Every finding on record at The Terrace at Crystal LLC

Based on observation, interview, and document review, the facility failed to ensure a shared blood glucometer (device to test blood sugar levels) was cleaned and disinfected properly between resident use to prevent transmission of bloodborne pathogens for 2 of 2 residents (R33, R38,) and failed to properly disinfect a blood glucose monitor following use with R31 and prior to placing on shelf at nursing station for use with other residents reviewed for shared use of medical equipment. This practice resulted in an immediate jeopardy (IJ) situation for R38 due to the risk of potential transmission of blood borne pathogens from R33 to R38. In addition, the facility failed to implement appropriate precautions against clostridium difficile colitis (CDI) (a inflammation of the colon caused by the bacteria clostridium difficile) including use of appropriate personal protective equipment (PPE) and isolation precautions to prevent the spread of CDI for 1 of 1 residents (R31) reviewed for transmission-based precautions (TBP), failed to ensure appropriate hand hygiene and glove hygiene were implemented to prevent cross contamination during a bed bath for 1 of 1 resident's (R15) who were observed during personal cares, and failed to provide proper infection control measures during catheter care for 1 of 1 resident's (R23) reviewed for catheter care.The IJ began and was identified on 6/3/26 at 7:33 a.m. when R33 who had a diagnosis of HIV (human immunodeficiency virus; a virus that attacks the body's immune system, and without treatment, it can lead to AIDS (acquired immunodeficiency syndrome; which can be fatal) had his blood glucose (Bg) checked via a finger stick blood test (finger is pricked with a lancet to obtain a small quantity of capillary blood for testing). The shared glucometer was not properly cleaned or disinfected and was then brought into R38's room to check his Bg. Nursing staff were also not able to verbalize a consistent process to clean and disinfect shared glucometers. The administrator and director of nursing (DON) were notified of the immediate jeopardy on 6/3/26 at 1:10 p.m. The facility implemented corrective action, and the immediacy was removed on 6/4/26 at 3:05 p.m., however non-compliance remained at the lower scope and severity level of an E; a pattern which indicated no actual harm with the potential for more than minimal harm that is not immediate jeopardy. Findings include: Glucometer: R33 R33's quarterly Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition, no behaviors or rejection of care. Substantial/maximal assist from staff was required for hygiene and he was dependent on staff to get dressed. R33 had diagnoses of diabetes mellitus (DM) II, non-Alzheimer's dementia, hemiplegia or hemiparesis, anxiety, depression, psychotic disorder. R33's diagnosis list dated 9/13/24, included HIV. R33's care area assessment (CAA) dated 6/18/25, identified activities of daily living (ADLs) was triggered and R33 was at risk for further decline in physical function related in part to HIV. R33's physician orders included: 11/21/25, Freestyle Libre or substitution (a continuous glucose monitoring (CGM) system that provides real-time glucose readings) 14-day sensor kit. Apply one kit as directed every two weeks. 12/20/24, check Bg daily before a meal, alternate times. 12/20/24, Abacavir-Dolutegravir-Lamivud Oral Tablet 600-50-300 MG, one tablet by mouth every day related to HIV. R33's care plan for diabetes mellitus dated 9/19/24, identified to follow provider's order regarding Bg parameters. The care plan did not address interventions for blood borne pathogens such as cleaning and disinfecting shared Bg equipment. R38 R38's quarterly MDS dated [DATE], identified severely impaired cognition, no behaviors or rejection of care and was dependent on staff assistance for hygiene and dressing. Diagnoses included DMII with hyperglycemia, heart failure, kidney failure, non-Alzheimer's dementia, cataracts, glaucoma or macular degeneration, and cirrhosis of the liver. R38's CAA dated 3/1/26, identified ADLs triggered because the resident needed assistance with ADLs, transfers and mobility. Staff will continue to provide assistance to resident as needed. R38's diagnosis list dated 11/26/24, did not include any blood borne pathogens. R38's physician orders identified: 10/6/25, please check Bg three times a day. 8/22/25, start Freestyle Libre CGM 2 or 3 for diabetes management R38's care plan dated 11/29/24, identified a diagnosis of DM. Interventions included fasting Bg as ordered and to follow provider orders for Bg parameters. The care plan did not address interventions for blood borne pathogens such as cleaning and disinfecting shared Bg equipment. During an observation on 6/3/26 at 7:33 a.m., licensed practical nurse (LPN)-B entered R33's room with a red tote of Bg supplies (gauze, alcohol wipes, single use lancets, test strips and Bg meter). LPN-B scanned R33's CGM upper arm and no reading was obtained. LPN-B stated sometimes his CGM did not work. LPN-B use alcohol-based hand rub (ABHR), put on gloves, wiped R33's finger with an alcohol wipe and pricked the finger with a single use lancet to obtain a sample of blood. The test strip was inserted into the Bg meter and brought to R33's finger to absorb the blood resulting in a reading of 134. LPN-B placed the lancet and test strip in the garbage wrapped up in her gloves, washed her hands, put the Bg meter in the red tote and exited the room. The contaminated Bg meter was placed in the tote test strip side and on top of unused lancets. LPN-B did not disinfect the Bg meter nor the tote it was in and put the tote on the counter at the nurse's station. A continuous observation of the tote began at this time. During an observation and interview on 6/3/26 at 7:52 a.m., LPN-B entered R38's room, used ABHR and put on gloves. LPN-B scanned R38's CGM and no reading was obtained. LPN-B removed her gloves, used ABHR hand rub, exited the room and picked up the same red tote with Bg supplies, R38's door remained open and LPN-B did not clean or disinfect the meter and supplies prior to re-entering R38's room. Upon re-entry LPN-B used ABHR, put new gloves on and asked R38 which finger she should prick. LPN-B moved the lancet and Bg meter close to R38 and was stopped by surveyor and asked to step out of the room. LPN-B was asked what was used to disinfect Bg equipment between uses and she replied she would use an alcohol wipe from the tote. LPN-B verified verbally that was not done between residents. When asked if alcohol disinfects for blood borne pathogens, she replied no and went to the nurse's station to get Micro-Kill One EPA reg 88494-2-37459, the label identified it was effective against organisms including hepatitis B virus, hepatitis C virus and Human Immunodeficiency Virus (HIV-1) (AIDS). LPN-B stated said she should have used this type of wipe. LPN-B re-entered R38's room, cleaned the Bg meter and wrapped it in a Micro-Kill wipe for 1 minute as directed on the bottle and repeated the Bg check. After the Bg test was completed, LPN-B was asked if there was a risk of transmitting blood borne pathogens by not cleaning and disinfecting shared equipment to which she replied yes. R31 R31's annual MDS indicated intact cognition, a diagnosis of Type I Diabetes, and received insulin on a routine basis. R31's physician's orders dated 6/3/26, indicated R31 was on contact precautions for Clostridioides difficile (C-diff., highly contagious bacterium that infect the colon, causing severe diarrhea). It further indicated an order dated 7/4/25, indicated Accu checks with scheduled meals and bedtime four times a day for blood sugar. R31's care guide dated 3/27/26, indicated R31 was diabetic and was on enhanced barrier precautions (EBP). R31's care plan dated 2/21/24, indicated R31 had diabetes mellitus type I with an intervention to obtain blood sugars per medical doctor (MD) order. R31 has an order for Dexcom. Sensor to change every 10 days. R31's progress note dated 6/3/26, indicated R31 complained of generalized body pain. Lab result received; C- diff was detected in the stool sample and the provider was updated. New order received for Fidaxomicin 200 milligrams (mg) twice per day for 10 days and Maalox 20 mg four time per day (as needed) for epigastric pain. R31 to remain on contact precautions. During observation on 6/3/26 at 7:48 a.m., licensed practical nurse (LPN)-A put on gloves and entered R31's room in order to check her blood sugar. Once LPN-A was finished using the glucometer, she used a Sani-cloth disposable wipe, wiped the glucometer for a few seconds, and put it in a clear plastic cup in a bin filled with blood testing supplies, and placed it on a shelf at the nursing station. The back of the Sani-cloth wipe container indicated contact time-use second germicidal wipe to thoroughly wet surface. Allow to remain wet 2 minutes, let air dry. LPN-A did not thoroughly wet the surface or allow it to remain wet for 2 minutes when cleaning the glucometer. During an interview on 6/3/26 at 8:06 a.m., registered nurse (RN)-A stated she had already completed all of her blood sugar checks for the day. RN-A stated after completing a resident's blood sugar check, she would use a Super Sani-Cloth wipe to clean the glucometer. RN-A stated she has five resident's requiring blood sugar checks. RN-A stated one glucometer was used for all residents on her unit. When asked how long the glucometer needed to remain wet, RN-A stated she would wrap the glucometer in the wipe and leave it in a plastic cup until it was needed again. During an interview on 6/3/26 at 8:10 a.m., trained medication aide (TMA)-A confirmed she was working on the first floor and stated no residents needed their blood sugars checked at this time. TMA-A stated they had one shared blood glucometer if residents did need their blood sugars checked on her unit. TMA-A stated that after completing a resident's blood sugar check, she would use a Micro-Kill bleach wipe to clean the glucometer and would wrap the glucometer in the wipe and leave it for three to four minutes. During an interview on 6/3/26 at 8:50 a.m., the infection preventionist (IP) stated cleaning and disinfecting wipes which were effective against blood borne pathogens should be used between uses of shared Bg meters per the disinfecting wipe package directions. The IP stated the Bg meter should be wiped until wet and allowed to remain wet for 2 minutes or as directed on the disinfecting wipes package directions. The IP stated alcohol wipes were not effective. The IP accompanied surveyor to observe the red tote. A Bg meter was wrapped up in a disinfecting wipe. The IP stated she changed out the red totes monthly, and agreed the tote was contaminated at this time, since the Bg meter was placed on top of the supplies in the tote after use and without being cleaned or disinfected. During an interview on 6/3/26 at 9:40 a.m., the director of nursing (DON) stated she expected shared Bg meters to be disinfected before, after, and in-between uses. The DON stated they would follow the manufacturer's recommendations on the bottle of disinfecting wipes and that alcohol wipes were not effective enough. The risks of not cleaning and disinfecting between uses included cross-contamination of resident infections which would include bloodborne pathogens. The DON stated the facility would not clean and disinfect according to the Bg meter instruction manual and would instead use the directions for the disinfecting wipes. The DON stated the Bg meters came with an instruction manual, and they could consult that for recommendations. During an interview on 6/3/26 at 11:32 a.m., the facility's Medical Director (MD) stated he would expect staff to clean and disinfect shared Bg meters with the proper disinfectants and per the infection control guidelines. Even if a drop of blood is present there was a risk of transmittal of blood borne pathogens from one resident to another. There was a risk of the transfer of blood borne pathogens with shared equipment, if the transfer occurred the potential for danger was high and the outcome of that transfer could be devastating. The facility policy Obtaining a Fingerstick Glucose Level, undated, identified to review the resident's care plan and provide for any special needs of the resident. Items needed included a disinfected Bg meter with sterile lancet or single resident use sprint loaded device or automatic or safety type lancet. Always ensure Bg meters intended for reuse are cleaned and disinfected between resident uses. Follow the instructions provided by the manufacturer of the Bg meter system to obtain a Bg reading. Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice. The undated user manual for EvenCare G3 Bg Meter, identified the Bg meter should be cleaned and disinfected between each patient. Wipe all external areas of the meter including both front and back surfaces until visibly wet. The following products have been validated for cleaning and disinfecting: Dispatch Hospital Cleaner Disinfectant Towels with Bleach (EPA Registration Number: 56392-8) Medline Micro-Kill+™ Disinfecting, Deodorizing, Cleaning Wipes with Alcohol (EPA Registration Number: 59894-10) Clorox Healthcare Bleach Germicidal and Disinfectant Wipes (EPA Registration Number: 67619-12) Medline Micro-Kill™ Bleach Germicidal Bleach Wipes (EPA Registration Number: 69687-1 . Other EPA registered wipes may be used for disinfecting the EVENCARE G3 system, however, these wipes have not been validated and could affect the performance of your meter. The IJ that began on 6/3/26 was removed on 6/4/26 when the facility reviewed blood glucose cleaning policies/protocols for accuracy based upon the type of device that was being used, and re-educated the staff on how to properly clean glucometers between residents, including length of time to be cleaned and use of appropriate products. Transmission-Based Precautions: R31 R31's annual MDS assessment dated [DATE] indicated R31 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. Diagnoses included diabetes mellitus, protein-calorie malnutrition, depression, and post-traumatic stress disorder (PTSD). R31's physician orders revealed an order dated 5/12/26 for collection of a stool sample to test for Clostridioides difficile (C. difficile). A subsequent physician order dated 5/29/26 again directed collection of stool testing. R31's progress note dated 5/15/26 indicated a stool sample had been collected and sent to the laboratory. R31's provider note dated 6/2/26 documented worsening diarrhea and abdominal pain and directed staff to determine whether the stool sample ordered on 5/12/26 had been collected and, if not, to reorder an enteric stool panel and C. difficile testing. The provider also ordered laboratory studies and directed staff to send the resident to the emergency department if abdominal pain worsened. R31's electronic medical record lacked documented laboratory results for the stool specimen reportedly collected and sent to the laboratory on 5/15/26. The electronic medical record also lacked evidence a second stool sample had been collected as ordered. Further review revealed no documentation indicating the resident had been placed on enteric precautions while stool testing for C. difficile was pending despite ongoing diarrhea and abdominal pain. During an interview and observation on 6/2/26 at 1:02 p.m., R31 stated she had experienced diarrhea three to four times that day and it had been occurring for weeks. R31 stated she believed staff collected a stool sample approximately one week earlier, but she had not received any information regarding the results. R31 appeared tired and lethargic and stated she did not feel well and had no energy. There was no transmission-based (TBP) precaution sign on R31's door and no personal protective equipment (PPE) outside of her room for staff use. During an interview on 6/2/26 at 2:10 p.m., licensed practical nurse (LPN)-A stated the resident had been refusing stool specimen collection at times and staff had been attempting to obtain the specimen for an extended period. During an interview on 6/4/26 at 8:22 a.m., the Nurse Manager and LPN-C stated staff had difficulty obtaining stool specimens because the resident did not always allow collection. When asked about stool testing results, the Nurse Manager stated the facility had received results the previous day confirming R31 tested positive for C. difficile. During an interview on 6/4/26 at 10:36 a.m., the Infection Preventionist (IP) stated R31 tested positive for C. difficile and had been started on antibiotic treatment the previous day. The IP stated R31 had been placed on contact precautions on 6/3/26 and added to the symptom management and surveillance list at that time. The IP stated a C. difficile-specific enteric precautions sign was available for use; however, a generic contact precautions sign was mistakenly posted on R31's door instead. The IP stated the stool specimen documented as collected on 5/15/26 had been collected and sent to the laboratory, but she was unsure what happened to the specimen and planned to follow up with the laboratory. The IP stated R31 should have been placed on enteric precautions while C. difficile testing was pending. During an interview on 6/4/26 at 11:15 a.m., the Nurse Manager and LPN-C stated he contacted the laboratory and learned the laboratory had no record of receiving a stool specimen from 5/15/26 despite nursing documentation indicating the specimen had been collected and sent. During an interview on 6/4/26 at 11:40 a.m., R31 stated she had become progressively sicker over the previous several weeks and felt miserable. R31 stated she was afraid to leave her room because she needed to use the bathroom so frequently, particularly after eating. She stated her stomach hurt frequently. The TBP sign hung on R31's door indicated R31 was on contact precautions, not enteric precautions, which would direct staff to wash their hands versus use hand sanitizer as hand sanitizer is ineffective against C. difficile spores. During an interview on 6/4/26 at 2:16 p.m., the Director of Nursing (DON) stated staff should have followed up on pending stool testing, maintained infection control precautions while awaiting results, and notified the provider if the resident refused specimen collection to ensure timely diagnosis and treatment. An undated facility policy, titled Clinical Policy and Procedure: Implementation of Transmission-Based Precautions indicated nursing staff must initiate TBP immediately if a resident had new, unexplained diarrhea and/or suspected C. difficile. R15 R15's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of chronic respiratory failure with hypoxia, morbid (severe) obesity, and muscle weakness. The MDS further included R15 had bilateral impairment on lower extremities and was dependent on staff for transfers. R15's Care Guide dated 3/27/26, lacked documentation R15 was on EBP. R15's Care Plan lacked documentation R15 was on EBP. During observation and interview on 6/2/26 10:17 a.m., two NA's (NA-G, NA-H) donned a gown and gloves and entered R15's room to give him a bed bath and transfer him from his bed to his personal mobility device (PMD). The door to R15's room had a sign which indicated he was on EBP and there was an isolation cart in the hallway outside his room. NA-G filled up 2 basins of water in the bathroom sink and put soap in one. NA-H used washcloths to wash, rinse, and dry his upper body. R15 stated he had a bowel movement, so NA-G used wipes to clean his peri area. Once the area was clean, NA-G removed their gloves and applied new ones. NA-G did not perform hand hygiene in between glove changes. R15 rolled onto his right side and NA-G used wipes to clean his backside/bottom. Then NA-G rolled and tucked the pad underneath him and grabbed a clean washcloth from the wash basin and handed it to NA-H. NA-G did not change their gloves in between washing R15's bottom and then touching the clean washcloth. NA-G grabbed another clean washcloth and put it in the rinse bucket to get it wet and handed it to NA-H who then rinsed R15's front peri area. NA-G then picked up a clean towel and handed it to NA-H so they could dry the area. NA-G emptied the wash basin and filled it with clean water and handed a clean washcloth to NA-H to wash R15's back, picked up the barrier cream, applied it to R15's bottom, then applied the same cream to his back. Then NA-G grabbed a clean washcloth and washed the skin fold under his left arm all while wearing the same gloves. Then both NA's removed their gowns and gloves and washed their hands in the bathroom sink. NA-F entered the room to assist with transferring R15 into his PMD. All three NA's transferred R15 from his bed into his PMD. NA-F and NA-G were not wearing gowns while transferring R15 from his bed to his PMD. R23 R23 annual MDS dated [DATE], indicated moderately impaired cognition and diagnoses of multiple sclerosis (autoimmune disease that affects the central nervous system), spastic hemiplegia (a neuromuscular condition of spasticity that results in the muscles on one side of the body being in a constant state of contraction), affecting the right dominant side, and muscle weakness. It further indicated R23 was dependent on staff for toileting and had a catheter. R23's care guide dated 3/27/26, indicated R23 was on enhanced barrier precautions (EBP) and required catheter cares every shift. R23 's care plan dated 3/13/26, indicated R23 was on EBP related to a foley catheter with an intervention of staff will follow enhanced barrier precautions during high contact activities/activities of daily living (ADL). During observation on 6/2/26 at 11:09 a.m., nursing assistants (NA)-F and NA-G transferred R23 from her bed to her electric wheelchair using the Hoyer (mechanical) lift. Once R23 was in her wheelchair, NA-F was holding onto her catheter bag and bent over to guide R23's feet and the catheter drainage bag was rubbing against her shirt. NA-F and NA-G were not wearing gowns while transferring R23. During interview on 6/2/26 at 11:18 a.m., NA-F stated when cleaning a resident, they should go from clean to dirty and should change their gloves and perform hand hygiene after changing a resident's brief. NA-F further stated they were aware R15 and R23 were on EBP and should have been wearing a gown and gloves when performing cares. This would include transfers and catheter cares. During interview on 6/2/26 at 11:45 a.m., NA-G stated when cleaning a resident, they should go from clean to dirty. Changing their gloves and hand hygiene should be done following brief changes, and they are required to wear a gown and gloves when performing cares for residents who are on EBP. NA-G further stated they know the resident was on EBP precautions because they have a sign on their door. During interview on 6/2/26 at 2:09 p.m., registered nurse (RN)-E stated when cleaning a resident, NA's should go from a clean area to a dirty area and they should be changing their gloves and performing hand hygiene following a brief change. RN-E further stated NA's should be wearing a gown and gloves while performing cares for a resident on EBP. During interview on 6/4/26 at 10:36 am, the infection preventionist (IP) stated nursing staff were only required to wear a gown when performing specific cares that related to the reason they were on EBP. For example, if a resident was on EBP due to a catheter, then staff were only required to wear a gown when performing catheter cares. The same would go for a wound, etc. Staff were not required to wear a gown if they were transferring the resident or changing their brief or any other high contact cares. The IP further stated nursing staff were expected to go from a clean area to a dirty area when bathing a resident or performing a brief change. They should also be changing their gloves and performing hand hygiene in between cares and after gloves were removed. The IP verified R15 was on EBP due to a wound and R23 was on EBP due to a catheter. The facility policy regarding hand hygiene and glove use (undated), indicated to use an alcohol-based hand rub containing at least 62% alcohol or alternatively soap and water for the following situations: -Before and after direct contact with residents -Before moving from a contaminated body site to a clean body site during resident care -After contact with blood or body fluids -After removing gloves. The facility policy regarding implementation of transmission-based precautions (undated), indicated long term care units must utilize EBP for residents with chronic, colonized Multidrug-Resistant Organisms (MDRO) or those with indwelling medical devices/chronic wounds without acute infection. EBP requires gown and glove use only during high contact care tasks.

Based on observation, interview, and document review, the facility failed to assess, monitor, follow up, and implement physician-ordered care for ongoing gastrointestinal symptoms, failed to obtain and track diagnostic testing results, failed to ensure ordered specialty referrals were completed, and failed to develop a care plan to address persistent diarrhea for 1 of 3 residents (R31) reviewed for quality of care. The deficient practice resulted in actual harm for R31 through delayed identification and treatment of Clostridioides difficile (C. difficile) infection, prolonged unresolved gastrointestinal symptoms, abdominal pain, impaired nutritional status, social isolation, and skin discomfort. In addition, the facility failed to ensure a physician's order was implemented for 1 of 1 residents (R37) reviewed for diagnostic testing. Findings include: R31's annual Minimum Data Set (MDS) assessment dated [DATE] indicated R31 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. Diagnoses included diabetes mellitus, protein-calorie malnutrition, depression, and post-traumatic stress disorder (PTSD). R31 was identified as always continent of bladder and bowel, independent with toileting and transfers, and used a wheelchair for mobility. The MDS further indicated R31 did not exhibit any rejection of care behaviors. R31's care plan dated 6/4/26, identified R31 as continent of bowel, required supervision of one staff for toileting, and directed staff to ask resident about bowel movements daily. The care plan indicated R31 refused medication, showers, and non-pharmacological interventions, and often slept on the toilet. An intervention dated 5/11/25 indicated R31 declined to sign a risk/benefit [form] regarding sleeping on the toilet. A gastrointestinal (GI) care plan focus included R1 had an alteration in GI status related to peptic ulcer disease, pancreatitis, and chronic nausea with a goal of the resident will remain free from discomfort, complication, or signs/symptoms related to GI alterations revised 4/16/26. Interventions included obtaining and monitor lab/diagnostic work as ordered, and to report results to the provider and follow up as indicated. The care plan lacked a problem, goals, or interventions related to ongoing diarrhea, abdominal pain, stool testing or monitoring for infectious gastrointestinal illness related to frequent stools, or management of gastrointestinal symptoms. R31's provider orders included Oxycodone HCl tablet 5 milligrams (mg), give 2.5 mg every 24 hours as needed for pain rated 7-10 (on a 1-10 scale, where higher numbers equate to higher levels of pain) starting 1/14/26. A provider note from date of service 4/21/26 indicated the facility will schedule a follow up for R31 with a GI specialist. A social services progress note dated 4/21/26, indicated R31 stated concerns that documentation sometimes reflected refusal of care, and R31 wanted staff to understand there were times she may be asleep and not responding rather than refusing care. R31 stated they were a deep sleeper and sometimes did not respond when staff attempted to wake them. R31 reported concerns that documentation should reflect when sleeping vs. refusing. A provider note from date of service 5/12/26, included R31 was on the toilet during the visit, and reported worsening diarrhea, abdominal pain, and nausea and described it as constant and watery. The note indicated an enteric stool panel and c-diff sample was ordered, and the facility will schedule a follow up appointment for R31 with a GI specialist. A provider order dated 5/12/26 included c-diff A/B stool sample every shift for nausea, abdominal pain, watery diarrhea and to discontinue once collected. R31's May 2026 Treatment Administration Record (TAR) dated 5/1/26-5/31-26, identified an order for c-diff A/B stool sample every shift for nausea, abdominal pain, watery diarrhea and to discontinue once collected starting 5/12/26. The order was documented as refused once on 5/14/26 and completed/administered seven times between 5/12 and 5/15. The TAR also included an order to offer toileting assistance during night rounds and document any refusals in a progress note starting 2/5/26. Each night was documented as completed, and no refusals were documented in the progress notes. A nursing note dated 5/15/26 indicted a stool sample was collected and the order faxed to the lab for a STAT (high priority) order. R31's Medication administration Record dated 5/1/26-5/31-26 indicated R31 was given Imodium A-D Oral Tablet 4 mg for diarrhea on 5/24/26. A dietary note dated 5/25/26, identified R31 weighed 84.2 pounds, and a stool sample had been collected for norovirus and c. diff. The note did not include results of the testing. The medical record lacked documented laboratory results for the stool specimen reportedly collected and sent to the laboratory on 5/15/26. R31's Medication Administration Record (MAR) dated 5/1/26 – 5/31/26, indicated R31 had and order for Oxycodone (2.5 milligrams for pain rated 7-10/10) as needed and received 6 doses between 5/13-5/28 for generalized body pain. No other doses were given that month. A provider note from date of service 5/28/26, included R31 had worsening diarrhea and abdominal pain, and included: was stool sample collected as ordered on 5/12/26? If not, please re-order enteric stool panel and c diff A/B sample. The note also included ok to send to ED for evaluation if patient reports worsening abdominal pain. Staff were instructed to follow up when lab results were available. R31's provider order dated 5/29/26, included please re-order enteric stool panel and C. diff A/B sample every shift. Please discontinue this order when collected. R31's MAR dated 5/1/26-5/31/26, identified the order placed 5/29/26 for enteric stool panel and c. diff A/B sample as unable to be completed twice and was documented as completed five times. R31's MAR dated 6/1/26-6/3/26, identified the order for enteric stool panel and c. diff A/B sample as completed five times and not completed due to resident refusal or resident sleeping three times. The MAR also indicated R31 had received a dose of as needed Oxycodone (2.5 milligrams for pain rated 7-10/10) on 6/1, 6/2, and 6/3 for generalized body pain. The medical record lacked evidence that a second stool sample had been collected as ordered prior to the survey start. The order was discontinued on 6/3/26. Further review revealed no evidence the follow-up appointment with the GI specialist had been scheduled or completed. R31's progress note dated 6/3/26 indicated R31's lab result was received and c. difficile was detected on the stool sample. Provider was updated, and new orders were received for Fidaxomicin (an antibiotic) and Maalox (for epigastric pain). During interview and observation on 6/2/26 at 1:02 p.m., R31 stated she had not received any follow-up regarding the gastrointestinal appointment because they just don't make the appointments. R31 stated she had experienced diarrhea three to four times that day and it had been going on for weeks. She stated she believed staff collected a stool sample approximately one week earlier, but she had not received any information regarding the results. Observation revealed R31 appeared tired and lethargic. R31 stated she did not feel well and had no energy. During an interview on 6/2/26 at 2:10 p.m., licensed practical nurse (LPN)-A stated the health unit coordinator (HUC) was responsible for scheduling follow-up appointments. When asked whether R31's stool sample had been collected, LPN-A stated the resident had been refusing collection, and staff had been attempting to obtain the specimen for some time. During an interview on 6/3/26 at 10:50 a.m., a health unit coordinator (HUC) Assistant who helped with scheduling duties stated HUC staff were responsible for scheduling appointments when follow-up appointments had not already been arranged by outside providers. The HUC Assistant stated the actual HUC completed most appointment scheduling responsibilities. The HUC Assistant stated she highlighted orders requiring follow-up and provided them to the other HUC for action. When asked about R31's ordered GI specialist appointments, the HUC Assistant continued reviewing records to determine status, stating she would continue to look into it. During an interview on 6/4/26 at 8:22 a.m., LPN-C, who was also the nurse manager, stated staff had difficulty obtaining stool specimens because the resident would not always allow collection. When asked about stool testing results, LPN-C stated the facility had received results the previous day confirming R31 tested positive for C. difficile. When asked about the stool sample documented as collected and sent to the laboratory on 5/15/26 and the status of the GI referral, LPN-C stated he would investigate. During a follow-up interview on 6/4/26 at 11:15 a.m., LPN-C stated he contacted the laboratory and learned the laboratory had no record of receiving a stool specimen from 5/15/26, despite nursing documentation indicating the specimen had been collected and sent. LPN-C stated the HUC responsible for appointment scheduling was absent and he was unable to determine the status of the gastrointestinal referral but had not found any documentation of the appointment being scheduled or completed. During observation and interview on 6/4/26 at 11:40 a.m., R31 was observed lying in bed under a blanket with the hood of her sweatshirt pulled over her head. R31 appeared withdrawn, lethargic, and visibly ill. She remained in bed throughout the interview, spoke softly, and reported she felt horrible. R31 stated she had become progressively sicker over the previous several weeks and felt miserable. She stated she was afraid to leave her room because she needed to use the bathroom so frequently, particularly after eating. R31 stated her stomach hurt frequently and she was not eating as much as usual. She further stated her buttocks had become sore from repeated bowel movements, frequent wiping, and spending increased time in bed. R31 rated the pain at 6 out of 10. R31 stated she never refused to provide a stool sample for testing. She stated staff frequently asked her to provide a sample when she did not need to have a bowel movement or when she was asleep and later documented that she had refused. R31 stated this had occurred with other aspects of her care as well, including medications and weight monitoring. R31 stated, I never refused. They would ask when I couldn't do it or when I was sleeping and then say I refused. R31 stated she believed the delay in obtaining the stool sample contributed to the length of time she remained ill without answers or treatment. During an interview on 6/4/26 at 2:16 p.m., the Director of Nursing (DON) stated nurses were expected to enter physician orders and referral information and the HUC was responsible for scheduling appointments as soon as possible. The DON stated staff should have followed up on pending stool testing, maintained infection control precautions while awaiting results, and notified the provider if the resident refused specimen collection to ensure quick diagnosis and treatment for R31. A call was placed to the provider on 6/5/26 at approximately 12:00 p.m., however a return call was not received. R37 R37's comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated R37 was cognitively intact, and diagnoses included end stage renal disease, pericardial effusion (fluid build-up in the sac around the heart), atrial flutter (a heart rhythm disorder), chronic heart failure, and dependence on renal dialysis. R37's care plan dated 1/6/26, indicated he was a vulnerable adult to complete treatments as ordered. A physician's order dated 4/30/26, directed staff to, Please ensure ECHO (echocardiogram - an ultrasound test to assess heart function) is scheduled for on or before June 1, 2026, for diagnosis of pericardial effusion. Review of R37's electronic medical record (EMR) lacked documentation that the ECHO had been scheduled, implemented, or completed. During an interview on 6/4/26 at 12:04 p.m., Director of Nursing (DON) and Administrator stated it was important to follow care plans because they reflected residents' needs and person-centered care. They stated it was important to follow physician orders because care was directed by the physician's orders. The DON and Administrator stated physician orders received through the fax system were entered by a floor nurse and verified by a second nurse. They stated medical records staff scheduled appointments and other items not related to medication administration. They further stated nurse managers were responsible for overseeing implementation of physician orders and updating care plans. The DON stated the order was not completed. A policy titled, Lab and Diagnostic Test Results - Clinical Protocol, undated, indicated physicians were to order testing based on resident needs. The policy indicated staff were to process test requisitions and arrange for ordered tests. The policy further indicated test results were to be reported to the facility and reviewed by a nurse.

