Every finding on record at The Green Prairie Rehabilitation Center

Based on observation, interview and document review, the facility failed to ensure a safe transfer using a mechanical lift was completed for 1 of 1 resident (R1) reviewed. R1 was resistive to care and did not want to get up from the bed, however, two staff members proceeded to place a hoyer sling underneath her and began to transfer her from the bed to a shower chair despite R1 being resistive. R1 became more physically behavioral while in the device (i.e., wiggling around, moving) which caused her shoulder to nudge free from the sling mid-air and resulted in an avoidable fall from the lift. R1 sustained a scalp hematoma (i.e., goose egg) with bleeding, bruising on her left side, increased pain, and mental anguish (i.e., tearfulness) from the event which constituted actual harm. However, the facility took multiple corrective actions starting on 8/27/26, prior to the onsite survey, so these findings are being issued at past noncompliance. Findings include: R1's quarterly Minimum Data Set (MDS), dated [DATE], identified R1 had moderate cognitive impairment but no hallucinations or delusions. R1 demonstrated no physical (i.e., hitting, kicking), verbal (i.e., threatening, screaming), other behavioral symptoms, or rejection of care behaviors during the review period. R1 received scheduled pain medication and non-pharmacological interventions for pain, with occasional pain reported during the previous five days. R1 rated the pain as, 01, on the 0 to 10 scale (10 being worst). Further, R1 had no recorded falls since admission/entry/reentry or the previous MDS assessment. R1's MHM (Monarch Healthcare Management) Lift/Mobility Status Form - V3, dated 6/25/26, identified R1 was unable to stand, pivot and walk without at least limited assistance from staff members. R1 had a history of falls recorded but was considered a candidate for using the sit/stand lift (i.e., mechanical stand). The section labeled, Lift Plan, identified the staff assessed R1 to use a full body lift with assist of two. The type and size of the sling to be used for R1 was recorded as, Medium Slings. The assessment marked that both the care plan and NA (nursing assistant) care sheets were updated. The evaluation concluded with a section labeled, Comments, which outlined, Depending on resident's behaviors, it will determine which lift will be used. Transferring resident to chair or to bed is done with the assist of 2. Either [stand] or Hoyer lift depending on assistance from resident. The completed evaluation lacked evidence of what specific behaviors R1 demonstrated which could impact her transfers. R1's MHM Weekly Skin Inspection V-6, dated 8/19/26, identified R1 received a shower and R1 allowed a full skin check to be completed. The form recorded R1 had a discoloration to her right leg and added, . bruise resolved to left elbow. No further bruising was recorded to R1's body with this evaluation. The Assignment 4 (NA care sheet), dated 8/26/26, identified R1's name and basic care instructions to provide care. R1 had a weekly bath/shower scheduled for Wednesday morning and the column labeled, Transfer, directed a 2 assist with an EZ Stand (mechanical stand device). However, the column labeled, Hoyer Sling Size, identified, Med [medium]. R1 was to have female caregivers only but the sheet lacked any further information on what, if any, behaviors R1 demonstrated which could impact her transfer status as identified on the previous lift/mobility evaluation (dated 6/25/26). R1's progress note, dated 8/26/26, identified that at approximately 7:15 a.m., the nurse heard screaming coming from R1's room. The note recorded, While entering the room, nurse (writer) stated if resident is refusing to take a shower at this time, keep her in bed until she is ready, while saying this, resident was being transferred from bed to shower chair using hoyer lift. Resident began moving in sling while being transferred and fell from hoyer lift. The nurse assessed R1 and 911 was called. R1 had swelling noted to the back of her head with blood coming from the area, but no other injuries were noted at that time. EMS arrived and R1 was sent to the hospital. Licensed practical nurse (LPN)-A authored the note, and R1 returned from the hospital on the same day at 10: 52 p.m.R1's ED Notes, dated 8/26/26, identified R1 presented from the care center via EMS who reported the care center staff were transferring R1 using a hoyer lift and dropped the [patient] about 4 feet. R1 sustained a head strike but no loss of consciousness. R1 had a large bump to posterior head with dried blood noted. R1 was complaining of right upper arm pain and was recorded with, Bruising and swelling to left thigh, knee, and ankle also noted. R1 had a series of imaging completed which were negative for fracture, and R1 was discharged back to the care center. R1's progress note, dated 8/27/26, identified a note completed in conjunction with a nursing order which read, Monitor for [signs and symptoms] of injury post fall X 72 hours [nursing order]. The staff recorded, bruising, hematoma.R1's SNF Follow-Up/Acute Visit note, dated 8/27/26, identified R1 was evaluated by the provider at the care center. R1's past medical history was outlined and the note recorded, She is functionally dependent, requiring assistance with ADLs and uses mobility aids. R1 had chronic right shoulder pain which was managed with Tylenol, lidocaine patches and topical agents. The note then recorded, On 8/26/2026, she was evaluated for a fall with hypotension and hematoma, managed conservatively, and discharged safely to her facility. R1 endorsed some nausea and dizziness upon exam but no headache. The note recorded, She is tearful recounting [the] fall. Has some noticeable pain in the left knee and grimaces with flexion and palpation of the knee. Does share that she did receive a hit to her left knee recently with fall. No overlying bruising. The physical exam recorded a nickel-sized abrasion on the scalp and palpable crepitus (medical term for popping, cracking, crunching, or grinding noise and sensation that comes from the knee joint during movement) with range-of-motion to the left knee. The findings for the abrasion and crepitus were both recorded in bold font. An assessment/plan was listed which recorded, 3. Fall, subsequent encounter . Reassuring work up in ED yesterday after fall from hoyer. Tearful from recounting experience as was understandably frightening. Imaging of left knee was obtained in ED which showed severe osteoarthritis which is correlated with crepitus with AROM today on exam. Some nausea reported which could be concussion related to head strike reported with fall from hoyer . - Schedule diclofenac gel 1% (topical cream for pain). R1's Incident Note, dated 8/29/26, identified R1 had late onset bruising to her bilateral lower extremities mostly on the posterior side of her left leg. The note recorded, Scattered bruising with pain to the touch. R1 stated the bruises were from the fall and . hurts only when we have to grab her legs and move them.R1's fall care plan, dated 8/27/26, identified R1 was at risk for falls due to a history of falls and impaired mobility. A goal was listed, Resident will be safe and free from falls. The plan listed multiple interventions including use of a low bed, following PT and OT instructions for mobility, and no pedals on the wheelchair. The plan also listed several interventions with a recorded initiation (start) date of 8/27/26. These interventions included providing education provided to all staff on how to care for the R1 while having behaviors, using a large-sized hoyer sling, and using a hoyer for all transfers to wheelchair and/or bed. On 8/31/26 at 9:50 a.m., R1 was observed lying in her bed asleep. R1 did not wake with verbal interaction. There were no visible hoyer slings in her room or wheelchair, and R1 was covered with blankets. In the hallway outside R1's room, a single Guldmann mechanical lift was present. There were no slings on the device. The device's user manual was zip-tied to it which identified step-by-step instructions on how to use the device and considerations for its use. There was a section labeled, Important, with several bulleted items including, Always plan your lift before commencing.Following, at 9:56 a.m., NA-B was interviewed and explained they were shown how to use the device by another NA when they started at the care center but felt they knew how to use it prior from working at other jobs. The nurse then watched them use it and signed them off on it. NA-B demonstrated how to use the device and explained the sling would be placed under the patient and hooked to each of the attachment points on the cradle (two total) using either the green or grey-colored loops. NA-B stated the loop color used did not matter to their knowledge, but they use the green-colored loop usually as it makes the sling have tighter fit around the resident's body. Each resident had their own sling stored in their room, and two NA were present for every transfer using the machine. R1 stated if a resident was behavioral or moving around while trying to lift them in the device, then they should just be put back, and the transfer should not be completed. If the resident started to move mid-transfer, such as in between the bed and destination, then they would likely just get them to the destination as quickly as possible. NA-B then stated they routinely worked with R1 and recalled R1's fall from the Guldmann mechanical lift on 8/26. NA-B was in the room assisting NA-C with the transfer when it happened. It was R1's shower day and R1 [was] never happy on her shower days so it was not unusual for R1 to have some behaviors. R1 refused to help move her feet off the bed for the NA but was not yelling or screaming loudly. NA-B and NA-C proceeded to place the large-sized sling and raise R1 up into the air using the lift. NA-B verified they did not check the sling size before they started the transfer. R1 then suddenly threw her arm out of the side of the harness so NA-B turned to quickly get R1's wheelchair but R1 fell onto the floor before they could place it. NA-B stated they didn't feel R1 did not want to get up on that morning, despite not helping with her feet, and the hollering was normal for R1. R1 was not being physically combative, or they would not have attempted the transfer. R1 seemed to fight it more [getting up] on days when she had a shower scheduled. NA-B stated the fall happened so fast and R1 sustained a goose egg from it on her head along with some bruising on her left side. The bruising was pretty bad. Since the fall, the DON educated NA-B that they should have just left R1 in a safe spot since she was behavioral, but NA-B stated, That is what we were trying to do [get her to the chair]. DON also mentioned they should have likely just left R1 in bed as residents have the right to refuse care or get up. NA-B stated that, in hindsight, they would not change anything from the actions up to the fall and added, Everything we did was right. NA-B then acknowledged the care sheet directed to use a medium sized sling which is not what they used that morning when R1 fell. This was just an error in the heat of the moment so they used the sling which had been in the room. The DON discovered the wrong sling after the fall and then reprimanded and educated them and NA-C on it. However, when R1 returned from the hospital, she (R1) was re-measured and found to require a large-sized sling, so while they didn't follow the care sheet on 8/26, they technically used the right sling size in hindsight. NA-B stated they were unsure who or how often the residents are re-measured for sling size at the center. NA-B then stated they would make sure to check for the correct sling size, in hindsight, with hoyer lift transfers. When interviewed on 8/31/26 at 10:28 a.m., NA-C stated they had worked at the care center for about four months now, and recalled they never really were given much, if any, training on how to use the lift devices adding, Nobody really talked about it. NA-C stated they had learned how to use it while in school and went about that, adding further, I just went with the flow. NA-C did not recall any nurses ever checking them off on using the device. NA-C stated a resident's sling size would be listed on the care plan and their care sheet but was unsure who decided on which size to use. The green-colored loops on the sling were used usually unless it was a larger person being transferred. The NA staff use the loops with what works best for us as the loops to use are not listed on the care plans. NA-C stated it was common sense to use the green loops. NA-C then recalled the incident with R1 on 8/26/26, and verified they were in the room assisting with the transfer with NA-B present. NA-C stated they started to provide care while R1 was still in bed and R1 had been starting to hit out at them and trying to pull her night gown back down as they were changing her. It was like R1 didn't want help or to do what they were trying to get done. NA-C stated they were told in training that if R1 was refusing to get up to then use the hoyer lift and not the mechanical stand adding that is why they used that device on 8/26/26. The large-sized sling was placed under R1 and NA-C verified they never checked the size prior to placing it. They checked the care plan (which called for a medium-sized) but that was after the fall happened. NA-C stated they just went off the assumption it was the correct sling as it had been in R1's room. R1 was then raised up from the bed in the sling using the mechanical lift when R1 started wiggling around. This happened as soon as she [R1] didn't feel her bed below her. NA-C pulled the lift away from the bed and then turned counterclockwise to position R1 and the device in the middle of the room. NA-B was on the opposite side getting the wheelchair ready when suddenly R1 slipped out of the sling and onto the floor. NA-C stated they had never been told prior to stop a transfer if someone is physically behavioral. NA-C also stated the lift device itself never malfunctioned to cause the fall, rather it was caused by R1 moving side to side while in the air trying to get out of it. During the transfer, the nurse opened R1's doorway and saw R1 in the air while conversing with NA-B about something. The nurse never said anything about leaving R1 in bed if refusing and reiterated documentation saying that is not true. NA-B stated that since the incident, the DON had provided re-education to them and others about transferring and checking the sling size prior. NA-C stated R1 would not have fallen out of the sling if she had not been moving around adding, No, not at all. NA-C stated they were made to sign some papers the following day by the DON about not following the nurses' instructions to leave R1 in bed but reiterated that was not true. NA-C stated that since the incident, R1 seemed a lot more sensitive and easily triggered and upset by small things, such as her hair not getting done. R1 seemed, in general, to be more anxious since the fall happened.When interviewed on 8/31/26 at 12:25 p.m., the director of therapy (DOR) stated the therapy department were not the people who measured for sling size or ever adjusted care plans with that information. R1 had been a stand-pivot transfer previously but lately needed more help. Therapy had re-evaluated R1 after she returned from the ER on [DATE] and deemed her to remain now a total hoyer for all transfers. DOR stated if a patient started to move and wiggle during a transfer, then the appropriate action would be stop the situation and not keep going. To keep going while the patient is moving would be putting yourself [caregiver] and the patient in danger in my opinion. Further, DOR stated any movement of a person in a lift, but also depending on how aggressive it was happening, could impact the safety of the person being transferred. When interviewed on 8/31/26 at 12:36 p.m., licensed practical nurse (LPN)-A stated they worked for an outside agency but picked up at the care center often for shifts. LPN-A recalled R1's fall on 8/26/26 and stated she heard screaming coming from R1's room through the closed door. LPN-A opened the door and saw R1 being transferred in the air using the mechanical lift by NA-B and NA-C. LPN-A asked what was happening as R1 was clearly upset, and then directed NA-B and NA-C to leave R1 in bed if she didn't want to get up or take a shower. The NA replied they were then going to be behind in work and would get in trouble by management. Then, as that comment was said aloud, R2 shifted her weight and moved then fell onto the floor. LPN-A immediately assessed R1 and found her to have a golf ball sized lump on her head with some bleeding. R1 was crying and really upset and didn't want anyone to touch her. LPN-A stated they finally got R1 sent to the hospital with EMS. LPN-A explained that the staff usually used a mechanical stand on R1 to help her transfer, and they were unsure why the aides elected to use a lift that day instead. LPN-A stated they did not do any education with staff on how to use the devices, rather that was the DON who did that. LPN-A verified the device itself did not break or malfunction to cause the fall, rather it was the NAs not stopping the transfer sooner and leaving R1 in bed like she had wanted. LPN-A stated, This [fall] would have been avoided. R1 was observed on 8/31/26 at 1:03 p.m. seated upright in her wheelchair while in her room playing with a puzzle on a card table. R1 had visible bruising on her hand and an interview was attempted. R1 was unable to recall how long she'd lived at the care center and mostly responded with, Yea, to questions. R1 was asked if she had any recent falls and again just responded aloud, Yea. R1 did not articulate any details about the fall, how it happened, or how she felt now about it when asked. On 8/31/26 at 1:25 p.m., the director of nursing (DON) and assistant director of nursing (ADON) were interviewed. DON explained lift use was trained to staff upon hire and then annually thereafter. The training included a show of the device, then a return demonstration to either a nurse or the DON/ADON. DON verified there had been no education to staff about behaviors of residents while in the device (i.e., start moving around, attempting to get out) prior to R1's fall on 8/26/26. The IDT discussed R1's fall and felt it happened due to R1's behavior. They had never thought to educate staff on how to handle transfers while behavioral prior as something like that had not happened. There was also not a formal process to ensure residents would be routinely identified and re-measured for sling size prior to the fall, however, that would now be redone annually or with a significant change in status. DON verified NA-B and NA-C both had training on the use of the lifts prior to operating them and would provide the information (see below). DON then recalled R1's fall on 8/26/26. The ADON received a call from the nurse who then updated the DON. The DON arrived onsite while R1 was being sent to the hospital. NA-B and NA-C were removed from the floor and immediately provided re-education on transfers with behavioral residents and using the care planned sling size. A VA report was then completed and submitted. The education provided to NA-B and NA-C was then started to be sent to all staff members and tracked via email responses. DON verified that upon remeasure, R1 needed a large-sized sling so the care plan was adjusted. A call was also placed to the lift company to help answer some questions to ensure the right lift sling was used. They also completed a whole house audit of residents who used the hoyer to ensure their care plans were correct and the sling was right. The DON stated the fall happened because R1 started moving around while in the air and the staff should have lowered her back down or put her back in bed. The fall was likely avoidable and would not have happened if they had done that. DON verified R1 obtained a goose egg and some bleeding from the fall along with some bruising on her left side. Further, DON reiterated they immediately started education with the staff. NA-B and NA-C's Facility Training Policy Acknowledged form(s), dated 4/30/26 and 7/15/25 respectively, identified they had been provided training on the mechanical lifts and transferring of patients. These forms were signed by the staff members and a nurse. On 8/31/26 at 2:47 p.m., a telephone interview was completed with the lift company representative (LCR)-A provided by the DON. He stated he was unsure of the details about R1's fall or the situation and said to contact corporate but was unsure of their contact information. He responded, I don't want to get involved with this. The provided Safe Resident Handling Program policy, dated 3/2020, identified procedures to ensure both the residents and staff members involved remained safe and free of injury with transfers and handling. Manual lifting would be minimized. Each resident would be assessed for safe patient handling needs using the MHM Lift/Mobility Status Form and for each relevant activity in the care delivery process. The information would then be in the care plan. Training to nurses and other employees would then be provided to demonstrate proper application and use of the handling equipment. The past noncompliance harm-level findings were corrected on 8/27/26, after the facility started and took multiple corrective actions. This included auditing all residents to ensure the correct lift sling size was care planned and available for use; updating R1's NA care sheet with current information; starting re-education with all staff members to ensure appropriate use of the mechanical lift; and re-assessing R1 for their transfer status to ensure safety. These actions were verified as completed during the onsite investigation and no other residents had sustained a fall from the lift in the care center.

