Every finding on record at The Estates at Twin Rivers LLC

Based on observation, interview, and document review, the facility failed to ensure a resident's dignity was maintained when a nephrostomy drainage bag (collection pouch that gathers urine directly from a tube surgically placed in the kidney) was left uncovered and visible from the hallway for 1 of 1 resident (R5) reviewed for dignity.Findings include:R5's quarterly Minimum Data Set (MDS), dated [DATE], identified R5 had moderate cognitive impairment, required assistance with activities of daily living (ADLs), and diagnoses included multiple sclerosis (a disease affecting the brain and spinal cord causing weakness and decreased physical function), and neurogenic bladder (loss of bladder control due to a nerve problem). The MDS further identified R5 had an indwelling catheter.R5's care plan, dated 6/1/26, identified R5 was incontinent of bowel and bladder related to multiple sclerosis and decreased mobility. The care plan identified R5 had a left nephrostomy tube due to kidney stones and a Foley catheter. The care plan directed staff to provide incontinence care, monitor for signs and symptoms of a UTI, empty the left nephrostomy as ordered, and ensure R5 was appropriately covered and dignity was provided.During an observation on 7/1/26 at 12:42 p.m., R5 was seated in a Broda wheelchair in his room with the door open to the hallway. R5's nephrostomy drainage bag was hanging uncovered from the left armrest of the chair. The uncovered nephrostomy drainage bag was visible from the hallway to anyone who walked by R5's room.During an observation and interview on 7/1/26 at 12:47 p.m., trained medication aide (TMA)-A entered R5's room with R5's meal tray. TMA-A stated the nephrostomy drainage bag was usually hung on the armrest of R5's wheelchair.During an interview on 7/1/26 at 1:08 p.m., the registered nurse case manager (RNCM) and director of nursing (DON) confirmed R5's nephrostomy drainage bag was not covered and was visible from the hallway. The RNCM and DON stated the nephrostomy drainage bag should have been covered because the uncovered bag was a dignity concern.The facility's Combined Federal and State [NAME] of Rights policy, dated 11/28/16, identified residents had the right to a dignified existence. The policy indicated the facility must treat each resident with respect and dignity and provide care in a manner and environment that promoted maintenance or enhancement of the resident's quality of life, recognized each resident's individuality, and protected and promoted resident rights.

Based on observation, interview, and document review, the facility failed to maintain resident equipment in a clean and sanitary manner for 1 of 1 resident (R14) reviewed for a safe, clean, comfortable, and homelike environment.Findings include:R14's quarterly Minimum Data Set (MDS), dated [DATE], identified R14 had severe cognitive impairment, required assistance with activities of daily living (ADLs), and diagnoses included stroke, hemiplegia, and dementia. During an observation on 6/29/26 at 1:23 p.m., R14's wheelchair was visibly soiled and the wheelchair frame had an accumulation of dirt and debris. The back of the wheelchair, behind the seat, had a buildup of dirt and debris. The wheelchair seat had a brown substance adhered to the edge of the seat, and food remnants were observed on the seat.During an observation on 6/30/26 at 9:33 a.m., R14 was lying in bed, and R14's wheelchair remained visibly soiled with previously identified dirt and debris.During an observation on 6/30/26 at 4:51 p.m., R14 was lying in bed, and R14's wheelchair remained visibly soiled with accumulated dirt and debris.During an observation on 7/1/26 at 9:33 a.m., R14 was seated in the wheelchair in R14's room. R14's wheelchair remained visibly soiled with accumulated dirt and debris.During an observation on 7/2/26 at 8:24 a.m., R14 was seated in the wheelchair in R14's room. R14's wheelchair remained visibly soiled with accumulated dirt and debris.During an interview on 7/2/26 at 12:08 p.m., nursing assistant (NA)-A stated night shift staff were responsible for cleaning resident wheelchairs when the wheelchairs were identified as dirty.During an interview on 7/2/26 at 1:24 p.m., the registered nurse case manager (RNCM) and director of nursing (DON) confirmed R14's wheelchair was visibly soiled with debris present on the wheelchair frame and seat. RNCM and DON stated the condition of the wheelchair was a concern and created an infection control concern. RNCM and DON stated nursing assistants were responsible for cleaning resident wheelchairs. RNCM and DON further stated wheelchairs should have been cleaned by night shift when residents were out of the chairs, and cleaned weekly during residents' scheduled showers.The facility's Wheelchair Cleaning Policy, undated, identified the purpose of the policy was to maintain a clean, safe, and homelike environment by ensuring wheelchairs were cleaned regularly. The policy directed staff to clean wheelchairs with mild detergent and water prior to disinfecting when wheelchairs were visibly soiled. The policy further directed staff to clean and disinfect all areas, including push handles, seat and backrest, armrests, footrests, leg rests, seat belts/straps, hand rims, brakes, wheelchair frames, cushions, and all high-touch surfaces. The policy indicated deep cleaning of wheelchairs was to be completed by night shift on residents' bath days and identified all staff were responsible for cleaning and disinfecting wheelchairs immediately when visibly soiled.

Based on interview and document review, the facility failed to ensure a psychotropic medication prescribed on an as-needed (PRN) basis was limited to 14 days, or had documentation from the prescribing practitioner with a rationale for continued use beyond 14 days, for 1 of 5 residents (R19) reviewed for unnecessary medications.Findings include:R19's significant change in status Minimum Data Set (MDS), dated [DATE], identified R19 had moderately impaired cognition and diagnoses included depression and chronic pain. The MDS further identified R19 received antianxiety and opioid (pain medication) medications.R19's care plan, dated 6/26/26, identified R19 was at risk for psychotropic medication adverse drug reactions (ADRs) related to the use of psychotropic medications and/or other medications used to treat a psychotropic indication. The care plan goal indicated R19 would not experience ADRs related to the current psychotropic medication regimen. Interventions directed staff to administer medications as ordered, monitor target behaviors and ADRs, report suspected ADRs to the medical provider, ensure medications were reviewed by the medical provider and pharmacist, and update the medical provider regarding medication effectiveness and/or ADRs as needed.R19's physician orders, dated 6/29/26, included an order initiated on 5/21/26 for lorazepam solutab (an antianxiety psychotropic medication) 0.5 milligrams (mg) by mouth every four hours as needed (PRN) for anxiety/restlessness. The order lacked a stop date and allowed the PRN psychotropic medication to remain available for use beyond 14 days. However, R19's electronic health record (EHR) lacked documentation the prescribing practitioner documented a clinical rationale for continued use of PRN lorazepam beyond 14 days.During an interview on 7/2/26 at 1:24 p.m., the registered nurse case manager (RNCM) and Director of Nursing (DON) reviewed R19's medical record and confirmed R19's PRN lorazepam order lacked a 14-day stop date. The RNCM and DON stated PRN psychotropic medications required a 14-day stop date unless the resident was receiving hospice services and the provider specified the duration. The RNCM stated the order should have been clarified with the provider. The RNCM and DON stated monitoring PRN psychotropic medications was important due to the potential for adverse side effects, and PRN use should not be prolonged without review. The RNCM and DON stated staff needed to monitor medication use, communicate with the provider, and evaluate if medication changes were needed based on the resident's continued use.A facility policy related to psychotropic medication use and PRN psychotropic medication duration requirements was requested; however, the facility did not provide a policy prior to the end of the survey.

Based on observation, interview, and document review, the facility failed to provide grooming assistance according to a resident's assessed needs and preferences for 1 of 1 resident (R8) reviewed for activities of daily living (ADL) care.Findings include:R8's quarterly Minimum Data Set (MDS), dated [DATE], identified R8 had severe cognitive impairment, required staff assistance with activities of daily living (ADLs), and diagnoses included stroke, dementia, and hemiplegia (weakness or paralysis affecting one side of the body).R8's care plan, printed 6/30/26, identified R8 had a self-care deficit related to weakness and dementia. The care plan identified R8 had a history of being combative with cares, yelled out instead of using the call light, and would be dressed, groomed, and bathed according to his preferences. Interventions directed staff to re-approach R8 if cares or treatments were refused, respect R8's choices, and document refusals. The care plan further identified R8 required assistance of one staff member with grooming and identified R8's shaving preference was to be shaved daily.A Vulnerable Adult Maltreatment Report, dated 12/8/25, identified family member (FM)-A reported R8's beard trimming had not occurred.During observation on 6/30/26 at 4:05 p.m., R8 was lying in bed with a full beard of approximately one to two inches in length.During observation on 7/1/26 at 12:21 p.m., R8 was seated at a table while a nursing assistant (NA) assisted R8 with eating. R8 continued to have a full beard of approximately one to two inches in length.During an interview on 7/2/26 at 12:08 p.m., NA-A stated staff should offer shaving assistance and notify the nurse if a resident refused. NA-A stated R8's beard was normal for him, staff did not shave him, and stated, I think he likes to have a beard. NA-A was unable to provide evidence R8 refused shaving assistance.During an interview on 7/2/26 at 1:24 p.m., the registered nurse case manager (RNCM) and Director of Nursing (DON) stated R8's beard had been present for a while. The RNCM and DON stated they expected staff to offer shaving assistance, and if R8 refused, the refusal should have been documented. The RNCM and DON reviewed R8's medical record and confirmed there was no specific task established for shaving, and acknowledged R8's care plan identified his preference was to be shaved daily.The facility's Activities of Daily Living (ADLs)/Maintain Abilities Policy, updated 3/31/23, identified the facility would create and sustain an environment that individualized each resident's quality of life by ensuring care and services were person-centered and honored each resident's preferences, choices, values, and beliefs. The policy indicated, based on the comprehensive assessment and consistent with the resident's needs and choices, the facility would provide necessary care and services. The policy further indicated residents who were unable to carry out activities of daily living would receive necessary services to maintain grooming and personal hygiene.

Based on observation, interview, and document review, the facility failed to ensure a nephrostomy drainage system was positioned to allow unobstructed dependent drainage of urine for 1 of 1 resident (R5) reviewed for indwelling catheter care.Findings include:R5's quarterly Minimum Data Set (MDS), dated [DATE], identified R5 had moderately impaired cognition, required assistance with activities of daily living (ADLs), and diagnoses included multiple sclerosis and neurogenic bladder (lack of bladder control due to nerve problems), and septicemia (severe infection in the bloodstream). The MDS further identified R5 had an indwelling urinary catheter.R5's care plan, printed 7/1/26, identified R5 had an alteration in elimination and was incontinent of bowel and bladder related to multiple sclerosis (MS), decreased mobility, left nephrostomy tube related to kidney stones, and Foley catheter placement. The care plan directed staff to monitor for signs and symptoms of UTIs, provide perineal care, and empty the left nephrostomy as ordered.During observation on 7/1/26 at 12:42 p.m., R5 was seated in a Broda wheelchair in his room with the door open to the hallway. R5's nephrostomy drainage bag was observed hanging from the left armrest of the wheelchair. The nephrostomy tubing was positioned off the side of the wheelchair and above the insertion site, which prevented dependent drainage of urine. The position of the tubing did not allow urine to flow freely away from the insertion site and created the potential for urine backflow.During observation on 7/1/26 at 12:47 p.m., trained medication aide (TMA)-A stated R5's nephrostomy drainage bag was hung from the wheelchair armrest and that it was typically hung this way.During an interview on 7/1/26 at 1:08 p.m., the registered nurse case manager (RNCM) and director of nursing (DON) observed R5's nephrostomy drainage system. The RNCM and DON confirmed the nephrostomy bag and tubing were positioned incorrectly and stated the placement did not allow urine to drain appropriately. The DON stated the nephrostomy drainage bag needed to remain below the insertion site to allow urine to flow freely and reduce the risk of urinary tract infections (UTIs).The facility's Indwelling Catheter Care Procedure, last reviewed 5/2025, directed staff to provide appropriate care of urinary drainage systems. The policy directed staff to place drainage tubing over the resident's leg and check the tubing for evidence of urine flow.

Based on observation, interview and document review, the facility failed to ensure appropriate infection control practices were performed for 1 of 2 residents (R4) reviewed for installation of eye drops.Findings include: R4's annual Minimum Data Set (MDS), dated [DATE], indicated R4 was cognitively intact, and diagnoses included diabetes, schizophrenia, depression, and anxiety. R4's physician's orders, printed 7/2/26, indicated an order for prednisolone acetate ophthalmic suspension 1 % (corticosteroid eye drops) to his right eye after having cataract surgery. During a medication pass observation on 6/30/26 at 4:32 p.m., registered nurse (RN)-B, after setting up R4's medications, which included prednisolone eye drops, entered R4's room. RN-B gave R4 his oral meds and inhaler. RN-B instructed R4 to tilt his head back, used her ungloved fingers to spread R4's eye lids (upper and lower), held them open and instilled the eye drop in R4's right eye. RN-A offered a tissue, exited room, walked back to the medication cart and placed R4's eye drop bottle back in the cart. During an interview on 6/30/26 at 4:41 p.m., RN-A stated she forgot to wash her hands and put on gloves before R4's eye drops were administered, and RN-A stated she should have washed her hands after the eye drops were given before she left the room. RN-A stated, I forgot, I am so sorry. During an interview on 7/2/26 at 10:37 a.m., the director of nursing (DON) and corporate registered nurse (CRN) both stated RN-B should have washed her hands, donned gloves, given the eye drops, doffed her gloves and washed hands after the eye drops were administered. The facility's Eye Drop, Ointment, and Gel Medications Administration procedure, undated, indicated before the administration of eye drops, staff will perform hand hygiene, put on examination gloves, and with a gloved finger, gently pull-down lower eyelid to form a pouch. After the administration of eye drops, staff will remove gloves and wash hands thoroughly with antimicrobial soap and water or facility approved hand sanitizer.

Based on interview and document review, the facility failed to ensure 1 of 5 residents (R12) were offered, educated on, and provided the pneumococcal vaccination series as recommended by the Center for Disease Control (CDC), who were reviewed for immunizations.Findings include: R12's quarterly Minimum Data Set (MDS), dated [DATE], indicated R12 admitted to the facility on [DATE], was [AGE] years of age, and diagnoses included diabetes and Parkinson's disease. R12's electronic health record (EHR) indicated R12 received PCV13 on 9/25/19, and PPSV23 on 10/22/20. The CDC's Adult Immunization Schedule, dated 10/7/25, indicated for persons [AGE] years of age and older who previously received both PCV13 and PPSV23, one dose of PCV20 or PCV21 was recommended at least 5 years after the last pneumococcal vaccine dose. R12 was eligible after 10/22/2025. However, R12's EHR lacked evidence that the resident and/or resident representative had been offered, educated on, and/or provided a PCV20 or PCV21 vaccine. During an interview on 7/2/26 at 10:20 a.m., director of nursing (DON) and assistant director of nursing (ADON) confirmed R12 was eligible for a PCV20 or PCV21, and the facility had not offered a PCV vaccine to R12.

Based on observation and interview, the facility failed to follow established infection control practices for 1 of 3 residents (R4) reviewed for hand hygiene when staff failed to perform hand hygiene and change gloves while performing care.Findings include: During an observation on 3/26/26 at 10:08 a.m., registered nurse (RN)-A and the nurse practitioner (NP) performed wound care for R4. RN-A was wearing gloves when she removed the wound dressing from R1's left heel, then removed the dressing from R1's right heel, sprayed both wounds with wound cleanser, wiped R1's left heel with gauze, and then used a clean gauze pad to wipe R1's right heel. RN-A failed to remove her gloves and perform hand hygiene following disposing of the dressings and between cleaning R1's left and right heel. R1's admission Minimum Data Set (MDS), dated [DATE], indicated she had diagnoses of multiple rib fractures, heart failure, dementia, anxiety, had a pressure ulcer, was cognitively intact, and required staff assistance with cares and transfers. R1's care plan, dated 2/23/26, indicated she had pressure ulcers on her left and right heels, followed by wound care. During an interview on 3/26/26 at 11:03 a.m., RN-A stated hand hygiene and changing gloves was necessary after removing wound dressings and between providing care for each wound to reduce potential spread of infection. During an interview on 3/26/26 at 10:42 a.m., the NP stated hand hygiene and changing gloves was expected after cares and between wounds because infection could ensue. During an interview on 3/26/26 at 11:24 a.m., the director of nursing (DON)/infection prevention (IP) nurse stated gloves should be changed when going from dirty to clean areas and hand hygiene should be performed after removing gloves by using hand sanitizer or washing with soap and water to prevent infection. The facility Wound Care Treatment Procedure, dated 2/2024, indicated:Remove the previous dressing.Dispose of previous dressing in designated container.Remove your gloves and complete hand hygiene.Clean the wound according to the physician's orders.Remove gloves, dispose of them in the designated container, and complete hand hygiene.Apply clean gloves and complete the residents dressing change while following the provider's order.

