Every finding on record at The Shores of Worthington

Based on observation, interview and document review, the facility failed to appropriately maintain and clean 4 of 4 freezers in the facility kitchen. The facility also failed to ensure staff followed infection control practices when handling and preparing food and ensure food preparation equipment was allowed to dry prior to stacking and returning to the storage rack. This had the potential to affect all 49 residents in the facility. Findings include: Observation on 4/27/26 at 11:15 a.m. with the dietary manager (DM) of freezers utilized in the kitchen identified:An upright freezer used for storage of soups had food particles, and white residue on door hinges, shelves, and floor of the freezer. The handles were smudged and showed where the door edges had been griped with unclean hands, causing food like particles and soil to adhere to the surfaces. The surface of the door hinges had a buildup of soil, tan food particles, and white buildup that had accumulated. The freezer also had ice buildup on the shelves and walls of the freezer. A freezer used to store ice cream products, contained a package of opened undated French toast slices, and an open undated package of pancakes. The DM reported he did not know when the items had been opened or last used and removed the items stating they should have been sealed in a bag and dated when opened. The freezer contained food particles that had spilled on the floor and shelves of the freezer, and the door was soiled where it had been handled by people opening and closing the freezer. A large chest freezer, containing boxed frozen foods, was located behind the steam table and beside the cook top. The lid edges, and indented surface of the lid handle were soiled, and the interior seal on the freezer lid contained buildup of food particles and soil. There was a large amount of ice built up on the walls and boxes in the freezer. An upright freezer identified as used to store vegetables, was observed with food particles on the floor and shelves, and a brown colored substance had run from the lower shelf down the base of the freezer. The surface of the door was smudged and had residue on the edges and handle of the freezer. Observation on 4/27/26 at 10:30 a.m. of the area used for storage of food preparation equipment (scoops, spoons, spatulas, pans, skillets, and steam table pans) with the DM identified:5 of 13 quarter steam table pans that had been stacked, stored and remained wet. 4 of 13 had been stored unclean with food residue still present on the interior surface.2 of 8 half steam table pans were stored in the storage area and remained wet. 1 of 6 small square steam table pans in the storage area remained wet and contained food residue.5 of 12 full size steam table pans had been stored wet and contained food residue on the interior surface. The drawer containing serving spoons, scoops, and spatulas contained a wet spatula and scoop containing food residue. Interview on 4/27/26 at 10:45 a.m. with the DM confirmed the pans had not been adequately washed and should have been allowed to air dry before being stacked for storage. He then returned the identified items to the dishwashing area to be rewashed and sanitized. He reported his expectation for food storage equipment was for them to be cleaned daily, and any spills or build up on surfaces cleaned. The DM was not aware of when the freezers had last been cleaned and/or defrosted, but identified it needed to be on a schedule and monitored to ensure completion. Observation on 4/28/26 at 11:14 a.m. with cook (C)-A as he prepared menu items for the lunch meal, which consisted of spaghetti with meatballs, and tomato sauce, garlic toast, lettuce salad with dressing, and diced pears. C-A was observed preparing mashed potatoes, gravy, and altered texture items including pureed meat balls with sauce, and mechanically chopped spaghetti, with meatballs and sauce. C-A carried the large pot with boiling spaghetti from the stove to the sink across the kitchen and poured it into a colander in the sink. He took a spray hose from the top of the sink and sprayed water over the noodles. After draining he carried the colander from the sink and dumped the cooked noodles into a plastic lined steamtable pan. C-A washed his hands and applied gloves and continued opening drawers to retrieve scoops, which were placed in the steamtable pans, arranged bowls on a side and went into the walk-in cooler using his gloved hands to open the door, and returned carrying a plastic container of shredded lettuce, and a second container of shredded cheese. He used his same gloved hands to remove the covers and place tongs in each of the containers. C-A began plating meals from the steamtable, turning lettuce into a bowl, added cheese and placed onto trays placed on the top counter of the steamtable, which the dietary aid covered and placed on the cart. After dishing several meals, C-A checked a menu slip, and preceded to go to the walk-in cooler, wearing same gloves, opened the door and retrieved a container of chicken salad. He used his same gloved hands to pick up a loaf of bread, opened it, reached in and removed 2 slices of bread which he held in his gloved hand. He then reached into the drawer that he opened with his right gloved hand and retrieved a scoop. He then placed the slices of bread on a plate, used his gloved hands to hold and remove the cover from the chicken salad, placed 2 scoops onto the bread, and used his gloved hand to place the second slice of bread on top and pushed it down. Further observation on 4/28/26 of the meal service identified C-A returned to the steam table and continued serving the meal with his same gloved hands, as he was plating noodles and adding meatballs and sauce. Some of the noodles would hang over the edge of the plate, and he used his gloved hand to put them back onto the plate, added a slice of bread with a fork and set the plate on the tray. C-A continued serving. At 12:15 p.m., C-A removed the glove from his right hand but continued wearing the same one on his left hand and went into the walk-in cooler and returned with a plastic container of cheese slices. He picked up the loaf of bread, removed 2 slices of bread which he placed on a plate, picked up each slice with his left hand, and held as he retrieved a spatula from the lower drawer, opened a container of butter and buttered both slices of bread, He then used his gloved hand to take out two slices of cheese which he placed on the buttered bread, and placed on a waiting tray. He reapplied a glove to his right hand and resumed serving from the steam table without first performing hand hygiene. At 12:30 p.m., C-A continued serving several more trays with the same process. C-A was then observed to have checked a tray slip, left the steam table to walk around to the other side of the room and use his gloved hands to move several items on the shelf and picked up a single serving package of jelly and peanut butter. He returned to the serving table, with no glove change or hand hygiene performed, and removed 2 slices of bread from the bag. He then opened the container of jelly with his gloved hand, used a table knife to spread on one slice of bread, and as he opened the peanut butter, it fell to the floor. C-A repeated the same processes throughout the service and failed to change his gloves and perform hand hygiene between tasks if he needed to leave the steam table. Interview on 4/28/26 at 5:00 p.m. with the DM confirmed C-A should have changed his gloves and performed hand hygiene between tasks, and anytime he had to leave and then return to serving at the steam table. He also identified C-A should have used a serving utensil to adjust food on a plate as it was not an acceptable practice to use a gloved hand. Review of the weekly cleaning log for 4/18/26 through 4/26/26, identified refrigerators and freezers were to be wiped down and were initiated as completed on 4/19/26, 4/12/26 and 4/5/26. The log failed to include cleaning of interior surfaces, seals, or hinges which contained a large amount of soil and food residue. The log also failed to include when freezers were to be defrosted and contained large amounts of ice built up on walls and items in the freezers. A policy on cleaning of the kitchen equipment was requested but not provided by the end of the survey period.

Based on interview and document review, the facility failed to ensure 4 of 5 sampled staff (nursing assistant (NA)-E, NA-F, AND NA-M) and dietary aide ((DA)-B) completed tuberculosis (TB) screening and testing upon hire. This had the potential to affect all 58 residents in the facility.Findings include: Review of employee health files for TB screening and testing identified:NA-E, with hire date of 2/4/26, had a TB screening completed on 3/13/26 and no TB testing completed. Review of NA-E time punches identified NA-E had worked 12 days since hire.DA-B, with hire date of 3/2/26, had undated TB screening completed, and 1st step TB test given on 2/9/26 and read on 2/11/26, however, the 2nd step TB test was given on 2/23/26 but never read.NA-M, with hire date of 1/21/26, there was no TB screening completed. NA-M did have their 1st and 2nd step TB test done and read.NA-F, with hire date of 3/17/26, had undated TB screening completed, and 1st TB test given on 3/23/26 and read on 3/26/26, however, there was no 2nd step TB completed. Interview on 4/29/26 at 12:32 p.m., with DON identified staff should have TB testing completed, the first step test should be completed upon hire prior to working with residents with the second step test to follow in about 2 weeks. Interview on 4/29/26 at 1:30 p.m., with human resource (HR) director identified typically the facility process was that new hires had a TB test completed on day one of employment. Then we follow up to see that the Mantoux test was checked and we let the staff know when they need to complete their second TB test. The staff TB form to document the test was typically left in the medication room for the nurse to complete. It was her responsibility to follow up with the nurse that the testing was completed and the form was filled out. She then would file in the TB form in the staff personnel file. Review of undated, Tuberculosis, Employee Screening policy identified new hired employees would be screened for latent tuberculosis infection (LTBI) and active tuberculosis (TB) disease using tuberculin skin test or interferon gamma release assay (IGRA) test and symptom screening prior to beginning employment. Employees will be screened for LTBI and TB disease after employment offer has been made and before duty assignment. The facility will accept TST and IGRA results within the last 90 days. If unable to obtain a skin test must be performed and negative reading obtained before beginning employment. Chest X-ray was also acceptable to rule out TB.

Based on interview and document review, the facility failed to notify the Office of Ombudsman of a discharge for 1 of 2 sampled residents (R5). Findings include: R5's 12/26/25, accepted, Entry Tracking record identified R5 returned on 12/19/25, from a short-term general hospital stay. Additional 12/26/25, accepted significant change in status Minimum Data Set (MDS) assessment identified R5's cognition was intact. R5 used a walker, was independent with all his care with some set up assistance or supervision needed. R5 had diagnoses of anemia, heart failure, high blood pressure, thyroid disorder, and chronic obstructive pulmonary disease (COPD). R5's progress notes identified on:12/5/25, R5 had positive results of COVID and was placed on isolation.12/10/25, R5 cough was not improving, and primary care provider was notified.12/11/25, new orders for duo neb treatments three times a day for 5 days.12/14/25, R5 denied cough or headache. R5 reports his throat is sore. He reported he had thicker secretions and trouble swallowing but this had been happening before COVID. He requested his pills be crushed. The nurse offered to request an assessment by speech, however R5 had declined.12/17/25, nebulizer treatment and cough medicine administered at 10:00 a.m. R5's cough was noted to be worsening. R5's lung sounds were diminished and he had noted wheezing. R5 reported that he gets relief following the nebulizer treatment.12/17/25, due to worsening symptoms, he remained in isolation and received an order to complete a chest X-ray.12/17/25, ambulance transported R5 to the hospital related to worsening cough and complaint of shortness of breath.12/17/25, received an update from hospital and R5 was admitted for shortness of breath and weakness.12/19/25, R5 returned to the facility. Interview on 4/29/26 at 12:05 p.m., with social service designee (SSD) identified she was responsible for notifying the ombudsman when a resident was discharged . She sends the notices to the Ombudsman monthly. She found that R5's hospital discharge notice to the Ombudsman was not completed for his 12/17/25, discharge to the hospital. She was unsure why she had missed that notification. Interview on 4/30/26 at 8:28 a.m., with director of nursing (DON) identified that the SSD was responsible for notification to the Ombudsman when a resident discharged . She revealed that the SSD had been on vacation at the time and the facility should have a backup plan for things like that. She would expect that all discharges were reported to the Ombudsman. Review of undated, Transfer or Discharge Notice identified that the resident and/or representative will be notified in writing of discharge or transfers with a copy being sent to the Office of the State Long-Term Care Ombudsman.

Based on interview and document review, the facility failed to revise the care plan for 1 of 1 sampled resident (R6) reviewed for pressure ulcers.Findings include: R6's 4/9/26, accepted Minimum Data Set (MDS) assessment identified R6 cognition was moderately impaired. R6 had limitations on one side of her lower extremity and required partial to substantial assistance for cares and transfers. R6 was at risk for developing pressure ulcers, used a pressure relieving device for her wheelchair and bed. During the assessment period R6 took antibiotic and diuretic. R6 had diagnoses of heart failure, arthritis, and depression. R6's 4/21/26, Skin Issues assessment identified a new pressure ulcer on the left dorsum (top side) 2nd digit (second toe). The pressure ulcer was identified as stage 2 (partial thickness skin loss with exposed dermis) that developed at the facility. The pressure ulcer was identified on 4/21/26 and measured 0.26 centimeters (cm) in length by 0.25 cm width and by 0.1 cm in depth. Bacitracin and a band aid was applied per primary care physician orders. The assessment identified R6 had been educated on leaving her shoe off due to pressure to toes and R6 had agreed. The care planning section of the assessment was blank and there were no further interventions or indication that the care plan would be revised following the identification of a new pressure ulcer. Review of 4/21/26, nursing progress note identified a new concern for R6's left 2nd toe with a review of R6's history of this toe. A wound assessment was completed, enhanced barrier precautions (EBP) were implemented, and the care plan was reviewed. There was an appointment set up for 4/22/26 with a provider who had seen R6 had seen prior related to her left toe. R6's current, undated care plan identified wound management of left 2nd toe with goal that wound would show signs of improvement. The interventions included measuring ulcers at regular intervals, monitoring ulcers for signs of infection, monitoring ulcers for signs of progression or declination, and provide wound care per treatment order. The care plan lacked the identification of leaving her shoe off due to pressure to toes as identified in the wound assessment. Interview on 4/28/26 at 10:34 a.m., with nursing assistant (NA)-B identified R6 had a sore on her left toe, but the nurse took care of that as it was preventative. She reported nurse aides did not do anything for R6's sore on her toe. Interview on 4/29/26 at 12:23 p.m., with NA-A identified she was unaware of any special interventions or anything that she was to do for R6's wound on her left toe. She reported that the nurse took care of R6's sore on her toe. Interview on 4/29/26 at 3:00 p.m., with the director of nursing (DON) identified she had completed the wound assessment and identified R6 she should take her shoes off as tolerated to relieve any pressure. She confirmed she had not put that intervention on the care plan for staff to encourage R6 to take her shoes off as tolerated. All nurses should be participating in resident care planning and revision when a resident needs changes to their care plan. She does complete reviews of care plans, and she should have revised R6's care plan to include the new intervention for her pressure wound. Review of the undated, Care Plans, Comprehensive Person-Centered policy identified assessments of resident's are ongoing and care plans are revised as resident's conditions change. The interdisciplinary team also reviews and updates the care plans when there has been a significant change in condition, the desired outcome has not been met, the resident was re-admitted from a hospital stay, and at least quarterly in conjunction with the MDS assessment.

Based on observation the facility failed to provide meals that were attractive and palatable during 1 of 1 observed meal service. Findings include: Observation on 4/28/26 at 11:30 a.m. until meal service was completed at 12:45 p.m. identified the menu for that meal was spaghetti with meat balls and sauce, garlic toast, and a lettuce salad. Additional food items prepared included mashed potatoes and gravy and canned pears. At 11:45 a.m., as cook-A began serving the meal for the lower-level dementia unit. The meal was plated, and the trays were loaded onto a cart which was pushed to the unit for serving. C-A used tongs to place spaghetti noodles onto the plates, and amounts of plated food to be served to residents were inconsistent with each plate. He then added a scoop of meatballs with sauce, a slice of toast and a bowl with lettuce topped with a small scoop of shredded cheese. A small plastic cup with diced pears was placed on the tray prior to being placed on the cart for delivery. Lettuce was identified as the vegetable served, and the only vegetable offered for those residents on altered texture diets, was mashed potatoes and gravy, (served with spaghetti). As the meal service progressed the noodles were becoming dried and gummy in appearance. C-A had to scrape the noodles from the bottom of the steam table pan to serve the final tray. In addition, the red plate covers had dried white residue on the surface, which the dietary manager identified as hard water residue. Silver ware was corroded with a dull grey appearance and spotted with white providing an old, soiled appearance. Bowls were light grey, and did not show the discoloration as easily, but white residue was visible on observation. Interview on 4/27/26 at 6:21 p.m. with R30 voiced concerns that food was overcooked, lacked flavor and there was no provision of seasonings to add to food served. She usually ate soup due to the condition of over cooked foods offered. She added, vegetables were not drained and were pooled in liquid when served and were cooked to the point of being mush, and fresh vegetables were not offered. R30 stated she chose to eat her meals in her room, and food was never hot when it was brought to her room. She reported concerns had also been voiced by other residents and discussed at resident council meetings. R30 reported she had purchased her own salad ingredients including bell peppers, onions, and tomatoes, which the kitchen did prepare for her, but only shredded lettuce was offered prior to her providing them. She further reported dishes and eating utensils were unappetizing due to heavy water spots and discoloration. The concerns had been voiced at food committee and resident council, but nothing had changed. Review of the 2/5/26, food committee minutes identified residents in attendance were R6, R15, R24, R28, R33 and R53. Staff in attendance included the dietary manager (DM), the activity director, and the activity aide. Discussion included water spotting on dishes and silverware, differences in preparation of menu items, menu likes and dislikes. There was no discussion concerning food temperature, palatability of food, consistent serving sizes, or availability of fresh fruits and vegetables. Review of the meeting minutes from 1/8/26, 11/6/25, and 10/1/25 followed the same format, but there was no discussion on the identified concern for palatability. Interview on 4/28/26 at 1:00 p.m. with the dietary manager (DM), who observed the final portion of the meal service, identified the noodles had become overcooked by the time the final trays were dished, and should not have been served. He further reported he had replaced bowls and cups recently, but hard water residue continued to be a problem, and he was hoping the facility would be able to do something about it. Interview on 4/28/26 at 5:50 p.m. the maintenance supervisor identified he had submitted a report and requested that a water service company assess the hard water issues in the kitchen a couple of months ago. He identified a company from Iowa had offered to come and assess the problem, but they were not licensed for Minnesota, and he had not received any additional information or response to the concerns from management. He reported the issues had continued to worsen with buildup of residue from hard water use in the kitchen. Interview on 4/29/26 at 12:40 p.m. with the registered dietitian (RD), commented that the hard water was a problem and she was hopeful it could be resolved, as it didn't make a meal have an attractive appearance when used for meal service. A policy for food preparation, palatability, and available food enhancement options was requested but not provided by the end of survey

Based on interview and document review, the facility failed to ensure 1 of 5 staff had initial and annual Alzheimer's and dementia training. Findings include: Review of nursing assistant (NA)-G's employee file identified she had a hire date of 1/10/25. Review of her Alzheimer's Disease or Related Disorder Training identified she had not completed training for an explanation of Alzheimer's disease and related disorders, assistance with activities of daily living, problem solving with challenging behaviors, or communication skills. Follow-up email reply on 4/29/26 at 5:08 p.m., from the director of nursing (DON) identified they were unable to locate NA-G's initial hiring documentation. An additional follow-up request for the DON's expectation for completion of initial Alzheimer's training was requested but not provided by the end of the survey period. Review of the current, undated In-Service Training policy identified all staff were required to participate in regular in-service education with an objective of ensuring staff were able to interact in a manner that enhanced the residents' quality of life and quality of care and could demonstrate competency in the topic areas of training. The required topics of training included effective communication with residents and families, resident rights, preventing abuse, dementia management and behavioral health. The training requirements were to be met prior to staff providing services to residents, annually, and as necessary based on the facility assessment. Completed training was to be documented with the date, time, topic, method, and summary of the competency.

