep environment free of clutter, monitor vital signs weekly, and monitor for medication side effects. R24's undated Group D nursing assistant sheet indicated safety interventions for R24 were low bed, floor mat and sensor alarm. R24's progress note dated 3/3/17, at 3:00 a.m. indicated R24's alarm was going off down the South Hall by the scale. R24 was found on his left side with a skin tear to the top of the left hand and a pink area to the left forehead. The Minnesota Incident Report dated 3/3/17, at 3:00 a.m. identified a possible cause of the fall was anxiety as the resident was propelling himself constantly. No interventions for R24 were listed on the form. The Fall Scene Investigation dated 3/3/17, at 3:20 a.m. identified R24 was last seen at 2:45 a.m., however, the areas for last time toileted, positioned, and offered fluids was blank on the form. The Post Fall Investigation/ Plan signed 3/6/17, indicated R24 was last toileted at 12:45 a.m. and an intervention added for staff to fold the scale when not in use. The rest of the form was blank. Although an intervention of folding the scale was implemented, it did not address R24's anxiety or initiate an intervention related to R24's anxiety. R24's progress note dated 5/4/17, at 2:00 a.m. indicated R24 had a fall from from his bed and was found lying on his right side on his floor mat between his night stand and his bed. R24 received an injury of two skin tears. The right elbow skin tear measured 2 centimeters (cm) x 0.5 cm. The right shoulder skin tear measured 3 cm x 0.5 cm. The fall investigation dated 5/3/17, indicated R24 had no environmental factors, no predisposing physiological factors, had dementia, and ambulating/transferring without assist with improper/no footwear. No predisposing factors were identified. Immediate action taken was first aid to the skin tears and due to the resident's continued restlessness, staff assisted him to his wheelchair. The Incident Review and Analysis dated 5/5/17, identified potential causative factors as unknown. Interventions added were to remove the over the bed table, and move the night stand away from the bed. Although interventions were added to reduce the chance of injury, it did not address a potential cause or an intervention to minimize the risk of a subsequent fall. R24's progress note dated 5/11/17, at 3:13 a.m. indicated R24's bed alarm went off in R24's room at 1:20 a.m. Staff found R24 lying on his stomach on the floor in a pool of blood, coming from a head laceration. R24 left with the paramedics at 1:55 a.m. There was no fall investigation. The Incident Review and Analysis dated 5/15/17, identified potential causative factors as resident attempting to get out of bed, unable to state why, but suspect toileting needs. Intervention added was to toilet on first night rounds. R24's 5/11/17, emergency room discharge report indicated he received seven sutures to a head laceration from his fall. This fall was similar to the fall on 5/3/17, however, the progress note did not indicate R24 was found on his fall mat or if the fall mat was in place at the time of the fall. There was no investigation completed to determine the details of the fall and minimize potential risk of further falls. During observation on 5/30/17, at 2:34 p.m. R24 was seated in his wheelchair wearing yellow Crocs sandals that did not have a strap behind the ankle. During observation on 5/31/17, at 7:37 p.m. R24 was lying in bed without a fall mat on the floor by the bedside. A pair of faded yellow Crocs sandals were on the floor. The bottom of the sandals were worn, as there was little tread remaining on the bottom of either sandal. During interview on 5/31/17, at 7:56 p.m. nursing assistant (NA)-H stated the fall mat was not on the floor as directed. NA-H looked for the fall mat and could not locate it. NA-H stated the only shoes R24 wore were the yellow Crocs sandals. NA-H also stated that when R24 was propelling his wheelchair with his feet his Crocs sandals often fell off. NA-H then left the room and went to help another resident. No floor mat was put by R24's bedside. During interview on 5/31/17, at 8:06 p.m. trained medication aid (TMA)-A stated a fall mat was to be on the floor next to R24's bed. TMA-A stated the fall mat was not at the bedside on the floor. TMA-A found the fall mat behind R24's door and placed it on the floor near R24's bed. TMA-A observed R24's sandals and stated they were worn. TMA-A further stated, I don't like them (Crocs sandals), dumbest