Every finding on record at The Lutheran Home: Belle Plaine

Based on observation, interview, and document review, the facility failed to administer intravenous (IV) medication according to professional standards of practice for 1 of 1 resident (R18) reviewed for IV medication administration. Findings include:R18's face sheet received on 7/7/26, indicated diagnoses of multiple sclerosis (chronic autoimmune disease of the central nervous system), functional quadriplegia (complete inability to move due to severe disability), with recent hospitalization for bacterium (bacteria in the blood stream) and urinary tract infection. R18's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, was understood and could understand. R18 was dependent upon staff for all activities of daily living and had an indwelling urinary catheter. R18 used a motorized wheelchair for mobility.R18's physician orders dated 6/26/26 - 7/31/26, cefazolin (antibiotic) in dextrose solution; 2 gram/100 mL (milter); 2 grams; intravenous for bacteremia, every eight hours; 7:00 a.m., 3:00 p.m., 11:00 p.m.R18's care plan dated 5/28/26, indicated R18 required an indwelling urinary catheter and would have care to prevent signs of infection.R18's provider discharge summary from the hospital dated 6/24/26, indicated discharge diagnosis of staphylococcus aureus bacteremia secondary to urinary tract infection and antibiotics for six weeks. During an observation on 7/6/26 at 6:10 p.m., observed R18 maneuver his motorized wheelchair into the dining room after returning from an outing.During an observation on 7/6/26 at 6:37 p.m., observed LPN-C assemble supplies to administer R18's IV antibiotic in the dining room. LPN-C stated that was where R18 wanted to receive the medication as he would eat supper right afterwards. LPN-C set supplies including gloves, packages of prefilled syringes of normal saline (NS), alcohol wipes, and cefazolin 2 grams in 120 ml NS via Easy Pump ball (also known as elastomeric pump - a medical device that slowly gives liquid medicine into veins) onto a wheelchair-height countertop outside of the kitchenette. The surface had not been cleaned or disinfected, nor had a barrier been set down first. A large trash receptable without a cover was positioned right next to the counter. With the assistance of registered nurse (RN)-C who was also a nurse manager, LPN-C began the process of flushing R18's PICC (peripherally inserted central catheter - a long thin flexible tube inserted into a vein in the upper arm) lumens. LPN-C opened a prefilled 10 ml syringe of NS. LPN-C removed the cap of the syringe and wiped the tip with an alcohol wipe, then attached the syringe to a PICC line lumen and flushed the line. Once complete, LPN-C obtained the Easy Pump, removed the cap from the distal tip of the IV tubing and wiped it with an alcohol wipe, then inserted the tip into the lumen and started the infusion. During an observation on 7/7/26 at 7:28 a.m., in R18's room, observed LPN-D administer cefazolin 2 grams in 120 ml NS via Easy Pump ball. Just prior to attaching the sterile IV tubing to the PICC line lumen, LPN-D wiped the sterile tip with an alcohol wipe. During an interview on 7/7/26 at 9:18 a.m., RN-C was informed of observations the evening prior with LPN-C and the morning of with LPN-D when they administered IV medication to R18. RN-C who was present the evening prior, stated she had not noticed/been aware of LPN-C wiping the tip of the prefilled syringe of NS with an alcohol wipe prior to flushing the PICC line lumen, nor had she noticed LPN-C wipe the tip of the sterile IV tubing prior to attaching it to the PICC line lumen. RN-C admitted that was not appropriate practice since the tip of the syringe of NS and the tip of the IV tubing were sterile and alcohol wipes were not, potentially causing contamination. RN-C stated they would need to do training on administering IV medications. During an interview on 7/7/26 at 1:40 p.m., the director of nursing (DON) was informed of findings with nurses administrating IV medication to R18: administering an IV medication in a public/contaminated location and using improper technique when they were observed wiping off the tip of the syringe of NS, and the distal tip of sterile IV tubing, potentially contaminating them. The DON acknowledged both were unacceptable practices and could cause contamination. Training for administrating IV medication for both nurses had been requested.During an interview on 7/7/26 at 3:24 p.m., LPN-D was informed of observation of wiping the sterile tip of the IV tubing with an alcohol wipe. LPN-D admitted doing so and stated she should not have because the tip of the IV tubing was sterile and the alcohol wipe was not; adding she must have been nervous. LPN-D stated she did not learn about IVs in nursing school, and it was at the facility she learned from observing other nurses.In an email dated 7/8/26 at 7:33 a.m., the DON stated LPN-C and LPN-D had not received formal education on administering IV medication to residents - just verbal training. The DON indicated she planned to give written education to them the next time they worked. Facility IV (intravenous) Medication Administration: Elastomeric policy, dated 2020, were instructions from vendor: option care health. The instructions outlined step by step the process and included photos. Instructions pertaining to survey observations included: use a clean work area, do not touch the tip of the syringe of NS after removing the cap; discard the syringe if it touches any unclean surface. Remove the protective cap from the medication tubing and attach the medication tubing firmly to the needleless connector on the IV catheter. Instructions did not direct staff to wipe off tip of NS syringe nor the distal insertion tip of medication tubing with an alcohol wipe.

Based on observation, interview, and document review, the facility failed to ensure individualized fall prevention interventions were communicated and implemented for 1 of 3 residents (R17) reviewed for falls. Findings Include: R17's admission Minimum Data Set (MDS) assessment dated [DATE], indicated moderately impaired cognition, dependent with toileting, toilet transfer, sit to stand; required substantial assistance with dressing, shower, roll left to right, sit to lying; partial/moderate assistance with personal hygiene, utilized a manual wheelchair, diagnoses included fractures and other multiple trauma, Alzheimer's disease, history of falling; had a fall in the last month, fracture related to a fall in the 6 months prior to admission, and a fall since admission. R17's care plan dated 7/2/26, is at risk for falls R/T (related to) cognitive and physical impairment. Dx (diagnosis) of unspecified fracture of right patella, subsequent encounter for closed fracture with routine healing and dementia, does not recognize her limitations, hx (history) of falls, drug regimen also places her at risk for falls. Fall 6/27/26/ and 7/1/26, indicated encourage rest periods when increasingly weak, do not leave alone in bathroom, walker next to bed/recliner to remind resident to use it if self-transferring, anti-roll back (auto locks) placed on w/c (wheelchair), check for functioning qd. (everyday), assure resident is wearing proper and well-maintained footwear, assure the floor is free of clutter, glare, liquids, R17's event report dated 7/1/26, indicated unwitnessed fall in R17's bathroom, attempting to self-transfer. R17's orders dated 7/2/26, indicated fall prevention-walker next to bed, low bed as needed when restless and after all needs have been met-toileting, hunger pain, etc. Document titled LTC Floor Cards dated 7/2/26, indicated R17 was A-2 (assist of two) EZ lift med sling, wheelchair, right knee fractures, brace on at all times, high fall risk, freq checks, hallucinates, non-weight bearing left wrist, low bed. The floor card failed to indicate R17's walker next to bed. On 7/1/26 at 10:29 a.m., R17 was observed seated in a wheelchair next to the bed with the left arm in a sling, a brace on the right leg, and the wheelchair positioned at the end of the bed, out of R17's reach.On 7/6/26 at 4:00 p.m., R17 was observed lying in bed with the bed in the low position. The wheelchair and walker were located at the end of the bed, and the walker was not positioned at the bedside.On 7/6/26 at 4:03 p.m., registered nurse (RN)-A stated R17 was a fall risk with interventions including a low bed, supervision, frequent checks, and assistance with transfers.On 7/6/26 at 4:05 p.m., RN-B, known as the nurse manager, was observed in R17's room while R17 remained in bed awaiting assistance from an additional staff member for a transfer. RN-B stated R17 was admitted with a right leg injury following a fall and sustained a fractured left wrist at the facility after self-transferring to the bathroom. RN-B stated therapy recommended keeping R17's walker at the bedside following the most recent fall. RN-B confirmed the walker, observed at the end of the bed, was not located at the bedside as expected. RN-B stated resident-specific interventions were expected to be included on the care sheets.On 7/6/26 at 4:20 p.m., nursing assistant (NA)-A stated fall interventions were located on the resident care sheet. NA-A stated they were unsure whether R17's walker was supposed to be within reach because that intervention was not on the care sheet and stated they would need to ask another staff member about R17's specific fall interventions.On 7/6/26 at 4:23 p.m., licensed practical nurse (LPN)-A, known as the evening clinical supervisor, stated they stated R17 was a fall risk and would expect the fall interventions on the resident care sheet, in the electronic medical record (EMR) fall event, in the 24-hour report, and R17's care plan.On 7/6/26 at 4:27 p.m., during a follow up interview NA-A stated R17's walker was expected to be at the bedside within reach and stated staff would not know that intervention was expected if it was not included on the care sheet.On 7/6/26 at 4:29 p.m., NA-B stated fall interventions were available on the resident care sheets and in the EMR. After reviewing the EMR, NA-B confirmed the order to keep the walker at the bedside was present in the point-of-care record but was not included on the resident care sheet as expected.On 7/6/26 at 4:33 p.m., NA-C, stated they had provided care to R17 that day, stated staff relied on verbal report and the resident care sheets for fall interventions. NA-C stated the walker was intentionally kept out of R17's reach because otherwise R17 would attempt to walk independently.On 7/6/26 at 4:36 p.m., RN-B and director of nursing (DON), DON stated R17's fall intervention to keep the walker next to the bed had been implemented on 7/1/26, and was part of the resident's point-of-care orders in the EMR. RN-B stated she updates the care sheets and confirmed the care sheet was not updated to include the walker at bedside and would have expected the intervention to appear there.On 7/7/26 at 3:16 p.m., the DON stated R17's fall intervention of the walker at bedside was expected documented on the 24-hour report, added to the resident's care card, and incorporated into the resident's care plan.Facility Fall Prevention and post fall management policy and procedure dated 9/25, indicated :Communicating Fall Risk Status 1. The resident's fall risk status and appropriate interventions are communicated using SBAR with nursing and other licensed ancillary staff: a. Communicate High Fall Risk status at shift report and current interventions in place. E DOCUMENTATION 1.Complete a fall risk score upon admission and repeated as reassessed must be documented in the resident health record. 2.Notification of high fall risk status to resident, and family 3.Teaching to resident and/or family. 4. Document risk for injury related to fall risk on care plan. POST FALL FOLLOW UP 6.Implement fall risk precautions if not already in force. 9.If a resident falls more than once, discuss with RN on call or manager further interventions. G Reporting Resident Falls a. Resident Falls must be reported through the standard incident reporting process which is available to throughout the facility. H Education and Competency of the Staff Education for Fall Risk Program includes how to identify residents at risk for falls, how to communicate the risk level to the resident, family and other members of the health care team, and the use of fall precautions and interventions. I. Analysis and Review of Resident Falls Data a. The Lutheran Home Interdisciplinary Team is responsible for analysis and review of resident fall data, causation, and intervention. Fall data will be reported to The Lutheran Home Campus Quality Assurance committee.

Based on observation, interview and document review, the facility failed to ensure staff consistently adhered to enhanced barrier precautions (EBP) in accordance with the Centers for Disease Control and Prevention (CDC) guidelines to reduce the potential spread of infection for 2 of 10 residents (R4 and R5) reviewed infection control practices. Findings include:R4's face sheet received on 7/8/26, included diagnosis of methicillin resistant staphylococcus aureus (a bacteria resistant to many antibiotics) infection to left thigh. R4's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, was understood and could understand. R4 required substantial assistance for activities of daily living (ADLs) and did not get out of bed.R4's physician orders dated 6/8/26, indicated orders for cleaning and dressing left lateral thigh wound, once a day. There were no orders for EBP.R4's care plan dated 3/9/26, indicated R4 had a left thigh and knee wound abscess. Care plan did not include EBP.During an interview and observation on 7/6/26 at 1:05 p.m., observed an over-the-door PPE (personal protective equipment) holder on R4's door. There was no sign on the door indicating if R4 was in enhanced barrier precautions (EBP) or transmission-based precautions (TBP). R4 stated she had a draining wound to her left thigh and that nurses wore gowns when they changed the dressing, but not for bed baths or when she used the bedpan.During an interview on 7/6/26 at 3:25 p.m., nursing assistant (NA)-C stated if a resident was on EBP, there would be a sign on the door to indicate EBP. NA-C stated for a resident who was on EPB, she would wear a gown and gloves while emptying a urinary drainage bag, but not if changing a residents clothing. During an observation at 7/6/26 at 6:55 p.m., EPB sign now on R4's door. During an observation on 7/7/26 at 7:40 a.m., in R4's room, NA-D and NA-E starting to provide morning cares. Neither had PPE on. During an interview 7/7/26 at 10:25 a.m., NA-D and NA-E both admitted they did not wear PPE when washing up and dressing R4. They stated they were aware R4 had a wound on her leg but didn't think they needed to wear gowns since they didn't do anything with her wound or wound dressing. R5's face sheet received on 7/8/26, included diagnosis of retention of urine. R5's admission MDS assessment dated [DATE], indicated moderately impaired cognition, clear speech, was understood and could usually understand. R5 required substantial assistance or was dependent upon staff for ADLs. R5 had an indwelling urinary catheter.R5's physician orders dated 4/21/26, indicated change foley catheter one time monthly for retention of urine. There were no orders for EBP.R5's care plan dated 5/15/26, included indwelling urinary catheter due to urinary retention. Care plan did not include EBP.During an interview and observation on 7/6/26 at 3:41 p.m., observed a urinary drainage bag hooked under R5's wheelchair. According to family member (FM)-B, staff did not wear a gown when they emptied R5's urinary drainage bag. During an observation on 7/7/26 at 7:17 a.m., observed NA-D assist R5 into the bathroom via wheelchair and assist R5 onto the toilet. NA-D had not worn PPE. NA-D left R5 with call light and exited the room. During an observation on 7/7/26 at 7:22 a.m., observed NA-F enter R5's room without donning PPE and assisted R5 from toilet to wheelchair, then wheeled R5 to the dining room. NA-F had not worn PPE. During an interview on 7/7/26 at 10:32 a.m., NA-D stated EBP was used when a resident had an infection. Together went to R5's room and read the EPB sign on the door which indicated: enhanced barrier precautions, everyone must wear gloves and gown for the following high contact activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device and wound care. NA-D was informed of the observation that morning, putting R5 on the toilet without PPE. NA-D stated, I guess I should have. NA-D stated she had training on EBP online and the infection preventionist sometimes went around and asked questions and provided education. During an interview on 7/7/26 at 10:50 a.m., NA-F was informed of an observation of her assisting R5 off the toilet without wearing PPE. Together went to R5's room and looked at the EBP sign on the door. R5 admitted she had not worn PPE when assisting R5 and stated she should have in order to prevent her uniform from becoming soiled.During an interview on 7/7/26 at 1:40 p.m., the director of nursing (DON) was informed of findings of staff not wearing PPE when providing high contact activities to residents on EPB. The DON stated the infection preventionist nurse did observations and on the spot retraining of staff but acknowledged they had a hard time getting staff to be compliant all of the time. The DON stated she expected staff to follow EBP for the protection of residents.Facility Enhanced Barrier Precautions policy with review date of 4/1/26, indicated the facility implemented enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced barrier precautions referred to the use of gown and gloves during high-contact resident care activities including dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use such as central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, and any skin opening requiring a dressing. All staff received training on enhanced barrier precautions upon hire and at least annually and were expected to comply with all designated precautions. Clear signage would be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment, and the high-contact resident care activities that require the use of gown and gloves.