Based on interview and record review the facility failed to prevent a significant medication error for 1 of 1 residents (R1) who was administered ten times the ordered dose of Haloperidol (antipsychotic medication) which resulted in R1 suffering toxic encephalopathy (neurological disorder caused by exposure to toxic agents), sedation, prolonged QT interval (heart takes longer than normal to recharge between beats) and hospitalization. This resulted in an immediate jeopardy (IJ). The IJ began on 10/21/25, when licensed practical nurse (LPN)-A changed R1's order for Haldol from 10 mg to 100 mg without a physician order. The Administrator and Director of Nursing (DON) were notified of the past non-compliance (PNC) IJ on 11/13/25 at 2:55 p.m. The facility immediately implemented corrective action on 11/7/25, and the deficient practice was corrected on 11/10/25, prior to the start of the survey and was therefore issued as a PNC IJ. Findings include R1's face sheet dated 11/7/25, identified diagnoses of schizoid personality disorder (pattern of detachment from social relationships and limited range of emotional expression), depression with recurring psychoactive symptoms, and long QT syndrome. R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had no cognition deficits, no issues with hearing and speech, had little interest or pleasure in doing things, sometimes felt socially isolated, had no behaviors, and required supervision assistance with activities of daily living including toileting and dressing. R1 received antipsychotic medications. R1's hospital Discharge summary dated [DATE] included a physician order for Haloperidol (Haldol-antipsychotic) 10 milligrams (mg) daily at bedtime for schizoid personality disorder. R1's facility physician orders included the prescription for Haloperidol 10 mg daily dated 10/16/25 and was discontinued on 10/21/2025, at 3:41 p.m. R1's record then identified on 10/21/25 licensed practical nurse (LPN)-A entered a new order changing the Haloperidol dose from 10 mg to 100 mg. In review of R1's record which included physician orders, nursing progress notes, and physician notes, there was no indication a physician had provided the facility with a verbal order, written order, and or an electronic order to increase the Haloperidol from 10 mg to 100 mg. Further, the record did not address the rationale for the large dose increase. On 11/13/25 at 12:11 p.m., a call was attempted with LPN-A however there was no answer so a message with left; a return call was not received. During a phone interview on 11/13/25 at 8:40 a.m., pharmacy technician (tech)-A verified the pharmacy had an order in the system from 10/21/25, that was discontinued for Haldol 10 mg and the order was increased to Haldol 100 mg. The order was written by the facility with a doctor signature attached to the order, but no physical order with a doctor signature was at the pharmacy. The facility had the order system integrated with the pharmacy's ordering system that allowed the facility to enter an order without an actual valid prescription because the system included automatic physician signature for orders that were entered. The pharmacy would process, fill, and deliver the medication. During a phone interview on 11/13/25 at 8:52 a.m., pharmacist (pharm)-B stated the facility had rounding medical providers, and the nurse would enter the orders on behalf of the providers. A technician at the pharmacy would process the orders received then a pharmacist would review the orders. The order for Haldol was received electronically and the order confirmed that it was electronically signed by the facility medical provider and verified by a nurse at the facility (LPN-A). Pharm-B stated the pharmacy does not normally see a dose that high of Haldol. The dose had a significant escalation and usually, the pharmacist would question an order with that significant of an increase but the pharmacist who processed the order may have assumed the order was correct. Pharm-B explained a resident that had an increase from Haldol 10 mg to 100 mg so quickly would likely experience sedation, blood pressure issues, extra pyramidal symptoms, and muscle tremors. R1's physical therapy (PT) encounter dated 11/5/25, identified R1 was very tired and difficult to wake. R1 had a long response time to questions and stated, I can't move my legs. PT-A moved R1's tray table and lowered bed for R1 to easily move to get legs to the edge of bed. R1 stopped responding to PT-A and sat with eyes closed and refused any further treatment. Nursing notified. R1's record review identified there were no nursing assessments, vital signs, or progress notes on 11/5/25. R1's PT encounter dated 11/6/25, identified R1 had a group activity that included standing and playing cards. During the activity R1 had two loss of balances and needed to sit back in the wheelchair. Standing activity was stopped as R1 struggled to maintain stand. During a phone interview on 11/13/25 at 9:12 a.m., nurse practitioner (NP)-A stated the facility had called her on 11/7/25, and informed her R1 had been very sleepy on 11/6/25, and requested a change in R1's psych meds since she had been getting a larger dose. NP-A directed the facility to call R1's psychologist for any requests to change psych medications. NP-A accessed R1's electronic medical record and began reviewing it. NP-A reviewed R1's medications that had been ordered from hospital discharge, psychology visit, and from NP-A's doctor and determined that none of them had ordered an increase in Haldol. NP-A called the facility and ordered Haldol to be held and to obtain labs. NP-A continued to review R1's electronic chart and decided since the Haldol was such a large quantity that she received, R1 needed to go to the hospital. Toxicity of Haldol can induce kidney injury and arrythmia of the heart. This was a significant error that could be very dangerous for R1, toxic encephalopathy and the QRT (heart rhythms) can be very dangerous. R1's progress notes dated 11/7/25 at 2:13 p.m., identified R1 had a change of condition in the morning and an assessment was done in which R1 was lethargic, sleepy, and had a change in mental status. Vital signs stable- and were blood pressure 152/64 (normal-120/80), temperature 97.5 (normal-99.1), heart rate 57 (normal 100), oxygen 99%(normal 100%) on room air, respiration rate 16. Nurse Practitioner (NP)-A notified and advised to send R1 to the emergency room for further evaluation as pertains to medication overdose. R1's Hospital Transfer assessment dated [DATE], identified R1 was sent to the emergency room for evaluation of medication overdose. During a phone interview on 11/13/25 at 12:38 p.m., the hospital medical doctor (MD)-A stated when R1 arrived at the hospital on [DATE], R1 was extremely stiff in lower extremities and neck, staring, and confused. MD-A had seen some improvement with QT levels, not the stiffness, and R1 had a tongue tremor. R1 was on day six of being off antipsychotic medications, received Ativan and MD-A thought R1 either had catatonia or hyperactive delirium. MD-A had never had a patient receive 100 mg of Haldol before and felt this was a significant medication error that caused harm to R1. MD-A stated so many people should have questioned the dose and it was a Swiss cheese model, there were so many holes where it should have been caught. During a phone interview on 11/13/25 at 12:29 p.m., hospital RN-A, indicated currently as of today (11/13/25) R1 required assist of two people to transfer and a mechanical lift. R1 has been drowsy and lethargic. R1 required assistance from staff to cut up food and bring to her mouth. R1 would wake up just long enough to grab food, chew and swallow, and fall back asleep. During an interview on 11/13/25 at 10:06 a.m., nursing assistant (NA)-A stated R1 had been quiet and kept to herself, tended to stay in her room and was tired a lot since admission. R1 was mobile and could get in and out of bed and go to the bathroom without assistance. NA-A recalled there was a particular day (NA-A was unable to recall a specific date), R1 had urinary incontinence in her bed, was not eating much, needed her food cut up, and was not responding to NA-A. NA-A reiterated it was unusual behavior for R1. During a phone interview on 11/13/25 at 12:18 p.m., registered nurse (RN)-B stated R1 was always in her room and not very active. RN-B explained prior to administering medication she would check the medication dose in the MAR against the dose on the card to verify accuracy of orders. RN-B stated she administered Haldol 100 mg to R1 on 10/24/25, and 11/2/25 and did not notice the order had recently changed or was a high dose. During an interview on 11/13/25 at 1:32 p.m., physical therapist PT-A stated when R1 participated in therapy, prior to the medication change, R1 had slow processing time, was soft spoken, and able to do a lot of things independently. PT-A noticed slight changes in R1 beginning on 10/31/25. Changes included R1 was slow to respond, sat on the edge of the bed with eyes closed, cried and was emotional, refused therapy, not much verbal response but denied anything was wrong. On 11/5/25, R1 stated she could not get her legs out of bed and could not move them. PT-A lowered the bed and cued R1 and she was able to move her legs out of the bed. PT-A was unsure why R1 thought she could not move her legs but did tell the nurse about the incident. During an interview on 11/13/25 at 10:17 a.m., interim director of nursing (DON) stated she began the role of DON on 10/27/25 and identified an issue with processes and order entries in the building and had begun teaching the nurses and health information management staff the processes of order entry. The processes and order entry breakdown included staff did not have a second nurse or health information staff complete a double check after transcribing an order into the system. The new process included all order entries must be double checked by two staff. DON or designee would run a daily report that included all new and discontinued orders, as well as verify accuracy of the transcription and double check. DON stated she had begun a psychotropic medication audit on 11/6/25 which included all residents that were on psychotropics, doses, when the medication was ordered, care plans, abnormal involuntary movement scale, consent forms, and gradual dose reductions but had not started reviewing the information in its entirety and had not paid attention to specific doses at that time. DON was made aware of the situation on 11/7/25, LPN-A was suspended immediately and terminated after facility investigation had been completed. During an interview on 11/13/25 at 2:45 p.m., Administrator stated the facility was working with the pharmacy to determine on the pharmacy end changes that will be incorporated but was unsure what they would be at the time of the interview. The expectation is that orders are transcribed from a physician order and double checked by a second staff member to ensure accuracy. The facility Change in a Residents Condition or Status policy, reviewed 11/7/25, identified the facility will promptly notify the resident, the physician, and the resident representative of changes in the residents medical/mental condition and/or status. The facility Medication Error Procedure, reviewed 11/7/25, identified the interdisciplinary team (IDT) evaluates medication usage to prevent and detect adverse consequences and medication related problems such as: adverse drug reactions and side effects. Medication errors should be assessed, documented, and reported according to federal and/or stated guidelines as appropriate. Medication errors will be rectified according to standard of practice and the facilities pharmacy policy for preventing and detecting adverse consequences and medication errors. The facility Medication Administration and transcription double check orders dated 11/7/25, identified orders are to be transcribed accurately, verified, and double checked by two nurses or health information management. The order must be initialed and dated by both parties. If the nurse feels there was an error with a medication dosage, notify the physician or pharmacy to follow-up. Notify physician, family, and nurse leadership immediately for medication errors and initiate orders to begin monitoring for adverse reactions to medication discrepancy. The PNC IJ that began on 10/21/25, was removed on 11/10/25, when it was verified, the facility implemented the following: -suspended on 11/7/25, and subsequently terminated LPN-A, the nurse who transcribed the order. -review of all residents on antipsychotic and psychotropic medications to ensure accuracy was completed on 11/7/25. -education provided to nursing staff on medication administration and transcription double check of orders completed on 11/10/25. -review by DON/designee daily of all orders discontinued and initiated into the order system began 11/7/25. -competency for psychotropic medications and side effects for nursing staff completed on 11/10/25. -reviewed policies and procedures related to medication administration and transcription double check, pharmacy, change of condition, and medication errors on 11/7/25.

Based on observation, interview and document review, the facility failed to consistently date fresh and frozen items at the time they were opened, or placed in a container, and failed to remove items which were beyond the acceptable date of use from the refrigerator. The facility also failed to consistently verify the temperatures of freezers were within the desired range to assure food integrity and follow through on the temperatures outside of the desired range. The staff also failed to consistently implement the use of hair nets and beard restraints while preparing and serving food. In addition, food temperature monitoring lacked consistency of completion following food preparation and prior to serving. This had the potential to affect all 32 current residents, as well as staff and visitors who ate the food from the kitchen. Findings include: Food storage: On 5/19/25 at 11:31 a.m., the culinary director (CD) reviewed the products of the refrigerator at this time. The CD stated food items should be used within seven days of placing in the refrigerator. The following items were noted to be in the refrigerator and outside of the stated parameters: A five-pound box of bacon, with half of the box remaining was observed to be in an opened paper box which was not sealed. This was removed by the CD. A bottle of lemon juice which was noted to be 32 ounces, with half of a bottle remaining. The manufacturer expiration date was noted to be 3/25. The bottle had been dated on 3/24 as being opened. A stack of sliced cheese, approximately one and a half inches in height, was wrapped in plastic wrap, and was dated 5/8/25. The wrapping was not secured, and one corner of the cheese was opened with cheese crumbling off. The package of cheese was free from mold. The CD removed the cheese from the refrigerator to be repackaged. A one pound package of butter, was observed to be partially unwrapped, and noted to have approximately half of the block remaining. This was undated. This removed from the refrigerator and disposed of. A six quart container was observed to be in the refrigerator with two quarts of black olives remaining. This was noted to be dated 5/1/25. This was removed from the refrigerator and disposed of. An open package of ham, containing six slices of ham was observed to be dated 5/6/25. This was removed from the refrigerator and disposed of. A one-pound package of bologna, white in color, with watery substance observed at the bottom of the packaging was noted to be dated 3/31/25. This was disposed of. A bag of precooked sausage, dated 5/8/25, was observed to be in the refrigerator. CD stated they had just placed this in the refrigerator on Friday, 5/16/25, however, acknowledged staff would be unaware of the date of 5/8/25 being the date received on delivery and not the date the bag was placed in the refrigerator. CD stated precooked foods could be stored seven days. A sandwich size baggy of chopped up onions was observed in the refrigerator, dated 5/7/25. There was a watery substance at the bottom of the bag, and the onions were soft to touch. This bag was removed and disposed of. On the upper shelf of the refrigerator, there was an undated plastic cup, approximately two ounces in size, of sour cream. This item was removed and disposed of. The dry storage room was surveyed and it was noted to have two onions which had two inches of green sprouts out of the top of them. The onions were noted by the CD to be soft and spoiled and were disposed of. A review of the food items in the freezer was completed and the following was identified. Within the freezer, there was noted to be two chunks of ham in a plastic bag, dated 5/14/25, which CD noted to weigh approximately one and a half pounds which had a large amount of ice crystals surrounding the chunk of ham and laying in the bottom of the bag. A second bag of ham was also noted to be in a plastic bag, covered with many crystals, both on the ham and in the bottom of the bag. This bag was measured at three pounds. CD stated she was unsure if the ham was not cooled down properly to cause formation of ice crystals. Both bags of ham were removed and disposed of. A four-pound bag of fully ice encrusted fajita blend vegetables was observed. This contained a pepper and onion mix. This was not opened and undated. This was removed and disposed of. A review of other frozen vegetables was completed with no other vegetables noted to be encased with ice. A bag of chili sauce was found thawed in freezer, with a date of being opened as 5/13/25, however, was not frozen. The bag was noted to weigh was almost three pounds. CD was unsure why this would have been dated 5/13/25, and yet be thawed to touch. On 5/20/25 at 3:20 p.m.,Regional Culinary Director (RCD) stated foods are dated upon arrival/receipt. RCD stated food products should then be dated with date opened. RCD stated if the food product was a cooked product, it was to be used within three days. RCD stated if it was cheese, it was to be discarded after seven days. Ham was to be disposed of within seven days. A facility policy, Food Receiving and Storage, revised October 2017, identified foods were to be received and stored in a manner that complied with safe food handling practices. The policy indicated all foods stored in the refrigerator or freezer were to be covered, labeled, and dated (use by date). Although the policy identified to products were to be dated, it lacked definition as to what the time frames were for the food products to be used by, with the exception being that beverages must be dated when opened and discarded after twenty four hours. A policy titled Refrigerators and Freezers, undated, indicated the facility will ensure safe refrigerator and freezer maintenance, temperature and sanitation, and will observe food expiration guidelines. The policy stated all food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of deliver) will be marked on cases and on individual items removed from cases for storage. Use by dates will be completed with expiration dates on all prepared foods in the refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened. All expired items were to be discarded. Although the policy addresses the use by date, the policy lacks specifications to what the parameters are to be used for determining the use by date. Monitoring of freezer temperatures: On 5/19/25 at 12:04 p.m., a review was completed of the freezer temperature log for freezer A. The log indicated the temperature was to be less than zero degrees, if temperature was higher than zero the staff were directed to contact the culinary manager ASAP (as soon as possible). Upon review of the log, it was noted the temperature was identified as being greater than zero degrees Fahrenheit on four occasions: on 5/12/25, the temperature was recorded as 2.6, on 5/13/25, the temperature was recorded as 2, on 5/14/25, the temperature was recorded as 13.5 degrees Fahrenheit. The log was noted to lack temperature monitoring in the afternoon on four dates (5/14/25, 5/15/25, 5/16/25, 5/18/25) CD stated she was unaware of the freezer temperature being greater than zero degrees. CD stated when the temperature was greater than zero degrees, the staff were to report this to the CD and follow up was to be initiated with maintenance. On 5/20/25 at 3:31 p.m., RCD stated the freezer at the time the temperature was out of range on the freezer, it may have been going under a defrost. RCD stated the temperature was to be monitored on the inside of the freezer. RCD stated she had reviewed the log. RCD stated when irregularity was noted, staff were to allow the freezer to cycle through and go back and recheck the temperature. RCD stated if the abnormality persisted, the CD was to follow up with maintenance, or other departments as indicated. A policy titled Refrigerators and Freezers, undated, indicated the facility will ensure safe refrigerator and freezer maintenance, temperature and sanitation, and will observe food expiration guidelines. The policy outlined that the temperatures of the freezer was to have been less than zero degrees Fahrenheit. The policy directed the supervisor to take immediate action if temperatures were out of range. Actions needed to correct the temperatures were to be recorded on the tracking sheet, including the repair personnel and/or department contacted. Hair nets and beard restraints: On 5/19/25 at 12:18 p.m., CD was observed to wearing a hair net; however, the sides of her hair were not completely contained within the hair net. CD was observed with hair net not partially covering her hair in the kitchen, and in the serving kitchen. On 5/20/25 at 12:26 p.m., RCD was observed in the serving kitchen. Although RCD was observed to have a hair net in place, it lacked coverage of her bangs, which were noted to be uncovered on her forehead. On 5/20/25 at 3:43 p.m., registered dietitian (RD) stated hair nets were to be worn in the kitchen, and outside of the kitchen when serving food. RD stated hair nets were to be worn so it covered all of the person's hair. Hair was to be tucked in, no matter what part of your hair it was. On 5/20/25 at 3:47 p.m., RDC acknowledged her bangs were not covered up by her hairnet and stated I know better. On 5/20/25 at 5:13 p.m., dietary assistant (DA)-B, was observed placing tablecloths on serving tables in the dining room. DA-B's hair was observed to be braided and pulled back away from her face, however, there were areas around forehead and ears where the hair net was not restraining/containing the hair. Upon interview, DA-B stated she was unaware her hair was outside of the hair net, and stated it was important for hair nets to be used so that the hair would not get into the food. On 5/21/25 at 4:45 p.m., DA-C was observed in the dining room setting up tables for the evening meal. DA-C was observed to have a hair net in place to cover his head, however, DA-C was also observed to have facial hair present with a light mustache and beard. DA-C was not wearing any facial hair restraint at this time. On 5/21/25 at 4:55 p.m., RDC was observed walking by at the time DA-C was preparing the dining room. Surveyor inquired of RDC if DA-C typically used a facial hair restraint? RDC stated, He typically does, for sure. 5/21/25 at 4:59 p.m., RDC approached surveyor and stated she had followed up on use of beard nets at the facility. RDC stated the facility lacked beard nets in house. RDC stated in the interim, DA-C would cover face with a face mask. A facility policy, Food Preparation and Service, revised April of 2019, identified under Food Service/Distribution that Food and nutrition services staff (were to) wear hair restraints (hair net, hat, beard, restraint, et.) so hair does not contact food. Temperature monitoring of meals served: On 5/19/25 at 12:14 p.m., temperature logs were received from 5/16/25 to the present time on 5/19/25 at 12:14 p.m. The culinary services cook (CSC)-A stated she had temped the foods earlier yet had not recorded them. The temperature log reflected no temperatures had been entered for 5/16/24-5/19/25. Additional logs were requested from the CD from the start of the month. Upon review of the temperature logs, it was noted from 5/1/25 -5/15/25, there were 11 meals out of 45 where temperatures were not recorded. CD stated the temperatures were to be checked prior to serving the meals, and indicated the temperatures were to be logged immediately after they are checked. On 5/20/25 at 3:32 p.m., RCD stated staff were to check the temperature of foods right before the meal was served. RCD stated there were interventions to maintain food temperatures which included heating pellets, heating plates, domed plates. If the food was not maintaining the desired temperature, her concern would be related to the delivery process, function of the steam table being on, and equipment being efficiently used. A facility policy titled Food Preparation and Service, revised April of 2019, identified under Food Preparation, Cooking and Holding Time/Temperatures that food thermometers used to check food temperatures were clean, sanitized, and calibrated for accuracy. The policy identified under Food Service and Distribution, that the proper hot and cold temperatures were maintained during food service. The policy indicated the temperature of foods held in steam tables were monitored throughout the meal by food and nutrition services staff. The policy lacked definition as to when the temperatures were to be initially taken prior to meals, and the parameters when the temperatures are to be rechecked.

Based on observation, interview and record review the facility failed to ensure urinary leg bags were effectively secured to prevent falling on the floor and being rolled over by wheelchair for 1 of 1 residents (R28) reviewed for urinary catheter. In addition, the facility failed to conduct ongoing surveillance for the infection control program to ensure tracking and trending of symptomatic illnesses not on antibiotics in the facility. This deficient practice had the potential to affect all 32 residents currently residing in the facility. Findings include: R28's admission Minimum Data Set (MDS) dated [DATE], indicated R28 had moderate cognitive impairment and required assistance with activities of daily living (ADL's) including dressing, grooming, bathing, and transfers. R28 was noted to have an indwelling catheter. R28's medical diagnoses included an artificial openings of the urinary tract, benign prostatic hyperplasia (a non-cancerous enlargement of the prostate gland in men which can lead to various urinary problems in men), renal insufficiency (a condition which the kidneys are not functioning at their full capacity), urinary tract infections, diabetes (a group of diseases which affects how the body uses blood sugar), specialized disorders of the bladder, and dementia. R28's care plan printed 5/21/25, identified R28 was on enhanced barrier precautions related to nephrostomy bag, was a fall risk related to nephrostomy tubes (a tube that drains urine from the bladder when the urine is unable to leave the body normally), had alteration in mobility related to nephrostomy tubes, and had self care deficit related to bilateral nephrostomy tubes. R28's lacks direction as to management of the nephrostomy bags, cares to be provided to the sites, and direction as to securing of nephrostomy bags for resident to maintain dignity, provide good infection control practices, and prevent falls. The Group one (1) CNA (certified nursing assistant) work list, updated 5/21/25, identified R28 was dependent with toileting and had nephrostomy tubes. The list lacked any further direction to staff as to how provide cares for the nephrostomy tubes and bags. On 5/19/25 at 3:59 p.m., R28 was observed next to the Transitional Care Unit (TCU) nurses station. R28 was positioned between the medication (med) cart and the wall, allowing room for wheelchairs to pass. R28 was observed to have urinary leg bag dragging below the left leg of his pants, with urinary leg bag laying on the floor. R28 was observed to moving in a back and forth motion and was observed to roll over his leg bag with the wheel of the wheel chair. Certified nursing assistant (CNA)-A was observed to walk by, pushing another resident. CNA-A observed R28's leg bag on the floor and went to correct this. CNA-A then stated to licensed practical nurse (LPN)-B she needed to help R28, and advised LPN-B to get gloves. CNA-A proceed to step away from residents to go and wash her hands. LPN-B proceeded to propel the resident CNA-A had been assisting to their room. While R28 was left unattended, he proceeded to roll back over the leg bag, which remained on the floor. LPN-B then returned and assisted R28 to his room. CNA-A returned to the nurses station after washing her hands, and stated she had observed R28's leg bag caught in the wheelchair, and that was why she stopped to help. CNA-A stated when she assisted R28, she was not wearing gloves, so needed to wash her hands. CNA-A stated she alerted LPN-B, who was at the medication cart, to provide assistance while she washed her hands. On 5/19/25 at 5:17 p.m., a follow-up interview was completed with LPN-B. LPN-B stated she had assisted the resident being pushed by CNA-A to their room, and then returned to the nurses station to help R28. LPN-B stated she assisted R28 to his room, and assisted with placement of leg bag, and tightened his leg band. LPN-B stated she had seen the leg bag on the floor. LPN-B stated with the leg bag being on the floor, there would be the exposure to bacteria, germs and added that was why she had fixed it. On 5/22/25 at 10:36 a.m., R28 was observed as he received personal cares. CNA-B proceeded with cares wearing a gown and gloves as required for cares. CNA-B was observed with appropriate infection control practice of hand hygiene and glove use. CNA-B proceeded to secure nephrostomy bags to R28's legs. The band CNA-B was using was a wider width strap, approximately two inches wide, such as a band used to secure a catheter tube to the upper thigh. CNA-B identified when using a leg bag, there were usually straps which threaded through the leg bag, however, these straps were not available for use. Upon observation of the leg bags, it was noted the area on the leg bag where straps would be threaded through had not been used. CNA-B stated the straps provided were too large for the bags to secure well to R28's legs. CNA-B stated she had asked about different straps, but this is what they give us. CNA-B stated the problem with positioning of the leg bags is related to how they sit on his legs. CNA-B then strapped leg bag to just below the knee, securing the large band at the top of the leg bag. There was no strap available to secure the bottom of the leg bag to the leg. During interview on 5/22/25 at 11:32 a.m., LPN Clinical Coordinator (CC)-A stated R28's leg bags should be secured properly on his legs and should not be on the floor due to concerns with dignity, as well as concerns for infection control, adding it was a sanitary issue. CC-A stated if the leg bag was laying on the floor, and run over by the wheelchair, there was a potential for the nephrostomy tubes to be pulled out or displaced. CC-A stated it was her expectation if a leg bag was observed to be laying on the floor, they were to be immediately assisted to their room to secure the bag properly. CCA stated they have tried a variety straps they have tried to find the best fit. CC-A stated she was unaware the current strap was not working effectively. During interview on 5/22/25, at 11:50 a.m., director of nursing (DON) stated the urinary leg bag should not be on the floor. DON stated the leg bags were to be secured, adding they typically came with a strap for the top and for the bottom, and stated she was unsure why this was not being used. DON identified concerns for infection control if the leg bag was observed to be laying on the floor. DON stated the leg bag should have been checked/changed. DON stated the leg bag was to be secured to the leg. DON stated the leg bags typically come with straps and they were to be used to secure the leg bags to the leg. DON stated this was important to prevent the tubes from being pulled/tugged on, as well as the potential for the leg bag from being on the floor. A facility policy, Indwelling Catheter Care Procedure, dated 7/21/23, was provided upon request for a policy for care and management of urinary drainage bags. This policy lacked information as to management of urinary drainage bag, including placement and process to secure, to ensure privacy, dignity, and prevention of opportunity for contamination. On 5/21/25 at 10:00 a.m., a line list was requested to show all residents who had symptoms of illness that were not on antibiotics for 5/25 but was not provided. During an interview on 5/21/25 at 10:00 a.m., the director of Nursing (DON), who was also the facility infection preventionist stated there was no process in the facility to keep a list of residents that had symptoms but were not on antibiotics. She would review the progress notes almost every day and would make mental notes of anybody with symptoms of respiratory concerns or gastrointestinal concerns. There was no actual list made of the residents with symptoms to keep track of the symptoms or to trend when and where they occurred. When the resident progress notes were reviewed and she remembered there were other residents who had similar symptoms, she would look at them to see if they were similar. The DON did not review the staff with illness, that was the administrator. They very rarely met to discuss staff who were sick to see if staff and residents had similar symptoms. During an interview on 5/21/25 at 10:24 a.m., the administrator stated she was the staff member notified when there was a call in. Sometimes, staff called into the facility and other times they called the administrator directly. The facility did ask why a person was calling in sick but did not require them to report symptoms for the purpose of tracking and trending. I would report to the DON symptoms that I felt might affect the resident and the facility but did not meet with her regularly to discuss all symptoms. Facility policy Infection Prevention and Control Program last revised 11/24 indicated surveillance tools were used to recognize the occurrence of infections, recording their number and frequency, detected outbreaks and epidemics, monitored employee infections, and detected unusual pathogens with infection control implications. Data gathered during surveillance would be used to oversee infections and spot trends.