Based on observation, interview, and document review, the facility failed to comprehensively assess and, if needed, develop or implement interventions to reduce distress and behaviors on bath days for 1 of 3 residents (R1) reviewed. R1 displayed signs of dementia with obvious cognitive impairment and was identified by the staff to have increased behaviors on her bath/shower days but the medical record lacked evidence this had been evaluated by the interdisciplinary team (IDT) to determine if additional interventions were needed.Findings include: R1's quarterly Minimum Data Set (MDS), dated [DATE], identified R1 had moderate cognitive impairment and no symptoms of delirium. R1 demonstrated no delusions, hallucinations, other behavior symptoms (i.e., physical, verbal, other), or any rejection of care behavior during the review period. R1's medical diagnoses included other neurological conditions, cerebral palsy, seizure disorder or epilepsy, and depression. R1's most recent MHM (Monarch Healthcare Management) Target Behavior Form - V6, dated 6/25/26, identified R1 consumed anti-depressant medication and had no recent changes to doses. The section labeled, Charted Behaviors, identified staff dictation which read, Resident has had increased behaviors such as yelling out when puzzle pieces fall on the floor or she doesn't like a certain staff member. Much of her behaviors are yelling out loud. There were no additional causative factors listed only dictation, See above [prior statement]. The non-pharmacological interventions written included redirection, food/fluids, and repositioning. The recommendations just recorded, Continue to use the non-pharmacological interventions. IDT reviewed the care plan and no changes were made, IDT also reviewed R1's target behavior monitoring orders and no changes were made.R1's Assignment 4 (care sheet), dated 8/26/26, identified R1 was scheduled for a Wednesday morning (AM) bath/shower. The column labeled, Special Needs, just directed to use female caregivers only. R1's progress notes, dated 6/1/26 to 8/31/26, identified multiple notes about observed behaviors which staff recorded under the order for monitoring target behavior. These included: On 6/3/26, R1 was anxious/yelling out before her shower that morning. Reassurance was given. R1 was upset about her puzzle piece. On 6/17/26, R1 was verbally aggressive with her shower that morning. On 7/22/26, R1 was combative with care that morning. The note recorded, . attempted to hit staff while helping her get ready for her shower. Resident was redirectable. On 8/5/26, R1 was again combative and yelling at staff while preparing for her shower. R1 was difficult to redirect but seemed calmer with redirection and reapproach. On 8/26/26, R1 was refusing to take a shower according to the nurse. R1 was being transferred using a mechanical lift and began to move around while being moved and fell onto the floor. R1 sustained a head strike and some bleeding. R1 was sent to the hospital for evaluation. R1's Follow Up Question Report, dated July 2026, identified R1's nursing assistant (NA) charting responses for the month. This included to chart what behavior happened, how many times on that shift, approaches attempted, and any trend. The charting recorded R1 as being resistive or refusing care on 7/1/26 (Wed), 7/7/26 (Wed), and 7/29/26 (Wed). In total, six (6) days had recorded behavior happen and of these, three (3) happened on R1's scheduled bath/shower day. R1's Follow Up Question Report, dated August 2026, identified the NA charting responses for the month. The same behavior questions were listed as July 2026, and the charting recorded R1 with only two behavioral episodes. On 8/5/26 (Wed), R1 was recorded as resisting care or refusing. On 8/26/26 (Wed), R1 was again recorded as resisting care or refusing. When interviewed on 8/31/26 at 9:56 a.m., NA-B stated they had worked with R1 multiple times and R1 had recently fallen due to behaviors while in the mechanical lift. NA-B recalled being there when R1 fell and stated it happened on R1's shower day then adding, She is never very happy on her shower days. NA-B explained R1 was just not a happy camper on her shower days and could be, at times, very combative and yell at the staff while they help her. NA-B questioned if maybe R1 just didn't want to get up early but then stated R1 seemed to fight it more [care] on days when she knows a shower is scheduled. It could be the water or something else and NA-B added, I'm just not totally sure. NA-B stated maybe an evening shift (i.e., PM) shower would help more as then R1 didn't have to get up so early. When interviewed on 8/31/26 at 10:28 a.m., NA-C stated they also had worked with R1 prior to her fall on 8/26/26. R1 liked her routines and would get mad if something was [NAME] with it each day. NA-C stated they had also noticed R1 to be generally more behavioral in the morning when a shower was scheduled. NA-C stated they thought it was waking up R1 earlier than usual to do it that may be upsetting her but was not sure. NA-C stated having a PM shower maybe better since R1 could then go immediately to bed adding, I think that would be so much better with her. NA-C stated it had always been like this with R1 on her scheduled shower days and her having more behaviors it seemed. On 8/31/26 at 1:03 p.m., R1 was observed seated in her wheelchair in her room, R1 was playing with a puzzle on a table and appeared clean and without odor present. An interview was attempted but R1 only responded to most questions with, Yea, and did not give a meaningful response. R1's cognition care plan, dated 11/2020, identified R1 had potential for impaired cognition due to her medical diagnoses and communication deficit. R1 was able to communicate her needs and feelings when asked. The plan added, Resident is compliant with cares, medications, and treatments. The plan directed to allow R1 time to communicate her needs/wants, document changes in orientation, and provide/maintain a consistent environment. The last time these interventions or that section was revised was 11/9/2020. The mood and behavior care plan, dated 9/2024, identified R1 as having an alteration in mood and behavior related to her change in level of independent and medical history. R1 had adjusted to placement at the center and was able to communicate her needs and feelings when asked. The plan here again outlined, Resident is compliant with cares, medications, and treatments. R1 disliked certain staff members. The plan listed interventions which included turning on the Vikings or Twins, being alert to changes with her mood/behavior, and monitoring her target behaviors per protocol. The last time these interventions were revised was recorded as 9/20/2024. However, the care plan lacked any interventions specific to R1's shower/bath event or day despite the care center staff noticing increased resistance to cares and more behaviors on those days and/or possibly with that event. R1's medical record was reviewed and lacked evidence the IDT had comprehensively assessed and determined what, if any, causative factors for R1's increased behaviors on the scheduled bathing days; nor evidence what, if any, interventions were considered or implemented on those days despite the NA charting showing obvious behaviors on multiple scheduled bath/shower days and the direct care staff seeing/feeling like R1 had increased behaviors on those days. On 8/31/26 at 1:25 p.m., the director of nursing (DON) and assistant director of nursing (ADON) were interviewed. DON acknowledged R1 had sustained a fall from the mechanical lift after becoming behavioral and moving around in the sling mid-transfer (see F689) and expressed the aides should have allowed R1 to refuse the care and not continued with the transfer when R1 was seeming to resist it. DON explained that behaviors were recorded in the point-of-care (POC) charting by the aides and told to notify the nurse when they happen so the nurses can better assess the situation. The nurses were also able to do behavior charting in their progress notes. DON stated they felt R1's behaviors had escalated since people of color were employed at the care center and R1 had it explained multiple times that everyone was there to help her and be kind. The nurse was responsible for assessing any behaviors and they would record that in the EMR system. DON stated they thought R1 used to be a scheduled PM bath, but it was moved to days (AM) as R1 also had behaviors on the PM but was unsure offhand when this was or what happened. R1 had been scheduled for a twice-a-week bath, too, but was reduced to one weekly for the behaviors. Following, at 3:06 p.m., DON had reviewed R1's medical record and reiterated nobody had reported any concerns with R1 having increased behaviors on her scheduled bathing day recently to them or the ADON. If concerns are seen, then they should be reported. DON stated they had just spoken with their regional nurse and didn't feel not bathing R1 in the shower or bath was an option. They were going to discuss what options they had further. DON stated the MDS nurse and the social services designee (SSD) were responsible to review the target behaviors being charted/tracked with the MDS cycle and could complete their assessments of them and update the care plans, if needed. A facility policy for behavior assessment and management was requested; however, none was received.

Based on observation, interview, and record review, the facility failed to ensure proper use of personal protective equipment (PPE) for 1 of 1 resident reviewed for enhanced barrier precautions (EBP)Findings include: R34's significant change Minimum Data Set (MDS) assessment, dated 9/17/25, indicated R34 was cognitively intact with no behaviors. R34 required partial/moderate assist with oral hygiene, showering, personal hygiene, dressing, some position changes, and sitting to standing. R34 required substantial assist with transferring and applying/removing footwear. It also indicated R34 was dependent on staff for toilet hygiene. R34 was continent of bowels and frequently incontinent of urine. The MDS also indicated R34 had open lesions and skin tears. R34's diagnoses list included cellulitis (infection under the skin) of lower limb.R34's care plan included altered nutrition related to wound healing, urinary incontinence, discomfort related to wounds and immobility, and alteration to skin related to wounds.R34's provider orders included: follow EBP while providing wound cares and other high contact care activities, as well as dressing change orders to all open lower leg wounds. During observation and interview on 12/1/25 at 2:38 p.m., a sign posted on outside R34's room indicated enhanced barrier precautions. The sign provided direction for applying and removing PPE as well as indications when PPE would be used. A plastic dresser containing gloves and gowns was located just outside R34's room. During the interview, R34 stated staff did not always wear gowns when providing cares. R34's stated he had a wound to his lower leg he sustained outside the facility as well as several open blisters from the swelling in his legs. The nurses provide dressing changes and his legs are wrapped to control the swelling. R34's lower legs were observed covered with a compression wrap with a portion of a bandage visible. During observation on 12/2/25 at 9:59 a.m., registered nurse (RN)-B sanitized hands, applied gown, and applied gloves prior to entering R34's room. A couple minutes later, nursing assistant (NA)-A entered R34's room, sanitized her hands, and applied gloves however did not apply a gown. R34 was seated on the commode. RN-B stood on the right side of R34 while NA-A stood to the left side of R34. R34 was assisted to a standing position with a gait belt by RN-B and NA-A. RN-B provided toileting cares while NA-A held the gait belt holding R34 steady. When toileting cares were completed, RN-B and NA-A assist R34 to his nearby recliner. Prior to R34 sitting, NA-A and RN-B reached behind R34 to hold his incontinence product in place while R34 sat down. NA-A's clothing made contact with R34. Once R34 was seated, NA-A removed R34's gait belt, removed gloves, performed hand hygiene, and then left the room. RN-B removed all PPE, washed hands, applied new PPE and provided wound cares to R34's lower extremities with no breaks of infection noted. During an interview on 12/2/25 at 1:50 p.m., NA-A stated infection control training is performed via online training as well as reminders from the facility director of nursing. NA-A indicated gowns and gloves are worn for residents on EBP when toileting or doing things with catheters. NA-A stated she would not wear a gown when transferring a resident on EBP. During an interview on 12/2/25 at 2:42 p.m., NA-B stated she worked for a staffing agency. NA-B reported no extra training for transmission-based precautions and would just read the signs on the door. NA-B stated she would apply PPE prior to entering a residents room anytime cares are performed however would not wear PPE just for transfers because there is no risk of spreading anything. During an interview on 12/2/25 at 2:50 p.m., RN-A could not recall any specific transmission-based precaution training, however stated there is a lot of signage. RN-A stated facility will show staff proper PPE application if staff is unfamiliar with the procedure. RN-A stated she would wear gowns for dressing changes but not for transfers unless there is risk of exposing the wound. RN-A then stated staff should wear gowns when transferring residents with indwelling catheters (tubing inserted in urinary bladder). During an interview on 12/3/25 at 10:41 a.m., the director of nursing (DON) stated staff receive online training upon hire and also perform competencies. She expects staff to read the signs posted on the residents' door for direction on applying PPE. If the facility admits a resident with something unusual the facility will do individual training. The DON stated she does audits of breaks in transmission-based precautions if an issue is reported to her. She does not do spot checks for EBP. The DON stated gown, and gloves are warn when staff are spending an extensive amount of time with residents such as performing cares and toileting. She also expects staff to wear gown and gloves when emptying indwelling catheter bags and dressing changes. She does not expect staff to wear gown and gloves when transferring residents. A policy titled Enhanced Barrier Precautions dated 4/1/24 indicated the purpose of EBP is for the prevention of transmission of multidrug-resistant organisms. EBP is defined as the use of gown and gloves for use during high-contact resident care activities for residents .at increased risk for MDRO [multi-drug resistant organism] acquisition (e.g., residents with wounds or indwelling medical devices). Under the heading Explanation and Compliance Guidelines the policy indicated to initiate enhanced barrier precautions for residents who have chronic wounds. The Implementation of Enhanced Barrier Precautions section indicated, in part, the Infection Preventionist will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education. The policy defined high-contact resident care activities to include: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care.