Based on observation, interview, and record review, the facility failed to protect 1 of 10 residents (R1) reviewed for sexual abuse, from sexual abuse by another resident (R2) who had a known history of sexually inappropriate behaviors. This resulted in an Immediate Jeopardy (IJ) when R1, who had severe cognitive impairment was sexually abused by R2 and was unable to independently protect herself from unwanted sexual contact. The IJ began on 2/5/26, when staff found R2 in a resident common area with his hand under R1's shirt touching her breast while she was resting in a recliner. R2 was placed on 1:1 supervision on 2/6/26; however, he was removed from 1:1 supervision on 2/11/26 and placed on 30-minute safety checks. The removal of continuous supervision left female residents vulnerable to R2's ongoing and escalating sexually inappropriate behaviors without sustained and consistent interventions to prevent reoccurrence. The Administrator, director of nursing (DON), social services, vice president of clinical services (via phone), and chief operations officer (via phone) were notified of IJ on 2/19/26 at 4:11 p.m. The citation was issued as at past non-compliance when the facility implemented a sustainable plan of correction which removed the immediacy on 2/7/26. Findings include R2's prior facility referral/screening record faxed to the facility on 8/19/25, included a face sheet dated 8/12/25. The records faxed from the previous facility also included R2's care plan, progress notes, and current medications. R2's progress notes dated 8/3/25 indicated R2 displayed behaviors of urinating in public and following and trying to touch/rub another resident's arm. Progress notes on 8/4/25 indicated between 8:49 a.m. to 10:03 a.m. R2 required staff redirection after he demonstrated repeated behaviors of rubbing female residents' shoulders and/or arms. Progress note at 10:49 a.m. indicated an incident had occurred that was reported to the State Agency and the family member was notified (incident was not defined). The prior facility had revised R2's care plan on 8/4/25 identified R2 had displayed inappropriate sexual advances towards female resident(s) with intervention to have 1:1 supervision to prevent behavior on 8/4/25. Progress notes between 8/5/25 through 8/18/25 indicated R2 was on 1:1 supervision with no further behaviors of touching female residents documented. R2's Family Medicine Visit dated 8/28/25, identified R2 was seen for a physical for potential transfer. R2 had been 1:1 supervision since 8/5/26. R2 can be easily redirected. R2's face sheet dated 2/19/26, identified R2's admission date to [NAME] of Worthington on 8/28/26 with diagnoses that included of vascular dementia, unspecified severity, with other behavioral disturbances, mixed obsessional thoughts and acts, and depression. R2's Behavioral Health visit note dated 8/6/25 scanned to [NAME] of [NAME] on 8/28/26 at 2:30 p.m. included Staff report that the patient is easily redirectable and will stop behaviors when told to. State report this week when he was noted by staff to be touching women shoulders and one woman's breast. Staff reports he touches himself in public and will pee in different public areas of the building. R2's Social Service-Resident Vulnerability and Susceptibility to Abuse assessment dated [DATE], Identified R2 had cognitive and communication impairments, and wandered into other resident rooms/belongings. Additionally identified R2 was a vulnerable adult unable to report, but no signs of abuse or neglect present. The box that was not checked (indicating not present) included Inappropriate sexual comments/or behavior. Section A1. If other, describe was blank. The assessment did not include R2's history of sexually inappropriate behaviors. R2's care plan dated 9/11/25, identified a focus of Impaired Social Interaction with nterventions dated 10/17/25, monitor R2's level of social interaction. Observe R2's interactions with others. R2 is allowed to stand and look at people. When/if R2 reaches out to touch other residents, intervene and offer staff companionship. Guardian states the only thing R2 wanted in life was to have a home and get married. R2 never did marry and seeks out companionship. If staff is unable to sit with him, redirect him to another area. Intervene when R2 attempts to touch peers without permission. R2 does not seem to understand personal space. Help guide him. Provide safety not judgement. R2's care plan was updated on 10/9/25, with a focus of Behavior Management: taking others food or drink. Interventions included: utilize diversion techniques as needed, provide verbal feedback to R2 regarding behavior, establish boundaries and limits with R2. Review of R2's care plan between 8/28/25 through 11/7/26 did not identify R2's history of sexually inappropriate behaviors as described in the referral documents (touching of woman's breast and rubbing women's shoulders) nor interventions that identified prevention measures and/or any known potential triggers to monitor to mitigate R2's risk of re-current inappropriate sexual touching behaviors. During an interview on 2/19/26 at 11:05 a.m., social worker (SW)-A felt R2's behaviors at the prior facility were directed at only one woman, was mutual in nature, and the woman had consented until the woman did not. When R2 first admitted , the sexual behaviors were not happening with female residents so historic sexual behaviors were not incorporated into the care plan upon admission. The care plan was updated when new behaviors were identified. Any nurses or management can update care plans when the need arises. Care plans represent how to care for the residents. Staff should always go to the charge nurse if they see a behavior. Staff could always go to management when they were uncertain if behavior was reportable or not. R2's quarterly MDS dated [DATE], identified R2 had severe cognitive impairment, no issues with hearing or speech, sometimes socially isolated. R2 had other behavioral symptoms not directed towards other (e.g. physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds.) R2 used a walker, needed partial assistance with dressing, setup or clean-up assistance with toileting, and was independent with walking in facility. R2 had a wander/elopement alarm. Between 11/4/25 and 2/1/26, progress notes repeatedly documented R2 hand holding and/or rubbing hands with female residents, rubbing/grabbing/attempting to touch female residents' arms/hands, standing over/in front of/standing by female residents and/or staring in dayroom settings, approaching/going toward female residents despite redirection, behavior involving breasts/chest, public sexual behavior (hands down pants), and agitation/anger/yelling/cussing associated with redirection; redirection/reminders/education were documented across the period with variable effectiveness documented. The following progress notes are representative excerpts from the record and are not an exhaustive listing of all entries reviewed during the period. R2's progress note dated 11/4/25, identified R2 sat at a table during breakfast holding a female residents hand. R2 then started rubbing her hand up and down with his hand. Nurse removed R2 and had him sit in the dayroom. Couple minutes later, R2 was up from recliner and standing over same resident. R2 stood over resident for almost 15 minutes before sitting back down in recliner. During evening hours R2 continued holding another female residents' hands, R2 would be asked to sit down, sit down and within 2-3 minutes, R2 would be standing next to resident holding her hand. R2 did this for almost an hour. R2's progress note dated 11/5/25, R2 had been observed rubbing arms of several female residents. Easily redirected each time, but behavior persisted throughout shift. R2's progress notes dated 11/6/25, identified R2 has been getting and staying close to the ladies. Approaching them in an inappropriate manner. Stopped by staff before he touched a resident on her breasts. Has a hard time with redirection. Continues to stand around women. Tried to touch several woman residents, however, staff were able to redirect. R2 will stand in one spot and stare at female residents and this does make some of them uncomfortable. Psychiatric doctor notified of increased inappropriate behaviors. POA called and stated she wanted staff to keep ahead of any incident, be very firm and set boundaries with R2. During the evening, R2 walked to a resident that was sitting in a recliner and held her hand and rubbed her hand up and down. R2 was advised not to touch people without permission and R2 stated she touched me. This was not true as R2 walked to her and that resident is unable to move herself. R2 would be told to leave her alone and he would turn around and when staff were not looking would go to resident again. The woman did not understand why R2 was holding her hand but did hold his hand back. R2 is very fast and will walk across the room back to the resident after being told to sit down. R2's care plan was updated 11/7/25, included Behavior Management: touching of other residents. Interventions included: provide verbal feedback to R2 regarding behavior. Remind R2 we are not to touch other residents. Establish boundaries and limits with R2. Redirect R2 away from other's things to his own. Offer R2 alternative objects/snacks/drinks. Try to pass R2's tray first. Do not allow physical contact with other residents. Intervene and direct R2 away from resident of interest or walk with him to his room. Although the care plan directed staff to not allow R2 physical contact, R2's record between 11/7/25 and 2/5/26 identified multiple instances staff did not prevent R2 from having physical contact with female residents. --removed bolded R2's progress note dated 11/9/25, identified R2 had been trying to hold hands with a female resident while she was sleeping. R2 had to be redirected more than 25 times. R2 is very quick and with three staff in the room, will be found standing over the female resident moments after staff seen him in a chair across the room. Female resident had to be moved to be near staff as it was too hard to keep R2 away. R2's progress note dated 11/12/25, identified R2 had been standing in front of female resident or sat next to them and tried to touch them if nobody was watching. R2's progress note dated 11/13/25, identified R2 was redirected various times to not touch another resident. R2 would walk up to the resident in the recliner and start massaging the resident's chest. Staff is on alert and will quickly redirect R2, trying to keep R2 away from female residents. R2 was looking around and then would walk to R1 and stand right by her, getting too close if no redirection. During a phone interview on 2/19/26 at 9:35 a.m., R2's guardian stated the facility knew all about R2's explained the escalation of sexual behaviors with female residents at both an Assisted Living and the nursing home he discharged from; both prior incidents started with obsessing over individual female residents, progressed to touching (like handholding) then resulted in touching female breasts before they accepted him to their memory care unit. The long-term care Ombudsman and guardian informed and discussed with the facility social worker (SW) R2's sexual behavioral history that had gone too far at two prior facilities R2 had resided at. Guardian informed SW of R2's sexual behaviors patterns including initial presentation and escalation and warned SW to not let anything start because it would go too far just like it had at the other two facilities. In response SW reassured Guardian that facility would be able to manage the behaviors. Not long after admission, Guardian was called because staff noticed R2 was rubbing ladies shoulders. Guardian stated R2 was easily redirectable, but his short-term memory was so short it did not take him long to forget what was just said- you cannot reason with [R2.] Facility staff were very aware to frequently redirect to stop R2 from rubbing shoulders. Memory care units should have the tricks of the trade for how to manage these behaviors but every time guardian had been at the facility R2 was sitting in the dayroom in a recliner facing R1, who was the lady R2 really liked. Guardian received a phone call from SW-A on 2/6/26, that R2 had gone under a female resident's shirt and touched her breast. Guardian felt the facility failed R2. During an interview on 2/19/26, at 9:08 a.m., licensed practical nurse (LPN)-A stated when R2 first admitted to facility, she was unaware of any behaviors. R2 was calm and redirectable. Staff knew as soon as R2 began eyeing them he would head in R1's direction, R2 had his attention always focused on R1. R2 began by just holding R1's hand but then it progressed to going up R1's arm. R1 and R2's care plans both reflected hand holding was permissible (however review of R2s care plan was not revised to include hand holding); staff were directed to redirect R2 from R1 and tell R2 to keep his hands to himself. During shift-to-shift report, the nurse would always report how much re-direction was given so the oncoming shift would be vigilant with R2's supervision. On 11/13/25, in the dayroom, LPN-A observed R2 standing over R1. R2 put his hand on the top of R1's chest by her neck area and rubbed the area. This was the first time LPN-A had witnessed R2 touch R1 someplace other than her hand. R2 was directed to keep his hands to himself and go to his recliner and sleep. R2's progress note dated 11/14/25, identified R2 kept going to R1 and attempted to touch her multiple times but was easily redirected with no behavior. R2's psychiatry visit note dated 11/14/25, identified chief complaint and staff concerns of increased inappropriate behaviors including touching women's breasts and rubbing and holding their hands. Behavioral concerns/inappropriate behaviors: start Brexpiprazole (antipsychotic medication) 0.5 milligrams (mg) daily for behavioral concerns likely secondary to dementia. R2 has had increasing inappropriate behaviors towards female residents and may benefit from low dose antipsychotic. Safety: staff to continue redirection, being very clear and direct with R2 when behaving inappropriately. R2 needs consistent redirection with clear expectations, which may include asking R2 to leave the day area when being inappropriate with other females. R2's care plan was not updated after psychiatry visit until 11/17/25. R2's progress notes dated 11/15/25, identified R2 was seen for a psychiatric visit by certified nurse practitioner (CNP)-A. Provide clear and direct redirection with R2. R2 was standing in front of female residents and tries to touch them. Staff have tried redirecting multiple times but ineffective. R2's Behavior Management care plan intervention updated 11/17/25, identified: Provide verbal feedback to R2 regarding behavior. Provide clear and direct redirection when R2 is acting inappropriately. R2 needs constant redirection with clear redirection, which may include asking R2 to redirect out of dayroom. R2's Nursing Note dated 11/19/25, identified director of nursing (DON) completed R2's assessment on phone call with guardian/power of attorney (POA)-A. Reviewed policies for Resident Sexual Expression, and resident to resident altercations. DON stated R2 was provided frequent monitoring while awake and firm re-direction when seeing this behavior. POA-A stated she wants to help facility prevent this from occurring, by maintaining communication with facility and psychiatry. R2's Resident Capacity to Consent to Sexual Activity dated 11/19/25, identified R2 is seeking companionship from a female resident per POA. R2 likes to socialize by placing hand on other female resident's hand. Noted to have been stopped by staff to move hand towards breast area. R2 easily redirectable but continues to touch residents' hands. R2 does not have the capacity to understand sexual options and the potential consequences of sexual choices. Precautions implemented to maintain resident safety including R2 has been on frequent monitoring while awake with frequent firm re-direction and reminders to not touch others without consent. R2 does not have any relationship with a resident. R2 is on a dementia unit. R2 is seeking companionship and wants to be affectionate. R2 understands the nature of the sexual activity in which he is engaging. The sexual choice is a voluntary choice. Does not have the ability to report unwanted sexual contact. Cannot report abuse but has the ability to say no to unwanted sexual contact. Female residents (female resident(s) were not identified) also noted to have dementia no nonverbal/verbal signs of distress. Resident is seeking companionship as he has always wanted a wife and kids, he is affectionate seeking female attention. POA states she does not feel resident is at risk to harm/hurt any other residents. Endorses that facility has limitations to private areas and agrees firm boundaries if consensual. R2 has been allowed to continue the relationship. Care plan has been updated. R2's Behavior Management care plan updated on 11/19/25, identified focus to include: touching of other residents without permission. Interventions updated: utilize diversion techniques as needed likes to watch TV and color. Provide frequent monitoring while awake. During an interview on 2/18/26 at 10:07 a.m., director of nursing (DON) stated prior to R2 residing at facility, he had a similar incident with breast touching. R2 saw psychiatry for mental health needs which continued after transfer to facility. Staff began to see R2 more touchy-feely in November, they went crazy charting on R2 including R2 standing and staring at residents, but no inappropriate touching had occurred. Staff were afraid it could escalate. In November, both residents were assessed for vulnerability risks, sexual assessment completed for R2, called guardians for both residents to identify how they felt about the situation with neither party having any concerns. R2 was redirectable when hand holding. DON completed an in-service with staff working at the time and education on documentation including subjective versus objective in charting, reportable and not reportable touch. R2 continued frequent monitoring while awake. R1 can verbalize her needs with yes/no and the guardian was okay with hand holding but wanted to be notified about escalation. R2 had a psychiatrist working with him prior. R1's face sheet dated 2/19/26, identified diagnoses of Alzheimer's, dementia with other behavioral disturbances, adjustment disorder with mixed anxiety and depressed mood. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 was widowed. R1 had moderate difficulty hearing, moderate impaired vision, severe cognitive impairment, and hallucinations. R1 used a walker and wheelchair for mobility. R1 was dependent on staff for toileting and lower body dressing, substantial assistance with upper body dressing. R1's Trauma Informed Care History dated 9/12/24, identified R1 was not alert, orientated, and cognitively intact to complete the assessment. R1's progress notes reviewed between 11/13/25 and 11/14/25 did not identify R1 was touched on the chest by R2. R1's progress note dated 11/19/25, identified DON spoke to R1's guardian about R2 seeking R1's attention/affection via hand holding and touching hand. Guardian stated no concerns as R1 can verbalize her emotions and if she is not showing any verbal/non-verbal problem she is not concerned. DON explained if the behavior escalated to inappropriate touching, facility would notify the guardian and follow policy. DON stated facility was frequently redirecting R2 and providing supervision as able. Reviewed policy with guardian and no questions or concerns verbalized. R1's care plan dated 3/7/25, identified Risk for Harm: Self Directed or Other-Directed with an intervention dated 11/20/25, utilize calming touch. Resident has a male resident that is fond of her by holding/touching hand. Residents' guardian is aware and ok with situation states Resident can verbalize concerns if any. The care plan did not identify which resident R1 could hold hands with. R1's progress note dated 11/20/25, identified social service (SS)-B spoke with R1 regarding other residents that live at facility. R1 stated no to feeling any fear or harm around other residents. Asked if she would be bothered by another resident holding hands with her and she replied no. R1 stated she liked when someone holds her hand. R2's Behavior Management care plan updated 12/11/25, to include in the focus: loss of interest in activities that previously brought joy. Wandering in other residents' rooms, urinating in public space. Interventions updated to include: utilize diversion techniques as needed. Likes to watch TV and color. POA supplies art supplies and other activities for R2 to do in his room. When resident is trying to touch another resident redirect to another area. Encourage R2 to sit in recliner to watch TV or go to room and work on art projects. Offer him a place at the table and offer a snack and beverage. Remind R2 that we cannot touch people without their permission. When wandering to others room or aimless-ask if he needs to use the bathroom and redirect him to his room. R2's psychiatry visit note dated 12/12/25, included behavioral concern/inappropriate behaviors and addressed changes to psychotropic medications as R2 is identifying inappropriate boundaries with peers, repetitive compulsions of stealing food and drink, restlessness, and anxiety. Discussed Naltrexone (medication to treat alcohol disorder) as guardian reports in the past this has improved R2's impulsivity, however, it is contraindicated due to elevated liver enzymes. Safety: staff to continue redirection, being very clear and direct with R2 when behaving inappropriately. R2 needs consistent redirection with clear expectations, which may include asking R2 to leave the day area when being inappropriate with other females. R2's progress note dated 12/13/25, identified R2 would go and stand over another resident while she was in the recliner, R2 had to be reminded numerous times to go and sit down and not stand over her. R2's progress note dated 12/15/25, identified R2 kept going to R1 and standing by her. When redirected would get upset and yell at staff. R2's progress note dated 1/1/26, identified R2 was found with his hand resting on shoulder of another resident after lunch. Easily redirected. R1's progress note dated 1/1/26, identified R2 had his hand on R1's shoulder. Nurse asked if resident was okay, and she stated yes. Asked if anyone hurt her or made her uncomfortable and R1 stated no. R2's progress note dated 1/12/26, identified R2 continued to approach female resident in her recliner and hold hands. Easily redirected but will continue to approach her over and over again. R2's progress note dated 1/17/26, identified R2 made multiple attempts to stand at the side of another resident's chair and hold her hands. Always easily redirected but redirection was required frequently. R2's progress note dated 1/30/26, identified R2 stood by a recliner chair around a female resident multiple times. After redirection, would go to another resident and put his hands on her shoulder. R2's progress note dated 2/1/26, identified R2 lifted his shirt up and stuck his hand down his pants while sitting with his legs spread over the top of the arms of the recliner in the dayroom. The facility reported incident (FRI) dated 2/6/26, identified yesterday morning (2/5/26), R1 was sitting in recliner resting and R2 had touched breast. During an interview on 2/18/26, at 11:40 a.m., NA-A stated when R2 first came to facility he did not have any issues. R2 stayed in his room mainly and would come to the dayroom and relax in a recliner. NA-A was unaware of any sexual history with R2, it had been okay for R2 to hold hands with female residents. A couple of months ago, R2 began touching R1's arm, standing beside her, watching her, and would move his chair to get closer to her. R1 would be asleep most of the time when R2 would do these things to her. On 2/5/26, between breakfast and lunch, NA-A returned to the dayroom and a resident was pointing towards R2 and R1. R2 was standing over R1, who was in a recliner, with his hand under her shirt touching her breast. NA-A told R2 to stop touching R1, back away from her, that it was inappropriate, and directed R2 to either go to his recliner or his room. R1 had been sleeping and woke up and said, what are you doing? NA-A stated she told the nurse to keep an eye on R2 because he had been constantly touching and staring at women and it literally takes half a second and he is up and out of that chair doing the same thing. During the rest of that shift (on 2/5/26), R2 was not just going towards R1 but also towards another resident, he touched her hand. Prior to the incident, R2 only had these behaviors with R1. After the incident R1 was moved out of the memory unit within one day. During an interview on 2/18/26 at 1:31 p.m., NA-B stated after her break on 2/5/26, probably around 9:30 a.m., NA-A told NA-B about the incident with R2 putting his hand on R1's breast. NA-A had said she told the nurse. For the rest of the day NA-B and NA-A tried to keep a close eye on R2 and kept having R2 go back to his room when he would go to the dayroom. R2 would wander a lot and go from recliner to recliner in the dayroom. NA-B had never seen R2 and R1 hold hands. R2's progress note dated 2/6/26 at 1:15 p.m., identified R2 was redirected to keep appropriate distance from other residents. At 3:00 p.m., due to new incident reported resident immediately placed on 1:1. R1's progress note dated 2/6/26, at 3:05 p.m., identified interdisciplinary team (IDT) met and discussed moving R1 to main area of facility. R1 moved to main area at 3:00 p.m. R1's physician order dated 2/6/26, identified to monitor any physical, emotional, or mental distress: document any findings or changes in R1's status for 14 days. R1's progress note dated 2/6/26, at 3:30 p.m., SW-A spoke with R1 around 11:00 a.m., while observing for behaviors and interactions with other residents. R1 has memory issues but able to speak freely when she wants to. Asked how R1 was doing, she nodded her head. Asked if she had any problems or concerns and if she felt safe. R1 looked at SW-A, smiled, and closed eyes. SW-A had an email conversation with guardian about moving R1 upstairs due to more behaviors of verbal outbursts and loud yelling on the memory unit and R1 no longer being an elopement risk. Decision made to move R1 sooner rather than later due to staff allegations of another resident inappropriately touching resident. Guardian notified of allegation and in agreement with course of action. R1's care plan dated 2/6/26, identified Safety General: Vulnerable Adult. Resident would remain safe in facility with interventions that include R1 was moved from memory care unit to new room immediately due to alleged abuse report. Monitor for any physical/mental/emotion signs of distress. R2's Behavior Management care plan updated 2/7/26, focus included impulsivity. Additional focus Safety General: Vulnerable Adult created on 2/7/26, with interventions that included R2 currently on 1:1 supervision with staff for safety. R2's fax cover sheet dated 2/7/26, to primary care physician, identified Vulnerable Adult (VA) filed due to R2 touched other resident inappropriately. No injury or issue noted. Do you have any order? Please advise? The fax was returned on 2/9/26, with a response to continue documenting behaviors and redirect R2. No medication changes at this time. Will be at facility on 2/13/26. R2's progress note dated 2/8/26, witnessed attempting to walk towards a dining table with female residents multiple times. Redirected successfully. 1:1 monitoring continues. R2's Behavior Management care plan updated 2/9/25, focus removed OCD and impulsivity. Interventions updated: have staff sit with R2 or visit. Help fulfil need of companionship. On 2/9/26, try to deter/stop physical contact from R2 with other residents. Have staff sit with him or visit. Help fulfill need of companionship. If wandering, ask him if he needs to use the bathroom and if so direct him to his bathroom. R2's progress note dated 2/11/26, identified R2 was on 1:1 for recent event. Removed from 1:1 after chart review and no action occurred, no concerns from staff. Continue on 30-minute safety checks at this time. R2's psychiatry visit note dated 2/13/26, identified chief complaint of more inappropriate behaviors. Last week, reportedly groped another resident. Will be transferring to an old man's nursing home. Staff continue redirection, being very clear and direct with R2 when behaving inappropriately. R2 was separated from female resident he was being inappropriate with. R2 will be transferring care next week to an all men's nursing home. During a continuous observation on 2/18/26 that began at 2:14 p.m. when R2 was sitting in a recliner in the common area eating ice cream; activity assistant (AA)-A was also in the common area. R2 then stood up turned his head toward staff and began slowly walking toward two female residents as AA-A began walking towards R2. When R2 reached the female residents, he asked how she was. AA-A asked R2 to sit in the recliner next to the female resident with a small side table separating them and asked if R2 wanted to play a game. RN-B redirected R2 back to his recliner across the room. At 2:19 p.m., R2 stood up from his recliner and began walking slowly to the female resident sitting across from him but then stopped and stared at her when he was halfway to her. NA-D walked up to R2 and asked if he wanted a drink or snack; R2 responded no. NA-D directed R2 to sit and then walked away. R2 remained standing where he was watching NA-D walk away. At 2:20 p.m., R2 moved closer to the female resident staring at her. NA-D watched from a distance. At 2:21 p.m., R2 stood in front of a different recliner staring at a female resident. R2 turned his walker and began walking toward the female in the recliner. RN-B went to R2 and told him to sit down. At 2:22 p.m., R2 went back to his recliner, turned around, and began walking back to the female resident. RN-B stated R2 needed to sit by NA-D at the dining room table. DON asked R2 if he wanted to go to his room and R2 began following DON down the hall. At 2:34 p.m., R2 was back in dayroom with SW-B following him. SW-B placed a blanket on R2 and sat in a chair next to him in his recliner. SW-B walked away from R2 to talk to DON and RN-B at medication cart. At 3:16 p.m., R2 began sitting forward in his chair. At 3:16 p.m., R2 was looking towards the medication cart and staff. At 3:18 p.m., R2 began sitting up in recliner and sat back down when he saw RN-B, DON, and SS-B were watching him. SW-B returned to the chair next to R2. R2's progress note dated 2/18/26, identified at 3:06 p.m., call placed to behavioral health to update on current behaviors. Progress note at 3:19 p.m., nurse brought forward concern of R2 attempting to seek female residents after lunch. Nurse kept R2 on 1:1 until notifying DON. Redirectable but placed on 1:1 for safety at this time. Progress note at 4:34 p.m., behavioral health returned call. R2 had been attempting to approach two ladies that have been resting in dayroom recliners. Has required multiple redirection attempts and has been a 1:1 since before lunch. Easily redirected but will reattempt in a matter of a few minutes. Order for Olanzapine (antipsychotic) 5mg as needed provided. R2 has been sent to room on several attempts for a distraction attempt, given snack and drinks, offered activity and declined. Watching TV in both his room and dayroom, will fall asleep and when wakes up will reattempt to approach ladies again. Has been diverted away before reaching them. Progress note at 6:45 p.m., R2 has made multiple attempts to approach female resident in recliner. Immediately redirected by NA and other staff providing 1:1. Easily redirected with no behaviors but requires frequent redirection. R2's Behavior Management care plan interventions updated 2/19/26, identified 1:1 with staff with escalation of behavior of trying to touch others. During an interview on 2/18/26 at 3:15 p.m., DON stated RN-B informed her that R2 had st

Based on interview and document review the facility failed to designate a physician to serve as Medical Director. This deficient practice had the potential to affect all 52 residents currently residing at the facility.Findings include Findings include:During an interview on 2/18/26 at 10:07 a.m., director of nursing (DON) stated the former Medical Director (MD) retired in June or July and the position has yet to be filled. During a follow-up interview on 2/19/26 at 2:58 p.m., DON stated she was the only person that reviewed clinical trends, participated in Quality Assurance Performance Improvement (QAPI) clinical review.During an interview on 2/19/26 at 3:18 p.m., Administrator stated the MD position had been vacant since July 2025. Administrator indicated that the medical physician group in town would not contract physicians with the facility. The facility has attempted two other medical groups and currently is working on contract negotiations with an MD from one of the groups. Administrator had informal conversations with physicians when they would round at facility. There was no notification to the Governing Body but they are aware I talk to ownership every day. Administrator was unsure how physician-level oversight, contractual obligations, and compliance with federal requirements were achieved since July 2025.The facility Medical Director policy reviewed 3/2/25, identified: Implementation of Resident Care Policies and Procedures:admission policies and care practices.Availability, qualifications and clinical functions of staff to meet resident needs.Advance Directives and end of life care.Provisions to enhance resident decision making.Communicating/resolving medical care issues.Procedures/guidance related to practitioner notification. Coordination of Medical Care:Ensure primary/ backup physician coverage.Ensure that physician services are available to attain and maintain highest level of functioning.Address and resolve issues between physicians, practitioners and facility staff.Input to the FacilityFacilitating feedback to physicians and practitioners regarding performance/practices.Review individual resident cases as requested.Review consultant recommendations.Discuss and intervene when medical care is inconsistent with current standards of practice. The Medical Director shall meet all other responsibilities of a qualified physician, as set forth in Federal and State law and will provide copies of current licenses as necessary to the facility.To develop written by-laws, rules and regulations, which are to be approved by the governing authority and which include delineation of the responsibilities of the attending physicians.To maintain liaison with the attending physicians to ensure that orders are written by them in a timely manner (as dictated by state code and facility policy) upon admissions/readmission of a residentTo periodically evaluate the adequacy and appropriateness of the health care professionals and supportive staff and servicesTo review incidents and accidents that occurs on the premises in order to identify hazards to health and safety.To give appropriate information to the Administrator in order to ensure a safe and sanitary environment for residents, visitors and staff.To be responsible for the execution of resident care policies.Ongoing service as requested. Additional Responsibilities to include preparation of: The standards and procedures for granting and withdrawing physician appointments and privileges.A plan for medical board meetings.The provision for the required initial and periodic medical examination for all residents.The requirements for clinical recordsPresenting and attending the Quality Assurance Performance Improvement meetings

Based on interview and document review the facility failed to incorporate a Medical Director into the Quality Assurance Performance Improvement (QAPI) committee. This deficient practice had the potential to affect all 52 residents currently residing at the facility.Findings include:Review of QAPI from July 2025-Januaray 2026, identified no Medical Director was in attendance for QAPIDuring an interview on 2/18/26 at 10:07 a.m., director of nursing (DON) stated the former Medical Director (MD) retired in June or July and the position has yet to be filled. During a follow-up interview on 2/19/26 at 2:58 p.m., DON stated she was the only person that reviewed clinical trends, participated in Quality Assurance Performance Improvement (QAPI) clinical review.During an interview on 2/19/26 at 3:18 p.m., Administrator stated the MD position had been vacant since July 2025. The former MD was a quarterly attendee for QAPI and he last attended in June 2025. This would only be the second quarter the facility was missing a MD. Administrator was unsure how physician-level oversight, contractual obligations, and compliance with federal requirements were achieved since July 2025.The facility QAPI plan undated, identified:This facility shall develop, implement, and maintain an ongoing, facility-wide QAPI Plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems.Policy Interpretation and ImplementationThe objectives of the QAPI Plan are to:Provide a means to identify and resolve present and potential negative outcomes related to resident care and services;Reinforce and build upon effective systems and processes related to the delivery of quality care and services;Provide structure and processes to correct identified quality and/or safety deficiencies;Establish and implement plans to correct deficiencies, and to monitor the effects of these action plans on resident outcome;Help departments, consultants, and ancillary services that provide direct or indirect care to residents to communicate effectively, and to delineate lines of authority, responsibility, and accountability;Provide a means to centralize and coordinate comprehensive QAPI activities in order to meet the needs of the residents and the facility; andEstablish systems and processes to maintain documentation relative to the QAPI Program, as a basis for demonstrating that there is an effective ongoing program.AuthorityThe owner and/or governing board (body) of our facility shall be ultimately responsible for the QAPI Program.The Administrator is responsible for assuring that this facility's QAPI Program complies with federal, state, and local regulatory agency requirements.ImplementationThe QAPI Committee shall oversee implementation of our QAPI Plan. A QAPI Coordinator shall coordinate QAPI Committee activities, including documentation.This committee shall meet monthly to review reports, evaluate the significance of data, and monitor quality-related activities of all departments, services, or committees.The QAPI Committee shall oversee and authorize QAPI activities, including data-collection tools, monitoring tools, and the basis for and appropriateness and effectiveness of QAPI activities.The committee shall approve any corrective actions, including changes in policies and/or procedures, employment practices, standards of care, etc., and shall also monitor all corrective activities for appropriateness and/or the need for alternative measures.The committee may recommend ways to reinforce and expand identified positive approaches and outcomes to various departments or services.Individual departments or services shall develop quality indicators for programs and services in which they are involved and which affect their function.Information regarding QAPI activities is confidential and may be disclosed only in accordance with applicable laws and regulations.Departments, services, and committees shall submit their reports to the QAPI Committee as directed by the committee.EvaluationThe facility shall evaluate the effectiveness of its QAPI Program at least annually and shall present their conclusions to the owner/governing board for review.The QAPI Committee, Administrator, and the governing board shall review and approve a summary of problems and corrective measures.CoordinatorThe QAPI Coordinator shall attend and/or review minutes of meetings of other committees or departments as needed.The QAPI Coordinator will help other committees, individuals, departments, and/or services develop quality indicators, monitoring tools, criteria, and assessment methodologies, and help them identify and evaluate concerns impacting resident care and safety.The QAPI Coordinator will act as a liaison among committees, individuals, services, and/or departments regarding QAPI activities

Based on observation, interview, and record review the facility failed to comprehensively assess and treat impaired skin integrity for 1of 1 residents (R3) who had acute dermatitis. Findings include: R3's face sheet dated 4/15/25, identified diagnoses of type two diabetes, obesity. R3's admission Minimum Data Set (MDS) dated [DATE], identified no cognitive deficits. Frequent incontinence of bladder and bowel. R3's care plan dated 3/25/25, identified R3 required extensive assistance with person hygiene and toilet use. R3's care plan dated 3/31/25, identified risk for impaired skin integrity and to monitor for moisture, apply barrier product as needed. A goal dated 4/4/25 included, skin integrity would be evaluated. Corresponding intervention directed staff to evaluate skin integrity. R3's hospital discharge orders dated 3/18/25, identified an order for bacitracin-neomycin-polymyxin 5-400-5000 milligrams (mg) unit ointment and apply 1 application twice daily to rash until clear. Clotrimazole 1% cream apply topically three times per day as needed, no diagnosis indicated. Hydrocortisone butyrate 0.1% cream apply one application topically three times per day as needed for rash. Triamcinolone acetonide 0.1% cream apply topically to affected areas twice daily as needed for atopic dermatitis. Interdry AG textile to opposing skin folds for prevention or treatment of irritated skin. Change every five days or if soiled. Leave a two inch tail outside of each end of affected area to wick away moisture. R3's physician orders dated 3/18/25 identified the aforementioned physician orders according to the hospital discharge summary. Review of R3's medication administration record (MAR) for March and April 2025, identified the treatment orders but there was no indication R3's skin care treatments were applied. The admission skin assessment dated [DATE] did not identify an issues with R3's skin. R3's progress note dated 3/18/25 at 1:29 p.m., identified the note as a nurse to nurse report from hospital. Under folds increased moisture and redness. R3's progress note dated 3/19/25 at 12:22 p.m., indicated R3's rash had healed. R3's skilled evaluation progress note dated 4/9/25 at 11:43 p.m., identified no skin issues on abdomen or groin area. During an observation on 4/10/25 at 7:46 a.m., R3 was in bed. Nursing assistant (NA)-A filled basin with water and applied gloves to provide morning cares. NA-A removed R3's brief. R3's abdomen was reddened across the whole apron fold and groin area was very red on both sides. NA-A stated R3's abdomen looked a little sore/red across the whole abdominal fold and was very red in the groin area on the creases. NA-A then dried the areas she had just cleaned and applied a new incontinent brief. NA-A left the R3's room and returned to the room with an antifungal cream and an antifungal powder. NA-A stated she would use the antifungal cream as the area was not moist but leave the powder in the room also; she the applied antifungal cream to abdominal fold and groin creases. NA-A left the room, walked to registered nurse (RN)-A and notified RN-A that R3 was ready for a breakfast tray. NA-A did not mention R3's reddened folds. During an observation and interview on 4/10/25 at 12:20 p.m., registered nurse infection preventionist (IP)-A stated skin should be checked at a minimum weekly during a bath. NA's should be doing a daily check during morning and evening cares. A notable change should be reported to the nurse. IP-A explained R3 had been admitted from the hospital, the hospital had reported to the facility R3 had redness under folds and moisture, but the facility did not see that when he admitted . When the initial assessment was completed, the staff verify skin conditions, and the facility charting did not show concerns in that area. IP-A went to R3's room and put gloves on. IP-A lowered pants and lifted abdominal fold and stated that the areas were definitely red and moist. R3 indicated he had a history of problems in that area. This facility was not providing enough hygiene. The facility where he resided at prior and would be returning to had given him showers four times a week, had three times a week in a bath with jets, and used a medicated spray to manage the skin issues. This facility could not provide him with bathing due to his condition. IP-A stated the issue should have been reported to the nurse, medical doctor notified. The area needed to have the moisture removed to decrease redness. If this goes untreated it could lead to sores/infection. IP-A felt that a powder and Interdry would be a good treatment for the areas. Education should be done on cleaning and drying the folds as well. During an interview on 4/10/25 at 2:35 p.m., RN-A stated she looked at R3's skin after NA-A said to look at it because it was very sore. RN-A got busy and behind in work, IP-A also told her about R3's skin, and thought a fax was started to send to the physician. This was the first time it was reported to her that R3 had a red groin. RN-A explained skin issues would be documented under the skin section of the daily skilled charting notes. RN-A reviewed the record and identified there was nothing documented pertaining to the condition. RN-A relied on the NA's to tell her if a resident had new skin issues so that the area would be assessed. During an interview on 4/10/25 at 2:53 p.m., director of nursing (DON) stated the floor nurses have had education on what to look for with skin concerns. DON would expect the NA's to notify the floor nurse of a skin concern and the nurse would examine and determine next steps. DON was unsure if antifungal could be given as a standing order but typically would call or send a fax to the physician for orders. If care and treatment were provided improperly or not at all, nothing good could come of it. Improper treatment of wounds could lead to worsening wound(s) and if medications were given incorrectly, that could lead to a negative outcome. During an interview on 4/11/25 at 2:24 p.m., DON and IP-A stated there have been discrepancies between what the hospital reports and what the resident actually has when they enter the building regarding wounds and dressings. It was absolutely not appropriate and out of the scope of practice for an NA to choose what product to apply on a resident. The facility Wound Care procedure dated 9/29/21, identified to begin by verifying the physician order for the procedure. Document in the medical record: type of wound care given, all assessment data, etc. Report other information in accordance with facility policy and professional standards of practice.

Based on observation, interview, and record review the facility failed to monitor and complete comprehensive skin assessments, evaluate the effectiveness of interventions, and provide physician ordered treatments as prescribed to prevent or negate the risk of deterioration or new ulcer development for 1 of 3 residents (R1) who was at risk for pressure ulcers and had a history of pressure ulcers. Findings include: R1's face sheet dated 4/9/25, identified diagnoses of obesity. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified no cognitive impairment. R1 was dependent with cares on lower body. Had an indwelling urinary catheter, always incontinent of bowels. R1 had frequent pain rated 10/10 with 10 as the worst pain ever experienced. R1 had a stage III pressure ulcer which indicated full thickness tissue loss. R1 had behaviors both verbal and physical directed at others, and rejected cares frequently. R1's wound evaluation dated 3/6/25, identified the stage III pressure ulcer to right ischial tuberosity was healed. R1's care plan dated 3/23/25, identified behavior management with interventions to attempt alternative time to provide care refused, monitor for signs and symptoms of infection. Pressure ulcer care dated 10/11/24, identified educate resident about proper skin care to prevent skin breakdown, encourage to frequently shift weight, provide skin care per facility guidelines, provide wound care per treatment order. Refused to sleep in bed and sleeps in the recliner per choice. R1's Braden scale for predicting pressure ulcer risk dated 4/8/25, identified a score of 13 which indicated moderate risk for pressure ulcers. R1's physician order dated 11/25/24, include the order to apply a mixture of calmoseptime external ointment mixed with collagen fibers to bilateral buttocks topically two times per day. R1's corresponding treatment administration record (TAR) between 3/6/25 through 4/10/25 identified the calmoseptime with collegene was marked as completed, however R1's record between 3/6/25 through 4/10/25 did not include corresponding assessments and monitoring of the area for which the treatment was being applied. During an observation on 4/10/25 at 10:49 a.m., nursing assistant (NA)-A, NA-B, and registered nurse (RN)-A entered R1's room to provide cares all wearing a gown, mask, and gloves. R1 demonstrated yelling behaviors toward all three staff during the episode of care. NA-A detached the tabs of the brief. Bowel movement present. NA-A sprayed peri-wash to the dried on bowel movement. RN-A began wiping bowel movement from both buttocks with wet wipes using her right hand. R1 stated his rectal area was very sore and to be careful. R1's bottom was noted to have many small, opened, red areas with bloody discharge on the right buttock and the left buttock had a heart shaped reddened area. RN-A stated they had some cream for that and squeezed a large amount of calmoseptime cream onto her right glove and rubbed it on bilateral buttocks pressure areas. RN-A did not mix the cream with collagen sprinkles nor measure the areas on R1's bottom. R1 began to scream and yelled ouch and I told you it was sore down there! NA-A took calmoseptime cream and squeezed some on right glove and put on creases of perineal region. NA-A removed gloves and asked NA-B to get her a new pair. NA-A put new gloves on. After transferring back to the recliner NA-A, NA-B, and RN-A removed gloves and washed hands in sink. During an interview on 4/10/25 at 11:17 a.m., RN-A stated the areas on R1's buttocks are moisture related sores. The treatment was to apply calmoseptime to the areas. A medical doctor had not looked at the areas but the DON would complete the assessments. In a subsequent interview on 4/10/25 at 2:35 p.m., RN-A stated she notified DON that R1's buttocks needed to be evaluated due to a change in the wounds. RN-A verified that collagen sprinkles were not used during wound treatment. RN-A was not comfortable with wounds and staging and would refer to DON on determining what treatment would be best and what stage a pressure injury would be considered. R1 is hard because when he yells it creates a rushed environment and steps get missed. R1's late entry progress note dated 4/10/25 created at 5:39 p.m. for 11:17 a.m., identified buttocks changed in appearance and current orders are for calmoseptime. Notified director of nursing (DON) and resident agreed to lay down after supper for wound picture. Corresponding wound assessments dated 4/10/25 at 6:15 p.m., by DON identified stage III (resolved stage III) pressure injury to right ischial tuberosity measured area: <0.1 centimeters (CM), length: 0.22cm and width: 0.31 cm, no depth was identified. Left ischial tuberosity stage III (resolved stage III) pressure injury area 5.87cm, length 2.42cm, width 2.96cm, no depth was identified. Wound orders updated to apply to both buttocks: cleanse with Vashe wound cleanser, apply collagen to open areas, cover with silicone bordered foam. Change every 3 days and as needed. During an interview on 4/10/25 at 2:11 p.m., RN-B stated moisture associated skin breakdown occurs when there is excessive moisture in an area. Once there is an area that has broken down it is more susceptible to breakdown. R1 is very adamant if he does not want to do something and the staff have to really try and coax him. RN-B would notify DON, and medical doctor if a change in wounds was noted. RN-B verified she was the nurse working with R1 on 4/9/25 and signed off that calmoseptime and collagen treatment had been completed. RN-B could not recall what condition the buttocks were in on 4/9/25 and did not remember looking at the wounds. During an interview on 4/10/25 at 12:20 p.m., infection preventionist (IP)-A stated the DON completed weekly wound rounds on residents. Skin should be checked a minimum of weekly on bath days by the nurses. NA's should observe skin daily with cares and report changes to the nurse. Charting daily on the condition of wounds/wound dressing if the dressing is not scheduled to be changed is the expectation. R1 typically allowed the staff to transfer him from recliner to bed once a day. Every shift the staff encourage him to change positions. R1's current wound treatment was not appropriate for to treat R1's skin. The facility had wound training with a product specific company early in 2025 and they provided the facility with laminated cards for the NA's to direct what creams or lotions to use with specific skin issues. The DON has encouraged the nurses to come to her or the assistant director of nursing (ADON) if they were unsure about a wound. During an interview on 4/10/25 at 2:53 p.m., DON stated she observed wounds on residents weekly. RN-A informed DON to look at R1's buttocks as she was not confident in staging pressure ulcers. DON explained RN-A should have applied the treatment as ordered. Improper pericare could lead to infection and improper wound care could lead to worsening of wounds, both of which are negative outcomes. The facility Pressure Ulcers/Skin Breakdown - Clinical Protocol dated 7/12/22, identified nursing staff and physician will assess and document an individuals significant risk factors for developing pressure ulcers. The physician will order pertinent wound treatments and help identify medical interventions related to wound management. The facility Wound Care procedure dated 9/29/21, identified to begin by verifying the physician order for the procedure. Document in the medical record: type of wound care given, all assessment data, etc. Report other information in accordance with facility policy and professional standards of practice.