Based on observation, interview and document review, the facility failed to provide 80 square feet of floor space per resident in 8 of 39 rooms (room #s 4,7,17,20, 21, 29, 35 and 36) which affected seven residents (R144, R92, R27, R5, R192, R21, and R2) who currently resided in these rooms. Findings include: During the entrance conference on 5/19/25 at 11:34 a.m., the facility administrator stated there had been no changes in resident room sizes, and there were waivers in place for room numbers: 4,7,17, 20, 21, 29,35, and 36 which did not meet the required minimum square footage. The following double resident rooms did not meet the required minimum square footage per resident: room [ROOM NUMBER] = 150 square feet, or 75 square feet per resident (empty). room [ROOM NUMBER] = 152.5 square feet, or 76.25 square feet per resident (R144). room [ROOM NUMBER] = 150 square feet or 75 square feet per resident (R92). room [ROOM NUMBER] = 150 square feet or 75 square feet per resident (empty). room [ROOM NUMBER] = 150 square feet or 75 square feet per resident (R27). room [ROOM NUMBER] = 150 square feet or 75 square feet per resident (R5). room [ROOM NUMBER] = 150 square feet or 75 square feet per resident (R192, R21). room [ROOM NUMBER] = 150 square feet or 75 square feet per resident (R2). Interview on 5/22/25 at 8:35 a.m., R92 stated she did not have a roommate at that time, but she had roommates before. Resident stated the size of the room was not an issue. She did not believe past roommates had complaints about the room size or functionality either. Interview on 5/22/25 at 8:53 a.m., Administrator confirmed one of the waivered rooms had two residents in it. Administrator stated the facility planned to keep these rooms available for double occupancy if needed based on census. Administrator provided list of rooms with waivers dated 4/28/25, it included room numbers, measurements, and square footage of each of the eight rooms.

Based on observation, interview and document review, the facility failed to ensure medications had both open dates and expiration dates marked on the medications so staff new how long the medications were good for. This had the ability to affect all residents on the transitional care unit (TCU) who received medications. Findings include: On 5/21/25 at 12:21 p.m., a review of the TCU medication care and treatment cart was performed. Three different insulin dial up pens were observed without open dates or expiration dates documented on the pens. Three different inhalers were also observed without open dates or expiration dates. During an interview on 5/21/25 at 12:36 p.m., licensed practical nurse (LPN)-A reviewed the medications and confirmed there were no open dates or expiration dates on the medications. LPN-A could not report when the medications were opened or how long they were good for once the medications were opened. LPN-A did not know how long insulins or inhalers were good for after opened and stated, I need to check with my supervisor. On 5/22/25 attempts to contact the pharmacy consultant were not successful. During an interview on 5/22/25 at 12:27 p.m., the director of nursing (DON) stated an expectation that medication would be dated with both the open date and expiration date, so staff were aware how long they were good to administer. Administering medication beyond the expiration date could result in the resident responding differently to the medication as the potency may change. A facility policy on dating and disposal of multi-use medication was requested, however, none was provided

Based on observation, interview and document review the facility failed to ensure food served to the residents was palatable, at a pleasing temperature, and in a timely manner for 4 of 4 residents R145, R29, R33, and R93 reviewed for food concerns. Findings include: R145's admission Minimum Data Set (MDS) dated [DATE], indicated R145 was cognitively intact. R145 was independent with all aspects of eating and was independent with mobility. R145's medical diagnoses included gastroesophageal reflux disease (GERD-acid indigestion) and diabetes (a disease which impacts the body's ability to process sugar in the blood). On 5/19/25 at 2:22 p.m., R145 stated the food was never warm. R145 went on to state she would love a hot meal. R145 stated the coffee was cold and the food was inconsistent. R145 did not indicate she had requested an alternate meal/new plate, or fresh coffee. R29's admission MDS dated [DATE], indicated R29 experienced moderate cognitive impairment. The assessment indicated R29 was independent with eating. R29's medical diagnoses included sequalae of cerebral infarction (details of cerebral infarction (stroke-and its effects it can cause to the brain including, but not limited to, change in mobility, loss of movement of one side of the body, vision problems, memory loss and difficulty with problem solving, emotional and behavioral changes, and seizures), heart failure (a condition where the heart is not able to pump enough blood for the body's needs for blood and oxygen), hypertension (high blood pressure), diabetes (a group of diseases which affects how the body uses blood sugar), and muscle weakness. On 5/19/25 at 3:36 p.m., R29 stated today the tray (at noon) was late. R29 stated there should be alternates for food. Today, there were no alternates ready for pork. R29 stated the culinary director went to make something as an alternate and provided chickens strips. R29 went on to state the food is late all the time. R33's admission MDS, completed on 3/3/25, indicated R33 had moderate cognitive impairment. R33 was independent with eating. R33's medical diagnoses included hyponatremia (low sodium (salt), a non-cancerous brain tumor, myocardial infarction (heart attack), generalized weakness, and unsteadiness. On 5/19/25 at 5:30 p.m., R33 stated the food is so-so. R33 commented the alternates available are the same things all the time. The food is not consistently hot, and described the food received with meal trays as pretty much warm. R33 stated she had not requested staff to warm up the meal tray if received at less than desired temperature. On 5/19/25 at 11:25 a.m., the culinary director (CD) stated mealtimes at the facility were at 8:00 a.m., 12:00 p.m., and 5:00 p.m. On 5/19/25 at 12:13 p.m., observation was completed in the dining room. Meal service was to begin at 12:00 p.m. At this time, beverages were being served by dietary aide (DA)-A, however, the noon meal had not begun being served. On 5/19/25 at 12:14 p.m., temperature logs were received from 5/16/25 to the present time on 5/19/25 at 12:14 p.m. The culinary services cook (CSC)-A stated she had temped the foods earlier yet had not recorded them. The temperature log reflected no temperatures had been entered for 5/16/24-5/19/25. Upon review of the temperature logs, it was noted from 5/1/25 -5/15/25, there were 11 meals out of 45 where temperatures were not recorded. On 5/19/25 at 12:25 p.m., the first meal was served, 25 minutes after the start of the designated mealtime. Upon initiation of meal service, it was identified there were no alternatives to the pork cutlet served. It was also identified that an alternate meat would need to be prepared as there were three residents who did not consume pork products. CD proceeded to the kitchen to prepare an alternate protein. On 5/20/25 at 12:01 p.m., meal service observation was initiated at this time in the dining room. DA-A was serving beverages to those residents present. At 12:17 p.m., the steam table arrived in the serving kitchen. At 12:24 p.m., it was noted the first meals were served to three residents. At 12:30 p.m., all residents have been served in the dining room. On 5/20/25 at 12:47 p.m., R93 stated it was a small lunch. Quality and quantity is always small. Timing is (was) always a thing. R93 stated he had enough to eat however, expressed concerns regarding the quality. R93 stated there was often an extended wait for meals. On 5/20/25 at 3:20 p.m., an interview was completed with the Regional Culinary Director (RCD), and Registered Dietitian (RD). RCD stated checking of the temperature of foods, should occur right before the meal was serve, and should be completed with every meal. RCD stated she was surprised there were concerns regarding foods as they used heating pellets to keep the plates warm, heated plates, and domed covers. RCD stated there may be some concerns regarding delivery once food was sent out for tray service. RCD stated if the food was reported to be not up to temperature, the food would be either reheated or the resident would be served a new plate. RCD stated she had heard mealtimes have been delayed at times. RCD and RD stated there were routine Food Council meetings to review resident concerns, and stated these meetings were often held on the same day as Resident Council. A request was made for Food Council meeting minutes; however, none were received. A facility policy, titled Meal Times, review 9/2012, identified it was the policy of the facility to serve meals to meet the standards of the surveying agencies, specifying no more than 14 hours between the evening meal of one day and the breakfast meal of the next day. Although the policy included a section which indicated Meal times will be: there lacked indicated times for breakfast, noon, and evening. The policy indicated the Hospitality Services Manager was responsible to monitor the system to assure adherence. The policy went on to state all staff were responsible for following this schedule. A facility policy titled Food and Nutrition Services, revised October of 2017, identified Each resident was provided with a nourishing, palatable, well-balanced diet that met his/her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. The policy identified the meals and/or nutritional supplements would be served within 45 minutes of either resident request or scheduled meal time. The policy also identified Meal times are posted in the facility common areas. A facility policy titled Food Preparation and Service, revised April of 2019, identified proper hot and cold temperatures were maintained during food service. It also identified the temperature of foods held in steam tables were monitored throughout the meal by food and nutrition services staff.

Based on observation, interview and document review the facility failed to implement interventions to maintain a dignified appearance related to the failure to properly secure urinary leg bags for 1 of 1 residents (R28) reviewed for urinary catheter. Findings include: R28's admission Minimum Data Set (MDS) dated [DATE], indicated R28 had moderate cognitive impairment and required assistance with activities of daily living (ADLs) including dressing, grooming, bathing, and transfers. R28 was noted to have an indwelling catheter. R28's medical diagnoses included an artificial opening of the urinary tract (nephrostomy tubes-tubes which drain urine from the kidneys), benign prostatic hyperplasia (a non-cancerous enlargement of the prostate gland which can lead to various urinary problems in men), renal insufficiency (a condition which the kidneys are not functioning at their full capacity), urinary tract infections, diabetes (a group of diseases which affects how the body uses blood sugar), specialized disorders of the bladder, and dementia. R28's care plan printed 5/21/25, identified R28 was on enhanced barrier precautions related to nephrostomy bag, was a fall risk related to nephrostomy tubes (a tube inserted through the skin directly into the kidney that drains urine when the urine is unable to leave the body normally), had alteration in mobility related to nephrostomy tubes, and had self care deficit related to bilateral nephrostomy tubes. R28's care plan lacked direction as to management of the nephrostomy bags, cares to be provided to the sites, and direction as to securing of nephrostomy bags for resident to maintain dignity and prevent falls. The Group one (1) CNA (certified nursing assistant) work list, updated 5/21/25, identified R28 was dependent with toileting and had nephrostomy tubes. The list lacked any further direction to staff as to how provide cares for the nephrostomy tubes and bags. On 5/19/25, at 3:59 p.m., R28 was observed seated in his wheelchair near the Transitional Care Unit (TCU) nurses station. R28 was positioned near the medication (med) cart and the wall. R28 was observed to have a urinary leg bag coming out of his left pant leg laying on the floor, with R28 observed dragging it as he self propelled his wheelchair. NA-A stopped to assist R28, but then stepped away to wash hands as had not been wearing gloves. NA-A requested licensed practical nurse (LPN)-B provide assist to R28. LPN-B proceeded to push the resident NA-A was assisting to her room, leaving R28 near the nurses station with the leg bag on the floor. LPN-B then returned to assist R28 to his room to secure leg bag. On 5/19/25 at 5:17 p.m., an interview was completed with LPN-B, she had assisted R28 to his room and placed his leg bag back on his leg and tightened the strap. LPN-B stated the concern for leg bag being on the floor was related to bacteria and germs. On 5/22/25 at 10:36 a.m., R28 was observed as he received personal cares. NA-B proceeded to secure nephrostomy bags to R28's legs. The band NA-B was using was a wider width, approximately two inches, such as a band used to secure a catheter tube to the upper thigh. NA-B identified when using a leg bag, there were usually straps which threaded through the leg bag, however, these straps were not available. NA-B stated the straps provided were too large for the bags to secure well to R28's legs. NA-B stated the straps did not work well to maintain the leg bag in place, and the leg bags slid down, at times out of pant legs. NA-B stated it was a concern when the leg bags slid down as the bag would pull on the tubes (nephrostomy tubes). NA-B stated they needed to make sure the (nephrostomy) dressings remained in place and free from drainage. NA-B stated she had asked about different straps, but this is what they give us. During interview on 5/22/25 at 11:32 a.m., LPN Clinical Coordinator (CC) stated R28's leg bags should be secured properly on his legs and should not be on the floor due to concerns with dignity, as well as concerns for infection control. CC stated the leg bags should be out of view. CC stated it was her expectation if a leg bag was observed to be laying on the floor, they should be immediately assisted to their room to secure the bag properly. CC stated they have tried a variety straps, they have tried to find the best fit. CC stated she was unaware the current strap was not working effectively. During interview on 5/22/25, at 11:50 a.m., director of nursing (DON) stated the urinary leg bag should not be on the floor. DON stated the leg bag should be secured. She added, they typically came with a strap for the top and for the bottom, and stated she was unsure why this was not being used. DON identified concerns for infection control as well as for dignity of the resident. A facility policy, Indwelling Catheter Care Procedure, dated 7/21/23, was provided upon request for care of urinary drainage bag management policy. This policy lacked information as to management of urinary drainage bag, including placement and process to secure, to ensure privacy and dignity. Upon request for a policy for maintaining resident dignity, the facility provided the document Combined Federal and State [NAME] of Rights, revised 6/18/19. Within the document, it identified the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The documented identified the facility must protect and promote the rights of the resident.

Based on observation, interview and record review, the facility failed to obtain proper consent for use of psychotropic medications (a drug which affects behavior, mood, thoughts or perception) for 1 of 5 residents (R35) reviewed for unnecessary medications. Findings include: R35's admission Minimum Data Set (MDS) dated [DATE], indicated R35 had impaired cognition. R35 was noted to receive assist with activities of daily living (ADLs) including dressing, grooming, bathing, and mobility. R35's medical diagnoses included unspecified encephalopathy (brain disease, damage, or malfunction which encompasses a range of conditions that could cause brain dysfunction, which might manifest as confusion, memory loss, personality changes, or severe symptoms like coma), cancer, atrial fibrillation (an abnormal heart rhythm which has been known to lead to complications including stroke, blood clots, and heart failure), hypertension (high blood pressure), arthritis (inflammation of joints), dementia, anxiety, depression, visual hallucinations (seeing something that is not there), adjustment disorder with anxiety, chronic pain syndrome, and fibromyalgia (symptoms of widespread chronic pain, headaches, depression and other symptoms). R35's care plan printed 5/22/25, indicated R35 had alteration in cognition related to confusion, disorientation to place and time. Poor insight to her deficits or cognitive loss. Poor historian. Sundowning type behaviors of crying and calling out. Has decreased in intensity since admission. The problem statement identified R35 had the diagnosis of major neurocognitive disorder, with behavioral disturbance, encephalopathy due to medical illness (various infections), visual hallucinations, and low vision due to retinal pigmentation disease. The care plan directed staff to follow recommendations from mental health provider. The care plan lacked indication of medications used to aide with mood state and behavior. R35's Medication Administration Record (MAR), printed 5/20/25, indicated R35 received the following medications: - lorazepam 0.5 milligrams (mg) by mouth one time a day for agitation. Start date of 4/3/25. (benzodiazepines used for anxiety). - lorazepam 0.5 mg by mouth every four hours as needed for anxiety or agitation for six months. Start date 4/3/2025. - risperidone 1 mg by mouth at bedtime for agitation/delirium. Start date of 5/5/25. (antipsychotic- works by changing certain signals in your brain which affect how you feel and act). - risperidone 0.5 mg by mouth two times a day for delirium/ agitation. Start date 5/5/25. R35 was noted to receive Lorazepam on 13 occasions in April, with results marked as effective on 10 of the 13 occasions used. This was noted to be used on two occasions in May (5/9/25, 5/13/25) with effective results on each occasion. The May MAR was reviewed for the dates of 5/1/25-5/20/25. A review of R35's medical record lacked indication informed consent had been received from R35's responsible party upon admission to the facility, as well as with change of medication dosing/frequency. On 5/20/25 at 3:52 p.m., R35 was observed in her room, resting on her bed, with blanket in place. R35 had a visitor in her room, playing her guitar, and singing to resident. Resident was observed to be awake and was interacting with her visitor. During interview on 5/22/25 at 1:46 p.m., the director of nursing (DON) stated completion of an informed consent was typically completed within the first week following admission if a resident was admitted on a psychotropic medication. DON stated this was typically completed by the floor nurse, however, if it had not been completed within that time frame, it was followed up on by either the licensed practical nurse, clinical coordinator (CC) or the DON. DON stated consents were to be obtained when new medications were added, as well as updated when changes were made in dosage and frequency of existing meds. A request was made for the documentation of informed consent for both risperidone and lorazepam, which were unable to be located in the medical record. DON stated she also did not find them uploaded on the record. DON stated it was important to receive informed consent for psychotropic medications, as they are medications which have the potential to have more adverse (negative ) side effects than other medications, and it is important to notify the responsible part of the possible side effects. The facility policy, titled Psychotropic Medication Use Policy, created 4/25, identified the facility would a. Obtain informed consent from the resident and/or resident representative and document education, information regarding the medication indication and directions for use, side effects and potential adverse consequences, risks and benefits of the medication and resident choice. b. Discuss any advance directives that the resident has formulated to provide care consistent with resident choice. c. The resident and/or responsible party will be notified regarding dose changes. d. This will be documented in the progress notes. e. Consents and any psychotropic medications will be reviewed quarterly at resident care conferences.