Based on interview, observation, and record review, the facility failed to provide direction and oversight of the activity program by ensuring a qualified professional directed the development, implementation, and coordination of resident activities. The facility failed to maintain leadership of the activity department after the Activities Director position became vacant, failed to ensure staff assigned activity responsibilities were trained and competent to perform the duties of the position, and failed to maintain basic components of the activity program including development and distribution of monthly activity calendars. This deficient practice had the potential to affect all 58 residents residing in the facility.Findings include: Record review of facility activity participation records and activity programming documents revealed the facility did not maintain a monthly activities calendar for May 2026. Record review further revealed residents residing on the third floor had limited opportunities to participate in organized activities and activity participation records reflected minimal documented activity attendance. (See F679)Observation conducted throughout the survey revealed no activities calendar was posted in common areas of the facility or in the elevator. Observation further revealed no organized activities occurring on the third floor during survey activities. (See F679)R3's quarterly Minimum Data Set (MDS), dated [DATE], indicated R3 was admitted to the facility on [DATE] and was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. During an interview on 6/1/26 at 1:05 p.m., R3 stated she and another resident had attempted to organize activities themselves because no formal activities were occurring. R3 stated she never saw the Activities Assistant on the third floor, did not receive an activities calendar, and was not informed about activities occurring elsewhere in the facility. R3 stated residents on the third floor were bored because staff did not routinely provide activities or notify residents of scheduled events.During an interview on 6/2/26 at 2:10 p.m., Licensed Practical Nurse (LPN)-A stated activities primarily occurred on the second floor and acknowledged activities were often resident-run on third floor. LPN-A stated activities were mainly on second floor to be honest. During an interview on 6/4/26 at 8:22 a.m., the Nurse Manager and LPN-C stated activities occurred mostly on the second floor and reported they were unsure whether an activities calendar was available for residents.During an interview on 6/4/26 at 8:48 a.m., Activities Assistant (AA)-A stated the facility had not had an Activities Director since April 2026 and department heads had been assisting with activities. AA-A stated she primarily conducted activities on the second floor and acknowledged most organized activities occurred there. AA-A stated she did not have formal activities training and did not know many of the responsibilities previously performed by the Activities Director. AA-A stated there had not been an activities calendar during the previous month and, although a calendar had been developed for the current month, she had not printed or distributed it. AA-A stated she had not received training regarding the responsibilities of the Activities Director position and acknowledged she was relying on department heads for guidance regarding activity programming.During an interview on 6/4/26 at 2:16 p.m., the Director of Nursing (DON) stated she was aware the facility did not have an Activities Director and acknowledged activities had not been routinely occurring on the third floor. The DON stated the facility expected a monthly activities calendar to be available to inform residents of scheduled activities. The DON stated the facility was attempting to hire an Activities Director but was unaware of where in the hiring process the facility was. A facility policy on the Activity Program, dated 3/2025, did not address the need for an activities director.

Based on interview and document review, the facility failed to ensure staff completed mandatory quality assurance and performance improvement (QAPI) training for 1 of 10 staff members, nursing assistant (NA)-J, who was reviewed for training requirements. This had the potential to affect all 58 residents residing in the facility. Findings include: Review of personnel records indicated the NA-J had not completed education that included QAPI in the last year. During an interview on 6/5/26 at 8:33 a.m., the director of nursing (DON) was informed that QAPI training records for NA-J were not found in the records provided. The DON stated that she expected QAPI training to be completed annually, so NA-J should have completed the training. The DON stated she would provide any additional records if found. No additional records showing NA-J had completed QAPI training in the last year were received. The facility's undated Staff Development Program policy, indicated all personnel must participate in initial orientation and regularly scheduled in-service training classes. The policy indicated that QAPI training was a mandatory in-service training class but did not indicate how often this training should be completed.

Based on interview and document review, the facility failed to ensure staff completed mandatory compliance and ethics training for 1 of 10 staff members, nursing assistant (NA)-J, reviewed for training requirements. This had the potential to affect all 58 residents residing in the facility. Findings include: Review of personnel records indicated the NA-J had not completed education that included compliance and ethics in the last year. During an interview on 6/5/26 at 8:33 a.m., the director of nursing (DON) was informed that compliance and ethics training records for NA-J were not found in the records provided. The DON stated that she expected compliance and ethics training to be completed annually, so NA-J should have completed the training. The DON stated she would provide any additional records if found. No additional records showing NA-J had completed compliance and ethics training in the last year were received. The facility's undated Staff Development Program policy, indicated all personnel must participate in initial orientation and regularly scheduled in-service training classes. The policy indicated that ethics training was a mandatory in-service training class but did not indicate how often this training should be completed.

Based on observation and interview, the facility failed to serve food in a sanitary manner by failing to ensure staff properly contained hair with a hairnet/beard net while serving food and preparing room trays. This had the potential to affect all residents residing on 2nd floor.Findings include:During a continual observation on 6/4/26 at 12:08 p.m. to 12:33 p.m., lunch was being served by a dietary aid from a warming table. The dietary aid was observed to be using resident menu tickets and preparing resident plates. The plates were either placed on top of the warming table and nursing staff picked up the plates and delivered them to residents in the dining room or placed them on plastic trays on the cart for delivery to resident rooms. The dietary aid was observed to be wearing gloves but not wearing a hairnet while serving and preparing food. Dietary aid was observed to have longer hair but was not pulled back or contained in any way. Dietary aid had a partial beard and a goatee that was approximately 1/2 inch to 1 1/2 inch long with the goatee being slightly longer. Dietary aid was not wearing a beard net on while serving and preparing food. During an interview 6/4/26 at 12:33 p.m., dietary aid (DA)-A stated they had just finished serving all the food for the floor. DA-A stated they had prepared all the room trays and served all the residents in the dining room. DA-A verified they did not have a hairnet on. DA-A stated, we typically wear one during serving. DA-A added, they took the hairnet off during break and forgot to put it back on. DA-A stated they did not have to wear a beard net. DA-A stated, they never said anything about it. DA-A stated their beard/goatee was about 2 inches long. During an interview 6/4/26 at 12:43 p.m., culinary district manager (CDM)-A stated all dietary staff were to wear hair nets, even if they were bald, and were to wear a beard net if they had more than a 5 o'clock shadow. CDM-A stated the expectation was anytime dietary staff were in the kitchen or serving/plating food on the floors; they were expected to wear hairnets and beard nets (if needed). CDM-A stated it's important to contain hair, so it doesn't drop into the food. During an interview on 6/4/26 at 12:53 p.m., director of nursing (DON) stated it would be expected that staff serving food would wear hairnets and beard nets so hair doesn't get into food as that would be an infection control concern.During an interview on 6/4/26 at 12:54 p.m., administrator stated it would be expected staff serving food would wear appropriate hair/beard nets to contain hair as that would be an infection control issue if hair got into the food. A facility policy titled Dietary Hair Restraints and Head Covering, dated 6/4/26, indicated all individuals entering food preparation, oof storage, warewashing, or plating areas must wear an approved, effective hair restraint that completely covers all head hair and, where applicable, facial hair. Furthermore, the document indicated the following under section III: Approved Hair Restraints: 1. Head Hair Restraints Hair Nets: Fine-mesh, commercial-grade hair nets that completely enclose thehair. Dietary Caps/Hats: Clean, facility-approved baseball-style caps or chef hats maybe worn only if they are paired with a mesh hair net to capture stray hairs alongthe nape of the neck and ears. Exclusions: Standard bandanas, visors, hair clips, or open-mesh caps without anunderlying fine hair net are strictly prohibited.2. Facial Hair Restraints (Beard Nets) Any individual with facial hair (including beards, long mustaches, or stubble)exceeding 1/4 inch in length must wear an approved beard restraint/snood thatcompletely covers the jawline, chin, and mouth.

Based on observations, interviews, and document review, the facility failed to ensure 1 of 1 resident (R60) reviewed for wandering received adequate supervision per his plan of care to ensure safety and prevent elopement. Furthermore, the facility failed to check to ensure the correct sling size before transferring for 2 of 2 residents (R15, R23) using a mechanical lift and failed to ensure compatible lifts and slings were used for 1 of 2 residents (R54) who used a mechanical lift. The facility also failed to assess a bed in the high position for safety for 1 of 1 resident (R20) reviewed for bed height. In addition, the facility failed to ensure oxygen equipment and smoking materials were managed according to the resident's physician orders and care plan and failed to consistently supervise and monitor the resident's compliance with smoking safety requirements for 1 of 1 resident (R8) who required supplemental oxygen and was reviewed for smoking safety. Findings include: Adequate Supervision- Wandering R60's admission Minimum Data Set (MDS) dated [DATE], indicated R2 had intact cognition with behavioral symptoms not direct at others ( 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), had no rejection of care behaviors, and had wandered one to three days during the lookback period (LBP). R2 required set-up help with eating, moderate assistance for hygiene needs, and required supervision for walking. R2 was diagnosed with dementia. R60's Elopement Risk Evaluation dated 4/25/26, indicated R60 was ambulatory, had a habit/history of wandering or attempting to leave the building, had asked to go home or to other specific locations, family had voiced concerns that the resident had the tendency to wander or elope, and was taking medication that may cause confusion. The evaluation indicated R60 was at risk for elopement. The evaluation indicated R60 would be placed on a secure unit, would have a check-in and out log, and staff were aware of his elopement risk. R60's care plan dated 4/28/26, indicated R60 had the potential for hearing impairment, so staff were to utilize the communication binder at the nurse's station as needed. The care plan indicated staff were to utilize an interpreting service and had the service's phone number, but the care plan did not include what language R60 spoke. R60's care plan indicated R60 was to receive close supervision while in the common area. The care plan indicated staff were to anticipate and meet R60's toileting needs. The care plan indicated staff were to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or a book. The care plan indicated staff were to identify patterns of wandering and intervene as appropriate. R60's provider progress note dated 5/1/26 at 1:54 p.m., indicated that R60 had flooded his room and staff had reported that he was fixated on turning on water sources. The note indicated that staff were to continue supportive care with R60 on the memory care unit. R60's order summary dated 5/28/26, included an order for 15-minute safety checks, to admit to the locked memory care unit, and close monitoring for safety. During an observation on 6/2/26 at 9:13 a.m., an unknown staff member left the memory care unit and did not look behind them as the door continued to close. R60 then followed the staff member out of the otherwise locked memory care doors, to the non-locked unit. Registered nurse (RN)-D, the nurse manager for the unit, appeared to witness this, ran to the memory care doors, exited, and then came back onto the memory care unit with R60. During continuous observation on 6/2/26 from 1:20 p.m. to 2:09 p.m., R60 was observed wandering in the non-locked second-floor common area before re-entering the locked unit at 2:09 p.m. RN-B was observed sitting at the second-floor nursing station desk. The facility was set up so the common area was in the front, then a hallway separating the common area from the nurses station that was placed perpendicular to the common area. The nurses station had a small wall on the common area side of the nurses station, so as RN-B sat at the left computer, she was not visible from all areas of the common area. - At 1:22 p.m., R60 was observed standing at the back side of the second floor common area, out of view of the nurse, inserting the prongs of a metal fork into the waistband of his pants, and then using the prongs in a pulling motion, as if trying to rip the pants fabric. - At 1:26 p.m., NA-I was observed standing in the second-floor common area before leaving out of view. R60 continued to walk around the common area picking up items, looking at windows, and talking to himself in a non-English language. - At 1:35 p.m., R60 was observed to continue to pull at his pants and wander around the edges of the room while talking to himself in a non-English language. - At 1:38 p.m., R60 was observed to find a corner of the room and urinate. RN-C was observed to enter the common area and ask the resident in English to go back to his room. R60 responded in a non-English language and did not follow RN-C as he re-entered the memory care unit. RN-C was not observed to use a translator or a communication binder to attempt communication with R60. During a second continuous observation on 6/2/26 from 2:13 to 2:48 p.m., R60 was observed wandering in the memory care dining room. R60 was again observed pulling at his pants and looking in various corners of the room. - At 2:33 p.m., R60 was observed out of view of RN-C, who was standing at a medication cart in the memory care hallway looking at a laptop. R60 was observed talking out loud in a non-English language as he pulled at his pants while walking along the wall of the dining room. R60 was observed to lower his pants and urinate on the wall. R60 then pulled his pants back up and continued to pace in the dining area. - At 2:40 p.m., R60 pulled out a chair and pointed at it, as if asking the surveyor to sit. The surveyor sat down. R60 was then observed to walk to the other side of the dining room, squat behind the far side of the steam table, with one hand on the steam table, and the other hand on the tall, metal, meal tray cart. R60 was then observed to pull a paper off of the wall behind him, appearing to use it to clean himself after having a bowel movement, and throw the paper to the side after use. R60 was then observed to pull pants back up and walk to the other side of the room. On further observation, stool was found on the far side of the steam table. RN-C continued standing in the hallway at the medication cart looking at the laptop and was unaware of the incident. R60's progress note dated 6/2/26 at 3:30 p.m., indicated R60 was restless and agitated during the shift. The note indicated R60 took all of his medications. The note indicated R60 escaped through the door while the author was passing medications. The note indicated R60 was redirected several times, but most times he declined. R60's progress note dated 6/2/26 at 5:04 p.m., indicated R60 wanders sometimes and had followed staff through the door twice. The note indicated the second time, R60 had wanted to stay on the LTC [long term care] side and had then been successfully redirected to the memory care unit. The note indicated non-verbal cues had been used to communicate with the resident. The note indicated staff had attempted to use the interpreter service, but they had been unable to understand what R60 was saying. During a continuous observation on 6/3/26 at 1:26 p.m. to 2:16 p.m., R60's door was observed closed with what sounded like water running and R60's voice talking in a different language intermittently. R60's room's entrance was the room closest to the exit doors to the adjacent unit. - At 1:35 p.m., activities assistant (A)-A was observed to exit the memory care unit, not look back after she exited as she continued walking. The exit door stayed open for greater than four seconds. - At 2:08 p.m., A-A was observed to exit the memory care unit, not looking back after she exited as she continued walking. The exit door stayed open for approximately 15 seconds, as the door had been pushed farther open. - At 2:16 p.m., surveyor entered R60's room, observed R60 sitting on his bed with a privacy curtain from the middle of the room tied to a privacy curtain from the front of his room, now hanging over his bed. R60's sink was observed running with stool on the floor of the bathroom. - During this time period, no staff were observed to check on R60. During an interview on 6/3/26 at 2:17 p.m., licensed practical nurse (LPN)-B stated she was supposed to be completing 15-minute safety checks on R60, but she had gotten busy, and they were not completed. During an interview on 6/4/26 at 9:22 a.m., RN-D, the unit nurse manager, stated staff were supposed to ensure the memory care door closed before leaving the area to ensure no resident followed them out, as had happened with R60. RN-D stated staff were supposed to check on R60 every 15 minutes to ensure his safety. The facility's Elopement Prevention and Missing Resident policy dated 3/3/26, indicated residents would be assessed for their elopement risk on admission. The policy indicated high-risk residents would have an individualized care plan with specific interventions, environmental safeguards (secured exits), staff supervision tailored to risk level, and documented elopement precautions in the medical record. Mechanical Lift Sling Size Verification R15 R15's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of chronic respiratory failure with hypoxia, morbid (severe) obesity, and muscle weakness. If further included R15 had bilateral impairment on lower extremities and was dependent on staff for transfers. R15's care guide dated 3/27/26, indicated R15 required assistance of 2-3 staff with transfers using a Hoyer lift. The care guide lacked documentation of what sized sling R15 required. R15's care plan dated 3/3/26, indicated R15 required a mechanical lift (Hoyer) and the assistance of 3 staff members when transferring to his power mobility device (PMD) and the assistance of 2 staff when transferring back to bed. R15's care plan lacked documentation of what sized sling should be used when transferring R15 using the Hoyer lift until 6/2/26 (after survey started). During interview on 6/1/26 at 11:58 a.m., R15 stated the facility didn't label each resident's sling with their name, so there was no way to determine if each resident was getting the right sling back. Once they go to laundry to get washed, they are put in a bin, and the nursing assistants have to go down and get them. During observation on 6/2/26 at 10:17 a.m., three NA's (NA-F, NA-G, and NA-H), transferred R15 from his bed to his PMD, using the Hoyer lift and the sling that was already in R15's room located in the seat of his PMD. All three NA's failed to check the size of the sling before transferring R15. During interview on 6/2/26 at 10:30 a.m., NA-H stated each resident had their own sling that are kept in their room and that's how they know which sling to use for each resident. NA-H verified the tag on R15's sling had a small round hole punched in the tag next to where it said size medium but was unsure whether that hole indicated the sling was that size. During interview on 6/3/26 at 11:40 a.m., licensed practical nurse (LPN)-A stated NA's should be referring to the care plan or care sheets in order to determine what size sling each resident used. LPN-A verified R15's sling size was not in the care plan or on the care sheets, stating It should be right there!. LPN-A further stated if the NA's were unsure as to what size sling a resident was supposed to use, they should ask a nurse or manager. LPN-A also verified the care sheets/guide dated 3/27/26 were the most current. R23 R23 annual Minimum Data Set (MDS) dated [DATE], indicated moderately impaired cognition and diagnoses of multiple sclerosis (autoimmune disease that affects the central nervous system), spastic hemiplegia (a neuromuscular condition of spasticity that results in the muscles on one side of the body being in a constant state of contraction), affecting the right dominant side, and muscle weakness. It further indicated R23 had bilateral lower extremity impairment and was dependent on staff for transfers. R23's care guide dated 3/27/26, indicated R23 should be transferred with a Hoyer lift and assist of 2 staff using a medium sling. R23 's care plan dated 3/13/26, indicated R23 had an activity of daily living (ADL) self-care deficit related to multiple sclerosis and spastic hemiplegia. It further included an intervention R23's required total assist of two staff for transfers using the Joerns HPL 700 lift with full body medium size sling. During observation on 6/2/26 at 11:09 a.m., two nursing assistants (NA)-F and NA-G transferred R23 from her bed into her electric wheelchair using the sling that was sitting in the seat of the wheelchair and the Hoyer lift. Neither NA-F or NA-G checked the size of the sling or if R23's name was in it before transferring her. NA-G verified the tag on the sling was worn down and had no markings to determine what brand or the size of the sling. During interview on 6/2/26 at 11:18 a.m., NA-F stated they used the sling that was in each resident's room to transfer them because each resident had their own sling and it was supposed to stay in there. NA-F stated there was an incident a while back where they weren't using the correct sized sling and a resident fell out of it, so management ordered new slings for everyone, and they were expected to stay in their rooms. NA-F further stated when the slings needed to be washed, they sent them down to laundry. Some residents had their names in them, and some didn't. If they didn't have their name on it, they would look in the care plan to find out what size the sling the resident should have. During interview on 6/2/26 at 11:45 a.m., NA- G stated each resident had their own sling, and it stayed in their room. NA-G further stated they used the sling that was in each resident's room to transfer them. If they were unsure if it was the correct sling for that specific resident, they would check the care plan for the correct sling size. During interview on 6/3/26 at 11:23 a.m., NA-E stated everyone should have their own sling in their wheelchair and that's the one they used to transfer them. NA-E further stated, if they were unsure of what size sling to use for a specific resident, they would look in the care plan or the big binder at the nursing station with all the cares (care guide). During interview on 6/4/26 at 8:37 a.m., NA-B brought R23 her breakfast tray. R23's sling for the Hoyer lift was sitting in the seat of her electric wheelchair. NA-B verified the tag on the sling was worn down to the point there wasn't any writing on it and was unable to determine the size of the sling. NA-B stated they knew it's R23's sling because it was always in her room. R23 reiterated that's how they knew each resident's sling size was because they just used the sling in each resident's room. NA-B also stated if they were unsure of what sling size a resident should be using, they would look in the care plan or care sheets/guide. During interview 6/4/26 at 9:15 a.m., LPN-D stated the sling size each resident used could be found in the care plan and on the care sheets and each sling should have the size indicated on the tag. NA's should be checking the size of the sling before transferring the residents' and if there was any question of what sized sling the resident was supposed to be using, they should ask the nurse. The facility policy titled Mechanical Lift (Hoyer) and Sling Safety dated 6/4/26, indicated floor staff are strictly prohibited form guessing a resident's sling size based on visual appearance. Before any lift transfer occurs, staff must verify the required size via three mandatory access points: -The electronic health record (EHR): the exact lift type, sling style, sling size, and specific strap loop colors, must be documented in the resident's CNA care card/Kardex profile. -The room visual aid: A discreet transfer communication icon or instruction sheet must be posted on the inside of the residents wardrobed door or above the bed headboard. -The individualized sling: slings used for total lifts must be designated as resident-specific, labeled clearly with the resident's name using a permanent fabric marker on the manufacturer's identification tag. The facility policy also included a competency checklist which indicated staff should verify the sling size by matching the sling's color-coded border to the precise size mandated in the resident's care plan. The facility policy titled Safe Patient Handling and Mechanical Lift (undated), indicated staff must verify the required lift type, sling size, and specialized instructions in the resident's care plan prior to every transfer. Sling and Lift Compatibility R54 R54's significant change MDS dated [DATE], identified she was never/rarely understood and had short- and long-term memory problems. No behavior was observed, and she was dependent on staff assistance for activities of daily living (ADLs). Diagnoses included diabetes mellitus type 1, aphasia (difficulty talking), and epilepsy. R54's care plan dated 1/5/25, identified ADL deficit related to TBI (traumatic brain injury). An intervention dated 5/28/24, identified the resident required total assist of two staff for transfers using the Invacare brand reliant lift, full body sling, medium size. The brand for the sling was not identified. R54's nursing assistant care guide dated 6/1/26, identified Invacare Hoyer/medium sling. The brand name for the sling was not identified. R54's most recent weight dated 5/20/26 at 23:34 (11:34 p.m.) was 154 pounds, and her most recent height dated 5/31/25 was 62 inches (about 5 ft 2 inches). During an observation and interview on 6/1/26 at 2:20 p.m., nursing assistants (NA)-C and NA-D were beginning to transfer R54 from her Broda chair to the bed with a Linak Invacare full body mechanical lift model MDS450EL. R54's lift sling was underneath her and the label with the size was worn out and the brand and size was unable to be identified at this time. NA-C was asked what size sling R54 was using and she said the label was too worn out, but R54's was probably a large or extra-large. The sling label was reviewed closely and had a faded brand name of Joerns. NA-C stated it was the right one because it was the one that was always in her room. They proceeded to finish the transfer to bed without being sure the sling and lift were correctly sized and if the brands matched. During an interview on 6/1/26 at 6:21 p.m., NA-B stated the sling size would be on the NA care guide, and there were a lot of different slings and lifts to choose from. As far she knew they were all ok to use for the residents. NA-B stated R54 seemed stable in the sling when they did the transfers today, if any concerns were noted they would let the nurse know. During an interview on 6/1/26 at 6:23 p.m., NA-A stated she would look in the care plan regarding transfer equipment to be used for a resident. NA-A did not have a care plan handy to show surveyor, and she stated we use the one that is normally in her room, however, could not verify what size sling to use. During an interview on 6/1/26 at 6:25 p.m., trained medication assistant (TMA)-A stated they would use the sling that was in the resident room. Sling size was determined by the resident's measurements. TMA-A was not sure if there was a documented assessment for sling sizes. During an observation on 6/2/26 at 8:27 a.m., NA-E and NA-B were beginning to transfer R54 from her bed to her Broda chair. They placed the same sling with the faded label Joerns brand underneath R54. NA-B brought an Invacare lift model MDS450EL in the room and they began to connect the sling to the mechanical lift. NA-E stated they could not use this lift and disconnected the sling and took the lift out of the room. NA-B asked if the battery was dead but NA-E was already out of the room. When NA-E entered she said a Joerns brand mechanical lift was required since the sling brand was Joerns. They could not use Invacare brand and Joerns brand together. When asked what size sling R54 used NA-E stated the label was too worn to read but hers should probably be large. During a phone call on 6/2/26 at 10:40 a.m., Joerns health care representative (JR)-A stated they do not recommend using different brands of slings with their lifts, such as Invacare, because the other brands have not been tested with Joerns lifts, they might make the transfer unsteady or the sling would not fasten correctly to the lift and the transfer might be unsteady. Using different brands would be unsafe. Invacare customer service: Invacare:40 AM phone interview - Shakia - did not give last name, US customer service rep- we do not recommend using different brands of slings with our lifts, such as Invacare- only Joerns. that is because other brands haven't been tested with our lifts and so they might be unsteady or wouldn't fasten the correct way, it would be potentially unsafe. During an interview on 6/2/26 at 9:20 a.m., registered nurse (RN)-C stated he would know the correct sling and lift to use on a resident by the physician's order. Orders were reviewed and the sling and lift specifications were not found. RN-C stated he was not sure where that information would be and to talk to the manager. During an interview on 6/2/26 at 9:16 a.m., RN-D stated sling and lift specifications would be found in the NA care guide, not necessarily in the care plan in the electronic medical record. RN-D reviewed the NA care guide and stated R54 should have a medium sling and if the label was worn, staff could go by the color-coded edges of the Joerns sling which identified the size base on the colors. RN-D stated they had several different lifts in the facility, and they could be used with different slings, unless the resident had a bariatric bed and equipment, that was specialized equipment and could not be used for all residents. During an observation on 6/2/26 at 11:35 a.m., NA-E brought R54 to her room. NA-B brought in the Invacare lift MDS450EL. R54 had the same Joerns sling underneath her in the Broda chair. NA-E stated we cannot use this lift because the brands are different and exited the room with the lift. During an interview on 6/2/26 at11:45 a.m., NA-E returned with a mechanical lift brand Joern's model number HPL700 and stated this was the one they used with her sling. The infection preventionist (IP) was nearby and verified this was the lift that should be used and was compatible with the sling. The sling label could not be read; however, the sling had a yellow border on it, and on the lift the yellow sling size was identified as a medium. During a follow up interview on 6/4/26 at 9:38 a.m., RN-D stated the lift, and sling should match in brands before using and size should be verified. She would expect staff to reference the NA care guides prior to providing care to ensure the correct transfer equipment was used. RN-D stated therapy did the assessment to determine sling and lift compatibility. During an interview on 6/4/26 at 9:56 a.m., the director of therapy services (DTS) stated therapy did not do assessments for sling and lift compatibility or sizes and was not sure who did. During an interview on 6/4/26 at 2:03 p.m., the director of nursing (DON) stated sling and lift specifications were on the NA care guide for staff to reference. She would expect the guides to be referenced prior to providing care to ensure a safe environment was provided. R20: Bed Height R20's quarterly Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition. No behaviors or rejection of care were identified. R20 was independent with bed mobility and needed partial/moderate assistance to stand from a seated position and for transfers. R20 had one fall since the prior assessment with injury. Diagnoses included epileptic seizures, aphasia (difficulty speaking), and non-Alzheimer's dementia. R20's Care Area Assessment (CAA) dated 7/11/25, identified he was at risk for falls due to body weakness and decrease in muscle weakness. See care plans for safety interventions and fall prevention efforts. R20's nursing assistant Care Guide dated 6/1/26, identified he refuses care and refuses housekeeping. The care guide did not mention bed height. R20's behavior care plan dated 1/9/26, identified no behaviors of raising his bed to a high level. R20's communication care plan dated 1/5/25, identified an intervention dated 4/23/24, to keep the bed in the lowest position. R20's falls care plan dated 7/6/25, identified an intervention dated 2/20/24, to keep the bed in a low position at night. R20's care guide dated 6/1/26, identified to notify the nurse if cares were refused. The care guide lacked description of bed height. R20's nursing progress note dated 1/19/26 at 23:55 (11:55 p.m.), identified he had fallen out of bed in the low position, after attempting to transfer to his wheelchair, and had not used his call light to alert staff even thought it was in reach. R20's nursing progress note dated 3/1/26 at 22:51 (10:51 p.m.), identified resident had a generalized seizure lasting about three minutes and used his call light to alert staff. R20's quarterly rehabilitation screening tool dated 4/15/26, addressed bed mobility as independent, to walk with therapy only, and lacked a bed safety assessment. R20's nursing Fall Risk assessment dated [DATE], identified he was at high risk for falls due to disorientation, chair bound status and psychotropic medication use. R20's nursing Lift/Mobility Status assessment dated [DATE], identified he could not stand, pivot or walk without physical assistance, he was not cooperative or non-combative and was independent with bed mobility. During an observation on 6/1/26 at 2:01p.m., R20 was in bed with his bed in a high position at about 4.25 feet off the ground. His bed remote was on his bed. R20 was asked if he was going to lower his bed and he replied no. During another observation and interview on 6/1/26 at 4:54 p.m., R20's bed was in the same high position. Nursing assistant (NA)-A entered the room to observe the bed at approximately 4.25 feet in height and replied she did not think his bed was normally that height and asked R20 to lower his bed and he said no. During an observation and interview on 6/2/26 at 8:03 a.m., R20's bed was in the same high position. R20 was awake in bed and said he was doing okay today. During an interview on 6/2/26 at 1:25 p.m., NA-B stated R20's bed was usually in a high position because he liked it that way and had no falls she was aware of, and the NA's would know of care planned safety interventions from the care guide, however, stated bed height should be at a safe level for the resident to transfer from. During an interview on 6/2/26 at 1:49 p.m., registered nurse (RN)-B stated resident beds should be in a low position for safety, or in the position specified in the care plan. If the bed was in a high position and a resident fell, the risk of injury would be increased. During an interview and observation on 6/2/26 at 1:54 p.m., RN-C stated beds should be in the lowest position for fall prevention. RN-C stated R20 controlled his own bed height and usually kept the bed in a high position. RN-C was brought to R20's room to observe the bed at about 4.25 feet off the ground and agreed the bed was in a high position. RN-C left and did not ask the resident to lower his bed. R20's care plan was reviewed with RN-C, and he verified there was an intervention to keep the bed in the lowest position, however, RN-C did not ask R20 to lower his bed. During an interview on 6/2/26 at 2:01 p.m., physical therapist (PT)-A stated R20 would follow instructions well during therapy sessions and thought he would understand the risks of having his bed at a higher height than what was care planned, and it might be beneficial for someone to discuss the risks and care plan interventions. PT-A agreed beds should be in a low position for safety, and his could be at a standard height for safety. During an interview on 6/2/26 at 2:17 p.m., PT-B stated standard bed height would be 2-3 feet off the ground for safety. He thought R20 kept his bed high so he could watch the TV. PT-B stated the therapy had not assessed him for bed height. During an interview on 6/4/26 at 9:44 a.m., RN-C stated R20 had a history of seizures and a fall from his bed. RN-C stated he preferred to have his bed at a higher height. RN-C stated therapy should have assessed bed height for safety, however nursing should have modified the care plan to show R20's choice to keep his bed in a high position. During an interview on 6/3/26 at 2:01 p.m., the director of nursing (DON) stated beds should always be in a low position. Nursing should encourage residents to use this safety intervention, however, sometimes a resident would choose to do otherwise. In that case, education and encouragement should be provided, risks and benefits discussed and documented, and care plans should be modified. The facility's undated Bed Safety policy identified the resident's sleeping environment would be assessed by the interdisciplinary team considering the resident's safety, medical conditions, comfort and freedom of movement, as well as input from the resident and family regarding bed environment. Resident safety measures that are identified as having a higher than usual risk for injury would be identified. Safe Smoking R8 R8's Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R8 was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact for daily decision making and able to participate in care planning. A physician order, dated 8/12/25, directed that R8's cigarettes and lighter were to be secured in the medication cart. The order instructed staff to provide the resident with one cigarette and one lighter at a time, document the date and time the items were issued, and ensure the lighter was returned and signed back in by nursing staff upon the resident's return. R8's care plan, revised 8/12/25, identified the resident as a smoker of cigarettes and marijuana and included an intervention directing staff to provide one cigarette and one lighter at a time and require return of the lighter when the resident returned to the unit. An additional intervention dated 7/26/25, directed staff to encourage the resident to leave lighters at the nursing station; however, the resident refused. During an interview on 6/1/26 at 12:47 p.m., R8 stated she smoked outside and took her oxygen tank and nasal cannula to the smoking patio. R8 stated she removed the nasal cannula from her nose and turned the oxygen off while smoking but kept the oxygen tank and tubing with he