Based on interview and document review, the facility failed to follow care plan interventions related to a resident transfer. Nursing assistant (NA)-A independently transferred 1 of 3 residents (R1) who required assist of 2 staff. This resulted in actual harm when R1 fell during a transfer in a lift, was sent to the emergency department for increased pain to her right arm and was diagnosed with a closed fracture of proximal end of right humerus (fracture of the shoulder joint). The facility took action to correct the deficient practice on [DATE], prior to start of the survey. Therefore, the deficiency was issued at past noncompliance (PNC)Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had mild cognitive impairment and required staff assistance with transfers, toileting, dressing, and bed mobility. R1 used a wheelchair, and diagnoses included vascular dementia, hemiplegia (paralysis on one side of the body), history of transient ischemic attacks ((temporary disruption of blood flow to the brain that resolves without permanent damage), chronic pain, and age-related osteoporosis. R1's Functional Abilities assessment dated [DATE], identified she transferred with an EZ stand (mechanical sit to stand lift) and required assist of two for all transfers. R1 was non-ambulatory. R1's care plan intervention dated [DATE], identified R1's transfer intervention as total assist of two with EZ stand for transfers on/off toilet/commode. R1's progress notes indicated: -[DATE] at 12:38 p.m., R1 received a shower; was very sleepy on bath days; did not go out to dining room for lunch until 12:15 p.m.-[DATE] at 11:15 p.m., indicated R1 had a fall at 1:15 p.m., (late entry) unknown if resident hit her head, was being transferred in the EZ stand and let go of the handles. When the resident let go, the NA tried to get the wheelchair behind her and resident fell. Resident stated her shoulder hurt initially and by 3:30 p.m. resident stated her whole right side of her body was hurting. Ambulance was called due to not knowing the extent of her injuries. R1 returned from the ER (emergency room) at 9:05 p.m. with diagnoses of closed fracture of proximal end of right humerus. R1 had a right arm sling on; morphine (narcotic pain medication) given in ER; new order for hydrocodone-acetminophen5-325mg (milligrams) take one tablet by mouth every 6 [six] hours as needed for pain (narcotic pain medication). R1's After Visit Summary from the emergency department dated [DATE], identified the reason for visit was fall with shoulder pain and diagnoses of closed fracture of proximal end of right humerus. R1's Physician order dated [DATE] at 7:25 p.m., instructed give one Norco (narcotic pain medication) every six hours as needed for pain; please be very gentle with movement of right arm as this arm/shoulder is broken; sling applied over clothes to right arm for comfort. The facility's document titled LTC (long term care) Floor Cards last updated [DATE], identified R1's transfer instructions as assist of two EZ stand or EZ lift when weaker, medium harness. The facility's Event Report closed on [DATE] at 7:47 p.m., identified on [DATE] at 1:15 p.m., R1 was transferred with EZ stand, let go, and fell against bed; unknown if R1 hit head. Pain observation was a 10 (ten) defined as excruciating pain, worst possible, interfered with ability to carry on with daily routines, socialization, or sleep. R1 refused to allow nurse to complete ROM (range of motion) to right arm. R1 sent to ED for evaluation. The facility evaluation included R1 let go of the handles of the EZ stand during a transfer; complained of right arm pain and later right leg pain after the incident; sent to the ER; diagnoses of humerus fracture; returned to the facility and changed to an EZ lift for transfers; sent back to the ER the following day due to low O2 (oxygen) sats (saturations) and increased respirations; died during hospital stay. When interviewed on [DATE] at 1:40 p.m., NA-B stated R1 always needed assist of two staff with the EZ stand transfer because R1 had a habit of just letting go of the handles NA-B further identified R1 would have spells where she just went blank and would take a few minutes to respond to them. NA-B stated the second person that assisted R1 with the transfer would be responsible to watch R1's hands closely and either remind R1 to keep her hands on the handlebar or put hand over R1's hand as a reminder; without that second person, she was likely to fall if she let go. NA-B also stated if R1 was tired like after her bath, she would not be able to stand or hold on so staff would transfer her with the EZ lift. NA-B stated she heard about R1's fall from the lift on [DATE] but was not working at the time. When interviewed on [DATE] at 1:49 p.m., director of nursing (DON) stated the facility investigation into R1's fall identified that NA-A transferred R1 independently when R1 was supposed to have two people to assist during transfers. The facility floor cards (care cheat sheets) had two (staff) assists with EZ stand transfers and the care plan said two assist with EZ stand transfers. The DON said it was her expectation that all staff followed the care planned interventions. The DON stated NA-A was a newer NA but had completed her initial education and orientation.When interviewed on [DATE] at 1:51 p.m., social worker (SW) indicated R1 required assist of two staff for transfers with the EZ stand because of a history of letting go of the handles during a transfer. The SW identified the care cards, and the care plan instructed to have two staff assist with transfers. When interviewed on [DATE] at 2:23 p.m., registered nurse (RN)-A stated she was the RN on call for [DATE] when R1 fell and went to the ED. RN-A stated R1 required two staff assist with EZ stand but NA-A transferred R1 without a second staff person and R1 let go of the handles and fell. RN-A further identified R1's care plan and the care cards (Floor Cards) identified two staff assist with all transfers. All staff are expected to follow the care plan and was not sure why NA-A did not. When interviewed on [DATE] at 2:25 p.m., NA-A identified she transferred R1 with the EZ stand without a second person in the room when R1 fell and was injured. NA-A further indicated she had attached the harness and straps to the EZ stand and had to help R1 hold on to the handlebars but then R1 let go of the handlebars and started slipping out of the harness. NA-A stated they were one to two feet from R1's wheelchair so she tried to get the wheelchair but was too late and R1 was on the floor. NA-A stated R1 had just completely let go of the handlebars. NA- A identified she had been a NA for just a couple of weeks and was aware that the care plan and the care cards said assist of two staff but everyone else was doing it [transfers] with one person and had been told by other NA's that R1 could be done with one staff assist so I assumed it was one or two assist [for R1's transfers]. NA-A indicated she was not aware of R1's history of letting go of the handlebars on the EZ stand lift. When interviewed on [DATE] at 3:30 p.m., RN-B indicated R1's care plan had changed to two staff assist a couple of months prior because sometimes she [R1] was not able to do it [transfer] safely and required a second person to hold R1's hands on the handlebars. RN-B also identified if R1 was tired, she did not have the strength to hold on to the bars or stand up then staff were to use the EZ lift. RN-B indicated R1's illness was a factor in the fall, but root cause of the fall was NA-A did not use two assist like the care plan instructed. When interviewed on [DATE] at 7:35 a.m., licensed practical nurse (LPN)-A identified she responded immediately after R1 fell and found R1 on her back at the end of the bed. LPN-A stated R1 did not have any initial complaints of pain but did have a rug burn on her right side around the rib cage area; one hour later R1 started to complain about having extreme pain in her right arm and thought R1 must be more seriously injured that initially thought. LPN-A called ambulance and R1's daughter. LPN-A stated initial investigation indicated NA-A transferred R1 alone instead of getting another staff as directed by the care plan. LPN-A stated, we had ample people to help that night, but [NA-A] said she was told if she felt comfortable doing it [EZ stand transfer] with one, she could. LPN-A stated R1 had switched to assist of two with EZ stand transfers because she was getting weaker and had let go of the handlebars. Facility Policy titled Safe Resident Handling last revised 4/25, identified EZ stand transfers with an assist of 1-2 depending on recommendations from therapy. The facility policy was updated 12/25 (after R1 fall) to reflect all EZ stands transfers require an assist of two staff. Facility policy titled Abuse Prohibition Plan and Vulnerable Adult Incident Reporting last revised [DATE], identified neglect was the failure of the facility, its employees or service providers to provide goods and services to a resident that were necessary to avoid physical harm, mental anguish, or emotional distress. Serious bodily injury included an injury involving extreme physical pain and involving loss or impairment of the function of a bodily member.The facility implemented the following corrective actions dated prior to the survey and were verified during survey as completed identifying past non-compliance: -NA-A had immediate re-education-Safe Patient Handling policy changed, implemented, and educated to staff. Policy now reflects two staff assist for all transfers.-All resident care plans were updated.-DON provided corrective action, re-education with return demonstration to NA-A.-Random transfer audits by nursing leadership implemented