Based on observation, interview and document review, the failed to facilitate resident preferences for bathing and meals for 1 of 1 resident (R27) reviewed for choices. Findings include: R27's admission Minimum Data Set (MDS) dated [DATE], indicated R27 was cognitively intact. The assessment identified R27 received assistance with activities of daily living (ADLs) including dressing, grooming, bathing, mobility, and incontinence care (managing of bowel and bladder). The MDS identified it was very important to R27 to choose between a tub bath, shower, bed bath, or sponge bath, and somewhat important to choose what clothes she wished to wear. R27's medical diagnoses included multiple sclerosis (MS), malnutrition (an imbalance of energy and nutrients consumed), thrombocytosis (increase platelet count), pseudobulbar affect (a condition characterized by uncontrollable and inappropriate episodes of laughing or crying, often disconnected from person's actual emotion state). R27 received routinely schedule pain medication, as well as availability of additional pain medication as needed. R27's care plan with a print date of 5/21/25, identified R27 had the potential for alteration in nutrition related to MS, severe protein calorie malnutrition and dyspepsia (indigestion). The goal for R27 was for her to meet estimated nutrient needs, and to either maintain weight or gain weight to ideal body weight range. The care plan directed staff to provide diet as ordered by the provider. Staff were also encouraged to monitor food and fluid intake per facility protocol and encourage adequate fluid intake. The care plan directed staff to offer fluids and snacks between meals. R27's care plan also identified R27 had a self care deficit related to post surgical status, weakness and MS. The goal indicated R27 will accept assistance with self cares and will be dressed, groomed, and bathed per preferences. The care plan directed staff to follow through with instructions provided by occupational therapy. Staff were also directed to provide with assist of one with dressing and bathing. R27's care plan also identified R27 had alteration in mobility related to post surgical status, weakness and MS. The care plan directed staff R27 was to receive physical therapy (PT) as per doctors orders, and instructed staff to follow PT instructions. The care plan indicated R27 was to receive assist with movement in and out of bed and was to receive assist of one with transfers, however lacked further instructions. Although R27's care plan indicated R27 was on enhanced barrier precautions (increase precautions implemented to prevent the spread of infection) related to surgical incisions, the care plan lacked indication as to how the surgical sites were to be managed, additionally lacked any restrictions in showering related to incisions. The Nursing Assistant care sheet dated 5/21/25, indicated R27 was to receive assistance to transfer with an EZ stand (a mechanical lift to aid in transfers) and did not ambulate. The NA care sheet outlined R27 required assist of one with dressing, bathing, toileting, and required set up for grooming and eating. The care sheet provided no additional instructions to staff for provision of care. On 5/19/25 at 5:48 p.m., R27 was served her evening meal. Family member (FM)-A was present in room and asked R27 what she was having for supper. R27 stated she was unaware of what she was having for supper, as she had not ordered the meal selection. R27 uncovered plate and stated it was a tuna fish sandwich and she did not wish to eat this. R27 observed the coffee came without sugar and cream, which she has requested be with meals, and there were also no straws on the tray for resident use with all beverages. R27 placed her call light on to request missing items on tray. R27 stated she was unaware of what the food choices were as she had no menu in her room. R27 stated there was an alternate menu available, however, the evening meal must be ordered by 3:00 p.m. in order to receive this. R27 stated she was unsure what alternatives were available or how to order them. R27 stated she had no special diet, and had been struggling with weight loss. R27 stated she was to receive two supplements per day to help nutrition, but was unsure she had received them consistently. R27 was noted to have liquid protein supplement drinks in her room, however, R27 they were brought in for her by her friend. On 5/19/25 at 5:58 p.m. R27 expressed frustration she had not received a bath/shower since she had arrived. FM-A affirmed that R27 had doctor's appointments last week and wished to receive a bath/shower before going to her appointments, however, had not received assistance. R27 stated an unidentified certified nursing assistant (NA) came in to provide assistance with a sponge bath, however, R27 wanted a shower to be able to wash her hair as it had not been washed in the weeks since admission. R27 stated the NA put it down that she refused her bath. R27 reported when she asked when she could receive a shower, was told she had to wait for the next shower day. R27 stated Nobody knows how to do a shower. R27 stated neither PT/OT had worked with her regarding the transfer required for completing a bath and shower. FM-A stated R27's hair had not washed since admission and R27 had expressed desire to shower prior to appointments due to lack of bathing since admission, and desire to be clean for medical appointments. On 5/20/25 1:01 p.m., R27 had been delivered her noon meal. R27 stated the tray lacked sugar and cream for coffee, as well as straws to use with her beverages. R27 stated she had requested this from staff however, they had not returned with the items. R27 stated this was the same case with breakfast. A tray slip was observed on resident tray, which identified R27 requested sugar and cream for coffee, and straws for all beverages. R27 stated she was unaware she was scheduled to receive a bath this afternoon, however, stated she would like her hair washed and linens changed. On 5/20/25 at 4:10 p.m., R27 was observed in her room. R27 stated the shower was completed and hair was washed twice. R27 identified the linens were placed back on bed properly, however, noted they had not been changed. On 5/20/25 at 3:49 p.m., an interview was held with both registered dietitian (RD) and regional culinary director (RCD), about availability of menus and the Bistro option for alternates. RD stated residents were provided with a regular menu and bistro menu upon admission. RD was unsure as to when updated menus were provided to those who remained in their rooms for meals. RD and RCD both stated the Bistro menus were available in the dining room for ordering alternatives. RD was unsure if Bistro menus were delivered to rooms for those who did not dine in the dining room. RD stated if there were specific requests by a resident, this was indicated on the tray slip and these requests should be facilitated by the dietary staff. R27's tray slip was reviewed at time with RD, and it was noted although the preferences/requests were on the dietary slip, it was not identified in the place where it was normally listed. During interview on 5/21/25 at 9:27 a.m., physical therapy assistant (PTA)-A stated she participated in the therapy for R27. At present time, PTA-A stated they were working with R27 on core strength, transfers into and out of bed, and in/out of wheelchair. PTA-A stated they were also working on range of motion (ROM) for lower extremities and joint mobility. PTA-A stated R27 has been an EZ Stand transfer for nursing staff since 4/29/25. Occupational therapist (OT)-A joined the conversation and stated both PT/OT are working with wheelchair positioning. OT-A stated OT-A does not have a specific goals for showers. OT-A stated she had not been informed by nursing staff of any concerns regarding showers, therefore, that had not been part of the therapy plan. During interview on 5/21/25 at 10:08 a.m., the clinical coordinator (CC)-A stated R27 had received assistance to complete bathing on 5/20/25. CC-A stated R27 was unable to complete showers/baths prior to that time related to incisions on her stomach following a laparoscopic procedure (A procedure completed with a scope through several small incisions on the abdomen). CC-A stated R27 required clearance from the medical provider because of the laparoscopic incisions. CC-A stated they had offered to complete a shower on an earlier occasion however, R27 had declined the shower related to the time of day. CC-A stated if it is not their shower day, staff were instructed to accommodate the request if we had extra time. CC-A stated she would expect staff would have offered it multiple times until she agreed to it. CC-A stated lack of shower, or washing of hair, for extended time would not feel very good. Residents were assigned a time for bathing/showering based on their room placement. They tried to work with residents a different day/time was requested however, it was not always possible. CC stated she was unaware of any concerns regarding bathing status until resident care conference on 5/15/25. CC stated R27 had received sponge baths since her admission however, she was unsure if her hair was washed. CC stated when there were recommendations for OT/PT this was relayed to staff. CC stated if staff had concerns with provision of care, PT/OT was consulted. CC stated when trays were delivered to residents in their room, it would be her expectation for staff to respond to requests made by residents upon receipt of their tray. During interview on 5/21/25 at 4:54 p.m., the director of nursing (DON) stated baths were scheduled on a weekly basis. This was completed based on their designated time based upon room placement. DON stated if the resident did not care for the time slot, there may be some flexibility in adjusting it, however, that was not always possible. DON stated We try to be flexible but there is only so much wiggle room in that. If a bath was refused, and it was requested on another day, and the aides had time, it may occur, otherwise the next bath/shower would be completed the following week on the routinely scheduled time. Upon inquiring why a shower was not completed for R27, DON stated that if the person had a laproscopic surgery, they would not have a shower if there were restrictions placed per the doctor's orders upon admission or following the procedure. If there were not restricted orders, the individual could receive a shower. A request was made for verification of orders in place upon admission to abstain from showers, however, DON failed to provide order which identified shower restrictions were in place upon admission. Upon review of R27's After Discharge Orders, from 4/28/25, the notes indicated resident had a laparoscopic procedure, however, had not restricted resident from receiving showers A review of the standing orders, filed 5/20/25 electronically, lacked indication for shower restrictions for those with laparascopic surgical sites. The document did refer to the policy Skin and Wound Management. The document, not labeled with R27's name, was identified as being signed by the provider 2/1/25. A review of the policy, Skin Assessment and Wound Management, dated 2/25 lacked indication as to management of a laparoscopic surgical site. The facility policy, titled Activities of Daily Living (ADL's) Maintain Ability Policy, dated 3/31/23, was reviewed. The statement of intent reads as follows: It is the policy of the facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident ' s quality of life by ensuring all staff, across all shifts and departments, understand the principles of quality of life, and honor and support these principles for each resident; and that the care and services provided are person-centered, and honor and support each resident ' s preferences, choices, values and beliefs. Upon review of the procedure, the policy indicated: The facility will provide care and services for the following activities of daily living: . d. Dining-eating, including meals and snacks, . The policy also identified: A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, . A policy was requested for resident choices and food preferences, but was not received.

Based on observation, interview and document review, the facility failed to consistently provide clean bed linens for 1 of 1 residents (R27) reviewed for choices and provision of assistance with activities of daily living (ADLs). Findings include: R27's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R27 was cognitively intact. The assessment identified R27 received assistance with ADLs including dressing, grooming, bathing, mobility, and incontinence care (managing of bowel and bladder). R27's medical diagnoses included multiple sclerosis (MS) and malnutrition (an imbalance of energy and nutrients consumed. R27's care plan dated 5/2/25, identified R27 had a self care deficit related to post surgical status, weakness and MS. The goal indicated R27 will accept assistance with self cares and will be dressed, groomed, and bathed per preferences. R27's care plan also identified R27 had alteration in mobility related to post surgical status, weakness and MS. On 5/19/25 at 5:58 p.m., R27 expressed frustration she had not received a bath/shower since she had arrived and expressed frustration regarding lack of change of bed linens. R27 stated she was unsure as to when the bedding had last been changed. R27 routinely remained in bed for meals due to mobility concerns. During interview on 5/20/25 at 1:01 p.m., R27 stated she was unaware she was scheduled to receive a bath this afternoon however, stated she would like her hair washed and linens changed. R27's bottom sheet had come off at the foot of the bed, and linens were noted to have small bread like crumbs and some tannish colored coffee spills on the top sheet. R27 ate all meals sitting in bed due to mobility concerns. On 5/20/25 at 3:10 p.m., it was noted R27's bedding was placed back on the mattress and was folded back, however, linens had not been changed, as evidenced of by tannish colored spots on bedding previously observed. On 5/20/25 at 4:10 p.m., R27 was observed back in her room. R27 stated the shower was completed and hair was washed twice. R27 identified the linens were placed back on bed properly, however, noted they had not been changed as the same tannish spots previously noted remained in the same location on the sheets. During interview on 5/21/25 at 10:08 a.m., the clinical coordinator (CC)-A stated linens should have been changed while she was in the shower. CC-A stated linen changes were done routinely on bath days, and in between as indicated if they were soiled. The facility policy, titled Activities of Daily Living (ADL's) Maintain Ability Policy, dated 3/31/23, was reviewed and the statement of intent reads as follows: It is the policy of the facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff, across all shifts and departments, understand the principles of quality of life, and honor and support these principles for each resident; and that the care and services provided are person-centered, and honor and support each resident ' s preferences, choices, values and beliefs. The policy lacked information regarding maintaining a clean, hygienic environment for residents, including provision of fresh bath and bed linens. A facility policy for change of bed linens was requested and was not provided.

Based on interview and document review, the facility failed to ensure a baseline care plan was developed to ensure all care needs were adequately addressed for 1 of 1 residents (R29) reviewed for range of motion. Findings include: R29's admission Minimum Data Set (MDS) dated [DATE], indicated R29 experienced moderate cognitive impairment. R29 was identified to have functional limitation of range of motion on one side with impairment on one side. R29 required assistance with activities of daily living (ADLs), including dressing, grooming, bathing, and mobility. R29's medical diagnoses included sequalae of cerebral infarction (details of cerebral infarction (stroke-and its effects it can cause to the brain including, but not limited to, change in mobility, loss of movement of one side of the body, vision problems, memory loss and difficulty with problem solving, emotional and behavioral changes, and seizures), heart failure (a condition where the heart is not able to pump enough blood for the body's needs for blood and oxygen), hypertension (high blood pressure), diabetes (a group of diseases which affects how the body uses blood sugar), muscle weakness, difficulty in walking and unsteadiness of his feet. A review of R29's medical record was completed. R29 was admitted on [DATE] (Friday). R29's 48-hour care plan was initiated on 2/3/25 and locked (no further entries were allowed) on 2/14/25. R29's 48-hour care plan identified the following: Self-care deficit related to L(left) side(d) weakness, impaired vision: The following goals were identified for R29: Resident will accept assistance with self-cares. Resident will be dressed, groomed and bathed per preferences. The following interventions were also identified: Occupational Therapy (OT) per MD (medical doctor) order Follow OT instructions. Assist with bathing with assist of one. Assist with dressing (Specify) [There were no specific interventions identified with this.] Mobility: Alteration in mobility related to left (L) sided weakness and impaired vision. The following goals were identified: Resident will move safely within their environment. The following interventions were outlined: Physical Therapy (PT) per MD order. Follow PT instructions. Assist with ambulation (Specify) [There were no specific interventions identified with this.] Assist with movement in bed and in/out of bed. [There were no specific interventions identified with this.] Assist with transfers with one to two assist. [The care plan lacked specification whether transfers were to be completed with one or two.] Fall Risk related to (L) side weakness, impaired vision: The following goals were identified: Resident will be safe and free from falls. The following interventions were included: Follow PT and OT instructions for mobility function. Follow resident specific fall prevention plan:(Specify) [There were no specific interventions identified with this.] Monitor and document on safety. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter/remove any potential causes if possible. Educate resident/family/ caregivers/IDT (Interdisciplinary Team) as to causes. Alteration in elimination: The following goals were identified: Resident will be continent during waking hours. Resident will continue to have at least one (1) continent void daily (qd). Resident will be free from signs/symptoms of UTI (urinary tract infections). [The care plan lacked indication of what symptoms were to be monitored for.] The following interventions were identified: Assist of one (1) with toileting. Provide assistance with peri-cares morning (AM), bedtime (HS) and as needed (PRN). Provide incontinent products and assist to change PRN. Alteration in psychosocial well-being. Resident is adjusting to nursing home placement, change in routine, and care needs: The following goals were identified: Resident's psychosocial needs will be met. The following interventions were identified: Will monitor safety concerns and evaluate PRN: smoking, elopement, suicide risk etc Will monitor mood state, refer PRN. Will monitor and respond to unmet needs. Alteration in Cognition. On 12/4/24 Resident was psychologically assessed in hospital and was determined that resident has insight deficits in terms of his stroke and function. Resident DX cerebral infraction, hyperlipidemia, type 2 diabetes, essential hypertension, chronic heart failure. The following goals were identified: Resident will communicate his/her basic needs as able. The following interventions were identified: Allow resident time to communicate his/her needs/wants. Document changes in orientation. Alteration in mood and behavior. Resident has hx of visual hallucinations and hx of insomnia. Verbalizes sexual comments to female staff. Refuses medications. DX (diagnosis) cerebral infraction, hyperlipidemia (high level of cholesterol-lipids/fats in the bloodstream, type two (2) diabetes, essential hypertension, chronic heart failure: The following goals were identified: Resident will respond to interventions by staff to calm and redirect. Resident's mood/behavioral state will remain stable. The following interventions were identified: MDS section D/PHQ 9 will be conducted per regulation and PRN. Monitor and document mood state/behaviors upon occurrence. Non-Pharm (pharmacological-interventions completed which do not include medications). Inform resident that comments are inappropriate. Change subject to topic related to his family or therapy goals. Redirect prn. Provide emotional support, validation, and comfort measures prn. Resident will have an appropriate discharge plan. Resident will have appropriate discharge plan. Resident is at risk for long term care. Resident diagnosis (DX) cerebral infraction, hyperlipidemia, type 2 diabetes, essential hypertension, chronic heart failure. The following goals were identified for R29: Resident/family will make safe and appropriate decisions regarding d/c (discharge). The following interventions were indicated: Staff will make necessary referrals as needed in order to carry out resident's d/c goals. Resident is categorically a vulnerable adult while resident resides in a Skilled Nursing Facility. Resident is at risk for decreased cognitive and physical abilities related to diagnosis including: cerebral infraction, hyperlipidemia, type two (2) diabetes, essential hypertension, chronic heart failure. The following goal was identified: Resident will remain free from abuse and/or neglect through his next review. The following interventions were identified: Monitor for signs of emotional distress or mood and behavior changes. Safety monitoring will be implemented as needed to ensure residents safety (i.e. 15 min checks,1:1, etc.) Staff will continue to follow the facility vulnerable adult & abuse reporting policy. The local Ombudsman, Adult Protection, Police, and/or state/financial agencies will be notified of any suspected abuse or financial exploitation as needed. R29's MHM 48 Hour Baseline Care Plan, dated 2/1/25, identified several sections to record R29's needs and the care plan interventions which would be provided. However, the following sections of the care plan were left blank and not completed: Communication Nutrition Psychotropic Medication Use Respiratory Skin Hospice Dialysis Smoking and, Enhanced Barrier Precautions. The baseline care plan lacked indication R29 was a type two diabetic, with nutritional needs, insulin administration, and lacked instruction to staff for monitoring of blood sugars to be provided by staff. The care plan lacked direction to staff to monitor for signs and symptoms of hyper or hypoglycemia (High or low blood sugar). Additionally, although resident was identified as having visual impairment, the care plan lacked any goals or interventions regarding the impairment itself, only how it may increase potential for falls. During interview on 5/23/25 at 1:05 p.m., director of nursing (DON) verified R29's care plan had not been completed within 48 hours. DON stated this was to completed at the time of admission and was to have been completed within that time. This was to completed by the nurse who admitted the resident. DON stated the 48 hour baseline care plan was important and it determined what care was needed by the staff, and directed staff on how to complete the care. A facility policy was requested for the development of a 48-hour care plan, but was not received.

Based on observation, interview and document review, the facility failed to revise resident care plans with updated interventions for 1 of 1 residents (R27) reviewed for choices and activities of daily. Findings include: R27's admission Minimum Data Set (MDS) assessment, dated 5/2/25, indicated R27 was cognitively intact. The assessment identified R27 received assistance with activities of daily living (ADL's) including dressing, grooming, bathing, mobility, and incontinence care (managing of bowel and bladder). The MDS identified it was very important to R27 to choose between a tub bath, shower, bed bath, or sponge bath, and somewhat important to choose what clothes she wished to wear. R27's medical diagnoses included multiple sclerosis, malnutrition (an imbalance of energy and nutrients consumed), thrombocytosis (increase platelet count), pseudobulbar affect (a condition characterized by uncontrollable and inappropriate episodes of laughing or crying, often disconnected from person's actual emotion state). R27 received routinely schedule pain medication, as well as availability of additional pain medication as needed. R27's care plan, print date of 5/21/25, identified R27 had alteration in mobility related to post hysterectomy (surgical removal of uterus), weakness, and MS (multiple sclerosis- a disease that causes breakdown of the protective covering of nerves. Multiple sclerosis can cause numbness, weakness, trouble walking, vision changes and other symptoms). This was initiated on 5/2/25. The care plan directed staff to follow ACP (Associated Clinic of Psychology) recommendation to offer reminders re: her options re: (regarding) transfers and offer of reassurance from staff. The care plan identified R27 was to receive physical therapy (PT) per medical doctor (MD) and to follow PT instructions. Staff were directed to assist with movements in bed and in/out of bed. Staff were directed to assist with transfers with assist of one. The care plan also identified R27 had a self-care deficit related to post hysterectomy, weakness, MS. The goal statement indicated resident will be dressed, groomed and bathed per preferences. The identified R27 was to receive occupational therapy (OT) per MD (medical doctor) and staff were directed to follow OT instructions. The care plan identified R27 was to receive assist of one with bathing and dressing. The care plan lacked information regarding resident's transfer into/out of wheelchair, wheelchair positioning, and amount of time to be up in wheelchair. Although the care plan indicated R27 was to be dressed, groomed, or bathed per preferences, the care plan lacked direction as to what R27 had expressed as her preference. The care plan lacked any direction as to work with R27 with transfers and mobility related to side effects of MS. Additionally, the care plan lacked direction to staff as to how bathing was to be completed, and how dressing changes were to be managed. R27 was admitted after she had undergone a laparoscopic hysterectomy and had four small surgical sites which were covered with dressings. A therapy communication from physical therapy, dated 4/29/25, indicated R27 was to be transferred with use of an EZ stand (a mechanical lift used to assist with transfers). The form indicated R27 was to be up in chair three times a day. The nursing assistant care sheet, updated 5/21/25, indicated R27 was to transfer with the EZ stand and did not ambulate. The care sheet also identified R27 received assist of one with dressing, bathing, and toileting. The care sheet indicated R27 received assist for set up for grooming and eating. The care sheet indicated R27 was able to make her needs known. The care sheet lacked direction to assist R27 up in the chair three times a day. The care sheet lacked any information as to any interventions to be implemented to make the transfers and mobility go easier. On 5/19/25 at 5:55 p.m., R27 stated the certified nursing assistants (CNA) don't know how to transfer, position, perform her cares, or move her due to her rigidity. R27 stated the staff were unsure how to transfer her to and from bed/wheelchair. R27 stated she had spastic rigidity (a response when it was difficult to flex joints related to the spasm). R27 stated if allowed time, she was able to relax and move as needed, however, stated were not allowing her the time and moved her quickly, when still displaying rigidity. On 5/21/25 at 9:27 a.m., occupational therapist (OT)-A stated they are working with R27 with wheelchair positioning. OT-A stated R27 was to be up in wheelchair daily for quality of life. On 5/21/25 at 10:08 a.m., licensed practical nurse (LPN), clinical coordinator (CC)-A stated physical therapy (PT) evaluated the safe way for R27 to transfer and move. This information was relayed to staff to implement. CC-A stated this information was to be on the care sheet so that staff were aware of how to care for R27. She was uncertain if R27's spastic rigidity was addressed in care plan, or care sheet. R27 was also on medication to help with spasms. CC-A stated most recent care conference was held on 5/15/25. CC-A stated at that time, R27 identified concerns regarding her hair not being washed, and not receiving a shower. Although this was identified on 5/15/25, and implemented on 5/20/25, the care plan and care sheet lacked indication of resident preference for bathing and desire to wash her hair. On 5/21/25 at 4:54 p.m., the director of nursing stated the care plan should be reflect resident preferences, as well as how care was to be delivered. DON stated the care plan was to be updated at the time changes implemented. DON stated this would include recommendations made by physical therapy. DON stated the care conferences were attended by CC-A. DON stated changes made to the care sheets were also to be reflected on the care plan, and should be completed at the same time. The care plan and care sheet should both accurately reflect what cares were to be performed by staff, as they direct staff as to what cares were to be performed. A request for the facility policy for care plan updates was requested but not received.