Based on observation, interview, and document review, the facility failed to ensure a resident room was maintained in a clean, sanitary manner for 1 of 1 resident (R5) whose room was in a state of disrepair. In addition, the facility failed to ensure the memory care dining room floor was kept in a clean and sanitary condition, which had the potential to affect all 10 residents residing on the memory care unit. Findings include: During an observation on 6/1/26 at 2:16 p.m., R5 was observed lying in bed which was positioned parallel to the wall. The wall was noted to have an area that was not painted the same color as the rest of the wall below the tv mounted on the wall (appeared as though plastic covering had been moved and area had not been re-painted). The wall across from the bed, by the closets, was noted to have multiple black marks on the wall which were approximately 8 inches long. The wall appeared to be dirty and was discolored with light brown marks in some areas. The ceiling above the window was observed to be discolored a yellowish color and was approximately the size of a basketball. It extended along the ceiling/wall another 8 inches or so each way with discoloration. The door frame, entering the room, was noted to have multiple scuff marks on along with areas of missing paint. During a follow up observation on 6/2/26 at 2:33 p.m., the observations above remained the same. During an interview on 6/2/26 at 2:24 p.m., R5's family member (FM)-C stated they have concerns with the environment at the facility. FM-C stated the facility was always disgusting. FM-C stated the facility was not clean, and smells bad. FM-C stated they have reported concerns with R5's room to the staff about the smell, the paint missing, the ceiling and they just brush it off. During an observation on 6/4/26 at 8:29 a.m., R5's wall was noted to have an area that was not painted the same color as the rest of the wall below the TV mounted on the wall (appeared as though plastic covering had been moved and area had not been re-painted). The wall across from the bed, by the closets, was noted to have multiple black marks on the wall which were approximately eight inches long. The wall appeared to be dirty and was discolored with light brown marks in some areas. The ceiling above the window was observed to be discolored a yellowish color and was approximately the size of a basketball. It extended along the ceiling/wall another 8 inches or so each way with discoloration. The door frame, entering the room, was noted to have multiple scuff marks along with areas of missing paint. During an observation on 6/3/26 at 7:29 a.m., the memory care dining room floor was observed with what appeared to be light-colored food crumbs, brown-colored crumbs of food, pieces of a white meat-looking substance, as well as what appeared to be spaghetti noodles under multiple dining tables. During an interview on 6/3/26 at 7:32 a.m., licensed practical nurse (LPN)-B stated it looked like the floors were not cleaned after last night's meal. LPN-B stated housekeeping was supposed to clean the floors after meals were served. During an interview on 6/3/26 at 7:39 a.m., the administrator confirmed she also observed the food under the dining tables and stated any staff member who observed the food under the tables should help clean it up, not just housekeeping. During an interview on 6/4/26 at 8:29 a.m., the director of maintenance (DOM) stated he had been planning on picking paint colors and buying new paint to condense the colors used for residents' rooms down significantly. The DOM stated that although he had been planning this, he had not yet bought any paint for this project or planned a date for this. The DOM stated he had not been notified the wall/ceiling disrepair in R5's room, and although he couldn't say for sure, there appeared to be some water damage on R5's ceiling that would need to be repaired. A facility policy titled Maintenance Service, revised 3/5/25, indicated the maintence department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.

Based on interview, observation, and record review, the facility failed to provide an ongoing program of activities designed to meet the interests and well-being of a resident(s) and failed to ensure residents were informed of available activities for 2 of 2 resident (R3 and R37) reviewed who identified group activities and participation in favorite activities as important (R3, R37). Findings include: R3's quarterly Minimum Data Set (MDS), dated [DATE], indicated R3 was admitted to the facility on [DATE] and was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. R3's Activity Interview for Daily and Activity Preferences, dated 3/28/25, indicated the facility completed a resident preference assessment designed to identify the importance of various daily routines, social interactions, and leisure activities. The assessment instructed residents to identify each preference as very important, somewhat important, not very important, not important at all, or important, but can't do or no choice. The assessment included questions regarding participation in group activities, involvement in favorite activities, choosing how to spend free time, and opportunities for social engagement. R3 identified doing things with groups of people and participating in favorite activities as somewhat important, indicating these activities were meaningful to her quality of life and personal preferences. R3's activity care plan, dated 10/5/24, identified preferences for meeting emotional, intellectual, physical, and social needs. Interventions directed staff to provide R3 with an activities calendar and notify her of any changes. Record review of facility activity participation sign-in sheets indicated R3 had no documented participation in activities between 5/1/26 and 5/16/26. The records further indicated the facility held an ice cream social on 5/15/26; however, R3 did not attend. Participation sign in sheets were not available for 5/17/26 - 5/31/26. Observation conducted throughout the survey revealed no activities calendar was posted in any public area on the third floor. Observation further revealed no activities calendar was posted in the facility elevator. During an interview on 6/1/26 at 1:05 p.m., R3 stated she and another resident had attempted to organize activities themselves by collecting money and prizes from other residents for a resident auction because no formal activities were occurring. R3 stated the facility had hired an activities aide, but she never saw the aide on the third floor. R3 stated she did not have an activities calendar, and no calendar was posted in the hallway. R3 stated she did not know what activities were occurring because activities, if held, occurred on the second floor and staff did not notify residents on the third floor. R3 stated, We are all bored up here on third floor. During an interview on 6/2/26 at 2:10 p.m., Licensed Practical Nurse (LPN)-A stated activities primarily occurred on the second floor and acknowledged that activities were often resident-run on third floor. LPN-A stated activities were mainly on second floor to be honest. During an interview on 6/4/26 at 8:22 a.m., the Nurse Manager and LPN-C stated they were unsure whether an activities calendar was available and reported activities occurred mostly on the second floor. During an interview on 6/4/26, Activities Assistant (AA)-A stated the facility had not had an Activities Director since April 2026 and department heads had been assisting with activities. AA-A stated most activities occurred on the second floor because the memory care unit was located there. AA-A stated she documented attendance on paper sign-in sheets. AA-A stated there had been no activities calendar during the previous month and although a calendar existed for the current month, she had not yet printed it for resident viewing. AA-A stated calendars would be distributed to residents if enough paper was available; otherwise, they would be posted in the elevator. AA-A stated R3 only attended larger social events such as monthly birthday parties and one ice cream social held during the year. Attendance records indicated R3 did not attend the ice cream social. During an interview on 6/4/26 at 2:16 p.m., the Director of Nursing (DON) stated she was aware the facility did not have an Activities Director and acknowledged activities had not been routinely occurring, especially on the third floor. The DON stated the facility expectation was for a monthly activities calendar to be available so residents would be aware of scheduled activities. The DON stated the facility was in the process of hiring an Activities Director. R37's comprehensive Minimum Data Set (MDS) assessment dated [DATE], indicated R37 was cognitively intact, and dependent on mechanical device and assist of 2 for transfers. R37 indicated it was very important to attend activities. R37's care plan dated 1/6/26, indicated he was to be encouraged to participate in activities that promote exercise, and improved mobility. During an interview on 6/1/26 at 4:16 p.m., R37 stated the facility did not have an Activities Director and reported there were no activities available. R37 stated he would have liked to participate in activities if they had been offered. During an interview on 6/2/26 at 2:09 p.m., Activities Assistant (A)-B stated he had worked at the facility for approximately one month and confirmed the facility did not have an Activities Director. A-B stated activities staff attempted to engage residents through trivia, word games, board games, and bingo. A-B confirmed there was no activities calendar posted on the community board on the third floor. During a follow-up interview on 6/4/26 at 8:32 a.m., R37 stated there was no activities calendar posted on the third floor and no information regarding available activities. R37 stated the resident had informed staff of a desire to attend an auction activity on Monday; however, no staff assisted the resident to attend. R37 stated the resident relied on staff assistance and a mechanical lift for transfers. The resident further stated staff did not invite the resident to activities and there was no communication regarding what activities were available or when they occurred. R37 stated the resident enjoyed television programs, previously attended bingo, and remained interested in participating in facility activities. R37 stated activities were important because they helped break up the day and expressed that the facility needed a full-time Activities Director. During an interview on 6/4/26 at 8:43 a.m., Licensed Practical Nurse (LPN)-C stated the facility previously had an Activities Director, but the individual had resigned. LPN-C stated the facility was interviewing candidates for the position and acknowledged activities were important for residents' mood and well-being. He confirmed there wasn't an activities calendar posted. During an interview on 6/4/26 at 12:04 p.m., the Director of Nursing (DON) and Administrator stated activities were important for meeting residents' individual needs and preferences. The Administrator stated the facility was actively interviewing candidates for the Activities Director position because of the unique needs of the resident population. A policy dated 3/6/25 titled, Activity Programs, indicated activity programs were designed to meet the interests of and support the physical, mental and psychosocial well-being. Activities were to be scheduled 7 days a week, and residents were given an opportunity to contribute to the planning. Activities offered were based on the comprehensive resident-centered assessments.

Based on observation, interview and document review, the facility failed to ensure a call light was within reach for a resident who had a history of seizure and fall and relied on staff assistance for 1 of 1 resident (R20) reviewed whose call light was not within reach.Findings include:R20's quarterly Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition. No behaviors or rejection of care were identified. R20 was independent with bed mobility and needed partial/moderate assistance to stand from a seated position and for transfers. R20 had one fall since the prior assessment with injury. Diagnoses included epileptic seizures, aphasia (difficulty speaking), and non-Alzheimer's dementia.R20's Care Area Assessment (CAA) dated 7/11/25, identified he was at risk for falls due to body weakness and decrease in muscle weakness. See care plans for safety interventions and fall prevention efforts.R20's communication care plan dated 1/5/25, identified an intervention dated 4/23/24, to Ensure/provide a safe environment: resident is able to use call light, make sure that call light in reach when resident is in his room.R20's activities of daily living (ADL) care plan dated 3/20/18, identified an intervention dated 2/20/24, to encourage resident to use bell to call for assistance.R20's behavior tracking dated 5/7/26 through 6/6/26, identified no behaviors were observed. Options included physical aggression, verbal aggression, threatening, reject care, wander, self-transfer, cry, withdrawn, neg statements, sleepy, awake at night, restless, short temper, socially inappropriate, hallucinate, or delusions. R20's nursing progress note dated 1/19/26 at 23:55 (11:55 p.m.), identified he had fallen out of bed in the low position after attempting to transfer to his wheelchair, and had not used his call light to alert staff even thought it was in reach.R20's nursing progress note dated 3/1/26 at 22:51 (10:51 p.m.), identified resident had a generalized seizure lasting about three minutes and used his call light to alert staff.During an observation on 6/1/26 at 2:01 p.m., R20 was in bed, his call light was on the wall wrapped around the call light switch box which was located above his head of bed and off to his left. During a follow up observation and interview on 6/1/26 at 4:54 p.m., R20's call light was still on the wall in the same position. R20 stated he would like his call light and nursing assistant (NA)-A was brought into the room and verified verbally he would not have been able to reach his call light, and it should have been within reach.During an interview on 6/2/26 at 1:25 p.m., NA-B stated all residents should have a call light within reach. The purpose of having assessments and care plan interventions was resident safety.During an interview on 6/4/26 at 2:01 p.m., the director of nursing (DON) stated call lights should always be within reach for safety reasons.The facility's undated Answering the Call Light policy identified when the resident was in bed or confined to the chair be sure the call light was within easy reach of the resident in order to respond to the resident's requests and needs.

Based on interview and document review, the facility failed to ensure physician-ordered vision services were arranged and provided by failing to schedule and follow through with a routine referral to a retinal specialist for 1 of 1 resident (R31) reviewed for vision services. This failure had the potential for more than minimal harm by delaying evaluation and treatment of reported vision symptoms and potential diabetes-related eye conditions. Findings include: R31's annual Minimum Data Set (MDS) assessment, dated 4/1/26, indicated R31 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. Diagnoses included diabetes mellitus, protein-calorie malnutrition, depression, and post-traumatic stress disorder (PTSD). R31's physician orders revealed a routine referral to a retinal specialist dated 1/19/26.R31's electronic medical record (EMR) lacked evidence the retinal specialist appointment had been scheduled or completed. The EMR also lacked documentation of follow-up regarding the referral or any consultation report from a retinal specialist.During an interview on 6/1/26 at 12:02 p.m., R31 stated she needed to see the eye doctor because her eyes were fuzzy and burned. R31 stated she had previously been told there was some edema behind my eyes or something and that she needed follow-up with a specialist. R31 stated the facility was supposed to make the referral but she had never heard anything further. R31 stated her last eye appointment had been over a year ago. During a follow up interview on 6/2/26 at 1:02 p.m., R31 stated she had not heard anything further about the eye doctor appointment. When asked why she thought the appointment had not occurred, R31 stated, Cause they just don't make the appointments.During an interview on 6/2/26 at 2:10 p.m., Licensed Practical Nurse (LPN)-A stated when there was an order in the EMR for a follow-up appointment, the health unit coordinator (HUC) downstairs was responsible for scheduling the appointment.During an interview on 6/3/26 at 10:50 a.m., a health unit coordinator (HUC) assistant stated HUC staff were responsible for scheduling appointments when outside providers had not already arranged follow-up. The HUC assistant stated she highlighted physician orders requiring follow-up appointments and provided them to the HUC responsible for scheduling. When asked about R31's retinal specialist referral, the HUC assistant reviewed the medical record but was unable to determine whether the appointment had been scheduled or completed and stated she would continue looking into it.During an interview on 6/4/26 at 8:22 a.m., Licensed Practical Nurse (LPN)-C, the nurse manager, stated he was unsure whether R31's retinal specialist appointment had been scheduled or completed and stated he would investigate.During a follow-up interview on 6/4/26 at 11:15 a.m., LPN-C stated the HUC was out sick and he had been unable to obtain additional information. LPN-C stated he did not find any documentation in the EMR indicating the appointment had been scheduled or that R31 had been seen by the retinal specialist.During an interview on 6/4/26 at 2:16 p.m., the Director of Nursing (DON) stated the expectation was that nurses entered physician orders and needed appointments into the EMR and the HUC scheduled follow-up appointments as soon as possible.An undated facility policy titled Clinical and Operational Policy: Vision Appointment Management stated the facility would ensure all residents had access to comprehensive vision care and would coordinate with external providers to deliver vision services safely and efficiently.

Based on observation, interview and document review the facility failed to assess for potential side effects of antipsychotic medication for 1 of 5 residents reviewed (R6) who was reviewed for unnecessary medications.Findings include:R6's quarterly Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition, rejection of care one to 3 days, and was dependent on staff assistance with dressing, bed mobility and toileting. R6 took an antipsychotic medication.R6's care plan dated 2/7/26, identified antipsychotic medication was used for Parkinson's. R6 was to be monitored for potential adverse effects and nursing staff were directed to document and record any findings. Potential adverse effects included: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, and unusual behavior symptoms. R6's physician order dated 4/25/25, identified to give quetiapine fumarate (an antipsychotic medication) 25 milligrams (mg) by mouth one time a day for Parkinson's disease (PD) and behavioral disturbance with agitation. Also give 50 mg by mouth one time a day for Parkinson disease and behavioral disturbance with agitation.R6's nursing order dated 4/26/26, identified to Complete AIMS - Abnormal Involuntary Movement Scale one time a day every 3 month(s) starting on the 20th for 3 day(s).R6's treatment administration records (TAR) identified:4/21/26 through 4/23/26, the order to complete the AIMS assessment was signed off as having been done daily for these three days, however, there were no assessment results documented in R6's record.5/19/26, the order sign off to complete the AIMS assessment was blank, and there were no assessment results documented in R6's record.6/1/26 through 6/4/26, no AIMS assessment had been signed off or documented in R6's record.During an observation on 6/1/26 at 12:52 p.m., R6 was seated in his wheelchair with a flat affect and a mild tremor in his fingers.During an interview on 6/4/26 at 9:44 a.m., registered nurse (RN)-D stated upon admission the nurse would enter the AIMS assessment into the medical record so nursing could complete it. RN-D stated AIMS was important to check for side effects, and the purpose of the assessments were for residents safety. During an interview on 6/4/26 at 2:01 p.m., the director of nursing (DON) when a resident was on an antipsychotic either the nurse working on the floor or the manager would place the order on the TAR to signal nursing to complete the AIMS assessment. Completed AIMS assessments would be documented in R6's medical record under assessments The purpose completing an AIMS assessment is mainly for the purpose of medication adjustments and so the pharmacy could review to see if any changes or side effects which may require medication adjustment. The facility's AIMS Assessment policy dated 6/4/26, identified an AIMS assessment was required for residents prescribed a second-generation antipsychotic such as quetiapine. A baseline assessment should be completed prior to starting an antipsychotic and every 3 months or sooner if changes for the elderly.

Based on interview and document review, the facility failed to ensure an adequate discharge planning process was maintained to ensure resident preference for discharge was met for 1 of 1 residents (R7) reviewed for discharge planning.Findings include:R7's quarterly Minimum Data Set (MDS) assessment, dated 5/13/26, identified R7 had short term and long-term memory problems and cognitive skills for daily decision making were severely impaired. Section Q indicated there was no active discharge planning occurring for resident to return to the community.During an interview on 6/1/26 at 2:11 p.m., R7's legal guardian (FM)-A stated they have expressed numerous times the desire for R7 to move closer to them. FM-A stated they would like to have R7 in St [NAME] as getting back and forth to the facility had become difficult. FM-A stated the facility had previously been looking for a facility closer but no longer was. FM-A stated they still wanted R7 to live in St [NAME] but have grown tired of asking all the time about moving and being told no. R7's care plan, printed 6/2/26, indicated R7's currently discharge plan was resident wishes to discharge to a facility closer to family with an initiation date of 8/8/25. The intervention to meet this goal was social service will coordinate services for necessary for discharge with an initiation of 8/8/25.The care plan lacked information on any referrals sent, updated or outcomes of any referrals made.R7's progress notes, dated 12/1/25 to 6/2/26, were reviewed and included the following:-2/10/26 indicated R7 had a legal guardian who made all decisions for him.The progress notes lacked information or updates if any referrals were sent, any follow up being done regarding R7's desire to move to a facility closer to family, or communication of coordination or updates to guardian.R7's Social Service Care Conference, dated 12/31/25, identified social services, staff nurse, and nurse manager were present during care conference. The document identified discharge planning needed as family would like him moved to a facility closer to them. Social services summary further indicated, resident's family would like him to discharge to a facility closer to them in Shoreview MN. Resident has been denied at many SNFs. Currently on [name] hospice as of 10/08.R7's Social Service Care Conference, dated 5/29/26, identified R7, family, nurse manager and social services were present for care conferences. The document identified no discharge planning needed as resident LTC hospice. During an interview on 6/3/26 at 12:59 p.m., registered nurse (RN)-A stated they did not participate in planning a resident discharge unless there was a specific assessment that was needed. RN-A stated the nurse manager, or social worker would assist in planning a resident discharge. RN-A was not sure if R7 or his family was interested in finding another facility.During an interview on 6/3/26 at 1:22 p.m., registered nurse manager (RN)-D stated social services takes the lead if a resident or their representative had requested the resident to move to another facility. RN-D stated the previous social worker was working on finding R7 another facility per the family request and thought R7 may have been denied at one facility but was unsure. RN-D stated they were unsure where the process was currently at.During an interview on 6/3/26 at 1:41 p.m., social services (SS)-A stated social services was responsible for coordinating discharge planning. SS-A stated R7 was on hospice when asked about any discharge plans. SS-A reviewed R7 medical records and verified R7's care plan indicated the desire to move closer to family. SS-A stated R7 had a recent care conference, and it was indicated that resident received long term care (LTC) and hospice services. SS-A stated she assumed the family was ok with R7 staying at the facility as it was not brought up or discussed during the most recent care conference. During a follow up interview on 6/3/26 at 2:18 p.m., SS-A stated she followed up with FM-A who indicated they wanted R7 to move to St [NAME] or closer to the rest of the family. SS-A stated discharge for R7 was not discussed during the care conference and should have been. SS-A stated she would follow up now as she was now aware that R7's guardian wants R7 to move to a facility closer. During an interview on 6/4/26 at 11:22 a.m., director of nursing (DON) stated that social services facilitates the process of a resident or their family has expressed a desire to discharge. DON stated nursing would assisting with the nursing part meaning any assessments needed or coordination with another facility for health-related needs.A facility policy on discharge planning was requested and not received.

Based on interview and document review, the facility failed to ensure a written transfer notice (including information such as the ombudsman information and the resident's appeal rights) and a written bed hold notice (including information such as the duration of the state bed-hold policy, the reserve bed payment policy, and the nursing facility's policies regarding bed-hold periods) was given as soon as practicable for 2 of 2 residents (R17, R63) reviewed for hospitalization.Findings include:R17's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R17 had moderate cognitive impairment with no hallucinations, delusions, or behaviors.R17's census listing dated 5/28/26, indicated R17 had a status of hospital unpaid leave starting on 5/26/26 and a status of active on 5/28/26.R17's progress note dated 5/26/26 at 2:02 p.m., indicated R17 was transferred to the hospital, and the power of attorney (POA) was contacted.An email correspondence dated 5/26/26 at 6:21 p.m., indicated the facility had asked R17's POA if she wanted a bed hold. The email did not include information such as the duration of the state bed-hold policy, the reserve bed payment policy, or the nursing facility's policy regarding bed-hold periods.R63's admission MDS dated [DATE], indicated R63 had intact cognition with no hallucinations, delusions, or behaviors.R63's Census dated 4/2/26, indicated R63 was coded as active on 3/16/26 and stop billing on 4/2/26.R63's progress note dated 4/2/26 at 9:23 a.m., indicated R63 had an order to send to the emergency department, and the significant other was notified and had declined a bed hold.R17 and R63's medical records were reviewed, and an indication that a written transfer notice, which included information such as the ombudsman information and the resident's rights, was given on transfer to the hospital was not found. Indication that R17, R63, or their resident representatives had been given a written bed-hold notice that included information such as the duration of the state bed-hold policy, the reserve bed payment policy, or the nursing facility's policy regarding bed-hold periods, on transfer to the hospital was not found. During an interview on 6/3/26 at 12:51 p.m., licensed practical nurse (LPN)-B stated that she sent documents such as the order summary, medication administration record, etc., but was unsure if a written transfer notice, which included information like ombudsman information and appeal rights, or a written bed hold notice was given on transfer to the hospital. RN-E stated she would have to follow up with the registered nurse (RN)-D, the nurse manager for the unit.During an interview on 6/4/26 at 9:29 a.m., RN-D stated she did not believe they had a process to give residents a written notice of transfer, which included information like ombudsman information and appeal rights. RN-D stated she would email the resident representative to see if they wanted a bed hold, but the email did not include information such as the duration of the state bed-hold policy, the reserve bed payment policy, or the nursing facility's policy regarding bed-hold periods.The facility's undated Emergency Transfer or Discharge policy, indicated that if an emergency transfer or discharge to the hospital occurred, staff should prepare a transfer form. The policy did not indicate what was included in this transfer form.

Based on interviews and document review, the facility failed to provide the opportunity to attend and participate in a care conference for 1 of 1 residents (R10) reviewed for care conferences.Findings include: R10's quarterly Minimum Data Set (MDS) assessment, dated 5/25/26, identified R10 had intact cognition with no hallucinations, delusions, rejection of care, or behaviors present. During an interview on 6/1/26 at 1:55 p.m., R10 was observed lying in bed with the television on. R10 stated she has not had a care conference recently, and indicated the last one was more than 3 months ago. R10's Social Service Conference form, dated 1/16/26, indicated a care conference was held with R10, R10's family member, nurse manager and social services. R10's progress notes dated 1/30/26 to 6/3/26 were reviewed and lacked indication of any care conference held or scheduled. During an interview on 6/3/26 at 1:29 p.m., registered nurse manager (RN)-D stated care conferences were arranged by social services and should be held quarterly, with any significant changes, and as needed. RN-D stated care conferences should follow the MDS assessment. During an interview on 6/3/26 at 1:46 p.m., social services (SS)-A stated they were responsible for care conferences and have been having their assistant help schedule care conferences. SS-A stated the expectation would be care conferences are held upon admission, quarterly, with significant changes, at discharge, or when requested. SS-A stated the facility was behind on care conferences when she started but the care conferences had been caught up. SS-A reviewed R10's medical record and verified R10's last care conference was 1/16/26. SS-A verified R10 had the following MDS assessments: quarterly 1/21/26, significant change in status 2/3/26 and 2/22/26, and a quarterly on 5/25/26. SS-A verified her assistant had not scheduled the care conferences and put it on the calendar. SS-A stated R10 should have had a care conference. During an interview on 6/3/26 at 1:53 p.m., R10's family member (FM)-B stated they typically attended care conferences either in person or via phone for R10. R10 stated they believed the last care conference was in January. R10 stated the next care conference was not scheduled, however R10 received a call from the facility to schedule during interview with the surveyor. During a follow up interview on 6/3/26 at 2:17 p.m., SS-A stated she thought she had the care conferences caught up and R10's must have been missed. SS-A stated R10's care conference had just been scheduled. During an interview on 6/4/26 at 11:21 a.m., director of nursing (DON) stated social services was responsible for coordinating care conferences. DON stated care conferences followed the MDS schedule. DON stated a resident should have a care conference every time a MDS assessment was completed such as a significant change, quarterly, annual, or admission assessment. DON stated it was important to have care conferences with family and their representatives to discuss resident care, any issues so they can be addressed and to help ensure family involvement. A facility policy titled Care Conference Policy reviewed 12/9/25, indicated care conferences will be held at all required intervals, promptly after significant changes, and at any time upon request.