Based on observation, interview, and record review the facility failed to ensure appropriate care and services were provided to prevent urinary tract infections to the extent possible for 1 of 2 residents (R1) who had an indwelling urinary catheter. Findings include: R1's face sheet dated 4/15/25, identified diagnoses of overactive bladder (urgent need to urinate), atrophy of testes (shrinkage of one or both testes), benign prostatic hyperplasia (enlarged prostate) with lower urinary tract symptoms (frequent/urgent need to urinate). R1's quarterly Minimum Data Set (MDS) dated [DATE], identified no cognitive impairment. R1 was dependent with cares on lower body. Had an indwelling urinary catheter, always incontinent of bowels. R1 had behaviors both verbal and physical directed at others and rejected cares frequently. R1's care plan dated 4/4/25, identified risk for urinary retention with foley catheter to be replaced monthly and as needed. Interventions included to evaluate for urinary complaints. R1 insisted that the catheter be placed. Monitor for abdominal distention and signs/symptoms of UTI. Evaluate for pain, urinary complaints, urine characteristics and cognitive changes. R1's physician order dated 8/30/24, identified an order for a urinary catheter 16 french 10 cubic centimeters (CC) balloon be placed, changed monthly with a diagnosis of urinary incontinence. R1's progress note dated 12/5/25, identified R1 returned from emergency department with a diagnosis of acute cystitis (inflammation of bladder often caused by bacteria) with hematuria (blood in urine). Start ciprofloxacin (antibiotic) twice daily for days. Maintain foley catheter with a 24 french 10 cc balloon. R1's physician order dated 1/5/25, included an order for 24 french catheter with 10 cc balloon. During an interview on 4/10/25 at 12:20 p.m., infection preventionist (IP)-A stated she was unable to find specific culture results for the UTI but that R1 went to the emergency department for treatment on 12/5/25. R1's progress note dated 3/6/25, identified urine analysis and urine culture (UA/UC) results from 3/5/25 were positive for a UTI. Will treat with Keflex (antibiotic). During an interview on 4/10/25 at 12:20 p.m., IP-A stated the UC growth showed ecoli and enterococcis faccaeilis. Reviewed that these bacteria spread from direct or indirect contact with healthcare workers hands. R1's progress note dated 3/7/25, identified foley catheter changed, urine dark with sediment, when pulled out tubing tip was full of mucous. Located a 20 french with 30cc balloon, 24 french was not available as ordered by the physician on 1/5/25. R1's progress note dated 4/4/25, identified UA/UC was ordered due to R1 having coke colored urine with blood present, and hallucinations. R1's progress note dated 4/5/25, identified UA was collected and ready to be sent to the lab. R1's record did not include the lab results. R1's progress note dated 4/7/25, indicated a physician order for Macrobid (antibiotic) two times a day for seven days started. Repeat UA in seven days. During an interview on 4/10/25 at 12:20 p.m., IP-A stated the bacteria that grew from the UC from 4/5/25, had multiple morphotypes present. IP-A went onto the computer and looked up what mulitiple morphotypes could be caused by and stated this bacteria can also be spread by direct or indirect contact with healthcare workers hands. During an observation on 4/10/25 at 10:49 a.m., nursing assistant (NA)-A, NA-B, and registered nurse (RN)-A entered R1's room to provide cares all wearing a gown, mask, and gloves. R1 had yelling behaviors directed at staff throughout the episode of care. NA-A detached the tabs of the brief. Bowel movement present. NA-A wiped with her right hand in penile area and NA-B sprayed periwash on the dried stool dried on to and adheared to R1's bottom area. As NA-B cleaned the stool in an upward motion across R1's scrotum and by the catheter R1 yelled that it hurt. NA-A then took a wet washcloth and wiped on the groin creases and bowel movement was present on the washcloth. NA-A had NA-B rinse the washcloth in the filled water basin. NA-A took the same wash cloth from the basin and wiped the creases again. NA-A then moved to R1's penis and wiped around the catheter tip and then down the catheter tubing with the dirty washcloth. NA-A used a clean, dry towel to dry the areas. NA-A then moved the catheter tubing with her right gloved hand to move it out of the way while R1 was turned to his left side. Without changing gloves and santizing hands, NA-A took calmoseptine cream and squeezed some on right glove and put on creases of perineal region. NA-A then removed gloves and asked NA-B to get her a new pair. NA-A put new gloves on without performing hand hygiene. After transferring back to the recliner NA-A, NA-B, and RN-A removed gloves and washed hands in sink. During an interview on 4/10/25 at 12:20 p.m., IP-A stated an investigation/analysis has not been completed nor surveillance activities such as audits in order to identify potential causal factors of R1's repeated UTI's so that interventions could be developed and implemented to prevent or reduce the risk. IP-A expected staff were to perform pericare following infection control guidelines. During an interview on 4/10/25 at 2:53 p.m., DON stated there had not been surveillance activities that addressed catheter related infections. If staff were not providing personal cares appropriately, that could lead to infection. DON and the ADON would be, but have not started, working on providing education and competencies with staff on catheter cares and pericares. During an interview on 4/11/25 at 11:36a.m., DON and IP-A stated the facility will increase fluids on residents with catheters. R1 preferred to drink mountain dew and was not good at drinking water. The nurses monitor for cognitive symptoms in R1 since the UTI he currently has, he was noted to have hallucinations as a symptom. Proper hand hygiene should be performed with pericares. The facility Urinary Catheter Care dated 11/1/21, identified to maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. It is not recommended to change the indwelling catheters or bags at fixed, routine intervals and instead based on clinical indications such as infection. Observe the resident for complications associated with urinary catheters.

Based on observation, interview, and record review the facility failed to perform appropriate hand hygiene during cares for 4 of 4 residents (R3, R4, R5, and R10) observed for personal cares. Findings include: R3 R3's face sheet dated 4/15/25, identified diagnoses of intertrochanteric fracture of left femur (broken hip). R3's care plan dated 3/25/25, identified personal hygiene required extensive assistance from staff. During an observation on 4/10/25 at 7:46 a.m., R3 was in bed. nursing assistant (NA)-A filled basin with water and applied gloves. Cleansed top half of body and face. Had R3 turn to the side and wiped bowel movement with wipes. NA-A without performing hand hygiene, returned to the front of R3 and cleaned penis pulling down foreskin and wiping away white particles with a washcloth. NA-A then took off gloves and without performing hand hygiene left and returned to R3's room and without performing hand hygiene put new gloves on. NA-A instructed R3 to turn and washed bottom with wipe. NA-A then took the washcloth to remove the remaining stool from R3's bottom. NA-A put the washcloth in the water basin to rinse it out. NA-A then used that same washcloth from the dirty water and finished cleaning R3's bottom. While wearing the same gloves NA-A dried R3's bottom area and applied a new incontinent brief. Rinsed basin out in sink and emptied water into toilet. NA-A removed gloves and without performing hand hygiene gave R3 his call light and then washed her hands. R4 R4's face sheet dated 4/10/25, identified moderate intellectual disabilities. R4's care plan dated 8/20/24, identified R4 required assistance of two staff and mechanical standing lift for toileting. During an observation on 4/10/25 at 8:23 a.m., R4 was seated on the commode (portable toilet) with the mechanical standing lift attached. NA-A and NA-B applied gloves. NA-B lifted R4 into a half standing position with the machine while NA-A cleaned bowel movement from R4's bottom area. R4 stated that it was sore. NA-A stated she would put ointment on when finished wiping. NA-A moved to R4's front and wiped peri area with the same gloved hand used to wipe the backside. NA-A removed the glove after wiping, grabbed a tube of preventative ointment and applied to rectal area. Removed other glove and pulled up R4's pants and incontinent product. NA-A applied another set of gloves to clean commode. Removed gloves when finished. Both NA's washed hands at R4's sink. R5 R5's face sheet dated 4/10/25, identified fracture of upper and lower end of right fibula (broken calf bone), and fracture of medial malleolus of right tibia (the bump on the side of the ankle). R5's care plan dated 4/8/25, identified R5 required assistance of two staff and mechanical lift for transfers. During an observation on 4/10/25 at 8:10 a.m., NA-A applied enhanced barrier precautions (EBP gown, gloves, mask) and entered room. NA-B was inside R5's room and opened the door. NA-B stepped out of the room and applied EBP. R5 was in the room attached to mechanical lift on the commode. NA-A and NA-B transferred R5 from the commode to the bed and removed the mechanical lift. NA-A wiped R5's bottom. Applied pants on R5's legs and incontinent product by rolling R5 side to side. Re-attached mechanical lift to R5. Transferred R5 to wheelchair and adjusted R5's shirt and boosted back in the wheelchair to R5's comfort. Gave R5 the call light and placed overhead table in front of wheelchair. Removed EBP and sanitized hands. R10 R10's face sheet dated 4/15/25, identified diagnoses of parkinsonism (difficulties with movement). R10's care plan dated 2/17/25, identified R10 required extensive assistance with personal hygiene. During an observation on 4/10/25 at 7:06 a.m., R10 was laying in bed. NA-C filled water in a basin.Applied gloves. Asked R10 to remove dentures so they could be brushed, removed and put in container to soak during cares. Washed face and abdominal region with soap and water after removing gown. After drying R10, applied a shirt. Opened brief and cleansed peri area. Grabbed another washcloth and cleaned backside. Put on a new incontinent product. Removed gloves and put a new pair on. Put a few gloves in her pocket. Put pants on. Had R10 sit on the edge of bed, put on socks, put walker in front of him. Transferred to wheelchair. Removed gloves and sanitized hands. During an interview on 4/10/25 at 8:36 a.m., NA-B stated that handwashing is done between residents. During an interview on 4/10/25 at 9:45 a.m., NA-C stated handwashing is done in the morning, on breaks, if bowel movements are bad and messy, otherwise hand sanitizer after exiting rooms. NA-C was unaware about handwashing between removing and applying new gloves. During an interview on 4/10/25 at 9:53 a.m., NA-A stated handwashing is used after coming in contact with a resident or leaving the room. It should be done between glove changes, I forgot. During an interview on 4/10/25 at 2:35 p.m., registered nurse (RN)-A stated hand sanitizing is done throughout the day, in between glove changes. Wash hands before and after cares. During an interview on 4/11/25 at 9:47 a.m., licensed practical nurse (LPN)-A stated management monitors, teaches, and reinforces hand hygiene and the importance of handwashing between pericare. During an interview on 4/10/25 at 12:20 p.m., registered nurse infection preventionist (IP)-A stated the staff should wash or sanitize hands after glove removal and should change gloves and sanitize or handwash after cleaning the peri area whether front or back. Staff should not clean bowels and use the same gloved hand or cleaning utensil to clean the front side. During an interview on 4/10/25 at 2:53 p.m., director of nursing (DON) stated they [management] observe a ton of handwashing, applying and removing gloves that are a month or two old. Nothing good can come of improper peri care, it could lead to an infection. Hand washing and/or sanitizing should be done more often than it is apparently. We have been pushing staff to wash hands when removing gloves and use the sink, it is available in every room. If cleaning something dirty, remove gloves, wash/sanitize hands, put on new gloves, it is not worth it to cross-contaminate. The facility policy Perineal Care dated 2/8/22, identified the procedure was to provide cleanliness to the resident, prevent infections and skin irritation. For a female resident wash perineal area, wiping front to back. Wash the rectal area wiping from the base of the labia towards and extending over the buttocks. For a male resident wash perineal area starting with urethra and working outward. Wash rectal area thoroughly including under the scrotum, the anus, and buttocks.

Based on interview and document review, the facility failed to ensure 9 of 15 sampled residents (R1, R5, R7, R8, R18, R20, R28, R41, and R42) care plans were developed and able to be revised as necessary. This has the potential to affect all 56 residents. Findings include: R41's face sheet identified he was admitted to the facility in September 2024. R41 had a recent hospital stay 11/4/24 through 11/6/24 and had diagnoses of hypoparathyroidism (parathyroid glands do not produce enough parathyroid hormone and treated with medication), history of a lumbar spinal fracture, right leg fracture, right artificial hip, hypothyroidism (thyroid gland does not produce enough thyroid hormone), generalized anxiety disorder, and multiple fractures of ribs. R41's 11/25/24, quarterly Minimum Data Set (MDS) identified R41 was admitted to the facility (from the now closed sister facility) in September 2024. R1 was noted to have delusions with no behaviors identified. R41's 11/19/24, physician progress note identified the PCP noted additional diagnoses from the previous visit of chronic hepatitis C, allergic rhinitis, elevated fasting glucose, pre-diabetes, and bilateral knee pain. R41's current, undated care plan identified R41 was noted to be independent with all Activities of Daily Living (ADL), and could transfer and perform personal cares independently. Staff noted in the Behavior Management focus the goals was for undesirable behaviors to be monitored and managed. Staff were to: 1) Attempt an alternate time to provide care if refused. 2) Educate R41 and his family (FM)-A of the necessity of care. 3) Ensure the safety of R41 and others. 4) Monitor for emotional factors that may contribute to new behaviors. No other interventions were noted or documented related to how staff were to provide appropriate care to R41 with repeated refusals of medication and care. There was also no mention of interventions for additional diagnoses listed from the PCP. Interview on 3/03/25 at 11:35 a.m., with RN-E, the MDS nurse identified the care plans used to be able to be individualized. Now they are canned or pre-programmed interventions. RN-E stated it was hard to individualize the care plans. RN-E agreed R41's increased behaviors were not care-planned, nor was his Hepatitis C. It does not allow for very accurate individualization of care plans. 39988 R8's Admission Record identified R8 was admitted in June of 2023 with the following diagnoses: stroke, peripheral vascular disease, overactive bladder, history of bladder infections, benign prostatic hyperplasia with urinary tract symptoms, long term use of anticoagulant, major depressive disorder, anxiety disorder, and atrial fibrillation. R8's 1/11/25, quarterly Minimum Data Set (MDS) assessment identified R8's cognition was intact. R8 had behaviors directed towards others, had other behaviors that were not directed towards others, and rejection of care that occurred 1 to 3 days during the assessment period. R8 was dependent on staff for most cares, R8 had an indwelling Foley catheter. Re had 1 stage 3 pressure ulcer and 2 unstageable pressure ulcers. R8 had 2 venous ulcers. R8 took a daily antipsychotic, antidepressant, anticoagulant, and opioid. R8's 2/26/25, Order Summary Report identified Xarelto 20 milligrams (mg) an (anticoagulant a blood thinner that prevents blood clots) one time a day for atrial fibrillation. R8 had a pressure ulcer on his right buttocks and sacral/lumbar region, and wounds on his bilateral lower extremities. R8's February Medication Administration Record identified R8 refused dressing treatments to wounds on lower extremity 12 times and other wound treatments for sacral and buttocks 15 times R8's undated, care plan identified R8 had pressure ulcers and staff were to educate on skin care to prevent skin breakdown. Staff were to encourage R8 to frequently shift weight and wear Prevalon boots while in bed or recliner. Staff were to provide wound care as ordered. There was no mention of a scheduled repositioning regimen to heal and prevent further pressure ulcers. There was no mention of what staff were to do if R8 refused wound care. R8 took Xarelto a blood thinner and there was no mention of the blood thinner on the care plan and what side effects staff should be monitoring for and reporting to the nurse. Interview on 3/4/25 at 8:15 a.m., with medical director identified his expectation was that a resident receiving medications such as anticoagulants that the nursing staff would monitor for side effects. Review of the 9/29/21, Wound Care policy identified that staff were to notify the supervisor if a resident refused wound care. R18's Admission Record identified R18 was admitted to the facility at the end of January 2025. R18 had the following diagnoses of chronic kidney disease stage 5, anemia, type 2 diabetes mellitus, and vitamin D deficiency. R18's 1/29/25, admission MDS assessment identified R18's cognition was intact. R18 had no behavior and required moderate assistance with cares. R18 took a daily anticoagulant, diuretic, and antiplatelet. R18 attended dialysis. R18's 1/24/25, care plan identified R18 required hemodialysis related to renal failure. R18 would have interventions should she have any signs of complications from dialysis occur through the review date. Staff were to encourage her to attend dialysis. Staff to monitor her intake. Staff to monitor and report sign or symptoms of infection to her access site. Staff were not to draw blood or take a blood pressure in arm with graft. The care plan lacked identification and location of her access sight to be monitored and of dialysis schedule or where R18 attended dialysis at. The care plan further lacked identification of nutritional status and diet to be provided. R20's Administration Record identified R20 was admitted in August of 2024 with the following diagnoses: hemiplegia, dementia with other behavioral disturbance, history of stroke, diabetes mellitus type 2, anxiety, and insomnia. R20's 2/14/25, quarterly MDS assessment identified R20's cognition was moderately impaired. R20 had no behaviors and required extensive assistance with most cares. R20 took pain medication, insulin, antipsychotic, antianxiety, antidepressant, antiplatelet, and hypoglycemic medications. R20's Order Summary Report identified R20 had his blood sugar checked one time a day before breakfast, R20 took insulin glargine (long acting) 25 units QD for type 2 diabetes and Metformin HCI 1000 mg twice a day for type 2 diabetes. Monitoring of R20's blood sugars located in his Medication Administration Record for February 2025, identified documentation of blood sugar as low as 60 and as high as 366. There was no mention of R20's normal blood sugar range or when the provider should be notified for further direction if blood sugars are low or high. R20's 2/5/25, care plan identified R20 was on a regular diet and would maintain adequate national status through the review date. The facility will provide and serve diet as ordered. There was no mention on R20's care plan that he was diabetic or for staff to monitor for hypo (low) or hyper (high) glycemia (blood sugar) and when to contact the provider for further guidance. Interview on 3/4/25 at 8:15 a.m., with medical director identified his expectation was that a resident diagnosed with diabetes that the nursing staff would monitor for signs and symptoms of hypo or hyper glycemia. R28's Admission Record identified R28 was admitted in January of 2021, with the following diagnoses: retention of urine, history of bladder infections, and chronic kidney disease. R28's 2/18/25, significant Minimum Data Set (MDS) identified R28's cognition was intact, she had no behaviors and was independent with cares. R28 had an indwelling catheter. Review of R28's 3/10/21, care plan identified R28 had an indwelling catheter related to urinary retention. Staff were to place a leg bag on in the morning and a drain bag placed at night. Staff were to use enhanced barrier precautions, monitor and document intake and output per facility policy. Staff were to monitor signs and symptoms of pain due to the catheter and for signs of infection. There was no mention of how staff were to care for the Foley catheter or how often staff were to provide catheter care. Interview on 3/3/25 at 11:24 a.m., with registered nurse (RN)-B confirmed that R28's care plan had no mention of providing catheter care and how frequently. R42's Admission Record identified R42 was admitted to the facility in August of 2024. R42 had the following diagnoses of type 2 diabetes mellitus, end stage renal disease, cirrhosis of liver, and history of traumatic fractures. R42's 2/19/25, quarterly MDS assessment identified R42's cognition was intact. R42 was dependent on staff for most cares. R42 had some behaviors towards others and rejection of care. R42 took insulin daily, an antidepressant and antiplatelet daily. R42 attended dialysis. R42's undated, care plan identified nutritional status as resident will consume 75% of meals and to modify diet as appropriate according to the resident's food tolerances and preferences. R42's care plan lacked identification that R42 was on dialysis, the location of an access site, any precaution that may be needed, or for any monitoring of an access site. The care plan lacked R42's dialysis schedule or where R42 attended dialysis. R42's 3/4/25, Order Summary Report identified R42 was on a renal diet. The order summary lacked identification of dialysis access site monitoring and lacked dialysis schedule. 47497 R1's Medical Diagnosis list from 3/3/25, identified R1 had a diagnosis of chronic atrial fibrillation and acquired coagulation factor deficiency. R1's 12/17/24, significant change Minimum Data Set (MDS) assessment identified she admitted to the facility in September of 2024, her cognition was severely impaired and was dependent on staff for activities of daily living (ADL)'s. R1 was taking an anticoagulant. R1's March 2025, administration record identified she was administered Warfarin daily. Administration record made no mention that staff should monitor for signs or symptoms of bleeding related to use of an anticoagulant. Review of R1's undated care plan had no mention of anticoagulant use, signs or symptoms to watch for such as bleeding or bruising, or what and when to report to the nurse. R7's 1/31/25, significant change Minimum Data Set (MDS) assessment identified her cognition was intact. R7 reported she had little interest or pleasure in doing things, she felt down and depressed, and had no energy nearly every day. R7 had physical impairments on both sides and was dependent on staff for ADL's. She had diagnosis of diabetes, dementia, anxiety, depression, pressure ulcer to the right buttock and right heal. R7 used antipsychotics and antidepressants on a routine basis, she used pain medication daily. Continuous observation on 3/3/25, from 4:00 p.m. through 6:15 p.m. 4:00 p.m., R7 was seated in her wheelchair in the common/dining area at a table. She had pressure relieving boots on her feet the right boot extends to several inches below the knee, and the left boot was misplaced above the ankle, skin was visible below the boot. She had a cushion under her right elbow. Her legs were not elevated, her feet were on the floor and her chair did not have foot pedals. R7 had slid down in her chair and was leaning back with eyes closed. 4:19 p.m., R7 remained in her wheelchair, awake, and in the same position. 4:30 p.m., R7 remained in her wheelchair, awake, and in the same position. She stopped several staff to visit with them, however, none of the staff offered to reposition her and did not prompt her to adjust her position in her chair. 4:50 p.m., she remained in her wheelchair, in the same position. The facility social worker designee sat next to her, R7 complained that her wrist hurt. 4:58 p.m., staff offered R7 pain medication for her wrist. 5:21 p.m., a CNA brought a warm pack to R7 and placed it on her wrist. She did not offer to reposition her or encourage her to adjust her position in her chair. 5:24 p.m., Facility staff brought R7 her supper meal tray. R7 told staff she wanted to eat in her room, staff returned her tray to the cart. 5:28 p.m., staff are bringing her back to her room, R7's feet are dragging on the floor. They stop after about 20 feet and another staff assists by lifting her legs up and they bring R7 back to her room wheeling backwards. They were discussing that they cannot find the foot pedals for her wheelchair. Interview at 5:30 p.m., with nursing assistant (NA)-D reported R7 had another wheelchair that is larger, however, she does not like to use it unless she is going out for an appointment. She reports that she delivered her room tray and that it was unusual that she was out in the common area as she normally stays in her room. Observations continue: 5:35 p.m., R7 was in her room, she remained seated in her wheelchair. She was in front of her overbed table and had her meal tray in front of her. 5:55 p.m., staff entered R7's room, nursing assistants asked her if she was going to eat anything, R7 told staff to take her tray. nursing assistant offered other food options, R7 agreed to try some pudding. The staff left the room. The nursing assistant did not offer to reposition R7. 6:15 p.m., R7 remained in her room, seated in her wheelchair. Staff were in and out of her room several times, however, they did not offer to reposition her. Interview on 3/3/25, at 6:15 p.m., With RN-B identified she was unsure how often R7 should be repositioned. She reviewed R7's care plan and identified she does not have scheduled repositioning. She reported she thought R7 had been up in her wheelchair since 1:00 p.m., she stated she had been out in the day room all afternoon. She identified that she would direct staff to reposition R7. R7's 2/11/25, wound consultant note identified R7's skin to left and right heel is dark red, purple, blistered, and open. Open area to right heel medial is a stage 3, the area on the right heel is a deep tissue injury the right lateral foot is also a deep tissue injury, and the left heel is a deep tissue injury all are secondary to pressure. The wound consultant note identified that in addition to the current interventions in place staff were to implement scheduled repositioning every 2 hours. Review of R7's undated care plan identified R7 had a pressure ulcer and staff should keep skin clean, monitor ulcer for signs of progression or declination, provide wound care per treatment order and encourage her to frequently shift weight. Staff should reposition R7 as she allows. The care plan made no mention of how often staff should reposition her. Interview on 3/4/25 at 8:15 a.m., with medical director identified his expectation was that a resident receiving medications such as anticoagulants that the nursing staff would monitor for side effects, in addition he would expect residents who are at risk for or have a pressure ulcer would be repositioned or at minimum be offered repositioning on a scheduled basis. 49336 R5's 122/25, Significant Change Minimum Data Set (MDS) identified was cognitively intact and was dependent on staff with cares and was incontinent of bowel and bladder. R5 had a diagnoses of atrial fibrillation, diabetes, anxiety, depression. R5 had a unhealed, unstageable deep tissue pressure ulcer that was present upon admission/entry or re-entry and was to receive surgical wound care and application of dressing to feet. R5's, March Summary Report identified R5 was to cleanse the wound with normal saline, apply medihoney gel to both areas of the right foot and cover with foam dressing every 3 days and as needed. R5's current, undated care plan identified: 1) R5 had stage 3 pressure ulcer, and the goal was to promote wound healing. Staff nurses were to measure pressure ulcers regularly, monitor for signs and symptoms of infection and provide wound care treatment. 2) R5 had a right foot big toe amputation, as well as skin impairment to the lateral (side) of the 5th digit of R5's right foot. Staff nurses were to apply Prevalon boots to R5's foot in bed and in wheelchair, and to use caution for transfers and mobility to prevent striking R5's arms, legs, and hands against sharp surfaces. 3) R5 was at risk for activities of daily living (ADLS) and the goal was to monitor for R5's improvement. R5 was to ask for assistance from staff if R5 required repositioning or elevation to meet R5's needs to prevent injury. There was no mention on the care plan of R5's refusals of care or scheduled repositioning. R26's 1/08/25, quarterly Minimum Data Set (MDS) identified R26 had a moderate cognitive impairment and had a diagnoses of diabetes, hypertension, arthritis, and seizures. R26 had orders for insulin and received insulin during the last 7 days of the look back period. R26's, February Order Summary Report sheet identified R26's blood sugar was to be checked twice a day and was to receive glargine (long-acting insulin) 22 units subcutaneously (fatty layer between the skin and muscle) at bedtime. R26's current, undated care plan made no mention in R26's care plan of diabetes management, as well as, protocols for hyperglycemia or hypoglycemia monitoring. R37's 1/15/25, admission Minimum Data Set (MDS) identified R37 was cognitively alert and required substantial/maximal assistance with activities of daily living (ADLs). R37 had a diagnoses of malnutrition, anxiety, diabetes and cirrhosis. Upon admission, R37 had a stage 3 and stage 4 pressure ulcer and required non-surgical dressings to R37's bilateral feet. R37's, March Order Summary identified: 1) bilateral heel wounds was to be cleansed with Vashe (wound cleanser), apply purocol plus to wound bed, cover with dry gauze, secure with kerlix and ace wrap every 2 days. 2) apply betadine swabsticks 10% povidone-Iodine to right plantar (bottom surface of the foot) daily. R37's current, undated care plan identified R37 goal was to promote wound healing and staff nurses were to administer antibiotic therapy as prescribed and provide wound care treatments as ordered. There was no mention on the care plan of what wound care treatments was to be followed. The facilities 11/30/21, Care Plans, Comprehensive Person-Centered policy identified the comprehensive person-centered care plan would describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, and incorporate risk factors associated with identified problems. Assessments of residents are ongoing, and care plans are revised as information about the residents and residents condition change.

Based on observation, interview, and document review, the facility failed to ensure the ice machine, kitchen and food prep areas were kept clean and sanitary. This has the ability to affect all 56 residents. Findings include: Observation and interview on 2/25/25 at 7:15 a.m., during the initial kitchen tour a stainless-steel food prep counter across from the stove had a lower shelf directly below. The lower shelf was used to store cutting boards, oatmeal, oil, cooking spray, and small cups used for serving condiments. The shelf had a dry black/brown substance on it and a brown liquid substance covering a large area of the shelf. In addition, approximately the first 3-5 inches from the edge of the shelf nearest to the stove and covering the full length of the shelf had a greasy, sticky build-up. The area had dirt and grime stuck to the greasy area. The shelf had a plastic container containing condiment cups, the container was visibly dirty with unknown brown substance. Food crumbs could be seen laying in the bottom of the container. On 2/25/25 at 4:45 p.m., during a follow up observation of the kitchen, identified cook-C was sitting on the freezer using her cellular phone. Interview on 2/25/25 at 4:45 p.m., with cook-C agreed with the above finding and identified they were not supposed to be sitting on the freezer as this area was at times used to set food on, in addition she identified they were not supposed to use their cell phones in the kitchen as this could be a source of cross contamination. Interview on 2/26/25, at 10:28 a.m., with the dietary manager (DM), she agreed with the concerns regarding the cleanliness of the kitchen, she identified that staff are signing off that they completed the cleaning, she reported that she may need to do some re-training with staff and she may have to be more specific on her cleaning logs as to what staff are expected to clean. Interview on 3/3/25 at 4:45 p.m., with the registered dietitian (RD), identified she would expect staff to only use their cell phone while on break and in the staff break room. Personal items such as cell phones should be left in a locker and not brought into the kitchen. She identified this practice could potentially cause cross contamination with food. In addition, she would not expect staff to use the chest freezer as a seating area. She identified that she has not completed any visual audits of the kitchen and was not aware of the lack of cleanliness. She would expect the dietary manager to be auditing regularly and ensuring the daily cleaning is completed properly. Observation on 2/26/25, at 8:40 a.m., of the ice machine located in a hallway connecting the main building with a house where offices were located. The ice machine had a white crusty buildup (like mineral deposits) visible from the outside of the machine located between the plastic hinged lid/door and the machine. inside the door at the top of the opening just above the ice bin, a strip of metal had a black/gray/brown spotty build up going all the way across. Some of the buildup was removable with a dry paper towel and friction rubbing the area. Interview on 2/25/25 at 8:40 a.m., with the Maintenance director identified he had been working in the building since last fall when they closed the other facility. He reported he does not keep a log of when he cleans and de-scales the ice machine, when it comes up in tells I clean it. He cleans it about every 6 months and does a deep clean about once a year. He reported it had been de-scaled last August of 2024 and cleaned a little before thanksgiving. Review of the Manitowok Indigo Ice Machine Manufacturer Installation, Use, and Care Manual identified the ice machine should be cleaned and sanitized every 6 months. Review of the General Sanitation of Kitchen policy identified the kitchen cleaning schedule with be outlined in writing, tasks will be assigned to the responsibility of a specific position, frequency of cleaning for each task will be defined. Employees will initial, and date when the task was completed.