Based on interview and document review, the facility failed to ensure medical records were complete and accurately documented for 1 of 1 resident (R6) reviewed for resident records.R6's quarterly Minimum Data Set (MDS) assessment, dated 8/28/25 identified R6 had no cognitive impairment. R6's MDS also indicated behavior symptoms (threatening others, screaming at others, or cursing at others) occurred 1 to 3 days.R6's care plan noted alteration in mood and behavior related to major depressive disorder. Further, resident is known to make inappropriate racial jokes or comments. Additionally, R6 appears to be malcontent as evidenced by complaints about wall paint, flooring, food, and staff. R6 will often refuse care from staff, then file a grievance stating staff did not care for her. Last, R6 can communicate her needs and feelings when asked.R6's orders indicated target behaviors should be monitored every shift, documented as the behavior observed, intervention used, and findings entered in the nursing progress notes. Target behaviors are outlined as: (A) isolation, (B) depressive statements, (C) crying, and (D) feelings of helplessness. Non-pharmacological interventions could include: (0) N/A, (1) redirection, (2) ambulation, (3) offer activity, (4) essential oils, (5) repositioning, (6) toileting, (7) provide 1:1, (8) offer food/fluids, (9) offer pain relief. During interview on 12/1/2025 at 5:36 p.m., R6 stated she gets annoyed with staff and other residents. R6 stated she stays in her room almost 95% of the time because she doesn't want to deal with anyone. R6 stated when she has left her room, she will get angry or upset very easily.R6's treatment administration record (TAR) dated on 10/17/25, target behavior monitoring had been document as no behaviors with no interventions for all three shifts. However, a progress note at 9:42 p.m. detailed R6 had been in her room all shift, slept all shift, and did not eat dinner.R6's TAR dated on 11/26/25, R6's target behavior monitoring was documented as no behaviors. However, upon review of R6's progress notes, at 2:05 a.m. R6 had verbal outbursts with staff, using racial slurs and profanities.R6's TAR dated on 11/28/25, R6's target behavior monitoring was documented as no behaviors. However, upon review of the progress notes, R6 had negative behaviors of refusing cares, accusing staff of things they did not do, and entering the hall to yell at staff.During interview on 12/2/25 at 11:35 a.m., nursing assistant (NA)-C and NA-D stated nursing assistants and nurses can document target behaviors. NA-D stated target behaviors are charted in the TAR. NA-C stated the providers look at the target behaviors in the TAR to know if the medications are working or not.During interview on 12/2/25 at 11:40 a.m., registered nurse (RN)-C stated it is an expectation to chart target behaviors in the TAR as you see them. RN-C stated she would update her charting in the TAR to reflect changes in behavior throughout her shift. RN-C stated the importance of accurate charting in the TAR is so that providers know if medications are working or not; inaccurate charting could mean a resident isn't being treated appropriately.During interview on 12/4/2025 at 10:08 a.m., director of nursing (DON) stated her general overview of R6's October and November TAR was resident had not experienced negative target behaviors. The DON confirmed R6 was prone to negative behaviors of verbal outbursts, racial slurs, refusing cares, and refusing to leave her room. The DON confirmed R6 had negative behaviors on 10/17/25, 11/26/25, and 11/28/25; indicating she would expect to see the specific behaviors documented in the TAR. The DON confirmed if staff had documented no behaviors at the beginning of the shift, then the resident had negative behaviors, the DON would expect staff to update the charting to reflect the specific negative target behaviors. The DON stated the importance of charting accurate target behaviors was so facility staff and providers know if behavior medications are effective. Inaccurate documentation could lead to untreated symptoms.During interview on 12/3/25 at 8:49 a.m., medical doctor (MD)-A stated he would expect target behavior monitoring and interventions to be document in the TAR, with a follow up progress note. MD-A stated it is important to know if a resident is experiencing negative behaviors so medications can be adjusted to treat ongoing symptoms. MD-A stated his general overview of R6's October and November TAR was the resident had not experienced negative target behaviors.A policy for medical record documentation was requested and not received.

Based on interview and record review, the facility failed to ensure the pharmacy consultant identified irregularities in monthly drug regimen reviews for 2 of 5 (R3 and R31) residents reviewed for unnecessary medications who received antipsychotic medications. Findings include: R3's quarterly Minimum Data Set (MDS) assessment, dated 9/25/25 indicated R3 had moderate cognitive impairment with no behaviors. R3 required partial to substantial assistance for personal and toileting hygiene as well as transfers. The MDS indicated R3 had diagnoses that included debility/cardiorespiratory conditions, orthostatic hypotension (a drop in blood pressure with position changes), heart failure, high blood pressure, and diabetes. R3's diagnoses list included: auditory hallucinations, heart failure, repeated falls, orthostatic blood pressure, and depression. R3's care plan titled Potential psychotropic drug ADRs [adverse drug reactions] related to daily use of psychotropic medications indicated: administer as ordered, monitor target behaviors as ordered, and monitor for ADR's such as orthostatic blood pressures monthly and TD [tardive dyskinesia-a potential side effect of antipsychotic medication use that causes abnormal involuntary muscle movement] screening or AIMS [Abnormal involuntary movement screening] per protocol. R3's Medication Administration Record (MAR) indicated the following: -9/29/25 quetiapine (a medication used to treat psychiatric symptoms) 12.5 mg at bedtime -10/17/25 quetiapine 12.5 mg at bedtime and 12.5 mg as needed -11/13/25 quetiapine 12.5 mg during the day and 25 mg at bedtime -antipsychotic medication side effect monitoring that included drowsiness, dizziness, and orthostatic blood pressure monitoring. The MAR lacked documentation orthostatic blood pressures were attempted. R3's vital signs lacked orthostatic blood pressures were attempted. R3's progress notes lacked documentation orthostatic blood pressures were attempted or if R3 refused. R3's medical record lacked a baseline assessment. R3's progress notes indicated the consultant pharmacist made recommendations on 10/3/25 and 11/3/25. On 12/1/25 the consultant pharmacist found no irregularities R3's Pharmacist Recommendation to Provider form dated 10/3/25 indicated R3 had an active order for quetiapine 12.5 mg at bedtime. The recommendation lacked mention of initiating orthostatic blood pressure monitoring or obtaining an baseline assessment. R3's Pharmacist Recommendation to Provider form dated 11/3/25 indicated R3 had an active order for quetiapine 25 mg at bedtime and 12.5 mg daily as needed. The recommendation lacked mention of initiating orthostatic blood pressure monitoring or assessment. R31 R31's quarterly Minimum Data Set (MDS) dated [DATE] indicated R31 had moderate cognitive impairment with no behaviors. R31 required partial to moderate assistance with personal and toileting hygiene as well as transfers. R31's diagnosis list included: chronic kidney disease, delirium, history of falling, depression, history of bladder and colon cancer. R31's care plan titled Potential for psychotropic drugs ADR's (adverse drug reactions) related to daily use of psychotropic medications indicated: administer medication as ordered, report suspected ADR's to provider, monitor monthly orthostatic blood pressure, and complete TD (tardive dyskinesia-a potential side effect of antipsychotic medication use that causes abnormal involuntary muscle movement) screening or AIMS (Abnormal involuntary movement screening) per protocol. R31's Medication Administration Record (MAR) indicated the following: -Give Seroquel (an antipsychotic medication used to treat psychiatric symptoms) 12.5mg one time a day at 4pm. -Give Seroquel 12.5mg one time a day at 8pm. -monitor orthostatic blood pressure monthly with receiving antipsychotic medications, on the 3rd of every month. The treatment administration record (TAR) lacked include documentation orthostatic blood pressures were attempted. R31's vital signs record lacked orthostatic blood pressures were attempted. R31's progress notes lacked documentation orthostatic blood pressures were attempted or any refusals. R31's pharmacy reviews dated July 2025 through December 2025 lacked noting the missing orthostatic measurements and did not recommend for them to be completed. During interview on 12/3/25 at 8:49 a.m. medical doctor (MD) stated orthostatic measurement are built into routine monitoring to be done at least monthly while residents are taking antipsychotic medications. MD expected pharmacy to confirm orthostatic blood pressures were being completed during the monthly pharmacy reviews; to make recommendations to complete if not being done. Further, MD stated he would expect the nursing staff to complete all three components (laying, sitting, standing) of orthostatic measurements; if one component couldn't be done due to resident medical status, MD would still expect to see the other components. MD would expect to be notified by nursing or pharmacy if orthostatic measurements weren't being done or were abnormal. During interview on 12/4/25 at 11:31 a.m., pharmacist stated pharmacy reviews were conducted monthly per regulation. Pharmacist stated she reviews the side effect monitoring, target behaviors, and vital signs. Pharmacist stated, if a resident had a pre-existing condition of orthostatic blood pressure; she would only check to see if orthostatic measurements were done if the resident had other cardiac symptoms such as dizziness or shortness of breath. Pharmacist stated she verifies the orthostatic measurement is done prior to starting; but does not monitor to make sure monthly orthostatic measurements are being completed. A policy titled Consultant Pharmacist Reports: Medication Regiment Review dated May 2022 indicated the pharmacist review involves a thorough review of resident's records and involves reporting findings with recommendations for improvement. The pharmacist reviews the medication regimen at least monthly; incorporating federally mandated standards of care.

Based on observation, interview, and document review, the facility failed to identify the root causes of falls in order to appropriately implement person centered interventions to help prevent further falls for 1 of 1 resident (R36) reviewed for accidents.Findings include:R36's comprehensive Minimum Data Set (MDS) assessment, dated 10/14/2025, indicated R36 had intact cognition, independent with eating, sit to stand movement, and ambulation with a walker. R36's admission fall assessment dated [DATE] indicated R36 was at risk for falls. R36's fall care area assessment (CAA) dated 10/2/2025, indicated R36 had previously fallen. R36 was at fall risk due to ongoing physical debility secondary to dementia. R36's care plan revised 10/2/25 outlined the following fall prevention interventions: call light pendant on, use call light pendant sign in room, keep room clean and free of clutter, keep call light within reach, monitor and document on safety. The care plan lacked further fall interventions added after 10/2/25 date.R36's incident progress notes identified the following falls:-11/17/25 at 1:53 p.m., due to ambulating in room without walker, tried to sit down in recliner and sat down too soon, sliding down front of recliner, no injuries.-11/26/25 at 6:24 p.m., due to ambulating in room without walker, trying to get something across the room, turned around and lost balance, no injuries.-11/30 at 12:05 p.m., due to ambulating from bed to chair without walker, feet got tangled and fell, nosebleed, left knee pain, bruising above left eye.-11/30 at 4:24 p.m., due to ambulating in room; unclear if R36 had been using walker at time of fall, 4cm abrasion to mid back.R36's record lacked an analysis of the each of the above falls and lacked any new interventions. During observation on 12/2/25 started at:-11:01 a.m.,R36 was sitting at side of bed with socks on (no grippers). Registered nurse (RN)-C and nursing assistant (NA)-A walked by R36's room.-11:03 a.m., R36 stood up. RN-C walked by room again, looking inside room, and continued walking. R36 walked to door and the closed door. NA-D walked by, opened door and saw R36 sitting on roommate's bed and asked R36 if she needed assistance; R36 stated she needed to use restroom. NA-D assisted R36 to the restroom without offering to put shoes on. NA-D left R36 in restroom alone and closed bathroom door then exited room and closed room door. -11:21 a.m., door was opened and observed R36 exited bathroom and did not use the walker. R36 sat down on roommate's bed and put on clean socks (no grippers) and shoes.-11:26 a.m., NA-A entered room and assisted R36 from roommate's bed back to her own chair and placed walker in front of her.During interview on 12/2/25 at 11:35 a.m., NA-A and NA-D stated R36 is a moderate fall risk due to intermittent confusion. NA-A stated R36 had fallen twice in one day because she just forgot how to walk. NA-D stated R36 falls mostly because she doesn't use her walker when ambulating in her room. NA-A and NA-D stated R36 should have gripper socks on or shoes when ambulating. NA-D confirmed she did not put shoes on R36 prior to placing her in the bathroom; NA-D confirmed this was not a safe thing to do for R36. During an interview on 12/2/25 at 11:40 a.m., RN-C stated R36 liked to walk out in the halls a lot and likes to attend the activities. RN-C confirmed R36 is a moderate fall risk due to intermittent confusion and not using her walker. RN-C confirmed R36 had been mildly injured from falling. RN-C stated the resident should have gripper socks and or shoes on. During interview on 12/2/25 at 2:28 p.m., director of nursing (DON), assistant director of nursing (ADON), and administrator confirmed R36 was a moderate fall risk. DON confirmed R36 had fallen four times in a week. ADON confirmed she would expect to see a comprehensive fall care plan to include appropriate footwear, frequent checks, and always keeping her walker close. DON confirmed R36's care plan was not comprehensive and did not include interventions for appropriate footwear and frequent observations. DON confirmed if staff walked by R36's room and saw resident without proper footwear she would expect them to stop and assist R36 with ensuring she had proper footwear on. During interview on 12/3/25 at 8:49 a.m., medical doctor (MD)-A confirmed he was familiar with R36 and her history and risk for falling. MD-A confirmed the interdisciplinary team had discussed R36 and her fall history and possible interventions. MD-A confirmed he would expect a comprehensive person-centered care plan for R36 to include appropriate footwear and frequent observations. A policy titled fall prevention and management dated 11/2025, if falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant.

Based on interview and record review, the facility failed to ensure a baseline abnormal involuntary movement assessment was performed for 1 of 1 residents (R3) and proper side effect monitoring was in place for 2 of 5 residents (R3 and R31) reviewed for unnecessary medications who receive antipsychotic medications.Findings include: R3's quarterly minimum data set (MDS) assessment, dated 9/25/25 indicated R3 had moderate cognitive impairment with no behaviors. R3 required partial to substantial assistance for personal and toileting hygiene as well as transfers. The MDS indicated R3 had diagnoses that included debility/cardiorespiratory conditions, orthostatic hypotension (a drop in blood pressure with position changes), heart failure, high blood pressure, and diabetes. R3's diagnoses list included: auditory hallucinations, heart failure, repeated falls, orthostatic blood pressure (a drop in blood pressure with position changes), and depression. R3's cognition care plan indicated R3's orientation fluctuates evidenced by continuous requests to call family, confusion about time, and requests for assistance from staff to get to his car. A care plan titled Potential psychotropic drug ADRs [adverse drug reactions] related to daily use of psychotropic medications indicated: administer as ordered, monitor target behaviors as ordered, and monitor for ADR's such as orthostatic blood pressures monthly and TD [tardive dyskinesia-a potential side effect of antipsychotic medication use that causes abnormal involuntary muscle movement] screening or AIMS [Abnormal involuntary movement screening] per protocol. R3's Medication Administration Record (MAR) indicated the following: -9/29/25 Seroquel (an antipsychotic medication used to treat psychiatric symptoms) 12.5 mg at bedtime -10/17/25 Seroquel 12.5 mg at bedtime and 12.5 mg as needed -11/13/25 Seroquel 12.5 mg during the day and 25 mg at bedtime -antipsychotic medication side effect monitoring that included drowsiness, dizziness, and orthostatic blood pressure monitoring. The Treatment Administration Record (TAR) lacked documentation orthostatic blood pressures were attempted. R3's vital signs record lacked orthostatic blood pressures were attempted. R3's progress notes lacked documentation orthostatic blood pressures were attempted or any refusals. R3's medical record lacked a baseline assessment. R31 R31's quarterly Minimum Data Set (MDS) assessment, dated 10/24/25 indicated R31 had moderate cognitive impairment with no behaviors. R31 required partial to moderate assistance with personal and toileting hygiene as well as transfers. R31's diagnosis list included: delirium, history of falling, depression, history of bladder and colon cancer. R31's care plan indicated R31 had some intermittent confusion, likes visiting with staff and other residents when he is in a good mood. A care plan titled Potential for psychotropic drugs ADR's (adverse drug reactions) related to daily use of psychotropic medications indicated: administer medication as ordered, report suspected ADR's to provider, monitor monthly orthostatic blood pressure, and complete TD (tardive dyskinesia-a potential side effect of antipsychotic medication use that causes abnormal involuntary muscle movement) screening or AIMS (Abnormal involuntary movement screening) per protocol. R31's Medication Administration Record (MAR) indicated the following: -Give Seroquel (an antipsychotic medication used to treat psychiatric symptoms) 12.5mg one time a day at 4pm. -Give Seroquel 12.5mg one time a day at 8pm. -monitor orthostatic blood pressure monthly while receiving antipsychotic medications, on the 3rd of every month. R31's Treatment Administration Record (TAR) did not include documentation orthostatic blood pressures were attempted. R31's vital signs lacked orthostatic blood pressures results. R31's progress notes lacked documentation orthostatic blood pressures were attempted or any refusals. During an interview on 12/3/25 at 10:00 a.m., registered nurse (RN)-C stated residents receiving antipsychotic medications have behavior monitoring documented on the TAR. If a resident is having odd symptoms, staff would obtain vital signs. RN-C stated orthostatic blood pressure monitoring is documented on the MAR/TAR. During interview on 12/3/25 at 10:41 a.m., the director of nursing (DON) stated when residents are prescribed antipsychotic medications, the facility obtains consent for the medication, and initiates monitoring for target behaviors, side effects, and orthostatic blood pressures. The DON also stated the facility does a baseline AIMs assessment at the start initiating the medication. The DON confirmed R3 and R31 did not have orthostatic blood pressure monitoring in place and confirmed R3's record lacked a baseline assessment. During interview on 12/3/25 at 8:49 a.m. medical doctor (MD)stated orthostatic measurement are built into routine monitoring to be done at least monthly while residents are taking antipsychotic medications. MD expected pharmacy to confirm orthostatic blood pressures were being completed during the monthly pharmacy reviews; to make recommendations to complete if not being done. Further, MD stated he would expect the nursing staff to complete all three components (laying, sitting, standing) of orthostatic measurements; if one component couldn't be done due to resident medical status, MD would still expect to see the other components. MD would expect to be notified by nursing or pharmacy if orthostatic measurements weren't being done or were abnormal. During interview on 12/4/25 at 11:31 a.m., pharmacist stated pharmacy reviews were conducted monthly per regulation. Pharmacist stated she reviews the side effect monitoring, target behaviors, and vital signs. Pharmacist stated, if a resident had a pre-existing condition of orthostatic blood pressure; she would only check to see if orthostatic measurements were done if the resident had other cardiac symptoms such as dizziness or shortness of breath. Pharmacist stated she verifies the orthostatic measurement is done prior to starting; but does not monitor to make sure monthly orthostatic measurements are being completed. A policy titled Psychotropic Medication Use Policy dated 5/2025, residents being prescribed antipsychotics will have orthostatic blood pressure performed monthly. Further, an AIMS assessment will be completed at baseline prior to initiation of an antipsychotic.