Based on observation, interview, and document review, the facility failed to implement interventions for 1 of 1 residents (R60) who required alternate means of communication due to hearing loss and being non-English speaking. Findings include:R60's admission Minimum Data Set (MDS) dated [DATE], indicated R2 had intact cognition with behavioral symptoms not direct at others (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), had no rejection of care behaviors, and had wandered one to three days during the lookback period (LBP). R2 required set-up help with eating, moderate assistance for hygiene needs, and required supervision for walking. The MDS indicated R2 had highly impaired hearing with no hearing aid or other hearing appliance.R60's care plan dated 4/28/26, indicated R60 had the potential for hearing impairment, so staff were to utilize the communication binder at the nurse's station as needed. The care plan indicated staff were to utilize an interpreting service and had the service's phone number, but the care plan did not include what language R60 spoke. The care plan indicated staff were to anticipate and meet R60's toileting needs.R60's order summary dated 5/28/26, included an order for 15-minute safety checks, admit to the locked memory care unit, and close monitoring for safety.R60's banner dated 6/1/26, indicated R60 had the special instructions to use an interpreting service during patient care, but it did not include what language R60 spoke.R60's progress note dated 6/2/26 at 5:04 p.m., indicated R60 wanders sometimes and had followed staff through the door twice. The note indicated the second time, R60 had wanted to stay on the LTC [long term care] side and had then been successfully redirected to the memory care unit. The note indicated non-verbal cues had been used to communicate with the resident. The note indicated staff had attempted to use the interpreter service, but they had been unable to understand what R60 was saying.During an interview on 6/2/26 at 11:55 a.m., registered nurse (RN)-C confirmed he was R60's nurse for the shift and stated he was unsure what language R60 spoke or what the expected process was to communicate with him.During an interview on 6/2/26 at 12:05 p.m., a Hmong interpreting service was utilized, and the interpreter was able to translate R60's words to English, although it was unclear how well R60 was able to hear the translator/his understanding, as he did not respond to some of the questions asked by the surveyor.During an interview on 6/2/26 at 12:07 p.m., nursing assistant (NA)-I stated she has worked with R60 and the translator was be used sometimes when they completed R60's morning cares. NA-I stated she would use the translator when the nurse manager would bring the phone with the translator on the line, as she was unsure what language R60 spoke.During an interview on 6/2/26 at 12:09 p.m., registered nurse (RN)-D, the nurse manager for the unit, stated R60 spoke Hmong and staff were supposed to use the translator when they did cares with him. RN-D stated the facility has a cordless phone and staff should be calling the interpreter line themselves when cares were going to be completed. RN-D stated staff occasionally asked for help with calling the translator but had not this morning. RN-D stated that R60 didn't always understand the interpreter, so she would expect staff to then attempt to use the communication binder to assess R60's needs.During continuous observation on 6/2/26 from 1:20 p.m. to 2:09 p.m., R60 was observed wandering in the non-locked second-floor common area before re-entering the locked unit at 2:09 p.m. RN-B was observed sitting at the second-floor nursing station desk. The facility was set up so the common area was in the front, and a hallway separating the common area from the nurses' station that was placed perpendicular to the common area. The nurses' station had a small wall on the common area side of the nurses' station, so as RN-B sat at the left computer, she was not visible from all areas of the common area.- At 1:22 p.m., R60 was observed standing at the back side of the second-floor common area, out of view of the nurse, inserting the prongs of a metal fork into the waistband of his pants, and then using the prongs in a pulling motion, as if trying to rip the pants fabric.- At 1:26 p.m., NA-I was observed standing in the second-floor common area before leaving out of view. R60 continued to walk around the common area picking up items, looking at windows, and talking to himself in a non-English language.- At 1:35 p.m., R60 was observed to continue to pull at his pants and wander around the edges of the room while talking to himself in a non-English language.- At 1:38 p.m., R60 was observed to find a corner of the room and urinate. RN-C was observed to enter the common area and ask the resident in English to go back to his room. R60 responded in a non-English language and did not follow RN-C as he re-entered the memory care unit. RN-C was not observed to use a translator or a communication binder to attempt communication with R60.- During this continuous observation, staff were not observed to use an interpreting service or the communication binder to attempt to speak with or assess R60's needs.During continuous observation from 2:13 to 2:48 a.m., R60 was observed wandering in the memory care dining room. R60 was again observed pulling at his pants and looking in various corners of the room.- At 2:13 p.m., RN-C was observed giving R60 two beverages to drink and setting them at a dining table. RN-C was again not observed using the communication binder or a translator to assess R60's needs.- At 2:33 p.m., R60 was observed out of view of RN-C, who was standing at a medication cart in the memory care hallway looking at a laptop. R60 was observed talking out loud in a non-English language as he pulled at his pants while walking along the wall of the dining room. R60 was observed to lower his pants and urinate on the wall. R60 then pulled his pants back up and continued to pace in the dining area.- At 2:40 p.m., R60 pulled out a chair and pointed at it, as if asking the surveyor to sit. The surveyor sat down. R60 was then observed to walk to the other side of the dining room, squat behind the far side of the steam table, with one hand on the steam table, and the other hand on the tall, metal, meal tray cart. R60 was then observed to pull a paper off of the wall behind him, appearing to use it to clean himself after having a bowel movement, and throw the paper to the side after use. R60 was then observed to pull pants back up and walk to the other side of the room. On further observation, stool was found on the far side of the steam table.- During this continuous observation, staff were not observed to use an interpreting service or the communication binder to attempt to speak with or assess R60's needs.The facility's Communication and Language Access Services policy dated 6/4/26, indicated the resident's primary language should be placed prominently in the electronic health record.

Based on observation, interview, and document review, the facility failed to ensure routine personal hygiene (i.e., shaving) were completed for 1 of 1 resident (R51) reviewed for activities of daily living (ADLs) and who were dependent on staff for their care.Findings include: R51's quarterly Minimum Data Set (MDS) assessment, dated 5/11/26, indicated R51 had intact cognition with no hallucinations, delusions, no behaviors, or rejection of care. MDS indicated R51 was dependent on staff for personal hygiene (i.e., shaving, combing hair, washing/drying hands), toileting, showering, dressing and mobility needs. R51's care plan, printed 6/4/26, indicated R5 had an ADL self-care performance deficit related to fatigue and morbid obesity which included the following interventions: - prefers no facial hair, provide grooming on shower days and as needed which was initiated on 6/26/25- BATHING/SHOWERING: The resident is totally dependent on 2-3 staff to provide bath/shower weekly on Tues and Fri PM and as needed. Resident prefers bed bath- PERSONAL HYGIENE/ORAL CARE: The resident is totally dependent on 2 staff for personal hygiene and oral care. R51's progress notes, dated 5/1/26 to 6/3/26, were reviewed and lacked evidence of refusals of shaving or completion of shaving.R51's Weekly Skin/bath assessment, dated 5/29/26 was reviewed and identified R51 received a bed bath. The audit form lacked evidence of facial shaving being offered or completed.R51's Weekly Skin/bath assessment, dated 5/22/26 was reviewed and identified R51 received a bed bath. The audit form lacked evidence of facial shaving being offered or completed.R51's Weekly Bath Audit, dated 5/27/26 was reviewed and identified R51 received a shower. The audit form lacked evidence of facial shaving being offered or completed.During an interview and observation on 6/1/26 at 11:59 a.m., R51 was observed with facial hair that was approximately 1/4 inch long. R51 stated the staff do not ask her if she wants to be shaved. R51 stated if she asked staff to shave her facial hair, the staff would but she found it embarrassing to have to ask to be shaved.On 6/3/26 at 12:33 p.m. R51 was observed to continue to have approximately 50 or so 1/4 inch long facial hairs on her chin and lower cheeks. R51 stated no staff had asked her if she wanted her facial hair removed and felt they should ask her daily or when they saw it. R51 stated, I don't wanna look like a man. On 6/3/26 at 1:00 p.m., registered nurse (RN)-A stated R51 required total staff assistance. RN-A stated nursing and aids should be asking if residents want to be shaved when they notice any facial hair. RN-A went and observed R51 facial hair. R51 was observed stating to RN-A she would like the facial hair removed and so she doesn't like looking like a man. RN-A stated R51's facial hair should have been and needed to be removed.On 6/3/26 at 1:25 p.m., registered nurse manager (RN)-D stated shaving was considered part of daily grooming. RN-D stated based on resident preferences, staff should be offering to shave or assist to shave resident anytime they provided cares. RN-D requested to review R51's medical record and provide additional information. No additional information was provided.On 6/4/26 at 11:21 a.m., director of nursing (DON) stated residents should be groomed per their preference. DON stated shaving should be offered with showers and as needed and documented if refused. A facility policy titled Activities of Daily Living (ADLs) Supporting, reviewed 11/2022, indicated Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with:a. hygiene (bathing, dressing, grooming, and oral care);b. mobility (transfer and ambulation, including walking);c. elimination (toileting);d. dining (meals and snacks); ande. communication (speech, language, and any functional communication systems).

Based on observation, interview and document review the facility failed to ensure a catheter drainage bag (CDB) remained below the level of the bladder for 1 of 2 residents (R6) reviewed for catheter care.Findings include:R6's quarterly Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition, rejection of care one to 3 days, and was dependent on staff assistance with dressing, bed mobility and toileting. R6 was always incontinent of bowel and bladder and had intermittent catheterization. Diagnoses included infective bursitis of the left elbow. R6's care plan dated 4/27/26, identified R6 had a catheter for neurogenic bladder. An intervention dated 5/12/26, identified to position catheter bag and tubing below the level of the bladder. During an observation and interview on 6/3/26 at 10:44 a.m., activities assistant (A)-A brought R6 in his wheelchair to the commons area by hallways and elevator. R6's CDB was hooked on his wheelchair arm rest above the level of the bladder. The catheter tubing contained urine that had not drained down. R6 stated he was moving the catheter tubing to try and get the urine to drain down into the CDB. During an interview on 6/3/26 at 10:46 a.m., nursing assistant (NA)-J stated R6's catheter should be positioned below the level of the bladder for drainage. During a follow up interview on 6/3/26 at 10:46 a.m., A-A stated R6 was at an activity for 1 and 1/2 hours. Activities staff did not touch catheters, so his remained on his wheelchair arm rest for the past 1 and 1/2 hours, and no one from nursing did anything with his catheter while he was at the activity. During a follow up observation on 6/3/26 at 10:49 a.m., NA-J put R6's CDB in a pillowcase and was attempting to connect the pillowcase to the stability bars under the wheelchair During an interview on 6/3/26 at 10:50 a.m., NA-F stated CDB should be placed below the level of the bladder. she wasn't sure who placed R6's catheter bag above the level of the bladder.During an interview on 6/3/26 at 10:54 a.m., registered nurse (RN)-A stated CDB should be below the level of the bladder for drainage. RN-A stated R6 was currently on antibiotics for a bladder infection.During an observation and interview on 6/3/26 at 10:52 a.m., RN-D was adjusting R6's catheter tubing so it would drain. RN-D confirmed verbally there was urine in the tubing, and it needed manual drainage. During a follow up interview on 6/3/26 at 11:02 a.m., RN-D stated CDB should be below the level of the bladder so the bladder can empty.During another observation on 6/4/26 at 8:43 a.m., R6 was seated in the dining room with his CDB hooked on his wheelchair arm rest above the level of the bladder. The catheter tubing contained urine that had not drained down. Several unidentified nursing staff were in the area and did not intervene to place the CDB below the level of the bladder. During an interview on 6/4/26 at 8:48 a.m., trained medication assistant (TMA)-A confirmed verbally R6's CDB was incorrectly placed above the level of the bladder and needed to be below the bladder to ensure drainage.During an interview on 6/4/26 at 2:04 p.m., the director of nursing (DON) stated CDB should be positioned below the level of the bladder to ensure urine drains and does not backflow.The facility's undated Urinary Catheter Care policy identified the CDB should be held or positioned lower than the level of the bladder to prevent the urine in the tubing and CDB from backflowing into the bladder.

Based on interview and document review, the facility failed to ensure a resident's physician completed the initial comprehensive 30-day visit for 1 of 3 (R50) newly admitted residents reviewed. Findings include:R50's admission Minimum Data Set (MDS) dated [DATE], indicated R50 was diagnosed with cancer, kidney disease, malnutrition, and a seizure disorder.R50's census report dated 4/23/26, indicated R50 remained an active resident at the facility, had a primary payer source of Medicare A, and admitted to the facility on [DATE].R50's medical record was reviewed, and a progress note indicating a visit had been completed by a physician was not found.During an interview on 6/5/26 at 8:52 a.m., the director of nursing (DON) stated that the physician should see the resident within the first 30 days of their stay. The DON stated she would look for a note indicating that a physician had seen R50 during her stay and would provide the records. Records indicating R50 had been seen by a physician were not received.The facility's Physician Visits policy dated 4/2013, indicated the attending physician will visit residents in a timely fashion, consistent with applicable State and Federal requirements. The policy indicated that the attending physician must visit the resident once every thirty days for the first 90 days.

Based on observation, interview and document review the facility failed to ensure dignity was maintained for 1 of 1 resident (R6) reviewed for catheters.R6's quarterly Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition, rejection of care one to three days, and was dependent on staff assistance with dressing, bed mobility and toileting. R6 was always incontinent of bowel and bladder and had intermittent catheterization. Diagnoses included infective bursitis of the left elbow. R6's care plan dated 4/27/26, identified R6 had a catheter for neurogenic bladder. An intervention dated 5/12/26, identified to position catheter bag and tubing below the level of the bladder and away from entrance room door.During an observation on 6/1/26 at 12:52 p.m., R6 was in the commons area near the elevator and hallways. He was seated in his wheelchair with clear yellow urine showing in his urinary catheter drainage (CDB), which was hung under his wheelchair. Nursing assistant (NA)- D brought R6 to his room, assisted him to transfer to bed. emptied out the CDB and hung it on the side of the bed facing out to the room entrance.R6's nursing progress note dated 6/1/26 at 16:16 (4:16 p.m.), identified he went to the hospital for urinary retention. R6's nurse practitioner (NP) progress note dated 6/2/26, identified R6 went to the emergency department (ED) yesterday (6/1/26) for foley catheter malfunction and returned with a functioning catheter. R6 was started on Macrobid (an antibiotic medication specifically designed to treat uncomplicated urinary tract infections. During an observation on 6/2/26 at 9:35 a.m., R6 was in the commons area with one other unidentified resident. R6's CDB was uncovered, however, there was a blue flap on one side of the catheter. The other side was clear and clear yellow urine was observed from the hallway. The blue side was facing toward the commons area, and the clear side out to the hallway and elevator space. Unidentified therapy staff came by and adjusted the wheelchair foot rest of the unidentified resident who was seated near R6 in the commons area and did not arrange for privacy of R6's CDB. The infection preventionist (IP) also came to talk to R6 and did not arrange for privacy of R6's CDB. R6's nurse RN-B was at her medication cart intermittently, within eyesight of R6 and did not arrange for privacy of R6's CDB.During an observation on 6/3/26 at 10:49 a.m., nursing assistant (NA)-F adjusted R6's CDB which was now in a pillowcase under his wheelchair.During an interview on 6/3/26 at 10:50 a.m., NA-J stated R6's CDB was possibly in the pillowcase for privacy reasons.During an interview on 6/3/26 at 11:02 a.m., registered nurse (RN)-A stated R6's CDB was in a pillowcase for privacy.During an interview on 6/4/26 at 8:48 a.m., trained medication assistant (TMA)-A stated R6's catheter should have the blue side of the new catheter bag facing out toward the public for privacy. TMA-A stated she was not sure if the facility had privacy bags that covered the entire catheter drainage bag.During an interview on 6/4/26 at 9:37 a.m., registered nurse (RN)-D stated catheter drainage bags should be covered to maintain dignity and to avoid bodily fluid display to the public.During an interview on 6/4/26 at 2:04 p.m., the director of nursing (DON) stated the facility had CDB with a blue cover on one side. Staff were expected to keep the blue side facing the public to cover the CDB to maintain dignity.The facility's Dignity policy dated 6/4/26, identified to keep catheter drainage bags and colostomy pouches covered with commercial covers or tucked out of plain sight. The purpose of the policy was to ensure employees maintain and enhance each resident's dignity, individuality and privacy.

Based on observation, interview, and document review, the facility failed to ensure 4 of 4 residents (R22, R53, R66 and R36) who exited the facility out of the front door after-hours had the ability to safely and timely reenter the building. This resulted in an immediate jeopardy situation for R22, R53, R66 and R36 who had to wait for an extended period of time in severe cold temperatures in order to get back into the building. This failure created a risk of serious harm, injury, impairment or death for any resident who may attempt to reenter the building after hours. The IJ began on 10/17/25 when the administrator had the after-hours door code to enter the facility changed without informing the residents it may affect and then did not provide the code or a consistently working system they could use to alert staff they needed reentry. The administrator and regional operations director (RM) for the facility were notified of the IJ on 12/4/25 at 4:35 p.m. The immediate jeopardy was removed on 12/5/25, but noncompliance remained at the lower scope and severity (level E), no actual harm with the potential for more than minimal harm that is not immediate jeopardy.As a result of the IDR review the start of IJ is changed from 10/17/25 to 11/28/25. Findings include: The facility's Grievance Tracking Log dated October 2025 included an entry with Date Received as 10/20 and identified Type of Concern as Door codes. The form lacked Actions Taken, Date of Solution, and Date Completed. A Grievance form submitted 10/20/25 from the resident council president (R17) and attached Council Action Form to the Administrator dated 11/12/25, identified a concern as Code to the front door was changed so residents are locked out after 11:00 PM, The council did not request this, and Smokers are blocking door. The section of the form titled Recommendations/Solutions from R17 was, Give code to residents, There are no visiting hours for friends and family so they can have the code. The Administrators written response dated 11/28/25 stated, For the safety of our resident and staff, we do not share the door codes with resident, family or friends. They can call staff if they need to enter the building after 11pm, when the front desk staff leave. There is a phone in the middle room by the entrance, and nursing staff are now assigned to first floor overnights. Summary of pertinent findings: Door codes were changed for resident/staff safety during overnights when there is less staff supervision on the first floor. There is a phone outside the door than [sic] guests/staff/residents can use to call the facility to be let in. When the doors are locked, the handicap button will not open the door for safety. During the day the handicap button works. The facility's October 2025 QAPI meeting minutes attended by RM and administrator identified Entrance door code change as an Customer Services Related Issue. The facility's November 2025 QAPI meeting minutes attended by RM and Administrator identified Entrance door code change as a Customer Services Related Issue with notations on Audits Currently working for concern of, Family communication and satisfaction: Family continue to complain that phones are not being answered on the floors. A notation in margin indicated, Assign a nurse each shift. During observation and interview with R16 on 12/2/25 at 7:17 a.m., R16 was outdoors on the front smoking patio. A garbage can was used to prop the door open between the unheated breezeway and the facility entrance to prevent it from closing. A sign on the door said, Please DO NOT prop this door open!!! There were no other staff, residents or visitors in the area. R17 stated he put the garbage can in the doorway every morning so I can get back in. Otherwise, it is locked and I can't get back inside. It is too cold to be stuck outside. During interview with R17 on 12/2/25 at 1:00 p.m., R17 stated he was the current resident council president and stated the facility changed the after-hours door code and did not give it to the residents. R17 admitted to filing a grievance in October of 2025 and said, It is an accident waiting to happen [when staff] do not answer [phone] to let residents back in. R17 said, the front door locks [after-hours] and residents can't get back in. During observation on 12/3/25 at 6:40 a.m., a state surveyor (SA) arrived at main entrance to building and was unable to enter. The door from unheated breezeway was locked. Four numbers were posted by the telephone in the unheated breezeway and none of the numbers were answered. The phone numbers were attempted multiple times with a consistent beep-beep sound that was heard when each number was dialed. At 6:48 a.m., an unknown staff member walked past the door and let the SA into the facility. R3's Comprehensive Minimum Data Set (MDS) dated [DATE], identified R3 as cognitively intact, did not reject care, and was independent in self-care, and utilized a motorized wheelchair. Diagnoses include anemia, hypertension, peripheral vascular disease, amputation of left lower leg, diabetes, depression, bipolar, post-traumatic stress disorder (PTSD), tobacco use, and chronic lung disease. During interview with R3 on 12/4/25 at 11:02 a.m., R3 stated she was a smoker and two of my friends got stuck outside last night and had to call me to get in. They [facility] won't give us the code [to unlock the door]. The phone [in the breezeway] did not work. R22's quarterly MDS dated [DATE], identified R22 as cognitively intact, did not reject care, and was independent in self-care, and utilized cane/crutches, walker and wheelchair for mobility. Diagnoses include hypertension, diabetes, amputation of left lower leg, tobacco use and chronic lung disease. R53's quarterly MDS dated [DATE], identified R53 as cognitively intact, did not reject care, and was independent in self-care, and utilized a wheelchair for mobility. Diagnoses include depression, bipolar, chronic back pain, and chronic lung disease. During interview with R22 and R53 on 12/4/25 at 11:17 a.m., both confirmed they were outside smoking late the night of 12/3/25 to 12/4/25 and could not reenter the facility after hours because the door was locked and the phone [in the breezeway] did not work. R22 and R53 stated none of the residents were told about the after-hours door code being changed. R22 stated, this is our home and we live here. We are not in prison or probation. This is our home, and we should have that code. Both agreed that sometimes we will put the garbage can to block the door from closing so we can get back in. R22 and R53 stated they went to smoke during the night of 12/3/25 and tried to reenter the facility at 12:15 a.m., on 12/4/25 and the door was locked and all four phone numbers that were posted in the breezeway did not work. Both stated there were no staff around to see that they were outside in the unheated breezeway. R22 said, **** it was too cold out here to stay out there much longer. R22 had his cellphone with him, and he called the facility, but no one answered the phone. He then he called another resident, R3, who got out of bed and took the elevator down to let them in. R22 said that both R22 and R53 were stuck out there about 20-30 minutes. R53 stated, my fingers were still cold 20 minutes after we got back in. Both said facility staff were notified about them being stuck outside in the cold but did nothing to assess or evaluate them after they reentered the facility. Both said they had been locked out of facility before. R22 said, we are grown. Not kids. Stop treating us like babies. We should have a say. We were never notified by this place about changing the code. According to Past Weather in [NAME] Minnesota, USA the temperature outside at midnight on 12/4/25 was -2 degrees Fahrenheit. R66's quarterly MDS dated [DATE] identified R66 as cognitively intact, did not reject care, and was independent in self-care, and utilized a wheelchair for mobility. Diagnoses include anemia, hypertension, peripheral vascular disease, amputation of left lower leg, arthritis, anxiety, bipolar, PTSD, tobacco use, and chronic lung disease. During interview with R66 on 12/4/25 at 11:35 a.m., R66 stated she was a smoker and was locked out of facility during a cold night about a week ago and 3 or 4 other times. R66 stated she was never informed about the code being changed and was surprised to find out her code did not work. Eventually someone [staff] let her in. R66 stated the phone in the unheated breezeway was not there a month ago and now they have a phone, but it does not work. R66 said residents talked to [administrator] but nothing is done. He said, No one could get the code. R66 said the situation is very frustrating and [facility] takes my social security check to live here, and I can't get in. R36's quarterly MDS dated [DATE], identified R36 with having independent decision-making skills, did not reject cares, independent with hygiene and dressing, and utilized a wheelchair for mobility. Diagnoses include diabetes, depression, PTSD, and chronic pain. During interview with R36 on 12/4/25 at 11:43 a.m., R36 stated she was a smoker and I have been stuck outside before. R36 stated facility had changed the after-hours door code and did not let any of the residents know what the new code was. The phone down there was not there at first and now the one [that is there] does not work. No one at the reception desk at night. I got in because I had to wait for someone to walk by before they would let me in. It was very cold. Had to wait 20 minutes. R36 could not recall what date it was that she said she was left outside. It was a total surprise. During interview with facility's infection control preventionist (IP) on 12/4/25 at 11:54 a.m., IP stated the after-hours door code was changed. We put a phone out there in the breezeway to have the residents call if they need to get in, and I don't know if the phone is working. During interview with receptionist (REP) on 12/4/25 at 12:06 p.m., REP stated her understanding was during the daytime between 7:00 a.m., and 10:00 p.m., no code is needed [to reenter], otherwise they [everyone] need a code to get in. REP also stated, I have heard of residents saying they could not get in which is why there is a phone out there to use if they get stuck out there. REP said, for safety I believe it is important for everyone to be able to get in during this cold weather. On 12/4/25 at 1:18 p.m., all four numbers were called from the phone provided in the breezeway. All four numbers rang once and then went to a busy tone; no staff were able to be reached using the telephone. During interview with maintenance director (DOM) on 12/4/25 at 1:30 p.m., stated he was directed by the Administrator to change the door code on 10/17/25 and again on 11/5/25. DOM said, at first we did not have a phone [in the breezeway]. DOM said, I had a suspicion it was going to be an issue [not giving out the after-hours door code] and wasn't sure if any or all the residents were told about the changing of the code. DOM stated, this is a safety concern if people cannot get back into the facility. It is too cold [sic] be left outside in this weather. During interview with registered nurse (RN)-A on 12/4/25 at 1:54 p.m., RN-A stated she was aware of the after-hours door code being changed and did not know if the residents were ever told about it or were informed of a new door code. They should have access to get into their home. During a joint interview with the administrator and the maintenance director on 12/4/25 at 2:27 p.m., the administrator stated he had changed the code to the door a few months ago due to safety concerns of unknown persons entering the building. However, the administrator stated he only shared that information with resident council president at that time. The administrator confirmed residents had recently brought concerns to him about wanting the new door code and being worried they would be stuck outside in the cold at night. The administrator stated he was unaware the phone was not working and did confirm that at times the phone system went down but that maintenance lived nearby and could fix it when needed. During the same interview, the maintenance director confirmed the phone system went down at times and that the only way staff would be aware the phones were not working was if they were trying to use the phone or noticed calls were not coming in. During observation on 12/4/25 at 2:35 p.m., the administrator attempted to use the phone in the breezeway. Three of four phone numbers provided would ring once and then go to a busy tone. One phone number did go through to a staff member on the floor. During interview with R40 on 12/5/25 at 11:55 a.m., R40 stated he was previous resident council president. R40 stated, I told [administrator] that people need to get back into this place, and the phone down there don't work when he changed the code. And he said he was not going to tell any of the residents the code. That is wrong of him. And he stated that the administrator was told that staff won't answer the phone if it does work. That phone hasn't worked regularly and everyone especially the staff know it but don't care. R40 stated, We feel beaten down and frustrated. The IJ was removed on 12/5/25 after a removal plan was implemented; however, non-compliance remained at an isolated scope with potential for more than minimal harm that is not immediate jeopardy (Level E). The facility implemented the following actions: The front door code was updated and provided to all residents, who were instructed not to share the code, and a resident acknowledgement form was completed. A wireless doorbell was installed at the front entrance with receivers located on each floor nursing stations. Residents were assessed for their ability to use the door code, wireless doorbell, and breezeway, new residents will be assessed on admission, and all will be re-assessed at readmission, quarterly, and with any significant change in condition. Residents were educated on the use of the front door code, wireless doorbell, breezeway phone, cold weather safety, and appropriate entry procedures Staff were educated to respond promptly to after-hours entry requests, assess residents for cold exposure or hypothermia, provide warming measures as needed, and document all incidents. An After-Hours Entry policy was developed and implemented, outlining procedures for code assignment, use of the wireless doorbell and breezeway phone, resident and staff responsibilities, assessment schedules, documentation expectations, and response to malfunctioning equipment. The maintenance director or designee will perform daily checks of the front door and wireless doorbell, log results, and immediately correct any identified issues Resident acknowledgement forms, assessment documentation, and maintenance logs will be maintained for tracking and accountability. Facility policy titled Dignity, revised February 2021 identify, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. A policy regarding facility hours and access was requested but not received.