Based on interview and document review, 1 of 1 Governing Body failed to provied appropriate oversight to ensure deficient practice had been corrected and coompliance achieved. Refer to F636, F656, F684, F758, F812, F842, F865, F880, F882, and F944. Findings include: Review of the QAPI meeting minute attendance from the 3/25/25 QAPI Meeting (meetings are held monthly) identified attendees present were the administrator, the director of nursing (DON) the assistant director of nursing (ADON), the infection preventionist (IP) the social services designee (SSD) and the pharmacist. The medical director was absent for this meeting. During the meeting, topics discussed were as follows: 1) Pressure Ulcers: There were 14 active pressure ulcers involving 5 residents. The facility goal was to have 5% pressure ulcer rate. Current facility percentage was left blank. After discussion, actions present were the facility was working on care plans and turning and repositioning, working on healing wounds. There was no measurable action or presentation of evaluation of the data to define commonalities such as where pressure ulcers were located on residents, possible causes, co-morbidities, areas for improvement, or potential education to staff or audits that should occur in order to achieve compliance. 2) Falls: There were a total of 16 falls in February. 2 documented minor injuries. There was no goal or current facility percentage listed. Actions identified were staff reviewed all care plans (CP) causative factors were reviewed. Isolation was a top contributor; however possible urinary tract infections (UTI) were noted as well. Staff were still looking at R1 t see if she could be care planned to safe transfers from bed in the lowest position as it seemed to be when she had been found on the floor. It was not plausible at that time. No other factors were identified or discussed such as time of day, residents requiring increased supervision, staff competence with transfers etc. 3) Infection control and antibiotic stewardship: There was no facility goal or current benchmark listed. There were 39 active cases of infection the previous month with 22 respiratory (26 new) with COVID, pneumonia, and RSV identified. 4 UTI, 1 case of bone infection, and 2 others noted but not identified. Actions taken were to continue isolation and testing and keeping residents on droplet precautions. It was noted they were working on getting the IP classes in infection control and surveillance, working on appropriate personal protective equipment (PPE) audits and handwashing. It was noted to continue for the foreseeable future There was no indication it had been discussed how the facility was to ensure the IP had received time to complete her training, who was in charge of oversight until that occurred, or how the facility was to achieve their goal or what education may be needed or evaluation of actions already in progress. 4) Plan of correction (deficiencies from the previous survey): Auditing for compliance with previous deficient practice had begun. Another area identified was regarding psychotropic diagnosis. Actions identified QAPI was to create/locate resources for training that could be implemented within the organizational structure. A few residents need to have their diagnoses reviewed and updated to ensure they had the appropriate diagnoses. There was no indication to identify any goals, or plans of action noted as to how the facility was going to achieve compliance, who was designated to oversee compliance of certain areas, or how they would achieve compliance noted as discussed. 5) Open positions: There were 20 positions open. There was no facility goal or current status noted, nor was there any discussion of how QAPI would work toward filling positions. There was also no mention of how staff shortages were affecting care at the facility, if staffing was being maintained according to positions noted to be required in the facility assessment in order to care for residents, or if the shortages had affected other areas such as the high number of pressure ulcers or resident falls etc 6) Grievances/Abuse reporting: 2 grievances were noted for call light response, 3 involving cares, 1 for environment, and 1 for diet. Actions noted were: a) A call light audit was run, and education was to continue with staff. Audits showed an average of a 10-minute response time, however, there was no indication staff had observed call lights to ensure the electronic data was accurate and staff were not simply shutting off the light. 1 family reported the light was on for an extended time and made her worry that if it was related to something serious, the resident could have a poor outcome. There was no indication what was an acceptable call light wait time was, how long or what the results identified were, or it the long wait times could have been a result of a lack of staff availability. b) Cares: A family felt care wasn't being provided to their standards. The care plan was changed to reflect requests. 1 resident felt staff treated her differently as she must wait longer for care. A meeting was held with family and the county case worker. Another family had voiced concerns over staff knowledge. c) Diets: A resident continued to be served food that are listed as foods she can't have. Staff had been educated and signed an understanding of the food identified. There was no indication QAPI identified competencies may be warranted if this was an ongoing issue. d) Antipsychotic Use: The facility goal was to have no more than 15%. there was no indication on what the present percentage was. Discussion: there was roughly 21% of antipsychotic medications used in the facility. Information was presented to the assistant DON (ADON) by the pharmacist (RPh). The notes included the last gradual dose reduction (GDR) and when drugs had been started. This was noted to help the MDS and keeping things more organized. There was no indication staff had reviewed deficiency related information regarding to correct diagnoses or if the pharmacist had reviewed all residents affected as part of his contractual service. e) Other areas: were noted in QAPI for Adverse events, resident immunizations, abuse allegations etc. Those areas also lacked thorough analysis of data. f) Emergency Meeting: Discussion was left blank. Action identified were each tag cited for the recertification survey previous to this survey. Audits were noted to be going forward from that point on to identify deficient practice. No staff were designated to make sure actions identified by the facility had been completed, residents identified or found to be at risk reviewed etc. QAPI identified the QAPI program deficiency cited needed to be more cognizant about documentation that reflects accuracy; however, no plan had been placed to ensure its completion by 4/3/25 (the completion date listed on the plan of correction) would occur. Interview and document review on 4/8/25 at 1:02 p.m., with the administrator identified he indicated the QAPI committee met to discuss the results of their previous survey. He had not provided oversight himself, as the regional nurse consultant was responsible to write the POC and determine what steps were necessary to ensure compliance. He noted the facility had such a short window to get deficient practice corrected. He was unaware the DON and ADON had not ensured the IP had time to complete her education to be able to oversee the infection control (IC) program independently, nor was he aware the DON and ADON were not providing direct oversight of the program until the IP was trained and deemed competent. The administrator also agreed he was ultimately responsible to ensure staff such as the director of nursing (DON), had provided the appropriate oversight to ensure all items identified in their POC were implemented to correct the deficient practice. The facility had educated staff to the policies, but agreed meaningful education and competencies to check staff had understood the education and applied it correctly had not occurred. He also had not ensured staff were educated to what the facility's specific QAPI plans, and monitoring was, nor had he ensured they were educated to the QAPI 's new PIP programs. He identified the facility was planning to change how they did QAPI to ensure they could be compliant with analyzing data, and providing oversight of any deficient practice, education, etc., but that had not occurred yet. Review of the 1/29/25, QAPI Policy identified the facility was to maintain a QAPI committee for continuous quality improvement and overall performance. One of QAPI's objectives was to establish and implement plans to correct deficiencies, and to monitor the effects of these actions plans on resident outcome. The governing body shall be ultimately responsible for the QAPI program.

Based on interview and document review, 1 of 1 Governing Body failed to provied appropriate oversight to ensure deficient practice had been corrected and coompliance achieved. Refer to F636, F656, F684, F758, F812, F842, F865, F880, F882, and F944. Findings include: Review of the QAPI meeting minute attendance from the 3/25/25 QAPI Meeting (meetings are held monthly) identified attendees present were the administrator, the director of nursing (DON) the assistant director of nursing (ADON), the infection preventionist (IP) the social services designee (SSD) and the pharmacist. The medical director was absent for this meeting. During the meeting, topics discussed were as follows: 1) Pressure Ulcers: There were 14 active pressure ulcers involving 5 residents. The facility goal was to have 5% pressure ulcer rate. Current facility percentage was left blank. After discussion, actions present were the facility was working on care plans and turning and repositioning, working on healing wounds. There was no measurable action or presentation of evaluation of the data to define commonalities such as where pressure ulcers were located on residents, possible causes, co-morbidities, areas for improvement, or potential education to staff or audits that should occur in order to achieve compliance. 2) Falls: There were a total of 16 falls in February. 2 documented minor injuries. There was no goal or current facility percentage listed. Actions identified were staff reviewed all care plans (CP) causative factors were reviewed. Isolation was a top contributor; however possible urinary tract infections (UTI) were noted as well. Staff were still looking at R1 t see if she could be care planned to safe transfers from bed in the lowest position as it seemed to be when she had been found on the floor. It was not plausible at that time. No other factors were identified or discussed such as time of day, residents requiring increased supervision, staff competence with transfers etc. 3) Infection control and antibiotic stewardship: There was no facility goal or current benchmark listed. There were 39 active cases of infection the previous month with 22 respiratory (26 new) with COVID, pneumonia, and RSV identified. 4 UTI, 1 case of bone infection, and 2 others noted but not identified. Actions taken were to continue isolation and testing and keeping residents on droplet precautions. It was noted they were working on getting the IP classes in infection control and surveillance, working on appropriate personal protective equipment (PPE) audits and handwashing. It was noted to continue for the foreseeable future There was no indication it had been discussed how the facility was to ensure the IP had received time to complete her training, who was in charge of oversight until that occurred, or how the facility was to achieve their goal or what education may be needed or evaluation of actions already in progress. 4) Plan of correction (deficiencies from the previous survey): Auditing for compliance with previous deficient practice had begun. Another area identified was regarding psychotropic diagnosis. Actions identified QAPI was to create/locate resources for training that could be implemented within the organizational structure. A few residents need to have their diagnoses reviewed and updated to ensure they had the appropriate diagnoses. There was no indication to identify any goals, or plans of action noted as to how the facility was going to achieve compliance, who was designated to oversee compliance of certain areas, or how they would achieve compliance noted as discussed. 5) Open positions: There were 20 positions open. There was no facility goal or current status noted, nor was there any discussion of how QAPI would work toward filling positions. There was also no mention of how staff shortages were affecting care at the facility, if staffing was being maintained according to positions noted to be required in the facility assessment in order to care for residents, or if the shortages had affected other areas such as the high number of pressure ulcers or resident falls etc 6) Grievances/Abuse reporting: 2 grievances were noted for call light response, 3 involving cares, 1 for environment, and 1 for diet. Actions noted were: a) A call light audit was run, and education was to continue with staff. Audits showed an average of a 10-minute response time, however, there was no indication staff had observed call lights to ensure the electronic data was accurate and staff were not simply shutting off the light. 1 family reported the light was on for an extended time and made her worry that if it was related to something serious, the resident could have a poor outcome. There was no indication what was an acceptable call light wait time was, how long or what the results identified were, or it the long wait times could have been a result of a lack of staff availability. b) Cares: A family felt care wasn't being provided to their standards. The care plan was changed to reflect requests. 1 resident felt staff treated her differently as she must wait longer for care. A meeting was held with family and the county case worker. Another family had voiced concerns over staff knowledge. c) Diets: A resident continued to be served food that are listed as foods she can't have. Staff had been educated and signed an understanding of the food identified. There was no indication QAPI identified competencies may be warranted if this was an ongoing issue. d) Antipsychotic Use: The facility goal was to have no more than 15%. there was no indication on what the present percentage was. Discussion: there was roughly 21% of antipsychotic medications used in the facility. Information was presented to the assistant DON (ADON) by the pharmacist (RPh). The notes included the last gradual dose reduction (GDR) and when drugs had been started. This was noted to help the MDS and keeping things more organized. There was no indication staff had reviewed deficiency related information regarding to correct diagnoses or if the pharmacist had reviewed all residents affected as part of his contractual service. e) Other areas: were noted in QAPI for Adverse events, resident immunizations, abuse allegations etc. Those areas also lacked thorough analysis of data. f) Emergency Meeting: Discussion was left blank. Action identified were each tag cited for the recertification survey previous to this survey. Audits were noted to be going forward from that point on to identify deficient practice. No staff were designated to make sure actions identified by the facility had been completed, residents identified or found to be at risk reviewed etc. QAPI identified the QAPI program deficiency cited needed to be more cognizant about documentation that reflects accuracy; however, no plan had been placed to ensure its completion by 4/3/25 (the completion date listed on the plan of correction) would occur. Interview and document review on 4/8/25 at 1:02 p.m., with the administrator identified he indicated the QAPI committee met to discuss the results of their previous survey. He had not provided oversight himself, as the regional nurse consultant was responsible to write the POC and determine what steps were necessary to ensure compliance. He noted the facility had such a short window to get deficient practice corrected. He was unaware the DON and ADON had not ensured the IP had time to complete her education to be able to oversee the infection control (IC) program independently, nor was he aware the DON and ADON were not providing direct oversight of the program until the IP was trained and deemed competent. The administrator also agreed he was ultimately responsible to ensure staff such as the director of nursing (DON), had provided the appropriate oversight to ensure all items identified in their POC were implemented to correct the deficient practice. The facility had educated staff to the policies, but agreed meaningful education and competencies to check staff had understood the education and applied it correctly had not occurred. He also had not ensured staff were educated to what the facility's specific QAPI plans, and monitoring was, nor had he ensured they were educated to the QAPI 's new PIP programs. He identified the facility was planning to change how they did QAPI to ensure they could be compliant with analyzing data, and providing oversight of any deficient practice, education, etc., but that had not occurred yet. Review of the 1/29/25, QAPI Policy identified the facility was to maintain a QAPI committee for continuous quality improvement and overall performance. One of QAPI's objectives was to establish and implement plans to correct deficiencies, and to monitor the effects of these actions plans on resident outcome. The governing body shall be ultimately responsible for the QAPI program.

Based on interview and document review the facility failed to implement 1 of 1 facility assessment protocol related to ensuring staff competencies were identified and completed respective to staff duties performed. This has the ability to affect all 56 residents. Findings include: Interview on 3/04/5 at 8:15 a.m., with medical director voiced agreement the facility was to review, identify and determine appropriate interventions and oversight of outcomes brought forth Interview on 3/04/25 at 2:26 p.m., with administrator identified the merge of two nursing homes, that included residents and staff, added an extra layer of challenges the facility was currently navigating. He identified updates of the facility assessment, had not yet been implemented, including staff education. However, He identified there was decisions made in relation to resident cares, resources and services that were to relay to all staff the facility's operational goals and performance improvement projects (PIP). Review of August 2024 Facility Assessment Tool identified the leadership team would discuss goals to ensure direct care staff are trained to provide services to residents. The facility identified staff education, training, certifications, testing, and facility policies to support the care needed for the residents. In addition, the facility would gather input from residents, family members and staff of concerns and expectations that would meet residents needs through regulatory, operational, maintenance and staff training requirements. Lastly, the facility would review resources annually, and would evaluate day to day operations, including emergencies, to identify and act on opportunities for improvement and to ensure residents care maintain their highest practicable physical, mental and psychosocial well-being.

Based on interview and document review, the facility failed to ensure data submitted to 1 of 1 Quality Assurance Performance Improvement (QAPI) committee was analyzed and documented to ensure areas identified had oversight for their perspective outcomes brought forth. This had the potential to affect all 56 residents. Findings include: Review QAPI minutes from February 2024 through January 2025, identified department heads were bringing data forth to QAPI on various topics such as infection control, falls, incident reports, vaccinations, etc. However, there was no documented benchmarks for goals the facility was trying to achieve, nor monitoring to determine if goals were met or QAPI needed to continue monitoring to ensure compliance. Interview on 3/04/5 at 8:15 a.m., with medical director voiced agreement the facility was to review, identify and determine appropriate interventions and oversight of outcomes brought forth. Interview on 3/04/25 at 2:09 p.m., with administrator identified the merge of two nursing homes, that includes residents and staff, added an extra layer of challenges the facility was currently navigating. He identified there was no measurable goals set, or if goals were met to improve areas identified in QAPI. He and the QAPI committee would need to formalize a process to identify improvements that would reflect changes as needed in QAPI. Review of December 20219 Quality Assurance and Performance Improvement (QAPI) policy identified the facility would review clinical and nonclinical systems to determine areas of improvement. The facility's performance improvement project (PIP) was identified in areas that were unique to the facility's needs. The QAPI committee would establish benchmarks to determine facility improvements, analyze data for accuracy and determine root cause. Lastly, the QAPI committee would modify QAPI template, as well as the facility assessment as needed to identify complexities and/or evolving resources and services.

Based on interview and document review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify facility specific concerns, implement an action plan to correct the identified concerns or to ensure the committee participated in the development and oversight of implementation of systems, and to ensure quality of life and quality of care were maintained for 57 residents residing in the facility. Findings include: Review of QAPI minutes from February 2024 to January 2025, identified on 4/19/24 the facility was to implement a performance improvement project (PIP) of abuse allegations. There was no mention on how the facility would meet goals, monitor progress or evaluate current measures to ensure compliance. Interview on 3/04/5 at 8:15 a.m., with medical director voiced agreement the facility was to review, identify and determine appropriate interventions and oversight of outcomes brought forth. Interview on 3/04/25 at 2:26 p.m., with administrator identified the merge of two nursing homes, that includes residents and staff, added an extra layer of challenges the facility was currently navigating. He identified there were challenges and improvements related to resident cares, resources and services to be streamlined and identified in QAPI. He identified the facility had no performance improvement projects in place at this time. Review of December 20219 Quality Assurance and Performance Improvement (QAPI) policy identified the facility would review clinical and nonclinical systems to determine areas of improvement. The facility's performance improvement project (PIP) was identified in areas that were unique to the facility's needs. The QAPI committee would establish benchmarks to determine facility improvements, analyze data for accuracy and determine root cause. Lastly, the QAPI committee would modify QAPI template, as well as the facility assessment as needed to identify complexities and/or evolving resources and services.