Based on observation, interview and document review, the facility failed to ensure flooring was fixed and secure for 1 of 1 resident (R6) reviewed for a safe, comfortable and homelike environment. R6's quarterly Minimum Data Set (MDS) assessment, dated 8/28/25 identified R6 had no cognitive impairment.During observation and interview on 12/1/25 at 5:35 p.m., R6 stated she was unhappy with the transition strip between her room floor and her bathroom floor. R6 stated the transition strip was not secured to the floor and she has caught her shoe on it when using the restroom. R6 stated she would have fixed the transition strip if she were at home. R6 stated she told the facility the transition strip was not secured approximately 2 weeks ago. R6 stated facility staff had not followed up with her about when it will be fixed.Record review showed facility staff submitted a maintenance request on 11/25/25 to have the transition strip repaired or secured. The maintenance record also showed the request to fix the transition strip was completed on 12/1/25; however, the transition strip had not been repaired or secured.During interview on 12/4/25 at 2:48 p.m., the administrator stated she was aware R6's transition strip needed to be repaired or secured. The administrator stated a flooring company recently upgraded the facility floors had been contacted about the transition strip needing repaired; this was the reason the maintenance record was changed to completed because the facility had contacted the flooring company. The administrator confirmed R6's transition strip from her room to the bathroom remained unsecured.A facility policy for maintenance requests was requested and not received.

Based on observation, interview, and document review, the facility failed to ensure residents call lights were answered in a timely manner for 2 of 2 residents (R6, R7) reviewed for grievances. Findings include: R7During an interview on 12/1/25 at 1:04 p.m., R7 stated she sometimes waits 45 minutes before staff respond to her call light. R7 reported I'm not supposed to be walking but sometimes I have to otherwise I have accidents. R7 also reported she has to search for staff when her urinary catheter bag is full. R7's comprehensive Minimum Data Set (MDS) assessment, dated 9/4/25 indicated R7 had mild cognitive impairment.R7's grievance form indicated on 10/2/25, the administrator answered R7's call light. R7 reported to the administrator her call light had been on for a long time. The administrator checked the call light response screen which indicated the call light was on for 12 minutes. The administrator asked the social services director to speak to R7. R7 reported to the social services director her call light was on for a long time without anyone answering. The call button was left on for the entirety of the conversation with both the administrator and social services director before being turned off. Resident stated the light had been on a long time (12 minutes before administrator to answer, 26 minutes total before social service director was able to shut it off after conversation). Resident stated they would like staff to acknowledge they are busy and to let resident know they see her call light is on and will be with her in time. Analysis indicated the social service director checked in with R7 on 10/8/25 who reported staff have been answering call light timely and providing times if unable to get to resident right way. R7's call light logs for dates 11/2/25-12/1/25 indicated R7 had 13 call light times ranging 22-61 minutes from 11/3-11/30/25. R6R6's quarterly (MDS) assessment, dated 11/7/25 indicated R6 was cognitively intact. R6's grievance form dated 9/19/25 indicated R6 reported she waited 1 hour on the morning and evening shift on 9/16 before staff answered her call light. Steps taken to investigate concern/grievance indicated the social service director ran call bell report noting 2 times R6 waited 58 minutes for call bell to be answered. Resolution/Prevent Actions/Follow up indicated R6 was informed of call bell times and staff were reminded to answer call lights promptly. The form indicated a date of resolution of 9/18/25. A resolution report dated 9/19/25 indicated no further review was required. R6's grievance form dated 11/4/25 indicated R6 reported she waited 1 hour for staff to answer her call light on 11/2/25. Steps taken to investigate concerns/grievance indicated the social services director ran the call light log for 11/2/25. The call light log indicated R6 waited 110 minutes during the day however the longest call light was 12 minutes on the evening shift. R6 was informed of the information and the social services director shared findings with nursing team. Date of Resolution was 11/3/25. Resolution report dated 11/4/25 indicated staff verbally educated about answering call lights in a timely manner. Analysis section indicated R6 reported she did not have to wait long in the morning and did not know why the call light was on that long. The grievance indicated there was no further review required. R6's call light logs dated 11/2/25-12/1/25 indicated R6 had 13 call light times ranging 21-71 minutes from 11/4-11/28/25.Further review of facility residents call light logs identified the following.R34R34's comprehensive MDS assessment, dated 11/21/25 indicated R34 was cognitively intact.During an interview on 12/1/25 at 2:32 p.m., R34 reported call light wait times at least 30 minutes up to an hour and a half. R34 reported he has had to just let it go because he could not wait any longer. R34's call light logs for 11/2/25-12/1/25 indicated R34 had 17 call light times ranging 22-80 minutes from 11/5-11/29/25.R1R1's comprehensive MDS assessment, dated 10/21/25 indicated R1 was cognitively intact.During an interview on 12/1/25 at 5:58 p.m., R1 reported he can take himself to the bathroom however needs assistance for toileting hygiene. R1 reported he takes his cell phone to the bathroom with him to play a game while waiting for the staff to answer the call light. R1 added, it takes two games of cribbage before staff come in.R1's call light logs for 11/2/25-12/1/25 indicated R1 had 2 call light times from 21-47 minutes on 11/4/25. In addition, Call light logs from 11/2/35-12/1/25 indicated R28, R15, and R25 had a total of 22 call lights ranging from 20-68 minutes from 11/2-11/28/25. During an interview on 12/02/2025 at 1:50 p.m., nursing assistant (NA)-A stated there are call light screens at the end of each hall that scrolls the room numbers with call lights on. NA-A stated bathroom call lights will scroll first followed by room call lights in order they were turned on. The screen at the end of the hall does not indicate how long the call light has been on. NA-A stated there is a computer screen at nurses' station that indicates exactly what time the call lights went on. During an interview on 12/4/25 at 3:38 p.m., with the administrator and director of nursing (DON), the administrator stated the facility social worker is responsible for documenting grievances. The expectation is to follow-up with the resident the day the grievance is filed and forward the grievance to the appropriate department. Each department is expected to respond to the grievance as soon as possible. The resident is informed of a short-term or long-term solution. If the resident is accepting of the solution, the grievance is closed. The administrator stated she expects the social worker to follow up with the resident and if the issue persists, file another grievance. The DON stated she was aware of R6's grievance and was not aware R7 made a similar grievance. The DON stated she expects call lights to be answered within 15 minutes. The call light logs were discussed with the administrator and DON. The administrator stated there are residents who will push multiple call lights repeatedly and the DON stated there are times staff answer the call light timely however forget to shut the call light off. The administrator stated she had not personally reviewed call light logs. The DON stated she was unaware the call light response times were that long. The DON stated staff use the computer at the nurses' station and the screens at the end of the halls to determine which call lights are on. She confirmed the screens at the end of each hall do not indicate how long the call light has been on.

Based on interview and document review, the facility failed to offer and/or provide a suitable and nourishing snack after dinner and before bedtime when there were more than 14 hours between the evening and morning meals. This had the potential to affect all residents in the facility who would require a snack. Findings include: The facility provided a survey preparation binder which included an undated flyer titled Mealtimes: Breakfast - 8:00 a.m. Lunch - 12:00 p.m. Dinner - 5:00 p.m. During an observation on 10/29/24 at 2:08 p.m., a wicker basket was on the counter in the resident dining room. The basket contained applesauce, granola bars, pudding, animal crackers and rice krispie bars. In the refrigerator on a tray were half sandwiches in plastic bags, pieces of fruit, and a squeeze container of jelly. During an interview on 10/30/24, at 6:55 a.m., dietary aide (DA)-A stated dietary staff made peanut butter sandwiches for residents who didn't eat much for meals and were hungry later. DA-A stated the sandwiches were for any resident. During an interview on 10/30/24 at 12:35 p.m., dietary manager (DM) was aware there should not be more than 14 hours between the evening and morning meals but was not aware the facility exceeded those hours. DM was aware a substantial snack was required for residents when there were more than 14 hours between the evening and morning meals but could not state what would be considered a substantial snack. During a telephone interview on 10/30/24 at 1:55 p.m., registered dietician (RD) stated she was not aware of the length of time between the evening and morning meals. When informed it was 15 hours, RD stated, residents should receive a substantial snack which would include a protein and a carbohydrate. RD was aware dietary staff made some peanut butter sandwiches and kept them in a refrigerator for staff to access but did know it they were offered to each resident, adding she had not reviewed the facility snack process recently. During an interview on 10/31/2024 at 10:43 a.m., the director of nursing (DON) and administrator were both aware there were 15 hours between the evening and morning meals. Neither were aware residents should receive a substantial snack consisting of a carbohydrate and a protein. The administrator stated peanut butter sandwiches were always available to residents, and indicated a substantial snack was not offered to or provided to residents. The DON added the residents were not offered nor did they receive a substantial snack after the dinner meal and before bedtime. The facility Meal Times policy dated 9/2012, indicated it was policy 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. Meal times would be: a. Breakfast (the space was blank) b. Noon (the space was blank) c. Evening (the space was blank) The hospitality services manager was responsible to monitor the system to assure adherence to this schedule. All staff were responsible for following this schedule.

Based on observation, interview and record review, the facility failed to provide physical therapy and occupational therapy as ordered for 1 of 1 resident (R5) reviewed for therapy services. Findings include: R5's Admission Record undated, identified R5 was admitted to the facility on [DATE]. Diagnoses included Epilepsy (A neurological disorder that causes seizures) and quadriplegia ( is the paralysis of both arms and legs due). R5's quarterly Minimum Data Set (MDS) dated [DATE], identified R5 was nonverbal and unable to determine cognitive status. The MDS identified R5 had impairments to both upper and lower extremities, could not ambulate, and was dependent on staff for all cares. R5's discharge instructions and active order summary from R5's former LTC facility, dated and signed 7/7/22, identified R5 was discharged to [NAME] Prairie Rehab Center. The order summary report indicated occupational therapy (OT) and physical therapy (PT) were to evaluate and treat as indicated after admitted to the facility. The order summary also indicated nursing to ensure passive range of motion (PROM) was completed to left ankle, left knee, and left hip daily with AM cares. R5's active Order Summary Reported dated 7/13/22 (from current facility) lacked orders for therapy or a PROM program. During an interview on 10/30/24 at 8:10 a.m., the occupational therapist (OT) stated new admissions with orders for therapy services would be evaluated by therapy staff within 48 hours of admission. OT was aware R5 had orders at the time of admission for OT and PT, but the decision was made not to perform the evaluations and treat as ordered because of a payor source concern. There also were no orders received to discontinue the therapy orders after the decision was made not to offer therapy to R5. During an interview on 10/30/24 at 1:34 p.m., the director of nursing (DON) confirmed the discharge orders from R5's prior LTC facility were also the admission orders for [NAME] Prairie Rehab Center. She also confirmed R5 had therapy orders and PROM orders at time of admission, but the orders were never started. The DON also confirmed the therapy orders and PROM orders were never entered into R5's EMR because there was a payor source issue and therapy was not going to perform the evaluation, so the orders were not needed. The provider should have been contacted and orders obtained to discontinue the therapy orders if they were not needed. During an interview on 10/31/24 at 8:54 a.m., the administrator stated she expected all new admission orders would be entered into the EMR by staff, and followed until new orders were obtained that overrode the prior orders. The facility therapy policy was requested but not provided.