Based on interview and document review, the facility failed to comprehensively assess and monitor for signs and symptoms of fluid overload for 1 of 3 residents (R1) who had diagnoses of congestive heart failure (CHF), was administered diuretics, and required daily weights. This resulted in an Immediate Jeopardy (IJ) for R1 who had 16-pound weight gain in 10 days, required hospitalization for diuresis then discharged home on hospice with acute renal (kidney) failure. The IJ began on 10/19/25, after the facility failed to comprehensively assess and notify the physician of nearly 7.5-pound weight gain which led to hospitalization on 10/23/25. The Administrator and director of nursing (DON) were notified of the IJ on 10/30/25 at 2:22 p.m. The IJ was removed on 11/4/25 at 3:00 p.m., but non-compliance remained at the lower scope and severity level D, which indicated no actual harm with the potential for more than minimal harm that is not immediate jeopardy.R1's face sheet dated 10/29/25, identified diagnoses of heart failure (heart does not pump blood as it should), hypertension (elevated blood pressure), and localized edema (swelling caused by fluid trapped in the tissues).R1's hospital Discharge summary dated [DATE], identified R1 was hospitalized for cellulitis (skin infection). The summary identified R1 was discharged to the facility on [DATE] with a new order for torsemide (diuretic medication) 80 milligrams (mg) daily to begin 10/14/25 (changed from previous diuretic of Furosemide 80 mg daily; summary did not include why this medication was changed). R1's first dose of the torsemide 80 mg was administered at the hospital. Diet orders included daily fluid intake of 2,000 milliliters (mL)/day.R1's physician orders dated 10/13/25, identified Torsemide 80 mg daily, fluid restriction of 2,000 mL, and daily weights (no parameters identified).The facility standing orders dated 9/25/25, included under heart failure management to call for weight gain 3 pounds (lbs ) or greater in 24 hours or 5lbs. in one week, assess lung sounds, peripheral edema, and respiratory status daily unless directed otherwise. This order set was not transcribed into R1's electronic physician orders. R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had no cognitive deficits, no behaviors, and was dependent on staff to bring drinks to her mouth. R1's baseline care plan dated 10/13/25, identified a 2,000 mL fluid restriction, low sodium, and needs to be fed. R1's care plan identified on 10/19/25, interventions of daily wt., however there were no other interventions identified for the management of fluid volume status. Review of R1's weight (wt ) record in conjunction with fluid intake and urine output included the following recorded values between 10/13/25 through 10/23/25, there was no indication comprehensive assessments were completed to determine if weight gain was fluid gains versus nutritional gains, no indication fluid intake was compared with urine output to determine adequate hydration needs and/or renal function status. On 10/13/25: 185.5 lbs., with intake of 680 mL, and urine out was not recorded. 10/14/25: 183.9 lbs., with intake of 1,160 mL, and medium amount of urine output at 8:07 p.m.10/15/25: 187.6 lbs., with intake of 960 mL, and urine out was not recorded.10/16/25: 188 lbs., with intake of 2,680 mL, and urine out was not recorded.10/17/25: 190.8 lbs., with intake of 1,380 mL, and urine out was not recorded.10/18/25: 189 lbs., with intake of 800 mL, and urine out was not recorded.10/19/25: 193 lbs., with intake of 860 mL, and urine out was not recorded.10/20/25: no weight recorded, with intake of 720 mL, and urine out was not recorded.10/21/25: 198.6 lbs., with intake of 1,540 mL, and medium amount of urine output at 2:14 p.m.10/22/25: 200.4 lbs., with intake of 1,620 mL, and large amount of urine output at 1:59 p.m.10/23/25: 202.4 lbs., with intake of 300 mL, and urine out was not recorded. Review of R1's record between 10/13/25 through 10/18/25, did not identify physician notification of the 4 lbs. weight increase. Further, there was no indication the physician was made aware of R1's weight gains since admission to the facility on [DATE]. In addition, the record did not include any assessments and/or monitoring for signs/symptoms of fluid volume overload and renal failure. R1's physician visit dated 10/18/25 directed staff to continue torsemide 60 mg daily every a.m., follow-up labs, continue daily weights, and consider discontinuing fluid restriction. (The visit note did not address weight gain of 4 lbs. since admit nor identify why R1's Furosemide was changed to Torsemide upon discharge from the hospital). During a phone interview on 10/30/25 at 9:02 a.m., physician assistant (PA)-A verified that the 60 mg was written in error, and he expected R1 to continue with torsemide 80mg daily. PA-A stated at the time of the visit he was not aware R1's weight had increased 4 lbs. since admission on [DATE]. During a phone interview on 10/30/25 at 8:57 a.m., pharmacist (PC) stated torsemide is stronger than furosemide and that furosemide is usually discontinued and torsemide started if a person is not seeing results from furosemide. The combination of fluid restriction and high dose of torsemide would dehydrate R1. PC thought if the rounding physicians at the facility were aware of R1's wt. gain, they would have adjusted the diuretic.R1's medication administration record (MAR) dated 10/29/25, identified R1 received torsemide 80 mg daily every morning from 10/14/25-10/23/25.R1's nutrition assessment progress note dated 10/19/25 at 8:31 p.m., identified even though R1's recorded weight on 10/19/18 was 194 lbs. (increase of 7.5 lbs ) the assessment indicated R1's Current Body weight (CBW)-187.6 # (10/15/25). Additionally, R1 was at increased risk for malnutrition. No nutritional changes warranted at this time. Registered dietician to monitor intake, weights, vitals, signs/symptoms of dehydration, skin integrity. R1's record reviewed between 10/19/25 through 10/22/25 there was no indication the physician was made aware of R1's weight gains since admission to the facility on [DATE]. In addition, the record did not include any assessments and/or monitoring for signs/symptoms of fluid volume overload and renal failure. R1's physician notification from the online patient portal dated 10/22/25, at 11:50 a.m., facility updated R1's clinic with lab results. Physician Assistant (PA) responded on 10/23/25 at 9:51 a.m., suspect R1 has acute kidney injury and sudden onset of dehydration. The note indicated R1's Creatinine level on 9/26/25 was 0.88 (baseline creatinine for females is 0.5-1.0) and current was 1.63, will plan to redraw labs next week.R1's occupational therapy (OT) treatment encounter note dated 10/23/25, identified R1 was approached after lunch for therapy. R1 was asleep in recliner and reported feeling weak today, which was consistent with physical therapy assistants encounter with R1 during morning therapy session in which R1 was unable to complete stand at 4 wheeled walker and required maximum assistant to stand with a sit to stand machine and tolerance was one minute maximum. R1 was unable to successfully transfer from her recliner with the sit to stand machine and used the mechanical lift and stood for 2:00 minutes and 2:30 requiring increased time for rest between each set. Notable SOB (shortness of breath) and increased fatigue. Notified registered nurse (RN) who was monitoring R1's increased weight as well. Shortened treatment session due to increased fatigue. R1's progress note dated 10/23/25 at 4:01 p.m., identified OT reported that during therapy session R1 was weak and had shortness of breath (SOB). R1 had audible, labored breathing, pale skin, warm and dry. Noted to have 17 lbs. wt. gain since admission and notified nurse practitioner (NP). NP requested R1 be sent to the hospital for evaluation. R1 left via ambulance. At 7:50 p.m., R1 was admitted to the hospital with congestive heart failure (CHF) exacerbation (heart cannot pump blood effectively to meet body's needs).R1's hospital record dated 10/27/25, identified R1 was admitted on [DATE] with diagnoses of CHF, fluid retention, and acute kidney injury. R1 reported SOB for the past couple days that worsened in the last 24 hours and was not able to participate in therapy d/t increased SOB. Chest x-ray showed CHF and/or fluid volume overload. Bumex (diuretic) intravenous (IV) with total dose 8 mg since admission with suboptimal diuresis and kidney function trending worse, respiratory status and upper extremity edema with no improvement. R1 had mild distress with tachypnea and 2-3-word conversational dyspnea, rales, general 2+ edema, R1 decided to do comfort cares and discharged home on hospice on 10/27/25.During a phone interview on 10/29/25 at 9:36 a.m., R1's family member (FM)-A stated since R1's hospitalization R1 had not been able to move her arms and was totally dependent on staff to provide fluids. On 10/23/25, R1 told her she felt like she had a urinary tract infection and that she could not urinate. At 3:00 p.m., RN-A called FM-A and stated she had quite a bit of a weight gain and the physician wanted her to go to the hospital to diuresed. FM-A stated R1 is at home and dying of acute kidney and heart failure. R1 ballooned up so much in her abdomen, arms, fingers, and thighs at the hospital. At the hospital, R1 was on intravenous bumex (medication used to get rid of extra fluid in the body) and it was not effective with no urine output and nothing in her bladder.During an interview on 10/28/25 at 1:38 p.m., nursing assistant (NA)-A stated on 10/13/25, she assisted R1 with eating and R1's hands were very puffy. She did not report this to the nurse. During a phone interview on 10/29/25 at 11:57 a.m., NA-C stated she worked during the day on 10/23/25 and thought R1 looked very puffy in general-every part of her looked puffy. NA-C could not recall if she helped R1 to the bathroom on 10/23/25 or if she was short of breath.During a phone interview on 10/29/25 at 11:34 a.m., NA-G stated she worked night shift and R1 rarely used the bathroom when she worked. NA-G could not recall if R1 used the bathroom at all on 10/22/25, but did not think R1 did. NA-G was unable to recall what R1 looked like. During a phone interview on 10/29/25 at 11:13 a.m., NA-H stated she worked day shift on 10/23/25 with R1. NA-H recalled taking R1 to the toilet after lunch and R1 urinated. NA-H did not recall R1 having shortness of breath or feeling weaker.During an interview on 10/28/25 at 1:47 p.m., OT-A stated since admission, R1 had been showing progress in both therapies. On 10/23/25, with both therapies, R1 complained of feeling weak, needing maximum assist to transfer, and had a hard time getting up. OT-A did not notice fluid in her extremities but did not examine them, noted shortness of breath and obtained 02 and pulse and they were unremarkable. OT-A treated R1 for about 15 minutes and she was very fatigued, so OT-A notified the floor nurse and RN-A of R1's weakness and SOB.During an interview on 10/28/25 at 1:15 p.m., licensed practical nurse (LPN)-A stated she did not recall R1 having edema, but also did not check for edema on R1, did not listen to R1's lung sounds, and did not notify family or physician of R1's wt. gain on any days that she worked. LPN-A thought R1's arms and wrists looked a little bigger than they were when she admitted on [DATE]. LPN-A stated she thought she mentioned R1's weight gain in passing to RN-A on 10/22/25, when the wt. was 200.4 lbs. LPN-A stated when the nurse puts the wt. in the resident's electronic medical record, they can look at the last wt. that was recorded, and they also can view the history of wts. that had been obtained. It would depend on if the wt. changed if the nurse would look at other wts. Usually, a physician would be notified if the wt. was 3 lbs. or more in one day or if there was a 5% wt. change. LPN-A verified R1 was on a fluid restriction and daily wts. LPN-A worked and obtained wts. on R1 on 10/15/25 (3.7 lb. wt. increase in one day), 10/17/25, and 10/22/25 (wt. was 200.4 lbs.).During a phone interview on 10/29/25 at 8:34 a.m., LPN-B stated daily wts. are done to watch for fluid accumulation and if wt. was going up it meant the resident is probably retaining fluid. The floor nurse would keep an eye on the wt. and when the electronic record identified a significant wt. change, the floor nurse would notify RN-A. Usually, there were parameters of so many lbs. in one day or one week in the order. RN-A worked 10/13/25, 10/14/25, 10/16/25, 10/18/25, 10/21/25 (up 5.6 lbs. since last wt.), and 10/23/25 (wt. up 16.4 lbs. since admission). Since admission, R1 had minimal edema, if any edema it was in her lower legs and no complaints or issues with shortness of breath, but LPN-A did not notice any edema on R1. R1 had some SOB with exertion, but that would be normal working with therapy. LPN-B did not listen to lung sounds, check edema, or notify the physician of R1's weight gain during any of the shifts she worked. On 10/23/25, LPN-A did a skin assessment on R1 and noticed no edema. LPN-A gave R1 her morning medications in the therapy room on 10/23/25, after PT had stated that R1 was short of breath and tired and did not think R1 looked in distress while standing with the sit to stand machine.During an interview on 10/30/25 at 9:45 a.m., clinical coordinator RN-A stated the clinical coordinators complete the admission paperwork and care plans. Daily wts. were ordered to check for increase or decrease of wt. and usually fall into the increase of wt. gain. R1 did not have parameters to watch for or notify the physician with her daily wts., it only identified daily wts. in the medication administration record (MAR). There was no documentation in R1's chart to monitor for parameters of edema or location of edema. R1 was unable to drink on her own and relied on staff to give her fluids and did not come anywhere near her fluid restriction limits. RN-a completed the admission paperwork for R1 and then was on vacation and returned to work 10/21/25. RN-A stated she reviewed the facility reports at home on [DATE], which included review of wts. that would be out of range and did not notice anything flagged for R1. RN-A stated on 10/21/25 and 10/22/25, she played catch-up and did not have a chance to look at the report on 10/21/25 and did not notice the wt. gain on 10/22/25. RN-A thought LPN-A may have indicated R1's wt. was creeping up on 10/22/25 but it did not register with her. On 10/23/25, R1's wt. flagged in the computer system for having a 5% increase. RN-A saw R1 at lunch on 10/23/25, and did not notice any SOB but later that afternoon when R1 was sent in she was struggling to breathe.During an interview on 10/30/25 at 12:27 p.m., DON stated it was the expectation of staff to implement interventions in the care plan related to heart failure and to include edema management if appropriate. The staff should look in a progress note or maybe the MAR to identify where a resident's edema is located, and staff should monitor edema every shift. When wt. gain is identified, staff should check for edema, recheck wt., obtain a set of vital signs, assess for shortness of breath, and notify physician of symptoms. Typically, probably, the clinical coordinator and the floor nurse that entered the wts., should check the wt. to make sure the resident has not gained and is outside the parameters. The facility was going to implement putting baseline wt. in the daily order because sometimes, if the resident has been at the facility for a few weeks, it is laborious to go back to the admission wt. to see what the wt. expectation was.During a phone interview on 10/20/25 at 9:02 a.m., PA-A stated huge weight differences can occur in days so if the facility can have a baseline weight or a goal weight that the facility goes against to check and notify the physician, it would be helpful. PA-A would have wanted to be notified of R1's wt. if it was 3-5 lbs. above baseline. If PA would have been aware of the wt. gain, he would have done a diuretic burst and ordered labs to see if that would have helped. It may have changed the outcome of hospitalization with exacerbation of CHF, acute kidney injury, and hospice. The facility Significant Weight Change policy dated 10/2025, identified the policy was to manage wt. gain/loss, typically defining a significant change as a 5% gain in one month or 10% in six months. The facility would conduct regular wt. monitoring to identify and document trends. If a resident experiences a significant wt. gain at any time, it must be assessed by a physician to determine the cause. When an out-of-range wt. is flagged upon electronic documentation, wt. gain should be addressed immediately to include re-weigh the resident for accuracy, contact physician with noted gain immediately, assess for edema and any symptoms of SOB, continue to monitor the resident for an adverse event.The IJ that began on 10/22/25, was removed on 11/4/25 at 3:02 p.m., when it was determined and verified the facility implemented the following:-identification of 23 like residents at-risk. Addition of baseline wt. to daily wt. orders along with parameters for wt. gain and to contact the physician for a 3 lb. increase in 24 hours or 5 lbs. increase in a week, edema assessments with baseline edema listed in physicians order, lung sounds added to interventions and care plans updated.-developed a new significant weight change policy and reviewed other applicable policies such as weight management, and vital signs.-developed a fluid restriction guideline/worksheet.-new admission order set created for residents admitting with diagnosis of CHF, edema, use of diuretics, and compression which includes daily edema checks, lung sounds, daily wts. with daily and seven-day parameter.-residents who have a diagnosis of heart failure and edema, but currently not at-risk, facility added baseline wts. on their weekly wt. assessment and edema checks with primary bath/skin checks of the week.-clinical coordinators are responsible for assessing and monitoring the resident for a change in condition with subsequent notification of medical provider.-staff completed review of newly developed significant weight change policy and procedure.-direct education reviewing how to assess for edema along with early recognition of heart failure symptoms completed before each licensed nurses next scheduled shift and availability of staff not regularly scheduled. Education also included in orientation of all newly hired staff.

Based on interview and record review the facility failed to report an allegation of deprivation of good within 2-hours to the State Agency (SA) for 1 of 1 resident (R1), who reported staff refused to transfer her to the toilet when requested and was incontinent of urine. Findings include:R1's nursing home incident report (NHIR) dated 6/16/25 at 3:07 p.m., identified R1 reported from 6/14/25-6/15/25 she put her call light on around midnight to use the toilet and sit in her recliner. Two aides came into the room and rudely told her What do you want to get up for and it is time for bed. The aides turned off the call light and left the room. Staff did not come back to the room until 2:30 a.m. and told R1 they were very busy. R1 reported that she hated it but had to urinate in her brief because they would not help her. R1 stated she waited in the wet brief until the morning when new staff were available to help her. R1 also indicated when she asked staff to transfer her according to her preference, staff responded I'm not going to lose my license, so we are not going to transfer you. Facility identified the nursing assistants through camera footage.R1's face sheet dated 7/9/25, identified diagnoses of mechanical complication of internal right hip prosthesis (presence of an artificial device to replace a missing body part), presence of artificial right hip.R1's comprehensive Minimum Data Set (MDS) dated [DATE], identified no issues with cognition, no behaviors towards staff or residents. Impairment on one side of lower extremity. Dependent on staff for toileting hygiene, lower body dressing, footwear; substantial assistance with movements in bed. Continent of bowel but frequent incontinence of urine.R1's care plan on 6/10/25, identified R1 was a vulnerable adult and staff should report any witnessed or suspected abuse per facility protocol.During an interview on 7/8/25 at 1:10 p.m., R1 stated the two nursing assistants should never have been nursing assistants. They are authoritative and drag one foot in front of the other. R1 felt that they just were not doing their jobs. If R1 asked for something it would take forever for them to do it but that night, they were not budging. R1 stated she had to use the bathroom, and they had gotten her up and were on the way and then could not do it saying things like they would lose their license and all sorts of things. R1 decided that it would be best to pee in my pants and not damage my leg. R1 decided that she should report the aides that morning and the aides were gone quick after she reported the incident.During a phone interview on 7/9/25 at 9:59 a.m., registered nurse (RN)-A stated she had worked the overnight shift on 6/14/25 into 6/15/25. NA-F had come to her because she felt unsafe transferring R1 using a mechanical lift because of the way R1 was demanding to be transferred. NA-F was very adamant about not transferring R1 in that manner. RN-A asked NA-E to transfer R1. It was not until the next morning or two days later that RN-A discovered that R1 had never been transferred. R1 was sleeping in her recliner that night and had never gotten into bed. NA-E was working on R1's unit that night and NA-F was scheduled as the float person that would help other NA's where needed. As far as RN-A was aware, NA-E and NA-F were never in R1's room together. RN-A had never had any issues with NA-E or NA-F prior to this. RN-A stated she reported the incident during shift to shift report the morning of 6/15/25. RN-A had not received concerns from R1 or about R1 that occurred during the night other than the transfer incident.During an interview on 7/8/25 at 1:45 p.m., licensed practical nurse (LPN)-A believed it was the morning of 6/14/25 when RN-A reported R1 was upset with the NA's for not transferring her the way she wanted to be transferred; NAs had thought the way R1 wanted to be transferred was unsafe so they did not transfer her the rest of the night to the bathroom. LPN-A did not know which NAs were involved. LPN-A thought the incident happened around 3:00 am and R1 was really frustrated the NAs would not listen. LPN-A explained she reported R1 was unhappy about the concerns pertaining to R1's transfers to LPN-B sometime that morning.During an interview on 7/9/25 at 9:53 a.m., LPN-B stated LPN-A had called her on 6/15/25 and said there was an issue with R1's transfer status and questions between the nurses and aides on night shift with turning off her light. LPN-B notified the director of nursing (DON) of the situation and tried to get ahold of RN-A to discuss what had happened. During an interview on 7/9/25 at 1:14p.m., DON stated LPN-B had reached out to her on 6/15/25 that there were some complaints regarding staff with R1. DON did not feel that what was reported seemed neglectful from her perception, if it had, an investigation would have begun. After R1's interview on the afternoon of 6/16/25, management staff felt that rather than provide education to staff, the incident needed to be reported. During an interview on 7/9/25 at 9:46 a.m., NA-A stated she reported to social worker (SW)-A on 6/16/25 that R1 was mad because the night aides would not take her to the bathroom because they did not feel comfortable with her toe-touch. R1's brief was soaked when NA-A assisted her on the morning of 6/15/25. R1 was upset about the incident because she paid a lot of money to be at the facility and felt that those NA's tag-teamed against her and did not want to help her.During an interview on 7/9/25 at 10:15 a.m. and 1:46 p.m., SW-A heard about the situation from NA-A and NA-B when they reported it to her on 6/16/25. DON, LPN-B, and RN-A did not inform SW-A of the situation. SW-A immediately went to R1 and interviewed her. SW-A filled out the NHIR form after the interview with R1 and that was why the report was made late. The Abuse, Neglect and Exploitation policy revised 5/23/24, identified the facility maintained an environment where resident are free form abuse, neglect, exploitation and misappropriation of property and all residents, staff, families, visitors, volunteers, and resident representatives are encouraged and supported in reporting any suspected acts of abuse, neglect, misappropriation of property, or exploitation. Deprivation by staff of goods or services include those that are necessary to attain or maintain physical, mental, and psychosocial well-being. In these cases, staff has the knowledge and ability to provide care and services, but choose not to do it, or acknowledge the request for assistance from a resident(s), which result in care deficits to a resident(s).