Based on observation, interview, and document review the facility failed to implement infection control strategies for respiratory protection to mitigate the risk and spread of Respiratory Syncytial Virus (causes infections of the respiratory tract) (RSV). As a result, the facility developed an outbreak where 13 residents (R4, R10, R5, R1, R14, R3, R2, R7, R8, R15, R13, R16, and R12) tested positive for RSV, and 7 residents were suspected to have RSV (R17, R19, R18, R21, R20, R6, R9); 3 residents (R4, R5, and R10) had to be seen in the emergency room , and 2 residents (R7, and R8) were hospitalized with RSV. These practices resulted in an immediate jeopardy (IJ) due to the likelihood of spread to the remaining 48 residents in the facility. The IJ began on 12/28/24, when the facility failed to implement infection control strategies to mitigate the risk and spread of RSV in the facility. The Administrator, director of nursing (DON) (by phone), clinical nurse consultant (CNC)-A (by phone), Infection Preventionist (IP)-A, clinical manager (CM)-A, and assistant DON (ADON) were notified of the IJ on 1/14/24 at 5:37 p.m. The immediate jeopardy was removed on 1/15/25 at 2:49 p.m., but noncompliance remained at the lower scope and severity level F, which indicated no actual harm with the potential for more than minimal harm that is not immediate jeopardy. Finding include: Isolation: Isolation separates sick people with a contagious disease from people who are not sick. Quarantine separates and restricts the movement of people who were exposed to a contagious disease to see if they become sick. Personal protective equipment (PPE): Personal protective equipment (PPE) refers to protective items or garments worn to protect the body or clothing from hazards that can cause injury and to protect residents from cross-transmission. These items may include a gown, gloves, eye protection and face mask. Enhanced barrier precautions (EBP): refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. Gowns and gloves are used as PPE. Transmission based precautions (TBP): refer to actions (precautions) implemented in addition to standard precautions that are based upon the means of transmission (airborne, contact, and droplet) in order to prevent or control infections. Airborne, contact and droplet are the three subcategories under TBP. Contact precautions: refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment. Use with gloves, and gowns as PPE. Droplet precautions: refer to actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions, masks are used as PPE. During an observation and interview on 1/10/25 at 8:30 a.m., registered nurse clinical manager (RNCM)-A stated the facility had Respiratory Syncytial Virus (RSV) and instructed staff to wear surgical masks. No signs were posted in the foyer or entrance area to alert visitors to wear a mask in facility. Fifteen residents were sitting in the dining room with 3-4 residents sitting at each table. No masks were on the residents. The facility staff were masked with surgical masks. Upon entrance to the dining room an unidentified nursing assistant (NA) moved the mask from under his chin to cover his nose and mouth while walking between residents. During an interviews on 1/10/25 at 2:06 p.m., infection Preventionist (IP)-A stated the first case of RSV was identified on 12/28/24 (R4) and had a total of seven positive cases to date with a new case identified today 1/10/25 (R2). R4 RSV positive on 12/28/24 R4's medical diagnoses dated 1/16/25, identified congestive heart failure (heart cannot pump blood well enough to meet the body's needs), and dependence on supplemental oxygen. R4's hospital ED note dated 12/28/24, identified R4 was seen due to cough and shortness of breath. R4 had known chronic obstructive pulmonary disease (COPD) and may have a COPD exacerbation. R4's ED identified RSV test was positive and likely the cause of the COPD exacerbation. There was no indication in the medical record, R4 was placed on isolation precautions (Droplet, contact precautions) with PPE upon return from the ED, even though they were diagnosed with RSV. R4's progress note dated 1/6/25, identified R4 had complained of coughing up small amounts of blood clots. Examined the clots to be mucous clots tinged with blood related to R4's harsh cough. The progress note identified R4 was off isolation precautions for RSV today however, the record did not identify precautions had been implemented. R4's progress note dated 1/9/25, identified R4 needed oxygen at 2 liters/min for shortness of breath with activity. R4's physician orders identified had an order for as needed oxygen. R4's medication administration record identified in December oxygen was used eleven times and in January used on 1/5/25, 1/9/25, and 1/13/25. R4's progress notes dated 1/10/25, identified R4 stated that every time he breathed in it makes him cough and lung sounds with crackles. At 5:30 a.m. R4 was transferred to the hospital due to non-stop coughing. At 1:30 p.m. R4 returned from hospital with diagnoses of RSV, that had continued from 12/28/24. R4's progress note dated 1/13/25, identified R4's cough was at baseline and will be removed from droplet precautions. R4's record did not identify precautions had ever been implemented. R4's respiratory symptom screeners between 1/11/25-1/15/25, identified R4 had a cough on all days between 1/12/25 through 1/15/25. R10 RSV positive on 12/31/25 R10's face sheet dated 1/15/25, identified diagnoses of hypoxemia (low oxygen) and diabetes. R10's progress notes identified the following: -12/28/24, R10 did not feel well and was coughing. -12/30/24, R10 required nebulizer treatment for wheezing. -12/31/24, indicated R10 had adventitious lung sounds, pain when breathing, nasal congestion, left ear pain, and cough. R10 was sent to the emergency department (ED). R10's ED note dated 12/31/24, identified R10 was positive for RSV and diagnosis of acute bronchiolitis (inflammation of bronchi in the lungs) due to RSV. R10 came to ED with complaints of a cough and feeling ill for more than 10 days and getting worse. R10 stated the cough occurred constantly and had been gradually getting worse. R10's progress note dated 12/31/24, identified ED called facility to notify of positive RSV test. Isolation precaution sign and tray/cart for personal protective equipment (PPE) was set up. Vital signs obtained on return from ED. R10's physician visit note dated 1/9/25, identified R10 continued with a persistent cough after RSV infection and will be taken off isolation today. Increased Duo Neb to three times daily for 7 days. R10's respiratory assessments between 1/11/25 through 1/4/25, identified R10 had diminished lung sounds on 1/12/25. R10's record reviewed between 12/28/24 through 1/13/25, identified R10 had respiratory illness symptoms that began on 12/28/24. R10's record and facility surveillance did not identify immediate implementation of TBP (transmission based precautions) nor ongoing consistent symptom monitoring between 12/28/24 through 1/10/25. R5 RSV positive on 1/2/25 R5's face sheet dated 1/16/25, identified diagnoses of diabetes mellitus type 2, and chronic kidney disease (condition where kidneys have been damaged). R5's progress note dated 12/26/24, identified R5 complained of an irritated throat. R5 was given cough drop and cough syrup. R5's progress note did not identify a respiratory assessment or vital testing was done. R5's progress note dated 12/28/24, identified R5 complained of throat irritation but did not indicate if a respiratory assessment, viral testing or provider was notified. R5's progress note dated 1/1/25, identified R5 went to clinic appointment to have an medication injection and on 12/31/24, R5 was transported by a medical van service to location where had unknown labs drawn. R5's record did not identify if R5 was provided with a mask during transport. R5's progress note dated 1/2/25, identified R5 complained of sore throat, congestion, runny nose and wheezing in lungs. COVID-19 test performed and negative results. Primary care provider was notified and ordered RSV test which was completed and sent to the clinic for results. R5's laboratory report dated 1/3/25, identified positive RSV test completed on 1/2/25. R5's progress note dated 1/3/25, identified R5's RSV test was positive. There was no indication that isolation/precautions were initiated even though R5 was positive for RSV. R5's progress note dated 1/7/25, identified R5 went to an outside appointment and was transported by a medical van service at 7:30 a.m. and returned to facility around noon. There was no indication that transportation service or outside appointment facility were aware of R5's RSV diagnosis to prevent the spread of infection. During an observation on 1/10/25 at 1:49 p.m., R5 was sitting alone at a table in the activity in the dining area playing bingo without a mask on. R5 coughed six times without a mask on and did not cover his mouth or sanitize his hands after coughing. R5's cough was wet/productive. There were ten other residents were in the area also playing bingo at tables spaced approximately 4-6 feet apart, one resident passed approximately 1-2 feet directly by R5. R5's progress note dated 1/10/25 at 7:31 p.m., identified R5 had worsening respiratory symptoms and increasing worsening cough. R5 had bilateral wheezes. R5 stated he has not gotten better and feels worse. Resident requested to be seen in the emergency department for evaluation (ED) R5's emergency department (ED) note dated 1/10/25 at 8:15 p.m., identified diagnoses of subacute cough. Presented to ED with dry cough. R5 was given breathing treatment and returned to the facility. During an interview on 1/10/25 at 1:52 p.m., LPN-A stated R5 just came out of isolation this week for RSV, however unable to give specific date he was removed. LPN-A was not sure how it was determined that residents could be removed from isolation and was unsure when R5 tested positive. LPN-A reviewed R5's record and verified R5 tested positive on 1/2/25 and was on isolation for 7 days. During an interview on 1/10/25 at 1:52 p.m., RN-A stated staff would monitor residents for symptoms of RSV through a cough and how they sound. They would be under precautions for seven days and then no longer were infectious. R1-positive on 1/3/25 R1's face sheet dated 1/15/25, identified R1 had diagnoses that included diabetes mellitus type 2. R1's record between 12/31/24 through 1/3/25 did not identify respiratory symptoms screening was completed. R1's progress note dated 1/3/25, identified R1 was having a non-productive cough worsening throughout the day, complained of not feeling well in her chest, and had a hoarse voice. R1 was tested for RSV. At 9:10 p.m., R1's lab test returned positive for RSV. Sign placed and staff will wear PPE. The progress note did not identify what type of precautions were implemented nor identify if isolation was implemented on 1/3/25. R1's progress notes dated 1/5/25 and 1/10/25, identified R1 went out to an appointment with a medical van transporting on 1/3/25 for wound care. R1's record did not identify if R1 wore a mask during the transport or if the wound clinic was informed of R1's positive test results. R1's progress note dated 1/11/25, identified R1 was on isolation precautions and slept well. R1 did not include respiratory assessments and monitoring were completed from 1/3/25-1/10/25 for RSV, even though the facility had several residents with RSV. R1's respiratory assessments were completed once on 1/11/25, 1/14/25, and 1/15/25. Completed four times on 1/12/25, and twice on 1/13/25. The assessments identified on 1/11/25, R1 had a dry non-productive cough and shortness of breath. On 1/13/25 and on 1/14/25, R1 had wheezes throughout lung lobs. During an observation on 1/10/25 at 10:13 a.m., R1 had two signs outside of her room, contact precautions and EBP (enhanced barrier precautions). Staff entered R1's room with no PPE on to transport her to the medical van for an appointment. R1 agreed to wear a mask when exiting room. During an interview on 1/10/25 at 9:13 a.m., licensed practical nurse (LPN)-A stated R1 had two precaution signs outside of her room, contact was for the RSV and EBP was for her wound. LPN-A could not articulate the difference between contact and EBP precautions. LPN-A stated R1 would be finishing contact precautions today, 1/10/25. LPN-A was unsure of the exact date R1 tested positive. LPN was aware of R1 still having a cough because R1 was getting over RSV. R14 RSV positive on 1/3/25 R14's face sheet dated 1/19/25, identified diagnoses of Parkinson's disease and congestive heart failure. R1's record between 12/28/24 through 1/3/25 did not identify respiratory symptom screening was completed, even though the facility had several residents with RSV. R14's progress note dated 1/3/25 at 2:48 p.m., identified R14 was not feeling well, poor appetite, lethargic, and weakness. Physician sent orders to test residents that are symptomatic for RSV; R14 tested positive for RSV. R14's record did not indicate TBP, and isolation were immediately implemented. R14's progress note dated 1/7/24 identified R14 had all meals in their room and continued to receive therapy services. R14's progress note dated 1/9/25, identified R14 was up in wheelchair for both meals. Progress note did not identify if R14 was in his room for meals. R14's record did not identify if and when TBP and isolation were implemented nor include symptom monitoring between 1/3/25 through 1/9/25. Between 1/9/25 and 1/15/25, R14's record included respiratory assessment which did not identify symptoms of illness. On 1/15/24, R14's was on isolation precautions, however, did not address PPE requirements. R3-positive on 1/3/25 R3's face sheet dated 1/16/25, identified diagnoses of diabetes mellitus type 2, and chronic kidney disease (damaged kidneys). R3's unsigned and undated physician order included place in isolation precautions per facility infection control policy. Corresponding treatment administration records identified x' in the boxes indicating the order was not completed. R3's record reviewed between 12/23/24 through 1/13/24, identified R3 had respiratory illness symptoms that began on 12/24/24. R3's record and facility surveillance did not identify immediate implementation of TBP after (PPE and isolation) on 12/23/24 nor identify ongoing symptom monitoring to determine appropriate discontinuation of PPE and isolation. R3's progress notes identified the following: -12/23/24, R3 had a sore throat and nasal congestion. COVID test negative. -12/24/24, R3 had a cough, an antibiotic and cough syrup was ordered by the physician. -12/29/24, R3 had hoarse voice, adventitious (abnormal) lung sounds, cough with secretions, and nasal congestion. R3's record did not indicate the physician was notified of the ongoing symptoms. -12/31/24, R3 had nasal congestion, crackles in lungs, and cough. Negative COVID test. -1/1/25, R3 had cough, congestion, and not feeling well. -1/2/25, R3 complained not feeling well, loss of appetite, and dry non-productive cough. -1/3/25, R3 tested positive for RSV. -1/4/25, R3 was administered cough medication. -1/12/25, indicated R3 did not receive a shower due to isolation precautions. -R3's progress note dated 1/13/25, identified R3 remained on precautions for RSV symptoms which included raspy voice, and occasional cough. Lung sounds were clear. During an observation on 1/10/25, R3 was in her wheelchair inside her room. R3 was sleeping. Two precaution signs posted on entrance to her room directing staff to use contact precautions and enhanced barrier precautions. A red biohazard bag was noted in R3's recliner with used personal protective gowns coming out of the top and resting on the armrest of the recliner. In addition, a red bin with the top open and multiple isolation gown noted to be hanging out the top and touching the sides of the bin. R2-RSV positive on 1/8/25 R2's face sheet dated 1/22/25, identified diagnoses of type 2 diabetes. R1's record between 12/31/24 through 1/7/25 did not identify respiratory symptoms screening was completed, even though the facility had several residents with RSV. R2's progress note dated 1/8/25, identified R2 to be coughing, adventitious sounding, tested for COVID and RSV. R2's record did not identify TBP were implemented. During record review on 1/10/24 at 8:00 a.m. R2's RSV test results were not included in her record. During an observation on 1/10/25 at 9:13 a.m., LPN-A stated she was aware R2 had a cough, and she knew she was tested for COVID-19/Influenza A&B and RSV but was unsure if she was negative. LPN-A entered R2's room with gloves on, no mask and no gown. While LPN-A used one of R2's fingers to check her blood sugar, R2 had her face turned toward LPN-A, R2 coughed three times without covering her mouth. LPN-A touched R2's hands then her own clothing. R2' progress note dated 1/10/25 at 1:37 p.m., identified call placed to hospital following up on lab results. R2 was positive for RSV. At 10:20 p.m., R2 was placed on droplet precautions. During an interview on 1/10/25 at 9:22 a.m., registered nurse (RN)-A stated she noted R2 had a cough on 1/8/25 and performed a COVID-19 test in house and did a swab for a quad test (COVID-19/Influenza A&B/RSV) test and took to the clinic. RN-A stated she was not sure of R2's test results but thought R2 tested negative. RN-A thought RSV would be droplet precautions verses contact precautions because RSV was a respiratory virus which required droplet. RN-A stated as of today 1/10/25, the facility had two active cases of RSV currently in the same unit R1 and R3. During an interview on 1/10/25 at 2:06 p.m., infection preventionist (IP)-A stated the facility had just received R2's positive test results for RSV collected at 4:00 p.m. on 1/8/25 that resulted on 1/8/25 at 5:22 p.m. IP-A stated R2 should have been placed on respiratory precautions on 1/8/25 due to being symptomatic. IP-A stated she was unaware a test had been performed on R2 on 1/8/25. IP-A confirmed R2 was not on contact or droplet precautions since 1/8/25 and would be placed in isolation today, 1/10/25. During an interview on 1/10/25 at 2:33 p.m., (RNCM)-A stated R2 was tested for COVID on the evening of 1/8/25 due to coughing in-house and a quad test was taken to the clinic. R2 was not put on isolation. R2 only had a cough on 1/8/25 and had not had one since. R2 did not leave her room very often; R2 ate in her room and did not attend activities and was not on TBP until 1/10/25 after the facility became aware. R7 RSV positive on 1/8/25 R7's face sheet dated 1/17/25, identified diagnoses of diabetes mellitus type 2, dementia, atrial fibrillation. R7's medical record did not identify respiratory assessment screening between the confirmed RSV outbreak on 12/31/24 through 1/8/24 the date R7 presented to the hospital with respiratory illness symptoms. R7's progress note dated 1/8/25, indicated R7 had irregular rapid heart rate, was lethargic, nauseated, tired, and pale. R7 was sent to the ED. R7's emergency department (ED) note dated 1/8/25, identified R7 presented in ED from the nursing home with atrial fibrillation and rapid ventricular rate in the context of decreased oral intake, generalized weakness and cough. R7's ED note identified R7 tested positive for RSV with reported symptoms that started on 1/6/25. R7's hospital discharge summary dated 1/10/25, identified R7 was admitted [DATE] to 1/10/25 for atrial fibrillation with rapid ventricular rate, RSV with acute bronchiolitis due to RSV, and acute cystitis (bladder infection). R7's discharge summary stated R7's presentation, including the rapid ventricular rate was triggered by acute RSV infection. R7's progress note dated 1/10/25, identified occasional cough due to RSV positive and placed on droplet precautions. R7's progress note did not identify if/when isolation was implemented. R7's respiratory assessments dated 1/10/25 through 1/15/25, identified cough on 1/10/25, 1/13/25 and 1/15/25. During an interview on 1/10/25 at 2:33 p.m., RNCM-A stated residents that were RSV positive did not need to isolate, if they came out of their room they had to wear a mask and distance themselves from other residents. Nursing monitored for common signs and symptoms and test if needed. Nursing did not document monitoring for every resident in the electronic record showing that monitoring was done. RNCM-A would start staff and resident tracing if the need developed. During an interview on 1/10/25 at 3:00 p.m., RNCM-A was in-person, and director of nursing (DON) via phone, DON verified that no monitoring had been completed of residents had been completed and no symptom monitoring of all residents had been done. DON stated IP-A should be ensuring these steps were completed. R8 RSV positive on 1/10/25. R8's face sheet dated 1/17/25, identified diagnoses of Alzheimer's, and dementia. R8's record between 12/31/24 through 1/9/25 did not include respiratory illness screening. R8's progress note dated 1/10/25 at 9:12 a.m., identified R8 was not eating this morning and unable to swallow pills and spit everything but water out. R8's progress note dated 1/10/25 at 8:44 p.m., identified outbreak of RSV per resp. screener R8 should be tested for RSV however did not identify if R8 had symptoms. Call placed to medical provider and test sent to lab. R8's progress noted dated 1/11/25 at 6:21 a.m., identified R8 was on droplet precautions for RSV pending results. R8's note indicated R8 had a new cough through the night. R8's record did not address isolation was immediately implemented. R8's progress note dated 1/11/15 at 12:31 p.m., identified lab results were positive for RSV. R8 unable to stay in room and had been wandering mostly in the dining room, sat at a table by himself, and was unable to keep mask pulled up on his face. R8's emergency department (ED) notes dated 1/13/25, identified R8 was seen on 1/13/25 at 9:33 p.m., with diagnoses of sepsis, and RSV. R8 was sent to ED for generalized and weakness and low blood pressure after testing positive at facility for RSV. ED gave breathing treatment and intravenous methylprednisolone, and normal saline. R8 was transferred to hospital. R8's hospital note dated 1/16/25, identified a stay from 1/14/25-1/16/25, with diagnoses of septic shock, with return to facility on hospice care. R15 RSV positive on 1/10/25 R15's face sheet dated 1/17/25, identified diagnoses of bradycardia (slow heart rate), and acute respiratory failure with hypoxia. R15's progress note dated 12/31/24, identified R15 had a large emesis. R15's record did not include further assessment. R15's between 12/28/24 through 1/2/25 did not include respiratory illness screening, even though the facility had several residents with RSV. R15's progress note dated 1/3/25 at 4:00 a.m., identified R15 stated she could not breathe. Oxygen saturation was 84% on 3 liters per minute of oxygen via nasal cannula. Noted clammy skin, and R15 was sweaty. At 3:56 p.m., R15 had a hoarse voice, was lethargic, and low appetite. Notified hospice. R15's progress note dated 1/5/25, indicated R15 was provided breathing treatment for audible wheezes and chest discomfort. At 10:44 p.m., R15 had non-productive cough, complained of a sore throat, and had an emesis. R15's progress note dated 1/6/25 at 2:30 a.m., identified complaints of pain to lower back and chest area when she coughs. At 3:48 a.m., coughing was at a minimum and wheezing was heard while breathing. R15's progress note dated 1/8/25 at 10:35 p.m., cough syrup had been given and was effective. R15's progress note dated 1/9/25 at 12:27 a.m., identified as needed oxygen was administered and effective. R15's progress notes indicated oxygen remained in place on 1/9/25, and 1/10/25. R15's progress note dated 1/10/25, identified respiratory assessment completed and indicated R15 should be tested for RSV. R15 was put on precautions pending test results. R15's record did not identify what type of precautions were implemented. R15's record identified test results on 1/11/25 at 2:27 p.m. were positive for RSV. R15's progress note dated 1/11/25 at 2:41 p.m., identified oxygen in use, moist/loose productive cough. R15's progress note dated 1/12/25, identified left and right lungs had crackles on auscultation, moist/loose productive cough present with small secretions. R15's progress note dated 1/13/25 at 1:53 p.m., identified R15 was coughing and gagging as she coughed. Although R15 demonstrated respiratory symptoms that began on 1/3/25, there was no indication testing had been completed with the onset of symptoms nor TBP were implemented until 1/10/25, 7 days after symptoms were identified. There was no indication that symptom monitoring was completed between 1/3/25 through 1/10/25. During an interview on 1/14/25 at 9:30 a.m., RN-A stated R15 was positive for RSV and had a roommate. For the roommate we pull the curtain and have her wear a mask when she leaves the room. During an observation on 1/14/25 at 9:34 a.m., R15 and roommate were both sitting in wheelchairs in their room. The curtain was partially drawn. R15 coughed which was very wet sounding, she did not cover her mouth or sanitize hands after. R13 RSV positive on 1/13/25 R13's face sheet dated 1/15/25, identified diagnoses of chronic obstructive pulmonary disease (COPD) (inflammation and obstruction of lung airways). R13's record identified between 12/31/24 through 1/9/25 did not include respiratory illness screening, even though the facility had an onset of RSV. R13's progress note dated 1/13/25 at 2:15 p.m., identified during respiratory screener R13 complained of cough, coughing up clear phlegm, experienced chest tightness. Placed on droplet precautions. Physician ordered test. At 8:53 p.m., RSV results returned positive. R13's record did not identify if/when isolation was implemented. R16 RSV positive on 1/13/25 R16's face sheet dated 1/19/25, identified diagnoses of congestive heart failure (heart cannot pump blood well enough to meet the body's needs), and acute kidney failure. R16's record identified between 12/28/24 through 1/9/25 did not include respiratory illness screening, even though the facility had several residents with RSV. R16's progress note dated 1/13/25 at 4:30 a.m., identified lung sounds wheezy and persistent non-productive cough. 5:47 a.m., a respiratory assessment was completed, and cough was noted to be dry and non-productive. R16's progress note dated 1/14/25 at 4:35 a.m., identified R16 was placed on droplet/contact precautions for RSV positive test on 1/13/35. At 10:24 p.m., cough was noted to be moist and non-productive with wheezing noted in lungs. During an observation on 1/14/25 at 10:56 a.m., R16 was in the activity/dining area sitting in a recliner without a mask on with multiple other residents in the area who also did not have masks on. R12-RSV positive on 1/14/25 R12's face sheet dated 1/17/25, identified diagnoses of myalgia (muscle pain). R12's record identified between 12/28/24 through 1/9/25 did not include respiratory illness screening, even though the facility had several residents with RSV. R12's progress note dated 1/13/25, identified new non-productive cough during respiratory screener. Lung sounds clear. Quad test completed and sent to lab. Droplet precautions Education provider to staff to perform hand hygiene, cough etiquette and distancing outside of room. R12's progress note did not indicated isolation was initiated. R12's lab report dated 1/14/25, identified RSV detected from nasal swab. During an interview on 1/14/25 at 9:25 a.m., activity aide (AA)-B stated the staff use hand sanitize prior to doing anything and wipe down things that they reuse. AA-B stated residents have the right to leave their rooms and when they do, they should be encouraged to mask up. AA-B was unsure if the residents had to wear a mask outside of their rooms but thought they did. AA-B thought residents would have to stay farther away from other residents if they were supposed to be on precautions and left their rooms. R17 suspected respiratory disease 1/10/25 R17's face sheet dated 1/19/25, identified R17 had diagnoses that included type 2 diabetes. R17's record between 12/28/24 through 1/7/25 did not include respiratory illness screening, even though the facility had several residents with RSV. R17's progress noted dated 1/8/25, lungs clear and no cough. R17's record did not include a respiratory screener on 1/9/25. R17's respiratory illness screener dated 1/10/25 thorough 1/15/25 did not identify any respiratory symptoms. R17's progress note dated 1/10/25 at 8:52 p.m., identified outbreak of RSV per respiratory screener resident should be tested for RSV. Test sent to lab. R17's progress note did not identify isolation or PPE was initiated. R17's progress note dated 1/11/25 at 6:28 a.m., identified R17 was placed on droplet precautions for RSV pending lab test results. R17 was noted to have an occasional non-productive cough throughout the night. At 12:23 p.m., cough was moist and non-productive. At 1:45 p.m., identified lab results were negative for RSV, influenza A and B, and COVID. R17's record did not identify an alternative diagnosis for the new cough and did not indicate when precautions were removed. During an observation and interview on 1/14/25 at 9:51 a.m. R17 sat in a recliner in the activity room without a mask on, which was not in accordance with R17's record dated 1/11/25 that directed droplet precautions. NA-A confirmed R17 was sitting in a recliner in the activity room with no mask on. R19 suspected respiratory disease 1/10/25 R19's face sheet dated 1/19/25, identified R19 had diagnoses that included type 2 diabetes. R19's record reviewed from 12/28/24 through 1/9/25, was not evident of ongoing consistent symptom monitoring was completed between 1/3/25 through 1/9/25, even though the facility had several residents with RSV. R19's progress note dated 1/10/25 at 8:51 p.m., identified the respiratory screener indicated R19 should be tested for RSV. R19's progress note did not specify symptoms or that isolation or TBP were initiated. During an observation on 1/10/25 at 1:10 p.m., R19 was laying in her bed with no respiratory symptoms observed. R19's progress note dated 1/11/25 at 8:08 a.m., identified R19 was placed on droplet precautions. No cough and afebrile. At 1:27 p.m., test results for respiratory diseases returned negative. Moist, non-productive cough noted. R19's progress notes did not indicate isolation or TBP were initiated after symptom onset on 1/11/25. R19's respiratory symptom screeners between 1/10/25-1/14/25, identified a moist non-productive cough on 1/11/25. R19's progress note dated 1/14/25, identified R19 left facility for an appointment out of state and did not return until after supper. R18 suspected respiratory disease 1/10/25 R18's face sheet dated 1/23/25, identified R18 had diagnoses that included type 2 diabetes R18's record reviewed from 12/28/24 through 1/9/25, did not include respiratory symptom screening, even though the facility had sever [TRUNCATED]

Based on interview and document review the facility failed to complete comprehensive fall analysis and implement individualized interventions to prevent re-current falls and/or mitigate the risk for falls with major injury for 2 of 3 residents (R7, R5) reviewed for falls. The facility's failures resulted in actual harm for R7 when she sustained left tibial fracture that required surgical repair. Finding include: R7's face sheet dated 12/12/24 identified R7 had diagnoses that included acquired absence of right leg above knee and type 2 diabetes. R7's admission Minimum Data Set (MDS) dated [DATE], identified R7 was admitted to the facility on [DATE] and had severe cognitive impairment with no signs or symptoms of delirium, behaviors or history of falls within six (6) months of admission. R7 had functional limitations in range of motion of one lower extremity, used a wheelchair, and was dependent on staff for hygiene needs, lower body dressing and chair to bed transfers. R7's ability to sit to stand and walk was not attempted due to medical condition. R7 was always incontinent of bowel and bladder, and administered insulin in addition to psychotropic, anticoagulant, and opioid medications. R7's undated fall Care Area Assessment (CAA) included, resident currently has falls related to cognitive deficits and amputation of LRL (sic). Resident will have less than 2 falls per month through the review date. The CAA indicated and identified R1 was at risk for falls related to cognitive impairment, diagnoses of cardiac dysrhythmias, incontinence, loss of limb, anxiety disorder, schizophrenia, and the medications as identified in the admission MDS. The CAA indicated falls would be addressed in the care plan with the overall objective to avoid complications and minimize risks. R7's fall risk evaluation dated 9/4/24, indicated R7 was at risk for falls with a history of three or more falls in the past three months. R7 was disoriented, chair bound/incontinent and was not able to perform gait/balance evaluation. The interventions listed were to evaluate for falls and if falls occur alert the provider. Although R7's fall risk evaluation and the MDS identified R7 was at risk for falls, R7's care plan dated 9/4/24 did not include and/or address a plan of care for falls. R7's care plan dated 9/4/24 identified the following focuses and interventions: -Current Functional Performance informed staff R7 required one person physical assist for toileting, for transfers R7 required total assist of two person with a full body mechanical lift using amputee sling. -Impaired physical mobility related to amputation leading to phantom limb included but was not limited the direction of for staff to allow R7 adequate time for response and ensure call light available. -Documented Safety -Concerns directed staff to perform safety risk evaluations on admission, as needed, and upon change of condition and Safety Measures- including strategies to reduce the risk of infection, falls, injury initiated as appropriate. In review of R7's fall record between 9/5/24 through 12/1/24 identified R7 had 11 total falls. R7's falls incident reports identified the following: R7's fall incident report dated 9/5/24, at 5:25 a.m. indicated R7 had an unwitnessed fall in her room with no injury. R7 had been found on the floor next to her bed with blankets under her bottom, she appeared to have slid from the bed. R7 stated she needed to get up and use the bathroom so she wouldn't be late for school. The incident report identified predisposing factors as R7 was admitted within 72-hours and confused, but did not indicate/identify R7 had needed to use the bathroom as a factor. The report did not include comprehensive fall analysis nor identify immediate fall prevention interventions and not evident R7's care plan was revised. R7's fall incident report dated 9/7/24 at 4:51 a.m. indicated R7 who was wheelchair bound had an unwitnessed fall in her room with no injury. A nursing assistant (NA) had been completing the 30-minute checks and found R7 on the floor drinking water in good spirits with stool smeared on her floor mat. R7 had reported she wanted to get up and get her water. In response to staff asking how she got on the floor, R7 gestured her hand in a gliding motion towards the floor. Predisposing factors included R7 was admitted within 72-hours, but did not/indicate identify R7's bowel incontinence nor R7's location of water and/or need for water. The report did not include a comprehensive fall analysis nor identify immediate fall prevention interventions. Furthermore not evident the care plan was revised to reflect the implementation of when/duration of 30-minute checks or usage of floor mat. R7's fall incident report dated 9/13/24 at 7:30 a.m. indicated R7 who was wheelchair bound normally does not ambulate at all had an unwitnessed fall. R7 was found sitting on the floor next to her bed and could not clearly inform staff if she hit her head or if her bottom hurt or not. Education provided to resident not get out of bed by herself but due to confusion instructions may not be understood. Predisposing factors identified included: confused, impaired memory, and incontinent. The report did not specify if R7 was incontinent when she was found. The report did not include a comprehensive fall analysis nor identify other fall interventions other than the immediate education that may not have been understood by R7. Further not evident of an assessment/evaluation to identify effectiveness of the education provided nor evident the care plan was revised to include resident education. R7's fall incident report dated 9/22/24 at 8:58 a.m. p.m. indicated at 5:25 p.m. R7 was in her room when an NA saw her pulling on the mattress, causing R7 to slide out of her wheelchair onto floor. R7 reported she had wanted to go to bed. Predisposing factors identified as confusion. The report did not include a comprehensive fall analysis nor identify immediate fall prevention interventions. Further not evident R7's care plan was revised. R7's fall incident report dated 10/19/24, indicated R7 had a witnessed fall with no injuries at 9:30 a.m. when she appeared to be repositioning herself in her wheelchair and slid out of her chair landing on her bottom. Prior to the fall during breakfast, R1 had been agitated/behavioral and very confused. R7 Unable to give description. Predisposing factors checked were none, but noted mental status as alert and confused. The report did not include a comprehensive fall analysis nor identify immediate fall prevention interventions. Further not evident R7's care plan was revised. R7's fall incident report dated 11/3/24, indicated R7 had unwitnessed fall around 3:15 p.m. with no injuries. R1 was found by housekeeping staff sitting on floor, on her blue mat, leaning against her bed around 3:15 p.m. Prior to fall NA had just been in room, and found R7 sitting at the edge of the bed. NA assisted R7 back to bed and bed was in the lowest position. R7 was at her night stand and going through her stuff when she lowered herself to the floor. R7 unable to say what she was doing when she lowered herself to the floor but told family she was trying to get into bed. R1 was alert and confused. Predisposing factors included, confused and impaired memory. The report did not include a comprehensive fall analysis nor identify immediate fall prevention interventions. Further not evident the care plan was revised to include appropriate bed height and usage of the floor mat. R7's care plan was revised to include a fall focus on 11/15/24, that identified R7 was at risk for falls however did not have individualized interventions that would prevent and/or mitigate R7's risk for falls including the usage of the fall mat, 30-minute checks, resident education, and bed height that was identified in the fall incident reports. The fall care plan only directed staff to evaluate for falls on admission and as needed and if a fall occurs, notify the provider. R7's fall incident report dated 11/26/24 at 1:40 p.m. indicated R7 had an unwitnessed fall with no injuries. R7's physician found R7 sitting on her floor mat. R7 reported she purposely put herself on the floor to get up. R7 was alert and confused. No predisposing factors were identified. Additionally, the report did not include a comprehensive fall analysis nor identify immediate fall prevention interventions. R7's fall incident report dated 11/27/24 at 6:45 a.m. indicated R7 had an unwitnessed fall in her room, she was found sitting on her floor mat next to her bed. R7 appeared calm but was not able to state what happened. The fall resulted in a skin tear to left lower leg with minor bleeding. Predisposing factors identified as confused. The report did not include a comprehensive fall analysis nor identify immediate fall prevention interventions. R7's fall incident report dated 11/29/24 at 7:00 a.m., indicated R7 had an unwitnessed fall and had an open area to her left shin. NA found R7 sitting on the floor mat next to her bed. The report included when asked why she was on the floor resident pointed to room mate. Then resident stated that she wanted to get up. The predisposing factor was identified as Resident is concerned about recent new room mate. The report did not include a comprehensive fall analysis nor identify immediate fall prevention interventions. R7's fall incident report dated 11/30/24 at 2:00 p.m., indicated R7 had an unwitnessed fall. NA found resident sitting on the floor next to the bed. R7 was alert and confused. The bed was in waist high position with no fall mat next to bed. R7 reported her whole leg hurt when the nurse did range of motion (ROM). R7 was sent to the emergency room for further evaluation and the aide was provided with education on following the care plan. Predisposing factors included, confused. The report did not include a comprehensive fall analysis nor identify immediate fall prevention interventions. R7's fall incident report 12/1/24 at 4:53 a.m. indicated R7 had an unwitnessed fall with no injuries. NA found R7 sitting on her floor mat next to her bed with her leg bent in front of her and incontinent of bowel, call light was in place and bed was in the lowest position. R7 was alert to person and place. Nurse had just been in her room at 4:35 a.m. to check on R7 since she was self-transferring from bed to the floor frequently. Predisposing factors identified as incontinent and R7 is very curious about roommate-wants to know what she is doing all the times. The report did not include a comprehensive fall analysis nor identify immediate fall prevention interventions. R7's progress notes dated 12/2/24 at 7:02 a.m., R7 was sent to ER due to left lower extremity became swollen, red, and painful. At 11:54 a.m. the ER called the facility informing R7 was being sent to another hospital for broken leg and possible surgery. R7's emergency department note dated 12/2/24, identified a hematoma (collection of blood) to the proximal (near) the tibia/fibula are of left lower leg and a fracture of the left proximal end of left tibia and was sent to another hospital for surgery. R7's hospital discharge summary dated 12/10/24, identified R7 was admitted on [DATE] for a closed fracture of left proximal tibia that required surgery on 12/3/24, cellulitis and abscess of left lower extremity. R7 was discharged back to the facility on [DATE] on IV antibiotics. The records did not include and was not evident the facility completed a comprehensive fall analysis that identified potential causal factors and/or root cause(s) so that appropriate determinations for individualized fall interventions could be developed and implemented to remove R7's fall risk associated with the potential causal factors/root cause. R5 R5's face sheet dated 12/16/24, identified diagnoses of malnutrition (condition where body does not get enough nutrients), chronic kidney disease (condition where kidneys have been damaged), osteoarthritis (condition with joint pain and stiffness), and weakness. R5's quarterly Minimum Data Set (MDS) dated [DATE] identified R5 had severe cognitive impairment. R5 was dependent on staff for dressing, grooming and hygiene and required maximum assistance for all transfer. R5 had two or more falls with no injury and one fall with minor injury. R5's fall care plan dated 8/17/24, indicated R5 was high risk for falls related to weakness, history of falls with the following: Call don't fall signs posted in room, anticipate needs, call light within reach, physical therapy (PT) to evaluate and treat or as needed. R5's fall incident report dated 10/12/24, indicated R5 had an unwitnessed fall at 7:40 p.m. R5 was found in her room laying on her back next to walker. Predisposing risk factors included confusion and ambulating without assistance. Immediate action taken: R5 assessed with no injuries noted. [NAME] removed and call light placed within reach. R5's record did not include a comprehensive analysis of the fall and R5's care plan was not revised. R5's fall incident report dated 10/13/24, indicated at 11:30 p.m. an NA witnessed R5 attempting to self-transfer in her room and was going to fall so NA assisted R5 to the floor. R5 stated I have to go I want to walk, can I go but she don't state where she want to go. No injuries were noted. Predisposing factors included confused, gait imbalance, using a walker, and alert but confused. Immediate actions taken: [NAME] removed and call light placed within reach. R5's record did not include a comprehensive analysis of the fall and R5's care plan was not revised. R5's fall incident report dated 10/15/24, indicated R5 had an unwitnessed fall at 6:00 a.m. R5 was yelling and when NA entered R5's room, R5 was found sitting upright behind a closed door. R5 was confused and unable to give any detail of what happened but kept asking staff to lock the door. Resident has delusions of men coming into her room and keeps trying to shut the door. No injuries noted. Predisposing factors included alert and confused, gait imbalance, impaired memory incontinent using a walker, and wanderer. Immediate action taken: R5 assessed for injuries and placed in wheelchair and took to dining area for close observation. R5's record did not include a comprehensive analysis of the fall and R5's care plan was not revised. R5's fall incident report dated 10/29/24, indicated R5 had an unwitnessed fall at 9:45 p.m., R5 had been in her bed and was found sitting on floor in front of wheelchair close to the bathroom, with gripper socks on, call light at bedside, and had been toileted within 30 minutes, no incontinence. R5 was unable to explain what happened. Predisposing factors included, confused. Immediate action taken: R5 was assessed for injury and noted to have bump on back of head. R5's record did not include a comprehensive analysis of the fall and R5's care plan was not revised. During an interview on 12/11/24 at 4:10 p.m., director of nursing (DON) confirmed causal analysis were not being completed and care plans were not revised. DON indicated she expected the facility policy be followed. After a fall occurs, a causal analysis was supposed to be completed and immediate interventions developed, implemented, and identified in the care plan. Review of the facility policy Falls, Clinical Protocol dated 10/4/2021, indicated the following: -Cause identification, 1) for an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. the staff; 3) the staff and practitioners will continue to collect and evaluate information until either the cause of the fall is identified, or it is determined the cause cannot be found or is not correct. -Treatment/management, 1) based on preceding assessment, the staff and physician will identify interventions to try to prevent subsequent falls and to address the risk clinically significant consequences of falling. 2) if under lying causes cannot be readily identified or corrected, staff will try carious relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for it continuation. 51576