Based on interview, observation and record review the facility failed to perform range of motion or ambulation (walking) as ordered for 2 of 2 residents (R14, R6) reviewed for restorative therapy programs. Findings include: R14's quarterly MDS dated [DATE], indicated R14 was cognitively intact, and diagnoses included stroke and hemiplegia or hemiparesis (loss of some or all ability to use one side of the body). R14 had functional limitation in range of motion to one side of the upper and lower extremities. R14 needed maximal assistance and dependent on staff for all mobility. R14's care plan dated 4/23/20, indicated impaired mobility related to stroke and resulted left side paresis. Interventions included two times a day when laying down range of motion (ROM) movements with left lower extremity (LLE), hip flexion/abduction and knee flexion for 20 repetitions. R14's Occupational Therapy (OT) Discharge Summary dated 6/5/20, indicated a ROM program had been made and given to nursing to follow. R14's passive range of motion (PROM) program from 10/1/24 - 10/28/24, indicated ten times documented not applicable (NA) and thirty-one times no charting was entered. During an interview on 10/28/24 at 3:48 p.m., R14 stated the staff did ROM on her LLE sometimes, but wished they did it more often because the LLE starts to hurt. During interview on 10/30/24 at 7:36 a.m., nurse assistant (NA)-B stated R14 was on a ROM program performed twice a day, with morning cares and then when R14 went to bed at night. After the ROM program was complete it would be documented in R14's record. NA-B reviewed R14's documentation and acknowledged areas with an NA as well as missing documentation. NA-B stated an unawareness of why somebody would mark NA on this resident's charting. NA-B was unaware of staff ability to not be able to complete the ROM program for R14. During an interview on 10/30/24 at 8:10 a.m., the therapy director (TD) stated a ROM program would be set up by the therapy department if therapy felt it would help keep the resident at a certain level and not get worse. Therapy set up the program and then nursing made sure it was completed. The TD reviewed R14's OT notes and verified on 6/5/20 R14 had been discharged from therapy with a ROM program in place. During an interview on 10/30/24 at 1:34 p.m., the director of nursing (DON) stated therapy communicates ROM programs with a therapy to nursing communication form. The form is given to the unit coordinator to enter into the electronic medical record. Nursing assistants document completion of the ROM program in the electronic medical record. The DON stated they do not check completion of documentation unless a concern is reported. The DON reviewed R14's record acknowledged there were several times since 10/1/24, no documentation was completed. The DON stated they would expect nursing staff to complete assigned ROM programs and report if unable to complete. 49893 R6 R6's quarterly MDS dated [DATE], indicated R6 was cognitively intact, had impaired range of motion to both arms and no impairment to either leg. R6 required substantial assist for toileting, showering, and activities of daily living (ADLs), partial/moderate assist sitting to standing and supervision/touch assist for ambulation/walking. R6's diagnosis list included rheumatoid arthritis (disorder of the joints causing deformity and decreased function), difficulty walking, muscle weakness, and chronic pain syndrome. R6's care plan indicated impaired mobility related to weakness due to rheumatoid arthritis. Interventions included walk to and from the bathroom with 1 assist and gait belt and walk from room to activities department with walker, gait belt and wheelchair to follow. During an interview on 10/28/24 at 2:05 p.m., R6 stated they are supposed to ambulate daily however lucky to ambulate once a week. During interview on 10/29/24 at 1:20 p.m., R6 stated they were not offered to walk on 10/28/24. R6 reported occasional refusals due to discomfort but would walk at least 5 times a week if offered. R6 stated they must use their legs to get around in their wheelchair because of the arthritis in their hands. R6 indicated they had the opportunity to use a motorized wheelchair and declined for fear of losing use of their legs. During observation and interview on 10/29/24 at 1:46 p.m., R6 was observed walking in the hall with the assistance. Nursing assistant (NA)-A stated R6 is on a daily walking program to and from the activity department. NA-A stated R6 goes through phases of refusing to ambulate. NA-A stated if R6 refuses staff document refused in the electronic medical record. NA-A stated not applicable would be documented if there was no time to assist R6 to walk. The only time documentation would be left blank is if staff forgot to document. During interview on 10/30/24 at 8:26 a.m., registered nurse (RN)-A stated therapy sets up ambulation programs. The nursing assistants document completion of walking programs in electronic medical record. RN-A stated R6's acceptance of walking is mood dependent. During interview on 10/20/24 at 8:39 a.m., physical therapist (PT)-A reported seeing R6 multiple times since admission for leg strengthening, walking program, and transfers/home exercise program. PT-A reported walking programs are communicated to nursing staff via therapy communication form. There is a binder containing all walking programs on the unit. PT-A stated they informally check in with residents on occasion however the therapy director does formalized check-ins at IDT (interdisciplinary team) meetings weekly. During interview on 10/30/24 at 8:58 a.m., the therapy director (TD) stated a Therapy to Nursing Communication form is filled out when restorative/walking programs are developed. Completion of program is documented in electronic medical record by the nursing assistants. TD confirmed R6's walking program included walking to and from the activity room daily. TD spoke to R6 on 10/2/24 and confirmed R6 reported walking program has been inconsistent. After speaking to R6, the TD compiled all walking programs onto one form and placed it in the linen rooms down each hall as a reminder for nursing staff to complete each program. Walking programs are also on nursing assistant care sheets. The therapy director stated R6 could experience increased weakness if walking program isn't completed consistently. The TD provided a document titled walking programs that listed all residents in the facility on walking programs with detailed instructions of the program. The form indicated R6 was to use platform walker to walk to bathroom for toileting needs and walk to activity room and back. During interview with NA-B and NA-C on 10/30/24 at 10:07 a.m., NA-B stated they would document not applicable if the resident was unable to transfer safely when attempting a walk. NA-B indicated performing R6's walking program was hit and miss and dependent on who was on duty for that day. NA-C stated R6 does not usually refuse to walk. Review of R6's walking program from 7/1/24 - 10/28/24 indicated the following: Out of 31 opportunities from 7/1/24-7/31/24, R8 walked twice and refused 10 times. Not applicable was documented 9 times and 10 opportunities lacked documentation. Out of 31 opportunities from 8/1/24-8/31/24, R8 walked 4 times and refused 9 times. Five opportunities were documented not applicable and 13 opportunities lacked documentation. Out of 30 opportunities from 9/1/24-9/30/24, R8 walked once and refused 7 times. Eight opportunities were documented not applicable and 14 opportunities lacked documentation. Out of 28 opportunities from 10/1/24-10/28/24, R8 walked 7 times and refused 4 times. Not applicable was documented for 5 opportunities and 14 opportunities lacked documentation. During interview on 10/30/24 at 10:41 a.m., the director of nursing (DON) stated therapy communicates walking programs by filling out therapy to nursing communication form. The form is given to the unit coordinator to enter into the electronic medical record. Nursing assistants document completion of walking program in the electronic medical record. Nursing assistants fill out communication form if residents have difficulty performing tasks. The DON stated they do not check completion of documentation unless a concern is reported. The DON stated they would expect nursing staff to complete assigned walking programs and report if unable to complete. Facility restorative/maintenance therapy program policy was requested but not provided.

Based on observation, interview, and document review, the facility failed to ensure hand hygiene was completed by 3 of 12 staff (NA-A, RN-A, and NA-B) observed prior to providing cares for 6 residents (R14, R4, R30, R37, R36 and R26). The facility was having a gastro-intestinal illness outbreak at the time. Findings: On 3/28/22, 1:45 p.m. two carts with personal protective equipment (PPE) were observed on the 200 hallway with signage posted on the doors to R22's and R10's room and R32's room, indicating persons entering the room should use, contact precautions (use PPE of gown, gloves and mask). Shortly after this, an additional cart with supplies was brought to a nearby room and a sign posted on R238's door also indicating staff were to use, contact precautions. On 3/28/22, 2:33 p.m. a nursing assistant (NA)-A stated the facility had, stomach flu going around and the residents had symptoms of vomiting and diarrhea. NA-A was already wearing eye protection and a mask, but was observed to put on a gown and gloves, enter R22's room with incontinence products, put them away, touching furniture in the room. Then NA-A removed gown and gloves, placed them in the refuse container inside R22's room, touching the lid which was contaminated, and then sanitized hands with alcohol sanitizer. NA-A stated facility had provided infection control education about two months prior, and said hand sanitizer does not always work well with gastro-intestinal illnesses and staff should wash hands with soap and warm water for at least 20 seconds when someone has a GI illness, but admitted she had not done so after removing PPE, or leaving R22's room. During an interview 3/29/22, 9:43 a.m. the director of nursing (DON) stated the first incident of GI illness had started on 3/26/22 when R22 developed loose stools and was placed on contact precautions. When the next resident became ill with nausea and loose stools on 3/27/22 they suspected possible Norovirus (a GI illness that is contagious and easily spread in a community living setting such as a nursing home). DON stated the medical director and all primary physicians were notified, and they initiated their Norovirus protocol. DON stated hand washing instead of the use of alcohol sanitizer had to be initiated as alcohol was not effective against GI illnesses such as Norovirus. DON said she and a nurse manager had been meeting with staff as they came to work to review the proper precautions. DON defined these precautions as being contact precautions with the use of soap and water handwashing for any person suspected of GI illness. On 3/29/22, 10:12 a.m. a registered nurse (RN)-A was observed without gloves, carrying a bag of soiled incontinent products and other trash from R238's room. R238's room still had a sign indicating staff should use contact precautions. RN-A was observed to carry the trash out a nearby building exit and go to the trash container to dispose of the bag. RN-A then returned to the building, used alcohol based hand sanitizer and walked to a medication cart, signed into the computer, opened the cart, removed a wound dressing, opened the dressing, wrote the date on the dressing with a marker sitting on the cart, and then went to the room of R14. RN-A knocked and entered R14's room and proceeded to apply the dressing to R14's ankle stating it was for protection. RN-A then left R14's room and returned to the medication cart and used alcohol based hand sanitizer, but did not clean the marker, the computer or the cart. On 3/29/22, 10:20 a.m. RN-A stated she had used alcohol based hand sanitizer after disposing of the contaminated trash from R238's room, and said she had not been told to use a soap and water wash when residents showed symptoms of GI illness. RN-A stated they should clean with a bleach solution if a person had a C-diff infection, but we think this is a virus, not C-diff. (C. difficile is a GI infection usually associated with antibiotic use.) At 3/29/22, 12:52 p.m. NA-B was observed while doing the task of picking up lunch trays after residents had finished eating. NA-B entered several rooms, picking up soiled trays and placing them on the cart for dirty trays. NA-B brought a soiled tray from R36 and placed it on the cart, then, without practicing hand hygiene picked up a clean drinking mug, went to the dining area and filled it, then returned with the cup and brought it to R4 in another room. NA-B was then observed to enter R7's room to retrieve a used lunch tray, placed it on the cart, entered R19's room and retrieved a used lunch tray and placed it on the cart. Then, NA-B was asked to assist with the care of R30. NA-B grabbed a transfer lift sitting in the hall and without practicing hand hygiene, entered R30's room. On 3/30/22, 8:30 a.m. NA-B was observed providing cares to R23, and when NA-B left R23, no hand hygiene was observed. NA-B was observed to get R37 to do a weight. NA-B did physically touch R37 during this process. Afterwards, NA-B was not observed to practice hand hygiene. NA-B then went get R36 for a morning weight, without doing hand hygiene before the task and even though R36 was touched during the process, NA-B did not practice hand hygiene after the task was complete. NA-B then proceeded to pass morning breakfast trays to R26 and R36 without performing hand hygiene first. During an interview 3/30/22, 8:42 a.m. NA-B stated the facility had provided infection control training within the past few months, and said the previous month the training had been on hand hygiene and the use of PPE. NA-B stated one way to prevent the spread of infection within the facility was by using hand sanitizer and by washing one's hands. NA-B stated it was expected use hand sanitizer before entering a resident's room, and upon exit. NA-B stated she did not recall any lapse in hand hygiene on her part. A facility document titled Resident GI Illness log indicated the first case of GI illness started on 3/28/22, R22 on the 200 wing, then R32, across the hall on 3/29/22 and R238, next door on 3/28/22. The next case was R17 on the 100 wing on 3/29/22, as well as R3 on the same date. R9 on the 300 hall and R10 on the 200 hall were also stricken on 3/29/22. On 3/30/22, R7 and R21 on the 100 wing became ill with GI illness, and on 3/31/22, R16 and R35 on the 100 unit became ill; R25 and R18 on the 200 unit became ill, and R23, R34 and R36 on the 300 unit became ill with GI illness. A facility policy titled MHM-Norovirus Prevention and Control marked as updated 3/4/22 indicated during outbreaks, residents with norovirus gastroenteritis will be placed on Contact Precautions for a minimum of 72 hours after the resolution of symptoms. Also, the policy indicated, during outbreaks, use soap and water for hand hygiene after providing care of having contact with residents suspected or confirmed with norovirus gastroenteritis. To prevent food-related outbreaks of norovirus gastroenteritis in healthcare settings, food handlers must perform hand hygiene prior to contact with or the preparation of food items and beverages. A facility policy and procedure titled Monarch Healthcare Management Handwashing policy dated 11/2019 indicated proper hand washing techniques should be used to protect [from] the spread of infection. [NAME] washing shall be completed before, during and after preparing food, before eating, before and after caring for someone who is sick, before and after treating a cut or wound, after using the toilet, after changing incontinent products or cleaning up after someone who has used the toilet, after blowing nose, coughing or sneezing, touching an animal or animal waste, after handling pet food or pet treats, after touching garbage. The implementation portion indicated, hand washing shall be performed by all employees, as necessary, between tasks and procedures, and after bathroom use to prevent cross contamination. According to the CDC, healthcare workers should use hand sanitizer immediately before touching a patient, before performing an aseptic task or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces and immediately after glove removal. The CDC recommends washing with soap and water when hands are visibly soiled, and after caring for a person with known or suspected infectious diarrhea, after known or suspected exposure to spores (e.g. B.antracis, C difficile outbreaks).