Based on observation, interview, and document review, the facility failed to ensure contact precautions were followed 1 of 1 resident (R1, R12 ) reviewed for contact precautions. In addition, the facility failed to ensure infection prevention practices were followed for medications and food storage. This had the potential to affect all 31 residents on the 3rd floor. Findings include: Contact Precautions R1's quarterly Minimum Data Set (MDS) assessment, dated 11/20/25, identified R1 had intact cognition, and demonstrated no delusional thinking. Further, the MDS identified R50 as having a primary medical condition of, Medically Complex Conditions, along with diagnoses of heart failure, high blood pressure, renal failure or insufficiency, and respiratory failure. During observation on 12/1/25 at 3:15 p.m., R1 was observed to have a single page document hung on the door that indicated: Contact Precautions. The sign included two stop signs on the signs indicating Everyone Must: clean their hands, including before entering and when leaving the room, with a picture of a hand and soap dispenser. Below that indicated providers and staff must also put on gloves before room entry, discard gloves before room exit, with a picture a gloves on the sign. Followed by: Put on gown before room entry, discard gown before room exits. Do not wear the same gown and glove for the care of more than one person with a picture of a gown. Followed by: Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person with a picture of a stethoscope. To the left of the door was a three-drawer plastic bin to the left of the door which contained disposable gowns, and gloves. On top of the plastic bin was hand sanitizer. R1 was observed sitting in her wheelchair in the hallway. During an observation and interview on 12/1/25 at 3:21 p.m., R1 was observed sitting in her wheelchair in her room. Surveyor introduced self and started interview at which time LPN-A was observed to enter R1's room without any PPE on. LPN-A prepared and started R1's nebulizer's machine. LPN-A stayed in R1's room while nebulizer machine was running. Surveyor excused self from room and asked to continue interview later which R1 agreed. At 3:26 p.m., LPN-A was observed to exit R1's room and perform hand hygiene with hand sanitizer. During a follow up interview on 12/1/25 at 4:05 p.m., R1 stated that staff do not wear gowns when they are assisting her. R1 stated they do wear gloves when helping her but no other PPE. R1 stated she was unaware of why there would be a contact precautions sign on her door. During an observation on 12/3/25 at 9:40 a.m., LPN-A was observed carrying a small cup of medications to R1's room. LPN-A was observed performing hand hygiene prior to entering R1's room. During continual observation, LPN-A was observed to come out of R1's room with an oxygen tank, walk down the hallway and fill it and go back into R1's room. R1 was observed to perform hand hygiene upon exiting R1's for the last time but was not observed with any other PPE on. During an interview on 12/3/25 at 9:57 a.m., LPN-A stated they had given R1 oral medications, filled R1's oxygen tank and assisted R1 in the bathroom. LPN-A stated they had not worn a PPE gown in R1's room. LPN-A stated they should have a worn a gown and PPE. LPN-A verified R1's door had a contact precaution sign on it. LPN-A stated they believed R1 was on contact precautions for a wound. R12 R12's admissions Minimum Data Set (MDS) dated [DATE] identified R12 with methicillin-resistant Staphylococcus aureus (MRSA), a multi drug resistant organism. In addition, R12 with intact cognition, and was taking antibiotics. R12's care plan dated 10/28/25 identified, The resident has MRSA and is on contact isolation r/t MRSA infection. Review of 2nd floor nurse care sheet identified R12 with Contact Precautions. During observation on 12/1/25 at 1:59 p.m., R12 door with posted Contact Precautions sign and personal protective equipment cart located outside his door. The sign directed staff and visitors to wear gloves and gown before entering the room. During observation and interview on 12/3/25 at 9:21 a.m., rehabilitation aide (RA) had R12 in wheelchair out in common area of 2nd floor in front of the nursing station and the main elevator. R12 was wearing a hospital gown and RA did not have personal protective equipment (PPE) gown and gloves on during transport. RA wheeled R12 to his room past the PPE cart posted outside his door and the Contact Precautions sign posted on his door. RA left room and sanitized her hands from sanitizer container resting on top of the PPE cart. R12 stated RA had not worn any PPE when she got me to be weighed down the hall. During interview with licensed practical nurse (LPN)-D on 12/3/25 at 9:30 a.m., LPN-D stated, Everyone who touches [R12] in his room, including wheeling him from the room to and from rehab should wear the gown and gloves. LPN-D stated R12 has MRSA in nares[nose] and wound. LPN-D stated staff care sheets identify residents on precautions pointing to the 2nd floor nurse care sheet. During interview with RA on 12/3/25 at 9:31 a.m., RA stated she I did not wear gown and gloves when I went into [R12] room to take him to the scale. I did not even see the cart there (pointing to the PPE cart and sign outside R12's room). RA stated, I should have worn the gown and gloves like the sign says. During interview with infection control preventionist (IP) on 12/4/25 at 11:54 a.m., IP stated expectation of staff to follow the signs that are posted on doors of residents on precautions. IP stated R12 was on contact precautions due to MRSA in nose and wound and not following precautions is risking everyone's health, including [R12]. A facility policy on contact precautions was requested but not received. Medication Storage During observation on 12/4/25 at 8:06 a.m., the third-floor medication room was inspected with licensed practical nurse (LPN)-A. The medication room had two refrigerators, one assigned to store medications and the other used to stored food items (e.g., boost supplement, apple sauce, etc.). The medication refrigerator contained several insulin pens, Mantoux vials and had 5- 8 oz cartoons of boost (nutritional supplement). The food refrigerator had a rectangular stainless-steel container with vanilla pudding, undated, and loosely covered with clear plastic wrap. The container had several spots of dry pudding touching an open plastic bag with 3 elastomeric intravenous pumps containing vancomycin (an antibiotic). One of the pump's tubing was sticking out of the plastic bag. The food refrigerator also contained 3 cartoons of boost. LPN-A stated medications should never been store in the food refrigerator, and we should never store food items in the refrigerator designated for medications. LPN-A added it posed a risk for contamination, and it was an infection control issue. During interview on 12/4/25 at 9:54 a.m., nurse manager/LPN-B stated the vancomycin was supposed to be stored in the medication refrigerator, and the staff should never store food in the refrigerator used for medications. LPN-3 indicated these findings represented infection control concerns. LPN-3 added, per nursing practice the food and medications should be kept separated. During interview on 12/5/25 at 9:09 a.m., the administrator stated there were two refrigerators in each med room, one was used for medications, and the other was used to store supplements, apple sauce, pudding and other food items used by the residents. Administrator stated it was unacceptable to store meds and food together. Administrator stated the concern was obviously an infection control issue due to risk for contamination. Facility policy titled Infection Prevention and Control Program dated 10/2018 indicated, an infection prevention and control program (IPCP) was established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

Based on observations, interview, and document review, the facility failed to ensure written Physician's Orders for Life Sustaining Treatment (i.e., POLST) were accurately entered, transcribed and reflected in the medical record to ensure current resuscitation measures (i.e., DNR - Do Not Resuscitate or CPR - Cardiopulmonary Resuscitation) would be performed in accordance with resident wishes for 1 of 2 residents (R1) reviewed for advanced directives. These findings constituted an immediate jeopardy (IJ) situation for R1 who would have received CPR against her declared wishes documented on a POLST dated [DATE].The IJ began on [DATE], when R1's POLST, indicating R1's wishes for DNR comfort focused treatment (allow natural death) was signed and it wasn't changed within the facility' electronic Medical Record (EMR) system (i.e., banner) to reflect R1's wishes. This error was not identified despite multiple opportunities; and a series of interviews with direct care nurses outlined they would implement the incorrect directions and begin CPR on R1 against her wishes due to this error. The administrator was notified of the IJ for R1 on [DATE] at 1:38 p.m. The IJ was removed on [DATE] after a removal plan was implemented; however, non-compliance remained at an isolated scope with potential for more than minimal harm that is not immediate jeopardy (Level D).Findings include:R1's quarterly Minimum Data Set (MDS) assessment, dated [DATE], identified R1 had intact cognition, and demonstrated no delusional thinking. Further, the MDS identified R1 as having a primary medical condition of, Medically Complex Conditions, along with diagnoses of heart failure, high blood pressure, renal failure or insufficiency, and respiratory failure with admission to the facility on [DATE].R1's health care directive, signed by R1 on [DATE], indicated R1's wishes included the following: allowed to die naturally and not be kept alive by artificial means or heroic measure; do not want any medical treatment that will not substantially improve my condition or help me recover, but will only postpone the moment of my death; however, I want whatever care is appropriate to keep me as comfortable and as free of pain as reasonable possible, including the administration of pain relieving drugs and surgical or medical procedures calculated to relieve my pain, even though some drugs or procedures may hasten my death; I specifically do not want any of the following: feeding tubes, artificial nutrition and hydration to prolong my life; tests, procedures or other treatments that will not add to my comfort or quality of life; resuscitation or intubation expect for the short-term purposes of organ donation.R1's hospital Discharge summary, dated [DATE], indicated R1's code status as DNAR/DNI (Do Not Attempt Resuscitation/Do Not Intubate) and was determined by patient.R1's hospital Discharge summary, dated [DATE], indicated R1's code status DNAR/DNI and was determined by patient, advance directive/POLST and family.R1's POLST, signed and dated by R1 on [DATE], indicated R1's wishes were DNR (Do Not Resuscitate) with comfort focused treatment.R1's care plan indicated R1 had signed Do Not Resuscitate (DNR) Orders with a creation date of [DATE].R1's order summary included the following:DNI with comfort measures starting [DATE] with end date of [DATE]admitted to hospice with a start date of [DATE]Full code with a start date of [DATE] and an end date of [DATE]DNR- do not attempt resuscitation - allow natural death with a start date of [DATE]R1's progress notes, dated [DATE] to [DATE], were reviewed and identified the following:[DATE] at 5 p.m.: resident returned to facility. Code status updated to DNIXXX[DATE] at 5:48 p.m. provider note indicated She had a health care directive dated [DATE] specifying no intubation, CPR, artificial nutrition, or treatments unlikely to provide meaningful recovery. In the ED, her DNR/DNI status was confirmed. The intensivist reviewed the directive with her designated decision makers, who requested removal of BiPAP and transition to comfort care. Other family members were informed and supportive, though unable to be present. Comfort measures were initiated, hospice consulted, and plans were made to return her to her nursing home with palliative support. Furthermore, the note indicated code status as full code.[DATE] at 11:21 p.m. provider note indicated She had a health care directive dated [DATE] specifying no intubation, CPR, artificial nutrition, or treatments unlikely to provide meaningful recovery. In the ED, her DNR/DNI status was confirmed. The intensivist reviewed the directive with her designated decision makers, who requested removal of BiPAP and transition to comfort care. Other family members were informed and supportive, though unable to be present. Comfort measures were initiated, hospice consulted, and plans were made to return her to her nursing home with palliative support. Furthermore, the note indicated code status as full code.[DATE] at 9:36 p.m.: staff called POA to update R1 signed a new POLST to be FULL code. POA stated per her record, R1's supposed to be DNR. Hospice called and waiting for a call back.R1's progress notes lacked indication that a conversation was had with R1 or R1's POA regarding wishes for code status upon return from the hospital on [DATE] or upon admission to hospice on [DATE].R1's hospice binder included the following information:[DATE] Interdisciplinary Group Meeting (IGM) note identified R1's code status was confirmed as DNR/DNI at recent emergency department (ED) visit along with having an advance directive stating R1 did not want any medical treatment that would not substantially help recovery, specifically not wanting feeding tubes, artificial nutrition, intubation or CPR. Code status listed as DNRXXX[DATE] IGM note indicated R1 code status as DNRXXX[DATE] IGM note indicated R1 code status as DNRXXX[DATE] IGM note included R1's hospice care plan indicated R1 code status as DNR.On [DATE] at 6:52 p.m., R1's Electronic Medical Record (EMR) banner indicated R1's code status as DNI with Comfort Measures.On [DATE] at 7:03 p.m., R1 stated if she were to be found unconscious without a pulse or breathing, she would want chest compressions to be done. Furthermore, R1 stated if I end up on the machine, pull the plug if I am nonfunctional. During a follow up interview at 7:51 p.m., R1 stated she would want to be intubated meaning she would want a tube put down her throat, if needed, if she was not breathing. R1 stated if it was found that she had brain damage, then pull the plug as I want a life that is functional. R1 was unsure if hospice or the facility discussed if she wanted CPR or to be intubated when she signed onto hospice. During an interview on [DATE] at 7:08 p.m., trained medication aid (TMA)-A stated if they found a resident unconscious they would get a nurse right away. TMA-A stated they wouldn't do anything without a nurse present.During an interview on [DATE] at 7:11 p.m., TMA-D stated if they found a resident unconscious, they would yell for more help. TMA-D stated they would check the EMR banner to see if the resident was full code or DNR and get the nurse. TMA-D stated they would ask the nurse what DNI means as they were not sure. TMA-D stated they would never start CPR without direction from a nurse. During an interview on [DATE] at 7:36 p.m. licensed practical nurse manager (LPN)-B stated the expectation would be if a resident was found on the floor, the staff would call for help. LPN-B stated a nurse would check the resident code status located in the EMR on the banner. LPN-B reviewed R1 medical record and verified R1 record indicated DNI with Comfort Measures. LPN-B stated R1's banner was not clear and should be clarified, DNI conflicts with comfort measures, and it should also indicate whether R1 was Full code or DNR. LPN-B verified the POLST in R1's records indicated R1 wishes were Full Code with selective treatment signed on [DATE]. LPN-B verified R1 signed onto hospice on [DATE] and a new POLST would typically be completed upon admission to hospice. LPN-B stated he could not find that a POLST had been completed since admission to hospice and it should be followed up on.During an interview on [DATE] at 7:36 p.m., registered nurse (RN)-B stated if a resident was found without a pulse, they would check for the code status on the EMR banner. RN-B stated if there wasn't a code status on the banner, then they would look in the hard chart at the nursing station. RN-B reviewed R1's banner which indicated DNI and stated that means do not intubate. RN-B reviewed R1's POLST in the EMR miscellaneous tab, dated [DATE]. After review, R1 stated they would initiate CPR according to the POLST on file. RN-B then reviewed the care plan and verified it indicated no CPR.During an interview on [DATE] at 7:54 p.m., director of nursing (DON) stated if a resident was unconscious, the expectation would be to check the resident pulse and implement their POLST. DON reviewed R1's EMR and stated the POLST in R1's chart dated [DATE] indicated to attempt resuscitation. DON stated R1 should have CPR initiated. DON reviewed care plan for R1 and stated the care plan indicated resident has signed do Not Resuscitate (DNR) Orders. DNR which was initiated on [DATE].During an interview on [DATE] at 11:59 a.m. hospice nursing assistant (NA)-L stated they didn't typically work with R1 and were covering for her regular hospice nursing assistant. NA-L stated they came to see her quick, was unsure if the nurse case manager would be out to see R1 today, and quickly ended the interview, stating she had to leave. During an interview on [DATE] at 12:27 p.m., RN-C verified they were R1's case manager. RN-C stated R1 signed a POLST upon admission with hospice which indicated R1's wishes to be DNR comfort focused treatment. RN-C stated another nurse had completed R1's admission but the process was to provide a signed copy of the POLST to the facility, and she was not aware the facility had R1 listed as a full code in their medical records. RN-C stated R1 had been listed as DNR in their system since admission to hospice. RN-C stated she received a request last night [DATE] to follow up as triage received a call from the facility indicating R1 expressed wishes to be full code. RN-C stated she had talked to R1's sister who was surprised by this and expressed R1's wishes had been to be DNR. During a follow up interview on [DATE] at 2:52 p.m., RN-C stated she met with R1 to clarify and R1's wishes were to be DNR with comfort focus treatment. RN-C stated a new POLST was completed and provided to the facility.During a follow up interview on [DATE] at 3:20 p.m. LPN-B stated a POLST indicating R1 wished to be DNR with comfort focused treatment was signed upon admission to hospice, but he was not able to locate a copy. LPN-B stated a nurse did follow up with R1 last night and R1 expressed wishes to be full code, and then today R1 met with her hospice RN case manager (RN-C) and expressed wishes to be DNR and a new POLST indicating these wishes (DNR) were signed. During a follow up interview on [DATE] at 11:57 a.m., LPN-B reviewed R1's hospice binder and documents within. LPN-B verified IGM's notes listed above were in R1's hospice binder. LPN-B stated it was a team approach, shared between nursing and social work, to ensure that coordination was done between hospice and the facility, and nursing and social work review documents within the hospice binder.During an interview on [DATE] at 1:45 p.m., director of admissions with hospice (AD)-A stated when a resident was admitted to hospice, their POLST status was reviewed. A POLST would be completed if a resident did not have one or updated if their current POLST did not match their current wishes. AD-A stated POLSTs were signed using docu-sign (a platform used to obtain electronic signatures) by residents/POA/guardians then transferred to the provider to sign within 24 hours. AD-A stated after the provider signs the POLSTs they were faxed from their EMR system to the facility for their records. AD-A stated R1 signed a new POLST upon admission with hospice on [DATE], and verified it was signed by their provider. AD-A stated it should have been sent to the facility after the physician signed the POLST.During an interview on [DATE] at 10:04 a.m., RN-A stated it was a shared responsibility between the floor nurses, the nurse manager, and social worker to ensure the documentation in the hospice chart matched the facility chart.During an interview on [DATE] at 10:32 a.m., R1's family member (FM)-B stated they were also the healthcare and financial power of attorney. FM-B stated they received a confusing call Monday [DATE] from the facility stating R1 had stated she wanted to be Full Code. FM-B stated R1 had been DNR since [DATE] per her wishes on her advance directive that had been provided to the facility. FM-B stated it had also been discussed when R1 was in the hospital and starting on hospice.During an interview on [DATE] at 11:00 a.m., director of social services (DSS) stated it was a collaboration between social services and nursing to ensure hospice care plans and facility information match. DSS stated information that was sent from hospice was reviewed by nursing and social services. During an interview on [DATE] at 1:40 p.m. LPN-A stated coordination with medical providers was done via phone, in-person, and through messaging on the portal system (online communication system). LPN-A reviewed the provider portal system and verified a POLST indicating DNR for R1 was uploaded in the provider system on [DATE] and signed as sister gave verbal consent over the phone. A message was left for the facility medical director on [DATE] at 12:19 p.m. with no return call.The IJ was removed on [DATE] after a removal plan was implemented; however, non-compliance remained at an isolated scope with potential for more than minimal harm that is not immediate jeopardy (Level D). The facility implemented the following actions:R1's code status was verified, a new POLST was signed, and any inconsistencies within the EMR, including the POLST, physician orders, EMR banner, and care plan were corrected. R1's status was communicated to staff. A full house audit of resident code statuses was conducted which identified three residents whose POLST was not signed by a provider, and one resident's POA was contacted to update their status. These records were uploaded and/or corrected as needed to be consistent with resident wishes throughout the medical record. The facility CPR/Code Status and Advance Directives policies were updated to expand verification requirements for code status at admission, readmission, significant change in condition, hospice involvement and any resident directed updates. In addition, a policy was created specifically for POLST documentation and procedures. A hospice Communication Protocol was created to ensure code status communication between agency and facility. Education was provided to all licensed staff and hospice partners regarding the POLST process, and any who were unavailable will be educated prior to their next shift. This training has also been added to orientation for new staff. The facility will continue to conduct audits to ensure all code status/POLST documentation accurately reflects residents' current wishes. A facility policy titled POLST Policy and Procedures, dated [DATE], indicated POLST orders must be verified and reviewed under the following conditions: admission and readmission, signification change in condition, initiation or changes in hospice care, whenever resident updates treatment preferences and during quarterly interdisciplinary care conferences. Furthermore, nursing leadership is responsible for reconciling POLST documentation across all systems and upon receipt of updated POLST information, nursing leadership must promptly update the EMR< physician orders and care plan to ensure full alignment. In additions, documentation of all updates, communications and reconciliations must be maintained in the EMR.

During observation, interview, and record review the facility failed to identify, implement, monitor and modify interventions to provide timely treatment and services to heal and to prevent further worsening of wounds. This failure resulted in harm for R254 when his bilateral heel pressure ulcers were not identified and addressed by facility until they progressed to stage three.Findings include:According to the national pressure injury advisory panel (NPIAP), pressure injury is defined as localized damage to the skin and underlying soft tissue usually over a bony prominence. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. In addition, the evolution of a deep tissue pressure injury (DTI) develops from an exerted pressure about 48 hours before visible signs of purple or maroon skin. Then, about 24 hours later, the epidermis (layer of skin) lifts and reveals a dark wound bed. A stage three pressure ulcer/injury is defined as a full thickness loss of skin.R254's admissions Minimum Data Set (MDS) dated [DATE], and quarterly MDS dated [DATE], identified risk for developing pressure ulcers, had no pressure ulcers, no unhealed pressure ulcers, no unstageable pressure ulcer/injuries, and no deep tissue injuries. In addition, R254 had intact cognition, no impairment of upper and lower extremities, and was independent with self-care and mobility. R254's significant change in status (SCSA) MDS dated [DATE], identified two stage three pressure ulcers, with none of them present upon his admission to facility. In addition, R254 had severe cognitive impairment and was dependent on staff for toileting, bathing, personal hygiene. Also, R254 required assistance with mobility including sit to lying and lying to sitting on side of the bed.R254's admission MDS care area assessments (CAA) dated [DATE], identified Potential risk factors for pressure ulcers. Section of form to identify Supporting Documentation. Provide the basis/reason for items being checked, including the location & date & source was left blank. R254's CAA for the [DATE], SCSA MDS identified Actual problem for Pressure Ulcer/Injury and, Skin breakdown with risk for further breakdown and impaired healing related to terminal condition. The Care Plan Considerations identified current pressure ulcer would be addressed in the care plan with overall objective to Slow or minimize decline.R254's medical diagnoses include diabetes, rheumatoid arthritis, depression, hypertension, and congestive heart failure (CHF).The Braden Scale for Predicting Pressure Ulcer Risk is an evidence-based assessment tool in health care used for predicting a patients' risk of developing pressure ulcers. It allows health care professional to implement preventive measures effectively. Scores of less than 9 indicate Severe Risk, scores of 10-12 indicate High Risk, scores of 13-14 indicate Moderate Risk, and scores of 15-18 indicate a Mild Risk.R254's Braden assessment scores (scale to assess patients' risk of developing pressure injuries) were:[DATE] score of 18,[DATE] score of 15,[DATE] score of 15,[DATE] score of 17,[DATE] score of 15, and[DATE] score of 16.R254's care plan with focus on Skin identified resident have actual wounds to both heels and potential for impairment to skin integrity fragile skin. Date initiated was [DATE]. CP Interventions identified Reposition Frequently and Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations was initiated [DATE]-four days before R254 expired.R254's provider progress notes (PN) dated [DATE], [DATE], [DATE], [DATE], [DATE] identified No rash, or lesions under Examination section of form. Provider PN dated [DATE] identified, No breakdown in hands or heels and to monitor for acute skin care breakdown.R254's hospital discharge summary (DC) dated [DATE], identified hospitalization from [DATE] to [DATE] for urinary retention and urinary tract infection. DC summary identified, no rashes, ulcerations on exposed skin surfaces. Upon admission to hospital R254 had bruising to coccyx which was identified [DATE], with no other skin issues identified.During review of PN dated [DATE] identified R254 readmitted to facility from hospitalization. PN failed to indicate any assessment or issues with skin integrity. PN dated [DATE] at 5:23 p.m., identified R254 felt like[sic] had an [sic] heart attack, and would like to go to the hospital for checkup. Orders were received to send to hospital. PN dated [DATE] at 11:07 p.m., stated R254 returned from hospital at 3:15 p.m. and failed to indicate any assessment or issues with skin integrity.R254's hospital DC summary dated [DATE], identified R254 hospitalized [DATE] to [DATE] for report of chest pain. During hospitalization on [DATE] a Pressure Injury: Suspected Deep Tissue Injury to left and right heels were first observed on [DATE] at 10:58 p.m., and both wounds were identified has being present Prior to Admission.R254's weekly bath audits (BA) dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], identified, no new alterations in skin. [NAME] were marked as, weekly wound assessment initiated and completed. R254's podiatry consultation noted dated [DATE], identified ulcer heels and monitor pressure.R254 was admitted to hospice services on [DATE], with terminal diagnosis of congestive heart failure. R254's hospice admission note identified, bilateral stage 3 pressure injuries on heels.R254's provider orders (PO) dated [DATE], initiated PO for left and right heel ulcers. The PO for left heel identified, left Heel wound order: cleanse with vashe (wound cleanser), skin prep to area, santyl (topical medication used to clean and remove dead tissue) to wound bed and apply mepilex (a foam dressing) to area, change daily. PO for right heel identified, Right heel wound orders: cleanse with vashe, paint heel with betadine, cover with gauze 4x4 and wrap with kerlix, change daily.During review of R254's EMR, the documentation of R254's left and right heel ulcers by infection control preventionist and facility wound nurse (IP) began on [DATE] by using the Skin and Wound Evaluation assessments. Measurements of wounds include:Left heel:[DATE]: 1.5 centimeters (cm) long x 1.7 cm wide x 1.2cm deep. Indicated this was a New, Stage 3 Full-Thickness skin loss and In House Acquired. Notation of, This is a new wound.Right heel:[DATE]: 5.5cm x 3.6cm x 2.2cm. Indicated this was a New, Stage 3 Full-Thickness skin loss and In House Acquired. R254's provider PN dated [DATE], identified Chief Complaint: f/u wound rounds. PN stated pressure ulcers of left and right heel were unstageable.Left heel measurements were:[DATE]: 1.73 cm x 1.27 cm,[DATE]: 2.2cm x 1.3 cm,[DATE]: 2.8cm x 2.6cm,[DATE]: 3.5 cm x 4.4cm.Right heel measurements were:[DATE]: 4.47cm x 3.0cm,[DATE]: 4.7cm x 6.6cm,[DATE]: 4.0cm x 6.2 cm.During review of R254's Skin and Wound Evaluation assessment for [DATE], the left heel wound measurements were 2.1cm x 2.3cm x 1.2cm deep and the right heel measurements were 8.7cm x 4.4cm x 2.7cm deep.During interview with wound care provider (WP) on [DATE] at 8:15 a.m., WP stated facility wide wound care rounds were performed with infection control preventionist (IP) twice per week. WP stated IP developed a list of residents who needed to be seen each time. WP stated facility nurses will tell [IP] of new wounds and IP assessed and obtained new wound care orders. IP then added these residents to his bi-weekly wound care rounds for monitoring and managing of wounds.During interview with director of nursing (DON) on [DATE] at 7:37 a.m., DON stated she was familiar with R254 because DON was the nurse manager on the unit where R254 lived on during the entire time of his facility stay. DON reviewed [DATE] hospital DC summary and agreed the documentation identified bilateral heel DTI's. DON reviewed R254's electronic medical record (EMR) and stated she was unable to determine if R254's DTIs were identified at the facility prior to R254's hospitalization on [DATE]. DON stated expectation of staff members who identify impaired skin issues to report ASAP to nurse, the nurse should assess and update the provider and document [sic] it in progress note. DON stated, first note of impaired skin issues with R254 was on [DATE], with the PO for wound care orders to both heels. DON stated R254's CP should have been updated and was not. DON stated first indication of wound care for R254 was placed in CP on [DATE], but not acted on until [DATE], when the IP obtained the PO. DON stated importance of identifying and acting on impaired skin integrity is to ensure appropriate interventions are initiated immediately. DON stated she was unable to determine when R254's DTIs occurred by looking at his EMR.During interview with LPN-B on [DATE] at 11:46 p.m., LPN-B stated expectation of staff to assess and check [residents] skin upon hospital return including feet and coccyx. LPN-B stated any new or developing skin issues should be addressed right away and provider should be contacted, orders received and notify the IP. In addition, a PN should be put in the EMR. LPN-B stated expectation of all skin to be checked weekly with the bath and documented in the weekly bath audit.During interview with LPN-A on [DATE] at 11:57 a.m., LPN-A stated expectation of staff to assess and check skin and to document in the EMR under the PN about skin condition. If there was a new skin injury, then staff were expected to chart it and notify the wound team. LPN-A stated CP interventions for skin care were changed and updated by the IP when they review [the wounds].During interview with LPN-B on [DATE] at 12:53 p.m., LPN-B stated a body audit should be done for all [residents] readmitting to facility. LPN-B reviewed R254's EMR and stated, no there is nothing there. LPN-B stated she remembered R254 during his facility stay and stated I remember seeing them [bilateral pressure ulcers to heels] two months before [R254] passed. Me and [IP] were doing something for [R254] and noticed it while changing his socks. I remember seeing it for the first time saying, ‘oh my God'. I did not document anything. That is [IP]'s job. IP is the wound nurse and should have done it, and continued, No, I do not see it was done.During interview with medical director (MD) on [DATE] at 8:58 a.m., MD reviewed R254's EMR and physician notes and stated, I expect the facility to have assessed [R254's] heels prior to [sic] admission to the hospital in October [[DATE]]. MD stated R254's EMR lacked orders, progress notes, and other documentation to support identifying R254's bilateral heel PU's until they progressed to stage three. MD stated, [it was] most likely avoidable.During interview with IP on [DATE] at 8:28 a.m., IP stated he was familiar with R254 during his facility stay. IP reviewed R254's EMR and stated, [[DATE]] is when we first identified [R254's] heel ulcers. IP stated he did not obtain PO for R254 until [DATE], and IP failed to document in the PN. IP stated expectation of staff to notify me ASAP when there is a new or worsening skin issue, then, I will assess and get orders from the [provider] and put the resident on ‘weekly wound rounds'. IP stated, we missed it and should have taken steps earlier to address [R254's] wound to his heels. IP reviewed R254's hospital DC summary dated [DATE], and stated, it shows there was identified DTI's to both heels at the time. We [Facility] did not identify any concerns until [DATE]. IP stated R254's bilateral heel wounds, should have been addressed by us before [DATE] [when R254] was admitted to the hospital. IP stated wound care rounds involve IP putting names on paper for people who I look at for wound rounds and then do the rounds with the provider and document in the EMR. IP stated the Braden documentation was used by the facility to determine pressure injury risk.During interview with hospice vice president of clinical operations (VP)-M on [DATE] at 11:23 a.m., VP-M reviewed R254's admission paperwork to hospice services on [DATE] and stated R254 had two wounds on admission. Stage three right and left heel pressure ulcers.During interview with IP on [DATE] at 11:44 a.m., IP stated expectation of the nurse at facility to perform a skin integrity assessment every time a patient came back from hospital and write a PN in the EMR. IP reviewed R254's EMR and stated it failed to show a skin assessment was done and PN failed to identify any issues with skin integrity when R254 returned to the facility on [DATE]. During interview with regional director (RD), administrator, and DON on [DATE] at 12:11 p.m., RD stated R254 could have gotten it [DTI's] from the hospital or transport. Also, RD stated, [facility] identified our documentation was not up to par and that R254 had a history of refusing care despite no interventions to address any refusals.During interview and review of IP Wound Rounds notes (WRN) dated [DATE] to [DATE], and [DATE] to [DATE], with IP on [DATE] at 11:44 a.m., IP stated he was unable to find the WRN's for dates between [DATE] to [DATE]. WRN for [DATE] identified a listing titled Pressure Ulcer with three resident names including R254 and no other information. IP reviewed his notes and EMR and was unable to determine rationale for listing R254 with PU on [DATE]. WRN for [DATE] identified R254 being seen for Rash-Ointment to be ordered. WRN dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] identified R254 as being seen.During interview with hospice team leader (H)-TL on [DATE] at 9:48 a.m., H-TL identified R254's hospice nurse manager no longer works for facility and reviewed R254's hospice admission paperwork. H-TL stated R254 had two stage three PU's to his heels on admission to hospice services on [DATE] and stated, facilities can just ‘let them go' and not do a good job of preventing or lessening the progression of pressure ulcers in residents who are on hospice. HT-L confirmed R254 passed away at the facility on [DATE].Facility policy titled Prevention of Pressure Injuries, revised [DATE] identified Inspect the skin on a daily basis and Inspect pressure pointes (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.). Facility policy titled Pressure Injury Risk Assessment, revised [DATE] identified purpose to provide guidelines for the structured assessment and identification of residents at risk of developing new pressure injuries or worsening of existing pressure injuries (PIs).