Based on interview, observation and document review the facility failed to safely use a mechanical lift per manufactures recommendations to transfer 1 of 1 resident (R1), who required a mechanical lift for transfers. This resulted in an immediate jeopardy (IJ) when R1 fell from a full body mechanical lift causing R1 to suffer three fractures to his thoracic and lumbar spine (T1, T6, and L1) requiring hopsital admission. In addition, the facility failed to ensure a system for completed comprehensive assessments for sling size and/or care plan developement and/or the care plan was followed for for 8 of 8 residents (R1, R2, R3, R5, R6, R7, R8, R9) reviewed who required full body mechanical lifts. The IJ began on 8/25/24 when staff failed to ensure lift sling was properly secured prior to the transfer causing R1 to fall from the mechanical lift. The administrator, regional nurse, and director of nursing (DON), and assistant director of nursing (ADON) were notified of the IJ on 8/27/24 at 4:55 p.m. The IJ was removed on 8/28/24 at 5:00 p.m., when the facility had implemented immediate corrective action to prevent recurrence, but noncompliance remained at a lower scope and severity of a E with no actual harm with potential for more than minimal harm that was not immediate jeopardy. Findings included: During observations on 8/27/24 between 10:23 a.m. to 2:28 p.m. the facility used the EZ-Way brand full body mechanical lifts and not the Hoyer brand full body mechanical lifts which the facility identified in their progress notes/documentation. A Facility Reported Incident (FRI) submitted to the state Agency (SA) on 8/26/24 at 1:03 a.m., alleged potential caregiver neglect when R1 fell backwards from the sling of the Hoyer (brand name of full body mechanical lift) during a transfer and sustained increased pain, emergency department (ED) evaluation, and compression fractures to his back. R1's admission Minimum Data Set (MDS) identified R1 was admitted on [DATE] and no other information was available. R1's brief interview of mental status (BIMS) dated 8/21/24, indicated R1 was severely cognitively impaired. R1's care plan dated 8/23/24 indicated R1 had diagnoses of vascular dementia, chronic kidney disease, and major depressive disorder with psychotic features. Also indicated R1 required two staff assist with a large sling and full body mechanical lift for transfers. R1 required one assist with bed mobility, eating, personal hygiene, dressing, and toileting. R1's Kardex (abbreviated care plan for nursing assistants (NA)) as of 8/27/24 indicated R1 required two staff assist with Hoyer Lift with large sling. R1's Lift/Transfer Evaluation dated 8/22/24, indicated R1 could not bear weight, was cooperative with transfers and repositioning, did not have any upper extremity strength, and could not assist with transfers. R1's weight range was between 100-200 pounds and does not lack any sensation in any body parts. An undated facility document labeled Sling Sizes indicated R1 required a large sling. R1's progress notes dated 8/25/24 at 11:17 p.m., indicated staff were transferring R1 from bed to wheelchair using Hoyer lift. While R1 was in the air he fell backwards, head was facing down. R1 hit his head on the floor and sustained a lump to the back of the head. R1 sent to ED for evaluation. A follow up progress note dated 8/25/24 at 11:29 p.m., indicated R1 had been transferred to a higher level of care hospital due to fractures and fluid in the lungs. R1's Progress Note dated 8/26/24 at 3:41 p.m., indicated R1 admitted to hospital and had a T1 fracture (upper back spine), T6 spinal fracture (mid back spine), L1 cerebral fracture (lower back) and was receiving pain management. During an interview on 8/27/24 at 1:30 p.m., nursing assistant (NA)-A indicated she was assisting NA-D with R1's transfer on 8/25/24 when R1 fell out of the lift. NA-A Indicated it was the first time she had worked with R1 that day. NA-A was not sure which size lift sling R1 was supposed to use but used the lift sling that was already underneath him in the chair, NA-A thought it may have been maroon/large but was not sure. NA-A stated R1's fall happened so fast, he just fell out. During an interview on 8/27/24 at 1:40 p.m., NA-D indicated she assisted NA-A with R1's transfer on 8/25/24 when R1 fell out of the lift. NA-D indicated it was her first time working with R1. NA-D explained they were transferring R1 from the bed to the recliner and one of the sling loops came off the lift hook and R1 fell out of the lift to the floor. NA-D Further indicated the sling was under R2 in bed so that is the one they used to transfer him. NA-D was not sure what color or size it was. NA-D verified they did not check R1's care plan indicating the sling size and did not stop to check the tension of the straps when lifting R1. NA-D Identified the sling sizes were on the resident's Kardex and a list was posted on the linen closet door. During an interview on 8/27/24 at 3:43 p.m., the director of nursing (DON) indicated NA-A and NA-D must not have stopped and checked that the lift sling loops were secured when R1 was lifted, and the sling was not taut. Further indicated, it was expected that staff would use the care planned sling, double check the size of the sling prior to transfer, and do their safety checks during the transfer to avoid resident injury. They were unsure what size the sling was when R1 fell . R2 R2's admission Minimum Data Set (MDS) identified R1 was admitted on [DATE] and no other information was available. R2's BIMS dated 8/27/24 indicated R2 was cognitively intact. R2's care plan dated 8/23/24, indicated R2 transferred with two total staff assist. R2 required assist of one staff with toileting, dressing, and bed mobility. Two staff assist with personal hygiene. The care plan did not identify the use of a full body mechanical lift or sling size. Diagnoses include hemiplegia, osteoarthritis, diabetes, and anxiety disorder. R2's Kardex as of 8/27/24, indicated R2 transferred with two-person physical assist. The Kardex did not identify the use of a full body mechanical lift or sling size. R2's Lift/Transfer Evaluation dated 8/22/24, indicated R2 could not bear weight, was cooperative with transfers and repositioning, did not have any upper extremity strength, and could not assist with transfers. R1's weight range is between 100-200 pounds and lacks sensation in some part of the body. An undated Facility document labeled Sling Sizes indicated R2 required a large sling. During an observation on 8/27/24 at 10:23 a.m., R2 was noted to be in his recliner with a beige full body lift sling under him. According to the EZ-Way Sling Color Coding System chart, a beige sling was a size medium sling. During an observation on 8/27/24 at 11:57 a.m., NA-C wheeled R2 out of his room in his wheelchair with the beige/medium sling under him in the wheelchair indicated R2 was transferred with the medium sling versus the large sling that R2 required for safe lift transfer. R3 R3's significant change MDS dated [DATE], identified R3 was dependent on staff for toileting, lower body dressing, transfers, and bed mobility. R3's BIMS dated 8/19/24, indicated R3 had intact cognition. R3's care plan revised 3/17/24, indicated R3 required assist of two staff with Hoyer lift and large sling for transfers. R3 required one assist with bed mobility. R3's Kardex dated 8/27/24, indicated R3 transferred with two staff assist and Hoyer lift with large size sling. R3's Lift Mobility Status dated 7/30/24, indicated R3 could bear weight on at least one leg, could grip the lift bar with at least one hand, was cooperative, less than 342 pounds and was to be transferred by a Hoyer lift. An undated Facility document labeled Sling Sizes indicated R3 required a large sling. During observation and interview on 8/27/24 at 10:49 a.m., R3 was sitting in a recliner when nursing assistant (NA)-A and NA-B placed a beige full body sling underneath her. NA-B stated, it is a brown sling, so it is a medium sling and referred to a color-coded chart on the lift with weights on it. Further indicated the nurses weighs the resident and then put the sling size in the Kardex so the NA's knew what sling size to use for transfers. NA-B confirmed the beige sling was the correct sling and proceeded with the transfer from recliner to wheelchair even though the Kardex directed the use of large size sling. R5 R5's admission Minimum Data Set (MDS) identified R5 was admitted on [DATE] and no other information was available. R5's BIMS dated 8/27/24, indicated R5 was cognitively intact. R5's care plan dated 8/26/24, identified R5 required two staff assist for transferring using a Hoyer lift and large sling. R5's diagnoses included osteoarthritis of both knees, diabetes, dementia, hearing loss, and anxiety disorder. R5's progress notes dated 8/27/24, indicated R5 also required two staff assist with bed mobility, dressing, and toileting. R5's Kardex dated 8/27/24 indicated R5 was totally dependent on two staff for transferring using the Hoyer lift and large sling. R5's Lift/Transfer Evaluation dated 8/22/24 indicated R5 was cooperative with transfers and repositioning; did not have upper extremity strength and could not assist with transfers; is less than 200 pounds and did not lack sensation in any part of the body. An undated facility document labeled Sling Sizes indicated R5 used a large Hoyer sling for transfers. During an observation on 8/27/24 at 10:20 a.m., R5 was noted to be sitting in her wheelchair with a beige full sling underneath her in the chair. According to the EZ Way Sling Color Coding System chart, a beige sling was a size medium sling. During observation and interview on 8/27/24 at 11:51 a.m., R5 was noted to be sitting in her wheelchair with a beige sling under her in the wheelchair when registered nurse (RN)-A and NA-B began to hook the beige sling up to the full body mechanical lift. RN-A and NA-B both stated R5 used a beige sling, size medium for transfers. As they began to lift R5 off the wheelchair, the SA evaluator stopped them and advised them R5's care plan directed that R5 used a large burgundy sling. RN-A indicated that the medium sling they were using worked for R5 so she would just change the care plan. RN-A and NA-B proceeded with the transfer from wheelchair to bed with the beige/medium sling. R6 R6's significant change MDS dated [DATE], indicated R6 had impairment on both upper and lower extremities and was totally dependent for transfers. No behaviors. R6 BIMS dated 7/26/24 indicated intact cognition. R6's care plan revised on 5/13/24, indicated R6 transferred with two assist and EZ-Stand (sit to stand lift) with all transfers using a large sling. The resident was also dependent on staff for bed mobility, dressing, and toileting. Care plan did not reflect R6's use of full body mechanical lift nor did it identify which sling to use for transfers with the full body mechanical lift. R6's Kardex dated 8/27/24, indicated transfers were to be completed with assist of two with the EZ-Stand lift with all transfers using the large sling. Kardex did not reflect R6's use of full body mechanical lift nor did it identify which sling to use for transfers with the full body mechanical lift. R6's Lift Mobility Status dated 7/30/24, indicated R6 could bear weight on at least one leg, could grip the lift bar with both hands, is cooperative, less than 342 pounds and lift will by the EZ-Stand lift. An undated facility document labeled Sling Sizes indicated R6 used a large Hoyer sling for transfers. During observation and interview on 8/27/24 at 11:40 a.m., R6 was seated in a wheelchair with a beige/medium sling underneath her when NA-B and NA-C came in the room with an EZ-Stand lift and a large harness and assisted R6 to stand. A beige/medium full body sling was hanging over a bar in R6's room. When asked, R6 indicated they (staff) used that in the mornings to get her out of bed and weigh her. R6 indicated she disliked the full body lift and confirmed the beige sling was used every morning. NA-B verified the beige/medium sling was used every morning to transfer R6 out of bed. NA-C also verified the beige/medium sling was used every morning to transfer R6 out of bed and was the correct size for R6. R7 R7's quarterly MDS dated [DATE], indicates R7 had no impairment on upper extremities but was impaired on both lower extremities, and dependent with transfers. Diagnoses included osteoarthritis to the left knee, below the knee amputee right leg, and anxiety disorder. R7's BIMS dated 6/15/24, indicated intact cognition. R7's care plan last revised on 2/8/24, identified R7 transferred with two assist and Hoyer lift with a large sling. R7 also required staff assist with dressing lower half of body, personal hygiene, and toileting. R7's Kardex was requested but not received. R7's Lift Mobility Status dated 6/22/24, indicated R7 could not bear weight, could tolerate a semi-reclined position, and lift to be used was a Hoyer lift. No other information was provided. An undated facility document labeled Sling Sizes indicates R7 used a large Hoyer lift sling for transfers. During observation and interview on 8/27/24 at 1:15 p.m., R7 was in bed and was noted to have a green full body sling in her wheelchair. R7 indicated she had an amputated leg so is unable to walk and needed to be transferred with a Hoyer lift. R7 further verified the green sling in the wheelchair was used for every transfer. According to the EZ-Way Sling Color Coding System chart, a green sling was considered a size extra-large sling. During an intterview on 8/27/24 at 1:20 p.m., NA-C indicated R7 was transferred with the full body mechanical lift and the green sling that was in the wheelchair. Further indicated the NAs tell the nurses the resident's weight and they tell them what size sling to use and the sling size was then written on a sheet of paper in the linen closet. R8 R8's annual Minimum Data Set (MDS) dated [DATE], indicated R8 had no upper extremity impairment, impaired movement on lower extremities, dependent on staff for all transfers and mobility. Diagnoses included cerebral infarction (stroke), peripheral vascular disease, arthritis, and anxiety. R8's BIMS dated 8/5/24, indicated moderate cognitive impairment. R8's care plan last revised on 8/26/24, indicated R9 transferred with the EZ-Stand with assist of two and extra-large sling. R8 also required assist of two staff with dressing and toileting. The care plan did not identify the use of a full body mechanical lift or sling size. R8's Kardex was requested but not received. R8's Lift Mobility Status dated 8/3/24, indicates R8 could bear weight on both legs, grab the lift bar with both hands, was cooperative, weight was less than 342 pounds, identified lift to be used as the EZ-Stand lift with extra-large sling. An undated facility document labeled Sling Sizes, indicated R8 used an extra-large Hoyer sling for transfers. During an observation on 8/27/24 at 2:28 p.m., R8 was noted sitting in a recliner and had a black sling under him. According to the EZ Way Sling Color Coding System chart, a black sling was considered a size double extra (XX)-large sling. R9 R9's admission MDS was in progress and identified R9 was admitted on [DATE] with no other information available. R9's BIMS dated 8/23/24, indicated intact cognition. R9's care plan dated 8/23/24, did not address transfer status or mobility status. R9's Kardex dated 8/27/24, indicated R9 transferred with two staff assist. Did not specify mode of transfer nor sling size. R9's progress note dated 8/23/24 at 1:21 p.m., indicated R9 admitted that day and was a two person assist with Hoyer lift and needed two staff for cares and activities of daily living (ADLs). The progress note did not identify the sling size. R9's Lift Mobility assessment dated [DATE], indicated R9 could not bear weight, was cooperative with transfers and repositioning, did have upper extremity strength, could not assist with transfers, and weight was 100-200 pounds. An undated facility document labeled Sling Sizes did not indicate what size sling R9 used for transfers. During observation on 8/27/24 at 11:13 a.m., R9 was noted to be in his wheelchair with a burgundy sling under him. According to the EZ-Way Sling Color Coding System chart, a burgundy sling is considered a size large sling. A large sling is indicated for a weights withing 190 -320 pounds. During an interview on 8/27/24 at 12:00 p.m., RN-A indicated they only used the resident's weight to determine what sling size to use and referred to the chart on the lift. During an interview on 8/27/24 at 3:10 p.m., the assistant director of nursing (ADON) indicated the lift/transfer evaluations did not determine what size sling to use. Further indicated she was not sure how the sling size was determined other than weight. During an interview on 8/27/24 at 3:43 p.m., the director of nursing (DON) indicated the facility did not have a good system of sling sizing for the residents that used lifts and was not aware that the wrong sling sizes were in the resident rooms and in use. Further indicated if staff were using the wrong size lift slings, it increased the resident's chance of falling out of the lift. During a follow-up interview on 8/27/24 at 4:02 p.m., the DON confirmed the wrong size lift slings were found in resident's rooms and stated all slings being used would be the correct size for the resident before any further lift transfers were completed. During an interview on 8/29/24 at 11:10 a.m., the EZ-Way company representative indicated if staff were not using the correct sized slings or stopping to do safety checks on the loop connections, it increased a resident's risk of falling out of the lift resulting in serious injury to the resident. The facility policy titled, Lifting Machine, using a Mechanical last reviewed 2/7/22, indicated the purpose of the procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions. The policy indicates staff to measure the resident for the proper sling size and purpose, according to the manufacturer's instructions. Double check the sling and machines weight limits against the resident's weight; place the sling under the resident and visually check the size to ensure it is not too large or to small; attach the sling straps to the sling bar according to the manufacturer's instructions; make sure the sling is securely attached to the clips and that it is properly balanced; check to make sure the resident's head, neck, and back are supported; before the resident is lifted double check the security of the sling attachment; examine all hooks, clips, or fasteners; check the stability of the straps; ensure the sling bar is securely attached and sound; lift the resident 2 inches from the surface and check the stability of the attachments, the fit of the sling, and the weight distribution; check the resident's comfort; slowly lift the resident only as high as necessary to complete the transfer. EZ Way Sling Sizing Chart, Form #2-150 Revised 7/31/18, indicated it is important to evaluate the width of a patient in relation to the width of the sling; it is important that no portion of the patient overlap the sides of the sling; color coding is used on the binding of sling but not used for specialty slings; it is important that the base of the sling be positioned two inches below the tailbone and the top of the sling is parallel with the top of the shoulder line (base of the neck). Further identifies the size/weight designations are merely estimates and basic guidelines. A proper fit will depend on factors other that weight measurements, including the height and girth of a patient. A proper fit will involve the judgement of the caregiver. The IJ was removed on 8/28/24 at 5:00 p.m. when it was verified the facility implemented the following corrective actions: *The facility policy, Lift Machine Using Mechanical Lift Policy and Procedure was reviewed by the facility and nurse leadership. Facility clinical leadership in-serviced all nurses and nurse aides on the Lift Machine Using Mechanical Lift Policy, the EZ Way *Sling Sizing Color Coded Chart with emphasis on measuring weight and height, where to locate this information in the care plan/Kardex and performed return demonstration lift mobility competencies. *The clinical interdisciplinary team (IDT) team were in-serviced on the admission and quarterly assessment schedule that included lift mobility and any changes to the resident status, the care plans updated as needed. *Assessments and care plans of current residents who utilized mechanical lifts were reviewed and updated. All residents were measured per manufacturer recommendations. Resident's rooms were searched, and any incorrect slings were removed.

Based on interview and record review the facility failed to comprehensively assess and implement interventions to provide adequate supervision for 1 of 1 residents (R1) who had a history of exit seeking behaviors. R1's elopement from the facility in an unlocked motor vehicle, resulted in an immediate jeopardy (IJ). The facility implemented immediate corrective action and was issued as past non-compliance. The immediate Jeopardy (IJ) began on 4/22/24, when R1 exited the facility and staff did not respond timely to the activation of a door alarm by R1's WanderGuard bracelet. R1 got into an unlocked vehicle and drove around the city for 1.5 hours until police stopped him. The Director of Nursing (DON), Assistant Director of Nursing (ADON), Social Service Designee (SSD), were notified of the IJ on 5/1/24 at 5:30 p.m. The facility implemented immediate corrective action on 4/23/23, and the IJ was issued at past non compliance. Findings include: R1's face sheet printed 5/1/24, identified diagnoses of Alzheimer's, dementia, and senile degeneration (mental deterioration associated with age) of the brain. R1's admission Minimum Data Set (MDS) dated [DATE], identified an admitted ,d+[DATE], indicated R1 had severe cognitive impairment with inattention, diabetes, disorganized thinking and daily wandering behaviors. R1 was independent walking throughout the facility. R1 had adequate vision and hearing and was able to make self understood and understood others. R1's elopement risk assessment dated [DATE], identified R1's risk factors for elopement included R1 was ambulatory, and habits of wandering and exit seeking. Additional risk factors included R1 had eloped from this setting or a previous one, family voiced concerns R1 may tend to exit seek or elope, and R1 was taking medications that may cause confusion. Analysis concluded that R1 was at risk for elopement and interventions included a personal safety alarm, frequent monitoring (was not defined), and staff aware of elopement risk. R1's care plan dated 2/15/24, identified R1 was a high risk for elopement and wandering related to senile dementia and history of elopement attempts. Interventions included, assess elopement status quarterly and as needed. Distract from wandering by offering pleasant diversions, structured activities, food, conversation, television, book (western preference). Wander guard (personal safety alarm that alerts staff if resident attempts to leave the facility) to right lower ankle. The careplan did not include intervention of frequent monitoring as per the elopement assessment dated [DATE]. R1's progress notes between 2/22/24 to 4/14/24 identified R1 had multiple documented occurrences where R1 had attempted to leave the facility and/or had exit seeking behaviors without further assessment and revisions to R1's individualized care plan to continuously manage R1's exit seeking behaviors in order to prevent and/or mitigate the risk of elopement from the facility. R1's progress note dated 2/22/24, identified R1 did exit the front door again. R1's progress note dated 2/25/24, identified R1 was found exiting the door by A-wing. Wander guard alarmed and he was found near the nursing assistant supply room at the top of the ramp by the ice machine. R1 was easily redirected back to room. R1's progress note dated 3/7/24, identified R1 attempted to open door and alarm went off so he stopped. R1's progress note dated 3/10/24, identified R1 was walking towards the exit door, managed to get outside the facility and was easily redirected in at 3:21 p.m. At 9:47 p.m., R1 walked out of the facility and staff brought him back in immediately. R1's progress note dated 3/13/24, identified R1 attempted to go outside and was easily redirected. R1's progress note dated 3/24/24, identified R1 was exiting seeking and set off the wander guard multiple times. R1's progress note dated 3/31/24, identified R1 continued to be 1:1 visual staffing to prevent leaving the building. R1's progress note dated 4/3/24, identified R1 attempting to open emergency door on B-wing. The alarm scared him, and he walked away. R1's progress note dated 4/9/24, identified R1 was wandering facility, 1:1 provided. Nurse followed R1 as he exited the building and was able to easily redirect back into the facility. R1's progress note dated 4/11/24, identified staff saw R1 walk out of the exit door and managed to get out and staff brought him back in. Another time R1 did not exit the building but did open the door and walked back in the facility by himself. A facility reported incident submitted to the State Agency dated 4/14/24, identified R1 had exited the building and went to the front patio/fence area. Returned to facility without difficulty. The summary identified the facility would include an order to check the wander guard every shift for placement and functioning, will continue to discuss with family about potential different placement, and R1's care plan updated with activity of choice as R1 had been a gardener. The care plan 2/15/24 was not updated to reflect the activity intervention. The facility elopement risk assessment dated [DATE], identified the same information from the 2/15/24 assessment but concluded with interventions of exit alarm, secure unit placement, visual barriers (stop sign, ribbon, tape, etc.), staff aware of elopement risk, and personalization of room. No changes were made to the care plan. During an interview on 5/1/24 at 9:02 a.m., registered nurse (RN)-A stated an awareness of R1's behaviors, R1 frequently wandered around the building and exit seek. R1 was independent with walking around the facility. R1 could sometimes walk very fast however, other times he would walk very slowly. When it was cold R1 would go into the entry way and return to the building without assistance. R1 could be distracted from wandering with food, following nurses around during medication passes, and watching sports or the lake. RN-A would always tell R1 at the beginning of the shift to not leave without her. R1 would not be safe to drive a car. During an interview on 5/1/24 at 9:18 a.m., housekeeper (H)-A stated R1 would always try to go outside so every time she worked, she would look for R1 to make sure he was safe inside the facility. R1's progress note dated 4/20/24, identified R1 had been exit seeking after family left. R1's medication administration record (MAR) for April 2024, identified on 4/22/24 R1 received Seroquel (antipsychotic) 25 milligrams (mg) at 1:00 p.m., and haloperidol (antipsychotic) 2 mg was given at 6:13 p.m., morphine 0.5 mL was given at 6:13 p.m. R1's progress note dated 4/22/24, identified R1 had attempted to leave the building twice. Nurse gave as needed medication of Haldol and morphine to calm R1. At 6:41 p.m., wander guard alarm sounded and at 6:42 p.m., staff opened the front door and did not see anyone but saw a vehicle drive away from the facility. Staff began a search for R1. A staff member realized his car was missing during the search and police were notified of missing resident and motor vehicle. Police returned R1 to facility at 8:15 p.m. R1 was transferred to a locked memory unit. Progress note identified R1 was driving a car around the city of Worthington, Minnesota for almost 1.5 hours without a drivers license and medication that could impair mental status, vision, and reaction time. During observation on 5/1/24 at 4:52 p.m., the distance from the front door to where the staff members vehicle was parked was approximate 120 feet. The facility is located across the street from a lake off a road that in one direction runs along the lake shore with a stretch of road that has the lake on both sides. If one were to turn right out of the facility the road either goes along the side of the lake or leads to highway 60 after a couple of turns. The police record dated 4/22/24, case 2024002271 identified they received two calls at 6:58 p.m. the first call reported a missing vehicle and the second call reported a missing resident. Officers arrived on scene and determined the incidents were related. At approximately 7:45 vehicle owner reported he found the vehicle being driven east on [NAME] Street and officers stopped the vehicle on county road 33 near [NAME] Avenue, according to Google maps was approximately 3.7 miles from the facility. The vehicle was returned to the owner and the resident was transferred back to the facility. The facility Elopement document dated 4/22/24, identified R1 as a wanderer, exit seeking along with confusion and impaired memory. Early afternoon and late evening the day of the event, there were a lot of visitors and other resident in and out of the facility prior to the incident. R1 had been restless prior to occurrence. A facility reported incident submitted to the State Agency dated 4/25/24, identified an alarm sounded at 6:41 p.m. Upon staff going outside to locate R1 they saw a motor vehicle leaving the premise. 911 was notified and staff searched the premise and did not locate R1. Sheriff returned R1 to the facility at 8:15 p.m. (1.5 hours after the documented time R1 had left the facility). The summary identified R1 had wanted to go home. R1 was transferred to a sister facility upon return. During an interview on 5/1/24 at 1:20 p.m., trained medication aide (TMA) indicated she had worked the evening shift on 4/22/24. TMA stated right before R1 left the facility around 6:45 p.m., R1 had been in a recliner by the window in view of the nursing station with licensed practical nurse (LPN)-A. TMA had left the area and went to Hall-C to use the restroom. She had heard the alarm, returned to the area, however R1 was not there. TMA went outside to the right, and LPN-A went to the left, but could not find R1 so she returned to building to alert all staff to begin the search. During an interview on 4/30/24 at 3:11 p.m., nursing assistant (NA)-A stated staff had to always watch R1 because he would try to leave, mainly through the front door. R1 wore a WanderGuard that would activate an alarm if he tried to exit the facility however, the WanderGuard did not lock the doors. NA-A worked the evening shift of 4/22/24, when R1 went missing sometime after supper, she could not remember what time it was. NA-A had last seen R1 sitting in a recliner by the window in the dining room. NA-A explained she and NA-B had been in a resident's room with the door closed so she did not hear the door alarm sounding until she came out of the room at which point they went to the front door. NA-A did not know how long the alarm had been sounding before hearing it. NA-B told NA-A he was going to drive around to look for R1 but found his car missing from the parking lot. During a phone interview on 5/1/24 at 10:50 a.m., NA-B stated the evening of 4/22/24 he was in a room with NA-A so they did not hear the alarm until they left the resident's room. NA-B did not know how long the alarm had been sounding but LPN-A was already outside looking for R1 when he got outside. NA-B walked toward the lake across the street from the facility because he was worried R1 had got in and drowned. As NA-B walked he passed a few people and asked them if they had seen R1. The group of ladies told NA-B they saw an older man walking down the path. That is when NA-B decided to return to the facility to get his car to search. When NA-B returned to the facility he found his car missing. NA-B and LPN-A got in a vehicle and drove around looking for R1. NA-B stated when they got to highway 60, approximately two miles from the facility, they saw R1 in the car going the opposite direction so they made a U-turn to follow him. NA-B called the police back to tell them they located R1 driving NA-B's car. The police advised them to follow R1 and not attempt to get him to stop, the police would intervene and pull R1 over. NA-B said R1 was really speeding but driving nice by himself. NA-B was worried R1 would get in an accident and hurt himself or someone else. NA-B stated he did not realize he had left his keys in the car when he had been on break. NA-B was surprised R1 knew how to start his vehicle, I had to have instructions from [NAME] to learn. During an interview on 5/1/24 at 12:52 p.m., NA-C stated the evening on 4/22/24 she did hear the alarm but was with a resident and could not immediately respond. NA-C did not know how long the alarm had been sounding prior to being shut off. After she completed cares with the resident, NA-C headed toward the front door and met NA-A and NA-B also going outside. NA-C went toward the lake and asked two ladies walking if they saw R1 which they had not. When NA-C walked back toward the facility, that is when we noticed NA-B's vehicle missing. NA-C went back into the building and that is when R2 told her that R1 had got in a vehicle and drove away. NA-C went back to helping residents in the facility During an interview on 5/1/24 at 10:05 a.m., R2 who had moderate cognitive impairment according to the quarterly MDS dated [DATE], stated from his window he watched R1 walk really fast out of the building and got into a vehicle. R1 backed up, made a U-turn, and drove off. R2 saw staff outside the building looking for R1, but was not sure if it was before or after R1 was in the vehicle. During an interview on 5/1/24 at 9:24 a.m., LPN-A stated on 4/22/24, R1 attempted to leave two times on his shift prior to the incident. After R1's first attempt to get out of the facility, he was redirected to sit in a chair in the dining room. After R1's second attempt he was assisted to sit in the recliner by the window to look at the lake and because R1 was restless and agitated LPN-A gave him morphine and haloperidol at 6:15 p.m. After 20 minutes R1 continued to sit in the chair awake and appeared calm so LPN-A left the nurses station to go downstairs. LPN-A heard the door alarming at approximately 6:41 p.m. LPN-A went outside and saw a car turning left out of the parking lot. LPN-A did not think much of it because he did not think R1 would drive a car. When LPN-A came back into the building he met NA-B who reported his car was missing. After the notifications to family, facility, and 911 were made NA-B and LPN-A took LPN-A's vehicle and began the search by turning left out of the facility parking lot. LPN-A drove down the road and there was a stop sign to go left or right and he took a right. LPN-A and NA-B passed two stop lights and then saw NA-B's car. They called the police while following R1 so they could stop him. R1 was going a minimum of 35 miles per hour. R1 went on a roundabout that led to a gravel road and that is when the police pulled him over. R1 got out of NA-B's car smiling. LPN-A reported he was surprised R1 had been driving good, he stopped at the stoplights but R1 should not have been driving especially after taking morphine and haloperidol. R1 was always exit seeking, he would try to escape the facility any chance he got. R1 should have had 1:1 supervision but there was not enough staff scheduled to provide that, instead R1 had the wander guard that alerted staff as he was exiting the building. In response to R1's exit seeking behaviors the direction and interventions were always to educate R1 not to leave, keep an eye on him, and provide him with medication. LPN-A was unaware of any other interventions that were utilized to prevent R1 from exit seeking or leaving the facility. During an interview on 5/1/24 at 1:50 p.m., family member (FM)-A stated R1 was an outdoors person and loved the outside view at the facility. FM-A wished the facility had doors that locked. FM-A stated when she was told R1 was driving a vehicle she was terrified that R1 would hurt himself, or if some little kid was out and [R1] mistook the gas for the brake. During an interview on 5124 at 2:09 p.m., director of nursing (DON) and assistant director of nursing (ADON) stated their expectations when a resident was exit seeking was to stay with the resident, divert, redirect, find out what the resident was seeking, distract them and see when the last time their needs were addressed. DON stated it would be hard to say what would have stopped R1 from exit seeking on 4/22/24. ADON stated there was a lot of business in the facility that day and that always seemed to be a trigger for R1. The facility policy titled Wander Management System updated 6/22, identified a wander management alarm system may be used on a resident who is deemed unsafe through the nursing assessment and documented on the resident's care plan that the resident was at risk for elopement. The wander management system should be checked every shift for placement and weekly for function. The facility policy titled Resident Elopement reviewed 6/22, identified that staff shall investigate and report all cases of missing residents. 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the charge nurse or DON. 4. if an employee discovers that a resident is missing from the facility, he/she shall initiate a search of the building and premise, if not located, notifications made to Administrator, DON, resident representative, physician, law enforcement, volunteer agencies, state agency. Proved search teams with resident identification information, initiate an extensive search of the surrounding area. 5. when resident returns to the facility examine the resident for injuries, contact the physician, notify resident representative, notify search teams, apply wander guard bracelet with MD order as needed, complete and file a risk management incident, report to the state agency and update care plan accordingly. Document relevant information in the resident's medical record. The past non-compliance IJ began on 4/22/23. The IJ was removed, and the deficient practice corrected on 4/23/24 when it was verified the facility had implemented corrective action that included: -discharged R1 to a secured memory care facility on 4/22/24. -The facility developed a new protocol to have staff always present in the area of the door leading out of the facility on 4/23/24. -The facility re-educated staff on response time to the door alarms, and providing adequate supervision for wandering residents on 4/23/24.