thing for an elderly man to wear. During interview on 6/1/17, at 1:12 p.m. licensed practical nurse (LPN)-A stated an intervention is initiated right away following a fall if we know the source of the fall. LPN-A stated there was not a falls committee to her knowledge, but falls were reviewed at stand up meetings Monday through Friday. LPN-A stated R24 usually had gripper socks on or the yellow Crocs sandals. LPN-A observed the Crocs sandals and stated there was no tread on the bottom of the sandals, I think we need to take those away, I'm going to take those out. LPN-A then removed the sandals from R24's room. During observation on 6/1/17, at 2:52 p.m. the scale at the end of the South hallway was unfolded and not in use. During interview on 6/2/17, at 8:10 a.m. LPN-C stated interventions are not routinely being put into place following a fall. LPN-C further stated there were too many people falling and hitting their heads and no one is doing anything about it. LPN-C stated she communicated this to the supervisors, but they just blow it off. LPN-C stated there were so many new nurses here that don't know what they are doing. LPN-C further stated the facility did not try to determine the cause of a fall or implement appropriate interventions to prevent future falls. LPN-C stated R24 can walk with assistance and many times she over hears the staff say just sit down, and no one offered to take him for a walk. LPN-C stated falls, definitely need to be taken more seriously. During observation on 6/2/17, at 8:31 a.m. the scale at the end of the South Hall was again unfolded and was not in use. R24 was self propelling himself in his wheelchair wearing gripper socks up and down the South Hall. During interview on 6/2/17, at 9:26 a.m. registered nurse (RN)-A reviewed R24's falls and stated on 5/3/17, a causative factor was not identified following the fall and the intervention put into place did not prevent future falls. RN-A stated the fall on 5/11/17, was similar to the fall on 5/3/17, and was not sure if a bladder assessment had been initiated. RN-A further stated a comprehensive fall assessment was only completed with the MDS assessments. RN-A further stated that an interdisciplinary team (IDT) was supposed to meet every morning for stand up meeting on business days, but stated the IDT is struggling with consistency of meetings at this time. During interview on 6/2/17, at 9:37 a.m. NA-D stated the scale at the end of the South Hall was supposed to be folded up when not in use. NA-D also stated it was left in the down position most of the time. During interview on 6/2/17, at 10:33 a.m. the director of nursing (DON) stated the fall process had changed since switching management companies a few months ago. When a resident falls the nurse is supposed to document the fall in the progress notes and fill out an investigation form in risk management. The DON stated the nurses should be putting an immediate intervention into place to try and prevent further falls and not just assessing and treating the immediate injuries. DON stated the IDT review had been bumpy and had not consistently been reviewing falls the following business day. DON stated she completed the Incident Review and Analysis following the IDT review of the fall. DON stated R24's fall on 5/3/17, happened on a Wednesday and the IDT did not review the incident until 5/5/17, on a Friday and stated a potential cause was not identified on the form, but thought it could be due to not sleeping and trazodone (antidepressant) was started on 5/9/17. DON stated after looking in risk management, a fall investigation was not completed following the fall on 5/11/17. DON further stated by reading the progress note dated 5/11/17, it was not clear if the fall mat was on the floor at the time of the fall on 5/11/17. DON stated she expected all fall interventions to be followed. DON stated following the fall on 5/11/17, she added an intervention for R24 to be toileted on the first night shift rounds, but did not complete a bladder assessment to identify if toileting times was a potential cause of the fall. DON stated R24's shoes had never been evaluated for safety and stated the shoes had been removed on 6/1/17, and family was contacted. DON further stated when reviewing falls at the IDT meetings, the fall investigation was not always looked at to try and determine the cause of the fall to put effective interventions into place. DON further stated falls can not be effectively evaluated without looking