Based on interview and document review, the facility failed to provide pressure ulcer care per physician orders, and notify the physician when they were unable to provide the ordered wound care for 1 of 2 residents (R2) reviewed who had pressure ulcers. This resulted in actual harm for R2 when the pressure ulcer deteriorated, became infected, and R2 was hospitalized for [REDACTED]. Findings include: R2's 5 day PPS Minimum Data Set ((MDS) dated [DATE], included cognitively intact, required extensive assistance with bed mobility, transfers and hygiene. R2 had 5 stage 4 pressure ulcers (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) and 1 unstageable pressure ulcer (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar), which were all present upon admission. An admission MDS had not been completed. R2's Braden Scale (scale used to determine pressure ulcer risk) dated 2/20/21, identified risk factors of confined to bed, very limited mobility, friction and shear concern. R2 had [DIAGNOSES REDACTED]. R2's care plan dated 2/22/21, identified R2 as having an alteration in skin integrity, pressure ulcer to right iliac crest (the curved upper border of the ileum which is the largest of the three bones that form the hip bone), stage 4. Staff were directed to: Monitor skin integrity during cares. Weekly skin inspection by nurse. Treatment to open areas per order. Monitor for skin breakdown and for signs and symptoms of infection. Report signs and symptoms to MD (doctor) or physician assistant. Document on skin condition and keep MD/physician assistant informed. R2's physician's orders [REDACTED]. Irrigate wound thoroughly with Microcyn (antimicrobial wound cleanser) wound cleanser. Pat dry. Paint intact skin surrounding wound with [MEDICATION NAME]- no sting barrier film. Cut wound vac (foam dressing in the wound bed connected to suction, to help aid in wound healing) foam dressing to fit wound and apply to wound bed. If bridging, (intact skin between open areas) be sure to apply drape to intact skin under the foam to protect skin from injury. Cover foam and bridge with vac drape to achieve seal. Set negative pressure at 125 mm Hg (millimeters of mercury/ a unit of pressure) continuous. Change on evening shift. R2's treatment administration record (TAR) for February 2021, showed no documentation from to ensure the wound vac was on and functioning properly every shift, from admission on 2/19/21, until the evening shift on 2/22/21, three days after admission. No other treatment to the stage 4 pressure ulcer on R2's right iliac crest had been identified. R2's medical record did not identify if R2's provider had been notified the wound vac to right iliac crest had not been implemented. When interviewed via phone on 3/10/21, at 12:06 p.m. the Operations Supervisor (OS) at Northwestern Respiratory (company that supplies wound vac and supplies to the facility) stated the intake department received an order for [REDACTED]. The driver was required to hand supplies to a nurse to sign for the delivery of the wound vac. When interviewed via phone on 3/10/21, at 2:51 p.m. licensed practical nurse (LPN)-B stated she worked the evening of 2/18/21, and remembered signing for a wound vac set up that was delivered to facility. LPN-B delivered it to the transitional care side of facility and placed the package on top of the counter at the nurses station. LPN-B had reported there was a delivery to, someone, but could not remember who. LPN-B was not responsible for R2 that evening. R2's progress note dated 2/19/21, at 3:24 p.m. included, Patient has many wounds on BLE (bilateral lower extremities) and one wound on right side of hip that a wound vac has been ordered for. Due to severe pain, wound on right hip was not measured and PM nurse was notified to measure when wound vac comes prior to placing on wound. When interviewed on 3/9/21, at 11:10 a.m. LPN-A stated she had admitted R2 on 2/19/21, and had measured all wounds except the one on her iliac crest, as R2 was having too much pain. She passed the information on to the afternoon shift to complete when the wound vac arrived. LPN-A did not know the wound vac had been delivered on 2/18/21. R2's progress note dated 2/19/21, at 10:05 p.m. included, New resident admitted to facility today. She c/o (complained of) excruciating pain all over body. Dressing did not get completed due to pain. Resident given PRN (per resident need or as needed) and scheduled pain medications that helped some, but not enough. Wound vac not delivered this shift. When interviewed via phone on 3/11/21, at 9:25 am, registered nurse (RN)-C stated she was working the evening R2 was admitted on [DATE]. R2 was in so much pain when she got to the facility. RN-C stated she offered to do wound care, but R2 refused due to pain. RN-C stated the wound vac did not arrive on her shift. RN-C reported she did not notify the physician of the refusal of wound care or that the wound vac hadn't arrived. RN-C was not aware of any facility policy of when to notify the provider. RN-C was not aware the wound vac had been delivered on 2/18/21. R2's progress note dated 2/21/21, at 2:10 p.m. included, Call placed to Northwest oxygen to find out status of wound vac ordered Friday. Order resent and wound vac to be delivered this pm. This was 2 days since R2 was admitted . There was no evidence in the medical record R2's provider had been contacted and orders obtained on how to manage the wound to her right iliac crest if the wound vac was not available. When interviewed via phone on 3/10/21, at 12:06 p.m. OS at Northwestern Respiratory stated, The on-call service received a call 2/21/21, stating the facility had not received wound vac. Driver was unable to see in the database that a wound vac had already been delivered 2/18/21; therefore another wound vac was delivered 2/21/21. We then picked up the extra wound vac on Wednesday (2/24/21). R2's progress note dated 2/22/21, at 1:36 p.m. included, wound vac changed this shift. When interviewed 3/10/21, 10:50 am, the writer of the note, RN-A, clarified, The wound vac was started, not changed. This was 3 days after admission. When interviewed on 3/10/21, at 10:50 a.m. the assistant director of nursing (ADON), stated the wound vac was delivered 2/21/21 with the incorrect tubing. The ADON stated that the improper tubing delivery 2/21/21, was likely the reason the wound vac wasn't started (2/21/21) once delivered. The ADON stated she was unsure what, if any, wound care had been done between 2/19/21 -2/22/21, when the wound vac wasn't being used. The ADON stated when there was an issue with the wound vac, the doctor should have been notified for an alternate treatment plan. However, R2's provider had not been notified and no wound care orders had been received. R2's Initial Wound Evaluation and Management Summary dated 2/23/21, from a wound physician MD-A, identified a stage 4 pressure ulcer to the right buttocks. The wound measured 8 cm (centimeters) by 5.8 cm by 3.1 cm. The wound contained undermining (occurs when the tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wound's edge) present with measurements 2.5 cm at 1 o'clock (location of undermining in comparison to the time on a clock). Drainage was described as moderate sero-sanguineous (yellowish with small amounts of blood). Wound bed showed 100% granulation tissue (light red or pink in color, and moist. An indicator of healing). R2's treatment administration record (TAR) for February 2021, identified R2 was to receive the physician ordered treatment to the right iliac 3 times per week on Tuesdays, Thursdays and Saturdays. The treatment ordered was: change right iliac crest dressing and perform wound care three times per week. Irrigate wound thoroughly with Microcyn (antimicrobial wound cleanser) wound cleanser. Pat dry. Paint intact skin surrounding wound with [MEDICATION NAME]- no sting barrier film. Cut wound vac (foam dressing in the wound bed connected to suction, to help aid in wound healing) foam dressing to fit wound and apply to wound bed. If bridging, (intact skin between open areas) be sure to apply drape to intact skin under the foam to protect skin from injury. Cover foam and bridge with vac drape to achieve seal. Set negative pressure at 125 mm Hg (millimeters of mercury/ a unit of pressure) continuous. The treatment was not signed out as being completed on Saturday 2/27/21, with the last treatment being identified on 2/25/21. When interviewed via phone 3/11/21, at 10:52 a.m. registered nurse (RN)-B stated she worked the evening of 2/27/21, and was unable to complete scheduled wound care during her shift due to not enough time. RN-B reported to LPN-C that wound care to right iliac crest still needed to be completed. When interviewed via phone 3/10/21, at 12:29 p.m. LPN-C stated she worked the evening of 2/27/21, and was not notified by RN-B that the wound care still needed to be completed for R2's right hip. LPN-C did not note the treatment had not been signed out by the previous shift. R2's Wound Evaluation and Management Summary dated 3/1/21, completed by MD-A, noted measurements of 7.2 cm x 6 cm x 3.2 cm. The undermining measurement was 5.2 cm at 5 o'clock. The drainage was described as moderate amount of serous (thin and watery and usually clear to yellowish or brownish appearance). The wound bed was described as 50% slough (yellowish/white material. Consists of dead cells that harbor organisms like bacteria, fungus, etc and slow/stop healing process. It can increase the risk of infection) and 50% granulation tissue. The summary also identified the wound progress had, Deteriorated, a culture was taken and an antibiotic started. The would required surgical debridement and a [DIAGNOSES REDACTED]. R2's late entry progress note dated 3/2/2, 4:05 a.m. included, At around 2 to 3 am resident's wound vac was beeping, and upon checking it was clogged, writer and the aide tried to look for an extra to replace the canister (the canister collects the wound drainage from the wound vac) but can't find anything. Contacted the supplier to ask if can deliver the canister ASAP and the lady the writer spoke with, will try if the (sic) can and promised to call back. And the other nurse received a call back and she was told that the canister will be delivered in the morning, during business hours, 3.2.21. Res (resident) turn off the machine since it was beeping and distracting. Will endorse to the AM nurse. When interviewed 3/10/21, at 10:50 a.m. the ADON stated there were numerous canisters in the box when the wound vac had been delivered and did not know why there had been none available to replace the canister on 3/2/21. If there were no canisters available the nurse should have contacted the provider and request a different treatment order. R2's progress note dated 3/2/21, at 5:23 p.m. included, Resident sent Abbott Northwestern hospital via Allina EMS at 1720 (5:20 p.m.). When interviewed via telephone on 3/9/21, at 9:32 a.m. R2 stated, she was sent to Abbott Northwestern Hospital 3/2/21. She was admitted to the nursing home 2/19/21 and stated the staff at the facility started the wound vac on 2/22/21. No other treatment to her right hip had been completed while waiting for the wound vac to arrive. The wound care was ordered for 3 times per week, and the last date of the wound care was 2/25/21. The wound care scheduled for 2/27/21 was not performed, she did not know why. The dressing did not get changed and wound care did not get completed again until 3/2/21 when the wound care doctor came. Overnight on 3/1/21, the, machine started beeping and the staff were unable to get it to stop. She reported that the canister on the wound vac was full and the staff were unable to find a replacement, so they turned the wound vac off. The wound vac remained off until the wound care doctor came and evaluated the wound. The wound doctor reported to her that the wound, wasn't clean enough to restart the wound vac. R2 stated the hip infection turned out to be a staph infection (an infection caused by a bacteria found on human skin, in the nose, armpit, groin, and other areas). When interviewed 3/9/21, at 2:05 p.m. wound doctor MD-A stated the wound on the right hip, looked good on her first visit (2/23/21), it was nice and granular. On the second visit (3/1/21), she was concerned about the hip wound. (R2) told her they wouldn't change the dressings. The hip wound had deteriorated. It was gray and odorous, which was a, huge change, from the previous week when had seen it. MD-A stated, the nurse told her they had issues with the wound vac cartridge and hadn't been running the wound vac since the previous night. MD-A was going to restart the wound vac after wound rounds, but the wound, wasn't clean enough to put the wound vac back on. MD-A called the primary physician's nurse practitioner (NP)-A and told her the wound looked infected. NP-A decided to send R2 to Abbott Northwestern Hospital. When interviewed 3/10/21, at 4:03 p.m. NP-A stated the main reason she sent (R2) to the hospital on [DATE], was for issues with uncontrolled pain and for a wound evaluation. (R2) was experiencing increasing pain after her recent spine surgery. NP-A received a call on 3/2/21 from MD-A stating R2's wound looked infected and MD-A had written new wound care orders and started antibiotics. NP-A contacted the physician assistant for (R2)'s neurosurgeon to inform them of her uncontrolled pain. The neurosurgery physician assistant requested (R2) be sent to the emergency department for imaging and an infectious disease evaluation. NP-A was unaware that the wound vac that was ordered to be started on the day of admission, 2/19/21, was not started until 2/22/21. NP-A was also unaware that on 3/2/21, between 2:00 am - 3:00 am, there was a problem with the wound vac, and since there was no replacement canister in the facility, the machine was turned off. NP-A stated, the delay in starting the wound vac, not obtaining alternate orders, missed dressing change on 2/27/21, and shutting the wound vac off on 3/2/21, would have resulted in deterioration of the pressure ulcer. NP-A stated she should have been notified of all of these issues, and if had been notified, would have made order changes. When interviewed by phone on 3/11/21, at 9:25 a.m. NP-A stated, the provider should have been notified, if they don't have the proper equipment, or the ability to do wound the wound care. When interviewed by phone on 3/11/21, at 11:03 a.m. MD-A stated, the delay in starting the wound vac, with no other treatment ordered, the missed wound care on 2/27/21, and shutting the wound vac off with no other treatment orders could have the caused deterioration to R2's iliac crest pressure ulcer. When interviewed by phone on 3/11/21, at 9:00 a.m. R2's social worker at Abbott Northwestern Hospital stated, R2 was readmitted because of worsening low back pain and for wound evaluation. They found she has some infection. Per the Infectious Disease note, she has staph aureus in the blood (sepsis) which may be originating from sacral wound, or may be originating from the spine as MRI (magnetic resonance imaging, a form of x-ray) showed. Per infectious disease note, they are not clear of the origin of [MEDICAL CONDITION]. A Wound Care procedure document dated October, 2010, indicated the purpose was to provide guidelines for the care of wounds to promote healing. This document indicated the following information should be recorded in the resident's medical record: the type of wound care given, the date and time the wound care was given, the position in which the resident was placed, the name and title of the individual performing the wound care, any change in the resident's condition, all assessment data (wound bed color, size, drainage, etc.) obtained when inspecting the wound, how the resident tolerated the procedure, any problems or complaints made by the resident related to the procedure, if the resident refused the treatment and why, and the signature and title of the person recording the data. This document also included, what to report: Notify the supervisor if the resident refuses the wound care. Report other information in accordance with facility policy and professional standards of practice. A facility Skin Assessment and Wound Management policy, last revised, July 2018, provided guidelines for assessing and managing wounds. The policy directed that with ongoing skin problems related to pressure ulcers, document skin condition on the Pressure Wound Evaluation weekly, until healed; update provider and resident/representative as needed; review skin concerns with interdisciplinary team at least monthly; update care plan as needed. It also indicated wound care will be provided per nursing or provider order; document treatment or refusal of treatment in the resident's medical record.