Based on interview and document review, the facility failed to ensure 1 of 1 resident (R4) was transferred with the appropriately sized mechanical lift sling, ensure nursing staff were appropriately trained to the manufactures instructions-for-use of the mechanical lift, and ensure staff followed facility policies and procedures by utilizing 2 staff for transfers. The deficient practice caused actual harm when R4 fell from the lift and sustained a laceration to her head and broken ribs. The IJ began on 4/29/22, when R4 was placed into a total body mechanical lift using the incorrect sling size by staff who were not trained to manufacturer's instructions for use or follow facility policy using 2 staff for transfer. R4 fell from the lift sling and received a head laceration and broken ribs. The facility administrator and director of nursing (DON) were notified of the IJ on 5/3/22 at 6:00 p.m., which was identified as a J-ISOLATED. The IJ was removed on 5/4/22 at 11:43 a.m., but non-compliance remained at the lower scope and severity of D-ISOLATED. Findings include: R4's 2/4/22, quarterly Minimum Data Set (MDS) identified she had a severe cognition, was non-verbal and was rarely understood. R4 required total dependence of staff for transfers. R4 had diagnosis of advanced dementia. Review of the 4/29/22, initial report to the State Agency identified R4 fell out of a total mechanical lift causing head injury. R4 was taken to the local hospital. Review of the 5/3/22 12:24 p.m., 5 day report to the SA identified 2 nurse aides (NA) were transferring R4 into the bath chair. R4 reportedly pulled herself forward to scratch her buttocks and tipped out of the side of the sling. R4 landed on the floor between the legs of the lift with her head on the base. R4 was given first aide and transferred to the local hospital emergency department (ED). The nurse on duty interviewed both NA's. It was found R4 did not have the correct size sling in place. R4 had a small sling, when she should have had a medium. R4's care plan was determined to be accurate with the size of the sling needed. Both aides were not near the lift as 1 NA had gone to get the bath chair and the other NA was operating the controls. Education was reported as being provided as well as staff competencies to policies and procedures for using lifts. All residents were to be re-measured on 5/25/22 by the manufacturer representative to ensure they had the correct sized sling and to train all staff on how to operate the sling and lift. Residents who required a total mechanical lift sling were measured for correct sling size. Care plans were reviewed for those residents affected. There was no mention the facility had identified staff had not been appropriately trained or retrained using manufacturer's instructions for use of the mechanical lifts. Review of a blank EZ Stand Competency Checklist identified its purpose was to assist in the proper training of operating the EZ Stand. It included a pre-operation checklist, stand operation section, and harness removal. It lacked instruction material to train staff but did note on the bottom to refer to the operator's manual that was supposed to be attached to the lift. Interview on 5/2/22 at 1:13 p.m., with the medical director (MD) identified he was notified of the incident after it had occurred. He was told 2 NA's were attempting to use the lift on R4. NA-E left to get something, and NA-D was left alone with R4 and used the mechanical lift. He reported staff told him potentially one NA wasn't paying attention and R4 somehow fell . R4 was sent to the ED. Staff were suspended pending the facility investigation. The MD was unaware staff were not trained to the manufacturer's instructions on the use of the mechanical lift. The MD agreed staff should have used the correct sling size and followed facility policy for use of 2 staff. The MD was also not aware staff competencies had either not been completed or had been signed off as having been completed prior to use of the lifts. Review of NA-D's employee file identified she was hired on 3/1/22. NA-D's time clock reports showed she received 18 hours of training from 3/3/22 through 3/10/22. 3/15/22 through 3/27/22 identified she received 38.25 hours of orientation to the facility. NA-D was a certified nursing assistant since April 2018. NA-D's full competency checklist and job description were blank and had not been signed by either NA-D or anyone overseeing competencies prior to NA-D providing basic cares for residents. NA-D had completed online training on safe use of mechanical lifts, however, there was no indication that was from the manufacturer on the specific lifts the facility used. NA-D had never worked with EZ-Way lifts before her employment at the facility. Interview on 5/3/21 at 1:11 p.m., with the DON identified she had no lift operator's manual onsite to be used for training. She was unaware the manual included operating instructions. Interview and EZ Way lift manual review on 5/3/22 at 2:26 p.m., with NA-D identified she was hired by the facility approximately 2 months prior. NA-D was a certified nurse aide. When NA-D was hired, she completed online training to provide basics for care giving. After that, she followed a mentor for the remainder of her training. NA-D was shown the operators manual for the EZ Way lift by this surveyor and reported she had never seen that manual for the EZ lift before, or its instructions for use. Inside the manual, the manufacturer noted slings were to be color coded by size required. NA-D was unaware the slings were color-coded according to the size required for the resident. NA-D recalled the incident. She was operating the lift and had lifted R4 off the bed. While she did this, she instructed NA-E to get the bath chair that was in the hallway. NA-D proceeded to lift R4 to the highest point and use the controls to swing R4 from the bed to where the bath chair would be placed once NA-E brought it into the room. Before that could happen, NA-D saw R4 reach for her buttocks to scratch and told her to not scratch when R4 slipped from the sling approximately 4 feet, striking the floor and legs of the lift with her head and body. NA-D felt it was ok to lift a resident as high as she wanted and was unaware a resident should only be lifted enough to clear the surface she was transferring from. Observation on 5/3/22 at 2:47 p.m., of the linen closet with NA-D identified that was where residents' clean slings were kept. NA-D was unaware of how to tell the size of a sling. NA-D stated she normally just used the sling that was in the resident's room. She indicated new labels had been placed on the outside of the laundry baskets to identify what size slings were in each basket. She recalled the sling she had used on R4 may have had gray (small) or burgundy (large) edging but was unsure what size that was. When verifying the size in each basket according to the label on the sling and color-coded edging, she indicated she had used the gray edged sling, sized small when the incident occurred. NA-D was told she should have used a medium sized sling. NA-D had grabbed a sling that was already in R4's room and had not verified the size was correct before use. NA-D also was unaware the lift had the corresponding color sizes labeled on the lift itself for easy recognition or the color-coded slings to the corresponding size. Review of NA-E's employee file identified she had been hired on 3/8/22. NA-E was not certified. NA-E had received 7.5 hours of online training and 26.5 hours of orientation. NA-E's lift competency inside her file noted her lift competency was shown and discussed however, there was no signature by the trainer or date of when this occurred. NA-E's main competency page was also blank and unsigned by any NA tasks she would be responsible for in order to perform tasks independently or with another staff. Interview and employee file review on 5/3/22 at 4:07 p.m. with NA-E identified her lift competency was incomplete as well as her other competencies for providing basic cares to residents. NA-E reported she received about 2 weeks of training where she followed another staff to learn residents routines. She could not recall a nurse overseeing or completing any competencies related to her performing resident care. Interview and employee file reviews on 5/3/22 at 4:35 p.m., with the DON identified the DON and training staff used the competency checklist to train staff, and not the actual instructions listed in the manual. The DON agreed staff failed to ensure staff competencies were filled out appropriately, dated and signed. She agreed staff had not received appropriate training as there was no manual for operating instructions onsite. She was unaware NA-D and NA-E and potentially other staff had not been appropriately trained to operate the lifts safely according to the manufacturer. She identified since R4's fall, she had labeled the bins for slings in the clean linen closet. The DON agreed staff caused R4 actual harm when R4 was lifted into the air by inappropriately trained staff, fell , and received laceration to her head and multiple rib fractures. The DON agreed the facility investigation did not identify staff were not appropriately trained and she was unsure who was responsible to view employee files to ensure competencies were performed by licensed nurses to unlicensed personnel. Review of the 8/10/18, EZ Way Smart Lift Operator's Instructions manual identified for safe operation of the lifts, operators should watch the training video, read through the manual, complete a competency checklist, and practice on fell ow staff members before use with patients. Staff were directed to ensure accessories such as slings used with each lift were appropriate for both the patient and transferring situation and could call the EZ Way hotline if they had questions. Although it was designed to work with 1 staff, depending on the situation and facility policy, and patient condition, 2 staff may be necessary. All equipment must be maintained regularly by competent staff according to the checklist provided. Those instructions were to be kept with the lifts at all times. While lifting the resident, the were only to be lifted enough to clear the bed or surface being moved from. The sling sizing chart identified a resident between 90- 220 pounds (lbs) was to use a beige colored medium sling. The height of the sling should be between 2 inches below the tailbone to top of a resident's shoulder line, therefore a proper fit was dependent on factors other than weight, including height and girth of a patient. Review of the current, undated Lifting Machine, Using A Mechanical policy identified at least 2 staff were needed to safely move a resident with a mechanical lift. Before using the left device, staff were to assess the resident's condition including physical and cognitive or emotional requirements. Staff were to measure for the proper sized sling and purpose according to manufacturer's guidelines. A double check of the resident's weight and sling to be used was to be obtained. Staff were to lift the resident after following manufacturer's instructions 2 inches from the surface to check the stability of attachments, the fit of the sling, and resident's weight distribution. Staff were only to lift the resident as high as necessary to complete the transfer. Staff were to document in the medical record the reason for the transfers, lift used, equipment size resident's condition before and after the procedure. The IJ was removed on 5/4/22 at 11:43 a.m., when it could be verified through observation, interview, and document review, the operators' manuals had been obtained for all lifts used in the facility and were placed in each lift per operators' instructions. All nursing staff were trained using the manual and included demonstrated competency. Staff were re-educated to correct sling size and to check the Kardex or care plan to ensure the correct size was listed. All other residents using mechanical lists were measured to ensure appropriate slings were used. Management was monitoring 2x daily and re-education would be provided until competency was attained.

Based on interview and document review, the facility failed to ensure interventions were developed and implemented to prevent falls for 1 of 1 resident (R2) who had a recent history of falls with fractures. R2 sustained actual harm after self transferring and ambulating without assistance of staff to the bathroom, which resulted in a fall with pelvic and [CONDITION(S)] with resulting hospitalization . Findings include: Review of the 3/31/22 at 10:43 a.m., State Agency (SA) report identified R2 was found on her bathroom floor at 4:00 a.m., when she self-transferred, ambulated to the bathroom, fell and was discovered seated on the floor complaining of right-sided groin pain. R2 was transferred to the hospital by ambulance where it was determined she had sustained a fracture. R2's 3/31/22, emergency room (ER) provider note documented a CT scan of the abdomen pelvis identified an acute distracted(separated) comminuted (break in at least two places) right superior and inferior pubic (pelvic bone) fracture. There was also a hematoma (bruise) along the right lateral pelvic wall and a questionable bladder injury. R2 was not able to state the cause of her fall and identified her pain level at 10/10 with movement. Consultation with surgery on-call recommended R2 be transferred to a larger acute care facility for further treatment and evaluation. R2 was stabilized and transferred to higher level of care by ambulance with family in attendance. R2 was admitted to acute care following the ED evaluation for further pain management and evaluation with discharge plan for return to LTC facility. R2's 5-day admission Minimum Data Set (MDS), assessment dated [DATE], identified R2 had severe cognitive impairment, and required extensive assistance from 1 staff for Activities of Daily Living, which included transfers and ambulation. R2 also had pain as a result of recent fractures prior to admission involving multiple rib fractures and lumbar (lower spine) fracture as a result of two falls. R2 had diagnoses of bladder incontinence, long-term use of blood thinning medication, anxiety and depression. R2 was also receiving daily scheduled medications for her anxiety, depression, pain, and fluid retention. R2's Care Area Assessment (CAA) dated 3/29/22, identified resident was assessed as at high risk for falls, had extreme pain and required extensive assist from one staff for all transfers, toileting and ambulation. R2 was identified as frequently incontinent of bladder and used pull ups for dignity. R2 had physical performance limits of impaired balance during transitions in addition to difficulty maintaining sitting balance. She was receiving therapy services for mobility, strengthening and transfers with a discharge goal of returning to her previous living situation. R2's current undated care plan listed R2 required 1 assist and cues depending on pain level and was independent at times. The care plan for toileting identified R2 required one assist to independent depending on pain level, and transfer was listed as supervision unless having pain. However, R2's care plan did not accurately reflect therapy's current instructions for mobility which included staff assistance with use of gait belt due to balance and transfer limitation. In addition, R2's care plan failed to identify either a toileting and/or plan for monitoring when R2 was frequently discover`ed attempting to self-transfer or already in the bathroom, without requesting assistance from staff. Review of R2's progress note dated 3/25/22, identified R2 needed assistance of one staff for all ADLs, transferring and toileting, at times R2 required limited to extensive assistance depending on pain level. Cognition was also identified as fluctuating dependent on her pain medication usage. Review of R2's progress note dated 3/29/22 identified R2 required assistance of 1 staff for all ADLs, transferring and toileting. Interview on 4/7/22 at 3:00 p.m., with the MDS coordinator and director of nursing (DON) confirmed R2's current care plan and CAA. They indicated the care plan was not accurate and should have been updated to include R2's lack of safety awareness, incontinence of bladder, and need for assistance with transfer and ambulation and indicated she was frequently non compliant with staff assistance. Interview on 4/6/22 at 12:54 p.m., with the Occupational Therapist (OT) identified R2 had increased pain as a result of 2 falls with fractures that took place prior to her admission to facility. She reported R2 had difficulty moving and was able to sit at the edge of her bed and transfer with assistance but was not cleared to self- transfer. The OT identified R2 had issues with safety awareness and balance that resulted in the need to have staff in attendance. The OT reported R2 told her she had gotten up independently and gone to bathroom, because she thought doing so would speed up her ability to go home. R2 was instructed she was not safe to self-transfer and ambulate without staff with her and reminded to use her call light and have staff with her. The OT identified,both physical and speech therapy, had also reminded R2 of the need to have staff with her due to balance and safety concerns. The OT reported R2 was able to understand how to use the call light but thought she also would forget at times. The OT indicated R2 was experiencing a lot of pain due to her rib and back fractures, and she was receiving a lot of pain medication which also impacted her balance and safety awareness. Interview on 4/6/22 at 3:34 p.m., with licensed practical nurse (LPN)-A identified R2 repeated attempted to self-transfer and had been instructed to use her call light, that she was not safe and she needed help. LPN-A reported when R2 was told she needed to have assistance she would respond, she knew, and she was sorry or stated she had forgotten, but continued to attempt to transfer without assistance. LPN-A reported when R2 was discovered attempting to self-transfer she was usually going to the bathroom, or at times attempting to transfer from the recliner to or from her bed. LPN-A identified she was not aware of R2 being on a toileting plan, having any posted reminders to have assistance, or other than routine checks as staff went about their duties on the hall. Interview on 4/6/22 at 4:30 p.m., with LPN-B identified she had been working on the night shift when R2 had fallen. LPN-B identified the resident that shared the bathroom with R2 had turned on her call light about 1:30 a.m., and pointed to the open bathroom door where R2 was seated on the floor of the bathroom facing the toilet with her back against the wall. LPN-B noted R2 had a large skin tear on her right elbow, was able to straighten her legs, and stated the only area that hurt was her right groin when she moved. LPN-B assessed R2, and explained she was going to contact the ambulance to have her checked out at the ED. LPN-B reported R2's call light was not on and still clipped to her pillow on the bed. Staff normally checked on R2 at midnight when doing rounds, again at 2:00 a.m., and at 5:30 a.m. when residents were starting to wake up. R2 did not have any signage or reminders in her room to call for assistance before attempting to self-transfer. Staff were to make certain her call light was always within reach. Notifications to the family, provider, and DON were completed and EMS was contacted to have R2 transported to the local ED. Upon arrival of the ambulance, R2 was unable to bear weight on her right leg and was assisted from the floor to gurney and had complained of right groin pain with movement. LPN-B identified she received a phone call from the ED that R2 had a fractured pelvis and was being transferred to a regional hospital. Interview on 4/6/22 at 4:51 p.m., with nursing assistant (NA)-A identified she had been working on the night shift when R2 had fallen in the bathroom. She identified she had done rounds and R2 had been sleeping quietly in bed about 1/2 hour before her fall. NA-A identified rounds were completed every (Q) 2 hours, but staff were checking resident rooms about Q 1/2 hour just to make certain everyone was alright. NA-A stated R2's bathroom light was on and the night light was on in the room, but the room lights were off. NA-A reported R2 would use her call light sometimes when she wanted to get up, but other times, she would just get up and go to the bathroom and staff would find her there. R2 was not on a toileting plan, and there were no signs or reminders for R2 to call for assistance before getting up. NA-A reported when R2 was reminded to use her call light she would state she was sorry and that she had forgotten but frequently did not remember to do so. She indicated when R2 was caught attempting to self-transfer it was usually because she wanted to use the bathroom. Interview on 4/7/22 at 9:06 a.m., with LPN-C identified R2 and she had a lot of pain and difficulty moving due to rib fractures from a previous fall at home. R2 voiced her plan to gain strength and manage her pain so she could return home. R2 was instructed to use of her call light and have staff assist her when she wanted to get up or needed something and verbalized understanding. LPN-C stated R2 felt if she was able to self-transfer, she would be able to go home sooner. R2 was reminded therapies were working with her to increase her strength and manage her pain so that she could go home, but she needed to wait until they felt it was safe for her to self-transfer. R2 verbalized understanding of the instruction. R2 was forgetful at times, and her comprehension could be considered questionable. LPN-C identified safety measures in place for R2 included her bed and room rearranged for convenience and to allow easier access to personal items. There was no formal monitoring in place, but staff would check on her as they were moving about in the hall. R2 had no reminders, or interventions in place to encourage/remind to have assistance with transfers and ambulation. R2 had orders for scheduled pain medication which included alternating [MEDICATION(S)] and Tylenol in addition to a [MEDICATION(S)] applied to her lower back daily. LPN-C reported R2 would use her call light at times to make a request of staff, but when she wanted to go to the bathroom or move from one surface to another, she would self- transfer and/or ambulate without using her call light to allow staff to assist her. LPN-C also reported during a conversation with R2's daughter, she was told her mother had told her, if she was able to prove her ability to be independent, she would be able to return home sooner. Interview on 4/7/22 at 10:28 a.m., with NA-B identified she had assisted R2 to and from the bathroom and utilized a gait belt to help steady her as she had some balance issues and at times complained of feeling dizzy when she got up. NA-B reported R2 would use her call light at times and allow staff to assist her with transfers and ambulation, but frequently staff would find R2 attempting to self-transfer, or already in the bathroom. She identified R2 had incontinence of bladder and wore pull ups for dignity. NA-B reported, she had to repeatedly remind R2 she needed to wait until she could apply the gait belt so she could assist her, but at times she was confused and state she did not know that or had forgotten. NA-B reported R2 was not on a toileting schedule, but when she attempted to self-transfer it was frequently because she wanted to go to the bathroom. There were no additional safety measures in place that she was aware of, and the only sign was the one posted on the outside of the bathroom door, labeling it as the bathroom. Staff checked in on R2 as they were working on the unit, because they were aware she would attempt to self-transfer and not use her call light. Interview on 4/7/22 at 10:43 a.m., with the medical director identified he had not actually seen R2 due to her recent admission and then her return to the hospital after her fall. If a resident was forgetting to use the call light and had a lack of safety awareness, he would expect further investigation into the cause with assessment and implementation of additional safety measures considered. Interview on 4/7/22 at 10:55 a.m., with NA-C identified R2 required staff assistance using a gait belt and her walker to transfer and/or ambulate to the bathroom due to unsteadiness and balance issues when she got up. NA-C identified when R2 was attempting to self-transfer it was usually because she wanted to go to the bathroom and when staff would remind her she needed to have staff with her for safety, she would not reply or stated she could do it herself. NA-C reported R2 did not have additional safety measures in place and was not on a toileting schedule. Staff were aware she was a high fall risk and would check on her randomly to attempt to assist her with transfers to avoid a fall. Interview and document review on 4/7/22 at 3:49 p.m., with the DON identified R2 did not have a toileting plan or safety measures identified other than to use the call light. The DON reviewed the current care plan and agreed it failed to include the current needs for safety awareness and the need for staff assistance with transfers and ambulation. The DON agreed there should have been additional investigation and root cause anyalysis (RCA) of R2's repeated failure to comply with safety recommendations and development of a plan to implement safety measures which could have possibly helped to avoid the additional fall and resulting fracture. Review of the 3/13/20 Falls and Fall Risk Managing policy identified based on evaluations and current data, staff would identify individualized interventions in an attempt to decrease a resident's fall risk. Staff were to monitor and re-evaluate a resident's response to interventions intended to reduce falling or fall risk factors. Review of the 10/17/19, Care Plans-Comprehensive policy identified interventions are designed after consideration of the resident's problem areas and causes. When possible, interventions address the underlying source of the problem area, rather than only addressing symptoms or triggers.

Based on observation, interview and document review, the facility failed to follow Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) guidelines to have ongoing surveillance and appropriate resident screening, monitoring, and quarantine or isolation for 6 of 30 residents (R2, R3, R4, R5, R6, and R7), who tested positive for COVID-19. The facility's failures resulted in an immediate jeopardy (IJ) situation for all 30 residents. The IJ began on 10/6/20, when it was identified the facility failed to immediately implement Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) guidelines for quarantine or isolation and use of transmission based precautions when residents first exhibited symptoms of COVID-19. The facility had implemented measures to correct the deficient practice by 10/27/20, resulting in PAST NON-COMPLIANCE. Findings include: When interviewed on 11/4/20 at 11:49 a.m., the director of nursing (DON) stated she had been ill with COVID until 11/3/20. The DON stated, the outbreak happened so fast, there was no time to update the surveillance documentation. The DON further stated, the infection preventionist (IP) in charge of the infection control program had resigned, with her last day of work being that day (11/4/20). The DON verified infection surveillance consisted of reviewing resident infections and antibiotics every day and explained, the dashboard, last 24 hours of progress notes, and discussion of infections during stand-up meetings were to be completed daily to identify symptoms of infections and any changes in resident condition. Review of the facility's Infection Control Program documentation, identified processes located in a binder and an infection line list stored on an electronic spreadsheet. The infection control line list electronic document included: resident name, room number, infection type, body system for infection, and surveillance definitions met such as symptoms, onset date, infection risk factors, diagnostics performed, type of test, specimen source, results, antibiotic name, type of precautions (such as whether transmission based precautions were in place), and date symptoms resolved. The facility's resident COVID-19 resident screening documentation tool identified staff were to notify the infection preventionist and implement transmission based precautions (TBP) when a resident had two or more symptoms present. Review of resident records and the infection control line listing identified the following: R2's nurses' notes identified between 10/6/20 and 10/15/20, R2 experienced frequent diarrhea. On 10/14/20, R2 tested positive for COVID and was moved to the COVID unit. The notes made no mention R2 was placed on TBP at the onset of diarrhea, a potential symptom of COVID-19. The October 2020, infection control line list did not include R2's symptoms of diarrhea. There was no indication R2's physician was notified when R2 developed the diarrhea. R3's nurses' notes identified between 10/7/20 through 10/14/20, R3 experienced frequent, intermittent diarrhea. On 10/14/20, R3 had nasal congestion, was tired, lethargic, hoarse and had crackles in her lungs. R3 was transferred and admitted to the hospital 10/14/20, and tested positive for COVID. R3 returned to the facility on [DATE], and was placed on TBP upon readmission. The October 2020, infection control line list did not include R3's symptoms of diarrhea. R3's progress notes did not indicate whether R3's physician was notified at the onset of diarrhea, and made no mention about whether R3 was placed on precautions at the onset of her symptoms. R4's nurses' notes identified on 10/11/20, R4 had diarrhea. On 10/14/20, R4 had a cough and tested positive for COVID. R4's notes made no mention R4 was placed on TBP at the onset of COVID symptoms. The October 2020, infection control line list did not include R4's symptoms of diarrhea. R5's nurses' notes identified on 10/6/20, R5 was not eating because he felt it caused him to have diarrhea. On 10/7/20, R5 had shortness of breath and low oxygen saturation during physical therapy. On 10/12/20, the notes indicated R5 had low oxygen saturation and diminished lung sounds. R5's bowel records identified R5 had diarrhea on 10/13/20. On 10/14/20, staff explained to R5 he needed to remain in his room related to COVID. On 10/16/20, the nurses' notes indicated R5 had a new cough, fever, and low oxygen saturation at 77 percent. On 10/16 20, R5 was tested and found positive for COVID and was transferred to the facility's COVID unit. R5's progress notes did not indicate whether R5 was placed on TBP at the onset of COVID symptoms. The October 2020 infection control line list did not include R5's loose stools. R6's nurses' notes identified R6 was hosptialized for a gastro-intestinal bleed on 9/27/20, returned to the facility on [DATE], and was on TBP and quarantine for 14 days. The nurses' notes indicated between 10/8/20 and 10/22/20, R6 experienced frequent diarrhea. R6 was tested for COVID and was positive on 10/22/20. R6's notes made no mention as to whether R6 remained on precautions after her 14-day isolation period ended 10/14/20, even when R6's diarrhea continued. No staff were able to verify the continued use of TBP or quarantine when symptomatic. R7's nurses' notes identified on 10/1/20, R7 was seen by her medical provider and treated for [REDACTED]. R7's nurse notes from 10/21/20, indicated R7 was placed on precautions during the past week, but did not specify the date. Review of the October 2020, infection control line list identified R7 was placed on TBP on 10/26/20 and was noted as having had no symptoms of COVID. The October 2020, line list made no mention R7 had nasal discharge on 10/1/20, or diarrhea between 10/10/20 and 10/29/20. There was no indication R7 was placed on TBP at the time of the initial onset of COVID symptoms. During interview with registered nurse (RN)-A on 11/5/20 at 4:35 p.m., RN-A stated symptoms of infection were reviewed during daily stand-up meetings, and the DON and the infection preventionist were responsible for the infection control program. RN-A stated symptoms of infection are documented in each resident's electronic medical record (EMR) in the progress notes, or included in the resident User Data Assessment (UDA) record. RN-A stated there was a UDA for COVID symptom documentation to be utilized in the EMR so if a resident had symptoms of COVID, staff were to document those symptoms on the UDA. Further, RN-A stated PPE was implemented only by the DON or the infection preventionist when symptoms of COVID were identified as present. When interviewed on 11/6/20 at 11:00 a.m., the DON identified the facility had experienced two COVID outbreaks, a small one in September 2020, and a larger one in October 2020. The DON verified following the September 2020 outbreak, the facility had not reviewed the data from the outbreak to identify any potential breaks in their infection control practices. During the second outbreak, most staff were unable to work due to COVID symptoms or had COVID positive test results. The DON stated she was unable to maintain an ongoing infection surveillance process due to the sudden outbreak. She agreed infection surveillance was supposed to be ongoing and continuous, and verified that had not occurred. The review of residents with COVID symptoms between the outbreaks identified residents with diarrhea, and respiratory symptoms without initiation of transmission based precautions. The DON verified residents with diarrhea were not necessarily included in their facility infection surveillance and stated she felt some of the residents had long-standing diarrhea. However, the DON agreed diarrhea was a symptom of COVID and was included in the resident COVID screening tool. She confirmed residents with long term diarrhea symptoms were not reviewed to identify any changes in bowel patterns, and the symptoms were not addressed with the resident's physicians to determine need for TBP. The DON further stated they would only initiate TBP when residents had two or more symptoms of COVID according to facility policy. The DON was unsure how the decision to implement TBP when two or more symptoms were present was identified. The DON said she expected staff to follow recommendations outlined by the CDC and CMS. The DON also stated she and the facility's infection preventionist were solely responsible for identifying and initiating TBP when COVID symptoms were identified. The DON stated nurses were to call her and the infection preventionist immediately to review symptoms and implement precautions. She agreed, there be would no way to monitor symptoms if they were not documented in the COVID Screening tool, or on a line list to determine potential outbreaks present in the facility. The DON stated she had felt the facility had implemented TBP appropriately and monitored appropriately for symptoms of COVID, and felt there was nothing further the facility could have done to prevent transmission of COVID after it was present in the facility. However, stated when she returned to work on 11/4/20, the facility had already initiated a new infection monitoring system. Nursing assistant (NA)-A was interviewed on 11/6/20 at 10:04 a.m. NA-A stated staff notify the charge nurse when residents have COVID symptoms, and the DON and infection preventionist tell staff when to implement PPE. During interview on 11/6/20 at 9:09 a.m., the administrator stated the facility had a COVID outbreak in September 2020, and again in October 2020. The administrator stated in October, almost all staff had became ill and they'd had to seek staffing supports from the State Emergency Operation Center to assist in providing resident care. The administrator also stated he'd been out with COVID and returned yesterday. The administrator verified they had not reviewed the September 2020 outbreak to identify any breeches in infection control practices to determine whether the facility could have done anything differently to prevent/minimize the COVID outbreaks. He agreed infection prevention should be ongoing and continuous, but stated the outbreak in October happened so fast, they were unable to keep up. On 11/6/20 at 10:52 a.m., an attempt was made to contact the facility's medical director. A message was left, but no call was returned at the time of the survey exit. The facility's undated, Pandemic COVID-19 Plan, identified the infection preventionist was to create a system to monitor and internally review transmission of COVID-19 among residents and staff in the facility. Information from monitoring was to be used to implement infection prevention interventions. The facility's 12/29/19, Infection Prevention and Control Program, identified the program was developed to address facility-specific infection control needs and requirements identified by the facility assessment and the infection control risk assessment. The policy indicated the program was reviewed annually and updated as necessary. The infection preventionist was responsible for coordination and oversight of the infection control program. The infection control committee was responsible for reviewing and providing feedback on the overall program. Surveillance data and reporting information was used to inform the committee of potential issues and trends. The reviews were to include documented infection incidents and corrective actions taken. Surveillance tools were used to recognize occurrences of infections, recording their number and frequency, detecting outbreaks and monitoring employee infections, adherence to infection prevention and control practices and detecting unusual pathogens with infection control implications. Outbreak management was a process to determine presence of an outbreak, manage affected residents, prevent the spread to other residents, documentation of information about the outbreak, reporting information to the appropriate public health officials, education of staff and the public, monitoring for recurrences, reviewing the care after the outbreak and recommending new or revised policies to handle similar future events. The facility's 8/13/20, COVID-19 Guidelines and Procedures for All Facilities, identified the facility was to continue surveillance of all residents using the UDA titled Existing Resident COVID-19 Screening Tool. Staff were to immediately place residents with suspected COVID into isolation, place a mask on the resident and close their door, contact the designated State Agencies, regional clinician and local hospital, resident's guardians, physicians, and any other providers of the resident's status. Staff were to also remember to update the infection control line list and resident care plan. The facility's undated, COVID-19 Recommendations for Long Term Care Facilities, identified all residents and staff were to be tested if symptomatic. Symptoms included fever greater than 100.0 degrees, or two or more temperatures greater than 99.0 degrees Fahrenheit (F), shortness of breath new or change in cough, chills, sore throat, muscle aches, new or worsening malaise, headache, new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, new confusion/altered mental status, and new or worsening [MEDICAL CONDITION]. A negative test only indicates an individual did not have [MEDICAL CONDITION] material at the time of testing, and repeat testing may be needed, testing compliments existing infection prevention practices and was not a replacement of good infection prevention control practices. The past non-compliance that began on 10/6/20, was verified to have been corrected by 10/27/20 when the facility had appropriately identified and initiated transmission based precautions for residents who were symptomatic for COVID-19. In addition, surveillance was updated. Verification of corrective action was confirmed through interview with facility staff, observation of care, and review of residents' medical records, infection control surveillance, policies and procedures, and staff training.