at a complete investigation. DON further stated she was aware of incomplete documentation and lack of interventions following a fall for resident's at the facility and she developed a plan in quality assurance to fix the situation, however; had not had the opportunity to train the nurses on the complete documentation and lack of interventions immediately following a fall. A facility policy Falls-Clinical Protocol dated 5/13, directed staff to, For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall . If underlying causes cannot be readily identified, or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try and get up and walk without waiting for assistance). WANDERGUARD MONITORING: R75's admission MDS dated [DATE], identified R75 had moderate cognitive impairment and wandering behavior that placed R75 at risk of getting to a potentially dangerous place. R75's care plan dated 2/15/17, indicated R75 was at risk for elopement related to attempts of leaving the facility and wandering. R75's goals were to have no incidence of elopement and remain safe during placement at the facility. Further, the care plan indicated an intervention of, Wanderguard placed. Review of the medical record revealed no elopement attempts since 2/17. R75's Treatment Administration Records (TAR's) were reviewed from 2/1/17,-5/31/17. The TAR's lacked any order or documentation to check R75's Wanderguard for placement or function until 5/31/17, when the nursing order was written to, Check function of wanderguard daily, and Check wanderguard every shift for placement and skin concerns. During observation on 5/31/17, at 1:33 p.m. R75 was outside on the smoking patio having a cigarette. R75 did not have a Wanderguard on. When observed on 5/31/17, at 7:17 p.m. R75 was lying in his bed on top of the blankets, fully clothed. He was watching television. R75 did not have a Wanderguard on. The Wanderguard was located on his bedside table, however; the band on the Wanderguard was broken. During interview on 5/31/17, at 7:18 p.m. R75 stated he used to wear a Wanderguard on his wrist, but the band on the Wanderguard broke about three weeks ago. R75 stated he told the staff the band was broken on the Wanderguard, but no one had fixed it or given him a new Wanderguard. R75 stated sometimes he kept the Wanderguard in his pants pocket and sometimes in his coat pocket, but not always. When interviewed on 5/31/17, at 7:26 p.m. TMA-A stated R75 wore a Wanderguard and it would sound an alarm if he attempted to go outside. At 7:30 p.m. surveyor and TMA-A went to R75's room together and R75's Wanderguard was sitting on his bedside table. The band on the Wanderguard was broken. TMA-A looked at R75's Wanderguard on his bedside table and stated R75 should have it attached to his body and not sitting on the bedside table. During interview on 5/31/17, at 7:33 p.m. the DON stated she would go and look at R75's Wanderguard. Together, the surveyor and the DON looked at R75's Wanderguard that was broken on his bedside table. The DON took the Wanderguard, replaced the band and placed the Wanderguard on R75's right wrist. The DON stated it was on the TAR for staff to check placement of R75's Wanderguard every shift. When interviewed on 6/1/17, at 7:54 a.m. NA-K stated R75 was an elopement risk and wore a Wanderguard located on his wheelchair. She stated she was not aware if any staff checked the placement or checked to see if R75's Wanderguard was working. NA-K stated she did not know how to check if a Wanderguard was working, adding, That is a good question. During interview on 6/1/17, at 8:04 a.m. NA-J stated R75 did not wear a Wanderguard. NA-J stated staff do not check to see if a resident wears a Wanderguard, adding staff was just aware of which residents wandered. When interviewed on 6/1/17, at 8:35 a.m. LPN-A stated R75 wore a Wanderguard on his left ankle and it was checked every shift to make sure it was on and the nurses documented in the resident's medication administration record. LPN-A stated the night shift staff checked the function of the Wanderguard. LPN-A stated the order for checking R75's Wanderguard had just got entered on 5/31/17, and prior to 5/31/17, no one was checking the placement or function of R75's Wanderguard. When informed the Wanderguard was on his right wrist, LPN-A stated she was not aware of that and thought it was located on his ankle. A facility Code Alert Wandering Monitor System policy dated 8/2013, indicated on a weekly basis each transmitter in use