Based on observation, interview and document review, the facility failed to implement interventions to ensure safe transfers for 2 of 3 residents (R21 and R17) reviewed for falls. R21 experienced harm, bone fractures and loss of function following a fall during transfer when the staff did not implement use of a gait belt. Findings include: During interview with R21 on 1/27/20 at 1:33 p.m., R21 stated she had fallen on 11/15/19, sustaining two fractures and requiring hospitalization . R21 stated staff had not use a gait belt during the transfer and stated, If she (the nursing assistant (NA) staff) had put the gait belt on, she could have pulled me back. R21 stated besides the fractures, she had to move to a different room when she came back from the hospital. She said this was because staff needed to use a ceiling lift since she could not stand, and stated it was very upsetting to her and she was happy when she could finally return to her original room. R21 said she had missed her roommate and her own personal items during the time she was in the room with the ceiling lift. When asked about her personal items, R21 stated she was told she had too many items to move, so they had to remain behind during that time. In addition, R21 said she had been unable to play the piano for some time after the fall, because she'd fractured her arm. She said this really bothered her because playing the piano brought joy to herself, and for other residents who were entertained by her music. According to R21's Admission Record in the electronic health record (EHR), R21 had multiple [DIAGNOSES REDACTED]. In addition, following the hospitalization in (MONTH) of 2019, the following [DIAGNOSES REDACTED]. According to R21's 9/8/19 quarterly Minimum Data Set (MDS) assessment, R21 required extensive weight bearing assistance of two persons to transfer and walk. The MDS indicated R21 was not steady when moving from a sitting to standing position, or when moving on and off the toilet and required human assistance. The MDS also indicated R21 was cognitively intact. According to R21's 12/9/19 quarterly MDS, R21 had become totally dependent on the assistance of two persons to transfer (no longer able to participate) and was unable to walk. The MDS indicated R21 remained cognitively intact. The care plan provide by the facility for R21 included: Transfer with limited to extensive assist with use of walker and gait belt. Assist of one, follow with wheelchair for ambulation. Her function varies related to obesity. The date of initiation was 3/22/18. The care plan had been modified 1/2/19, to indicate R21 required extensive assist of two persons and a gait belt for transfers. Revisions 11/19/19 indicated the resident required two staff assist with bed mobility, and two assist with Hoyer lift (mechanical lift) for transfers due to left humerus fracture and right fibula fracture. In a documented Employee Statement of Reported Incident dated 11/15/19, NA-G wrote: I was helping the resident in room (resident's room #) to the bathroom. I forgot to put the gait belt around her. She started to fall backwards and I caught her and tried to push her up a little for her to get her balance back, but then she fell forward. She did not hit her head but says that her left arm is hurting. A progress note in R21's EHR dated 11/15/19 at 5:00 p.m. included: The resident fell to the floor. It happened when she entered the bathroom She had her walker with her and had a CNA (certified nursing assistant) walking behind her. The resident was trying to go down slowly, but she lost the grip of her walker. She fell in front of the toilet. Did not hit her head. The resident was not able to turn to her side due to severe pain in L (left) arm. She was kept lying still till ambulance crew and firemen arrived. She was assisted out from the bathroom, then she was transferred to ER (emergency room ). R21's Hospital Discharge Summary dated 11/19/19, indicated R21 was admitted to the hospital on [DATE] after suffering a mechanical fall at the skilled nursing facility. The summary indicated R21's admitting [DIAGNOSES REDACTED]. Following admission, the hospital also identified R21 had a displaced [MEDICAL CONDITION] fibula (lower leg bone). The discharge summary further indicated during hospitalization , R21 suffered a drop in hemoglobin and increase in leukocytes attributed to the stress of the fall. R21 was discharged back to the facility on [DATE] with a non-weight bearing status for both the upper and lower extremity injuries. A Physical Therapy (PT) Plan of Care dated 11/19/19, indicated R21 had suffered a decline in function and impaired ability to perform ambulation and transfers due to recent fractures. Due to those impairments, the document indicated R21 would require skilled PT in order to regain her previous level of function. An Occupational Therapy (OT) Plan of Care, also dated 11/19/19, indicated R21 would require OT. The facility's social worker (SW) documented an EHR progress note 11/19/19 at 3:12 p.m. including: Resident returned (from hospital), needed a Hoyer lift for transfers. Resident is temporarily moved to (room #) since this room has a ceiling lift. On 11/25/19 at 3:10 p.m., the SW documented note indicating R21 had been tearful at times since returning from hospital and had expressed feeling down and depressed. Resident was unable to play the piano due to her arm fracture. (Resident name) stated, 'Music is my whole life. That is what I enjoy and what I am good at. If I can't do that, it's sad'. On 12/6/19 at 3:43 p.m., the SW again documented that R21 had felt down due to her recent decline in health and lack of independence. Resident became tearful and stated that she is fearful of walking into the bathroom again when she can and falling. In a physician's progress note dated 12/19/19, the physician documented R21 had experienced a fall 11/15/19, related to not using a gait belt, resulting in fractures to the upper left extremity and lower right extremity. The note also indicated medication changes were necessary to establish better pain control for R21. A physician assistant's progress note dated 1/15/20, referenced R21's inability to play the piano currently: Mood has been stable, though she misses playing the piano with both hands. During interview 1/29/20 at 2:27 p.m., licensed practical nurse (LPN)-A stated she had been working on 11/15/19 when R21 fell . LPN-A stated when she had arrived at R21's room to assist after the fall, she had not observed a gait belt on R21. LPN-A said the facility's administrator had spoken to NA-G about gait belt use, but NA-G had not been removed from duty. During a follow up interview with R21 on 1/30/20 at 11:08 a.m., she stated, I won't name any staff, but they are going to do what they want to do. About three quarters of the staff do not use gait belts when providing assistance. R21 also said she didn't feel like she could tell the staff what to do, but would remind them that she had previously gotten hurt when a gait belt wasn't used. The director of nursing (DON) was interviewed at 1:56 p.m. on 1/30/20. The DON stated she had not been working 11/15/19, when R21 had fallen and verified the administrator had taken care of counseling NA-G that day. The DON stated NA-G, and all staff, had previously received training on the importance of using a gait belt during transfers, and disciplinary action had been taken in relation to R21's fall. The DON said following R21's fall incident, she had provided training again for all staff in relation to gait belt use. However, the DON was unable to provide any dates, corresponding documentation, or attendance sheets to verify the training. The DON also stated she had not conducted any formal audits of gait belt use by NA-G, or any other staff, but instead watched for gait belt usage when making rounds. The DON stated NA-G had previously received discipline regarding failure to complete resident care. Documentation of NA-G's personnel record was reviewed 1/30/20. A 10/1/19 disciplinary record indicated residents had complained their cares were not being completed by NA-[NAME] The documentation indicated it had been verified a resident assigned to NA-G on 9/23/19, had not received assistance from NA-G for cares. The disciplinary action document indicated NA-G had been instructed to follow-up with assigned residents to verify their needs had been met, and if NA-G did not know her assigned duties, or required further orientation, she was expected to ask. A request was made for documentation of further skills training, or competency assessment, related to the use of gait belts following the 11/15/19 incident with R21. The facility only provided NA-G's original skills assessment dated [DATE], which did not include assessment of the use of gait belts. In a post survey letter documented by the interim administrator 2/3/20, the administrator confirmed NA-G had transferred R21 without the use of a gait belt resulting in a fall, and verified R21 had sustained fractures and required hospitalization . Further the document indicated NA-G had previously received and acknowledged, training on the expectation of gait belt use within the facility. A 6/2019 revised Fall Prevention and Management policy, indicated facility staff would identify interventions related to a resident's specific risks to attempt to prevent falls or to minimize complications from falling. Documentation of the facility's Certified Nursing Assistant (CNA) job description indicated it was the responsibility of a CNA to provide quality care as identified in the care plan. It included: Assist resident with transfers in and out of bed and into wheelchair with correct use of transfer belt. R17's quarterly MDS, dated [DATE], indicated R17 requires one physical assist with activities of living (ADL's), not steady walking (only able to stabilize with human assistance), had a fall with injury since admission, had severe cognitive impairment and [DIAGNOSES REDACTED]. During observation on 1/29/20, at 7:59 a.m., NA-H applied a gait belt around R17's waist and had R17 use her walker to transfer from her recliner to her bed. R17's care plan last review date 6/25/19, included at risk for falling related to unsteady gait, self transfer attempts and dementia with cognitive impairment impacts risk. Interventions included walker and gait belt for transfers/ambulation and low bed while occupied. A Minnesota Department of Health (MDH) incident report, dated 7/21/19, included resident found in room on floor next to bed. Small laceration to forehead and right ankle. First aide done. Resident assisted back to bed. Resident's bed was not in low position as care planned. Staff educated on importance of following plan of care. Investigation in progress. R17's resident progress note dated 7/20/2019, included resident heard yelling help. Found on floor beside bed. Injuries include 5 mm (millimeter) laceration to right occipital area with light bleeding, 1/4 inch diameter skin tear below right knee cap and 1/4 inch diameter skin tear on right ankle bone. During interview on 1/29/20, at 10:55 a.m., NA-F stated she had forgot to put R17's bed in the lowest position and R17 had fallen out of bed. R17's bed was to be all the way to the floor due to R17 would crawl out of bed to use the bathroom. NA-F stated obviously it was not safe for R17 as the bed was not in the lowest position. NA-F stated she had been educated regarding following the resident care plan. The facility five day investigation report dated 7/26/19, indicated the residents plan of care had not been followed at the time of the incident. Residents bed was to be in low position. Staff observed resident laying on the floor next to her bed that was not in a low position. Staff received verbal education immediately on the plan of care for resident and this was passed through report to have staff check all resident safety interventions prior to leaving the room and that assisted resident with getting ready for bed the night the event occurred. Certified nursing assistant (CNA) admitted that she did put resident to bed that evening and forgot to place the residents bed in low position as directed by the care plan. CNA was educated on the use of assignment sheets for a residents plan of care and to double check at the end of her shift to be sure that all safety equipment is in place for her residents prior to leaving shift. Employee educated on importance of following care plan. Although the facility investigation indicated NA-F had been educated there was no documentation of the education provided to NA-F or for facility wide education provided to staff regarding following the resident care plan for safety interventions to protect all residents following the incident. The investigation also indicated RN-D, LPN-A and NA-F had been interviewed regarding the incident, however the facility had no documentation of the interviews. A MDH incident report, dated 8/30/19, indicated RN reports that CNA was ambulating resident out of the bathroom. Resident became unsteady and was lowered to the floor. No injury noted. CNA does report that she was not using the gait belt as it was care planned. CNA was immediately educated by floor RN. Investigation in progress. R17's resident progress note dated 8/30/19, included fall while ambulating, lowered to floor. Resident ambulating from bathroom with staff. Care plan not followed as gait belt was not being used. Resident became unsteady and was lowered to the floor with no injuries. Contributing factor was no gait belt used and loss of balance. During interview on 1/29/20, at 10:58 a.m., NA-B stated she had ambulated R17 with a walker to the bathroom to use the toilet and on the way back from using the toilet R17 had hit the wheel of her walker, which caused R17 to become unsteady and she fell . NA-B stated R17 does not walk the best and she is unsteady when walking. NA-B stated she did not use a gait belt when she was assisting R17 with ambulation to and from the toilet. NA-B stated a staff person at the time of the incident had reminded her to always use a gait belt. During interview on 1/29/20, at 11:08 a.m., RN-C stated she had been on duty when R17 had fallen on 8/30/19. RN-C stated NA-B had not used a gait belt when ambulating R17 and at the time of the incident she had provided education to NA-B regarding use of a gait belt. The facility five day investigation dated 9/3/19, included CNA was not utilizing a gait belt at the time of the incident. Resident tripped, lost her balance and was lowered to the floor by the CNA and did not sustain any injuries. CNA immediately removed from the floor and verbally educated by floor nurse regarding importance of following plan of care for residents. DON additionally followed up with CNA later in the day to discuss incident and reeducate regarding following the resident plan of care. CNA will be provided written counseling prior to next work shift in regards to following resident plan of care. The investigation file included employee statement of reported incident sheets dated 8/30/19, one signed by RN-C and one signed by the DON, however there was no signature by NA-B. Although the facility investigation indicated NA-B would be provided written counseling, there was no documentation of signature by NA-B having had received the counseling. In addition, there was no documented facility wide education provided to staff regarding use of a gait belt for safety to protect all residents following the incident. The investigation also indicated RN-C and NA-B had been interviewed regarding the incident, however the facility had no documentation of the interviews. During interview on 1/29/20, at 1:21 p.m., the DON verified the investigations regarding the above MDH incident reports lacked documentation of interviews completed. The DON stated she had made a cardboard board care card regarding following the resident care plan for all safety interventions (not just for bed in low position and use of gait belt) to educate all staff and had a sign up sheet for staff to sign to acknowledge. The DON stated she had no documentation of the education regarding the facility wide education provided (which included the date the education was provided and content of education). The facility policy Application and use of Transfer Belt, dated 9/11, indicated to apply transfer belt on resident and to ensure safety during transferring or walking.

Based on observation, interview and document review, the facility failed to ensure all items on room trays were covered for 6 of 6 room trays delivered observed during two dining observation. Findings include: On 1/27/20, at 5:03 p.m. nursing assistant (NA)-A started to deliver room trays. NA-A delivered room trays to a resident who ate their meal in a common area of the facility on a tray table and to rooms [ROOM NUMBERS]. NA-B was observed to deliver a room tray to room [ROOM NUMBER]. There were no covers on the beverages, which included water and coffee. There were no covers on the small dishes of mandarin oranges, the lettuce salads or the containers of salad dressing on any of the room trays. On 1/27/20, at 5:15 p.m. NA-B verified the lettuce salads, fruit, salad dressing and beverages were not covered when the room trays were transported to resident rooms. NA-B stated it had been this way since she started almost six months ago. On 1/28/20, at 12:08 p.m. room trays were delivered to rooms [ROOM NUMBERS] and the coffee and water was not covered. NA-C verified the beverages on the room trays did not have covers. On 1/29/20, at 11:19 a.m. the certified dietary manager/registered dietician stated the expectation was when the trays are being transported from the cart to the resident rooms everything should be covered to prevent cross-contamination. The Accident Prevention in Food Transportation policy dated 9/12 included, Food and beverages will be kept covered in transit.

Based on interview and document review, the facility failed to ensure choices were offered for more than one bath a week and wake times for 2 of 2 residents (R22, R86) reviewed for choices. Findings include: R22 was interviewed on 1/27/20, at 1:17 p.m. R22 stated would like more than one shower a week. R22 stated they (facility staff) have not asked him how many showers he would like a week. R22's quarterly minimum data set (MDS) assessment dated [DATE], identified R22 to be cognitively intact with a brief interview for mental status score of 14, with clear speech, was understood, and understands. On 1/28/20, at 3:53 p.m. social services (SS)-A stated she did not ask residents for their preference for bathing and directed writer to ask the activity director. On 1/28/20, 3:55 p.m. activities (A)-A stated she did not ask residents their bathing preferences. A-A stated she thought it would be SS-A as she did all of the admission paperwork or the nurse that admitted them. On 1/28/20, at 4:07 p.m. registered nurse (RN)-B stated nurses ask on admission assessment bathing frequency and preferences related to bathing. On 1/30/20, at 8:38 a.m. the director of nursing (DON) stated R22's bathing preference was left blank on the admission assessment as he did not have a preference for type of bath or a time preference. The DON verified the admission assessment did not ask residents their preference for frequency of bathing. The DON verified the IDT (interdisciplinary team) care conference form did not address frequency of bathing preference. On 1/30/20, at 10:36 a.m. the DON stated R22 said a shower was ok; he preferred to have it in the evening and stated he would like a shower twice a week as he was sweating more. The DON stated R22's bath schedule would be updated to twice a week. AWAKE TIME R86's admission Minimum Data Set ((MDS) dated [DATE] indicated R86 had intact cognition with a brief interview for mental status score of 14. The MDS further indicated R86 had clear speech, was understood and understands. R86's sleep disturbance evaluation indicated R86's normal arise time was between 7:00 a.m. and 8:00 a.m. R86 was interviewed on 1/27/20, at 2:18 p.m. R86 stated that morning staff got him up at 6:00 a.m. and he was not sure why they got him up so early when breakfast was not until 8:00 a.m. R86 stated he usually got up about 7:00 a.m. R86 stated he thought staff did ask him upon admission what time he would like to get up and he stated he would prefer to get up around 7:00 a.m. On 1/29/20, at 7:15 a.m. nursing assistant (NA)-D stated she went in and asked R86 this morning when he would like to get up. NA-D stated some residents have it in their care plan a specific time to get up. NA-D stated if they do not have a specific time in their care plan to get up she would knock on the door and ask if they were ready to get up. On 1/28/20, at 3:53 p.m. social services (SS)-A stated she did not ask residents for their preference for awake times and directed writer to ask the activity director. On 1/28/20, 3:55 p.m. activities (A)-A stated she did not ask residents what preference was for awake times. A-A stated she thought it would be SS-A as she did all of the admission paperwork or the nurse that admitted them. On 1/28/20, at 4:07 p.m. registered nurse (RN)-B stated awake and bed times if they have a specific request was completed by the social worker upon admission. On 01/30/20, at 8:42 a.m. the director of nursing (DON) stated the facility did not have any specific questions they ask residents about what time they would like to get up and stated there was not documentation we ask residents when they would like to get up. The DON stated it was not on the initial assessment by nursing. On 1/30/20, at 10:30 a.m. during an interview with the DON and RN-B. The DON stated R86 told her staff come in at 6:00 a.m. to wake him up but it did not make any difference to him. The DON stated R86 told her he usually got up at 7:00 a.m. Register nurse (RN)-B stated she did ask R86 his sleep preference on the sleep assessment and stated R86 had indicated he would like to get up between 7:00 a.m. and 8:00 a.m. RN-B provided the sleep assessment to the surveyor. The DON verified the facility did have documentation of R86's preference to get up between 7:00 a.m. and 8:00 a.m. and verified his preference for awake time had not been care planned. The DON stated upon admission the facility would implement a preference form so we try to work with their schedule for awake times and stated this could be communicated to the aides through the assignment sheets. A policy was requested on resident choices and was not provided.