Based on observation, interview and document review, the facility failed to ensure allegations of abuse and neglect were identified, investigated and appropriate action taken to protect 5 of 5 residents (R31, R183, R4, R14, and R000) who reported being afraid, felt unsafe in their own home and were handled roughly when being cared for by nursing assistant (NA)-A and NA-C. The facility's failure to investigate, and protect residents resulted in an immediate jeopardy situation which had the potenial to affect all 42 residents. The immediate jeopardy began on 5/30/19, when R31 indicated staff were rough and rude during cares, and fearful of retaliation if she reported the incidents. The Administrator, Director of Nurses, and consultant were notified of the immediate jeopardy at 5:28 p.m. on 5/30/19. The immediate jeopardy was removed on 6/4/19, after it could be verified the facility had implemented an acceptable removal plan however, noncompliance remained at the lower scope and severity level of F level,- widespread, indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R31's [DIAGNOSES REDACTED]. R31's 5/9/19, quarterly MDS identified she had moderate cognitive impairment. She required extensive assistance of 2 staff for all ADL's. R31 used a mechanical stand lift. R31's care plan, revised on 2/26/19, indicated R31 was susceptible for abuse and staff were to follow the facility abuse and prevention policy and procedure. During observation and interview on 5/28/19 at 12:59 p.m., R31 had multiple bruises on her hands. When asked how she got them, she responded every time you get in that EZ lift thing you get bumps. NA-A then entered the room and R31 stopped talking. R31 was transferred to her wheelchair and taken to the tub room using the EZ stand. During evening meal on 5/28/19, the director of nursing (DON) indicated family member (FM)-A wanted to visit with a surveyor. During observation and interview on 5/28/19 at 6:12 p.m. with R31 and FM-A, R31 indicated NA-A pulls the mechanical lift harness roughly from behind her. When asked if R31 had reported this to anyone, she indicated she was afraid of retaliation. FM-A indicated R31, told her to stay quiet. R31 went on to say you have to be careful of what you say around here, it will come back to you. When asked if she has ever been hurt, R31 would not answer and turned her head to look at the door while she said they are out there, they are listening to everything. While FM-A was talking, R31 stated to her you don't understand, you have to keep your mouth shut. During phone interview on 5/29/19 at 9:10 a.m., FM-B indicated concerns related to the lack of care provided to the resident, lack of staff, and long call light wait times. FM-B indicated the following examples: (1) on 5/25/19 at 7:40 a.m., R31 placed a phone call to FM-B and stated she was still in bed. When FM-B arrived at the facility at 8:40 a.m., she could hear R31 crying from down the hall. FM-B found R31 still in bed when she entered her room. Breakfast is scheduled for 7:30 a.m. and the other residents had been down for breakfast; however, it was 9:20 a.m. before the residents eating in their room received their breakfast. When FM-B asked the NA why R31 was still in bed, NA indicated she was trying to take care of 16 residents by herself. FM-B discussed the situation with the director of nursing (DON) and she indicated there was enough staff to take care of the residents. (2) On the evening of 5/27/19, R31's call light was on from 6:11 p.m. until 7:15 p.m., greater than one hour. During further interview with FM-B, she indicated NA-A is disrespectful, rough, and rude to R31, which she has reported to staff previously but could not recall when. FM-B went on to say NA-A does not give R31 an option of what she would like to do, she just does it (ex: just puts her in the recliner instead of asking if she would like to sit in the recliner or lay down). FM-B indicated R31 will try not to ask for help if she knows NA-A is working so FM-B had asked for NA-A not to work with R31, but was told she will work wherever she is needed. FM-B indicated R31 is afraid nobody will show up and she will be left alone to die. She is afraid of retaliation because the family is causing waves, R31 believed NA-A would be rougher and hurt her because FM-A and FM-B reported her. During review of facility grievances reports identified FM-B had called social worker (SW) several times and complained of staff neglecting residents, especially R31. There was no indication these grievances had been followed up on. Review of NA-A's last Employee Job Performance Evaluation, dated 11/29/16, indicated NA-A had opportunity for improvement in her working relations. Comments on the evaluations included occasional resident expresses that she works too fast and unclear how to take her comments. NA-A's file also indicated six disciplinary actions regarding respect and dignity to residents. Her last disciplinary action, dated 3/28/18, indicated it was NA-A's second written warning and required NA-A to filter her direct communication with residents, and to avoid making statements which may be demeaning/hurtful/or condescending. Although this was a report of abuse, the facility only filed an internal grievance and failed to file a report with the state agency. The facility continued to allow NA-A to work with all residents, even though she had a pattern of allegations against her. During interview on 5/30/19 at 9:55 a.m., the administrator (A), director of nursing (DON), and nurse consultant were notified of complaints of neglect and abuse regarding NA-A. They were further updated that residents feared retaliation of increased lack of cares if they report concerns. They indicated if NA-A was working they would immediately suspend her and begin an investigation. During interview on 5/30/19 at 11:45 a.m., with the DON confirmed employee job evaluations were at least 1.5 years behind, disciplinary actions and competencies were in the employee file. She indicated NA-A has a difficult time pacing herself and needed reminders to slow down and listen to residents. R183 was interviewed on 5/28/19 at 2:37 p.m., she indicated that she had a concern with NA-C who scrubbed too hard during personal cares and had told him to be more gentle. R183's admission Minimum Date Set (MDS) on 5/23/19 identified no cognitive impairment and required extensive assistance for dressing, bed mobility and was dependent on two staff for all transfers with a total lift. During an interview on 5/29/19 at 3:30 p.m., the LSW indicated that she has had pretty limited conversations with R183 since her admission to the facility, and was unaware of concerns NA-C was rough with cares to R183. During an interview on 5/30/19 at 7:49 a.m., with NA-C he indicated R183 wishes on non-[MEDICAL TREATMENT] days to remain in bed for the day, but staff do check her every 2 hours. He further indicated R183 does not care for me providing cares to her so RN-C will allow other staff to go in for cares and this has seemed to work well. During an interview on 5/30/19 at 8:02 a.m., licensed practical nurse (LPN)-A indicated R183 is a resident who recently transferred here from another facility and is getting to know staff. She indicated R183 does not prefer NA-C to care for her because he doesn't listen to her. NA-C does continue to help with R183's cares, but LPN-A will have him leave the room and have another staff assist to ensure R183 she is comfortable with cares. LPN-A indicated she has not told anyone else about R183's concerns, but did provide verbal education to NA-C about R183's complaints. LPN-A advised NA-C he needed to listen to R183 about her concerns regarding cares. There was no indication LPN-A had followed up past the verbal education nor had she reported this to the administrator or DON. On 05/30/19 at 8:53 a.m., NA-J indicated R183 prefers females aids over male aides. If NA-C is down R183's wing, she will take care of that resident and have NA-C assist with a resident down her wing. NA-J indicated we try to work around it, and was unaware of any concerns with other staff being rough with any other residents during cares. R4 was interviewed on 5/30/19 at 11:55 a.m., and indicated a male nurse aide (NA)-C rubs her too hard with cares, and stated I have told the director of nurses (DON). He rubs too hard down there, pointing to her perineal area, during the discussion. She indicated her bottom was very sore and when he rubs too hard it hurts more. During interview on 5/31/19 at 1:56 p.m., with licensed practice nurse (LPN)-A indicated she was told by the DON a couple weeks ago to watch nursing assistant (NA)-C because there were some reports from other residents that he was being rough. After reports, LPN-A watched NA-C by popping in during morning cares that he was providing with residents. Furthermore, she stated I'd notice it if something was wrong. My version of rough may be different than a resident's. LPN-A would not elaborate on what her version of rough was. R14 quarterly MDS, dated [DATE] identified moderate cognitive impaired and was independent with all activities of daily living. R14's care plan last revised on 4/17/19, indicates resident has moderate cognitive impairment but handling his own finances, able to make his needs known, and able to choose. R14 was interviewed on 5/31/19 at 9:20 a.m., stated that, I don't want to squeal but some staff are ok but some are not. I got into a fight with a male NA when he was shaving me. He may have had a bad morning but it felt like he had it in for me, he was pulling the hair out of my chin instead of cutting it. I told some of the nurses but they didn't say too much about it. He still works here but I won't let him touch me anymore. R14 identified the NA as NA-C. R000's April, 2019 Minimum Data Set (MDS) (exact date withheld for anonymity) identified R000 had intact cognition and required extensive assistance of 2 staff with all Activities of Daily Living (ADL). R000 stated during an interview on 5/31/19 at 9:35 a.m., they were insistent on remaining anonymous because if the DON or other staff found out I told you, they may even hurt me worse. R000 complained they had been hurt by a male NA but refused to give his name because of the fear of, he may come back and hurt me more for telling. R000 stated they never reported this to the nurse and they may figure out whom brought it to their attention. Review of NA-C's employee file identified there had been no disciplinary actions documented. During interview on 5/30/19 at 11:45 a.m., with the DON confirmed employee job evaluations were at least 1.5 years behind, disciplinary actions and competencies were in the employee file, and the facility was starting a new process but had not implemented anything yet. During an interview on 5/31/19 at 1:05 p.m., DON indicated her expectation was if concerns about care were reported to a nurse. That nurse should provide oversight and supervision of that staff person. The DON further stated if the concern continued to be a consistent problem, then the next step would be to report it to herself. Charge nurses are responsible to follow up with concerns that are brought to their attention by any resident. The DON was unaware of any rough handling of residents by NA-C and they would be investigating these concerns immediately. The DON later confirmed NA-C resigned from the facility as a NA. The immediate jeopardy that began on 5/30/19 was removed on 6/4/19, when the facility suspended the NA-A and completed an investigation along with a resident survey to identify patterns of concern. They began educating staff on the Abuse Prevention Program policy and implemented a random survey process for the social worker or designee to conduct survey questionnaires, and developed an audit tool to monitor the survey questionnaires. However, noncompliance remained at the lower scope and severity level of [NAME] pattern, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facilities Abuse Prevention Program, undated, indicated the following: (1) residents shall be free from mistreatment, abuse, neglect, exploitation and misappropriation of property, (2) it is the responsibility of all staff to provide a safe environment, (3) care and treatment shall be monitored by all staff on an ongoing basis to assure residents are free from abuse, (4) suspected abuse shall be thoroughly investigated and documented, (5) staff, volunteers, family, and others are encouraged to report incidents of abuse or suspected abuse and are assured they will be protected from repercussions or retaliation, and (6) staff are trained upon hire and annually regarding resident rights including right to freedom from abuse, (7) supervision of staff to identify inappropriate behaviors, The policy further indicated all employees are mandated reporters and should report incidents to the charge nurse or the director of nursing, social service director, or administrator and reported to Office of Health Facility Complaints (OHFC) when deemed necessary. The Superior Healthcare Management Abuse Prevention Program Policy, undated, indicated the facility was committed to protecting their residents from abuse. The policy further indicated staff are mandated to have orientation and training on (1) abuse prevention, (2) identification and reporting of abuse, (3) protecting residents during abuse investigation, (4) timely and thorough investigation of all reports and allegations of abuse (5) ongoing review and analysis of abuse incidents, and (6) implementation of changes to prevent future occurrences of abuse.

Based on observation, interview, and record review, the facility failed to ensure appropriate supervision of 1 of 2 residents (R285) identified at risk for elopements resulting in an immediate jeopardy. In addition to the resident in the immediate jeopardy, the facility failed to reassess and implement falls interventions for 2 of 2 residents (R30 and R184) whom had repeated falls. The immediate jeopardy began on 5/29/19 when a Code Green alert sounded, identifying R285 had left the facility unwitnessed at approximately 4:20 p.m. through the north entrance when no staff were present on the lower level transitional care unit (TCU), where R285 resided at the time of the elopement. The administrator, director of nurses (DON), and the registered nurse consultant were notified of the immediate jeopardy at 5:28 p.m. on 5/30/19. The immediate jeopardy was removed on 5/31/19 at 1:11 p.m., after the facility took steps to remove the immediacy by re-educating staff, re-assessing all residents who may be at risk, and ensuring 1 staff person was on the TCU unit at all times. Non-compliance remained at the lower scope and severity level of D, isolated with no actual harm but potential for more than minimal harm. Findings include: ELOPEMENT R285's admission Minimum Data Set ((MDS) dated [DATE], identified R285 was admitted to facility on in May, 2019. [DIAGNOSES REDACTED]. Her Brief Interview for Mental Status (BIMS) showed she was cognitively intact. She required extensive assist of 1 staff for bed mobility, limited assist 1 staff for transfer and walking, and supervision of 1 staff with dressing. R285 exhibited wandering 1-3 days during the lookback period. R285's nursing progress notes identified on 5/30/19 at 9:30 a.m., the incident report of the code green from 5/29/19 was filed later that day at 10:19 p.m. The report identified a code green status was called regarding R285 who had left the facility without staff knowledge. The resident was standing outdoors, had luggage with her and was carrying her coat. R285 was agitated, delusional, and offered paranoid thoughts when staff assisted her back into the building. There was no indication if the wander guard alarm sounded, or staff were present in the TCU when R285 left the building unsupervised. R285's 5/17/19, Care Area analysis (CAA's) behavioral symptoms including: yelling and screaming at staff, refusing therapy and cares, wandering around, thinking she needed to go someplace or has an appointment. It was discussed with her care team a need for a wander guard until her urinary tract infection [MEDICAL CONDITION] cleared up and then to determine if the UTI was the reasoning for her increased behaviors. R285 had a history of [REDACTED]. Her current mental health may impact her ability to return to the community. R285 had decline in cognitive with delusions, which impacted her ability to sit still. R285 would often think she had to be some place, which resulted in wandering and refusal of care with yelling and screaming. R285's family felt this was a significant decline from her baseline when she was admitted . R285 was able to walk up and down the hallway independently and wished to return to the community setting. R285's medications were [MEDICATION NAME] (antipsychotic) daily for a [DIAGNOSES REDACTED].She displayed cognitive loss and dementia, short term memory, forgetfulness, delusions (altered reality), and false beliefs. R285's 5/14/19 care plan identified R285 was a risk for elopement related to her wandering behaviors, restlessness, and unspecified [MEDICAL CONDITION], with the goal to remain safe within the facility. Interventions on 5/14/19 included the placement of a Wander guard. Staff were to re-direct R285 if she showed behaviors of exit seeking. Staff were to monitor for behaviors of pacing and wandering. Review of the medical notes identified the following behaviors: Progress note on 5/14/19 at 10:35 a.m., nursing was informed by the therapy department, the resident was having psychoses of talking with her sister who was not present. Physician notification fax dated 5/15/19 at 10:08 a.m., identified R285's primary care provider (PCP) was notified regarding her mood/behavior concerns, being disruptive and hallucinating, calling law enforcement and attempting to leave the facility. Progress note on 5/20/19 at 1:43 p.m., identified R285 was agitated that morning and wanted to leave the facility. Stated she was going to call the cops if they would not let her leave because her sister was waiting outside. Redirected and just stood with her bag for a while before going back to her room. Medication record indicated [MEDICATION NAME] started on 5/18/19 for 7 day related to a urinary tract infection. Last date [MEDICATION NAME] administered was 5/23/19 at 9:00 a.m. R285's behavior charting on 5/20/19 identified R285 continued with wandering behavior, talking to herself, and was experiencing visual hallucinations, On 5/24/19 at 3:02 p.m., R285 once more was notes to be experiencing visual hallucinations and had packed her belongs and refused to allow nursing to assess her. R285's 14 day/change MDS dated [DATE] identified R285 had decreased cognition and was assessed with [REDACTED]. Review of progress note dated: (1) 5/28/19 at 1:39 p.m., identified staff met with family (F)-C to discuss current behaviors and they have not really been involved in her care. Prior to admission, R285's neighbor told them R285 had been getting really mixed up and the police had been at her home several times. A referral was made to behavioral health but there had been no openings. R285 continued to have significant increase in delusions/hallucinations since admission. It was recommended that they speak with the county to have her screened as she will need to go back to Iowa where she owns a home and will need services. There was no mention the facility took steps to find behavioral health services in the area. (2) 5/29/19 at 10:15 p.m., R285 made an attempt to elope from this facility and was found agitated, delusional and paranoid. R285 was seen in the emergency department (ED) but returned back to the facility with no new orders. She continued to wear wander guard and was placed on hourly observation by staff. During interview on 5/30/19 at 11:58 a.m., registered nurse (RN)-C indicated in the TCU, where R285 resided, there was usually 1 nurses aid (NA) and 1 licensed nurse. RN-C had been aware of the elopement as she had been working on the TCU the day of 5/29/19. She was required to go upstairs to the main floor for an in-service meeting when she heard the code green called. Some staff got up to leave the in-service to assist in the search; as RN-C was not aware of whom eloped, how resident was found, or who located her. RN-C indicated R285 does have a wander guard in place. There was no NA's in the TCU unit at the time when R285 left the building, however, there were 2 NA's working on the upper level. Although the WanderGuard appeared to be working properly, the door exiting the building to the TCU does not auto lock when the alarm sounds. Therefore, with staff off the unit, no one was available to hear the alarm. Interview on 5/30/19 at 1:40 p.m., RN-C indicated that she did not know if the alarm sounded when resident exited the building but the TCU exit door does not lock if the alarm is activated. Interview on 5/30/19 at 2:25 p.m. with RN-D identified office staff were upstairs in a room, and not in the hallway directly above the TCU exit door. The Wander guard alarm system was observed and tested on [DATE] at 2:31 p.m., identified the TCU exit door alarm were heard and working appropriately while standing at the door. Another surveyor went to listen and observed for alarm sounds upstairs directly above the TCU exit door. The alarm was not audible from upstairs. If staff were not located in the TCU they were unable to hear the Wander guard system alarm. The door upon activation of the system did not lock, but sounded. If staff remained on the unit, they could have been alerted to any resident leaving the building. Observation and interview with R285 on 5/30/19 at 1:30 p.m., indicated the building was owned by Donald Trump and herself. R285 stated she went outside yesterday (5/29/19) and was on the sidewalk outside the door. She was heading any place other than here. R285's wander guard was on her left wrist. R285 indicated her sister was muzzled and in the attic to keep her quiet. Interview on 5/30/19 at 2:10 p.m., with RN-D identified on 5/29/19 at approximately 4:00 p.m., RN-D left the TCU unit to go upstairs and assist another nurse who requested assistance with a procedure. While RN-D was upstairs involved in a sterile procedure she heard a code green. This code identifies a nurse or a NA to go to TCU to assist. When RN-D finally made it back down to the TCU unit, she was told R285 tried to elope between 4:30 and 4:45 p.m. multiple staff. Documentation showed R285's unnamed family member needed to be called to assist R285 back into the facility. R285 was then transferred to the emergency department (ED) to rule out any medical concerns and plan to transfer to a mental health unit at another facility but returned to the facility after her ED assessment. Interview on 6/3/19 at 2:45 p.m., with medical director identified he talked to the DON and was aware of survey team being at the facility but did not remember all the issues during the survey. He did not have an expectation as he indicated since the elopement is a non-medical issue he does not get involved. That task fell to the A and DON to handle unless it has to do with medical issues. Interview on 6/03/19 at 3:44 p.m., with the A identified the facility assessment had not specifically address elopement even though R285 left the facility without staff knowledge. Review of the undated Elopement Policy identified staff shall promptly report any resident who tried to leave the premises or is suspected of being missing to the charge nurse or director of nursing. Reviewed Facility Assessment Tool last reviewed on 5/6/19 identified there was no mention how to provide care for residents with the potential for elopement, or what facility needs would be based on an assessment. The immediate jeopardy that began on 5/30/19 was removed on 5/31/19, when the facility took steps to re-educate staff on elopements, ensure 1 staff remained on the TCU unit at all times, assess other residents at risk, and review and revise policies as necessary. However, noncompliance remained at the lower scope and severity level of D- isolated, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. FALLS R30's admission Minimum Data Set (MDS) on 5/2/19, identified R30 had cognitive impairment, required total assistance of 2 staff for all transfers, bed mobility, dressing, and toileting. R30 also had a history of [REDACTED]. R30's 5/2/19 MDS Care Area Assessment (CAA) identified she was at risk for falls and behaviors. R30's current undated facility care plan included she was a fall risk due to poor balance, communication and cognition. R30 had history of falls. Interventions included body pillows were used when in bed to promote proper body alignment. A floor mat was used while R30 was in bed. Staff were required to keep the bed in low position, and keep the head of the bed (HOB) elevated due to aspiration (fluid or food inadvertently goes into the lungs vs the stomach) risk. No interventions were updated in the care plan to address falls from her recliner. R30 was also at risk for bleeding as evidenced by her anti-coagulant use. There was no mention of R30's increased bleeding risk as a concern after her fall evaluation. R30's 5/28/19 hospice note identified she was a fall risk but there were no interventions related to fall risk identified in the hospice care plan. R30's incident reports identified the following falls: (1) On 5/5/19 at 9:44 p.m., R30 was found on the floor in a prayer-like position face down on the mattress and knees on the floor. R30 was weepy, nonverbal, with no signs of pain. Interventions were to keep her bed in low position at all times, and add body pillows at the side of the bed to ensure proper body alignment, and keep HOB elevated related to aspiration risk. (2) On 5/21/19 at 1:30 p.m., R30 was found on the floor lying on her side in the day room by a visitor. R30 was in the recliner prior to the unwitnessed fall. She was alert. No injuries were noted. Staff asked R30 if she was having pain. R30 did not answer, however, no physical signs the resident was in pain were noted by staff. Fall factors included weakness and impaired memory. The medical doctor (MD) and family was informed. Interventions included to monitor resident when up in day room, and be alert for restlessness and provide interventions to reduce restlessness. (3) On 5/30/10 at 10:34 am. R30 fell unwitnessed from the recliner in her room She was found face down yelling, I hit my head bad! She repeated this phrase over and over. Ice was applied to her forehead on the right side. Ice was applied to her forehead. Hospice was notified and they are coming into the facility to check on condition. R30 sustained a hematoma to the top of her scalp. Unsure on orientation as she is unable to vocally speak much to staff. She was recently more weepy and cried often. She frequently refused medication, meals, and tube feedings. She had increased signs of pain and discomfort. Tylenol was given this. R30's care plan had no further interventions provided following the fall from her recliner in her room. There was no indication neurological (neuro) checks were implemented to evaluate R30's level of consciousness after the fall. Interview on 5/30/19 at 11:05 a.m., with licence practical nurse (LPN)-B indicated R30's physical signs of pain are difficult to determine. R30 fell unwitnessed from her recliner today and staff were to monitor R30 while she was in her recliner. There was no mention how often or at what specific interval, R30 would need supervision. LPN-B identified R30 remained in her room majority of the time, she cried a lot when out of her room in social settings. Although staff identified the need for supervision, that intervention was never placed into R30's care plan. R30's 5/30/19 progress notes identified R30 fell again that same day after, while staff were assisting residents to the dining room on the lower level at the time of fall. There was no documentation to support staff were appropriately supervising R30 immediately prior to the fall. Interview on 5/30/19 at 5:03 p.m., with NA-B identified she was familiar with R30 worked on R30's wing and was aware she fell today. NA-B stated R30 needed 1 to 1 care and started hospice yesterday. R30 became anxious easily, and had a recent increase in falls. NA-B was unsure about what specific interventions were in place prior to R30's fall and was unaware of changes or additions to the interventions after her fall today. Fall interventions were usually verbal and reported at shift change or interventions were identified on resident care sheets. Interview on 6/03/19 at 4:28 p.m., with the administrator-(A) identified he expected staff to know R30's fall prevention and interventions. The facility analyzed the falls using root cause analysis to identify find patterns to put interventions in place. Interventions were expected to be evaluated to ensure falls were prevented as much as possible. Fall investigations were not reviewed at the time of the fall, as part of interdisciplinary team (IDT) oversight, to identify causes to implement immediate interventions. The A's goal would be to implement fall rounding by the IDT at the time falls occur to better analyze each fall. Interview on 6/03/19 at 4:48 p.m., with the DON identified she expected staff to attempt to find triggers or causes of falls. If a resident falls more than twice in 30 days, the resident was screened by therapy. If a resident had repeat falls, their equipment was evaluated for appropriateness. The DON was unable to determine the root cause analysis for R30's recent falls. R30 had received a new wheelchair and a new recliner after she fell from the recliner on 5/21/19. Any interventions implemented were expected to be added to R30's care plan in the EMR. Changes in the care plan were communicated verbally through the charge nurse. Interventions are documented in the notes portion in the incident reports. NAs also use the kardex in electronic record to review care plan interventions. R184's MDS on 5/2/19 identified [DIAGNOSES REDACTED]. He required a total mechanical lift and was dependent upon staff for assistance with transfers related to his [MEDICAL CONDITION]. R184 was observed on 5/28/19 6:20 p.m., with nursing assistant (NA)-F and licensed practical nurse (LPN)-E while being transferred to bed with an EZ total lift. Staff lifted the mattress edge up from the floor, and placed the total lift legs underneath the mattress. After R184 was transferred onto the mattress NA-F and LPN-E were not able to remove the lift legs out from under the mattress. They attempted to call another NA, but no other staff came to assist. LPN-E stated, we usually transfer him with three staff. We are supposed to use the lift and bring it in towards the foot end of the bed, but that doesn't work, so we have to do it this way. Staff tried to lift both side of the mattress, to attempt to remove the lift, causing R184's body to shift on the mattress to the opposite side. R184's care plan dated 5/15/19 identified he had R184 has had an actual fall with no injuries noted related to poor comprehension, bilateral lower [MEDICAL CONDITION], and confusion thinking he is able to walk. Staff were to anticipate and provide interventions of repositioning, a body pillow to alert resident to parameter of mattress, continue interventions on the at-risk plan, call light within reach, and his mattress on floor to optimize resident safety when in bed. R184 had a known history of repeated falls out of bed related to confusion and restlessness. R184's fall assessment on 5/15/19 indicated he had a history of [REDACTED]. Transfer with assist of two with the total mechanical lift. R184 had two prosthetic legs, but was unable to use safely until his confusion resided. During observation on 5/29/19 at 2:37 p.m., maintenance entered R184's room with a high/low bed frame and placed the mattress on the frame rather than directly on the floor. There was no indication why maintenance was now placing a frame under R184's mattress, vs. the direct placement on the floor as in the above observation on 5/28/19. During interview on 5/30/19 at 4:12 p.m. NA-G stated I was not trained in using the lift with the mattress on the floor. I am glad they put the frame back in his room it was not safe. During interview on 6/03/19 at 4:44 p.m. with the director of nurses (DON) indicated the mattress on the floor was temporary to try to prevent falls from his bed. Although R184 was identified as a risk for falls, and had a history of [REDACTED]. Review of the undated Falls and Fall Risk, Managing policy identified: (1) Staff were to identify appropriate interventions to reduce the risk of resident's falls, along with the pharmacist, medical doctor, and nursing staff. There was no mention therapy was involved with identifying ways to reduce falls risk. (2) If falls recur, staff will implement additional or different interventions, or identify why current interventions remain relevant. (3) Staff were to monitor and document each resident's response to interventions. If a resident continued to fall, staff were to consult with the medical doctor to reconsider other causes that may not have been identified.

Based on observation, interview and record review, the facility failed to ensure 1 of 1 resident (R287) reviewed for pain, received pain medications in a timely manner. This resulted in actual harm for R287 who experienced severe pain when the facility ran out of her supply of narcotic pain medication. The findings include: R287 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During interview with R287 on 7/9/18 at 6:58 p.m., she reported she'd been out of pain pills for an entire day and was in pain. R287 was crying and her posture/movements indicated she was in pain. She stated she was supposed to take a pain pill every four hours for pain control but added, they don't always last that long. R287's family member also present during the interview, verified R287's report, She was out of pain pills all night, the doctor had ordered 20 tablets but when they are taken every four hours they don't last that long, she went a whole day without her pills, she was very uncomfortable and crying. During interview with licensed practical nurse (LPN)-C on 7/11/18 at 7:44 a.m., LPN-C stated, Most of the medications come from the machine upstairs, and if it is an [MEDICATION NAME] or something, the pharmacy will let us know we need a script and we will fax the doctor for a script. It usually is taken care of by the next shift. Registered nurse (RN)-A stated during interview on 7/12/18 at 9:49 a.m., Nursing calls the pharmacy and they will send it out on the delivery for the same night. If it is needed now, the nurses call the pharmacy from town. Although RN-A stated that the doctor had given R287 20 tablets of the pain medication and they ran out. RN-A stated they had faxed the doctor for a script but the regular doctor was on vacation, so they had to call the clinic on call. RN-A said once the pharmacy received a prescription, they would authorize it so it could be sent out. During interview on 7/12/18, at 2:04 p.m., LPN-B stated, ( R287) has chronic and acute pain. There was some lag time between the getting the script from the clinic to the pharmacy. Usually the pharmacy contacts the clinic but not always, and they don't communicate it with us. We may not know until it doesn't come out of the medication administration machine. We tried Tylenol and ice for pain control (for R287) which may have given her some relief but not 100%. I don't think her quality of life was affected, she (R287) wasn't stuck in bed or anything. Review of the electronic medical record (EMAR) indicated R287 had not received the scheduled doses of [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg (milligrams) on 7/3/18 at 12 a.m., 4 a.m., 8 a.m., or 12 p.m. According to the documentation, R287's pain rating was documented at a 9 on a 0-10 pain scale (0=no pain to 10=the worst pain ever) during this time frame. A facsimile (fax) request to R287's physician dated 7/3/18, indicated: Resident came to facility with [MEDICATION NAME]-[MEDICATION NAME] tablet 5-325 mg give one tablet by mouth every 4 hours for pain control r/t (related to) wedge compression fracture of T11-T12 Vertebra. Initial encounter for closed fracture order was only for 20 doses and is completed. Gave Tylenol and ice throughout the night with little to no relief. Resident is still in constant pain and rates pain 8-10 (10 being the most severe pain) all day. Can you send a new script to pharmacy so resident can resume pain regimen. The physician's response included: RX (prescription) sent to (Dr's name) to sign electronically. The facility's policy Medication Orders 12/28/17, indicated staff were to reorder medications when the resident has not less than 5-7 days worth. In addition the policy indicated hard scripts must be current if not on file can in order to refill a narcotic. Pharmacy can try to reach physician, but facility staff are responsible for getting new order. The facility's Medication Administration policy last reviewed 5/10/18, indicated medications were to be administered within one (1) hour of their prescribed time, unless otherwise specified. The contracted pharmacy policy Unavailable Medications last revised 6/15, indicated if facility nursing staff were unable to obtain a response from the attending physician, the nurse should notify the nursing supervisor and contact the facility medical director for orders and/or direction. The contracted pharmacy onsite formulary printed on 7/12/18, indicated [MEDICATION NAME]/APAP tablet 5-325 mg were available in the automated dispensing unit (ADU) emergency supply kit.