would be tested by the nurse of each resident who wore the transmitter unit. The alarm and transmitter would be tested by taking the resident through the alarmed doors and document appropriately in the resident's medical record. The policy also indicated the wrist or ankle band would be checked on a weekly basis for wear and tear, and replaced as necessary. This would be documented in the resident's medical record. SMOKING: R75's admission MDS dated [DATE], identified R75 had moderate cognitive impairment, required limited assistance with activities of daily living (ADLs) and did not use any tobacco products. R75's undated [DIAGNOSES REDACTED]. R75's care plan dated 3/22/17, identified a focus area of, Resident currently smokes at this facility, and listed a goal for R75 of, Resident will smoke safely. The care plan listed interventions which included, Independent with smoking per evaluation and Smoking apron per evaluation. R75's Smoking Evaluation dated 3/10/17, indicated R75 had cognitive loss and a visual deficit and smoked two to five times per day. The evaluation identified R75 required adaptive equipment which included a Smoking apron. The smoking evaluation summary and interventions indicated R75 was able to safely get himself outside, light his own cigarette, and properly dispose of his cigarette. R75 was accepting of wearing a smoking apron and accepting of facility smoking times. The smoking policy and times were also reviewed with R75 and his significant other and they agreed to them. During interview on 5/30/17, at 1:32 p.m. R75 stated he went outside four times a day to smoke and there were specific times of the day posted by the nurse's station of when he could go out to smoke. He also stated the staff gave him his cigarettes when it was time to go out to smoke. During observation on 5/30/17, at 1:32 p.m. R75 went outside to the smoking patio in his wheelchair. He had a smoking apron on his lap, but the smoking apron was not opened. The apron remained folded on his lap the entire time he was outside smoking. R75 was able to light his cigarette by himself, ash safely, and extinguish his cigarette without difficulty. However, the entire time R75 was smoking, the safety apron remained folded on his lap. There was no staff supervising R75 while he smoked. When observed on 5/31/17, at 1:28 p.m. R75 was sitting by the nurse's station requesting his cigarettes. Staff handed him two cigarettes, his lighter, and a smoking apron. R75 propelled himself outside to the smoking patio. The smoking apron remained folded on his lap. At 1:31 p.m. NA-L went outside to the smoking patio and told R75 he must have his apron on to be outside smoking. NA-L placed the smoking apron on R75 and then went back inside the facility. On 5/31/17, at 1:33 p.m. R75 stated sometimes he wore the smoking apron and sometimes he did not, depending on how he felt. R75 stated he typically just placed the smoking apron on his lap. On 5/31/17, at 7:23 p.m. NA-H stated R75 was a smoker and he went outside to smoke. She further stated R75 had to wear a smoking apron when he was smoking and she did not believe R75 needed a staff member to be outside with R75 when he smoked. During interview on 5/31/17, at 7:26 p.m. TMA-A stated R75 was a smoker. She further stated residents that smoke were evaluated to be safe smoking and if the resident was able to light, ash, and extinguish safely, the resident was allowed to smoke. TMA-A also stated for extra safety, residents had to wear a smoking apron. When interviewed on 5/31/17, at 7:44 p.m. the DON stated R75 was a smoker and R75 was asked to wear a smoking apron when he went outside to smoke. The DON further stated R75 usually just set the smoking apron on his lap when he smoked. DON added, if R75's smoking assessment indicated R75 was supposed to be wearing a smoking apron, then he should have been wearing it. During interview on 6/1/17, at 8:35 a.m. licensed practical nurse (LPN)-A stated R75 had to wear an apron when he smoked per his smoking evaluation. LPN-A stated R75 should be wearing the smoking apron over his neck so it covered his chest and body and not just be folded on his lap. LPN-A also added R75 often just placed it on his lap. This could potentially be a problem. R27's admission MDS dated [DATE], identified R27 had moderate cognitive impairment and currently used tobacco products. R27's most recent Smoking Evaluation Form dated 5/25/17, identified R27 had no cognitive loss and was alert and orientated. The