Based on observation, interview, and document review, the facility failed to utilize infection control practices while assisting multiple residents (R19, R33, R34, R35) to eat at once in 1 of 3 dining areas. Also, the facility failed to utilize infection control practices for 1 of 1 resident (R47) reviewed for oxygen use. Findings include: MEAL ASSISTANCE WITHOUT HAND HYGIENE R19's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R19 had short and long-term memory problems and severely impaired cognitive skills for daily decision making. R19 was dependent on staff for eating and had diagnoses which included gastro-esophageal reflux disease (stomach acid flows back up into the esophagus and causes heartburn), Alzheimer's disease, and depression. R33's quarterly MDS assessment dated [DATE], indicated R33 had severe cognitive impairment and required substantial and/or maximal staff assistance with eating. R33's diagnoses included hypertension, dementia, and anxiety. R34's annual MDS assessment dated [DATE], indicated R34 had short and long-term memory problems and severely impaired cognitive skills for daily decision making. R34 was dependent on staff for eating and had diagnoses which included coronary artery disease, hypertension, diabetes mellitus, Alzheimer's disease, anxiety, and depression. R35's significant change MDS assessment dated [DATE], indicated R35 had short and long-term memory problems and severely impaired cognitive skills for daily decision making. R35 was dependent on staff for eating and had diagnoses which included chronic kidney disease and dementia. On 4/28/25 at 5:14 p.m., residents in the memory care area were assisted with dining. Nursing assistant (NA)-H sat between R34 and R35 and assisted them with food and beverages. NA-H switched between each residents' utensils and drinks primarily using their right hand and did not perform hand hygiene in between. On 4/28/25 at 5:48 p.m., NA-H stated they did not want to use their left, non-dominant hand to feed the other resident, because they did not want to spill on the resident. On 4/29/25 at 11:48 a.m., NA-G sat between R19 and R33 and assisted them with food and beverages. NA-G wore gloves and switched between residents' utensils and drinks primarily using their right hand and did not perform hand hygiene in between. On 4/29/25 at 12:25 p.m., NA-G verified they used their right hand to feed both residents at the same time. NA-G stated they should use one hand for each resident if assisting at the same time but did not want to spill on the resident by using their non-dominant hand. On 4/30/25 at 1:28 p.m., registered nurse (RN)-B stated staff were allowed to assist two residents with meals at the same time but needed to use a different hand unless hand hygiene was performed between residents. On 4/30/25 at 2:59 p.m., the director of nursing (DON) expected staff to perform hand hygiene between assisting residents with meals or designate one hand per resident to avoid cross-contamination. Facility Hand Hygiene policy dated 5/21/24, indicated: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The policy applied to all staff working in all locations within the facility. The policy directed staff to perform hand hygiene between resident contacts and use of gloves did not replace hand hygiene. NASAL CANNULA R47's quarterly MDS assessment dated [DATE], indicated R47 had short and long-term memory problems and severely impaired cognitive skills for daily decision making. R47 had disorganized thinking, no hallucinations, no delusions, no behavioral symptoms, and no rejection of care. R47 had no impairment to upper or lower extremities, used a walker and wheelchair, and required substantial/maximal assistance with most activities of daily living. R47's diagnoses included heart failure, hypertension, diabetes mellitus, and aphasia (disorder which affects how you speak and understand language). R47's care plan dated 4/28/25, indicated R47 was at risk for disease related complications related to dementia, chronic respiratory failure with hypoxia, chronic kidney disease, type two diabetes mellitus, hypertension, encephalopathy (change in how the brain works due to underlying condition), chronic congestive heart failure, tachycardia, and history of TIA (transient ischemic attack; temporary blockage of blood flow to the brain). The care plan directed staff to monitor for changes in respiratory status and give supplemental oxygen as ordered. R47's orders indicated, okay for oxygen two liters per nasal cannula and titrate as able to keep oxygen saturation above 88 percent every shift with a start date of 1/3/25. An order dated 4/28/25, directed staff to change and date oxygen tubing weekly while resident is on oxygen use and to discontinue the order if oxygen was no longer needed. On 4/28/25 at 5:31 p.m., R47's nasal cannula oxygen tubing was observed on the ground behind her as she wheeled herself to the kitchenette window. R47 spoke with the culinary aid near two nursing assistants who assisted other residents with eating. At 5:35 p.m., registered nurse (RN)-B picked up R47's nasal cannula and placed on back of wheelchair. RN-B went to the medication cart and returned with a square wipe, cleaned R47's nasal cannula, and placed the nasal cannula back on R47. At 5:37 p.m., RN-B stated they used an alcohol wipe to clean R47's nasal cannula. On 4/29/25 at 1:45 p.m., licensed practical nurse (LPN)-B stated they would replace a nasal cannula if was on the floor rather than clean, since nasal cannulas were placed in the nares. LPN-B stated they would use an alcohol wipe to clean a nasal cannula if the resident touched the tubing with sticky hands and made the tubing sticky. LPN-B stated staff tried to wean R47 off the supplemental oxygen, but R47 would get dizzy without the supplemental oxygen. On 4/30/25 at 12:25 p.m., LPN-A stated they considered a nasal cannula contaminated if touched the floor and would replace with a new nasal cannula after checking resident's oxygen saturation level and if resident was breathing okay. On 4/30/25 at 1:28 p.m., registered nurse (RN)-B stated they cleaned R47's nasal cannula after observed on the floor and placed back on R47, since they did not know how long R47 was without her supplemental oxygen. RN-B stated they would normally replace nasal cannulas observed on the floor. On 4/30/25 at 2:59 p.m., the director of nursing (DON) stated staff would usually replace a nasal cannula which had dropped on the floor for infection prevention reasons. The DON was okay the staff cleaned the nasal cannula and placed on the resident, since staff did not know how long the resident was without their supplemental oxygen. The DON stated the resident's supplemental oxygen was important, so the resident's oxygen saturation level did not drop. The [NAME] Labs' Instruction for use with reference number 16SOFT-7, indicated: Single patient use. Do not sterilize. Keep tubing straight and free from kinks. Facility Oxygen Administration policy dated 2/25/25, indicated: Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated.

Based on interview and document review, the facility failed to ensure the pneumococcal (PCV20) vaccine was offered or administered as recommended by the Centers for Disease Control (CDC) for 4 of 5 residents (R7, R15, R10, R41) reviewed for immunizations. This had the ability to affect all residents residing in the facility who had not been offered the PCV 20 vaccine. Findings include: R7's face sheet printed 4/30/25, indicated diagnoses of chronic kidney disease, malaise, low back pain, and congestive heart failure. R7's discharge Minimum Data Set (MDS) dated [DATE], indicated intact cognition, no rejection of care, and substantial assistance with showering, dressing, and personal hygiene. R7's care plan dated 3/5/25, indicated resident at risk for disease related complications related to diagnoses and resident will be free of serious complications. Interventions included administer medications per provider orders, observe for adverse medication side effects and monitor effectiveness. R15's face sheet printed 4/30/25, indicated diagnoses of unspecified dementia, agitation, open wound of neck, and anxiety. R15's quarterly MDS dated [DATE], indicated moderately impaired cognition, no behavioral symptoms, and substantial assistance with toileting hygiene, bathing, and lower body dressing. R15's care plan dated 1/14/25, indicated resident had difficulty making needs known related to diagnoses of dementia and disorientation with goal of resident's needs will be met by staff. R10's face sheet printed 4/30/25, indicated diagnoses of arthritis, dysphagia (difficulty swallowing), retention of urine, and abnormal weight loss. R10's quarterly MDS dated [DATE], indicated intact cognition, no rejection of care, impairment of upper and lower extremities, and substantial assistance with personal hygiene. R10's care plan dated 12/12/23, indicated resident had impaired mobility related to contractures, disease progression, and activity tolerance and intervention of extensive assistance of one to two staff for transfers, turning, and repositioning. R41's face sheet printed 4/30/25, indicated diagnoses of repeated falls, restless leg syndrome, Alzheimer's disease, and age-related physical debility. R41's significant change MDS dated [DATE], indicated severely impaired cognition, no behavioral symptoms, dependent on staff for toileting hygiene, and substantial assistance with upper and lower body dressing. R41's care plan dated 11/13/23, indicated resident had cognitive deficits due to diagnoses, needed a secure memory care unit, and would make appropriate decisions and maintain current decision-making capacity. During record review, there was no documentation in R7, R15, R10, or R41's EMR (electronic medical record) for the PCV 20 vaccine or evidence the facility had attempted to educate residents on or offer the PCV 20 vaccine. Additionally, there was no documentation in R7, R15, R10, or R41's record that they had refused previously offered vaccines or the PCV 20 vaccine. During interview on 4/29/25 at 11:45 a.m., licensed practical nurse (LPN)-D also known as infection preventionist stated R7, R15, R10, and R41 were up to date on their vaccine schedules and have no further vaccinations needed. During interview on 4/30/25 at 10:45 a.m., LPN-D stated she now realized she should have offered the PCV 20 vaccine to residents. LPN-D further stated she missed the updated information on vaccines and had not heard about the new pneumococcal vaccines that needed to be offered. LPN-D stated she would come up with a process to get the PCV 20 or 21 vaccine offered to residents based on CDC recommendations. During interview on 4/30/25 at 10:46 a.m., director of nursing (DON) stated she expected vaccines to be offered to all residents based on current CDC guidelines. Facility Pneumococcal Vaccine (Series) policy revised 4/1/25, indicated the following: It is our policy to offer our residents, staff and volunteer workers immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations. 1. Each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted. Any additional efforts to obtain information shall be documented, including efforts to determine date of immunization or type of vaccine received. 5. The type of pneumococcal vaccine (PCV 15, PCV 20, or PPSV23/PPSV) offered will depend upon the recipient's age and susceptibility to pneumonia, in accordance with current CDC guidelines and recommendations.

Based on observation, interview and document review, the facility failed to ensure preferences for bedtime were honored and implemented for 1 of 1 resident (R26) reviewed for choices. Additionally, the facility failed to ensure food preferences were honored for 1 of 2 residents (R45) reviewed for choices related to food. Findings include: R26's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R26 had severe cognitive impairment, no behaviors or rejection of care, utilized a wheelchair, dependent on staff for chair/bed to chair transfer, lower body dressing, toileting hygiene, and required substantial/maximal assistance with personal hygiene, diagnoses included seizure disorder and repeated falls. R26's annual MDS dated [DATE], indicated R26 bedtime was very important to choose. R26's care plan dated 2/11/25, indicated encourage to engage in daily and activity preferences and interventions included offer individualized care based on customary routine, R26 has indicated for his daily preferences that it is very important, to choose his own bedtime (likes to go to bed between 6-7pm and get up in the morning around 6am or earlier), impaired mobility R/T (related to) weakness and failure to thrive, left sided weakness from previous stroke, bed mobility: extensive assistance from 1-2 staff with turning and repositioning resident in bed. On 4/28/25 at 5:24 p.m., R26 was seated in his wheelchair in his room with his call light activated. Nursing assistant (NA)-A entered R26's room and R26 stated he would like to go to bed now. NA-A stated R26 can't be put to bed until 7:00 p.m., R26 again asked to go to bed, and NA-A stated, I legally can't put you to bed until 7:00 p.m., you've only been up for about ten minutes since eating supper, you wait a little bit. NA-A exited R26's room and R26 remained seated in his wheelchair. On 4/28/25 at 5:26 p.m., R26 was seated in a wheelchair in his room, and stated he would like to go to bed now, but was told by staff he couldn't' and had to wait. R26 stated there was a time frame of 7:00 p.m., before they will allow me to go to bed. On 4/28/25 at 5:37 p.m., NA-A stated R26 enjoyed going to bed early, and she doesn't want to put him to bed and then get him up in an hour again. NA-A stated staff encouraged R26 to stay up until 7:00 p.m., and 6:30 p.m., was the earliest she would assist R26 to bed. NA-A stated in her schooling she learned residents were not allowed to go to bed until 7:00 p.m., and the nursing staff at the facility stated he wasn't allowed to go to bed until 6:30 p.m. On 4/28/25 at 5:46 p.m., R26 continued to sit in his wheelchair and shook his head side to side and stated he was mad he can't go to bed. On 4/28/25 at 5:47 p.m., NA-B stated residents can go to bed when requested and stated R26 was expected to be put to bed when he requested his bedtime. NA-B stated she was going to his room now to assist R26 to bed per his request. NA-B was observed to enter R26's room. On 4/28/25 at 5:49 p.m., licensed practical nurse (LPN)-A stated if a resident requested to go to bed staff were expected to assist the resident to bed and were not expected to make R26 wait a certain time before he could go to bed. LPN-A stated R26 liked to go to bed after the evening meal and that was his routine. On 4/29/25 at 11:54 a.m., registered nurse (RN)-A stated R26 preferred to go to bed early and was very routine after his evening meal and stated if staff were able to accommodate R26's early request for bedtime, they should not make him wait. On 4/29/25 at 3:52 p.m., the director of nursing (DON) stated residents were allowed to go to bed upon their request and stated there was no timeframe residents needed to wait for to be placed into bed. The DON stated staff were expected to assist R26 to bed when he requested if staff were available and expected staff to honor R26's bedtime preference. Facility Resident Rights policy dated 10/10/22, indicated : Policy: The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The facility will also provide the resident with prompt notice (if any) of changes in any State or Federal laws relating to resident rights or facility rules during the resident's stay in the facility. Receipt of any such information must be acknowledged in writing. The facility will ensure that all direct care and indirect care staff members, including contractors and volunteers, are educated on the rights of residents and the responsibility of the facility to properly care for its residents. Training topics will be appropriate to the individual's role. 48299 FOOD PREFERENCES R45's quarterly MDS assessment dated [DATE], indicated R45 had severe cognitive impairment, behaviors not directed toward others and wandering which occurred one to three days during the MDS look back period, and no rejection of cares. The MDS indicated R45 used a walker, required setup or clean-up assistance for eating, and diagnoses included diabetes mellitus, Alzheimer's disease, and anxiety. R45's care plan dated 4/28/25, lacked preference to not have corn with meals. R45's progress note dated 9/2/24, indicated R45 stated he did not eat his soup because corn gave him loose stools. The dietary aid and unit manager were informed to add information to R45's diet card. R45's Admission Nutritional assessment dated [DATE], lacked information under the section Describe R45's food preferences, likes/dislikes, religious/cultural/ethnic food needs. R45's Quarterly Nutritional Assessments dated 10/21/24, 1/13/25 and 4/7/25, also lacked information under the section described above. On 4/28/25 at 1:58 p.m., R45 stated he asked for a different vegetable when served corn, since corn gave him diarrhea. On 4/29/25 at 1:11 p.m., nursing assistant (NA)-F stated diet cards located in the kitchen listed residents' food preferences. NA-F had not heard R45 would not want corn. On 4/29/25 at 1:25 p.m., dietary aid (DA)-A stated they served residents based on their diet cards. R45's diet card listed his diet and instructed to give large portions. DA-A stated resident preferences were printed on the bottom of diet cards and verified R45's diet card did not list preferences. On 4/29/25 at 1:51 p.m., licensed practical nurse (LPN)-B stated most residents did not complain about their food and found alternatives for those who did. LPN-B stated R45 told staff what he wanted or did not want and did not know anything specific he did not like. On 4/29/25 at 3:23 p.m., NA-D stated each resident had a diet card which listed allergies and preferences. NA-D stated R45 did not eat regular corn but ate cream of corn. On 4/29/25 at 3:37 p.m., NA-E stated they would reference R45's diet card to know whether to serve him corn or not. On 4/30/25 at 1:28 p.m., registered nurse (RN)-B stated R45 indicated Tylenol gave him diarrhea but was not aware of corn. RN-B expected R45 to have no corn on his diet card if he requested. On 4/30/25 at 2:13 p.m., the dietician stated they asked residents about their food preference during the admission assessment if the assistant culinary services manager (ACM) and director of culinary services (DCS) had not asked already. The dietician did not have access to R45's medical record at the time of interview and stated they were not as familiar with R45. On 4/30/25 at 2:45 p.m., ACM stated the dietician, DCS, or themselves asked residents about their food preferences, and they or DCS updated diet cards and a book in the kitchen. ACM stated R45's diet card was updated today to include no corn. On 4/30/25 at 2:59 p.m., the director of nursing (DON) stated residents' food preferences were on their diet cards and important to list related to residents' health and rights. Facility Meal Identification Policy dated 5/1/25, indicated: Policy: A meal identification (ID) and food preferences card (meal ID card/ticket) will be used to properly identify each individual's needs including food and beverage preferences. The meal ID card/ticket may be a permanent card that is gathered, cleaned, and sanitized after each meal, or may be printed daily from a database and disposed of after meals. The director of food and nutrition services or designee will visit a newly admitted individual to obtain food and beverage preferences, dislikes and food allergies/intolerances before a permanent meal ID card/ticket is written.