Based on observation, interview and document review, the facility failed to comprehensively assess and implement interventions to reduce the risk of falls for 2 of 3 residents (R1, R3) reviewed for accidents. This resulted in actual harm for R1 who fell multiple times without being assessed, and obtained a [MEDICAL CONDITION] which required emergency medical care. Findings include: R1's Hospital Discharge Summary printed 1/13/20, identified R1 was being discharged from the hospital to the nursing home with a principle [DIAGNOSES REDACTED]. R1's fracture had been deemed as a non-operative fracture, and R1 was sent to the nursing home with pain medication and orders for physical therapy. A section labeled, After Discharge Orders and Instructions, was listed which identified R1 had orders for activity and weight bearing as tolerated with dictation reading, Nursing staff to re-evaluate and modify as appropriate. Further, the summary identified R1 had been assessed as being at high risk for falls while admitted to the hospital. R1's 5-Day Minimum Data Set ((MDS) dated [DATE], identified R1 had intact cognition, and required extensive assistance with his activities of daily living (ADLs). Further, R1 had sustained falls within the month prior to his admission to the nursing home, however, had sustained no falls since his admission. A telephone call was placed to R1's family member (FM)-A on 2/20/20, at 11:51 a.m. A return call was provided on 2/20/20, at 4:12 p.m. from FM-A who explained R1 had admitted to the nursing home from the hospital after he fell and sustained a left [MEDICAL CONDITION]. FM-A expressed significant concern as after R1 admitted to the nursing home, he proceeded to fall several times and, at times, sustained injuries including hitting his head where he cracked it open and had to be sent to the hospital, where he received treatment and a CT scan. FM-A stated she kept voicing concerns to the facility about R1 and his safety, however, the facility was just not very responsive, so FM-A voiced she visited R1 frequently as she didn't feel like he was safe there. R1 spent a majority of his time in his room and in his wheelchair, and FM-A expressed the facility would call her after R1 would fall and just kept voicing to her there was nothing to worry about, and never really did update her with their new interventions or actions to help keep R1 safe until she was able to get hold of the director of nursing (DON). The DON explained different things which were being done which included hipsters (cushioned briefs) and anti-roll brakes on R1's wheelchair, however, at no time had there been discussion about increasing R1's supervision (i.e. safety checks, one to one). FM-A stated the supervision of R1 was important as he had paralysis on one side of his body, and if his call light was not answered timely, he would attempt to do things on his own. FM-A explained R1 never had any type of grab bar or bed rail attached to his bed, which FM-A stated she had requested, however, was told it was considered a restraint and was not allowed. FM-A voiced she was frustrated with that response, as a grab bar or rail would have helped make sure R1 didn't fall from bed and would help him stay stable while he stood at the bedside to void using his urinal. R1's initial MHM Fall Review Evaluation dated 1/11/20, identified R1 had sustained falls within the past six months prior to admission. R1's medication use was reviewed which included hypoglycemics, antihypertensives, narcotics and sedatives, and R1 was recorded as being alert and orientated to person, place and time. R1 had no sensory deficits identified and no orthostasis (sudden change in blood pressure with position change) present, however, R1 was identified as being unable to independently come to a standing position. The assessment identified two additional sections to be completed which included Environmental Factors and Summary/Interventions. However, these sections were left blank. R1's subsequent MHM 48-hour Baseline Care Plan V-2, dated 1/14/20, identified a section labeled Fall Risk, along with options to select to identify R1's needs. The plan identified a checkmark placed next to Focus: Fall Risk related to, and Goal: Resident will be safe and free from falls, which identified the section would be applicable to R1, however, the remainder of the section, including areas to write out and checkmark subsequent interventions, were all left blank and not completed. There were no recorded fall interventions on the temporary, baseline care plan to help ensure R1 remained safe and free of falls until his comprehensive care plan (completed within 21 days after admission) would be completed. However, an electronic care plan initiated 1/14/20, identified R1 as a fall risk due to his left [MEDICAL CONDITION], and listed out three falls which happened on 1/15/20, 1/18/20, and 1/20/20. A goal was listed which identified, (R1) will be safe and free from falls, and listed four interventions including anti slip grips to the floor by his bed (initiated 1/15/20), anti tips to his wheelchair (initiated 1/18/20), gripper socks (initiated 1/18/20), and hipsters at all times except bathing (initiated 1/21/20). Both care plans lacked information or interventions which had been assessed or implemented upon R1's admission to the nursing home, despite being hospitalized for [REDACTED]. R1's progress note(s) and medical record identified the following recorded entries: On 1/11/20, a progress note identified R1 admitted to the nursing home from Mercy hospital where he had been due to a left [MEDICAL CONDITION]. On 1/13/20, a progress note identified R1 as being alert and orientated to time, person, and situation. The note continued, (R1) able to move about in bed and get up to sitting position on his own. He is using the urinal to void. Stand up at bedside to useit (sic) and wants to be as independent as he is able. A subsequent note on 1/13/20, identified R1 had met with members of the interdisciplinary team (IDT) to review his care needs. R1 declined a copy of their initial care plan. However, the note lacked any dictation or evidence R1's fall risk had been reviewed and discussed with him, nor did the note contain any evidence of which fall interventions, if any, were in place after R1 had been admitted to the nursing home for two days. On 1/14/20, a progress note recorded R1 as being up in his wheelchair for several hours and, Attempting to transfer self onto toilet, but is unsteady-became upset when writer attempted to assist him. Further, R1 was recorded as appearing unhappy and complained of different things including, . that he doesn't need as much help as we want to give him. On 1/15/20, at 12:30 a.m. an 'SBAR (Situation, Background, Assessment, Recommendation) - Change of Condition' progress note identified the staff heard R1 yelling from his room, and responded to find him sitting on the floor with his back resting against the bed. R1 reported he was standing up to use the urinal when his left hand (affected side) slid off the bed, and caused him to lose his balance and fall. R1 denied hitting his head, and was able to move all extremities as prior. The section of the noted labeled Assessment identified R1's vital signs and he sustained no injuries, however, dictation read, . although (R1) states he thinks he will have a bruise on his left hip. Further, the final section of the note was labeled Recommendations and identified, (R1) states that his left hand was not positioned correctly on the bed and that is why it slipped. Asked him if he could call for help but this seems unlikely as he is very independent. Told him he could also attempt to use urinal lying down. The note lacked any assessment of R1's condition or actions immediately prior to the fall, including his last time voiding, recent oral intake, medications consumed within the past few hours which could have contributed to the fall, or any assessment or actions to address R1's voiding habits or routines despite having fallen while attempting to use the urinal. A subsequent progress note on 1/15/20, identified the DON had been updated on R1's fall. R1 was recorded as sleeping most of the remainder of the night, and used the urinal by sitting up on the edge of the bed instead of standing. R1 reported his left leg hurt and rated his pain as an eight out of 10 (10 being the worst). Further, an additional note, dated 1/15/20, identified FM-A had been updated on R1's fall, and requested an x-ray be completed since he fell on to his affected side. A corresponding North Star Mobile X-ray report dated 1/17/20, identified R1 did not sustain a fracture or acute injury as a result of the fall on 1/15/20. R1's corresponding incident report dated 1/15/20, identified R1 was found sitting on the floor with his back to the bed and legs extended. R1 voiced he was using his left hand to prop himself up while standing at the bedside to use the urinal, when his hand slipped and caused him to lose his balance. R1 sustained no injuries as a result of the fall. The report continued, (R1) is very independent -- does not want help --I can do it. A section labeled Predisposing Physiological Factors identified R1 had an unsteady gait, history of falls, gait imbalance, and consumed several medications on a routine basis including [MEDICAL CONDITION] and anticonvulsants. Further, the report outlined a section labeled Predisposing Situation Factors which identified, Responding to toileting needs. The report lacked any data or reference to the last time R1 had voided prior to his fall, or any immediate interventions taken to ensure R1 was safe and did not fall again while trying to void using the urinal. R1's corresponding MHM Incident Review and Analysis V-3 dated 1/16/20, identified R1's fall from 1/15/20, was reviewed which identified it as, Fall from bed. The form listed a total of four sections to be completed. The section labeled Incident Analysis outlined several sections to be completed including describing any causal factors of the fall, and included several written prompts including any toileting factors, time of day,and environmental factors. However, this section had none of that prompted data and listed, Fall occurred during (night) shift. There was no recorded data or analysis of R1's toileting factors, or environmental factors despite these being listed as prompts within the assessment. The section provided additional spacing to write any identified contributing factors, and listed several prompts for this section including diagnoses, cognitive status, and consumed medications. This section was dictated with, Resident was admitted [DATE] with femoral neck fracture, [MEDICAL CONDITION] from cerebral infarction affecting left side. There was no recorded mention of R1's cognitive status, other medical diagnoses, or consumed medications despite these being listed as prompts within the assessment. The assessment continued and listed a section labeled, Follow-up/Interventions, which asked for current interventions in place which read, See Care plan. A series of other interventions were listed which could be selected as being implemented at that time by placing a checkmark next to them; these included several examples to help reduce the risk of falls including anti-roll brakes to the wheelchair, changes to the resident' toileting plan, environmental changes, and signage being placed in the room to remind to ask for assistance. However, none of these were selected and they were all left blank, however, dictation was present underneath these which outlined, Intervention: anti slip strips to floor in front of bed, gripper socks to be worn at all times except while bathing. Further, the assessment had various things to place a checkmark next to when completed which included completing staff education, updating the care plan, and, Appropriate assessment/s completed. These were all selected with a visible checkmark placed next to them. The final section of the form was labeled Additional Notes which recorded R1 was attempting to use the urinal independently at his bedside when he slid off the bed. The note continued, (R1) can be impulsive and unaware of safety limitations. The assessment concluded with the DON's signature and date. On 1/18/20, at 12:51 a.m. an 'SBAR' progress note was recorded which identified R1 had sustained another fall. R1 had been sitting up in his wheelchair when it had tipped over. R1 was found laying on his right side, with the wheelchair on it's side next to him, and the note outlined, . has (history) of falls, this is the second fall this week. R1 received a 2 by (x) 2 centimeter (cm) abrasion on his forehead which was cleansed and a small dressing applied. However, the remainder of the note sections, including 'Response' and 'Recommendations' were left blank and not completed. R1's corresponding incident report dated 1/18/20, identified R1 was found on the floor by the nursing assistant (NA) staff laying on his right side. R1 voiced he was trying to go to bed and the report writer had witnessed him playing computer games earlier, however, the report did not clarify a time frame. R1 received a small abrasion on the (right) side of forehead, cleansed and bandage applied. A section labeled Predisposing Environmental Factors identified R1's failed to lock his wheelchair brakes, and was confused and had a recent change in condition. However, again, the report lacked any identified immediate interventions taken to ensure R1 did not sustain another fall from his wheelchair. R1's corresponding MHM Incident Review and Analysis V-3 dated 1/21/20 (three days after R1 fell ), identified R1's fall from 1/18/20, was reviewed which identified it as, Fall from chair or wheelchair. The form listed a total of four sections to be completed. The section labeled Incident Analysis outlined several sections to be completed including describing any causal factors of the fall, and included the same written prompts including any toileting factors, time of day,and environmental factors. However, this section had none of that prompted data and listed, See care plan. There was no recorded data or analysis of R1's toileting factors, environmental factors, or explanation of what R1 was doing at the time of, or immediately prior to the fall, despite these being listed as prompts within the assessment. The section provided additional spacing to write any identified contributing factors, and listed several prompts for this section including diagnoses, cognitive status, and consumed medications. This section was dictated with, Cerebral infarction affecting left side, femoral neck (fracture). There was no recorded mention of R1's cognitive status, other medical diagnoses, or consumed medications despite these being listed as prompts within the assessment. The assessment continued and listed a section labeled Follow-up/Interventions which asked for current interventions in place which read, Resident to wear gripper socks at all times except while bathing, anti tips to wheelchair. A series of other interventions were listed which could be selected as being implemented at that time by placing a checkmark next to them; these included several examples to help reduce the risk of falls including anti-roll brakes to the wheelchair, changes to the resident' toileting plan, environmental changes, and signage being placed in the room to remind to ask for assistance. However, none of these were selected and they were all left blank and no further dictation was present in the section of the assessment. Further, the assessment had various things to place a checkmark next to when completed which included completing staff education, updating the care plan, and, Appropriate assessment/s completed. However, the option to select and identify the appropriate assessments had been completed was left blank and unchecked. The final section of the form was labeled Additional Notes which recorded R1 was attempting to get into bed independently when his wheelchair tipped over and he fell . R1 was recorded as being cognitively impaired and not remembering his physical limitations. The assessment concluded with the DON's signature and date. On 1/18/20, a progress note was recorded which identified FM-A had called the nursing home to discuss R1's falls. R1 had sustained two falls thus far, and FM-A was recorded as wondering why R1 had fallen, and continued to fall. The staff explained R1 had anti-slip strips installed next to his bed, and reviewed R1's pain medication consumption and blood glucose levels with FM-A to see if a correlation had been present. Further, FM-A was told the facility would have the physician or provider see R1 at the next facility visit on 1/20/20. However, R1's medical record lacked evidence of a physician and/or provider visit being completed on 1/20/20. On 1/21/20, at 2:14 p.m. a progress note identified R1 had fallen in the bathroom while trying to pull himself up on the grab bar, but his hand kept slipping down the grab bar so he went to the ground. R1 denied hitting his head and had normal range of motion. A subsequent note, dated 1/21/20, identified a clarification which read, The hand splint was on the left hand, during R1's fall. R1's corresponding incident report dated 1/21/20, at 2:21 p.m., identified R1 fell from the toilet and was on the floor when the report writer responded. R1 denied hitting his head, however, did complain of left hip pain. R1 was recorded as having a hand splint in place which therapy was trialing for him and that hand slipped on the grab bar. R1 reported his hand was slipping down the grab bar while attempting to rise from the toilet, so he lowered himself to the floor. R1 was recorded in the report as having a history of falls, being forgetful, and not being able to always realize his limitations. However, the report again lacked any information on if immediate interventions were taken to prevent similar fall recurrence. R1's corresponding MHM Incident Review and Analysis V-3 dated 1/22/20, identified R1's fall from 1/21/20 at 2:21 p.m. was reviewed which identified R1 had been, Found on floor. Again, the form listed a total of four sections to be completed. The section labeled Incident Analysis outlined several sections to be completed including describing any causal factors of the fall, and included the same written prompts including any toileting factors, time of day,and environmental factors. However, this section had none of that prompted data and listed, Resident was attempting to take off his pants independently. There was no recorded data or analysis of R1's toileting factors, environmental factors, or explanation of what R1 was doing at the time of, or immediately prior to the fall, despite these being listed as prompts within the assessment. The section provided additional spacing to write any identified contributing factors and listed several prompts for this section including diagnoses, cognitive status and consumed medications. This section was dictated with [MEDICAL CONDITION] from cerebral infarction affecting left side. There was no recorded mention of R1's cognitive status, other medical [DIAGNOSES REDACTED]. The next section labeled Follow-up/Interventions which asked for current interventions in place which read, See care plan. A series of other interventions were listed which could be selected as being implemented at that time by placing a checkmark next to them; these included several examples to help reduce the risk of falls including anti-roll brakes to the wheelchair, changes to the resident' toileting plan, environmental changes, and signage being placed in the room to remind to ask for assistance. However, none of these were selected and they were all left blank, however, dictation was present which read, Hipsters to be worn at all times except while bathing. Further, the assessment had various things to place a checkmark next to when completed which included completing staff education, updating the care plan, and, Appropriate assessment/s completed. These were all checked as being completed. The final section of the form was labeled Additional Notes which recorded R1 was attempting to remove his pants when he stood up and lost his balance causing him to fall which resulted in a laceration to his forehead. The note identified R1 was noted to have increased weakness over the previous two days, and concluded with dictation which read, . was sent to ER (emergency room ) for evaluation and closure of laceration. Resident does not always remember his physical limitations, resident did not call for assistance with removing his pants. The assessment concluded with the DON's signature and date. There was no evidence in R1's progress note completed on 1/21/20 at 2:14 p.m., R1 had sustained an injury to his head which was reflected in the corresponding MHM Incident Review and Analysis assessment which reviewed the fall on 1/21/20, at 2:21 p.m. On 1/21/20, at 8:44 p.m. an 'SBAR' progress note was recorded which identified staff heard a noise in R1's room, and entered to find R1 on the floor. The note outlined, . found resident face down on the floor, blood on floor, and resident's pants were around his ankles. R1 was identified as having increased weakness for the past couple days and had sustained another fall, on the same date, prior in the afternoon (2:14 p.m.) due to self transferring. The note identified 911 was called and R1 was recorded as having an injury which read, . 2 - 3 cm (centimeter) lac (laceration) noted mid fore-head, bleeding profusely. R1 stated he was sitting in the wheelchair and trying to get his pants off when he fell . R1 was transported to the Emergency Department (ED) for his sustained injuries. A subsequent note dated 1/22/20, identified R1 returned from the ED with a bandage present on his forehead. R1 had laboratory work completed along with multiple CT scan(s) in the ED which showed no changes and added, Hospital could find no reason for increased weakness or falls. Further, the note added, (R1) stated they used 'surgical glue' on his [MEDICAL CONDITION]. R1's corresponding incident report dated 1/22/20, identified staff heard a noise in R1's room and responded. R1 was recorded as, . face down on floor, blood on face and floor, residents pants were around his ankles. R1 voiced he was trying to remove his pants and fell forward from the wheelchair. The report identified staff held pressure to a wound on his mid-forehead and called 911. R1 received a laceration to the top of his scalp and was listed as, lethargic (drowsy). A recorded environmental factor was listed, Failure to lock w/c (wheelchair) brakes, along with several other factors including R1 being forgetful, having an unsteady gait and a history of falls. There was no recorded evidence on the report regarding if R1's wheelchair had anti-roll brakes installed on them or not when this fall occurred, despite that intervention being identified as needed from a prior fall (1/18/20). R1's After Visit Summary dated 1/21/20, identified R1 was seen in the ED for a fall with subsequent [MEDICAL CONDITION]. A series of imaging tests were completed which included CT scan(s) and an EK[NAME] The indication of the CT scan(s) was recorded as, Head trauma, mod-severe, and, Neck trauma, midline tenderness. No acute findings were identified, however, discharge instructions to care for R1's recorded [DIAGNOSES REDACTED]. There were no identified MHM Incident Review and Analysis assessment(s) identified in R1's medical record which formally addressed or assessed R1's fall on 1/21/20, at 8:44 p.m. which resulted in R1 obtaining a [MEDICAL CONDITION], and requiring emergency care in the ED. A Twin Cities Physicians progress note dated 1/22/20, identified R1 was seen by his physician for , 2nd fall in week, med (medication) review. R1 was a [AGE] year old male with a past medical history significant for stroke with resulted left sided weakness, depression, and diabetes mellitus. R1 admitted to the nursing home for therapy, however, was recorded as not been making good progress and appears to be increasingly fatigued. R1's [MEDICAL CONDITION] and [MEDICAL CONDITION] was evaluated which identified R1 had a history of [REDACTED]. A section labeled Review of Systems identified R1 as sedated but easily arousable, and had dictation which read, Gen: No falls, fevers, chills (complaints of) fatigue. A physical examination was completed which identified, Bruise on forehead. An assessment and plan was listed which identified R1 consumed multiple medications which could increase his fatigue and sedation, so some would be decreased. However, the completed note lacked any additional dictation or assessment of R1's repeated falls to ensure potential trends, causative factors or subsequent nursing-provided interventions (i.e. increased supervision, toileting habits analysis) were identified and implemented to reduce R1's risk of continued falls despite having sustained four falls, including one with a [MEDICAL CONDITION], prior to the note being completed on 1/22/20. On 1/23/20, a progress note was recorded which identified R1 was transferred back to the hospital and admitted for an elevated temperature and shortness of breath (unrelated to the fall on 1/21/20). R1 did not return to the nursing home. When interviewed on 2/20/20, at 12:15 p.m. nursing assistant (NA)-A stated they recalled R1 and voiced his cognition was not always quite there. R1 was very determined to do things on his own, most of the time, and staff would often find him alone in the bathroom after he self transferred himself there as he didn't like to wait. NA-A expressed she did not recall R1 ever being placed on more supervision specific interventions, such as 30 or 15 minute checks for safety, however, felt it had been implied by some of the nurses so they tried to keep him out of his room and by the nursing station. However, NA-A added, this was not done until towards the very end of his stay at the nursing home. When interviewed on 2/20/20, at 2:13 p.m. NA-B stated they recalled R1 as someone who liked to transfer himself a lot. NA-B recalled R1 had fallen trying to pull his pants up on 1/21/20, when they had to call the ambulance to take him to the ED for a head injury. NA-B stated they often reminded R1 to use his call light, however, he often would not use it and just self transfer as he thought he could do it on his own. NA-B stated she had thought not keeping R1's wheelchair next to his bed would maybe stop him from self transferring and remind him to use the call light, however, verified they didn't do that with him. NA-B stated she did not recall R1 ever being placed on formal checks for safety, despite his known history of self transfers and not using the call light, and verified the NA staff were not doing them during R1's stay at the nursing home adding the nurses should have been the one's doing them if they were needed. R1's medical record was reviewed and lacked evidence R1 had ever been comprehensively assessed for his fall risk despite having an identified history of falls with injury upon admission, nor was there evidence of any interventions being placed prior to R1's initial fall at the nursing home despite having this history. The record lacked evidence R1 was comprehensively assessed or reviewed after each subsequent fall to ensure causal factors were identified and appropriate interventions were determined and placed, including reviewing R1's toileting habits despite multiple falls occurring while attempting to void without physical assistance; nor did the record demonstrate R1's direct supervision needs (i.e. safety checks) were assessed or increased despite multiple falls while attempting to self transfer and being repeatedly identified as impulsive and un-accepting of help. On 2/21/20, at 8:10 a.m. the physical therapy assistant (PTA)-A and certified occupational therapy assistant (COTA)-A were interviewed and voiced they both recalled R1's stay at the nursing home. R1 had reported falling 60 times within the past year to them and the main focus of his therapy was gait training. COTA-A recalled R1 as a pretty high fall risk and recommended assistance with all transfers as a result, however, R1 often didn't follow recommendations due to his cognition. R1 was stubborn and very impulsive, and PTA-A stated his transfers were pretty sketchy. They reviewed R1's treatment plan and voiced they had noticed a decline with R1's cognition during his stay at the nursing home which seemed to accelerate towards the end of his stay. This resulted in staff even having to use a mechanical lift to transfer him. They recalled R1 had sustained repeated falls during his admission to the nursing home which resulted in staff trying to keep a closer watch on him towards the end of his stay, however, they could not recall any formal safety checks or one to one supervision ever being done for R1. PTA-A and COTA-A expressed there were several interventions which could be implemented for someone who was impulsive or had cognitive impairment, including hanging signage in their room to remind them to ask for help, providing more constant supervision, and setting up toileting schedules to better try to meet a resident' need before they self transfer. When questioned if R1 ever had signage hung in his room directing to ask for assistance, PTA-A responded, I don't remember. On 2/21/20, at 8:35 a.m. the DON and regional nurse consultant (RNC) were interviewed as R1's medical record was reviewed. DON explained the person who completed R1's initial fall risk evaluation (MHM Fall Review Evaluation dated 1/11/20) should have recorded if there were any environmental hazards, and completed the assessment' summary to identify their findings and subsequent actions taken to decrease R1's risk of falls. DON verified the lack of documentation in the assessment, and stated it was not done, adding it should have been completed to demonstrate what actions were identified and taken to keep him safe. RNC acknowledged these findings and expressed, I agree. R1's temporary care plan was reviewed, and DON verified the lack of recorded interventions being identified upon R1's admission. DON stated there should have been interventions identified on the care plan and the lack of them was concerning, however, DON expressed she recalled several interventions had been put in place and just not documented on the temporary care plan. DON explained the facility' process when a fall happens included assessing the resident for injuries immediately after a fall, documenting the incident in the 'risk management' system (the completed incident reports), and placing an immediate intervention to help prevent additional falls while the IDT meets to review the fall and help determine the root cause of it. DON reviewed each of R1's completed incident reports in the 'risk management' section of the record and stated they each lacked evidence of what immediate interventions were put into place to help prevent continued falls for R1. DON expressed, I can see where you're (surveyor) going. DON explained each subsequent intervention taken for R1's falls and reviewed each completed MHM Incident Review aloud. The DON acknowledged she was aware R1 was impulsive, so they felt gripper slippers and anti-slip strips would make it safer while R1 stood to urinate after his first fall on 1/15/20, however, the DON verified the assessment piece of the review (i.e. assessing causative and contributing factors) had not been completed correctly. R1's sustained a second fall on 1/18/20, which they added anti-roll brakes to his wheelchair to help prevent it moving if he attempted to stand up, however, again, acknowledged the evaluation of causative and contributing factors was not completed correctly. On 1/21/20, R1 sustained a fall while in his bathroom after he self transferred. DON stated their thought process then turned to more prevention of