Based on observation, interview and document review the facility failed to notify a family member/responsible party of a resident to resident altercation for 1 of 3 residents (R23) reviewed for abuse. Findings include: According to a Nursing Home Incident Reporting, a report was submitted to the state agency (SA) on 1/7/20, 8:00 p.m. indicating R23 was seated in his broda chair (a specialized wheelchair used for supportive positioning, among other things) in the facility dining room when another resident (R24) grabbed R23's chair, shook it and threatened to tip it over with R23 in it. R24 was removed from the area by staff. According to the Admission Record in R23's electronic Health Record (EHR), R23 had a spinal injury, Down's syndrome and [MEDICAL CONDITION]. According R23's EHR care plan, R23 was admitted to the facility following a hospital stay related to a fall he had sustained that resulted in Central Cord Syndrome of the cervical 5th, 6th and 7th level of his spinal cord. The care plan noted R23 had poor safety awareness. A review of R23's EHR failed to show documentation that his family or responsible person had been notified of the incident. During a telephone interview 1/30/20, 1:04 p.m. a family member (FM-A) stated he had not been notified of the incident on 1/7/20. FM-A stated an expectation to be notified of significant incidents and alleged that the facility had not always contacted him about other significant events such as when R23 had lost a tooth, or significant [MEDICAL CONDITION] activity. According to an interview 1/30/20, 1:27 p.m. a registered nurse (RN-A) stated she had been present when R24 had shaken R23's chair and threatened to tip it over. RN-A said she had called the administrator to report the incident and had asked if she needed to make any other calls. She stated, they said I didn't need to make any other calls. RN-A said she was pretty sure she did not call the family According to an interview on 1/30/20, at 1:56 p.m. the director of nursing (DON) stated any incident between residents should be documented in the chart of each resident. DON confirmed the responsible person for R23, should have been notified of the incident on 1/7/20. The facility policy titled Abuse Prohibition/Vulnerable Adult Plan updated 7/5/2019, indicated families should be notified of vulnerable adult incidents and if abuse is suspected, let them know an investigation is in process.

Based on observation, interview and document review the facility failed to ensure freedom from abuse and prevent the potential of future incidents of a resident to resident altercation for 2 of 3 residents ( R23 and R24) reviewed. Findings include: During an observation 1/27/20, at 5:01 p.m. R24 was observed to be agitated and verbally loud prior to the evening meal. Staff allowed him to remain in the hall but encouraged him to stay where they could see him. At 6:05 p.m. R24 chose to eat his evening meal in the hallway near the nurses' station. Following the meal, R24 remained seated in the area with a small table, a drink and snack. R23 was seated in his broda chair and was placed within arms reach of R24. R24 was observed to push his table back and forth in a nervous manner and looked at R23 repeatedly. Several unidentified staff walked past and R24 asked why R24 was sitting there. RN-A then passed by and R24 asked why R23 was sitting next to him. RN-A told R24 that someone was in R23's room with his room-mate so R23 would have to hang out there for a time. At 6:57 p.m. staff took R23 to his room and R24 remained seated in the hall. According to the Admission Record in the electronic Health Record (EHR), R23 had [DIAGNOSES REDACTED]. R23 care plan indicated R23 had poor safety awareness and is a Vulnerable adult due to dependencies and R23 cognitive impairment may impact his ability to report maltreatment. According to a Minimum Data Set (MDS) assessment dated [DATE], R23 was determined to be severely cognitively impaired, unable to walk and totally dependent on staff for locomotion. The MDS indicated R23 had limited range of motion (ROM) in all four extremities. According to the Admission Record in the EHR, R24 was admitted for pneumonia after suffering a [MEDICAL CONDITION]. He was also marked as having a [DIAGNOSES REDACTED]. According to an MDS assessment dated [DATE], R24 was assessed as having a minor cognitive impairment, but on 1/9/20 his cognition was assessed again with a score showing moderate cognitive impairment. The 12/10/19 MDS indicated R24 had limitation of movement in one lower limb but full ROM in his upper extremities. According to a care planned focus problem dated 1/10/20, R24 had an alteration in behavior and had been involved in a resident to resident incident on 1/7/20. R24 had physical and/or verbal aggression with a [DIAGNOSES REDACTED]. A target behavior was listed as agitation, physical and/or verbal aggression, paranoid statements. Associated interventions included: supervise in the dining room and redirected as necessary; limit the number of re-directions to reduce increased anxiety; be alert to mood and behavior changes; re-direct resident by offering food, fluids, toileting, repositioning, etc.; provide for residents safety; remove from crowded areas when agitated; staff to provide one on one attention until resident is safe and calm; validate feelings and provide emotional support; monitor for target behaviors. According to a Nursing Home Incident Reporting, a report was submitted to the state agency (SA) on 1/7/20, 8:00 p.m. indicating R23 was seated in his broda chair (a specialized wheelchair used for supportive positioning) in the facility dining room when R24 grabbed R23's chair, shook it and threatened to tip it over with R23 in it. According to the report, R24 also made verbal threats about burning down the facility, and was removed from the area by staff. R24 progress note dated 1/7/20, at 10:02 p.m. included: At supper time, resident was agitated. He grabbed the wheelchair of another resident and jerked it quite hard. He said, I'll tip him over. He also said, I'll burn the place down and went over to the fire extinguisher cabinet and pulled the door open. He was removed from the area but came back in and grabbed another resident's wheelchair. Staff tried to speak with him as to why he was targeting others. He replied, they threatened me first. This was a witnessed incident. Administrator, DON (director of nursing) and family notified. Resident placed on 15 minutes checks. R23's record lacked any other documentation of the resident to resident incident from 1/7/20. The EHR care plan failed to indicate any updated interventions related to his vulnerability for resident to resident altercations, nor any additional measures to keep him safe from residents who might act out against him except: follow resident care plan to ensure safety (no further description) and monitor for non-verbal signs of maltreatment dated 12/19/18. In addition, preventative interventions included to post the Resident Bill of Rights and the Abuse Prevention policy in the facility. According to target behavior monitoring document in the EHR, R24 had exhibited 14 episodes of agitation, physical and or verbal aggression, and paranoid statements between 1/11 and 1/29/20. During interview at 3:16 p.m. on 1/29/20, registered nurse (RN-A) stated she had been present on 1/7/20 when R24 had shaken R23's chair and threatened to tip it over. RN-A said since the event, staff were attempting to keep R24 where they could supervise him to ensure safety for other residents. RN-A said R24 did not move around the facility much on his own, but was capable of self-locomotion. During interview 1/30/20 at 1:56 p.m., the DON confirmed the incident between R23 and R24 had occurred. The DON stated staff received training upon orientation, and annually, on dementia care and behavioral control. The DON stated it was important to separate residents when there was an altercation and to monitor for safety. The DON further stated the incident should have been documented in both charts (for R23 and R24) and both care plans should have been updated. The DON stated they did not want to isolate a resident however, if the resident was agitated, it would be better to keep them apart from other residents. DON confirmed R24 and R23 should not have been seated next to each other on 1/27/20. The facility policy titled Abuse Prohibition/Vulnerable Adult Plan updated 7/5/2019, included: Abuse is defined as the willful (deliberate action) infliction of injury or intimidation. The purpose of the policy included: To identify and remedy any abusive situation and to prevent injury. Also, the policy indicated the interdisciplinary care team would develop plans to ensure residents are not subjected to aggressive incidents by other residents.

Based on interview and document review the facility staff failed to immediately report an allegation of resident-to-resident abuse to the administrator and to the state agency (SA) within two hours for 1 of 3 residents (R30). In addition, the facility failed to report an allegation of verbal abuse to the SA within two hours for 1 of 1 resident (R85) reviewed for abuse. Findings include: R30's initial vulnerable adult report submitted to the SA on 8/12/19, at 6:30 p.m. included, Friday, (MONTH) 9 at approximately 7:40 pm, the CNA (certified nursing assistant) heard a resident yelling in the hallway. When she went to see what was going on, she found R5 sitting in her wheelchair and attempting to push the door open to R30's room. CNA (certified nursing assistant) stated R5 was confused and yelling at R30 on the other side of the door. R5 was stating that she wanted to enforce the rules about keeping doors open. The CNA was able to take R5 away from R30's room and wheeled R5 to the nurses station where she sat for 30 minutes and was able to calm down. The CNAs then took R5 to bed where she stayed the rest of the CNA's shift. The CNA and nurse spoke with R30 after the incident and comforted her as she was visibly upset. R30's family member (FM)-B, visited the facility after the event and discussed the situation with the nurse. Monday (MONTH) 12, Administrator and social worker were alerted to the situation. Licensed social worker completed PHQ9 on both residents. Both residents scored a 0 indicating no signs of depression. R5 does not recall the event. R30 recalls the event and was offered a different room on another wing to reside in the facility. LSW (licensed social worker) spoke to FM-B, no concerns at this time. Both residents are safe at this time. Investigation in progress. What action was taken to protect the resident: Removal of R5 from R30's doorway. Offered a different room down a different hallway for R30. Review of the initial report made to the SA revealed the incident occurred on 8/9/19, at approximately 7:40 p.m., the administrator was not made aware until 8/12/19 and the initial report was made to the SA on 8/12/19 at 9:46 a.m. On 1/29/20, at 12:47 p.m. nursing assistant (NA)-F stated she reported the incident to the nurse immediately. On 01/29/20, at 2:23 p.m. social services (SS)-A stated staff did not alert the social worker, the director of nursing or administrator until the following Monday when we came back. SS-A stated we educated staff that we needed to be alerted immediately if these things happen so we could report them. On 1/30/20, at 10:17 a.m. registered nurse (RN)-A stated she did not report this incident to anyone and stated, I made that mistake. RN-A stated she should have reported the incident to the administrator as soon as both residents were safe. RN-A stated she would have to report it (abuse) right away. RN-A stated she thought the facility had twenty-four hours to report it (abuse) to the S[NAME] R85 R85's initial vulnerable adult report submitted to the SA on 8/7/19, at 1:21 p.m. included, Resident reported to LSW (licensed social worker) that he feels that a, select few aides and nurses have been snotty, giving me crap, making snide comments, and being verbally abusive. LSW (licensed social worker) inquired further in regard to specific staff members and resident stated multiple times that he could not come up with a description or name. At the end of the conversation, he thought he remembered that it was a darker red head with green scrubs. Resident was safe at the time of the interview. LSW (licensed social worker) immediately reported incident to administrator and the DON (director of nursing). Administrator and DON (director of nursing) confirmed there were no darker red heads wearing green scrubs at the time of the report or staff on at this time. Investigation in progress. There was no alleged perpetrator. What action was taken to protect the resident: Confirmed no staff fitting the description was working. Review of the initial report made to the SA revealed the facility staff became aware of the allegation of verbal abuse on 8/7/19, at 10:45 a.m. and the initial report was made to the SA on 8/7/19 at 1:21 p.m., which was two hours and 36 minutes after the allegation of verbal abuse was made. On 1/29/20, at 1:58 p.m. the director of nursing (DON) stated physical abuse needed to be reported within two hours to the SA and stated we would also notify the police. The DON stated she thought the facility had twenty-four hours to report verbal abuse to the S[NAME] The DON stated according to the facility policy, an allegation of abuse needed to be reported within two hours to the S[NAME] The DON verified the facility did not follow the policy to report the allegation of verbal abuse within two hours. On 1/30/20, at 9:02 a.m. the district administrator stated allegation of abuse are to be immediately reported to the administrator and within two hours to the S[NAME] The district administrator stated education will be provided to staff on expectations, as well as guidelines and regulations for full understanding. The district administrator verified the facility policy was not followed to report allegations of abuse immediately to the administrator and within two hours to the S[NAME] The Abuse Prevention/Vulnerable Adult Plan dated 12/18 included, Notification the facility administrator immediately of any incidents of resident abuse, alleged or suspected abuse, injury of unknown origin, neglect, financial exploitation, or involuntary seclusion will occur immediately .Suspected Abuse shall be reported to the online reporting process not later than 2 hours after forming the suspicion of abuse.