Based on interview and document review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the current status and needs for 1 of 1 resident (R45) reviewed for MDS accuracy related to alarms. Findings include: R45's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R45 had severe cognitive impairment, behaviors not directed toward others and wandering which occurred one to three days during the MDS look back period, and no rejection of cares. The MDS indicated R45 used a walker and had diagnoses which included diabetes mellitus, Alzheimer's disease, and anxiety. The MDS, Section P, indicated R45 used a wander/elopement alarm less than daily. R45's care plan dated 4/28/25, indicated R45 was on a locked unit due to elopement risk, with an edited date of 2/4/25, and did not indicate R45 used an alarm. R45's orders printed 4/30/25, indicated okay for locked unit dated 10/2/24 and did not indicate R45 used an alarm. R45's quarterly Supportive Devices assessment dated [DATE], indicated R45 did not use a wanderguard and lacked indication of other type of alarm. On 4/30/25 at 1:28 p.m., registered nurse (RN)-B stated R45 wandered at night and did not have a wander/elopement alarm since admission to the locked unit. On 4/30/25 at 2:29 p.m., the MDS coordinator stated the completed Section P based on information from unit managers and care plans. The MDS coordinator stated R45 was on a different unit prior to admission to the memory care area, and R45's MDS selection for wander/elopement alarm was an error and would modify. On 4/30/25 at 2:59 p.m., the director of nursing (DON) stated MDS accuracy was important to ensure correct reimbursement and resident and/or responsible party payment. Centers for Medicare and Medicaid Service's Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2024, defined wander/elopement alarms as devices such as bracelets, pins/buttons worn on the resident's clothing, sensors in shoes, or building/unit sensor worn by/attached to the resident which activated an alarm and/or alerted the staff when the resident neared or exited a specific area or the building. Wander/elopement alarms included devices attached to the resident's assistive device or other belongings.

Based on observation, interview and document review, the facility failed to provide routine removal of facial hair for 1 of 2 residents (R13) reviewed for activities of daily living (ADLs) who were dependent on staff for cares. Findings include: R13's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, no rejection of care, utilized a wheelchair, required substantial/maximal assistance with personal hygiene (the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene). R13's care plan dated 3/3/25, indicated R13 required one assist with all ADL task, legally blind, staff assist resident with handing her things needed for tasks as well as describe where things are compared to a clock, interventions personal hygiene: extensive assistance from one staff with grooming needs including combing hair, brushing teeth, shaving, washing/drying face/hands. On 4/28/25 at 3:52 p.m., R13 was observed with varied lengths (approximately 1/4 inch to 1 inch) white hairs on her chin. R13 stated she was not sure if she had a razor. R13 stated she would like her chin hairs shaved and required assistance as she was legally blind. R13 stated some of her chin hairs were going into her mouth. R13 stated she got a bath once a week and staff had not shaved or offered her shaving. On 4/29/25 at 10:52 a.m., R13 was seated in wheelchair well groomed, with varied lengths of white whiskers on chin, and stated she thought she had an electric razor somewhere in her room. R13 again stated staff had not offered to shave her, and further stated staff should notice when she needed to be shaved. On 4/29/25 11:00 a.m., nursing assistant (NA)-C stated he assisted R13's with morning ADL cares this morning and confirmed R13 required staff assistance for hygiene cares and shaving. NA-C stated R13 was not offered shaving as expected with morning cares today. On 4/29/25 at 11:48 a.m., registered nurse (RN)-A, confirmed R13 needed assistance with cares and required staff to assist her with shaving. RN-A stated NA's were responsible for morning cares and assisting residents daily with shaving. On 4/30/25 at 7:16 a.m., the director of nursing (DON) confirmed R13's chin hairs were long and would have expected R13 offered shaving and shaved with morning cares. Facility Activities of Daily Living policy dated 1/25, indicated: Grooming should be performed at least daily, including but not limited to combing, brushing teeth including denture cares, shaving residents, observing nails for cleanliness and trimming needs, etc.

Based on interview and document review, the facility failed to implement a bowel movement (BM) protocol for 1 of 1 resident (R7) reviewed for constipation. Findings include: R7's five-day Minimum Data Set (MDS) assessment dated [DATE], indicated R7 had intact cognition, no rejection of care, utilized a walker and wheelchair, dependent on staff for toileting hygiene, required substantial/maximal assistance with toilet transfer, always continent of bowel, and diagnoses included constipation and lower back pain. R7's care plan dated 3/11/25, indicated R7 required assist of one for toileting needs, occasional incontinent episodes, interventions encourage and provide adequate fluid, fiber, and exercise to promote elimination and prevent constipation, bowel meds PRN (as needed) per standing orders/protocol, document BMs (bowel movements) per NH (nursing home) protocol, update MD/NP/family as needed, (medical doctor/nurse practitioner), observe for s/e (side effect) and effectiveness, extensive assist of one staff for toileting needs, staff assist with peri care after each toileting, and assist of 1-2 for transfers on/off toilet/commode. R7's Medication Administration Record (MAR) dated 4/1/25-4/30/25, indicated Miralax (used to treat constipation) powder ; 17 gram/dose diagnosis constipation and administered on 4/25/25 at 5:28 p.m., reason no BM x 4 days. R7's document Bowel Movements printed 4/30/25, indicated : 4/20/25 at 9:40 a.m., Bowel Movement: Medium 4/20/25 at 3:21 p.m., Bowel Movement: Small 4/24/25 at 5:52 a.m., Bowel Movement: None 4/25/25 at 6:13 a.m., Bowel Movement: None 4/25/25 at 9:00 p.m., Bowel Movement: None 4/25/25 at 9:03 p.m., Bowel Movement: Small 4/28/25 at 2:46 p.m., Bowel Movement: Large On 4/28/25 at 4:20 p.m., R7 was observed lying in bed and reported experiencing ongoing issues with constipation. He stated that it was not unusual for him to go more than three days without a bowel movement. R7 reported not being aware of any constipation medications administered by nursing staff and denied receiving education or encouragement to increase fluid intake. R7 stated that earlier in the day a nurse had to perform digital stool removal to relieve impaction. On 4/29/25 at 10:11 a.m., R7 was again observed in bed and stated that no stool softeners had been offered on 4/28 or 4/29. R7 expressed willingness to take a stool softener if it had been offered, noting that it may have helped alleviate his symptoms. On 4/29/25 at 3:17 p.m., licensed practical nurse (LPN)-C stated the facility had a bowel protocol and observed LPN-C to look through binders at the nursing station for the protocol. LPN-C asked registered nurse (RN)-C, known as the clinical coordinator, for the bowel protocol and RN-C stated she was not sure what the exact information was for the bowel protocol or standing orders or where the bowel interventions were located. RN-C stated if a resident had not had a bowel movement for three days prune juice would be initiated, and she knew that from nursing judgment. LPN-C was then observed and asked RN-A where the facility bowel protocol was located. RN-A stated she was taught on day two of no bowel movement the resident was put on nursing's radar and stated on day three she would offer a suppository or Senna (oral stool softener). RN-A stated the overnight nurse ran a list with the residents that had not had a bowel movement for three days and stated nursing was expected to look at the resident orders and if the resident had PRN medications for constipation, she would offer those medications to residents or initiate standing orders with the stool softeners. RN-A confirmed the standing orders included a variety of medication options for constipation and did not have specific directions. On 4/30/25 at 7:19 a.m., LPN-A stated the night shift prints a bowel movement list from the electronic medical record (EMR), and the list indicated residents who have not had a bowel movement for three days. LPN-A stated if a resident was on the bowel movement list the residents PRN orders for constipation were initiated. LPN-A further stated on day three of no bowel movement she would administer a suppository for a resident if they did not have PRN orders. LPN-A stated there was previously a bowel protocol to follow and now the residents have PRN orders on the electronic medical record to follow. LPN-A confirmed on 4/28/25, she digitally removed R7's hard impacted stool. LPN-A stated R7 had a PRN Miralax order for constipation, and confirmed she did not offer R7 Miralax. LPN-A stated having specific directions would be helpful to know the steps and what to administer for residents experiencing constipation. On 4/30/25 at 8:47 a.m., the director of nursing (DON) stated nursing was expected to monitor resident bowel movements every shift and use nursing judgment for offering medications for constipation. The DON stated nursing was expected to offer constipation relieving measures on the third day of a resident not having a bowel movement. The DON confirmed the standing orders were not specific on what day to initiate the standing orders. The DON stated nursing staff were expected to document bowel movements and interventions implemented for constipation. The DON confirmed R7 did not have a bowel movement from 4/21/25-4/24/25, and no constipation relieving interventions were implemented or documented. The DON stated on 4/28/25, staff were expected to have implemented other measures besides digital bowel removal or documentation of resident education. The DON confirmed the facility did not have a policy on constipation. Facility document titled Standing Orders for Skilled Nursing Facilities dated 4/22, indicated Bowel: Constipation (Perform steps Sequential) Consider rectal check to determine if impaction is present Encourage 2,000 ml (milliliter) daily fluid unless contraindicated Consult nutrition services for dietary recommendations Senna 2 tables PO (by mouth) at HS (bedtime) prn Reattempt Senna or Bisacodyl if no results after 24 hours and notify provider Monitor and record results from treatment

Based on interview and document review, the facility failed to ensure written notice of transfer was provided to the resident and/or resident representative for 1 of 2 residents (R44) reviewed for hospitalization . Findings include: R44's facesheet, included diagnoses of Alzheimer's disease, retention of urine, and urinary tract infection. R44's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R44's impaired cognition R44 was usually understood and could usually understand. R44 did not walk and was dependent on staff for most activities of daily living (ADL). R44's care plan with revised date of 7/30/24, indicated indwelling catheter related to urinary retention; staff were to manage the catheter to prevent UTI and obstruction in drainage. During an interview on 8/4/24 at 1:33 p.m., family member (FM)-E stated R44 had been hospitalized overnight in April 2024 for a urinary tract infection. FM-E did not recall receiving a written notice of transfer. This document was not seen in the scanned documents section of the electronic medical record (EMR). Progress note dated 4/18/24 at 5:00 a.m., indicated R44 was experiencing abdominal distention and discomfort, a fever, and his urinary catheter was not draining well. An okay was received by the hospice provider to send R44 to the emergency room . Progress note dated 4/19/24 at 2:55 p.m., indicated R44 was still in the hospital. Progress note dated 4/21/24 at 6:05 p.m., indicated R44 would be returning to the facility that evening. During an interview on 8/5/24 at 4:34 p.m., registered nurse (RN)-A provided transfer documentation for R44's April hospitalization , but the documentation did not include written notice of transfer to be given to the resident representative and the ombudsman. During an interview on 8/6/24 at 10:31 a.m., RN-A stated she did not know who in the facility completed a written notice of transfer when a resident was transferred to the hospital, adding nursing did not. During an interview on 8/06/24 at 10:50 a.m., the director of nursing stated nursing did not complete a written notice of transfer when a resident was transferred to the hospital and thought social services might do that. During an interview on 8/06/24 at 11:04 a.m., resident and family liaison (RFL)-B stated social services did not complete a written notification of transfer form of any kind and thought nursing might do that. RFL-B stated she did inform the ombudsman each month of residents who were transferred. During an interview on 8/6/24, at 11:45 a.m., the DON stated they facility did not have a policy on written notice of transfer.

Based on observation, interview and document review, the facility failed to implement therapy recommendations in a timely manner to maintain strength and mobility for 1 of 1 resident (R41) reviewed for range of motion (ROM). Findings include: R41's face sheet, indicated diagnoses of Parkinson's disease, age-related physical debility, and weakness. R41's admission Minimum Data Set (MDS) assessment dated [DATE], identified no cognitive impairment, the ability to understand and be understood, no rejection of care, limited range of motion on both sides of upper and lower extremities, and physical assist with personal hygiene, bed mobility, dressing, toilet use, and transfers. R41's care plan dated 6/26/2024 and revised 8/5/2024, indicated staff were to assist resident with ROM (range of motion) to bilateral upper and lower extremities as resident tolerates and resident totally dependent on staff for all transfers and mobility. R41's PT (physical therapy) Therapist Evaluation Summary dated 6/11/2024, indicated staff were to assist R41 with upper and lower body passive range of motion programs daily and to see attachments for passive stretches recommended. Also instructed to provide slow and gentle stretches during range of motion and to ensure R41's tolerance with verbal and visual pain assessments. R41's OT (occupational therapy) Therapist Evaluation Summary dated 6/12/2024, indicated a recommendation of bilateral upper extremity PROM (passive range of motion) for staff to perform daily to prevent worsening muscle contractures. R41's Kardex (used by nursing assistance's) dated 8/5/2024, failed to include any reference to PROM exercises. R41's orders dated 8/5/2024, failed to include any reference to PROM exercises. On 8/5/2024 at 10:26 a.m., R41 was observed in his wheelchair with arms bent up towards his chest. R41 stated staff had not completed exercises with him and he would have liked them to do exercises and stretching with him. On 8/5/2024 at 3:33 p.m., registered nurse (RN)-C stated the PROM exercises were missed when therapy recommended them and the recommendations for R41 had not been started. RN-C further stated that going forward the recommendations will be implemented right away. On 8/6/2024 at 8:40 a.m., occupational therapist (OT)-F stated the therapy department gave the recommendation to nursing on 6/12/2024. OT-F further stated the lack of PROM did not cause change in functional ability for R41 due to already severely impaired active movement and functional control of extremities. OT-F also stated R41 would still benefit from implementation of the PROM recommendations. On 8/6/2024 at 10:45 a.m., director of nursing (DON) stated she would expect PROM recommendations to be implemented timely to prevent decline in functional abilities. A policy titled Prevention of Decline in Range of Motion revised 1/2024, stated the following: a. Based on the comprehensive assessment, the facility will provide interventions, exercises and/or therapy to maintain or improve range of motion. b. The facility will provide treatment and care in accordance with professional standards of practice. This includes, but is not limited to: assistance as needed (active assisted, passive, and supervision).

Based on observation, interview and record review, the facility failed to ensure doses of a controlled substance were stored in a manner to reduce the risk of theft and/or diversion in 1 of 1 refrigerators observed for medication storage. Findings include: During an observation on 8/6/24 at 7:52 a.m., observed two nurses, licensed practical nurse (LPN)-A and registered nurse (RN)-B perform shift change narcotic reconciliation in a medication cart at the Mainstreet nurses station. At the end of the narcotic count, LPN-A stated they also needed to count the narcotics in the refrigerator. During an observation of the small dorm-size refrigerator in the locked medication room, an opened, multi-dose bottle of lorazepam (a medication to relieve anxiety) concentrate, 2 mg/ml (milligrams per milliliter) was observed on a shelf on the door of the refrigerator - not in a separately locked, permanently affixed compartment in the refrigerator. During an interview on 8/6/24 at 12:38 p.m., the director of nursing (DON) was informed of the observation and stated she was unaware lorazepam, a schedule IV medication, needed to be in a separately locked, permanently affixed compartment in the refrigerator. Facility Medication Storage policy dated 7/24, indicated if a medication was supplied in a unit-dose system, schedule III-IV medications could be stored in trays with other medications.

Based on interview, and record review, the facility failed to inform the resident or representative of the right to not sign the arbitration agreement as a condition of admission or as a requirement to continue to receive care at the facility. Findings include: An Admission Agreement, undated, included a portion titled Arbitration Agreement Clause that included subsections including contractual and/or property damage disputes, personal injury, wrongful death or medical malpractice, exclusion from arbitration, right to legal counsel, location of arbitration, time limitation for arbitration, limitation on damages and allocation of costs and limited resident right to rescind this binding agreement clause. The next page of the admission agreement included Signatures of Parties to Agreement for the entire document. Two pages behind the signature page is a Notice of Right to Rescind Binding Arbitration Clause informing they have a right to rescind the agreement regarding binding arbitration within 30 days and must send the notice certified mail or hand deliver no later than 30 days from admission agreement signature. The Admission Agreement and Arbitration Agreement Clause did not include a section to inform the resident or representative of the right to not sign the arbitration agreement. During interview on 8/5/24 at 12:38 p.m., the director of nursing stated no residents or representatives have signed the arbitration agreement at the facility and no residents have filed a dispute. During interview on 8/5/24 at 1:59 p.m., admissions coordinator (AC)-A indicated all the residents in the facility have signed the arbitration agreement which is part of the admission agreement. They do not require separate signatures. AC-A stated none of the residents or families have submitted the Notice of Right to Rescind. AC-A indicated she gives a verbal explanation of arbitration prior to the resident or representative signing the admission agreement but does not inform them of the right to not sign the Arbitration Agreement section. During interview on 8/5/24 at 2:00 p.m., the administrator stated only one signature is required for admission which includes the arbitration agreement also and if the resident doesn't want to agree to arbitration, they are required to submit the Notice of Right to Rescind Binding Arbitration Clause. The administrator indicated there is an assumption that could be made since the admission agreement is required for admission. During interview on 8/5/24 at 4:14 p.m., the administrator confirmed the current agreement does not include written documentation that arbitration is not a requirement of admission to the facility or continuation of care.