evaluation identified R27 had no visual deficits which could interfere with his ability to smoke safely, however, listed a question, Can the resident safely utilize lighter/matches? This was answered as, No, by the evaluator. Further, the evaluation identified R27 was determined to be able to smoke independently and listed, Facility specific interventions including need for adaptive equipment, with a written, X placed next to, Smoking apron (device covering skin and clothes to prevent burns from dropped ashes). R27's care plan dated 4/20/17, identified R27 to be currently smoking while at the nursing home with a goal listed of, Resident will smoke safely. Further, the care plan listed interventions including, Use walker while going outside to smoke, and, Smoking apron per evaluation. During observation on 5/30/17, at 1:34 p.m. R27 came to the nursing station and was provided a folded up gray colored smoking apron, lighter and three single cigarettes from licensed practical nurse (LPN)-E. R27 ambulated outside using his walker and sat in a chair on the patio. R27 placed the folded up smoking apron on the table outside and proceeded to light his cigarette(s) and smoke them. R27 did not drop any ashes and had no burn holes visible in his clothing. R27 stated the staff was aware he was not wearing the provided smoking apron but had, never questioned it. During interview on 6/1/17, at 8:52 a.m. NA-D stated R27 went outside to smoke several times during her shift at the designated, smoke times. NA-D stated R27 took the smoking apron outside with him and staff only assisted him with it if he wanted it as, That's up to him. NA-D stated use of the smoking apron was, Highly recommended, though to reduce the risk of burns. NA-D stated she had never been directed to monitor R27 when he is outside smoking. When interviewed on 6/1/17, at 12:16 p.m. the assistant director of nursing (ADON) stated R27 should be using the smoking apron as directed by his most recent evaluation. A facility Resident Smoking Policy dated 6/14, indicated residents that required supervision and/or assistance with smoking would be evaluated for need of adaptive equipment (i.e., flame retardant apron, cigarette extension holder). Any resident who did not comply with this policy would lose independent smoking privileges, until re-evaluated and determined to be safe to smoke independently.

Based on observation, interview and document review, the facility failed to comprehensively assess pressure ulcer risk, implement interventions and conduct weekly skin monitoring for 1 of 3 residents (R18), who developed multiple pressure ulcers after admission, resulting in actual harm. In addition, the facility failed to consistently monitor pressure ulcer characteristics for 1 of 3 residents (R44) reviewed who had a current pressure ulcer. Findings include: R18's Admission Record indicated R18 admitted to the facility on [DATE]. R18's [DIAGNOSES REDACTED]. R18 was discharged from the facility with home care on 3/31/17. R18's hospital discharge summary dated 3/15/17, indicated R18's skin was intact other than surgical wounds covered with dressings. R18's Admit/Initial Data Collection dated 3/15/17, identified 18 separate skin impairment sites as follows: right antecubital, left antecubital, right elbow, left elbow, right thigh front, left thigh front, left knee front, right knee rear, right lower leg front, left lower leg front, right lower leg rear, left lower leg rear, right ankle inner, left ankle inner listed twice, right ankle outer listed twice, and left ankle outer. The assessment did not identify the type of skin impairment and lacked any measurements. The assessment did not address any area of concern to either of R18's heels. R18's Tissue Tolerance Observation (assessment to determine specific pressure to an area over the course of a specified time) dated 3/16/17, indicated a lying repositioning schedule of every two hours, however; the assessment did not determine R18's heel pressure as a post surgical resident. The observation did not include a sitting recommendation for repositioning. R18's Braden Scale (assessment to identify pressure ulcer risk) dated 3/20/17, was not completed, the assessment was blank. R18's undated Initial Care Plan (temporary care plan) for skin integrity did not include interventions to minimize pressure ulcer risk. The care plan for mobility/safety directed staff to assist with transfers, assist with bed mobility, and turn and reposition or reminders