Based on interview and document review the facility failed to ensure admission orders on 1/8/25 for a diuretic (medicine that increases urine production and help lower blood pressure and fluid retention) were clarified and followed up for R1. As a result, R1 did not receive diuretic for sixteen days. This resulted in a significant medication error and actual harm when R1 was hospitalized for congestive heart failure (CHF) exacerbation. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE] identified R1 admitted to facility from hospital on 1/8/25, had intact cognition, required substantial assistance for toileting and personal hygiene, and did not reject care. In addition, R1 had medical diagnoses of congestive heart failure, atrial fibrillation (irregular heart rhythm), arthritis, and a history of a left femur fracture. Also, R1 taking diuretics. R1's hospital discharge orders to facility dated 1/8/25 identified medication order of Furosemide (diuretic) 40 MG tablet For: Cardiac Failure, High Blood Pressure. Commonly know as: LASIX Take 1 Tablet (40 mg) by mouth two times a day. 1 tab daily, extra tab as directed by cardiology. R1 nursing progress note (PN) from licensed practical nurse (LPN)-C dated 1/8/25 at 7:51 p.m., stated, [R1] arrived at facility around 3:10 p.m. R1's nursing PN from LPN-C dated 1/9/25 at 12:00, Late Entry: Note Text: Writer called [hospital] for clarification on resident's Lasix order from discharge. Writer spoke with the HUC (health unit coordinator) on the unit who stated that nursing staff was busy and was unable to come to the phone. The HUC said a nurse would return the call when they have time. Writer updated oncoming PM staff. Review of R1's PN from 1/9/25 to 1/23/25 indicated no mention of follow up regarding Lasix order. R1's provider order dated 1/23/25 at 5:53 p.m., identified order for lasix to 40 mg po BID scheduled (AM and 2pm daily. Diagnosis associated with order state, Acute on chronic systolic (congestive) heart failure. Review of R1's January 2025 medication administration treatment administration record (MARTAR) identified Lasix was not ordered for R1 until 1/24/25 at 2:00 p.m., indicating R1 did not receive Lasix for sixteen days. R1's January MAR/TAR Chart Codes indicated R1 was coded as a 6 starting on the January 24, 2025, evening time slot which correlated with 6=hospitalized . R1's PN from LPN-D dated 1/24/25 at 3:15 a.m., R1 was sent to the hospital for decreasing oxygen saturations and wheezing noted to left upper lobe of lung. R1's hospital admission progress note dated 1/24/25 stated R1 was brought in today due to complaint of SOB (shortness of breath) and dyspnea on exertion with orthopnea (exertion) Oxygen saturation was reported as low in the 80's at the facility, but, up to the 90's on arrival of EMS and also here in the hospital. According to transfer records, patient was not taking Lasix at TCU due to some confusion about her medication orders. R1's hospital discharge summary dated 2/10/25 stated R1 was hospitalized . R1 hospitalized from 1/24/25 to 2/10/25 due to CHF exacerbation. During interview with LPN-C on 2/11/25 at 9:31 a.m., LPN-C stated, I was the one who admitted [R1] that day. [LPN-A] put orders in. She told me to double check them. I called hospital to clarify [Lasix order] on the 9th. I think I asked overnight to follow up. I asked to speak to the nurse at the hospital and the HUC said [nurse] was busy. I never got a call back. LPN-C stated the follow up got lost in the queues. It was a big thing. [R1's] missed doses. Because she has CHF (congestive heart failure). The way we do orders is not good. We really don't know who is doing what and things get missed. Things like this should not happen. During interview with LPN-B on 2/11/25 at 9:29 a.m., LPN-B stated, expectation for orders is we go through the information. Put the orders in and another nurse is to double check to make sure nothing gets missed. During interview with R1 on 2/11/25 at 9:45 a.m., R1 stated, No, I don't think I got that pill. I take it to keep me from filling up with fluid. Got short of breath and tired. Couldn't catch my breath. They had to send me back to the hospital for it. During interview with administrator on 2/11/25 at 10:10 a.m., the administrator stated, it is fair to say that the orders were not clarified and double checked. It was missed and should not have been. Fair to say [R1] went from the [January] 8th to the 24th when she was admitted to the hospital without having the medication and should have. We are looking into the process of double checking the orders. Need to work on that. During interview with nurse practitioner (NA)-A on 2/11/25 at 10:37 a.m., NP-A stated, [R1] was supposed to be taking [furosemide] from the hospital. NP-A stated R1 takes it because of heart failure. It looks like on 1/23/25 [facility] reached out to us. Wanted a range. NP-A stated, missing a dose or multiple doses[sic] it is a concern because it could increase the fluid overload and cause heart failure exacerbation. NP-A stated the facility was in charge of putting in orders from the hospital and, it was not in. Lasix was not [clarified] or put in. NP-A stated, This is a major medication error and I have major concerns on medication orders not being followed up and double checked at that facility. During interview with LPN-A on 2/11/25 at 11:25 a.m., LPN-A stated she had been in unit manager role of 3rd floor for a year and half. LPN-A stated, the call was put out to the hospital to clarify [Lasix] order. The nurse was busy and never called back here. LPN-A stated expectation of staff is to notify her if there is no response from the hospital. I was not aware or notified to follow up. LPN-A stated On the 24th [January] someone came to me or maybe in report [R1] was having problems breathing. And that is how I was made aware. LPN-A stated the process for putting in orders and clarifying and following up with orders is the responsibility of either me or the admitting nurse. LPN-A stated, concern for missed doses because [R1] has CHF. That is the last thing we want is for her to go back to the hospital. During interview with facility's medical director (MD) on 2/12/25 at 12:00 p.m., MD stated, [facility] messed up with [R1] orders. And the staff are accountable. They have had issues with orders and faxes. Turnover there is also high. We start new policies and procedures and then there is turnover and we have to start over. It is frustrating for the provider to practice like that and the staff too. It is a vicious cycle. MD stated R1 did not receive Lasix for 16 days prior to being readmitted to the hospital for CHF exacerbation. During interview with LPN-D on 2/12/25 at 6:49 a.m., LPN-D stated she was the nurse that sent R1 to the hospital on 1/24/25. LPN-D stated, for my first visual check with [R1] around midnight her vitals signs and oxygenation were fine, and then on my second time 2-3 hours later I checked [R1] again and the O2 sat was low. So I did the vital signs again and it was still low, Like 80% on room air. I asked staff to help me sit [R1] up and they helped me. It was [still] low and I had to put [R1} on 4 liters of oxygen nasal cannula. Her lungs were not clear. I have a son with asthma and know that [R1] lungs were definitely not clear. LPN-D stated she contacted the provider on-call and they gave me orders to send [R1] in to the ER. LPN-D stated she was familiar with R1 so I knew her baseline. LPN-D stated, the process for obtaining orders was, whoever obtains the order they put it in the computer. It is not acted on yet until a second nurse verifies the order. LPN-D reviewed R1's EMR and verified the Lasix order was never entered on admission to the facility on [DATE]. During interview with R1 on 2/12/25 at 7:03 a.m., R1 stated, I am feeling better since I got back [to facility]. I knew what meds I was supposed to be taking when I was first admitted . I was taking the water pill [Lasix] at home. Been taking it for years. But it wasn't given to me right when I was admitted . That is why I had to go back [to the hospital]. Should never ever have happened. Facility policy titled Medication and Treatment Orders revised July 2016, state Orders for medications and treatments will be consistent with principles of safe and effective order writing.

Based on interview and document review, the facility failed to provide adequate supervision while out of the facility at an appointment for 1 of 3 residents (R1). This deficient practice resulted in an immediate jeopardy (IJ) for R1 when R1 went to an appointment without supervision and the facility did not know his whereabouts until 20 hours after he left. The immediate jeopardy began on 7/24/24 when the facility sent R1 to an appointment without supervision, R1 did not come back to the facility, and the facility did not know his whereabouts until 20 hours after he left. The director of nursing (DON) and administrator were notified of the immediate jeopardy at 12:15 p.m. on 8/2/24. The IJ was removed on 8/6/24, but noncompliance remained at the lower scope and severity level of D - isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's Diagnoses List dated 1/25/24 indicated R1 had dementia and type 2 diabetes. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 used a wheelchair as his primary mode of locomtion, transferred with supervision and did not ambulate. R1's care plan dated 6/6/24 indicated R1 had impaired cognition related to his dementia diagnosis. R1's Provider Orders dated 7/19/24 indicated R1 had a dental appointment on 7/24/24. R1's family member (FM)-A would be escorting R1 to the appointment with a transport company pick up time of 1:30 p.m. - 2:00 p.m. On 7/31/24 at 10:42 a.m., FM-A stated she had attempted to call the facility about 1:00 p.m. to inform them she was unable to escort R1 to the appointment, but no one answered the phone. In the past, when she had not arrived at the facility to escort R1, a staff member had called her to determine what was happening. She did not receive a call on 7/24/24, so she assumed the facility either had someone to send with R1, or they had rescheduled the appointment as had occurred previously. In the past, when R1's appointment was completed, she would call the facility so they could arrange for the transport company to pick them up from the appointment. The first phone call FM-A received on 7/24/24 was a call from a nurse about 10:00 p.m. to inform her R1 had not returned from his appointment. On 7/31/24 at 12:38 p.m. registered nurse (RN)-A stated family or a staff person needed to escort R1 to appointments. R1's order for the appointment on 7/24/24 indicated FM-A would be escorting R1. RN-A handed R1's appointment envelope to licensed practical nurse (LPN)-B when he assisted with taking R1 downstairs to the transportation pick-up area. On 7/31/24 at 11:12 a.m., transport company (TC)-A representative stated there was no note in their file indicating someone would be riding with R1 to the appointment. In the past, there had been an indication either family or a staff member would be riding with a resident. The pick-up driver did not receive an envelope from the facility. When he arrived at the appropriate address, he assisted R1 to the front desk of the building and requested information at the desk as to where in the building R1's appointment was. The driver assisted R1 to the correct office and was told the appointment would take about an hour. This information was placed in R1's notes with the transport company. A driver in the area about 75 minutes later stopped to see if R1 was ready to return to the facility because there had been no phone call for a return pick up. The pick-up driver was told that R1 had left the clinic approximately 45 minutes earlier. The driver searched the front area of the building and the surrounding outside area for R1, but did not see him. A call was placed to the facility around 3:45 p.m.- 4:00 p.m. to notify them R1 was not at the clinic but no one answered the phone. On 7/31/24 at 1:09 p.m., health unit coordinator (HUC)-A stated FM-A would be riding with R1 to his appointment, and she entered this information in R1's electronic health record (EHR) and wrote this on R1's appointment envelope. The envelope was placed in the appropriate area of the nurse's desk to send with R1. If FM-A was available, she would always ride with R1 in the transport vehicle. Around 6:00 p.m. she was notified by LPN-A R1 had not returned from his appointment. She called the transport company, but they were closed. She relayed this information to LPN-A. She did not notify anyone else because the LPN-A was handling the situation. On 7/31/24 at 2:12 p.m., LPN-B stated he brought R1 down the elevator to the transportation pick up area where R1 was placed in the transportation vehicle without an escort. LPN-B did not remember if R1 had his appointment envelope. He did not know FM-A was escorting R1 to the appointment. On 7/31/24 at 2:53 p.m., nursing assistant (NA)-A stated she first noticed R1 missing at 3:30 p.m. She notified LPN-A who suggested R1 might be at an activity. Later, NA-A was delivering trays for supper and R1 was not in his room. She told LPN-A who stated R1 was at an appointment with his niece. A search for R1 was not completed until residents were being assisted to bed. NA-A stated R1 did not self-propel forward in his wheelchair very quickly and would have struggled getting around by himself. On 7/31/24 at 3:45 p.m., RN-B stated at approximately 11:00 p.m. on 7/24/24 she received a call from LPN-A who stated R1 had not returned from his appointment. She added the director of nursing (DON) to the call. When she arrived at the facility the next morning between 7:30 a.m. to 8:00 a.m. R1 was still missing. She called the local hospitals and the dental clinic but R1 was not at any of those locations. A team meeting was held approximately 8:00 a.m. to assign search areas. At approximately 10:00 a.m. she found R1 approximately 5 miles from the dental office. R1 was sent to the emergency room , and then back to the facility with no injuries. On 7/31/24 at 4:15 p.m., LPN-A stated she thought R1 was at an appointment with FM-A. She noticed R1 was not in his room before supper when she went to check his blood sugar. She asked HUC-A to see when R1 was returning. HUC-A told LPN-A she tried calling the transport company, but they were closed. She called FM-A who said she had not accompanied R1 to the appointment. LPN-A could not remember what time FM-A was called. She then called RN-B and DON who instructed staff to search the building. On 8/1/24 at 1:27 p.m., R1 confirmed he went to a dental appointment last week. After the appointment, he took the bus to the Salvation Army. R1 was unable to provide more details about the incident. On 8/1/2024 at 2:36 p.m., DON stated she received a call from RN-B and LPN-A at 11:22 p.m. on 7/24/24. She was told R1 had not returned from his dental appointment. She instructed staff to search the entire building. R1 was not found during this search. At approximately 11:45 p.m., DON instructed LPN-A to call all of R1's family members while she called the police to report R1 missing. The officer took the report, then stated he would go looking for R1. The DON went and searched the area around the dental clinic. R1 was not found. She went to the facility, then went home approximately 3:30 a.m. She returned to the building about 8:00 a.m. on 7/25/24. A team meeting was held to formulate a plan. Staff members went out in teams of two to look for R1. Approximately 10:00 a.m. she received a call from RN-B that R1 had been located approximately 5 miles from the dental clinic. She stated staff should have known R1 needed an escort to the appointment, and should not have allowed transport to take him. Staff also should have informed her when R1 could not be found around supper time. The facility policy Safety and Supervision of Residents dated 7/17 directed an individualized, resident-centered approach to safety and accident hazards. Resident supervision is determined by the resident's assessed needs. The immediate jeopardy that began on 7/24/24, was removed on 8/6/24 when the facility reviewed and revised their current policy, and created new policies on the safety and supervision of residents with appointments with staff or family supervision, and missing persons. The facility implemented a new system for resident appointment, and provided information to all transportation companies utilized about new facility process for resident escorts. The facility completed audits on all residents to determine if they needed an escort to appointments. The facility educated staff on these policies and procedures. This was verified through observation, interview and document review.

Based on interview and document review, the facility failed to ensure safe transfers with a full body mechanical lift resulting in a left femur fracture for 1 of 3 residents (R1) reviewed for accidents. The facility failed to complete a comprehensive sling assessment and use appropriate slings for the mechanical lifts per manufacture instructions. The immediate jeopardy (IJ) began on 4/2/24 when two nursing assistants used a Lumex brand full body sling with a Joerns Hoyer brand mechanical lift resulting in a fall with fracture for R1. The administrator and director of nursing (DON) were notified of the IJ on 4/9/24 at 5:00 p.m. The IJ was removed on 4/12/24 at 1:00 p.m. but noncompliance remained at the lower scope and severity of a level D isolated, which indicated no actual harm with potential for more than minimal harm that was not immediate jeopardy. R1's Diagnoses List undated indicated diagnoses which included metabolic encephalopathy (chemical imbalance in the blood which causes changes in the brain) and Alzheimer's Disease. R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1 rarely/never understands or is understood, and was dependent on staff for all transfers. R1's care plan dated 2/27/24 indicated she required total assist of two staff using the Hoyer lift for all transfers. The care plan lacked indication of what size sling was to be used or which brand sling to use with which mechanical lift. On 4/2/24 at 9:30 a.m. a progress note indicated during transfer with a Joerns Hoyer lift (mechanical lift), one of the straps from the Lumex brand sling disconnected from the machine. Two staff members lowered R1 to the floor. On 4/3/24 at 1:00 p.m. a progress note indicated R1's left knee was swollen and warm to the touch. R1 had facial grimacing and was moaning and groaning. An order was obtained for an x-ray. On 4/4/24 at 11:03 a.m. a progress note indicated x-ray results indicated R1 had a femur fracture. R1 was transported to the hospital. On 4/8/24 at 2:07 p.m., nursing assistant (NA)-A stated she and NA-B connected R1 (who was in bed) to the mechanical lift, verified placement of the sling loops on the mechanical lift, and pulled the mechanical lift legs out from underneath the bed in order to transfer R1 to the chair. As they were transferring R1 in the mechanical lift, the area of the lift where the sling was hooked tilted, and the top loop of the sling slipped off the hook of the mechanical lift. NA-A observed the sling was no longer securing R1's right shoulder. She supported R1's upper body while NA-B supported R1's head, and they used the mechanical lift to lower R1 to the floor. As R1 was going down to the floor, her left foot bent, and somehow became tucked underneath her body while they lowered her to the floor. The sling size was not listed in the care plan or on the paper nursing assistant care guides. NA-A stated they (NAs) could choose the sling size by looking at a resident's body type. On 4/8/24 at 2:48 p.m., LPN-A stated staff know which sling to use by looking at a resident's body. She did not know if slings could be used with different brands of mechanical lifts. A sling sizing guide was requested but was not provided. On 4/8/24 at 3:24 p.m., NA-C stated if a resident did not have a sling in their room, the nursing assistant could look at the resident's body size and pick the size sling which would fit. On 4/8/24 at 3:37 p.m., NA-D stated sling size was not documented on the nursing assistant care sheets. If a nursing assistant was unfamiliar with a resident and needed a new sling, the nursing assistant would need to talk to another nursing assistant who knew the resident better to obtain sling size. On 4/9/24 NA-B stated she and NA-A connected R1 to the Hoyer brand mechanical lift using a black sling (Lumex brand) with a green strap which indicated size large, verified placement of the sling loops on the mechanical lift, and pulled the mechanical lift out from underneath the bed in order to transfer R1 to the chair. As they were transferring R1 in the mechanical lift, the area of the lift where the sling was hooked tilted, and the top loop of the sling slipped off the hook of the mechanical lift. NA-A observed the sling was no longer securing R1's right shoulder. She supported R1's head, and NA-A supported R1's upper body while they used the mechanical lift to lower R1 to the floor. As R1 was going down to the floor, her left foot bent, and became tucked underneath her body. NA-B stated the sling size was not listed on the paper nursing assistant care guides. On 4/9/24 at 10:30 a.m., RN-A stated sling size was determined by the resident's weight, and NAs were able to determine which sling size to use with that information. A Joerns Hoyer full mechanical lift was observed with RN-A, who confirmed there was no indication on the lift for the weight ranges for slings. RN-A confirmed there were no weight ranges indicated with the sling sizes on the sticker or any where else on the mechanical lift. On 4/9/24 at 12:19 p.m., a customer service representative from Lumex stated Lumex slings were designed for use with Lumex brand mechanical lifts. Safety could not be assured if the Lumex slings were utilized with a different brand of mechanical lift. On 4/9/24 at 1:11 p.m., a blue Medline sling was observed in a resident wheelchair. NA-E confirmed the size XXL Medline brand sling was used with the Joerns Hoyer lift to transfer the resident from the wheelchair to the bed. NA-E also confirmed the brand of the other mechanical lift on the floor could be utilized for transfers was a Proactive brand lift. On 4/9/24 at 1:43 p.m., the DON stated the facility utilized four different brands of mechanical lifts: Hoyer, Invacare, Best Care and Proactive. The sling brand and mechanical lift brand should be the same. Hoyer brand slings were ordered and received, but had not been placed into use yet. Invacare slings had been ordered, but not received. Bestcare and Proactive slings had not been ordered. She could not guarantee a resident's sling size was documented for staff to access. The nurse managers should be selecting sling size for a resident. Manufacture's recommendations for Joerns Hoyer mechanical lift included: DO NOT use a sling unless it is recommended for use with the lift. Using other manufacturer's products on Hoyer products is potentially unsafe and could result in serious injury to patient and/or caregiver. The facility Lifting Machine, Using a Mechanical Lift policy undated directed staff to measure the resident for proper sling size and purpose, according to manufacturer's instructions. The immediate jeopardy that began on 4/2/24, was removed on 4/12/24, when the facility provided a full body sling that matched the brand of full body lift and completed a comprehensive sling assessment for each resident utilizing a full body lift for transfers and started education to all staff who perform transfers or assessments. Facility education completed on 4/8/24 included a video created by the Hoyer company. Included in this video is a warning to use only Hoyer Parts. Do not interchange other manufacturer parts. This was verified by observation, interview and document review on 4/12/24.

Based on observation, interview and document review, the facility failed to ensure resident's safety, by assessing each resident for the risk of substance abuse, and develop a care plan with interventions for each resident, who had been identified as at risk, with efforts to prevent overdose (OD), which would include increased monitoring and supervision, resulting in risk of potential serious harm, injury, impairment, or death to 2 of 3 residents (R1, R2) who were reviewed. The immediate jeopardy began on 8/19/23, when R2 overdosed, was hospitalized and the facility failed to assess, develop and implement care planning interventions to prevent overdose for R2. The administrator and interim director of nursing (DON) were notified of the immediate jeopardy on 10/27/23. The immediate jeopardy was removed on 10/30/23, but noncompliance remained at the lower scope and severity of a D, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's quarterly Minimal Data Set (MDS) dated [DATE], identified R1 had diagnoses which included opioid dependence, post-traumatic stress disorder, anxiety and had moderate cognitive impairment. R1 was independent with activities of daily living (ADLs) such as dressing, transferring, toileting or mobility. R1's physician orders dated 10/24/23, revealed R1 had orders for antidepressant and antipsychotic medications. R1's care plan dated 10/24/23, lacked evidence of substance abuse history and interventions for efforts to prevent an overdose. R1's Emergency Department (ED) Note dated 12/5/22, revealed R1 was brought to the ED related to altered mental status. History of drug use was of suspicion for altered mental stated. R1 had endorsed she used heroin yesterday and was given 0.5 (milligram) mg of Narcan on her way to the ED by EMS. R1's record lacked evidence R1's substance use incident had been investigated and interventions were implemented in efforts to prevent future OD. R1's Behavioral Health Comprehensive assessment dated [DATE], indicated R1 had revealed personal triggers for substance use which included: son dying, trying to cope with the loss on her own, and physical pain. R1 had stated, I want to be clean again, but I don't want to be in pain. I don't' want to be depressed and I don't want to have anxiety either. R1 had reported beginning Methadone and seeing a psychologist would be helpful in making this change. Further, R1's reasons for drug use included: to cope with stress, to relieve physical pain, to cope with anxiety, to cope with depression, makes it easier to talk with people, to cope with family problems, and afraid of withdrawal symptoms/to feel better. R1's Regulatory Visit note dated 8/10/23, indicated R1 had a history of being found unresponsive and she had been discovered with a needle in her hand while using drugs. R1 exhibited drug seeking behavior and drug use as very common. Nursing reported episodes of, acting fun, like she is high on something. R1 had a a history of substance abuse and appears to be using drugs currently per call notes from nursing staff, R1 would refuse to be sent in and had instances where they have had to administer Narcan. R2's quarterly MDS dated [DATE], indicated R2 diagnoses included: opioid dependence with other opioid induced disorder, viral hepatitis C, anxiety disorder, and cognitively intact. R2 was independent with ADLs. R2's care plan dated 10/24/23, lacked evidence of substance abuse history and any interventions for efforts to prevent an overdose. R2's Physician Orders dated 4/21/23, revealed referral to chemical dependency for evaluation and treat related to substance abuse. However, R2's record lacked evidence a referral was made. Review of R2's progress notes indicated: -On 8/17/23 at 9:35 p.m., R2 was found unresponsive in another resident's room but had a pulse. Narcan 4 mg was administered and 911 was called. R2 became responsive after approximately 6 minutes. R2 declined going to the hospital upon police and paramedic's arrival. -On 8/19/23 at 8:22 p.m., R2 overdosed outside. Another resident came to alert nursing staff and had already called 911. R1 was taken by paramedics to the hospital. -On 8/20/23 at 1:30 a.m., R2 returned from the hospital. R2 reported pain on right shoulder rating 8/10 and R2 stated he suspects injury to his right collar bone during the OD incident. R2's record lacked evidence R1's overdose incident had been investigated and interventions were implemented in efforts to prevent future OD. R2's Progress Note from Associated Clinic of Psychology (ACP) dated 8/30/23, indicated R2 expressed he was doing better, and reflected on his overdose. R2 had admitted the incident was his 19th overdose. R2 reported he had been struggling with pain and depression. ACP treatment recommendations/plan included R2 had agreed to attend narcotics anonymous (NA) which social services agreed to follow up, and R2 agreed to try to detox to help getting into the methadone clinic for help with his pain and drug addiction. R2's Progress note from ACP dated 9/27/23, indicated R2 presented with a labile, depressed affect and mood. R2 expressed that he was struggling at this time and observed him to be under the influence. ACP consulted with social services after the session. ACP treatment recommendations/plan included R2 again agreed to NA and social services agree to follow up, and R2 again agreed to try to detox. In addition, ACP added bipolar disorder, current episode depressed severe with psychotic features and alcohol use disorder severe to R2's diagnoses. However, R2's record lacked evidence ACP recommendations were followed-up on regarding offering R2 NA meetings or detox options. R2's History and Physical note dated 8/30/23, indicated visit was warranted due to R2 being found unresponsive and Narcan administered. R2 had multiple emergency department hospitalization s in the month of August 2023 with most recent 8/19/23 to 8/20/23 for opiate overdose. On 10/24/23 at 1:58 p.m., nursing assistant (NA)-A stated R1 was observed to be high and would be slumped over all the way down in her wheelchair, and that is how we know. In addition, NA-A stated R2 was also suspected of substance abuse. On 10/24/23 at 4:57 p.m., R1 was observed in her room laying in bed with the lights off and appeared to be sleeping. R1 stated she was not feeling well and declined interview and requested not to be approached again. On 10/24/23 at 5:01 p.m., R2 was observed in his room laying in his bed with the lights off and appeared to be sleeping. R2 stated he was not feeling well and declined to be interviewed. On 10/25/23 at 10:21 a.m., licensed practical nurse (LPN)-B stated R1 does illegal drugs but was unsure what type of drug, adding staff have caught her with needles and passed out. Further, LPN-B stated R1 uses so many drugs we will find her slumped over in her wheelchair and LPN-B added she assumed R1 was using methamphetamine. LPN-B indicated R2 would report to the nurse and say, I took some stuff and I don't want to die and R2 had reported he had taken Fentanyl. LPN-B stated R2 had overdosed due to substance abuse and staff had sent him to the ER a lot. Further, LPN-B stated when a resident was suspected of substance abuse staff are expected to call 911, update the physician, hold any medications, notify the director of nursing (DON), as well as assessing the resident and monitoring vital signs every 4 hours. On 10/25/23 at 10:43 a.m., registered nurse (RN)-A stated staff were made aware if a resident was determined to be at risk of substance abuse by referring to each resident's care plan. RN-A stated R1 had a history of using substances and had been suspected to actively use but was unsure what substance or where R1 would get her supply. Further, RN-A identified R2 was suspected of substance abuse but was unsure what substance or where R2 gets his supply. RN-A stated R2 had OD approximately a month ago and Narcan had to be administered. RN-A indicated she was unaware of interventions for efforts to prevent overdose for R1 or R2. In addition, RN-A stated staff were expected to notify the physician and get orders to hold medications and obtain vitals, complete hourly checks, and notify the DON if substance abuse was suspected. On 10/25/23 at 11:12 a.m., NA-B stated staff are made aware of substance abuse risk in each resident's care plan, however the resident's care plan does not always contain the information. NA-B stated she had observed R1, slumped over and maybe she was under the influence. On 10/25/23 at 1:13 p.m. LPN-A stated upon admission each resident's medical record was reviewed and would reveal if a resident had a history of substance abuse. LPN-A stated she would be responsible for initiating substance abuse risk in the resident's care plan when identified but was unaware of who would be responsible for developing and/or implementing interventions related to substance abuse. Further, LPN-A stated staff were expected to obtain vital signs every shift, monitor the resident as best they will allow, and visually see the resident every couple hour, when a resident was suspected of substance abuse. LPN-A stated OD incidents were discussed in IDT meetings but was unaware of R1 and R2's OD incidents. Further, LPN-A stated no staff had reported concerns of R1 or R2 using any substances or being under the influence and LPN-A was unaware of R1 and R2's history of substance abuse. In addition, LPN-A confirmed R1 and R2's care plans lacked evidence of risk of substance abuse and interventions or efforts to prevent future OD. On 10/25/23 at 3:15 p.m., DON stated currently there was no facility process to assess resident's and determine substance abuse risk. DON confirmed there are 8 residents residing in the facility who have been suspected of substance abuse and are at risk for OD, which included R1 and R2. DON stated nurse managers would be expected to update resident's care plans to include risk of substance abuse and interventions. Further, DON stated if staff expected substance abuse the provider would need to be updated, obtain orders to hold medications, monitor vital signs every shift, and visual contact every 1-2 hours. DON stated following an OD incident, staff would be expected to complete an incident report in Risk Management and the incident would be discussed in IDT meeting to determine a plan going forward. DON confirmed for R1 and R2 that has not happened. DON also indicated social services and physicians were not very involved in substance abuse right now. On 10/27/23 at 10:52 a.m., DON was unaware of when or why R2 had stopped seeing ACP. DON stated R1 and R2 were both offered ACP services and declined following suspicision of illegal drug use incidents, however R1 and R2's records lack evidence of when R1 and R2 were offered or refusals and stated usually the record will have a note from staff or from ACP. Further, DON confirmed R2 had an order for referral to chemical dependency treatment, however this order was not completed. On 10/27/23 at 11:08 a.m., social service designee (SSD) stated she was not involved with interventions for residents with substance use disorders, and this would be a nursing function. Further, SSD confirmed she was aware R1 had a history of illegal substance use, adding she believed R2's drug of choice was Heroin and was aware of R2's illegal substance use which was Fentanyl pills. SSD confirmed both R1 and R2 had OD and required Narcan to be administered while receiving services at the facility. In addition, SSD stated OD incidents were discussed with the IDT, but efforts to prevent future ODs were not discussed. SSD denied assisting neither R1 or R2 with any behavioral health services related to substance abuse disorders, treatment planning, safety related to overdose prevention, or therapies related to mental health disorders and/or loss and grief therapy and groups. On 10/27/23 at 11:55 a.m., nurse practitioner (NP)-A indicated R1 had a history of substance abuse and was actively using. NP-A stated she was aware R1 required Narcan to be administered for an OD, and NP-A had observed R1 not being able to hold a conversation during an assessment she was attempting to conduct with R1. NP-A also noted she had been made aware R1 had been observed by staff in August of 2023 to be unresponsive with a needle in her hand. NP-A confirmed she was aware R2 had a history of using illegal substances as well and was aware Narcan had to be administered for an OD. In addition, NP-A stated staff were expected to notify the physician when they suspect illegal drug use so the physician could provide orders to hold medications, and staff would be expected to monitor the individual frequently and obtain vitals per facility policy. NP-A stated the facility had psychiatry services and would be expected to make a referral for the individuals who have substance abuse disorders to ensure their mental health would be managed appropriately. On 10/27/23 at 12:26 p.m., administrator indicated R1 was admitted to the facility as an active drug user and ACP services were offered and declined as R1 denied having a drug problem. Administrator stated since admitting to the facility, R1 had to have Narcan administered on two separate occasions for a drug overdose. Administrator confirmed R2 was also actively using illegal substances and would go to the community to buy drugs and staff were all aware of this. In addition, administrator stated staff were aware which residents were using illegal substances and who were current users and staff were expected to keep an eye on the individual as they can but there was no specific protocol. Administrator stated ODs were discussed in morning meeting with the IDT, however IDT would not discuss efforts to prevent future ODs. At the time of survey, facility failed to provide evidence of a substance abuse policy or protocol. The immediate jeopardy that began on 8/19/23, was removed on 10/30/23, when the facility re-assessed R1 and R2 using the Drug Abuse Screening test, facility reached out to behavioral health services to review R1 and R2 current status, reviewed drug patterns, implemented 15-minute checks for 24 hours and vital sign checks every two hours for 24 hours for R1 and R2 if suspicion or witnessed use of illegal substances. and care plans had been updated as indicated. Facility policy and procedures were developed related to subtance abuse. Additionally, all staff were trained on new policy and procedure and revised care plans for R1 and R2.