Based on observation and interview, the facility failed to follow proper procedures to prevent the spread of infection when emptying a urinary drainage bag for 1 of 1 resident (R44) observed for infection control practices. Findings include: R44's facesheet, included diagnoses of Alzheimer's disease, retention of urine, and urinary tract infection (UTI). R44's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R44's was cognitively impaired. R44 was usually understood and could usually understand. R44 did not walk and was dependent on staff for most activities of daily living (ADL). Physician orders dated 11/14/23, included monitoring Foley (a type of indwelling catheter) output each shift. R44's care plan with revised date of 7/30/24, indicated indwelling catheter related to urinary retention; staff were to manage the catheter to prevent UTI. The drainage bag was to be emptied every shift. During an interview on 8/4/24 at 1:28 p.m., family member (FM)-E stated R44 had a urinary catheter in place because, His urine doesn't come out. FM-E stated R44 had a bad UTI in April 2024 and was hospitalized . During an observation on 8/5/24 at 1:24 p.m., in R44's room, nursing assistants (NA)-A and NA-B moved R44 from his wheelchair to the toilet via an EZ-stand (a device that helps someone stand up from a chair). While R44 sat on the toilet, NA-A set the urinary drainage bag directly on the floor next to the toilet and emptied the urine from the urinary drainage bag into a urinal. During an interview on 8/5/24 at 1:36 p.m., NA-A was informed of the observation of the urinary drainage bag on the floor. NA-A stated she had to do that to get the clamp open on the port to drain out the urine. NA-A indicated it could cause bacteria to enter R44's urinary drainage system and stated, He's had infections. During an interview on 8/5/24 at 2:47 p.m., registered nurse (RN)-A indicated, That's a big infection control issue and stated she would have expected the urinary drainage bag to be hooked onto something when emptying it. During an interview on 8/6/24 at 10:50 a.m., the director of nursing (DON) was informed of the observation of a NA setting a urinary drainage bag on the floor of the bathroom to empty it and acknowledged that was not the proper way to empty the bag and could contribute to a UTI. Facility Catheter Care policy dated 7/3/23, indicated it was the policy of the facility to ensure residents with indwelling catheters received appropriate catheter care when an indwelling catheter was in use; to ensure the drainage bag was not touching floor surfaces unless barrier was provided.

Based on observation, interview, and document review, the facility failed to ensure nurse staff postings were accurate and up-to-date on a daily basis. This had the potential to affect all 50 residents who resided in the facility and/or any visitors who may have wished to view the information. Findings include: During interview on 8/4/24 at 12:00 p.m., trained medication assistant indicated he was called in to work this morning to assist, as a nurse on the unit had called in for the shift. During observation on 8/4/24, at 7:06 p.m., staff posting dated Friday 8/2/24 was posted on a back wall by the reception desk. The form included date, census, registered nurse (RN), licensed practice nurse (LPN's), trained medication assistant (TMA) and nursing assistant (NA) for each scheduled shift with total hours all listed at 8 hours. Total hours was present for each shift. During observation and interview on 8/5/24 at 8:33 a.m., the receptionist indicated she is not responsible for changing the posted staffing for the day. The staff posting remained dated as Friday 8/2/24. During interview on 8/5/24 at 8:36 a.m., the scheduler (S)-D indicated on Friday she will post the Saturday and Sunday postings behind Friday. S-D indicated she frequently comes in on Monday and Friday remains the posted staff hours. S-D stated she will review the working schedules staff use to make any corrections that occurred over the weekends to staffing such as call ins. S-D confirmed a licensed practical nurse (LPN) called in for Sunday 8/5/24 and a trained medication assistant (TMA) replaced the LPN position. S-D stated she will make the necessary changes to the posted hours usually after the nursing posted hours are taken down as that is when she discovers the call ins which sometimes requires changes. S-D is unsure who is responsible for ensuring the correct date posting is posted but thought it would be the charge nurse who is working over the weekend. S-D added sometimes the charge nurse is on-call versus being in the building though. During observation and interview on 8/5/24 at 8:45 a.m., the director of nursing (DON) confirmed the posted hours remained on Friday 8/2/24. The DON indicated there is always a charge nurse in the building on weekends. A policy and procedure on nursing staffing posts was requested but none received.

Based on interview and document review, the facility failed to ensure allegations of potential abuse were immediately reported to the State Agency (SA) no later than 2 hours after knowledge of the allegation of abuse for 1 of 3 residents (R1) reviewed for abuse. Findings include: R1 quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had moderate cognitive impairment and diagnoses which included: dementia, psychotic disorder, seizure disorder, depression, and hypertension. Indicated R1 required maximum assistance for hygiene and bed mobility. A review of the facility SA report revealed resident indicated to LPN-A she was sexually assaulted on 5/22/24 at 1:35 p.m. SA report identified staff became aware of the incident on 5/22/24 at 4:11 p.m., and was reported to the administrator on 5/22/24 at 4:20 p.m. SA report was submitted on 522/24 at 5:46 p.m. The SA report was made four hours and 11 minutes after resident reported the sexual assault to staff. The report was submitted to the SA two hours and 11 minutes past the two hour required time frame. A review of the progress note dated 5/22/24 at 1:35 p.m., revealed R1 informed LPN-A on 5/22/24, about being sexually assaulted the previous night. A review of the progress note dated 5/22/24 at 4:00 p.m., revealed that the registered nurse (RN)-A reported to the director of nursing (DON), administrator and social services that R1 reported being sexually assaulted. During an interview on 5/29/24 at 9:57 a.m., LPN-A stated she was not aware allegations of abuse were to be reported immediately. LPN-A indicated R1 had a history of talking about her past sexual trauma and had been more delusional since recent medication changes had taken place. R1 was talking about snow and Christmas at the same time she alleged she had been sexually abused the previous night. LPN-A stated she received education about the requirement to report accusations of abuse immediately after the 5/22/24, allegation of abuse was reported to her. During an interview on 5/29/24 at 9:40 a.m., RN-A stated she became aware of the allegation of abuse on 5/22/24, when she reviewed progress notes LPN-A had entered on 5/22/24 at 1:35 p.m. RN-A indicated she was under the impression R1 was reporting past sexual history when LPN-A informed her about the allegation earlier in the shift. RN-A stated R1 often discussed her past sexual abuse experience. RN-A indicated she contacted the director of nursing (DON) immediately when she realized it was a current allegation of abuse. During an interview on 5/29/24 at 12:14 p.m., DON verified the SA report was submitted late due to the lack of communication. DON stated the expectation was staff would report the incident immediately to ensure resident safety. During an interview on 5/29/24 at 1:00 p.m., the administrator verified the SA report was submitted late. The administrator expected staff to notify the administrator immediately. The administrator stated staff had been educated since 5/22/24, to report to the administrator immediately all allegations of abuse. Review of the facility policy titled Abuse Prohibition Plan and Vulnerable Adult Incident Reporting dated 9/23/21, identified sexual abuse was non-consensual sexual contact of any type with a resident. Generally, sexual contact was nonconsensual if the resident either: appeared to want the contact to occur, but lacked the cognitive ability to consent; or did not want the contact to occur. Other examples of non-consensual sexual contact may include but were not limited to, situations where a resident was sedated, temporarily unconscious, or in a coma. Review of the facility policy titled Abuse Policy, undated, identified the facility would ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, that may constitute reasonable suspicion of a crime were reported immediately, but not later than two hours after the allegation was made, if the events that caused the allegation involved abuse or result in serious bodily injury.

Based on observation, interview, and document review, the facility failed to ensure medications were labeled with current, accurate physician orders and in accordance with the standard of care to reduce the risk of adverse events (i.e., errors) for 1 of 7 residents (R40) observed to receive medication during the survey. Findings include: During observation on [DATE] at 11:55 a.m., licensed practical nurse (LPN)-A prepared an Insulin Aspart pen 100 unit/mL for R40 from a mobile medication cart. The label instructed to subcutaneously inject 6 units of Insulin Aspart 100 units/mL twice daily before breakfast and lunch and to hold if blood sugar was less than 150. LPN-A administered the Insulin Aspart to the resident and returned the insulin pen to the cart. Review of the electronic medical record had an order dated [DATE] which directed staff to inject Insulin Aspart 100 unit/mL solution injection subcutaneously (0.06 mL/6 unit) twice a day at breakfast and lunch and to hold if blood sugar less than 120. The electronic medical record also had an order dated [DATE] which directed staff to inject Insulin Aspart 100 unit/mL solution injection subcutaneously (0.04 mL/4 unit) daily at supper and to hold insulin if blood sugar less than 120. During interview on [DATE] at 12:42 p.m., LPN-B stated they would verify the order and put a sticker on the medication label to indicate the order changed or remove medication from the cart and ask pharmacy for a new label if they discovered a medication label did not match current orders. LPN-B stated they would report the discrepancy to the next shift. LPN-B verified the label on R40's Insulin Aspart pen instructed to hold the insulin if R40's blood sugars was less than 150 and R40's MAR instructed to hold the insulin if blood sugar was less than 120. LPN-B stated the label did not describe R40's order to receive 4 units of Insulin Aspart 100 unit/mL at supper time either. During observation and interview of medication cart on [DATE] at 4:12 p.m., TMA-A verified the medication cart held expired Tylenol suppositories 650 mg for R40 with expiration date of [DATE]. TMA-A verified Tylenol suppositories were supposed to be stored in a refrigerator as indicated on its label. During interview on [DATE] at 5:11 p.m., the director of nursing (DON) stated if a medication order changed, staff should put a change of direction sticker on the medication label. The DON stated they expected staff to have placed a sticker on the insulin pen and follow the order in the MAR or clarify the order. The DON stated the risk of the insulin pen label and MAR not matching depended on the dosing of the insulin given or held. The DON stated they expected medications to be discarded immediately if expired and stored according to appropriate guidelines. The facility's policy Medication Labels dated ,d+[DATE], indicated if the physician's direction for use changed or the label was inaccurate, the nurse may place a direction change-refer to chart label on the container indicating there was a change in directions for use. The policy directed the medication nurse to check the resident's MAR or the physician's order for current information and staff to inform the pharmacy prior to the next refill of the prescription so the new container shows an accurate label. The medication storage policy was requested but not provided.