to offload every two hours and as needed. R18's admission Minimum Data Set ((MDS) dated [DATE], did not identify R18's cognitive status. The MDS indicated R18 needed extensive assistance with bed mobility and transfers. The MDS identified R18 was at risk to develop pressure ulcers and currently did not have pressure ulcers. The MDS included pressure relieving interventions of a pressure reducing device in bed and a pressure reducing device in the chair. The MDS did not identify a turn and reposition schedule for R18. The MDS further identified use of a diuretic (medication to control fluid). R18's pressure ulcer Care Area Assessment (CAA) dated 3/28/17, indicated R18 was at risk to develop pressure ulcers related to a need for extensive assistance with bed mobility and frequent bladder and bowel incontinence. R18 admitted to the facility with surgical incisions with staples to the right hip. R18 had no history of pressure ulcers and no current pressure ulcers. The CAA directed staff to refer to the admission skin assessment and weekly skin assessment. Interventions in place included a pressure reduction mattress and wheelchair cushion. Staff was to assist with turning and repositioning. R18's Skin Evaluation dated 3/29/17, indicated a Stage 1 pressure ulcer (intact skin with non-blanchable redness of a localized area usually over a bony prominence) on the right heel measuring 2 centimeters (cm) x 2 cm. Staff identified the area as a blister. The assessment also identified a Stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) to the left heel measuring 2 cm x 1 cm x 0.3 cm. The assessment did not include any further description of the pressure ulcers, interventions, physician notification or treatment initiated. There was no evidence a Skin Evaluation was completed the previous week on 3/22/17, as the treatment sheet directed, although it was initiated as completed. There was no indication of characteristics or interventions identified as part of the assessment. R18's progress notes dated 3/29/17, through discharge on 3/31/17, did not include evidence the physician was notified of the development of two Stage 2 pressure ulcers, nor did the notes identify implementation of interventions or treatments. R18's Doctor Order Sheet dated 3/29/17, did not indicate the physician was notified of the two Stage 2 pressure ulcers. The order included an order to discharge home with home care, but did not include orders to treat pressure ulcers. On 6/1/17, at 12:05 p.m. the licensed dietician (LD)-A stated she had completed R18's Nutritional Assessment on 3/23/17, and reviewed R18's hospital discharge summary, progress notes and nursing assessments, which did not identify any pressure ulcers. LD-A stated she had completed her assessment prior to the skin assessment on 3/29/17, identifying the pressure ulcers. LD-A further stated she was not notified of the pressure ulcers and would expect to be, so protein needs could be re-evaluated and appropriate interventions implemented to promote healing. During interview on 6/2/17, at 8:23 a.m. licensed practical nurse (LPN)-C stated a full skin assessment was required to be completed within 24 hours of admission and then weekly after that. LPN-C stated a skin assessment form was required weekly and it was not acceptable to just initial off on the treatment sheet. LPN-C stated the treatment sheet was a reminder to complete the assessment. LPN-C further stated the Braden assessments were completed by the registered nurse who did the MDS assessment. LPN-C stated if a new pressure area was identified, a treatment would be initiated, along with notifying the physician, family and director of nursing. LPN-C stated the floor nurse admitting the resident was responsible to fill out all areas of the temporary care plan. On 6/2/17, at 9:20 a.m. registered nurse (RN)-A looked at the initial care plan and stated the skin risk area did not have any interventions. RN-A then reviewed the 3/20/17, Braden assessment and stated it was blank and had not been completed. RN-A stated the floor nurses were responsible for completing the Braden along with the temporary care plan. RN-A stated when she has time she would assist the nurses with assessments. RN-A further stated the weekly skin assessments were to be documented on the form in the electronic medical record (EMR). RN-A reviewed the 3/29/17, skin assessment and stated it indicated R18 developed two Stage 2 pressure ulcers on her heels. RN-A stated the physician should