Based on observation, interview, and document review, the facility failed to perform timely comprehensive skin assessments, follow provider orders for therapy to assess for necessary equipment, provide interventions, monitoring, and care for pressure ulcer prevention, management and treatment who was admitted to the facility without pressure ulcers for 1 of 3 residents (R3) reviewed for pressure ulcers R3 was harmed when the facility failed to develop and implement interventions to promote healing and prevention resulting in R3 developing an unstageable pressure ulcer. Findings include: According to the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, Rev. 211, 02-03-23 an Unstageable Pressure Ulcer: Obscured full-thickness skin and tissue loss is full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) should only be removed after careful clinical consideration and consultation with the resident's physician, or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then the reclassified stage should be assigned. The pressure ulcer does not have to be completely debrided or free of all slough or eschar for reclassification of stage to occur. R3's annual minimum data set (MDS), dated [DATE], indicated R3 had severe cognitive impairment, had diagnoses of multiple sclerosis (MS) an autoimmune disease that affects the brain and spinal cord resulting in fatigue, numbness/tingling, muscle spasms, stiffness, and pain, Peripheral Vascular Disease (PVD) the reduced circulation of blood to a body part other than the brain or heart caused by a narrowed or blocked blood vessel, elevating your legs above heart level to keep blood from pooling in them can be beneficial to promote wound healing, and impaired gait and immobility. R3 required extensive assist of two staff with bed mobility, dressing, hygiene, and toilet use and was a total assist of two staff with transfers. R3 was at risk for pressure ulcers but did not identify any. R3's identify care area assessment (CAA) for pressure ulcers dated 5/19/23, indicated R3's extrinsic risk factors indicate pressure-needed a special mattress or seat cushion to reduce or relieve pressure. Intrinsic risk factors were immobility, altered mental status, cognitive loss, and incontinence. Pressure ulcer functional status would be addressed in the care plan. R3's care plan indicated a focus of (PVD), dated 5/22/23, with interventions to elevate legs when sitting or sleeping. An additional focus, dated 2/13/20, indicated R3 has a risk of injury to skin integrity related to PVD, immobility and history of contractures, with interventions dated 5/22/23, to provide a pressure relieving cushion while up in his chair, to provide a pressure relieving mattress to protect his skin while in bed and needed assist to provide bilateral foam boots. The care plan lacked interventions to have therapy assess for a new wheelchair and new wheelchair cushion, also lacked the order to lay down after meals (breakfast and lunch) for at least 90 minutes. R3's integrated wound care note, dated 6/13/23, indicated R3 was being seen for evaluation and treatment recommendation for a pressure ulcer to the right posterior (back) inferior (low) thigh. Physical exam indicated an unstageable pressure ulcer with a moderate amount of serosanguinous (combination of blood and serous fluid) drainage with 90% slough and 10% granulation (the appearance of the red, bumpy tissue in the wound bed as the wound heals) tissue measuring 2.5 centimeters (cm) (length) x 1.5 cm (width) x 0.1 cm (depth) with a total circumference area of 3.75 cm. Treatment recommendations to cleanse with Vashe (a saline based wound cleanser that contains hypochlorous acid as a preservative that inhibits microbial contamination within the solution); apply Santyl (an ointment is an FDA-approved prescription medicine that removes dead tissue from wounds so they can start to heal), cover with silicone border dressing to change daily and prn (as needed). Implement facility pressure ulcer prevention protocol, pressure redistribution mattress, incontinence care prn and optimize nutrition. Plan of care discussed with facility staff. R3's Treatment Administration Record (TAR) dated June 2023, indicated R3's right posterior inferior thigh pressure ulcer wound treatment order was not implemented until 6/17/23, indicating R3 missed three days of dressing changes from 6/14/23 to 6/16/23. R3's progress note dated 6/19/23, indicated a Braden Scale, a skin risk assessment for predicting pressure sore risk, was completed with a score of 13, indicating R3 was at moderate risk for skin breakdown. R3's record was reviewed from 5/1/23 to 9/20/23 and no identification of when or how the unstageable pressure ulcer was first found, however the wound clinic saw R3 on 6/13/23. The medical record does not indicate if R3's pressure ulcer wound was reassessed or if a provider was notified of the missed dressing changes. Further, there was no indication a comprehensive wound assessment was completed for 14 days, between 6/13/23 and 6/27/23. R3's integrated wound care note, dated 6/28/23, indicated R3's unstageable pressure ulcer to right posterior inferior thigh was evaluated and assessed. Physical exam indicated the wound was deteriorating with 80% soft moist necrotic tissue (dead tissue), 15% adherent slough (nonviable tissue) and 5% granulation tissue with a small to moderate amount of serosanguinous drainage measuring 3.3 cm x 1.2 cm x 0.2 cm total circumference of 3.96 cm. Autolytic (using chemical enzymes to debride)-chemical (Vashe), enzymatic (Santyl), and mechanical debridement performed with cares. Treatment recommendations are to cleanse with Vashe, pat dry, apply skin prep to periphery, apply nickel thin amount of Santyl to non-intact area only; cover with 1 -2 layers of xeroform (non-adherent primary dressing maintains a moist wound environment to promote wound healing), secure with gauze border dressing. New Order to modify cushion of wheelchair due to pressure ridge against wound, plan of care discussed with staff. R3's integrated wound care note, dated 7/5/23, indicated R3's unstageable pressure ulcer to right posterior inferior thigh was evaluated and assessed. Physical exam indicated the wound was improving with 60% eschar and 40% slough with a moderate amount of serosanguinous drainage measuring 2.5 cm x 1.8 cm total circumference of 4.5 cm. Autolytic chemical (Vashe), enzymatic (Santyl), and mechanical debridement performed with cares. Treatment recommendations are to cleanse with Vashe; apply Santyl; calcium alginate-no silver (turns into a gel as they come in contact with wound exudate to provide a moist wound environment that facilitates autolytic debridement); and cover with silicone border dressing. New Order to lay down in bed after breakfast and lunch for at least 90 minutes daily and modify cushion of wheelchair due to pressure ridge against wound. Plan of care to consult therapy for proper chair fitting and discussed with facility staff. R3's integrated wound note dated 7/11/23, indicated R3's unstageable pressure ulcer to right posterior inferior thigh was evaluated and assessed. Physical exam indicated the wound had no change with 60% eschar and 40% slough with a moderate amount of serosanguinous drainage measuring 3.5 cm x 1.5 cm x 0.3 cm, total circumference of 5.25 cm. Treatment recommendations are no new changes to dressing. Reiterated to have [R3] lay down in bed after breakfast and lunch for at least 90 minutes daily and modify cushion of wheelchair due to pressure ridge against wound. Plan of care to consult therapy for proper chair fitting and discussed with facility staff. R3's Order Summary, dated 7/14/23, to turn and reposition every two to three hours, float heels off bed. R3's integrated wound care note dated 7/18/23, indicated R3's unstageable pressure ulcer to right posterior inferior thigh was evaluated and assessed. Physical exam indicated the wound had no change with 60% slough and 40% granulation with a moderate amount of purulent drainage (a thick, milky white discharge indicating an unhealthy wound or infection that requires immediate attention) measuring 3.5 cm x 2.5 cm x 0.5 cm, total circumference of 8.75 cm. R3's pressure ulcer also indicated undermining at 11:00 to 1:00 measuring 1.6 cm. Treatment recommendations are no new changes to dressing. Further indicated, MUST lay down in bed after meals. MUST have therapy evaluation for new wheelchair and wheelchair cushion. Plan of care discussed with facility staff. R3's TAR, dated July 2023, indicated R3's pressure ulcer dressing was not changed on 7/15/23 and 7/31/23 indicated by a blank space where the signature of the nurse who performed the dressing change under those dates. Further indicated there was a new order on 7/14/23, for R3 to be turned and repositioned every two to three hours, there were several hours where this was not completed for R3 on the following days: 7/15/23, 7/19/23, 7/20/23, 7/21/23, 7/22/23, 7/24/23, 7/26/23, 7/27/23 and 7/31/23, the spaces provided were left blank. R3's record lacked wound assessments for 13 days, between 7/18/23 and 8/1/23. R3's quarterly MDS, dated [DATE], indicated R3 was at risk for pressure ulcers, and had an unstageable pressure ulcer that was not present upon admission, which required a pressure ulcer device for bed, pressure ulcer care and applications of ointments/medications other than to feet. R3's MDS lacked a pressure reducing device for R3's chair and lacked a turning and repositioning program for pressure ulcer prevention. Last identified physical therapy (PT) services were 3/23/21 to 5/5/21. R3's Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE], indicated a score of 14 indicating R3 was at moderate risk for skin breakdown. Further indicated R3 was completely limited with ability to respond to meaningfully pressure related discomfort, skin is often, but not always moist, ability to walk is severely limited or non-existent, cannot bear own weight and/or must be assisted into own chair or bed, very limited ability to change and control body position, can make occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. R3's integrated wound care note dated 8/1/23, indicated R3's unstageable pressure ulcer to right posterior inferior thigh was evaluated and assessed. Physical exam indicated the wound had no change with 60% granulation and 40% slough with a moderate amount of purulent drainage measuring 3.5 cm x 2 cm x 0.3 cm, total circumference measured 7 cm. R3's pressure ulcer also indicated undermining at 11:00 to 1:00 measuring 1.5 cm. Treatment recommendations are no new changes to dressing. Further indicated, MUST lay down in bed after meals. MUST have therapy evaluation for new wheelchair and wheelchair cushion. Plan of care-needs treatment evaluation for wheelchair fitting and discussed with facility staff. R3's integrated wound care note dated 8/8/23, indicated R3's unstageable pressure ulcer to right posterior inferior thigh was evaluated and assessed. Physical exam indicated the wound had no change with 90% granulation and 10% slough with a moderate amount of serosanguinous drainage measuring 3.6 cm x 2.5 cm x 0.3 cm, total circumference measured 9 cm. R3's pressure ulcer also indicated undermining at 11:00 to 1:00 measuring 1.0 cm. Treatment recommendations are no new dressing changes to dressing. Further indicated, MUST lay down in bed after meals. MUST have therapy evaluation for new wheelchair and wheelchair cushion. Plan of care-needs PT evaluation for new wheelchair fitting and seat cushion and discussed with facility staff. R3's TAR, dated August 2023, indicated R3's pressure ulcer dressing was not changed on 8/19/23, indicated by a blank space where the signature of the nurse who performed the dressing change should be under that date. R3 was to be turned and repositioned every two to three hours, there were several hours where this was not completed for R3 on the following days: 8/7/23, 8/8/23, 8/9/23, 8/12/23, 8/13/23, 8/19/23, 8/23/23, 8/28/23, 8/30/23 and 8/31/23, the spaces provided were left blank. R3's record lacked comprehensive wound assessments for 19 days from 8/9/23 to 8/28/23. R3's integrated wound care note dated 8/28/23, indicated R3's unstageable pressure ulcer to right posterior inferior thigh was evaluated and assessed. Physical exam indicated the wound was improving with 100% granulation tissue with a moderate amount of serosanguinous drainage measuring 3.0 cm x 1.6 cm x 0.2 cm, total circumference measured 4.8 cm. No indication of undermining. Treatment recommendations are no new dressing changes ordered. Further indicated, MUST lay down in bed after meals. MUST have therapy evaluation for new wheelchair and wheelchair cushion. Plan of care-needs PT evaluation for new wheelchair and seat cushion and discussed with facility staff. R3's integrated wound care note dated 9/5/23, indicated R3's unstageable pressure ulcer to right posterior inferior thigh was evaluated and assessed. Physical exam indicated the wound was improving with 100% granulation tissue with a moderate amount of serosanguinous drainage measuring 2.5 cm x 2.0 cm x 0.1 cm, total circumference measured 5.0 cm. Treatment recommendations are no new dressing changes ordered. Further indicated, MUST lay down in bed after meals. MUST have therapy evaluation for new wheelchair and wheelchair cushion. Plan of care-needs PT evaluation for new wheelchair and seat cushion and discussed with facility staff. R3's active Order Summary, dated 9/7/23, Needs PT eval for new wheelchair and seat cushion. Pressure relief/offloading, pressure ulcer prevention protocol to include pressure redistribution mattress, heel offloading and turn and repositioning. R3's integrated wound care note dated 9/12/23, indicated R3's unstageable pressure ulcer to right posterior inferior thigh was evaluated and assessed. Physical exam indicated the wound was improving with 100% granulation tissue with a moderate amount of serosanguinous drainage measuring 1.8 cm x 1.5 cm x 0.1 cm, total circumference measured 2.7 cm. Treatment recommendations are no new dressing changes ordered. Further indicated, MUST lay down in bed after meals. MUST have therapy evaluation for new wheelchair and wheelchair cushion. Plan of care- discussed with facility staff. R3's integrated wound care note dated 9/19/23, indicated R3's unstageable pressure ulcer to right posterior inferior thigh was evaluated and assessed. Physical exam indicated the wound was improving with 100% granulation tissue with a moderate amount of serosanguinous drainage measuring 2.5 cm x 1.5 cm x 0.1 cm, total circumference measured 3.75 cm. Treatment recommendations are no new dressing change ordered. Further indicated, MUST lay down in bed after meals. MUST have therapy evaluation for new wheelchair and wheelchair cushion. Plan of care- discussed with facility staff. R3's TAR, dated September 2023, indicated R3 was to be turned and repositioned every two to three hours, there were several hours where this was not completed for R3 on the following days: 9/4/23, 9/7/23, 9/11/23, and 9/18/23 the spaces provided were left blank. During an observation on 9/19/23, at 3:12 p.m. R3 was seated in a Tilt-In Space wheelchair watching television in his room, R3's right and left thigh are resting at the lip of R3's wheelchair cushion with both feet dangling, nothing to rest the feet on to remove pressure from the thigh area. During an observation on 9/20/23, at 10:49 a.m. R3 was seated in a Tilt-In Space wheelchair watching television in his room, R3's right and left thigh are resting at the lip of R3's wheelchair cushion with both feet dangling, nothing to rest the feet on to remove pressure from the thigh area. During an observation on 9/20/23, at 1:42 p.m. PT-A pulled back the dressing affixed to R3's right posterior inferior thigh, wound bed was red and bumpy indicating granulation tissue with a small amount of slough, cream colored tissue around the edges of the wound bed. No redness surrounding the wound, the dressing had a small amount of serosanguinous drainage noted. During an observation and interview on 9/20/23, at 12:47 p.m. R3 was seated in wheelchair in the dining room and had just finished eating his lunch, nursing assistant (NA)-A started wheeling R3 down the hall to his room and positioned R3 in front of his television next to his bed, R3's feet continue to have no support to offload pressure to thigh area. NA-A stated she got R3 out of bed and into his wheelchair at 7:30 a.m. NA-A stated we do not have enough staff on this floor to get R3 laid down after breakfast, we do not even get everyone up and out of bed today until almost 11:00 a.m. NA-A verified R3 had not been repositioned for over five hours and stated an awareness of R3 having a pressure ulcer behind the right knee, that R3 should be repositioned and offloaded every 2 hours for prevention of worsening of pressure ulcers. NA-A stated she worked at the facility for over twenty years. R3 always had the same wheelchair and wheelchair cushion, it had not been replaced. During an interview on 9/20/23, at 12:52 p.m. nursing assistant (NA)-B stated he had worked at the facility for a couple of years and had never noticed R3 to have a new wheelchair or wheelchair cushion. NA-B was aware that R3 had a pressure ulcer and stated they did not have time to lay R3 down after breakfast to offload or reposition as they were still getting other residents out of bed and ready for the day. NA-B stated all residents who are at risk for pressure ulcers or have pressure ulcers need to be repositioned every two hours. During an interview on 9/20/23, at 1:17 p.m. director of therapy services, (DOTS)-A stated an unawareness of R3 having an unstageable pressure ulcer or any provider order for therapy to assess R3 for a new wheelchair or wheelchair cushion. DOTS-A stated she just became the director in July, there was no bridge program from the last director to me. If the provider from the wound clinic had orders for therapy to assess, the nurse rounding with the provider would put the orders in the medical record and therapy would assess and evaluate in the same day, then therapy would write out recommendations on a communication from and give one to the floor nurse, one to the nurse manager, and one to the director of nursing (DON). During an observation and interview on 9/20/23, at 1:28 p.m. physical therapist (PT)-A stated he was not aware R3 had an unstageable pressure ulcer and was not aware of any provider order to assess R3 for a new wheelchair and wheelchair cushion. PT-A and DOTS-A walked to R3's room, where R3 was lying in bed. PT-A stated that [R3] had a Tilt-In Space wheelchair, and it looked like there was a specialized formed cushion for positioning in [R3's] seat. [R3] should have support on his feet otherwise all the pressure is on [R3's] thigh, right where his pressure ulcer was. PT-A stated because his feet were dangling it caused the pressure in the thigh area and the pressure was preventable. PT-A stated turning and repositioning recommendation to nursing every two hours will help until therapy could get [R3] evaluated and assessed. DOTS-A stated the cause of R3's pressure ulcer to the back of his thigh is from his wheelchair causing his legs to dangle cutting off blood supply. PT-A pulled back the dressing on the back of R3's thigh and stated the wound is 90% granulation and 10% slough, a stage 3 pressure ulcer. The DOTS-A stated therapy would have to order pressure mapping to determine high pressure areas to ensure [R3] gets the best wheelchair and cushion to prevent pressure to this thigh area and to help ensure healing. DOTS-A stated this should have been done right away when it was ordered in July. PT-A stated the best way to prevent pressure ulcers is by changing a person's lying or sitting position by turning and repositioning frequently, especially for R3 who was dependent on staff for mobility. During an interview on 9/20/23, at 1:54 p.m. licensed practical nurse (LPN)-A stated he was the nurse that rounds with the nurse practitioners every Tuesday and Wednesday and would be the nurse responsible to ensure new wound orders get put in the computer. LPN-A verified that the provider on 6/28/23, ordered for R3 to modify cushion of wheelchair due to pressure ridge against his pressure ulcer. And, further verified that every weekly wound note to current date addressed that R3 needed to be assessed by therapy to have a new wheelchair and wheelchair cushion to prevent pressure to his existing pressure wound and was not aware that therapy has not yet completed it. LPN-A was unable to articulate or show documentation of how therapy was notified of this order. During an interview on 9/20/23, at 2:14 p.m. the DON verified R3's provider order for therapy to evaluate and assess the need for a new wheelchair and wheelchair cushion to help offload pressure to existing pressure ulcer was not completed. The DON stated with a new order for therapy, the order should be placed in therapy's mailbox and therapy will assess and evaluate, also the nurse is responsible for inputting the order in the computer, where therapy would see it. The DON stated his expectation is that [R3] should have been repositioned every two hours per the provider orders to help prevent pressure ulcers. The DON stated if a wound dressing change is left blank on the TAR, and there was no progress note indicating the dressing change was completed that the dressing change was not performed. All wound dressing orders would be performed as ordered. The DON stated R3's wheelchair appeared to be the cause of the unstageable pressure ulcer to the back of R3's right thigh. During an interview on 9/20/23, at 2:36 p.m. the administrator stated when a provider gives orders for a therapy evaluation it needs to be done immediately. The administrator confirmed that R3's order for therapy to evaluate and assess for a new wheelchair and cushion for pressure ulcer prevention were not performed when ordered on 6/28/23 and should have been. The administrator stated facility protocol is that residents should be repositioned every two hours when they have pressure ulcers. Facility policy, Pressure Ulcers/Skin Breakdown-Clinical Protocol, dated June 2022, Assessment and Recognition included the facility responsibility of: Monitoring 1. During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or poorly-healing wounds. 2. The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. a. Healing may be delayed or may not occur, or additional ulcers may occur because of other factors which cannot be modified. b. Current approaches should be reviewed for whether they remain pertinent to the resident/patient's medical conditions, are affected by factors influencing wound development or healing, and the impact of specific treatment choices made by the resident/patient or a substitute decision-maker.

Based on interview and document review, the facility failed to ensure electronic health record (EHR) banner and Physician Order for Life Sustaining Treatment (POLST) accurately reflected current resuscitation wishes for 1 of 6 (R1) residents reviewed for advance directives. This deficient practice resulted in an immediate jeopardy (IJ) for R1 who would have received cardiopulmonary resuscitation (CPR), contrary to his wishes, in the absence of a pulse or respirations. The IJ began on [DATE], when R1's signed POLST identified R1 was not to receive CPR, however; R1's EHR's banner and physician orders identified R1's wishes were to receive CPR. The administrator was notified of the IJ on [DATE] at 3:47 p.m. The IJ was removed on [DATE] at 4:00 p.m., when the facility had implemented corrective action, however; non-compliance remained at the lower scope and severity level of D, isolated with no actual harm but potential to cause more than minimal harm. Findings include: R1's Provider Order dated [DATE] indicated R1's code status was full code (to resuscitate). R1's POLST signed on [DATE] by R1 and his primary provider directed, Do not attempt resuscitation/DNR. R1's care plan printed on [DATE] lacked R1's resuscitation status. On [DATE] R1's care conference note indicated R1 was listed as a full code resuscitation status, but wanted this changed to do not resuscitate (DNR). On [DATE] at 10:25 a.m., R1 was interviewed and confirmed in the event his heart stopped or he was not breathing, he would not want staff to perform CPR. R1 stated, I don't want to come back a vegetable. I have told that to everyone who has asked me. On [DATE] at 10:36 a.m., registered nurse (RN)-A verified R1's POLST wishes were to be DNR status, and the banner in R1's EHR which instructed staff to perform CPR on R1 was inaccurate. RN-A stated she would check the resident's EHR banner to determine their resuscitation status. On [DATE] at 10:53 a.m., licensed practical nurse (LPN)-A stated a resident's code status was in the EHR and in their paper chart on the POLST. LPN-A stated the EHR and the POLST should match. LPN-A confirmed R1's EHR indicated he was a full code. LPN-A stated if a resident's code status changed, the EHR should be updated immediately. On [DATE] at 11:22 a.m., LPN-B stated she would check both the EHR and the POLST for resucutation status. LPN-B stated if discrepancies were noted on a residents EHR and their POLST, CPR could be started on a resident that does not want to be resuscitated, or a resident could be allowed to die naturally when they had wanted to be resuscitated. On [DATE] at 11:59 a.m. LPN-C stated she would check the resident's EHR banner to determine their resuscitation status. On [DATE] at 2:14 p.m., the administrator stated staff should look for a resident's code status in the EHR on the banner. The facility policy Advance Directives policy dated ,d+[DATE], directed a POLST form is a form designed to improve patient care by creating a portable medical order that records patients treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patients current medical condition into consideration. Do Not Resuscitate (DNR) - indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used. The IJ was removed on [DATE] at 4:00 p.m., when the facility developed and implemented a systemic removal plan which was verified by interview and document review: Residents' records were reviewed to ensure the POLST form and the electronic health records were updated to ensure resident's wishes for advance directives. All nurses were educated on the policy for advanced directives, obtaining and documenting the POLST to reflect the resident's wishes, as evidenced by the Education Sign in Sheet and interviews. New processes were put in place to ensure the current POLST and EHR banner were the correct code status of each resident, as well as ongoing reviews and audits of POLSTs and care plans.

Based on observation, interview and document review, the facility failed to protect 4 of 4 (R2, R5, R9, R10) residents from resident-to-resident abuse when R1 physically abused them. In addition, the facility failed to implement immediate and ongoing interventions to keep residents safe from further abuse which resulted in an immediate jeopardy (IJ) situation for (R2, R5, R9, R10) and potential for harm, injury, impairment, or death to all 19 residents currently residing on the 2nd floor memory care unit. The immediate jeopardy began on 7/11/22, when R1 was observed to bite R5 and facility failed to implement interventions to protect other residents from R1's behaviors, which lead to additional resident to resident physical altercations, and was identified on 8/3/22. The administrator, director of nursing, social service assistant, dietary director, and business office manager were notified of the IJ at 6:38 p.m. on 8/3/22. The immediate jeopardy was removed on 8/5/22, but noncompliance remained at the lower scope and severity level 2 scope and severity level of an E, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's annual Minimal Data Set (MDS) dated [DATE], indicated R1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of MDS, indicated R1 did not exhibit physical behaviors. R1's care plan dated 12/14/19, indicated R1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's care plan lacked evidence of interventions for safeguarding vulnerable residents living with/near vicinity of R1. R2's quarterly MDS dated [DATE], indicated R2 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of MDS, indicated R2 did not exhibit behaviors. R9's quarterly MDS dated [DATE], indicated R9 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of MDS, indicated R9 exhibited delusional behavior. R10's quarterly MDS dated [DATE], indicated R10 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility report to the State Agency (SA) dated 7/11/22, indicated R1 was observed to have R5's thumb in her mouth (biting). Review of facility's 5-day investigation lacked evidence of actions implemented to protect other residents from R1's physical behaviors. Review of facility report to the SA dated 7/23/22, R1 was observed making threats towards R2 punched R2 on the arm. At the time of the incident, R1 and R2 shared the same room. Review of facility's 5-day investigation lacked evidence of actions implemented to protect R2 from further abuse as well as other residents from R1's physical behaviors. On 8/1/22, at 3:00 p.m. R1 and R2 were observed in their shared room with the door closed. On 8/3/22, during continuous observation starting at 1:27 p.m. surveyor heard screaming coming from the day room (open common area that include nursing station/hallway threshold /day room). Surveyor observed R1 continuing to yell out in the day room while additional staff removed R9 from the day room while she made comments such as, she grabbed my arm and she hit me hard referring to R1. R1 remained in the day room with other residents. At 1:40 p.m. R1 was observed still upset and yelling in the dayroom while speaking with social services (SS)-A. SS-A was observed to leave R1 in the day room as R1 continued to be upset. R1 was then observed to self-propel in her wheelchair to R10 who was sitting in his wheelchair in the day room and kicked his shin. Trained medication aide (TMA)-B and registered nurse (RN)-A intervened and separated R1 and R10. Staff removed R10 from the day room, however, R1 remained in the day room area with other residents. R1 moved near nursing station area. Surveyor was in the commons area by nursing station with R1, no other facility staff were in the area. R1 was observed to be making threatening gestures towards another resident in the area and sticking her tongue out. At 1:56 p.m. R1 continued to be upset and making threatening gestures to another resident in area and began to self-propel in her wheelchair to resident while staff was at the nursing cart and staff was able to intervene. On 8/3/22, 2:35 p.m. R1 was observed in the commons area with other residents and the nursing station was unsupervised. On 8/2/22, 10:26 a.m. nursing assist (NA)-A indicated R1 was physical with staff and residents a lot and interventions were to reapproach and while in the commons area with other residents staff are to watch and a staff member was expected to sit in the room while R1 was in the commons area. On 8/2/22, at 11:36 a.m. NA-B stated she was assisting R1 and R2 with morning cares when R1 became aggressive and beat R2 on her arm, wrist and leg. R2 then got upset and hit R1 on her arm and legs. Further, NA-B stated she was not sure what intervention was implemented following the incident as it is not my job to decide what to do. On 8/2/22, at 12:02 p.m. TMA-A stated R1 had an explosive temper and you can't come close to her, or she will hurt you. On 8/2/22, at 4:53 p.m. social services (SS)-A stated R1 had physical behaviors and can't be near most residents. Further SS stated staff were expected to separate R1 from other residents by 3-4 feet when agitated to give her some space. SS confirmed there were no additional intervention implemented following R1's incidents with R2 and R5. On 8/3/22, at approximately 1:30 p.m. TMA-B stated R9 was attempting to sit behind R1 in the recliner when her walker bumped into R1 which caused R1 to hit R9 on her arm. On 8/3/22, at approximately 1:35 p.m. health unit coordinator (HUC)-B confirmed she witnessed R1 slap R9 on her arm. On 8/3/22, at 2:12 p.m. NA-E indicated she was not aware of R1's history of aggressive behaviors towards other residents. On 8/3/22, at 2:34 p.m. R9 was laying in her bed and immediately became tearful and stated, I didn't do anything, I was going to sit in the chair, and she started pounding on me. I am scared of her; she should be in a different area. I guess I will just stay in my room and go out for meals and not go out there by her. On 8/3/22, at 3:25 p.m. TMA-B indicated she was not aware of R1 having a history of being physically aggressive with other residents. When asked how staff protect other residents when R1 is upset, TMA-B stated she had never been in a situation where she felt she needed to protect other residents from R1. On 8/3/22 at 4:35 p.m. interview with nurse manager and director of nursing (DON) stated SS was in charge of the investigation and implementing interventions following the determination of a root cause. DON stated staff were expected to keep residents safe and separate residents following an altercation, so another incident does not occur. DON confirmed R1's care plan had not been updated with interventions for physical behaviors since 2019 and the care guide sheet as of 8/3/22, had no safety interventions for R1's behaviors. Review of facility policy titled Reporting Abuse to Facility Management, not dated, indicated the facility does not condone resident abuse by anyone including other residents. Review of facility policy titled Abuse Investigation and Reporting dated 12/6/21, directed staff to protect residents during abuse investigations. Further review of abuse policy lacked evidence of clear guidance on how staff will immediately protect residents following a resident to resident altercation and implementing appropriate interventions following an altercation. The immediate jeopardy that began on 7/11/22, was removed on 8/5/22 at 1:55 p.m., when the facility updated R1's care plan to include behavioral interventions such as encouraging R1 to engage in appropriate activities, prevent over crowding or close enough to touch others, R1 was moved to a private room, and assigned nursing assistant to transport R1 to and from dining area or lounge and R1 to remain within eye sight of staff. In addition, staff's care guides were updated to reflect R1's interventions, staff were educated on updated interventions as well as abuse and reporting, but noncompliance remained at a lower scope and severity level of an E, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy.