Based on observation, interview, and document review, the facility failed to provide adequate supervision for 1 of 1 resident (R1), who was at risk for elopement. R1 unknowing left a secured memory care unit and was found outside near the street which resulted in an immediate jeopardy. The facility implemented corrective action and is being issued at past non-compliance. The IJ began on 5/22/23 when R1 exited the building through the screen porch double doors of the secured memory care unit unsupervised. The facility's administrator, director of nursing (DON), and registered nurse clinical coordinator (RCC) were notified of the IJ at 5:37 p.m. on 5/31/23. The facility implemented immediate corrective action on 5/23/23, prior to the start of the survey and was issued as past non-compliance (PNC). Findings include: R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified diagnoses including dementia (brain disease causing memory loss) and anxiety (condition causing persistent worry or fear). R1 had severely impaired cognition, disorganized thinking and inability to recall recent events. Furthermore, the MDS indicated R1 exhibited wandering behaviors that occurred less than daily but did not identify whether behaviors were significant enough to place R1 at significant risk for getting into a dangerous place. R1 required set-up to limited assistance of one staff to meet activities of daily living (ADLs), was ambulatory without use of assistive devices, but required limited assistance of one staff when ambulating off unit. R1's care plan, dated 1/17/23, indicated R1 was at risk for falls; had impaired cognition with memory loss, decreased attention span, and disorganized thinking. Care plan indicated R1 exhibited wandering and exit-seeking behaviors, and had a history of elopement Care plan interventions for R1 included staff would observe/monitor for changes in behavior, would monitor wandering activity, and would be always supervised when off the unit to reduce the risk of elopement. R1's physician orders, printed on 5/31/23, indicated staff to monitor R1's behaviors related to anxiety and wandering, to determine effectiveness of psychoactive medications (Risperidone, Buspar, and Citalopram). Behavioral assessment, reviewed from 5/17/23-5/31/23, indicated R1 displayed behaviors including being socially offensive towards others, was physically aggressive towards others, refused cares, wandered/paced, hoarding dirty clothing and napkins, rummaging, and going in and out of other residents' rooms without permission. During period reviewed, R1 exhibited behaviors 15 times over course of all shifts, staff provided interventions, R1's behaviors remained unchanged. Elopement risk assessment, dated 1/4/23, indicated R1 was at risk for elopement based upon factors including having a predisposing disease, was ambulatory, had intermittent confusion, took psychoactive medications, had a history of elopement in past 6 months. A fall risk assessment, completed on 3/31/23 and again on 4/16/23, indicated R1 was at risk for falls. The fall risk assessment identified R1 had two falls in past 2 months. Facility incident report, dated 5/22/23 at 8:01 p.m., indicated at approximately 4:45 p.m., licensed practical nurse (LPN)-Z returned to unit following break at 4:45 p.m., observed other staff bringing residents to dining area for dinner meal, heard staff member calling R1's name looking for her. LPN-Z began looking for R1 as well, observed the code keypad on wall next to double doors, marked Screen Porch, had a green colored light, indicating doors were not secured. LPN-Z indicated she was able to get through double doors of Screen Porch, held open both doors to wait for audible alarm to sound, which LPN observed audible alarm did not sound for either door checked. LPN-Z indicated exit from Screen Porch doors led outside of gated area, which R1 would have had access to facility yard, sidewalk, and road. LPN-Z returned inside facility, manually secured with keys both doors of the Screen Porch, ambulated towards front of unit, noted R1 being returned to unit per SW-A and administrator. Facility incident report indicated elopement having occurred on 5/22/23 between approximately 5-5:30 p.m. During a phone interview, on 5/30/23 at 4:32 p.m. family member (FM)-E indicated R1's cognition was poor, required staff assistance and reminders to meet ADL needs, required 1 staff to accompany R1 if going off memory care unit if R1 goes off unit. FM-E reported awareness of R1 displaying behaviors of anxiety, wandering, and exit-seeking; stated prior to recent elopement incident, R1 had attempted to elope one other time approximately 2 years ago. FM-E indicated she had been notified per staff on 5/22/23, R1 had eloped earlier that day from secure memory unit of facility through an unlocked door found, R1 was found outside in front of facility building per staff and was brought back to memory care unit per administrator. FM-E indicated nurse who contacted her informed her following 5/22/23 elopement incident, R1 was placed on 15-minute visual checks per staff and staff had ensured all doors to memory unit were now secured. During an interview, on 5/31/23 at 10:13 a.m., nursing assistant (NA)-A indicated was familiar with R1's care needs. NA-A stated R1 was mainly independent with ADLs, required constant reminders from staff throughout the day to complete ADL tasks, occasionally refused cares, wandered, and tried to open doors on unit frequently, required 1 staff to accompany R1 anytime when going off unit. NA-A stated staff relied upon secured system to ensure doors on unit were locked appropriately. NA-A indicated awareness of R1's care plan needs when wandering or exit-seeking, which included re-direction per staff, engage R1 with an activity. NA-A stated she was informed of R1's recent elopement incident, had occurred on 5/22/23 while NA-A was working in another unit of facility. NA-A reported she had been informed by other staff that R1 was found outside per administrator, unaware of how incident occurred as all doors on memory unit should have been secured. NA-A indicated R1 had an incident of elopement one other time, approximately 1 year ago. NA-A stated since R1's recent elopement on 5/22/23, staff were to check on R1's whereabouts every 15-minutes and all staff needed to complete two courses of elopement re-training online through Relias. While observed, on 5/31/23 at 10:33 a.m., it was noted all four doors to memory unit were secured, visualization of code keypad next to doors were all colored red, indicative of being locked. All doors to memory unit remained secured when tried to manually open. During an interview, on 5/31/23 at 10:48 a.m., maintenance (M)-A indicated maintenance staff were available to take care of maintenance issues, even after business hours, staff aware maintenance could be contacted with emergencies 24 hours per day, 7 days per week; if maintenance concerns arose non-emergently, staff aware to send work order through the TELS computer system. M-A reported doors to memory care unit were secured doors, held closed per magnetic hold, managed by Summit Fire. M-A indicated all secured doors have a code keypad on wall next to doors, required a certain code to unlock secured doors. M-A stated code keypad next to secured doors had a colored button to indicate whether the doors were secured, if button was red in color the doors were secured, if button was green in color the doors were unsecured. M-A reported if secured doors became unlocked, not only would the code keypad button turn green in color, but staff would then need to secure door manually with a key. M-A indicated if a power outage occurs, power outage will automatically unsecure doors to facility, which had occurred recently on 5/21/23, staff aware to lock all doors manually with key to ensure security of doors. M-A reported maintenance staff did not routinely check secured doors, only if a concern was brought to their attention or upon yearly inspection, stated there had never been a problem to check secured doors routinely until recently when a resident had eloped. M-A indicated awareness of an unsecured door on memory unit, Screen Porch doors affected, as a staff member noticed a button on code keypad next to doors on wall was colored green, indicative of doors being unsecured. M-A stated staff notified him of incident right away, staff had manually secured doors by locking them with key, unsecured doors were addressed per maintenance staff the next morning following the elopement incident and ensured to be working appropriately. Since recent elopement incident, on 5/22/23, M-A reported maintenance staff would check and keep a record log to ensure secured doors were working appropriately following a power outage. Maintenance was unsure why the door was not secured, but implemented routing door checks after a power outage and nursing staff to check them on each shift. While interviewed, on 5/31/23 at 11:09 a.m., licensed practical nurse (LPN)-A indicated she had worked on and off at facility for approximately 1 year, was familiar with R1's care needs. LPN-A indicated R1 was mainly independent, needed reminders to complete ADLs, shuffled feet when ambulating and required staff to accompany R1 when off unit for safety. LPN-A reported R1 was known to wander and exit-seek, exhibited sundowning behaviors daily around 3:00 p.m., where R1 became more anxious, confused, agitated, and would occasionally yell at staff and refuse cares. LPN-A reported R1 was at high risk for elopement due to her behaviors and elopement risk assessment completed. LPN-A reported awareness of R1's elopement incident that had occurred on 5/22/23. LPN-A reported when doors became unsecured, a clicking sound could be heard, the button on the code keypad on wall next to doors turned green indicating doors were unsecured. LPN-A indicated awareness if doors on memory care unit were unsecured, staff had to manually lock all the doors with a key, key located at nurse's station in the locked medication cart and notify maintenance. Since R1's 5/22/23 elopement incident, LPN-A also reported staff must visually check on R1 every 15-minutes. During an interview, on 5/31/23 at 11:53 a.m., social services (SS)-A indicated involvement in R1's 5/22/23 elopement incident. SS-A stated when she was leaving work for the day at approximately 4:50 p.m., she had gotten in her car, left employee parking lot, drove around to front of facility building, saw R1 on sidewalk about to approach street area at approximately 4:55 p.m. SS-A reported she immediately stopped car, got out of car, ran over to R1's location to keep R1 from crossing street. SS-A indicated she attempted to assist R1 back to facility, but R1 was resistive, R1 stated she needed to go home to find her kids. SS-A stated she had her cell phone with her, contacted administrator to inform of situation and need for assistance. Administrator immediately responded to assist with R1, administrator conversed with R1, administrator and SS-A assisted R1 back to facility at approximately 5:00 p.m. SS-A reported no injuries noted to R1 upon brief visualization following elopement incident. SS-A initially stated it was unknown how R1 eloped from secured memory unit, through investigation findings, staff determined double doors of Screen Porch had been unsecured, as licensed nurse on unit that day noticed button on code keypad code next to doors was colored in green, indicative of unsecured doors. SS-A reported Screen Porch doors were located outside of the memory care unit's fenced area and if R1 had used those doors to leave facility, R1 would have been able to ambulate on sidewalk or through the paved parking lot towards street in front of facility. SS-A indicated R1 was at risk for elopement as had left secured memory care unit one other time approximately 1 year ago. During an observation on 5/31/23 at 12:48 p.m., together with SS-A and Occupational Therapy (OT)-A, walked the route R1 had approximately taken when left the facility, OT-A measured approximately distance using a measuring wheel. R1 ambulated on uneven terrain including grass, a pavement, rock/sand debris, potholes, a parking lot containing construction equipment, onto a sidewalk that led in front of facility towards a busy street. SS-A identified approximate location site on sidewalk where she had found R1 standing, which was approximately 2 ft away from stepping into a busy street. Total distance measured per OT-A using measuring wheel was 186 yards. While observed, on 5/31/23 at 3:53 p.m., R1 was noted sitting at table in the living/common room area of secured memory unit, R1 was looking at a magazine provided per staff, R1 appeared calm in manner at time. Nursing staff present at nursing station, R1 within nursing staff view. Activity staff member observed occasionally interacting with R1 and other residents in living/common room area. During an interview, on 5/31/23 at 4:50 p.m., administrator indicated involvement with R1's 5/22/23 elopement incident, stated he received a phone call from SS-A at approximately 4:55 p.m., SS-A found R1 unsupervised on sidewalk in front of facility entrance, SS-A requested additional staff assistance to escort R1 back to facility, as R1 was being resistive. Administrator stated he immediately responded to SS-A's request for additional assistance, and able to converse with R1, administrator and SS-A assisted R1 back to facility's secured memory unit at approximately 5:00 p.m. Administrator indicated unawareness of how R1 eloped from secured memory unit, stated he initially believed secured doors to memory unit became unsecured following a power outage on 5/21/23. Administrator stated he had contacted the night nurse who had worked following power outage, night nurse had stated she had checked all doors on memory care unit and all doors were secured. Administrator reported investigation findings of R1's 5/22/23 elopement incident indicated staff had last visualized R1 in memory care unit on 5/22/23 at approximately 4:30-4:45 p.m. as staff were escorting other residents to dining area, staff realized R1 was not present in dining room. Administrator indicated staff in memory care unit immediately began unit room searches looking for R1 and calling out R1's name, LPN-Z working on unit that day noticed the Screen Porch doors button on code keypad on wall next to doors were colored green, indicative of unsecured doors. Administrator stated a staff member was about to leave memory care unit to go outside to look for R1, but administrator and SS-A were returning to memory care unit with R1. Administrator reported R1 had been out of facility unsupervised for no more than 15 minutes. Administrator indicated memory care unit relied on a magnetic-alarm system to ensure security of all doors on unit. Administrator further stated staff should have been trained at time of hire and/or orientation to unit floor on each resident's care plan and maintenance concern process, including what to do if a power outage occurs, staff should have received education to check all secured doors to memory unit as was expected to be performed daily on night shift. Administrator verified R1 should not have been off memory care unit unsupervised. Facility policy, titled Resident Elopement/Resident Missing, reviewed 3/22/23, consisted of all staff responsibility to prevent any resident who attempts to elope. The PNC IJ began on 5/22/23, was removed on 5/23/23, and verified the facility implemented the following actions; -15-minute safety checks for R1 - placed a small picture of R1 behind each nurse's station and at front desk to alert staff if R1 seen outside of secure memory care unit -physician evaluation of R1 to rule out any medical concerns and to further evaluate mental health condition, and medication changes made -created sign off sheets to ensure all doors were secured on memory care unit and required two staff signatures at each change of shift daily -staff completed re-education on elopement.

Based on observation, interview and document review, the facility failed to communicate a change in the plan of care to oncoming staff with resident falling again and fracturing a hip for 1 of 3 residents (R1) reviewed for falls. Findings include: R1's diagnosis list dated 8/6/21, indicated R1 had diagnoses of Alzheimer's disease, polyneuropathy (damage to the nerves located outside of the brain and spinal cord that often causes weakness, numbness, and pain), and repeated falls. R1's Associated Clinic of Psychology (ACP) note dated 1/14/21, indicated R1 had poor ability to retain information because of her cognitive impairment. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was severely cognitively impaired and required limited assistance or supervision (1 person) with bed mobility, transfers, locomotion on/off unit, dressing, and toileting; R1 was independent with eating but required extensive assistance with personal hygiene. R1's MDS indicated she had one fall with no injury and one fall with major injury since admission. R1's fall care plan was initiated on 3/25/21 and revised on 4/13/21. R1's care plan dated 4/13/21, indicated R1 was a fall risk related to her unsteady gait and interventions included educating her about safe ambulation, encouraging independence, and updating the plan of care with changes as needed. Since 4/13/21, R1 had four falls without revision of her care plan. * The incident report dated 5/9/21, indicated R1 was found on floor in her room with her walker at the other end of room. The intervention was to teach resident to always use her walker and yet also noted R1 was impulsive and lacked an ability to understand. R1's record lacked documentation her care plan was updated. * The incident report dated 5/24/21, indicated R1 was found on the bathroom floor and was noted to be mentally unable to follow directions. No interventions were identified. R1's record lacked documentation her care plan was updated. * The incident report dated 7/23/21, at 8:30 a.m. indicated R1 was found on bathroom floor at 5:30 a.m. and was wet with urine; R1 suffered a blow to the back of her head resulting in a hematoma and behavioral changes. Intervention was continue to monitor. R1's record lacked documentation her care plan was updated. * The incident report dated 7/23/21, at 10:55 a.m. indicated R1 fell again in the doorway of her room, suffering a fractured hip. Intervention was x-ray - one on one right now. R1's care plan was updated on 8/5/21 (13 days post-fall), around 6:30 p.m. to include an assist of two with transfers, use of EZ lift, and removing walker from her room. R1's Neurological Assessment worksheet dated 7/23/21, indicated neurological checks were completed at 5:30 a.m., 5:45 a.m., 6:00 a.m., 7:00 a.m., 8:00 a.m., and 10 a.m The record lacked indication of neurological checks being completed after R1's second fall and head strike at 10:30 a.m R1's progress note (PN) dated 7/23/21, at 8:12 a.m. noted R 1 was found on the floor in urine with a large hematoma to the back of her head. Assessments included neurological assessment and the identified intervention was continue to observe. R1's PN dated 7/23/21, at 11:09 a.m. indicated R1 fell and hit the back of her head again against the door frame; interventions were x-ray - one on one right now. R1's PN dated 7/23/21, at 7:04 p.m. indicated night staff notified registered nurse (RN)-A (clinical coordinator) of fall at 6:00 a.m. that R1 had fallen at 8:30 a.m. and night staff notified RN-A they contacted the provider at 7:30 a.m. and were instructed to monitor R1; but now R1 was very aggressive and not behaving normally. The PN indicated after 8:30 a.m. RN-A assessed R1 and noted R1 was unable to open her left eye and had a goose egg on the back of her head. The PN also indicated neurological checks suggested R1's condition was getting worse. The PN indicated R1 was able to standup with gait belt and assist of one. The PN indicated the provider evaluated R1 at 10:30 a.m. and shortly thereafter, R1 fell again and sustained a hip fracture; the family declined treatment for the hip fracture and radiological evaluation of head. The PN lacked indication of a change in interventions after the first or second fall. R1's PN dated 7/23/21, at 7:04 p.m. indicated R1 was admitted to hospice. The interdisciplinary team (IDT) note dated 7/23/21, noted R1 fell and had a bump on the back of her head; the note lacked any interventions. RN-A's email dated 7/23/21, at 6:29 p.m. indicated R1 now had a soft touch call light and was a two-person pivot transfer, she was signed up with hospice, she was to use a wheelchair, she was not to use a walker, and to remove the walker from her room. During an interview on 8/5/21, at 10:38 a.m., nursing assistant (NA)-C stated she worked on the day R1 fell (7/23/21) but did not witness any falls. NA-C stated when she came on that morning, R1 seemed normal and was walking independently with her walker. NA-C stated she heard R1 might have fallen overnight, but there were no changes in her care. After the second fall, NA-C stated R1 had a soft touch call light and now needed two people and a gait belt to be transferred; she no longer used a walker. During an interview on 8/5/21, at 1:14 p.m. NA-B stated she heard R1 fell before her day shift and when she arrived, she thought R1 was one was a little a groggy and she checked on her occasionally. NA-B stated there was no change in her plan of care and R1 got up for breakfast; she seemed okay and was moving around fine. NA-B stated after breakfast, she and NA-A started toileting rounds. NA-B stated she was coming out of another resident's room and saw R1 stumbling out without her walker, and she fell on her butt and hit her head on the door frame. NA-B stated NA-F and herself used a lift to put R1 in chair next to her room and brought her walker to her; RN-A and NA-A examined R1 and then or soon after they put her in a wheelchair. NA-B stated they had cards on the floor to tell NA what cares to use; there were no special interventions with R1 after the first fall. NA-B stated she was told to keep an eye on her but no specific direction. NA-B stated after the second fall, she was supposed to transfer with her walker but RN-A sent an e-mail that night saying R1 fractured her hip, and she was now to use a WC and a two-person pivot; she took her walker away the next day. NA-B was part of R1's care team that day. During an interview on 8/6/21, at 2:02 p.m. NA-F stated she was helping NA-B walking another resident and she saw R1 standing in her doorway without her walker. NA-F stated as she approached her, R1 [NAME]-tottered backward and hit her head on the corner of the doorway and slid to the floor. NA-F stated she heard R1 fell earlier and might have hurt her hip, but there were no changes in her care from previous days. After the second fall, NA-F stated she got a wheelchair and was told R1 should not walk anymore. During an interview on 8/6/21, at 3:00 p.m. RN-A stated she arrived at the facility between 8:30 a.m. and 9:00 a.m. and went to assess R1; R1's left eye was not opening, and she was dozing off but still yelling at people. RN-A stated she called the provider after IDT meeting because R1 seemed more sleepy, more aggressive, and her left eye was not opening; the provider ordered stat labs. RN-A stated R1 wanted to go to bed so one staff used a gait belt to get her up and used her walker to take her to the bathroom and then bed. RN-A stated the provider arrived and assessed R1 and while they were discussing next steps, staff yelled R1 had fallen again. RN-A verified the investigative report noted the plan of care was being followed at the time of the second fall; she noted the plan of care had not changed after the first fall as they were waiting on what the provider wanted to do. RN-A stated she asked staff to use a gait belt and assist R1 with her walker when ambulating. RN-A stated the care plan was not updated but she could update the nursing aide's cards. When asked if a root cause analysis was done, RN-A responded, sort of .yes/no; she explained staff completed the incident report information and it asked the questions relevant to falls. During an interview on 8/6/21, at 4:30 p.m. the director of nursing (DON) stated she was familiar in general about R1's fall but did not know any details. The DON stated the on-call provider instructed staff to monitor R1 and RN-A did everything possible that you could do at the time. The DON stated her expectation would be to follow the policy after a fall, including altering the plan of care; she stated the plan was changed after the second fall with fractured hip and R1 was placed in hospice. The DON stated, Whatever she [RN-A] did was the right thing to do [and] she didn't need to do more. During an interview on 8/6/21, at 4:46 p.m. the administrator stated she was part of the interdisciplinary team (IDT) meeting in the mornings when falls were discussed; she stated interventions are discussed in the IDT and they should be in the IDT notes. The administrator verified the IDT notes for the morning of 7/23/21, noted R1 fell but there were no interventions. During an interview on 8/6/21, at 6:37 p.m. RN-A stated when there is a change in the plan of care it is communicated: 1) verbally at shift-to-shift report; 2) updating the nursing aide cards; and 3) through e-mail communication. RN-A sated she sent an e-mail that night (7/23/21 after the second fall) to staff but did not change the cards that day. RN-A verified she was not present at the shift-to-shift report on 7/23/21 for nights and days. During an interview on 8/7/21, at 3:38 a.m. trained medication aide (TMA)-A stated on 7/23/21, he and a NA were doing toileting rounds on the secured unit when he came upon R1 in her doorway in urine. TMA-A stated he called licensed practical nurse (LPN)-D, who was on the second-floor long-term care unit; after LPN-D assessed R1, they used a lift to get R1 in a wheelchair. TMA-A stated R1 hit the back of her head and it was bruised; he stated there was not a change in her care. During an interview on 8/7/21, at 3:55 a.m. LPN-D stated she was called to the secured unit because R1 had fallen. LPN-D stated she found R1 siting in the doorway to her room and she checked her over and initiated neurological checks, which were for 15 minutes times two, then every 30 minutes times two, and then every hour times two. LPN-D stated this was protocol after a fall. LPN-D stated there was not a change in her plan of care; they were just to observe her. LPN-D stated she was pretty sure she told the day aides about the fall; there were no nurses to tell, and RN-A already knew. The facility's Fall Prevention and Post-Fall Management policy dated 5/27/21, indicated the facility would complete an assessment with every suspected fall including using a risk score using Fall Scale and reassessing safety interventions in place and updating as appropriate. The policy indicated post-fall baseline neurological checks should be conducted every four hours for 24 hours and evaluate the resident to determine if every 15 minutes to 30 minutes safety checks should be implemented. The facility's Care Planning/Care Conference policy dated 5/21, indicated the facility would conduct ongoing assessment with revision of care plans as information about the resident and resident's condition changed.