have been updated along with the managers to ensure treatments were appropriate and the cause of the pressure ulcers could be investigated. RN-A stated she did not visually inspect R18's skin when completing the MDS and relied on nursing documentation in the electronic medical record to do her assessment. On 6/2/17, at 9:41 a.m. RN-B stated she was not told R18 had developed two Stage 2 pressure ulcers on her heels. RN-B stated the initial care plan needed to be completed within 24 hours of admission and should have included a skin integrity plan with interventions to prevent pressure ulcers. RN-B stated the MDS nurse was responsible for completing the Braden assessment and the floor nurses were required to complete a full skin audit weekly and document the findings on a form. RN-B further stated the MDS nurse should have noticed the assessments were not completed when doing the MDS assessments and should have told a supervisor. During interview on 6/2/17, at 10:24 a.m. the director of nursing (DON) stated she had identified assessments and care plans for skin were an issue and had started re training staff the previous week. The DON further stated her expectations were timely and complete assessments along with completed temporary care plans. DON stated R18 developing two Stage 2 pressures ulcers after admission was a concern. On 6/2/17, at 11:31 a.m. a telephone message was left for R18's physician. On 6/5/17, at 1:38 p.m., via telephone, R18's physician stated R18 did not have pressure ulcers upon admission to the facility and she was not made aware R18 had developed two Stage 2 pressure ulcers after admission. The physician stated she expected the facility to implement interventions to prevent pressure ulcer and would expect to be notified when a resident developed pressure ulcers in order to provide appropriate treatment. This resulted in actual harm for R18. Although, the facility implemented a pressure reducing mattress and cushion when R18 admitted to the facility on [DATE], following a right [MEDICAL CONDITION]. The facility failed to comprehensively assess and address R18's risk of pressure ulcer development on her heels, implement interventions to prevent pressure ulcer development, and monitor R18's skin on a weekly basis. As a result, R18 developed two Stage 2 pressures ulcers on their bilateral heels, 14 days following admission to the nursing home which resulted in actual harm for R18. The undated facility Wound Process Checklist directed staff to 1. Notify MD/Treatment as ordered. 2. Notified family and/or responsible party. 3. Education completed with resident and family/ responsible party including review of risks and benefits. 4. Start weekly wound documentation form. 5. Notify nurse manager/ wound nurse. 6. Complete new tissue tolerance audit. 7. Complete new tissue tolerance evaluation. 8. Refer to dietary. 9. Refer to therapies. 10. Refer to interdisciplinary team members as appropriate. 11. Update care plan 12. Update nursing assignment care list. 13. Communicate in report. R44's annual Minimum Data Set ((MDS) dated [DATE], identified R44 had moderate cognitive impairment, required extensive assistance with activities of daily living (ADLs), had a current stage III (described as full thickness tissue loss) pressure ulcer and remained at risk for pressure ulcer development. R44's care plan dated 5/8/17, identified R44 had a pressure ulcer due to bowel and bladder incontinence and limited mobility. The care plan identified R44 had a current stage III pressure ulcer on his buttock and directed staff to complete, Weekly wound assessment, and, Conduct weekly skin inspection. During observation on 6/2/17, at 9:57 a.m. licensed practical nurse (LPN)-C set up supplies in R44's room to change his pressure ulcer dressing. R44 was in bed on an air mattress, positioned on his left side. LPN-C removed a foam dressing from R44's coccyx exposing a visible pressure ulcer. The removed dressing had no visible drainage present. R44's pressure ulcer appeared to be approximately 2 cm (centimeters) by 1 cm in size. The wound lacked any odor. LPN-C stated she did not routinely measure the ulcer with dressing changes as, That's only scheduled or whatever. LPN-C sprayed R44's wound using a saline wound cleanser; however, R44 became resistive to the procedure and the dressing change was ceased. LPN-C completed no measurements of R44's pressure ulcer. When interviewed on 6/2/17, at 10:26 a.m. LPN-C stated she was unaware who was assigned