Based on observation, interview and document review, the facility failed to identify, assess, monitor and implement interventions to prevent mechanical injuries for 1 of 1 residents (R15) who was reviewed for catheter care. This resulted in actual harm for R15 who developed a mechanical injury to his genitals secondary to urinary/catheter care. Findings include: R15's quarterly Minimum Data Set ((MDS) dated [DATE], identified R15 admitted to facility on 7/2/19, was cognitively intact and required extensive assistance with activities of daily living (ADL's). R15 had an indwelling catheter. Further, the MDS indicated R15 was at risk for developing pressure ulcers, and did not have any current pressure ulcers or other identified skin problems. R15's urinary Care Area Assessment (CAA) dated 7/2/19, identified R15 had a Foley catheter in place, required assistance with toileting needs and incontinence care. Although the urinary CAA identified R15 was at risk for skin breakdown, the CAA failed to identify any current skin conditions. R15's Pressure Ulcer/injury CAA dated 7/15/19, identified R15 required some assistance with bed mobility, was at risk for skin breakdown and had intact skin. R15's Hospital Discharge Summary stated 7/2/19, identified no skin concerns on examination. R15's care plan revised 7/18/19, identified R15 had a Foley catheter related to [MEDICAL CONDITION], with a goal of: R15 would be free of complications of indwelling catheter. Interventions included: assist of one with toileting, monitor for sign of bladder infection, change Foley catheter according to facility policy and Foley catheter care according to facility policy. The care plan lacked any interventions to prevent skin breakdown or mechanical injury from the catheter. R15's Hospital Operative Report dated 9/17/19, identified R15's Foley catheter was slightly eroding on the ventral portion (undersurface of penis) of the urethra (duct that transmits urine from the bladder to the exterior of the body during urination). The hospital report did not identify any interventions, measurements or further description of R15's penile erosion. R15's progress note(s) identified the following: - 9/20/19, R15 had stated to nurse I think my catheter is in the wrong hole. Nursing checked and documented the catheter was inserted into the left side of penis. No further assessment , intervention or follow through was documented. There was no indication there was additional erosion or damage at the catheter site. -10/17/2019, R15's Foley catheter was changed using sterile technique; there was a small amount of blood. The procedure was tolerated well. This documentation did not reflect any changes in the structure of R15's head and shaft of penis. -10/19/19, R15's catheter was intact, with no additional documentation to reflect any abnormalities. R15's weekly skin assessments identified the following: - 8/1/19, No overt skin issues noted. - 8/8/19, No skin issues noted, skin is intact/warm/moist. - 8/15/19, Groin/perianal areas reddened, no open areas. - 8/22/19, No new skin issues noted. - 8/26/19, No skin alteration noted. - 9/13/19, No issues, skin intact. - 9/20/19, Skin was intact. - 10/4/19, No skin issues noted. - 10/11/19, Coccyx reddened, no other skin issues. - 10/18/19, Sacrum had bleachable redness. R15's Order Summary Report printed 10/25/19, directed staff to change R15's Foley catheter monthly, catheter cares were to be completed twice daily and weekly skin inspection by licensed nurse every Friday evening after bath. On 10/25/19, at 9:30 a.m. R15's genitals was observed with the director of nursing (DON). DON applied gloves, assisted R15 to stand and lowered R15's pants. A foam leg strap, that held the catheter in place slid down R15's leg to the knee level, which pulled on his penis. R15 grabbed the foam leg strap and pulled it upwards himself stating the strap keeps sliding down and pulling on my penis. R15 sat down on side of bed and the foam leg strap again slid back down the leg tugging on his penis. R15 again pulled up the leg strap. R15 stated he always had pain anytime his penis or catheter was moved. The Foley catheter was inserted through the urethra (tube that leads from the bladder through the penis to transport urine). The DON lifted R15's penis, on the ventral side of the glans (head of the penis) and there was a large split approximately 2.5 centimeters long, from the tip through the glans. At the bottom of the glans on the shaft of the penis, there was another split that extended on both sides of the shaft approximately 1.5 cm in length. The catheter tubing eroded from the tip of the glans to the shaft on the ventral portion of R15's penis making the urethral tube to be fully visible. The wound bed was pink in color with no bleeding, drainage, odor or signs of infection. Wound edges were smooth and regular. The DON's raised her eye brows raised and with her mouth partially open, inquired of R15 Does that hurt? R15 stated, it only hurts when you move it. Following cares, and upon exiting room, the DON stated she was unaware R15's penis had even slight erosion, much less to the extent of erosion he had now. When interviewed on 10/25/19, at 9:30 a.m. nurse practitioner (NP) stated she was aware of R15's penis eroding due to the catheter and had read the urology report; however, stated she had not assessed R15's eroded penis despite having read the hospital operative report which identified penile erosion. NP stated on 10/11/19, she had requested the staff use an elastic leg strap with Velcro rather than the flimsy foam one, that slides down, the facility did not provide the recommended strap. Further, the NP stated using the correct catheter strap could have potentially slowed the erosion of R15's penis. NP stated the erosion would continue unless the offending problem, like tension, was removed. NP stated R15 declined reconstructive surgery, when it was offered. However, there was no indication in R15's medical record that reconstructive surgery had been offered to R15. The provider order dated 10/11/19, directed the staff use an elastic leg strap with Velcro, 14 days before the DON was aware of R15's genital erosion. When interviewed on 10/25/19, at 11:00 a.m. licensed practical nurse (LPN)-A stated she had not seen progress notes that identified R15 had any catheter concern or erosion identified. When interviewed on 10/25/19, at 11:14 a.m. DON stated she was not aware a different leg strap had been ordered by the NP. All orders and progress notes were reviewed every weekday morning. DON was not aware how R15's NP order or progress note on 9/20/19, regarding the catheter in the wrong hole was missed. DON further stated if she saw the note with catheter placement concerns, she would have R15 assessed by staff, with the doctor and urologist contacted in follow up. DON was not aware the urologist had identified R15's penile erosion on 9/17/19. When they receive appointment notes the nurses were expected to review the note, enter the progress notes and orders placed into R15's electronic treatment record (ETAR) for monitoring. R15's penis should have been measured weekly to ensure the erosion was not worsening and no infection developed. DON reviewed R15's weekly skin inspections and progress notes and stated the penile erosion was never identified, or assessed, by nursing. Further, This was not a normal body condition and should have been documented and monitored. R15 was admitted to the facility on [DATE], with an indwelling catheter with no concerns regarding skin condition. On 9/17/19 a hospital operative note identified R15 had slight erosion to ventral portion on urethra. On 10/25/19, R15's catheter tubing was observed to have eroded through the skin from the tip of the penis to the shaft causing full tissue loss of the ventral portion of R15's penis The facility failed to identify, assess, monitor and implement interventions to prevent mechanical injuries for R15. This resulted in actual harm for R15 who developed a mechanical injury to the genitals secondary to urinary/catheter care and failure to promptly assess and intervene. A pressure ulcer policy, catheter care policy and assessment policy were requested, however none were received.

Based on observation, interview and document review, the facility failed to immediately report and investigate an allegation of sexual abuse, and failed to implement immediate interventions to protect other residents from sexual abuse when R6 reported having been sexually abused by R5. R5 subsequently sexually abused 5 additional residents (R4, R3, R1, R2, R7). This resulted in psychosocial harm for R3 who was having difficulty sleeping and received a new [DIAGNOSES REDACTED]. The facility failed to comprehensively assess and implement resident specific interventions for R6, R4, R1, R2 and R7, to identify potential changes in their emotional status. In addition, the facility failed to ensure appropriate interventions were implemented to protect all residents in the facility from R5. This resulted in an immediate jeopardy (IJ) situation with the potential to effect all 39 current residents residing in the facility. The IJ began on 12/23/18, when R6 reported having been sexually abused by R5 and the facility failed to report the incident immediately to the administrator and State Agency (SA), and failed to implement immediate interventions to protect other residents from being sexually abused by R5. R5 subsequently sexually abused 5 additional residents (R4, R3, R1, R2, R7). The administrator, interim director of nursing (IDON) and regional director of operations (RDO) were notified of the IJ on 1/9/19, at 6:06 p.m. which was identified as widespread (L). The IJ was removed on 1/11/19, but noncompliance remained at the lower scope and severity level of G, since R3 sustained actual emotional harm. Findings include: R5's admission Minimum Data Set ((MDS) dated [DATE], indicated R5 had moderate cognitive impairment and no symptoms of depression were identified. The MDS indicated R5 had not exhibited any behaviors towards others, and required extensive assistance with activities of daily living (ADLs). The MDS included a [DIAGNOSES REDACTED]. R5's progress note(s) identified the following: - 12/23/18, completed as a late entry, identified R5 was touching R6's legs in the dining room area and telling her he sucks women's legs. R6 was very upset. R5 and R6 were separated. R5 told the nurse he liked legs and R5 wheels himself into female residents rooms. - 12/24/18, R5 was witnessed grabbing a female resident's (R4) vaginal area. R5 was immediately separated from R4. The note indicated R5 was not able to recall the incident when questioned, and indicated the residents would be separated when in common areas. - 12/24/18, R5 was started on 15 minute checks. Nurse practitioner (NP) was notified of resident's actions and ordered labs to rule out infection. Email was sent to the pharmacist for a medication review. - 12/24/18, Spoke to R5's son, family member (FM)-A. FM-A reported R5 had never exhibited sexual behaviors in the past. - 12/24/18, R5 continues on 15- 30 minute checks. - 12/25/18, R5 was on 15 minute checks and went into R2's room and was telling her to open her legs so he can soak (sic) on her crotch. He was immediately taken out and placed at the nurse's station. At lunch he wheeled himself to another table and grabbed R1 on the private part. It was explained to R5 it was inappropriate. R5 did not respond. This note also indicated FM-A was expected to visit R5 that day and speak with him about his behavior. - 12/25/18, Spoke with the facility administrator regarding R5's behavior. - 12/25/18, Call placed to NP and updated her on resident's behavior. Suggested putting resident on a 1:1 while resident was awake. - 12/29/18, R5 was alert and oriented and continued to be on 15 minute checks. No behaviors. - 12/31/18, No concerns per 1:1. R5 has no recollection of entering rooms of peers. No further observation of making sexual inappropriate comments to others. - 1/1/18, R5 continues to be on every 15 minute checks. No behaviors. - 1/2/18, the note indicated, on 12/24/18 R5 was placed on 15 minute checks due to grabbing another resident in the vaginal area in the dining room and making inappropriate statements to R2 and R3. residents were immediately separated. Pharmacist (pharm) D was asked to do a complete medication review to see if his medications may be contributing to R5's increased sexual advances. No issues with medications were identified. NP ordered labs and and R5's son (FM-A) was notified. Resident continued on 15 minute checks. IDT met to discuss discontinuing 15 minute checks based on behavioral charting, no depression symptoms and no further sexually inappropriate behaviors. R5 did not recall any of the incidents and has agreed to meet with psych on 1/3/19. R5's physician orders [REDACTED]. - 12/24/18, monitor sleep status x three days, laboratory work was ordered- complete blood count (CBC) and comprehensive metabolic panel (CMP) today, and push fluids for three days. - 12/25/18, [MEDICATION NAME] (antidepressant) 20 milligrams every morning for dementia without behavioral disturbances. Obtain Urinalysis and Urine culture. - 12/27/18- physician changed [DIAGNOSES REDACTED]. - 1/2/19- OK to see Associated Clinic of Psychology (ACP). R5's lab results identified: 12/25/18, CMP was unremarkable with ranges within normal limits. 12/25/18, CBC, unremarkable with ranges within normal limits. 12/25/18, Urinalysis and Culture were negative for infection. R5's care plan revised 12/27/18, identified R5 had an alteration in behavior and was entering rooms of female peers, making inappropriate verbalizations and gestures of sexual nature. Interventions included: 1:1 12/26/18, through 12/28/18. 15 minute checks through 12/30/18, and 30 min checks effective 12/31/18. Administer medication as ordered, be alert to mood and behavior changes, use kind firm approach, psych visits and medical follow up as needed, encourage family to spend time with resident and document on behaviors. The 15 Minute Checks form for R5 indicated: - 12/24/18, 15 minute checks were initiated at 3:30 p.m. and were completed as instructed. No inappropriate sexual behavior was identified during the checks on 12/24/18. - 12/25/18, During 15 minute checks at 10:00 a.m. R5 was in R2's room telling her to open her legs, he wants to suck on her crotch. During 15 minute checks at 12:00 p.m. R5 grabbed R1 in the private area while in the dining room. Per care plan, R5 was placed on 1:1's on 12/25/18. - 12/26/18, 15 minute checks continued and did not identify any sexual behaviors. - 12/27/18, 15 minute checks continued and did not identify any sexual behaviors; however, there was no evidence R5 was checked on between 4:30 p.m. and 5:45 p.m. - 12/28/18, 15 minute checks continued until 10:15 p.m. No sexual behaviors were identified. There was no evidence 15 minute checks were completed from 10:30 p.m. to 11:45 p.m. - 12/29/18, 15 minute checks continued and did not identify any sexual behaviors. - 12/30/18, There was no evidence R5 was checked on every 15 minutes from 12:00 a.m. until 5:45 a.m. No sexual behaviors were documented. - 12/31/18, 15 minute checks were completed from 12:00 a.m. until 6:00 a.m. There was no documented evidence 15 minute checks were completed from 6:00 a.m. until 1:45 p.m. There were no sexual behaviors identified. - 1/1/19, 15 minute checks were completed without any evidence of sexual behaviors. -1/2/18, 15 minute checks were completed until discontinued at 2:45 p.m. No sexual behaviors were identified. R5's ACP progress note dated 1/3/19, identified R5 was referred to ACP for making sexually inappropriate comments to female peers and entering the rooms of female residents. R5 was ambulatory with a wheelchair. R5 had no psychotic symptoms during their visit. Cognitive impairment was present. R5 reported his mood was up and down and reported having loneliness and would desire a companion. Staff have noticed him aggressively approaching many female residents inappropriately around Christmas. The behavior has not continued. R5 did not recall acting inappropriately but was aware because of the conversation and stated he was aware of his behavior. R5 recognized it was not okay and had not behaved in this manner since. Following the incidents R5 was placed on frequent checks, which have since ceased, due to discontinuation of his behaviors. Interventions included were: obtain reading glasses, provide newspaper, if R5 wanted to attend an activity staff are encouraged to strategically place him away from females, follow up with the female residents affected, staff should be trained to be aware of where R5 is at all times to mitigate future incidents. R5's medical record lacked a comprehensive assessment of his hyperactive sexuality or causative factors. The facility's decision making process was not documented to justify eliminating the frequent checks of R5. R5's (MONTH) 2019 Medication Administration Record [REDACTED]. However, there was no resident specific behaviors identified for staff to monitor. During continuous observation on 1/8/19, from 12:40 p.m. until 3:15 p.m., R5 remained in his room. R5 self transferred multiple times from his wheelchair to his bed. The privacy curtain was closed and R5's bed was near the window, opposite the curtain. Staff were not observed to check on R5 every 30 minutes per his care plan dated 12/27/18. During observation on 1/8/19, at 3:27 p.m. R5 left his room via wheelchair. R5 went past the nurses' station where staff were present. No one asked R5 where he was going. R5 went to the dining room and watched the movie that was playing. R5 watched the entire movie and was seated by himself and was supervised by the therapeutic program director (TPD). During interview on 1/9/19, at 1:52 p.m. R5 stated he vaguely remembered touching female residents inappropriately. He did not recall saying anything sexually inappropriate, but was told he did so. R5 stated he did it because boys will be boys. R5 stated he stopped because he was told he could not act that way and stated, I quit, no big deal. The facility provided an undated incident log of incidents investigated by the facility. The log identified R6, R3, R1 and R2 had each experienced a resident to resident abuse incident with R5. R6's quarterly MDS dated [DATE], identified R6 was cognitively intact and had minimal depression symptoms. R6 required extensive staff assistance with ADL's. The MDS included a [DIAGNOSES REDACTED]. R6's progress notes from 12/20/18, through 1/8/19, were reviewed. A progress noted dated 1/8/19, identified the social worker completed a depression scale in follow up from an incident on 12/23/18. The progress note did not identify the incident but indicated R6 was doing fine. However, R5's progress note dated 12/23/18, completed as a late entry, identified R5 was touching R6's legs in the dining room area, was telling her he sucks women's legs, and that R6 was very upset. R5 and R6 were separated. R5 told the nurse he liked legs and R5 also wheels himself into female residents rooms. During interview on 1/8/19, at 3:04 p.m. R6 stated she was alone in the dining area with R5. R5 started stroking her legs and saying he liked woman's legs. R6 told R5 to stop touching her legs because they were hers. R6 said R5 then stated he liked to suck on women's legs. R6 stated she started moving away from R5 and R5 tried touching her leg again, but then a nursing assistant came into the dining room along with a nurse. R6 could not recall the staff names. R6 said she asked the nurse who R5 was, and told the nurse R5 was being sexually inappropriate and it was not wanted. R6 could not remember the date of the incident but stated it was prior to Christmas. R6 also stated, on a later date maybe a day or two after R5 had touched R6, she witnessed R5 trying to get into R3's room. R6 said a nursing assistant had stopped R5 from going into the room. R6 said she suspected R5 had tried entering her room but left when she'd asked who was entering. R6 said, A couple of days ago, the social worker came in an talked to mer and offered a psychology consult but I declined, that was the only time staff asked about the incident. R6 stated she was not afraid of R6 but he made her uncomfortable. I would be a little uneasy if he was in close proximity (of her) and was not supervised by staff. R6's (MONTH) 2019, MAR indicated [REDACTED]. The entry did not include resident specific behaviors staff were to monitor R6 for, and no behaviors were identified. R6's progress note dated 1/4/19, identified R6 had no further concerns about an encounter with peer who entered her room on 12/23/18. Reviewed any emotional distress and also discussed in house psych services that are available to her. Resident stated she had no further concerns re: the incident and that she was more concerned about her current physical status. Declined offer of psych services, 'I don't need that.' R6's Patient Health Questionnaire 9 (PHQ-9 scale for monitoring depression) identified: -1/4/19- score was 10, indicating moderate depression. -1/8/19- score was 9, indicating mild depression. Although the facility completed follow up depression scales, the facility failed to comprehensively assess R6's emotional status and implement resident specific interventions. A report to the SA was requested for review, the facility failed to provide a report submitted to the SA. During interview on 1/9/19, at 12:37 p.m. the administrator stated she became aware of the incident with R5 and R6 on 12/26/18, during resident interviews. A grievance form was filed but the allegation was not reported to the SA. The administrator stated they did not report the incident between R5 and R6 to the SA because R6 was cognitively intact and R6 stated she felt safe. However, the administrator verified the incident should have been reported to the administrator immediately, and in hind sight should have been reported to the SA immediately, an investigation should have been completed and a report should have been submitted. R4's quarterly MDS dated [DATE], identified R4 had moderate cognitive impairment and required extensive to total dependence of staff for assistance with ADL's. R4 had no symptoms of depression and included a [DIAGNOSES REDACTED]. R4's progress notes from 12/23/18, through 1/9/19, identified: - 12/24/18, Staff reported to writer they saw another resident touch (R4) inappropriately at the dining room table. Residents were immediately separated. Resident was brought back to her room, she denied any pain or discomfort to vaginal area. Two nurses did complete a vaginal exam and there were no areas of redness or concerns identified. Will keep residents apart when in common area. - 12/27/18, Social worker met with resident, no verbalized concerns, no concerns with family regarding the 12/24/18 incident. Resident has not displayed any changes in her mood or behavioral issues. - 1/3/19, Social worker met with resident. Resident was more verbal and stated 'no' when asked if she had any concerns regarding her care or interactions with others. When asked if she would like to talk to someone about how she was doing and coping with things in her life she stated 'no'. Reviewed status, cognition with psychologist. No noted distress in behavior or mood. Per review no clinical justification for psych services at the time. R4's SA initial report was submitted on 12/24/18, which identified a culinary staff member had witnessed R5 wheel his wheelchair next to R4's wheelchair in the dining room where R5 touched R4 in the crotch. Staff intervened and the residents were separated. The investigation report submitted to the SA on 12/31/18, indicated the care plans for R4 and R5 and facility policies were followed. The reported indicated the facility interviewed all residents and completed skin checks on non interviewable residents. The investigation identified employees were interviewed. The investigation identified interventions for R5, which included: R5's family was asked about past sexual behavior, R5 was placed on 15 minute checks (did not identify when), R5 had labs and medications reviewed for causative factors. After another incident on 12/25/18, R5 was placed on 1:1 supervision while awake and 15 minute checks while in bed. The physician prescribed R5 [MEDICATION NAME] (antidepressant) for sexual inhibitions. Staff updated 3 female care plans to monitor for signs of mental anguish and those residents were set up for scheduled psychiatric services. The investigation report also indicated staff had been educated on monitoring for signs and symptoms of mental anguish and signs and symptoms of inappropriate sexual behaviors. Although the nursing schedule for 12/24/18, identified 7 nursing staff working from 6:00 a.m. until 3:00 p.m., an internal investigation identified only one staff member had been interviewed related to R4's allegation of sexual abuse. R4's care plan revised 12/31/18, identified R4's mood status was stable. There were no signs or symptoms of mental anguish related to incident of male resident exhibiting sexual inappropriateness towards her. Interventions included: follow up with family as needed., observe for any changes in resident mood status, psych Services as needed and social services one to one as needed. R4's (MONTH) 2019, MAR indicated [REDACTED]. However, the note did not identify any resident specific behaviors staff were to monitor for and no behaviors were identified. R4's PHQ-9's identified: -1/4/19- score was 3, indicating minimal depression. -1/8/19- score was 3, indicating minimal depression. Although the facility completed follow up depression scales, the facility failed to comprehensively assess R4's emotional status and implement resident specific interventions. R3's admission MDS dated [DATE], identified R3 was cognitively intact and identified moderately severe depression symptoms. R3 required extensive assistance with ADL's. The MDS included [DIAGNOSES REDACTED]. On 1/8/18, at 1:52 p.m. R3 stated R5 came into her room when the door was shut, and started fondling her leg before then fondling her private parts over her clothes when she was in her room seated in her wheelchair. R3 said R5 then asked her to get in bed so he could lick my private area. R3 said she had called for help and an unidentified staff member came and took R5 out of her room. R3 said the staff member apologized and shut the door after removing R5 from R3's room. R3 said she then telephoned her boyfriend because she was afraid of R5. R3 said, About five minutes later (R5) opened the door to my room again and said, 'get on the bed, I want to lick your cunt'. R3 said she yelled again and another unidentified staff member came. R3 said she'd told the staff member what R5 did and the staff member apologized and removed R5 from R3's room and shut the door when she left. R3 said, About five minutes later (R5) returned to my room and opened the door and entered the room again. (R5) repeated I want to lick your cunt. My boyfriend was approaching the room and overheard him say that, and he removed (R5) from the room. I was scared of him and afraid he was going to sexually molest me. I was molested as a child ant it scared me. As R3 was relaying the events that occurred, her voice was quivering and she had tears coming from her eyes. I'm worried he will be back, I don't sleep at night even though they (facility staff) tell me he is on 15 minute checks. A lot can happen in 15 minutes. Every time someone opens her door I am instantly awake and afraid it is (R5). R3 stated she usually stayed up later at night but did not have trouble sleeping when she decided to go to bed, but that it is different now and she can't fall asleep. R3 stated she'd told the interim director of nursing (IDON), a couple days after the incident that she was afraid of R5 and did not feel other woman were safe in the facility. R3 said the IDON had told her they would report the incident to the SA. R3 stated she was offered psych services and had seen psych. R3 said staff were not coming in and asking her how she was feeling, or sleeping, or whether she was afraid of R5 or if there had been any further incidents with R5. R3 stated she did not want to see R5 and was not sure if the facility could do anything to make her feel safe again. She said when she sees R5 in the hallway she turns and goes the other direction. R3 stated she still attended activities but felt safer because staff were present during activities. On 1/9/18, at 9:26 a.m. R3 stated she'd had a nightmare about (R5) last night, it was horrible, I'm thankful it was just a dream. R3 stated she still cried daily regarding R5 and dwelled on what she could have done differently. I pushed him away and yelled , but it was not good enough. What made him think he had the right to to do that to me. R3 said she had so many questions and staff have not provided her with any answers. R3's progress notes from 12/23/18, through 1/9/19 were reviewed and identified: - 12/27/18, a social service note, identified R3 stated she had no further concerns related to the incident with a male peer who made inappropriate comments and gestures. R3 stated she felt safe in the facility. - 12/31/18, Social services met with R3 and resident stated she was coping well with adjustment and recent situation with peer who entered her room. R3 plans to see psych services on 1/3/19. - 1/1/19, at 4:40 a.m. R3 had not slept at all on the shift and had been up watching television and playing on her tablet. - 1/2/19, R3 approached IDON today inquiring about the investigation regarding the incident from 12/25/18. IDON explained the investigation was confidential, but there had been no further incidents. R3 stated she felt safe and was grateful the facility was taking it seriously. R3's SA initial report was dated as submitted on 12/25/18. However, the incident was identified as having occurred on 12/24/18. The initial report indicated R3 had reported she was sexually molested by R5, and that R5 had told her to get into bed because I want to eat your cunt. The investigation report submitted to the SA on 1/2/19, included R3's account of the events from 12/24/18. In addition, the investigative report included: The facility policy was followed along with the care plan. No changes made to the policy or procedures. All residents were interviewed regarding their sense of safety and whether or not they felt others were safe in the facility. Four other female residents reported similar incidents with R5. Residents that were unable to be interviewed received a full body assessment. The investigation identified interventions implemented for R5 including: R5 was placed on 15 minute checks, R5 had labs and medications reviewed for causative factors. After another incident 12/25/18, R5 was placed on 1:1 supervision while awake and 15 minute checks while in bed. The physician prescribed R5 [MEDICATION NAME] for sexual inhibitions. R5 made the same or similar statements to other residents on 12/23/18, 12/24/18 and 12/25/18. The internal investigation identified one staff member had been interviewed related to R3's allegations. The investigation report did not document how R5 had approached R3 three different times or how the incident had occurred. R3's (MONTH) (YEAR), MAR indicated [REDACTED]. The MAR indicated [REDACTED] - 12/25/18, R3 slept 2 hours. - 12/26/18, R3 slept 8 hours. - 12/27/18, R3 slept 8 hours. - 12/28/18, R3 slept 4.5 hours. - 12/29/18, R3 slept 6 hours. - 12/30/18, R3 slept 3 hours. - 12/31/18, R3 slept 1 hour. R3's (MONTH) 2019, MAR indicated [REDACTED] - 1/1/19, R3 slept 1.5 hours. - 1/2/19, R3 slept 2 hours. - 1/3/19, R3 slept 2 hours. - 1/4/19, R3 slept 3 hours. - 1/5/19, R3 slept 7 hours. - 1/6/19, R3 slept 6 hours. - 1/7/19, R3 slept 2 hours. - 1/8/19, R3 slept 2 hours. R3's medical record lacked a comprehensive assessment of R3's sleep patterns in order to identify appropriate interventions. R3's nurse practitioner (NP) progress note dated 1/2/19, identified R3 was tearful and had reported she was sexually assaulted three times by another resident at the facility about a week prior to the visit. R3 stated the resident said vulgar things and touched her vagina while she was clothed. The note further indicated the facility was aware and reports had been made, but R3 still reported she did not feel safe and was wondering what the facility follow up would be. R3 stated she was more depressed. The NP identified the plan regarding reported of increase in depressed mood therapeutic support had been given and psychology was to follow up. Additionally NP discussed R3's concerns with the assistant director of nursing (ADON) and the ADON stated she would follow up with R3 and update her on the plan. R3's physician orders [REDACTED]. R3's ACP progress note dated 1/3/19, identified R3 reported her sleep as poor, due to anxiety about strangers entering her room. R3's mood presented as anxious and depressed with feelings of overwhelm, ruminating thoughts, fears about the future and tearfulness. R3 was tearful and exhibiting signs [MEDICAL CONDITION] following the incident. R3 presented with an emotionally labile mood. Recommendations included: R3 would benefit from R5 apologizing for his behavior, staff had explored changing R5's room, but felt his room was appropriate because his bed was located near the window, staff should consider moving the medication cart to a visible spot so R3 could see who was entering her room, help R3 to feel heard and validate her emotions, R3 would benefit from aromatherapy, Staff should knock and announce themselves before entering her room, R3 was encouraged to incorporate a hobby and R3 would continue to benefits from staff support. R3's care plan revised 1/4/19, identified R3 was coping well related to incident with male resident who made inappropriate gestures and comments. Interventions included: encourage to engage in deep breathing and self care exercises to regulate mood, ensure med cart was not blocking resident view of who is entering her room, follow up with family as needed, monitor hours of sleep within a 24 hour period, observe for any changes in resident mood status, psych services as needed, social services as needed and validate her emotions so she feels heard. R3's PHQ-9's included: -12/27/18, scored 16, which identified moderately severe depression. - 1/3/19, scored 10, which identified mild depression. Although the facility completed follow up depression scales, the facility failed to comprehensively assess R3's emotional status and implement resident specific interventions. R1's admission MDS dated [DATE], identified R1 had severe cognitive impairment and identified mild depression symptoms. R1 required extensive assistance for ADL's. The MDS included [DIAGNOSES REDACTED]. R1's progress note dated 1/3/19, identified R1 had a recent situation observed by staff where a male resident had touched R5 on her thigh. The note indicated, per social services on 12/28/18, 12/31/18 and 1/2/19, R1 could not recall the incident. The note also indicated staff had spoken with R1's daughter and and offered in house psych services, but the daughter had decided psych services were not needed at the time. The note indicated staff were to continue to offer support and reassurance, Continue to observe for changes in R3's mood and behavioral status. The progress notes from 12/24/18, through 1/3/19, did not identify any incidents that had occurred between R1 and a male resident. An initial report to the SA submitted on 1/2/19, indicated an incident had occurred to R1 on 12/25/18. The initial report identified a nursing assistant witnessed R5 touching R1's mid to upper thigh. The report indicated a nursing assistant had told R5 it was not appropriate, and had removed R5 from the dining room. An investigative report submitted to the SA on 1/3/19, indicated during the incident on 12/25/18, an unidentified nursing assistant removed R5 from the area where R1 was. The report also indicated R1 was alert and oriented to herself. As a result of a previous event on 12/24/18, R5 was placed on 15 minute checks. The report indicated facility policies were followed along with R5's care plan. No changes made to the policy or procedures. All residents were interviewed regarding their sense of safety and whether or not they felt others were safe in the facility. Four other female residents reported similar incidents with R5. Residents that were unable to be interviewed received a full body assessment. The investigation identified interventions for R5, which included: R5 was placed on 15 minute checks, R5 had labs and medications reviewed for causative factors. Upon another incident on 12/25/18, R5 was placed on 1:1 supervision while awake and 15 minute checks while in bed. The physician prescribed R5 [MEDICATION NAME] for sexual inhibitions. R5 was scheduled to meet with psychiatry. Four female resident reported similar events with R5 and R5 had a [DIAGNOSES REDACTED]. Staff had been updated on monitoring for signs and symptoms of mental anguish for the female residents and symptoms of sexually inappropriate behaviors. The internal investigation identified one employee had been identified as being interviewed related to R1's allegations against R5. R1's Weekly Skin assessment dated [DATE], did not identify any skin concerns. R1's care plan dated 1/2/19, identified R1 had feelings of powerlessness related to male resident who wandered into her room and made inappropriate gestures towards her. Interventions included: although declined psych services offer as needed, contact family with any questions or concerns related to resident mood status, encourage family visits and support, observe for any changes in residents mood and behavior status, offer resident reassurance and support and social services as needed. The care plan did not identify what specific signs the staff should monitor for R1 which could identify R1 was displaying changes in emotional status. R1's (MONTH) 2019, MAR indicated [REDACTED]. The entry did not include resident specific behaviors staff were to monitor for. The day shift notes for 1/4/19, 1/5/19, 1/6/19, indicated other, see nurses notes. The corresponding nurses notes did not identify any behaviors. The evening shift for 1/7/19, did not indicated monitoring having been completed. No behaviors were identified. R1's PHQ-9's identified: - 12/28/18, score of 9, which indicated mild depression. - 1/3/19, score of 5, which indicated mild depression. - 1/7/19, score of 5 , which indicated mild depression. Although the facility completed follow up depression scales, the facility failed to comprehensively assess R1's emotional status and implement resident specific interventions. R2's quarterly MDS dated [DATE], identified R2 had moderate cognitive impairment and identified minimal depression symptoms. R2 required extensive assistance with ADL's included [DIAGNOSES REDACTED]. During interview on 1/8/19, at 1:42 p.m.