Based on observation, interview and document review, the facility failed to ensure personal hygiene for facial hair removal and brushing of teeth was provided for 2 of 3 residents (R30, R19) reviewed, who was dependent on staff assistance with activities of daily living (ADL's). Findings Include: R30 was interviewed and observed on 1/27/2020, at 1:53 p.m. R30 had facial hairs on her lower chin and around her upper lip. R30 stated there was an aide that sometimes help her with that (facial hair removal). R30 was observed on 1/28/20, at 11:03 a.m. sitting in her wheelchair in her room. The facial hair remained on her upper lip and chin. R30's quarterly Minimum Data Set (MDS) assessment dated [DATE]; identified R30 required limited assist of one for personal hygiene needs, had clear speech was understood and understands. Her brief interview mental score was not assessed. R30's care plan dated 7/10//19 included R30 was limited in ability to maintain grooming/personal hygiene, dressing and bathing related to advanced age. Interventions included. Provide non-distracting environment for grooming/personal hygiene. Upon her awakening or retiring for the evening. Instruct resident in proper grooming/personal hygiene techniques. On 1/29/20, at 7:24 a.m. nursing assistant (NA)-D stated the NA who got R30 up this morning worked overnights and left for the day at 7:00 a.m. NA-D stated facial hair removal was completed whenever it was needed. NA-D verified through observation R30 had facial hair around her mouth that needed to be trimmed. On 1/29/20, at 7:49 a.m. the director of nursing (DON) stated staff should be looking at resident facial hair daily and offer to remove it. At 7:54 a.m. the DON stated she did notice R30 had a few facial hairs and stated she instructed the nursing assistant to ask her if she would like to be shaved. On 1/30/20, at 8:98 a.m. the DON stated R30 did have her facial hair plucked yesterday by staff. The DON stated R30 told the DON she did pluck and would like to do so independently. R30 told the DON she would like to continue with this but would not mind help as her vision was declining and she was unable to see some of the hairs at times and missed them. The DON stated R30 was offered assistance with this and R30 preferred to have assistance with hair removal if needed every two weeks. R30 was observed to have facial hair 1/27/20, 1/28/20 and 1/29/20. The DON stated staff should be looking at resident facial hair daily and offer to remove it. On 1/29/20, after the facial hair was brought to the attention of the DON, the DON instructed staff to offer assistance with removal of R30's the facial hair and the facial hair was removed. R30's care plan did not indicate R30 preferred to pluck her own facial hair independently at the time of the survey. R19 R19's quarterly MDS assessment, dated 12/1/19, indicated R19 required extensive assist for personal hygiene cares, had moderate cognitive impairment and [DIAGNOSES REDACTED]. R19's care plan, included resident is limited in ability to maintain grooming/personal hygiene related to dense [MEDICAL CONDITION] from stroke. Interventions included upon his awakening or retiring for the evening. Instruct resident in proper grooming/personal hygiene techniques. Set up for BID (twice daily) partials. Allow sufficient time to complete grooming/personal hygiene. Encourage him to brush his teeth BID as he is able. Has full upper dentures with lower natural teeth with some missing. Staff to complete tasks as he is unable. During interview on 1/27/20, at 6:04 p.m., R19 stated the facility staff only brushed his teeth once or twice a week and they should be brushing his teeth everyday. R19 stated they use a foam brush on a stick to take food out of his mouth and once in a while they would use a regular toothbrush. R19 had a full upper denture in mouth and own lower teeth. During observation on 1/27/20, at 6:19 p.m., NA-B when providing bedtime cares to R19, had removed R19's upper dentures, brushed the upper dentures, placed the upper dentures in a denture cup with a denture tablet to soak. NA-B did not offer or encourage R19 to brush his lower teeth. During interview on 1/27/20, at 6:45 p.m., NA-B verified she had not brushed R19's lower teeth or offered or encouraged R19 to brush his lower teeth. NA-B stated R19 was to have his teeth brushed in the am and pm. During interview on 1/29/20, at 1:27 p.m., the DON stated she would expect oral cares be provided according to R19's care plan. The Activities of Daily Living (ADLs), Supporting policy revised (MONTH) (YEAR) included, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on interview and document review, the facility failed to immediately notify the nurse practitioner that a medication ordered to lower the residents potassium was not given as ordered when the nursing staff changed the date of administration for one of three residents (R1) reviewed. R1 died and the cause of death on the death certificate is listed as [MEDICAL CONDITION] (elevated potassium). Findings include: A review was completed of the medication order policies dated 2006, the policy indicates that the prescriber is to be contacted for direction when delivery of a medication will be delayed or the medication is not or will not be available. Resident #1's (R1) medical record was reviewed. A progress noted dated [DATE] at 2:31 p.m. indicated that R1 was admitted to the facility on [DATE] for short term stay for rehabilitation with the plan to return home when able. The hospital dismissal summary dated [DATE], indicated R1's electrolytes should be checked on [DATE] and the resident's fluid status should be assessed due to holding the medication [MEDICATION NAME] which is used to treat fluid retention ([MEDICAL CONDITION]). The clinic laboratory report dated [DATE] indicated that R1's blood was drawn at 8:05 a.m. Electrolytes where checked and R1's potassium result was 6.2 and identified as a critical laboratory level. The document indicated the laboratories reference range for potassium was 3.5 to 4.9. The potassium critical laboratory result was called to the facility at 8:44 a.m. A physician progress notes [REDACTED]. NP-E saw R1 and met with a family member after nursing staff reported that R1 "was not doing well". NP-E noted that R1 was in no acute distress, he was confused, didn't know where he was, and did not know his date of birth. NP-E discussed R1's elevated potassium level with the family member. The family member agreed with the plan to treat the [MEDICAL CONDITION] at the facility by administering [MEDICATION NAME] 30 grams (gm) today and re-check the potassium level in three days. (Lippincott Nursing 2012 Drug Handbook indicated [MEDICATION NAME] is a potassium removing resin used to decrease the potassium level in individuals with [MEDICAL CONDITION].) The nurse practitioner (NP-E) orders were reviewed and an order dated [DATE] at 11:43 included but was not limited to the following: [MEDICATION NAME] 30 grams orally "today." A nursing progress note dated [DATE] at 3:56 p.m. was the first nursing progress note related to the resident's critical potassium laboratory value and it indicated that NP-E was with the resident and reviewed laboratory results. NP-E ordered [MEDICATION NAME] 30 grams orally "today" for [MEDICAL CONDITION]. The resident's electrolytes were ordered to be rechecked on [DATE]. In addition the [MEDICATION NAME] was ordered to be restarted at 20 milligrams once a day for [MEDICAL CONDITION]. The Medication Administration History dated [DATE]-[DATE] was reviewed related to the [MEDICATION NAME] order: The document indicated [MEDICATION NAME] 30 grams orally was to be given once on [DATE] on the 3:00 p.m.-11:00 p.m. shift. On [DATE] at 9:44 p.m. RN-C documented the [MEDICATION NAME] was not administered because the drug was unavailable. Nursing progress note written by RN-C on [DATE] at 11:18 p.m. indicated that [MEDICATION NAME] was not delivered from the pharmacy. The scheduled date and time was changed on the MAR and the order was re- faxed to the pharmacy. The documentation indicates R1 is very sleepy this shift and difficult to administer medications. The resident's respirations were documented to be elevated at 32. There was no documentation that the physician or NP-E were called to inform the medication was not delivered or to get an order to change the administration date of the medication. The next nursing progress note written by licensed practical nurse (LPN)-H was [DATE] at 4:34 a.m. and indicated "Entered room at 4 am to find resident had passed away." The document of death for R1 with date of death listed as [DATE] was reviewed and indicated R1's immediate cause of death is [MEDICAL CONDITION]. RN-C was interviewed on [DATE] at 1:00 p.m. She stated that she worked the 2:00 p.m.- 10:30 p.m. shift on [DATE] and worked on R1's unit. She was aware of the new [MEDICATION NAME] order for R1 at the beginning of the shift. RN-C did not know the facility policy on what to do when a medication is not available to complete an order. She stated that she did not consult with the NP-E, the pharmacy or the DON. She stated that she was very busy that shift and didn't think to call anyone. She was aware of the after hours pharmacist being available but did not call them. There was no documentation to indicate that NP-E was informed that R1 did not receive the ordered [MEDICATION NAME] and that the order was changed to a different date and time for administration. LPN-H was interviewed on [DATE] at 2:30 p.m. She reported that she worked the 10:30 p.m.-7:00 a.m. shift on [DATE]. She received end of shift report from RN-C related to R1. RN-C reported that R1's potassium level was high and [MEDICATION NAME] was ordered to be administered on [DATE] but that the medication did not arrive with the pharmacy delivery. RN-C reported to her that she had changed the time on the MAR for the [MEDICATION NAME] from [DATE] evening shift to [DATE] on the day shift. LPN-H did not notify the physician, call the pharmacist or check the emergency kit for the medication. NP-E was interviewed on [DATE] at 1:40 p.m. and on [DATE] at 2:00 p.m. She stated that on the morning of [DATE] she received a call from an RN (unknown) to report that R-1's potassium level was 6.2. She ordered [MEDICATION NAME] 30 gm to be given on [DATE]. She confirmed with an RN (unknown) at the facility that [MEDICATION NAME] was available in the emergency medication kit (e-kit). She did not receive a call from facility staff on [DATE] informing her that R1 had not not received the prescribed [MEDICATION NAME]. If NP-E had been called she would have told the nurse that the medication was in the e-kit and requested the nurse check the e-kit. The Director of Nursing (DON) was interviewed on [DATE] at 1:00 p.m. She stated that on [DATE] at 6:30 a.m. LPN-H informed her that R1 had died and had not received the [MEDICATION NAME] as ordered on [DATE]. The DON said that the staff have resources they can call during the evening and night shift when there are questions or problems. There is always an on call physician/nurse practitioner and a pharmacist available for consultation and direction. The DON was available by phone during the evening and night shift. RN-C did not consult with the DON or the pharmacy and did not notify the nurse NP-E that R1 did not get the [MEDICATION NAME] as ordered or that the medication administration time and date were changed.

Based on documentation review, interviews and observations the facility failed to ensure that residents were free from significant medication errors when a medication was omitted for one of three residents (R1) reviewed. R1 did not receive a one time dose of [MEDICATION NAME] for an elevated potassium level and the resident died within 24 hours and the cause of death was [MEDICAL CONDITION] (elevated potassium). Findings include: Resident #1's (R1) medical record was reviewed. A progress noted dated [DATE] at 2:31 p.m. indicated that R1 was admitted to the facility on [DATE] for short term stay for rehabilitation with the plan to return home when able. The hospital dismissal summary dated [DATE], indicated R1's electrolytes should be checked on [DATE] and the resident's fluid status should be assessed due to holding the medication [MEDICATION NAME] which is used to treat fluid retention ([MEDICAL CONDITION]). The clinic laboratory report dated [DATE] indicated that R1's blood was drawn at 8:05 a.m. Electrolytes where checked and R1's potassium result was 6.2 and identified as a critical laboratory level. The document indicated the laboratories reference range for potassium was 3.5 to 4.9. The potassium critical laboratory result was called to the facility at 8:44 a.m. The laboratory results were faxed to the facility on [DATE] at 8:59 a.m. A progress note completed by nurse practitioner (NP)-E dated [DATE] at 10:54 a.m. was reviewed. NP-E saw R1 and met with a family member after nursing staff reported that R1 "was not doing well". NP-E noted that R1 was in no acute distress, he was confused, didn't know where he was, and did not know his date of birth. NP-E discussed R1's elevated potassium level with the family member. The family member agreed with the plan to treat the [MEDICAL CONDITION] at the facility by administering [MEDICATION NAME] 30 grams (gm) today and re-check the potassium level in three days. (Lippincott Nursing 2012 Drug Handbook indicated [MEDICATION NAME] is a potassium removing resin used to decrease the potassium level in individuals with [MEDICAL CONDITION].) NP-E's orders were reviewed and an order dated [DATE] at 11:43 included but was not limited to the following: [MEDICATION NAME] 30 grams orally "today." The order was stamped "faxed [DATE] (year not specified) to the pharmacy. A nursing progress note dated [DATE] at 3:56 p.m. was the first nursing progress note related to the resident's critical potassium laboratory value and it indicated that NP-E was with the resident and reviewed laboratory results. NP-E ordered [MEDICATION NAME] 30 grams orally "today" for [MEDICAL CONDITION]. The resident's electrolytes were ordered to be rechecked on [DATE]. In addition the [MEDICATION NAME] was ordered to be restarted at 20 milligrams once a day for [MEDICAL CONDITION]. The Medication Administration History dated [DATE]-[DATE] was reviewed related to the [MEDICATION NAME] order: The document indicated [MEDICATION NAME] 30 grams orally was to be given once on [DATE] on the 3:00 p.m.-11:00 p.m. shift. On [DATE] at 9:44 p.m. RN-C documented the [MEDICATION NAME] was not administered because the drug was unavailable. Nursing progress note written by RN-C on [DATE] at 11:18 p.m. indicated that [MEDICATION NAME] was not delivered from the pharmacy. The scheduled date and time was changed on the MAR and the order was re- faxed to the pharmacy. The documentation indicates R1 is very sleepy this shift and difficult to administer medications. The resident's respirations were documented to be elevated at 32. There was no documentation that the physician or NP-E were called to inform the medication was not delivered or to get an order to change the administration date of the medication. The next nursing progress note written by licensed practical nurse (LPN)-H was [DATE] at 4:34 a.m. and indicated "Entered room at 4 am to find resident had passed away." The document of death for R1 with date of death listed as [DATE] was reviewed and indicated R1's immediate cause of death is [MEDICAL CONDITION]. NP-E was interviewed on [DATE] at 1:40 p.m. and on [DATE] at 2:00 p.m. She stated that on the morning of [DATE] she received a call from an RN (unknown) to report that R-1's potassium level was 6.2. She reported that the normal range for potassium is 3.5 - 5.0. At approximately 10:45 a.m. on [DATE] she assessed R1 and met with R1's family member. She told the family member that they could send R1 to the hospital for the elevated potassium or they could treat R1 at the facility by administering [MEDICATION NAME]. The family member agreed to treat R1 at the facility with [MEDICATION NAME]. NP-E wrote the order for [MEDICATION NAME] and gave the order to RN-B to be transcribed. She confirmed that [MEDICATION NAME] is available in the emergency kit (e-kit) with an RN (unknown). On [DATE] NP-E did not receive notification that R1 did not receiving the prescribed [MEDICATION NAME]. If NP-E would have been notified she would have told the nurse that the medication was in the e-kit and told the nurse to check the e-kit. she knew the medication was available and had they called her, she could have told them. Registered Nurse B (RN-B) was interviewed on [DATE] at 2:30 p.m. She stated that on [DATE] at approximately 3:30 p.m. NP-E handed R1's physician's orders [REDACTED]. She added R1's order to the doctors rounds summary and placed the doctors rounds summary on a clipboard in the nurses station to communicate the physician's and nurse practitioner orders/changes to the nursing staff. RN-C was interviewed on [DATE] at 1:00 p.m. She stated that she worked the 2:00 p.m.- 10:30 p.m. shift on [DATE] and worked on R1's unit. She was aware of the [MEDICATION NAME] order at the beginning of the shift and she was waiting for the pharmacy to deliver the [MEDICATION NAME]. The pharmacy delivery arrived between 9:30 p.m. and 10:00 p.m. and the [MEDICATION NAME] was not in the delivery. Although [MEDICATION NAME] was on the e-kit inventory list, RN-C stated she checked the e-kit inventory list and did not see [MEDICATION NAME] on the list. RN-C consulted with RN-F. RN-F told her to check the e-kit. RN-C did not know the facility policy on what to do when a medication is not available to complete an order. RN-C stated that she did not consult with the nurse practitioner, the pharmacy or the DON. She was aware of the after hours pharmacist being available but did not call them. She reported that during the evening shift R1's respiration rate was ,[DATE] and that the rest of his vital signs were stable. She stated that R1 had two or three episodes of being unresponsive but when they elevated the head of his bed he would become responsive. RN-F was interviewed on [DATE] at 1:30 p.m. She stated that she worked the 2:00 p.m. - 10:30 p.m. shift on [DATE]. She stated that late into the shift RN-C told her that the [MEDICATION NAME] was not delivered by the pharmacy. RN-F suggested RN-C check the e-kit. RN-F knew [MEDICATION NAME] was in the e-kit and told RN-C that. She stated that she worked on a different unit that evening and did not see R1. Towards the end of the shift Nursing Assistant-I (NA-I) reported that R1 was not doing very well, that R1 was getting weaker. RN-F then went to check R1 but was told RN-C was already in R1's room so RN-F went back to finish charting. She was not aware R1 did not receive the scheduled [MEDICATION NAME]. Licensed Practical Nurse H (LPN-H) was interviewed on [DATE] at 2:30 p.m. She reported that she worked the 10:30 p.m.-7:00 a.m. shift on [DATE]. She received end of shift report from RN-C. RN-C reported that R1's potassium level was high and [MEDICATION NAME] was ordered to be administered on [DATE] but that the medication did not arrive with the pharmacy delivery. RN-C reported to LPN-H that she had changed the time on the MAR for the [MEDICATION NAME] from [DATE] evening shift to [DATE] on the day shift. RN-C told LPN-H that [MEDICATION NAME] was not in the e-kit. LPN-H did not notify the physician, call the pharmacist or check the e-kit. The Director of Nursing (DON) was interviewed on [DATE] at 1:00 p.m. She stated that on [DATE] at 6:30 a.m. she was informed by LPN-H that R1 had died and that R1 had not received the [MEDICATION NAME] as ordered on [DATE]. She checked the e-kit and found the lock that is placed on the e-kit by pharmacy staff was intact. She reviewed the e-kit inventory list and [MEDICATION NAME] was on the list. She stated that there is a pharmacist on call after hours for consults or when emergency medications not available in the e-kit. The lead pharmacist (Pharm-J) for the facility was interviewed on [DATE] at 2:10 p.m. He stated that the pharmacy was responsible for maintaining the inventory in the facility's e-kit and that [MEDICATION NAME] is stocked in the e-kit. He did not send the [MEDICATION NAME] to the facility that evening because he knew the facility had it in the e-kit. The pharmacy did not contact the facility and tell them that they were not sending it. There is a pharmacist on call after store hours for the facility staff to call for consultations or emergency medication dispensing. There were no calls to the on-call pharmacist from the facility during the [DATE]-[DATE] on-call shift. On [DATE] at 9:00 a.m. the emergency medication kit (e-kit) was observed and the e-kit was located in a cupboard in the medication room. The lock was intact, the inventory list was attached to the box. Another e-kit inventory list was observed posted by a telephone in the nurses station and matched the inventory list attached to the e-kit. Another inventory list provided by the pharmacy was compared to and matched the inventory lists located in the facility. The [MEDICATION NAME] was listed on all three inventory lists. The medication orders policies and procedures dated 2006 were reviewed and indicated that the prescriber is to be contacted for direction when delivery of a medication will be delayed or the medication is not or will not be available.