or responsible to measure and document characteristics of pressure ulcers. LPN-C stated floor staff only measure the pressure ulcer if directed to by the treatment administration record (TAR). Further, LPN-C stated R44's pressure ulcer, Looked pretty good, today compared to when she last observed it. R44's Treatment Administration Record (TAR) dated 4/25/17, to 5/30/17, directed staff, Complete Weekly wound evaluation (Monarch Health Management (MHM) Weekly Wound Evaluation) under forms tab for coccyx wound. This was scheduled to be completed on a weekly basis on 4/26/17, 5/3/17, 5/10/17, 5/17/17, 5/24/17 and 5/31/17. However, on 5/3/17, the entry was recorded as, Absent from home, and on 5/10/17, the entry was recorded as, Drug refused. Further, on 5/17/17, the entry was recorded as, Other / See Nurses Notes. R44's MHM Weekly Wound Evaluation dated 4/30/17, identified R44 had a stage III pressure ulcer on his coccyx. The ulcer was measured as 2 cm (centimeters; length) X (by) 0.1 cm (width) X 0.3 cm (depth) in size with 100% granulation tissue (red tissue indicative of healing) in the wound bed. The ulcer had no drainage or odor present. Further, the evaluation included a section labeled, Summary, with, No new changes. Continues to go to wound clinic every 2 weeks. R44's MHM Weekly Wound Evaluation dated 5/1/17, (one day after previous evaluation), identified R44 had a stage III pressure ulcer on his coccyx. The ulcer was measured as 2 cm (length) X 0.2 cm (width) X 0.3 cm (depth) in size with 100% granulation tissue (red tissue indicative of healing) in the wound bed. The ulcer was identified to have, Scant drainage now present with no odor present. Further, the evaluation again included a section labeled, Summary, with, NA (not applicable) - Does go to wound clinic 5/3/17. R44's subsequent MHM Weekly Wound Evaluation dated 5/19/17, (18 days after last evaluation), identified R44 now had an, Unstageable (known wound but unable to visualize the wound bed) ulcer on his coccyx. The ulcer was measured as 2.3 cm (length) X 0.3 cm (width) X 0.4 cm (depth) in size. A, Further description of the wound, section was left blank with no amount of or type of drainage being selected, along with no dictation of any odor being selected. The only selected option was, Wound Edges, which were identified as, Intact. Further, the evaluation again included a section labeled, Summary, however, this section was left blank. R44's most recent MHM Weekly Wound Evaluation dated 5/30/17, (10 days after previous evaluation), identified R44 had a stage III pressure ulcer on his coccyx. The ulcer was measured as 1.8 cm (length) X 0.3 cm (width) X 0.4 cm (depth) in size with 50% granulation tissue and 25% slough (dead tissue typically white or yellow in color) in the wound bed. The ulcer was identified to have no drainage or odor present. Further, the section labeled, Summary, identified, No changes to care plan at this time. Wound has had some improvement. R44's medical record was reviewed. There was no additional documentation identified to demonstrate R44's pressure ulcer and associated characteristics had been consistently monitored on a routine basis to ensure appropriate monitoring for healing and need for treatment/intervention changes. R44's Ridgeview Medical Center Wound & Hyperbaric Healing Center sheets identified he had been seen for treatment and evaluation of his pressure ulcer on 4/19/17, 5/3/17, and 5/17/17. However, none of the provided notes from the center identified any measurements or characteristics of the wound. The most recent visit on 5/17/17, only identified the pressure ulcer to be, Sl (slightly) less deep, and provided dressing change orders. When interviewed on 6/2/17, at 11:35 a.m. the director of nursing (DON) stated the floor nurses were responsible to measure and document R44's pressure ulcer on a weekly basis using the MHM Weekly Wound Evaluation form(s) in the electronic medical record. The DON reviewed R44's medical record and stated his pressure ulcer had not been tracked weekly, but should have been, for continued monitoring to ensure the wound is healing, and R44's, Treatment (was) still effective. A facility Weekly Charting Wound Ulcer Documentation policy dated 9/11, identified a purpose which included, .the following components should be a part of your weekly (underlined) charting, and listed several components including the stage of the pressure ulcer, dimensions of the ulcer, and if undermining and/or tunneling is present.