Based on observation, interview and document review, the facility failed to comprehensively assess, develop and implement interventions to promote healing and prevent worsening of pressure ulcers, and to prevent new pressure ulcers from developing, for 1 of 3 residents (R74) reviewed with current pressure ulcers. R74 sustained actual harm when the facility failed to comprehensively reassess R74 to identify risks and implement prevention interventions, which resulted in the development of a stage four (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone) pressure ulcer. In addition, a second pressure ulcer later developed, an unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by nonviable tissue). Findings include: R74's face sheet printed on 9/20/18, indicated R74 was admitted to the facility on [DATE]. Review of R74's Minimum Data Set (MDS) assessments and progress notes, indicated R74 did not have a pressure ulcer when admitted to the facility. The face sheet further identified R74 was readmitted from an in-patient psychiatric stay on 2/16/18. Skin assessment notes indicated R74 developed a pressure ulcer on 4/3/18, which deteriorated into a stage four pressure ulcer. The notes also indicated R74 developed a second pressure ulcer on 5/28/18. R74's discharge return anticipated MDS dated [DATE], indicated R74 did not have a pressure ulcer at that time. R74's quarterly MDS dated [DATE], identified that R74 had moderate cognitive impairment and had [DIAGNOSES REDACTED]. The MDS identified R74 required extensive assistance (weight bearing support) with activities of daily living (ADLs) which included bed mobility, transfers and personal hygiene. R74 was frequently incontinent of urine and continent of bowel. The MDS further indicated R74 was not at risk of developing pressure ulcers, and had no current or recently healed pressure ulcers. The MDS did not identify that R74 was on a turning and repositioning program to prevent a pressure ulcer from developing. The record further lacked evidence of a completed tissue tolerance (ability of the skin and the supporting structures to endure the effects of pressure without adverse effects) during this reference period. The MDS revealed R74 occasionally rejected care (bloodwork, taking medications, ADL assistance that was necessary to achieve the resident's goals for health and well-being). Review of R74's Braden Scale for Predicting Pressure Sore Risk form dated 3/2/18, identified that R74 was at mild risk for skin breakdown due to being chairfast, and had a problem with friction and shear. The Braden form did not indicate any issues with nutrition, skin moisture or activity. A medical provider's note dated 3/21/18, identified R74 to be wheelchair bound and dependent with ADL's. The note indicated R74's mood was stable. Furthermore, the note identified R74 had a decreased serum protein ([MEDICATION NAME]-a simple protein, which can indicate compromised nutritional status) level with registered dietitian following for protein powder supplement. R74's nurse's notes from 4/3/18, indicated R74 had been observed to have a left hip pressure area, measuring 4.5 centimeter (cm) x 3 cm, irregular webbed shaped chicken foot print like appearance, dark purple in color. On 4/5/18, the note indicated R74's left hip dressing was removed and there was shedding of nonviable tissue. A 4/4/18 work order, indicated staff had requested an air mattress be placed on R74's bed to promote pressure ulcer healing. A nurse's note dated 4/13/18, identified R74's left hip area as having a suspected deep tissue injury (intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface). The note indicated the first layer of skin had a dark brown/ black area with a large amount of drainage noted on the dressing when it was removed. R74's medical record lacked evidence of comprehensive reassessment following the development of the left hip stage four pressure ulcer. There was no updated Braden assessment conducted to determine skin risk factors, nor assessment of the residents tolerance for prolonged pressure over bony prominences, no further nutritional assessment, and no Significant Change in Status Assessment (SCSA) MDS and Care Area Assessment (CAA) on record. The medical record also revealed that R74 was not evaluated by therapy or nursing to help determine how to decrease pressure while seated in the wheelchair or lying on the bed, in order to prevent further skin issues for 2 weeks (only on 4/19/18) following the discovery of the pressure ulcer on 4/3/18. R74's laboratory reports were reviewed and indicated on 4/11/18, R74 had a low [MEDICATION NAME] level of 3.2 (normal range 3.5-5.0). A subsequent report dated 4/26/18, indicated R74's [MEDICATION NAME] level remained low at 3.3, and indicated a copy had been provided to the dietician for follow-up on protein and [MEDICATION NAME] labs. R74's medical record lacked evidence the resident's nutritional status had been evaluated by the facility dietician for risk factors, or nutritional interventions to promote pressure ulcer healing following the development of the first pressure ulcer. R74's medical provider note dated 4/17/18, indicated R74 would only sleep on her left side which was identified as a chronic sleep behavior for R74. The note indicated R74 refused to be repositioned on her back or right side, and identified R74 had an unstageable pressure ulcer to the left lateral hip. The provider note indicated Keflex (an antibiotic) was ordered to treat a wound infection, and indicated R74 had an x-ray of the left hip with no acute findings noted. Review of an occupational therapy (OT) note dated 4/19/18, indicated R74 had been referred to OT due to the pressure ulcer to the left lateral hip. The note indicated that R74's current wheelchair was too narrow. The note also indicated there was pressure being applied to the bilateral (both) upper thighs and lateral (sides of) hips against the arm rest panel and the upper thighs against the arm bar. The note further indicated R74's feet were not touching the floor placing R74 at increased risk for shear friction of sacral region (back wall of pelvis). Furthermore, the note indicated that a ROHO cushion (pressure relieving device) was on the seat of R74's wheelchair, however there was no air pressure in the cushion at that time to keep the cushion inflated and prevent pressure. An OT note dated 5/1/18, indicated the wound clinic was satisfied with R74's increased repositioning schedule along with R74's wider wheelchair. Review of medical record identified on 5/9/18, the left hip pressure ulcer declined, and measurements were 4.4 cm x 5.4 cm with necrotic tissue covering majority of wound bed measuring 4.2 cm x 5.4 cm. R74's weekly skin assessment note dated 5/26/18, indicated the development of a second pressure ulcer describing R74 as having a large reddened area on the right buttock measuring 11 cm x 9 cm, with blister like areas in the center measuring 4 cm x 5 cm. The skin assessment note dated 5/28/18, indicated R74 had a stage two pressure ulcer on the right buttock measuring 2.5 cm x 3.7 cm. At that point the facility initiated a SCSA review. R74 also had a Braden, tissue tolerance and nutritional assessment completed at that time. The nutritional assessment dated [DATE], identified R74 to be at high nutritional risk due to overall condition and new open areas. The Wound Clinic note dated 6/7/18, indicated R74 should have a specialty air mattress for bed due to a stage 3 ulcer to right buttock and unstageable pressure ulcer to left ischial tuberosity (lateral hip bone). The Wound Clinic note dated 7/17/18, included two questions for the facility, the first asking whether a new wheelchair and cushion had been ordered as wounds were getting worse; the second asking whether a specialty air mattress for the resident's bed had been obtained as R74's wounds were getting worse. The Wound Clinic note dated 7/31/18, indicated R74's new wheelchair and cushion looked great. A Wound Clinic note dated 8/14/18, identified R74's pressure ulcer on the right buttock had declined and was now diagnosed as unstageable. R74's weekly wound round and skin assessment notes lacked evidence of trialed and changed interventions to promote healing and prevention of further pressure ulcer development. R74's care plan dated 6/11/18, indicated R74 had a self-care deficit and required assistance from facility staff for ADLs, transfers and toileting. R74's care plan indicated R74 had a stage three pressure ulcer (full-thickness loss of skin, in which adipose (fat) is visible in the ulcer) to right buttock and an unstageable pressure ulcer to the left lateral hip area. R74's care plan approach included to utilize an off loading air mattress on R74's bed, ROHO (specialized pressure reducing) cushion in wheelchair, and to ensure R74 was up for 1 hour for meals only, then bed rest per the Wound Clinic. On 9/18/18, at 8:58 a.m. R74 was observed to be seated in a wheelchair at the table eating breakfast. R74 was unable to answer any questions regarding how she was doing. R74's verbal responses did not make sense to the questions asked. On 9/19/18, at 9:27 a.m. R74's dressing change was observed and two large open areas were observed: licensed practical nurse (LPN)-B (the acting unit manager) identified R74's left lateral hip pressure ulcer was 6 cm deep, with 6.5 cm tunneling at nine o'clock. LPN-B stated the tunneling was new and had not been noted on previous assessments. LPN-B also stated she did not feel any bone or hardware. LPN-B identified R74's right buttock pressure ulcer as 4.1 cm deep with necrotic tissue in the wound base, and a foul odor. LPN-B indicated both wounds had been measured a few days ago and did not need more specific measurements at that time. On 9/19/18, at 10:15 a.m. (LPN)-B stated R74 frequently refused turning and repositioning and preferred to lay on her left side. LPN-B also said R74 was not able to move in bed without staff assistance, and stated R74's mobility had declined upon return from an in-patient psychiatric stay in (MONTH) of (YEAR). LPN-B stated R74 was on a turning and repositioning schedule of every one hour thirty minutes, to two hours in (MONTH) (YEAR). LPN-B stated on 4/3/18, there was a webbed pressure area that looked like a chicken foot recorded in R74's medical record. LPN-B stated an air mattress was placed on R74's bed on 4/4/18, to promote healing. LPN-B also stated R74's left hip currently had infected hardware from a previous hip replacement. LPN-B explained that on 5/26/18, R74 had developed a stage two (partial-thickness loss of skin with exposed dermis) on the right buttock. LPN-B further explained R74 was now on comfort cares effective 9/11/18, in part due to wound progression. LPN-B was unable to find any documentation regarding R74 refusing cares or turning/repositioning and stated she would need to look further. On 9/20/18, at 9:53 a.m. nursing assistant (NA)-A stated resident behaviors were supposed to be documented in the computerized chart. NA-A stated R74 was completely incontinent of both urine and feces, but did allow staff to provide care after explanation. On 9/20/18, at 10:09 a.m. LPN-C stated all behaviors were documented in the nurses' notes. LPN-C stated R74 had always refused ADLs and turning and repositioning. LPN-C stated the refusals had been part of R74's personality since admission. LPN-C stated when R74 came back from the in-patient psychiatry stay in (MONTH) (YEAR), she was sleepier and more incontinent. On 9/20/18, at 10:26 a.m. NA-B stated R74 did not move much after her return from the in-patient psychiatry stay. NA-B also said R74 was incontinent of urine and feces due to her refusal to use a bed pan. On 9/20/18, at 11:52 a.m. R74's quarterly MDS dated [DATE], was reviewed with registered nurse (RN)-C. RN-C confirmed R74 had been identified as having no risk for developing pressure ulcers. RN-C stated only the facility used only the Braden to assess a resident's risk for developing pressure ulcers. RN-C further stated R74's Braden dated 3/2/18, had identified R74 as slightly limited with mobility which RN-C stated was to indicate R74 was able to move with minimal staff assistance. RN-C verified R74's MDS reflected R74 required the use of two facility staff with extensive assistance for transfers, bed mobility, and that R74 was unable to walk at that time. RN-C acknowledged there was a discrepancy from the Braden score. RN-C further stated she would have scored the Braden lower due to R74's decreased mobility status. RN-C confirmed R74 did not have a significant change assessment completed until 5/30/18, and verified that a significant change assessment would be appropriate with the occurrence of a new stage two (partial-thickness loss of skin with exposed dermis) or stage three (full-thickness loss of skin, in which adipose (fat) is visible in the ulcer) and/ or new unstageable or progression from stage two to three or four pressure ulcer. RN-C stated they would also review a resident's continence, transfer status and mobility. RN-C indicated that she was not sure when their MDS staff had been made aware of R74's pressure ulcer. RN-C stated that the development of a new pressure ulcer should be communicated in the facility's daily interdisciplinary team meeting (IDT). On 9/20/18, at 12:46 p.m. LPN-B stated the facility considered both the tissue tolerance and Braden combined as a resident's comprehensive skin assessment for any resident's quarterly, annual and/or significant change assessment. On 9/20/18, at 1:47 p.m. the director of nursing (DON) stated to determine when a resident was at risk for developing pressure ulcers it was the expectation that both the Braden, tissue tolerance and weekly skin assessment would be considered in addition to the resident's overall medical condition. The DON also stated R74's resistance with cares, in addition to refusals with turning and repositioning, were factors when the pressure ulcer to R74's left hip had developed. In addition, the DON stated although there had been discussion about R74 having infected hardware in the left hip, it had not been proven. During a telephone interview on 9/20/18, at 2:35 p.m. the facility's medical director (MD) stated it was her expectation that a full skin assessment would be completed at the time of admission. The MD stated weekly skin assessments would also be completed and more often should a concern arise. The MD stated when a resident refused care and interventions, she would expect facility staff to go back and try again, and keep trying. The MD further explained that if a resident refused cares and interventions, and the facility staff were unable to complete within a 24 hour period, the assigned nurse should make a comment in the nurses' notes and report verbally to the next nurse. The MD verified R74 was not as mobile as she used to be secondary to mental changes, and stated she thought the decline in mobility could have been a contributing factor to the pressure ulcer development. The MD stated, R74 being run down physical and nutritionally lead to the progression and lack of healing. A call was placed to Wound Clinic on 9/20/18 however, the clinic manager stated they were unable to release any information without consent. A call was placed to R74's guardian on 9/17/18 at 6:35 p.m., with no response and no ability to leave a message. The facility's Pressure Ulcer/Skin Breakdown Clinical Protocol formulated 2/19/16, identified the intent of the protocol to be for assessment and identification of a resident's risk for developing pressure ulcer. The protocol indicated that a pressure ulcer risk assessment would be completed upon admission, with each additional assessment; quarterly, annually and with significant changes. Further, the protocol indicated skin would be assessed for the presence of pressure ulcers on admission, and on a weekly basis, and more frequently if indicated. The protocol also indicated dietary would be notified to assess for any possible need for nutritional supplementation.