Based on documentation review and interviews the facility failed to adequately supervise 1 of 4 residents (R1) who were reviewed for elopement needs. R1 was neglected when R1 eloped the facility during the night shift when he was on 15-minute checks. Before the facility was aware of R1's disappearance, he slipped on the ice, hit his head, and a bystander took him to the hospital. The facility failed to reassess R1 after a previous elopement from the facility. The facility failed to have adequate staffing to complete the 15-minute checks, and failed to implement dementia services for R1. Findings include: R1's medical record was reviewed. R1 was admitted on [DATE], and his [DIAGNOSES REDACTED]. An Elopement Risk Evaluation dated 08/23/17, indicated no elopement risk for R1. No further elopement risk evaluations were completed. A physician order [REDACTED]. Document whereabouts in progress notes at the end of shift related to history of attempts to exit facility in the middle of the night. Every night shift for refusal to wear wander-guard. A care plan dated 11/15/17, indicated R1 was found returning from the outside of the facility building and refused wander-guard placement. Interventions included staff to monitor R1's location at night related to R1 wandering only at night. A nurse's note dated 11/20/17, at 5:44 a.m., indicated R1 was up wandering in the hallway at 11:15 p.m. all the way to the north door. R1 looked out door. He went to the kitchen, sat in a chair in the dark twice, sat by the fireplace, and sat in a chair by the front door. At 4:30 a.m. R1 sat in a chair in his room and napped. R1 then went to sleep in his bed. A nurse's note dated 11/19/17, at 5:46 a.m. R1 awake since 12:00 a.m. He walked to the dining room, walked to the kitchen twice, and walked in the hallway most of the time. A nurse's note dated 12/03/17, at 5:58 a.m. indicated R1 was awake the entire shift except for when he napped 2 to 3 times for 10 to 15 minutes. R1 walked the hallways at least 15 times. A nurse's note dated 12/06/17, at 6:24 a.m. indicated R1 was up and walked the hallway at the beginning of the shift. R1 went to bed at 11:40 p.m., came out into the hallway at 5:50 a.m., and stated, How can I get out of this place? A nurse's note dated 12/17/17, at 5:41 a.m., indicated R1 walked in the hallways from 11:00 p.m. until 5:41 a.m. and was still awake. A nurse's note dated 01/10/18, at 4:47 a.m., indicated R1 was up most of the night paced the hallways and asked several times how to get out of the facility. R1 stated he needed to leave and at one point came out of his room with his [NAME]et on and stated someone was going to pick him up. R1 stated he was going to Wisconsin. Staff redirected R1. A nurse's note dated 01/27/18, indicated R1 was more restless than usual even for himself. R1 was in and out of his room at least 20 times during the night. The facility did not comprehensively reassess R1 for elopement risk after one attempt to leave the facility, or after the seven times R1 exhibited behaviors that indicated exit seeking. A schedule dated 01/30/18, indicated on the night shift were 2 nurses, 2 nursing assistants, and 1 of nursing assistant in training. A census dated 01/31/18, indicated the facility had 42 residents, 11 residents on the transitional care unit (TCU) and 31 residents on the long term care units. A nurse's note dated 01/31/18, at 2:08 a.m., indicated registered nurse (RN)-G received a call from LPN-K. LPN-K reported to RN-G that the hospital called the facility and reported R1 was at the hospital. RN-G informed R1's spouse and R1's spouse had already spoken to the hospital. The hospital nurse informed RN-G that R1 was at the hospital with lump and a scrape on his head. Hospital records dated 01/31/18, indicated the hospital admitted R1 for a contusion/abrasion to his left forehead, and [MEDICAL CONDITION]. During an interview on 02/22/18 at 1:47 p.m. nursing assistant (NA)-E, stated she saw R1 approximately 1:00 p.m. walking towards the dining area. NA-E stated R1 was upset and wanted to leave the facility. NA-E stated she attempted to calm R1, and then needed to attend a different resident. NA-E did not see R1 again that night. NA-E stated she did not know R1 was on 15-minute checks. NA-E stated she was very busy and assumed RN-G checked on R1. NA-E stated she attended to several residents that transferred with mechanical lifts. NA-E stated she had a new nursing assistant to train, and spent time gathering equipment from the basement. NA-E needed to help NA-F who worked on the long-term unit and was a new nursing assistant. During an interview on 02/22/18, at 3:57 p.m. registered nurse (RN)-G, stated she worked cared for R1 on 01/31/18. RN-G stated she did not know R1 was out of the facility until the hospital notified licensed practical nurse (LPN)--K at approximately 1:30 a.m. R1 usually sleeps until approximately 1:00 a.m. and then wanders the facility hallways. RN-G did not see R1 on the night of 01/31/18. RN-G assumed R1 was sleeping and did not know he was out of the room. RN-G stated she did not check R1 every 15 minutes because she was extremely busy with half of the residents in the building. While the NA-E, and the NA on orientation, gathered equipment and stocked rooms, RN-G needed to toilet other residents and answer call lights. During an interview on 02/27/18, at 10:15 a.m. family member (FM)-I, stated R1 put on his coat, walked out of the facility, and slipped on the ice. FM-I stated R1 did not recall the incident. During an interview on 02/27/18, at 10:19 a.m. family member (FM)-H stated R1 slipped out of the facility in the middle of the night. The weather outside was icy and snowy. R1 was hungry for pizza, slipped out of the facility, and staff did not see him leave. FM-H stated R1 did not have a good memory and only recalled that he slipped on the ice and went to the hospital. During an interview on 02/28/17 at 9:36 a.m. the administrator (AD)-J stated R1 was restless during the evening and roamed the building. AD stated some time ago (she was unable to recall exact date) R1 left the building at night, rang the doorbell, and staff immediately let him back into the facility. AD stated R1 was care planned for staff to be aware of and monitor his location on the night shift. Staff attempted several times to place a wander-guard. R1 did not have an elopement risk assessment done after his admit. During an interview on 02/28/18, at 2:02 p.m. LPN-K stated she worked on the long-term care unit on 10/31/18, the night R1 left the facility. LPN-K did not see R1 that night and did not know he was missing until the hospital called her at approximately 1:00 a.m. LPN-K stated she cared for 21 or 22 residents, it was busier than usual, and she had just sat down to chart when the hospital called. A policy titled Missing Resident/Elopement, dated 10/96, indicated the facility is committed to providing a safe environment for all residents. Assure that each resident is assessed on an ongoing basis and has appropriate safety precautions in place. A policy titled Abuse Prevention/Vulnerable Adult Plan, undated, indicated the facility will ensure that residents are not subjected to neglect by anyone. A form titled Training Outline, Topic: Supervision and Frequent Rounding, dated 02/02/18, indicated the facility rounding procedure is: while the needs of each resident are unique, all residents must be checked in on regularly. In general, that means we are rounding on every resident a minimum of every 2 hours.

Based on interview and record review, the facility failed to promote the healing of a pressure ulcer for one of five residents (R1) reviewed when R1's sacral ulcer was not monitored, became worse, and required hospitalization . Findings include: R1's medical record was reviewed. R1 was admitted with a [DIAGNOSES REDACTED]. Review of R1's comprehensive skin assessment dated [DATE] indicated R1 had a pressure ulcer (unknown location). This assessment identified R1 at risk for pressure ulcer due to a pressure ulcer, needing assistance with mobility, impaired sensory perception, incontinence of bladder and bowel, pain, and diabetic [MEDICAL CONDITION]. R1's comprehensive skin assessment included a tissue tolerance test. The tissue tolerance test was done in the lying position. It indicated the resident's skin was red and blanched (turned white) with gentle pressure. R1's intervention was to reposition every two hours. No tissue tolerance test was documented for a sitting position. R1's immediate plan of care, not dated, indicated R1 had a pressure ulcer. R1's immediate care plan did not identify the location of R1's pressure ulcer. R1's interventions included turning and repositioning every two hours, ulcer care, and dressing application to the pressure ulcer. R1's physician order [REDACTED]. R1's treatment administration record dated December 2016 indicated licensed staff documented the application of R1's [MEDICATION NAME] ointment as prescribed by R1's physician. R1's comprehensive care plan dated December 12, 2016 indicated R1 did not have a pressure ulcer. Nursing progress note dated December 13, 2016 indicated R1 was dependent on two staff for transfers and one staff for all activities of daily living (ADLs). Nursing progress note dated December 17, 2016 indicated R1's family member reported that the resident's left hip pain was increasing with movement. Nursing progress note dated December 20, 2016 indicated that R1 reported not receiving adequate care to help heal R1's sacral pressure ulcer. Nursing progress note dated December 21, 2016 indicated R1's family member reported to the Director of Nursing (DON) that the sacral pressure ulcer was worse than when R1 was admitted to the facility. The DON assessed R1's pressure ulcer, contacted R1's physician who ordered silversorb dressing once daily for R1's sacral ulcer. Nursing progress note dated December 22, 2016 indicated R1's family member called 911 for emergency services to treat R1's sacral pressure ulcer. Review of R1's hospital emergency record dated December 22, 2016 described the ulcer as large decubital sacral ulcer with eschar. The sacral pressure ulcer measured 7 centimeters (cm) by 5 cm. The Director of Social Services was interviewed on January 5, 2017 at 2:44 p.m. and stated a family member alerted her that R1's sacral pressure ulcer was larger than when R1 was admitted to the facility. Nursing assistant (NA)-B was interviewed on January 5, 2017 at 3:13 p.m. and stated R1's sacrum was excoriated, open, and bleeding. Licensed practical nurse (LPN)-C was interviewed on January 5, 2017 at 3:42 p.m. and stated R1's sacrum was red and excoriated in the center of the sacrum. LPN-D was interviewed on January 5, 2017 at 4:44 p.m. and stated R1's sacrum was excoriated and bleeding. The DON was interviewed on January 5, 2017 at 5:28 p.m. and stated she is the wound nurse for the facility, but was not aware of R1's sacral pressure ulcer until a family member told her on December 21, 2016. The DON obtained a physician telephone order for scheduled wound dressing once daily instead of the barrier cream application. The DON stated that nurses should have been monitoring R1's excoriation twice a day when they applied the barrier cream to R1's sacrum. She stated nurses were expected to notify her or the physician if excoriation was worse or not healing. The DON stated R1 was admitted to a hospital with a [DIAGNOSES REDACTED]. R1's family member (FM)-F was interviewed on January 26, 2017 at 4:20 p.m. and stated R1 was admitted with a small sacral ulcer. FM-F stated she reported R1's worsened sacral ulcer to the DON. R1's FM-F also reported to the facility's executive director that staff were not repositioning R1 every two hours and that R1 was sitting in a chair for up 12 hours at times. The facility policy and procedure titled Skin Integrity Guideline, not dated, indicated that licensed staff will develop a routine schedule to review patients/residents with wounds or at risk on a weekly basis and document findings. The plan of care will address problems, goals and interventions. Residents' skin integrity will be evaluated/observed for risk of skin breakdown and existing areas including but not limited to bruising, skin tears, wounds, abrasions, arterial and venous wounds and pressure ulcers within 24 hours of admission, quarterly, and with decline in condition.