Based on interview and document review, the facility failed to ensure residents identified at risk for worsening skin wounds received the necessary care and treatment to prevent the development of maggots in a wound for 1 or 1 residents (R6) who was hospitalized for a wound infestation. This resulted in harm for R6. Findings include: R6 was observed on 8/1/22, visiting with the nurses at the nurses station. A bandage on her left lower leg presented with signs of weeping yellow tinge coming through the bandage. A Facility Reported Incident (FRI) submitted to the Stage Agency (SA) on 8/1/22, at 9:59 p.m. identified licensed staff who worked the 8/1/22 evening shift removed R6's dressing per her treatment orders and observed multiple maggots in wound bed secondary to date on dressing being approximately 3 (three) days old. R6's Emergency Department Staff Physician Note dated 8/2/22, at 12:49 a.m. identified on exam R6's left lower extremity (LLE) showed evidence of necrotic appearing tissue and lacked larva/maggots on exam. The note indicated R6's family showed the provider a video with what appeared to be larva present particularly on the LLE. Due to R6's initial diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's Hospitalist Progress Note dated 8/4/22, identified IV antibiotics were stopped as infectious disease (ID) on 8/4/22, felt R6's LLE wounds were not infected. A wound care consult was ordered. Wound care consult notes were requested: none were provided. R6's quarterly Minimum Data Set (MDS) dated [DATE], identified R6's cognitive status was not tested ; however, the MDS identified R6 was independent with mobility and daily cares. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the MDS identified R6 was free of ulcers, wounds, or skin problems; however, staff applied an ointment/medication to R6. R6's Care Plan printed 8/9/22, identified R6 resisted treatments to her legs related to (r/t) confusion and provided examples of non-compliance: leg elevation, decreased fluid intake, and leg treatments. Interventions were identified as educating R6 of the possible outcome(s) of not complying with treatment or cares, encouraging her to participate as much as possible during cares, and giving clear explanation of all care activities prior to and as they occur during each contact. Further, R6's Care Plan identified on 6/7/22, R6 had an open area to her lower extremities related to increased [CONDITION(S)] and scratching the fragile skin. R6's goals were to be free from open [CONDITION(S)] or injuries to her lower extremities, she would be free of complications to the open [CONDITION(S)], the open [CONDITION(S)] would remain stable, and she would maintain or develop clean and intact skin by the review date. Interventions were to avoid scratching, educate her of causative factors and measures to prevent skin injury, encourage good nutrition and hydration to promote healthier skin, identify/document potential causative factors and eliminate/resolve where possible, keep skin clean and dry, use lotion to skin, report abnormalities to the provider, assistance to apply wraps ordered by physical therapy (PT) to bilateral extremities, and weekly treatment documentation. R6's Care Plan lacked evidence of individualized interventions which directed staff on actions, outside of verbal education and reminders, to attempt when R6 resisted wound care active and preventative treatments. Vohra Wound Physicians Initial Wound Evaluation and Management Summary, dated 6/7/22, identified R6 was examined to have one lymphademic wound (full thickness) to her right leg (1 cm (centimeter - length) x 1.4cm (width); 1.40cm surface area (length x width); 100 percent (%) granulation (sign of healing) tissue) and one to her left leg (2.8cm x 1.3cm; 90% slough (dead skin tissue). Initial provider orders were as follows: -Xeroform sterile gauze covered by a Kerlix dressing (to both legs) QD (every day). R6's TARs (treatment administration record(s) dated 6/7/22 - 8/1/22, directed staff to cleanse the back of R6's left leg and apply a dry dressing BID (twice a day) before ace wraps were applied; however the MARs/TARs lacked the QD Xeroform/Kerlix order to both legs and lacked evidence of any directed wound care order to R6's right leg. -Recommendation was provided to elevate leg(s). R6's MARs/TARs dated 6/7/22 - 8/1/22 directed staff to encourage R6 to elevate her legs while lying in bed and lacked directions for leg elevation at other times. Subsequent [NAME] visits identified the following information (wound care orders and recommended leg elevation remained unchanged from the 6/7/22 order unless indicated): -6/14/22: Right leg wound progress deteriorated (2cm x 6cm; 12cm surface area; 80% slough, and 20% granulation tissue) and the left leg improved. -6/24/22: Right leg wound progress improved and the left leg remained unchanged. An order was provided for PT (physical therapy) to evaluate for multilayer compression wraps for [CONDITION(S)]. R6's medical record lacked evidence of the PT order or that PT was updated to the order. -7/5/22: Right leg wound progress showed the wound resolved. The left leg (1cm x 0.5cm; 0.50cm surface area; 5% slough; 95% granulation) wound progress improved. -7/12/22: Left leg wound progress deteriorated (18cm x 36cm; 648cm surface area; 5% slough; 95% granulation). In response, Aquaphor was ordered to be applied QD to the periwound (outside edges of the wound). In addition, the dictation indicated an initial evaluation of a full thickness lymphademic wound of R6's right leg was completed (9cm x 8cm; 72cm surface area, 100% granulation tissue) with an associated procedure note: This wound has previously undergone autolytic debridement. In response, Xeroform sterile gauze covered by a Kerlix dressing and Aquaphor applied periwound QD was ordered. R6's TARs dated 7/12/22 - 8/1/22, directed staff to apply Aquaphor ointment to R6's lower leg/extremities BID and PRN (as needed); however, the TARs lacked evidence of the 7/12/22 Aquaphor directed left leg periwound order. In addition, the MARs/TARs dated 7/12/22-8/1/22, lacked evidence staff were directed to provide, or provided, the Xeroform/Kerlix order to R6's right leg wound. -7/19/22: Left leg (4.6cm x 1cm; 4.6cm surface area; 5% slough) and right leg (1.6cm x 0.7cm; 1.12cm surface area; 100% granulation) wound progresses improved. -7/26/22: Left leg (12cm x 5cm; 60cm surface area; 90% slough; 10% granulation) and right leg (1.4cm x 1.6cm; 2.24 cm surface area; 100% granulation) wound progresses deteriorated. In response, Santyl (enzymatic debridement agent) was ordered QD to be applied to both wounds. R6's MARs/TARs dated 7/26/22 - 8/1/22, lacked evidence staff were directed to apply, or applied, Santyl to R6's bilateral leg wounds. R6's 6/1/22 - 8/1/22 MARs/TARs, identified the following additional skin/wound care treatments: -TAR: Ace wraps on every morning and removed at bedtime for [CONDITION(S)] (fluid in the legs), in which they were to be applied at 8:00 a.m. -TAR: [CONDITION(S)] wraps to lower extremities QD which were directed to be applied at 8:00 a.m. -TAR: If R6 refused [CONDITION(S)] wraps, start TED (compression socks decrease blood clots) stockings instead every shift. R6's Skin and Wound Evaluation V5 dated 6/7/22, identified R6 had a new open lesion. The location box remained blank. The evaluation identified R6 experienced increased [CONDITION(S)] to her lower extremities which caused her to scratch at the area causing it to open. PT worked with R6 to control the fluid build-up. Nursing initiated an order to apply Aquiform to the area twice daily (BID) to help minimize the itching. In addition, staff encouraged R6's compliance with set up treatments and lower extremity wraps, to sleep in her bed and to not scratch at her legs (right leg font skin area). R6's Skin and Wound Evaluation V5.0 dated 7/12/22, identified R6 had a new open lesion. The location box remained blank. The evaluation identified R6's wound was slow to heal as R6 kept removing the dressing to scratch at the area. The wound dressing order remained the same. In addition, R6 was educated on the importance of keeping the dressing intact and to avoid scratching the wounds. R6's Skin and Wound Evaluation V5.0 dated 7/19/22, identified R6 had a new left shin open lesion. The evaluation identified R6's wound status was stable; however, the wound was at risk for deteriorating as R6 continuously scratched and removed the dressing. The wound dressing order remained the same. In addition, R6 was educated to not scratch the wound and not to remove the wound dressing. R6's Skin and Wound Evaluation V5.0 dated 7/26/22, identified R6 had a new left shin open lesion. The evaluation identified R6's wound progress stalled and R6 continued to scratch the wound and remove the dressing herself. Wound dressing stayed the same. In addition, R6 was educated on the importance of not scratching to allow proper healing of the wound and advised to allow the dressing to remain in place. A subsequent Skin and Wound Evaluation V5.0 dated 7/26/22, identified R6 had a right shin rash which was slow to heal. The evaluation was uncompleted. R6's progress notes identified the following entries: -5/31/22: R6 was observed to have an open area at the back of her left leg. -6/7/22: R6 was alert to self with confusion. She was seen by the wound doctor and no changes were made on her treatment orders. -6/28/22: R6 was not assessed during wound rounds secondary to her being non-compliant at time of rounds. -7/14/22: R6 was confused and both feet are open and weepy, washed with soap and water and then cleanser, Xeroform applied and wrapped with calyx. -8/1/22, at 1:21 p.m. R6 was noncompliant with her dressing change treatment. The incoming nurse was notified of [R6's] non cooperation to try and change the wounds at the end of the shift. -8/1/22, at 10:09 p.m. R6's daughter was updated related to R6's complicated impaired wound bed. -8/1/22, at 10:14 p.m. R6's on-call provider updated on wound status and provided an order to send R6 to the emergency room to evaluate and treat her bilateral wound extremities. 8/1/22, at 11:54 p.m. R6 was alert and oriented to self with some confusion. Her bilateral wounds on her feet were severely affected [sic] and multiple maggots were presenting from the wounds. At 11:10 p.m. R6 was sent to the hospital. R6's progress notes, dated 7/27/22 - 8/1/22, at 1:21 p.m. lacked evidence R6 refused wound care treatments or that on 7/27/22, R6's family completed the dressing change. When interviewed on 8/4/22, at 3:15 p.m. LPN-E stated she worked with R6 on the evening of 8/1/22, and provided her wound treatments. She explained the day nurse updated her R6 refused her day shift dressing change and asked LPN-E to complete it. That evening LPN-E started to encourage R6 to return to her room around 7:30 p.m., as she refused her shower despite multiple attempts that shift, in order for her to at least complete R6's dressing change. It took R6 two hours before she complied. When LPN-E opened the left leg wound dressing, she stated, I realized it was infected. The maggots started coming out . LPN-E confirmed she did not count the maggots as they just dropped on the floor; however, stated there were more than one but not 10 of them, and she described them as white in color and about a centimeter long. LPN-E stated the wound was not draining and the dressing was not clean; however, she described the dressing as if had lotion or Vaseline on it which then picked up debris when R6 rubbed up against things and it stuck to the dressing. She added because R6 preferred to wear dresses, the dressings were exposed and got dirty. Lastly, LPN-E stated she did not recall if there was a date on the dressing when she removed it. During a telephone interview on 8/5/22, at 8:46 a.m. the wound care physician (WCP) stated she provided weekly resident wound care rounds in which rounds consisted typically of the nurse manager (LPN)-B, a nurse if available, and then a nursing assistant (NA) would follow when first floor wound rounds were conducted. She explained staff prepare the residents for her visit in which either she or the staff removed the old dressings. She then examined and assessed the wounds in which LPN-B took notes related to suggested wound care treatment changes and/or recommendations. Once the visit was over, the nurse would complete the ordered treatment. She confirmed she did not review each resident's medical record (progress notes/MAR/TAR) during each visit to review the orders and to ensure her orders were being carried out as she prescribed. She explained that was the facility's responsibility. She stated when she observed something [dressing] missing she inquired if the order was on the MAR/TAR. The WCP confirmed she observed probably one or two patients every week with incorrectly performed wound care treatments which she stated was more common if I changed the dressing the previous visit. She continued there were times when there was a lag on getting the dressing that I ordered .I am not sure what happens. She acknowledged there were also times when she was required to inquire as to the whereabouts of an ordered dressing or the Santyl. She stated, It has been an ongoing process to fix it [supply issues]. She responded she generally is not updated on facility issues related to order clarification requests and/or issues related to obtaining ordered treatment supplies. She typically found out about concerns when she returned to the facility the following week. The WCP verbalized she had spoken to the DON about her concerns; however, she had not drilled down to find out the reasons for the concerns: It would seem there should be a uniform process. When the WCP ordered wound treatments she had specific thoughts in mind and rationalizations as to why she chose, or did not choose, a particular treatment. She explained if a resident was provided wound care treatment(s) she did not order, the treatment error would make it more difficult for her to evaluate and assess the wound: It slows down the evaluation process and the wound may show a failure to progress. The wound may also decline and/or the wound may develop moisture associated skin damage if staff failed to provide a barrier cream. The WCP stated her dictated progress notes, with updated orders, were available to the staff the same day as the wound rounds in which she expected the staff to review the dictation for any order or recommendation adjustments. and/or the need for any clarifications. and then process her orders and recommendations as written. The WCP stated, .in general they are trying very hard and it seems they need some guidance on the process. It is not just measuring the wounds .the orders need to be in and done correctly. Supplies need to be in the facility and in the room and they may need some process changes or at least to look at that process. The WCP stated during wound rounds on 7/26/22, R6's wound was assessed to have deteriorated; however, the wound was free from signs and symptoms of infection or maggots. She was unable to comment on information related to maggots in a wound; however, she did not feel that the application of incorrect dressings would have caused them. She explained she had reviewed some literature and read maggots were not a hygiene concern, but a fly issue. She stated she had not observed R6's dressings off when she visited and did not have issues with dirty dressings; however, she commented, If [staff] were covering [the legs] and the dressings were on, it is hard to say that it led to the maggots. The WCP stated with the 7/26/22 rounds, R6's legs looked wetter and thus she ordered the Santyl to debride them. She again stated she expected staff to process her orders and follow them as directed. When the WCP was questioned about R6's therapy order, she confirmed she did not know if the recommendation was completed: I would have expected it to be done or an explanation [as to why not completed]. She acknowledged she was not aware R6 worked with PT since she started wound rounds with her. When interviewed on 8/5/22, at 1:08 p.m. R6's FM-B stated when she arrived on 7/27/22, R6 lacked dressings to her legs as R6 sat in the day room. The legs were oozing clear liquid and bleeding profusely. FM-B explained she walked her back to her room and she provided wound care to R6's legs. She cleansed the wounds with wound cleaner and wrapped the legs with gauze after she sterilized everything and used gloves. FM-B stated she had attempted to ask the nurse to apply dressings to R6's legs; however, she explained they were getting him to work somewhere else. FM-B stated she had not visited with R6 between the time she changed her dressings on 7/27/22 and when she arrived back to the facility on [DATE]. During interview on 8/5/22, at 2:05 p.m. LPN-C stated when an order was received the health unit coordinator (HUC) initially entered the order into the MAR/TAR. After, a nurse performed a double check. LPN-C explained wound care provider orders were processed like any other doctor. He confirmed orders were expected to be processed exactly how the order was written by the provider and the order was expected to be followed. LPN-C stated if orders were not processed or followed risks to the residents may occur: It would depend on what the error was. He provided a verbal example in which during dressing changes he had personally observed an ABD or a [MEDICATION(S)] on a resident; however, upon his review of the MAR/TAR, these types of dressings were not the active order. LPN-C explained if the wrong dressing or treatment was observed, he reviewed the MAR/TAR and it was not his overall practice to review the actual provider order. LPN-C acknowledged discussions with the nurse manager about such concerns and other medication order process concerns and verbalized he was not involved in the weekly wound round process. He verbalized R6's dressings came off at night and in the morning she would not have dressings on [based on R6's wound care orders, her wounds would always be covered]. LPN-C confirmed on the morning of 7/27/22, he observed R6 without dressings on her legs and her legs were bleeding. On 7/27/22, around lunch time, FM-B approached him after they arrived and asked if he could apply R6's dressings. He stated he informed FM-B he needed to address another resident's concern at that moment. Around 11:00 a.m. LPN-C observed Kerlix on R6's legs and he learned FM-B had applied it. LPN-C stated as soon as FM-B left the facility, he assisted R6 back to her room and re-applied the ordered dressings. He confirmed FM-B applied just plain gauze dressing. LPN-C denied he dated the dressing on 7/27/22; however, he acknowledged he should have dated the dressing and he should have documented that days dressing change status. When interviewed on 8/5/22, at 2:50 p.m. the evening nurse supervisor (LPN)-D stated when she received orders or order changes she processed them and then the order was double checked by another nurse. She expected the order to be processed as written and if the nurse questioned the order the provider was to be updated for clarifications. Further, she expected the nurses to follow the orders as prescribed. LPN-D confirmed [MEDICATION(S)] and Xeroform were not the same dressing and expected to see Xeroform on a wound if that was the dressing ordered and not [MEDICATION(S)]. She explained if a wound care order was not followed as prescribed, That might cause the wound to deteriorate. She confirmed she was unaware of any current concerns related to staff not following provider orders or nurses finding non-ordered dressings on residents. Further, she confirmed she was not aware of any wound treatment supply issues. LPN-D acknowledged she observed R6's leg on 7/27/22, and witnessed multiple maggots. She denied she had observed a date on R6's dressing that evening and explained the dressing was dry and a brownish dark color was on the inside of the dressing. She denied the wound had any odor and reported it really did not look different from the last time she had observed it. On 8/5/22, at 3:15 p.m. the director of rehab (DOR) and physical therapist (PT)-A were interviewed together. The DOR reviewed R6's therapy notes and confirmed therapy was not updated on the WCP's 6/24/22, therapy orders; however, she explained R6 was involved with therapy from 5/2/22 through 7/22/22. PT-A stated he was not involved in R6's wound care; however, he provided her with full body [CONDITION(S)] treatment and he worked with her on [CONDITION(S)] wraps. He acknowledged R6 only allowed them for very short periods of time and then she made attempts to remove them herself. The DOR stated she would expect nursing staff to update her related to any provider orders for therapy, even if they already worked with the resident, to ensure what was ordered was already part of the resident's treatment plan. When interviewed on 8/9/22, at 11:49 a.m. LPN-B stated he started the nurse manager role in May (approximately two months prior). He explained during wound rounds he took notes based on comments provided by the WCP, and once the WCP completed her dictated reports, he reviewed them and ensured the orders in the MAR/TAR were updated and/or current. He explained he or the nurses could process the WCP orders and stated he expected the order for the WCP and the order entered into the MAR/TAR were exact. He confirmed all orders were expected to be double checked and co-signed on the order sheet and then the HUC would scan the order into the medical record. LPN-B stated the WCP did not send regular orders and they just get scanned in. He confirmed he did not co-sign the WCP orders or that he asked another nurse to double check the orders; however, if another nurse was to process the WCP orders, he expected them to have another nurse co-sign them. He stated processing and following the WCP orders were expected and were important to help minimize the risk of the wound getting out of hand such as infection or decreased healing. He acknowledged he printed out the orders and went through them one at a time to check them for accuracy and indicated it was a lot for one person. In addition, he acknowledged he lacked any observations the wrong dressings or treatments were provided to residents. He confirmed the facility experienced no recent order supply concerns. LPN-B stated he performed R6's dressing change on 7/30/22, in which he did not observe any concerns. He explained R6 took her dressings off herself and staff could change her dressings and there was no guarantee it is going to stay there. That is why there is a two times day dressing changes. He acknowledged he expected nurses to place a dressing on R6's legs as directed, if R6's legs lacked a dressing. He explained the dressings served a purpose of helping to improve healing and to decrease [CONDITION(S)]. LPN-B stated R6 had not declined dressing changes for him and he was unaware she declined them for other nurses. When LPN-B was questioned on [MEDICATION(S)] or Xeroform dressings, he was unable to answer if they were the same dressing or different; however, he stated, What is in the MAR and TAR is what is expected to follow. If staff have questions they can reference the orders from the doctor. During interview on 8/9/22, at 1:39 p.m. the DON stated the WCP dictated notes and orders did not come the traditional way as other provider orders were received. She confirmed the WCP dictation and orders were available for review within 24 hours in which nurse management and leadership was responsible to make sure the orders were updated, current, and processed as wrote by the WCP. In addition, she expected staff to follow the order as prescribed and if there were concerns identified with the order, the provider was to be contacted for clarification. The DON stated if staff failed to follow an order as prescribed staff were not doing what they were expected to do, which could cause a wound infection. The DON stated during a conversation with R6's FM-B on 8/1/22, FM-B changed R6's dressings on 7/27/22. Staff failed to notify her of this incident. In addition, FM-B informed her no one had changed R6's dressings since. The DON explained during her investigation into R6's wound being found with maggots the dressings were changed by staff despite FM-B's statements they had not. When the DON was questioned as to why the 8/1/22, FRI indicated the dressing was not changed for three days, she explained she panicked and took FM-B's initial statements into account and I thought the worst. The DON confirmed [MEDICATION(S)] and Xeroform are different dressings in which Xeroform is more medicated. She explained a lot of their seasoned nurses have left which may be one reason for some of the wound care/dressing concerns. She stated, when she first started in April, there were definite education issues and she commented it appeared as if they needed to have the wound care supply representative out to the facility for staff training. A policy for physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy identified drug and biological orders were to be recorded on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy lacked direction on the facility's process for nurse order processing and transcription or expectations related to medication and/or treatment administration. An undated policy Wound Care identified the purpose of the procedure was to provide guidelines for the care of wounds to promote healing. The policy directed staff to verify the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .e. type of wound care provided, any changes in the resident's condition, all assessment data obtained when inspecting the wound, how the resident tolerated the procedure, any problems or complaints reported, and if the resident refused the treatment and the reason why. In addition, the policy directed to notify the supervisor if the resident refused the wound care and to report other information in accordance with facility policy and professional standards of practice.

Based on interview and document review, the facility failed to implement a system for immediate identification of resuscitation status during emergency situations for 1 of 1 residents (R1) who arrested and received CPR which did not honor his wishes for DNR status. This resulted in an immediate jeopardy (IJ) when EMS provided cardiopulmonary resuscitation (CPR) to R1, and this went against R1's wishes to not resuscitate. The IJ began on [DATE], at approximately 1:30 a.m. when R1 was found lying on his room floor bleeding profusely from his head. 911 was called and life sustaining interventions were provided for R1 by paramedics when the facility was unable to find a copy of R1's resuscitation status. CPR was initiated and defibrillating shocks were delivered in an attempt to revive R1 before facility staff provided R1's resuscitation status at 1:48 a.m. R1 was then pronounced dead. The administrator was notified of the IJ on [DATE], at 5:26 p.m. The IJ was removed on [DATE], at 2:01 p.m. when the facility successfully implemented a removal plan, but scope and severity remained at a level D, no actual harm with potential for more than minimal harm. Findings include: On [DATE], a report to the state agency (SA) indicated R1 was found unresponsive on the floor after falling and hitting his head. 911 was called and life sustaining interventions were initiated including CPR, defibrillating shocks, and attempted intubation, despite R1 being on hospice and with a code status of DNR. R1's Face Sheet printed [DATE], indicated R1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's admission Minimum Data Set (MDS) dated [DATE], indicated he was moderately cognitively impaired. R1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, R1 was receiving hospice care. On [DATE], at 6:00 a.m. a progress note written by licensed practical nurse (LPN)-A indicated at approximately 1:20 a.m. he was alerted to R1's room where he found him on the floor bleeding from the head. LPN-A called for LPN-C to assist, and LPN-A called 911. Paramedics arrived and immediately started CPR. LPN-A and LPN-C found R1's code status and passed it to the paramedics. On [DATE], at 9:20 a.m. hospice case manager registered nurse (RN)-A was interviewed and stated R1 had been admitted to hospice on [DATE], and he had indicated DNR status on his POLST when he admitted to hospice. RN-A stated R1 had chosen to be a DNR resuscitation status even prior to his admission to hospice. RN-A stated on [DATE], at 2:24 a.m. she was notified by law enforcement R1 had fallen at approximately 1:30 a.m. RN-A stated she spoke to licensed practical nurse (LPN)-A who told her he called 911 at approximately 1:30 a.m. and they couldn't find R1's resuscitation status until 1:48 a.m. RN-A stated LPN-A told her paramedics would not discontinue lifesaving interventions for R1 without proof of his code status. On [DATE], at 1:08 p.m. R1's family member (FM)-A was interviewed and stated R1's wishes were to be a DNR code status. FM-A stated he couldn't understand how something like this happened. FM-A stated R1 was on hospice for a reason. On [DATE], at 2:25 p.m. LPN-B was interviewed and stated she did not know where to find a resident's code status in the computer and she was never taught where to look. On [DATE], at 2:35 p.m. the director of nursing (DON) was interviewed. The DON stated she wasn't sure why staff couldn't find R1's code status. The DON stated a comprehensive investigation had not been completed; she had only reviewed the coroner's report, took a written statement from nursing assistant (NA)-A, and interviewed RN-B who was anxious. The DON stated the receptionist contacted her by text message and a phone call at 1:41 a.m. to notify her off R1's fall. The DON stated she told the receptionist she was pretty sure R1 was a DNR. The DON stated she was told LPN-C was trying to locate R1's code status and POLST. The DON stated she had only provided re-education to LPN-A and LPN-C and no facility wide training was implemented or completed but she was planning on doing so. On [DATE], at 3:02 p.m. NA-A was interviewed and stated she saw R1 lying on his floor and she screamed for help. NA-A stated LPN-A called 911. NA-A stated she did not know if R1 was a full code or a DNR status, and she did not know where this information was located. NA-A stated the nurses should know where to find code status information. NA-A stated she did not remember what happened after paramedics arrived as she was scared and nervous. On [DATE], at 3:16 p.m. LPN-A was interviewed and stated NA-A notified him R1 was on the floor bleeding. LPN-A stated when he found R1, he was unresponsive with shallow breathing. LPN-A stated he called for LPN-C who came to look at R1, and this was when they decided to call 911. LPN-A stated LPN-C went to look for R1's code status while he called 911 and the DON. The DON told him R1 may be a DNR status. LPN-A stated he was not aware R1 was on hospice. LPN-A stated they eventually found R1's code status and gave it to paramedics so they would stop CPR. LPN-A stated he had not worked in five days and had never worked with R1 before, and that was why he was unable to find R1's code status. LPN-A stated he did not receive any re-education after the incident. On [DATE], at 4:06 p.m. LPN-C was interviewed and stated someone came to get him to assist with R1 the night he was found on the floor. LPN-C stated he saw R1 on the floor and bleeding, and LPN-A called 911. LPN-C stated paramedics and law enforcement arrived around 1:40 a.m., R1 was unresponsive, and paramedics started CPR. LPN-C stated they tried to tell paramedics R1 was a DNR, but the paramedics stated they wanted to see proof before they would stop CPR. LPN-C stated he was later able to provide R1's POLST for them. On [DATE], at 9:18 a.m. LPN-D was interviewed. LPN-D was asked to locate a random resident's code status in the electronic medical record (EMR). LPN-A stated she was not aware where a resident's code status was located in the EMR. LPN-A was told to checked under R4's cover sheet banner and the Face Sheet, and both lacked R4's resuscitation status. LPN-D confirmed R4 had no resuscitation orders or a POLST on file for R4 indicating code status. The facility Emergency Procedure - Cardiopulmonary Resuscitation policy last reviewed [DATE], directed CPR certified staff members shall initiate CPR unless it is known that a DNR order that specifically prohibits CPR and/or external defibrillation exists for that individual; or there are obvious signs of irreversible death (e.g., rigor mortis). The IJ was removed on [DATE], at 2:01 p.m. when the facility implemented a systemic plan which included the following actions: reviewed and updated their CPR policy, mandatory education of all nursing staff on the CPR policy, mandatory education on location and use of DNR/POLST binder placed at each nursing station and in electronic medical records, DNR/POLST policies starting on [DATE], medical record audits for code status for all residents was completed on [DATE], then one time per month and then one time quarterly, initiating code blue mock drills capturing all three shifts staggered and unannounced monthly, staff knowledge checks done monthly for three months and then quarterly thereafter.

Based on observation, interview and document review, the facility failed to conduct a thorough root cause analysis of potential causative factors to determine person-centered interventions, and failed to consistently implement fall interventions to prevent and/or reduce the likelihood of future falls for 1 of 3 residents (R7) reviewed for falls. This resulted in actual harm for R7 who experienced frequent falls, and who required sutures to [MEDICAL CONDITION] twice as a result of falls. In addition, the facility failed to follow care planned interventions and therapy recommendations to reduce the risk for aspiration/choking for 1 of 1 resident (R13) reviewed for supervision during dining. Findings include: R7's [DIAGNOSES REDACTED]. R7's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R7 exhibited severely impaired cognition and verbal behavioral symptoms. The MDS indicated R7 did not reject cares and had no wandering symptoms. Further, the MDS indicated R7 required physical supervision assistance of two staff with transfers, walking in the room, walking in the corridor and locomotion in the unit. The MDS indicated for balance, R7 used a walker and was not steady but was able to stabilize without human assistance. R7's care plan dated 12/16/18, identified a self care performance deficit related to [MEDICAL CONDITION]. The care plan directed staff for ambulation, R7 required one staff assistance with use of walker and constant supervision from a sitter per physical/occupational therapy recommendation on 9/27/19. The care plan also identified for transfers R7 required one staff assistance. R7's falls Care Area Assessment (CAA) dated 12/26/19, identified a risk for falls due to being unsteady however, indicated she was able to stabilize without human assistance. On 10/14/19, at 4:11 p.m. when asked if she had fallen recently R7 stated I fall a lot. The floor is waxed and I have been falling a lot. I feel bouncy and dizzy. I do have problems with my feet. When asked if she used the call light to get staff assistance R7 stated at times when she used the call light the staff did not come. When asked if she had any injuries from the falls R7 stated Yes. On 10/14/19, at 6:12 p.m. R7 was observed to stand up from the dining room chair using her walker then started to ambulate out of the dining area. As R7 went across the dining room, nursing assistant (NA)-E was observed standing by the refrigerator and did not offer or cue R7 to wait for assistance to ambulate to her room. At 6:13 p.m. as R7 got near the entrance door to the dining room, registered nurse (RN)-C approached R7 and stated, are you finished I will walk with you. However, although RN-C walked out of the dining room with R7, RN-C was observed to go into the nursing station to call the kitchen for more food leaving R7 to ambulate alone down the hallway, a distance approximately 50 feet. R7 was observed to lean to the right side with a shuffling gait. At 6:16 p.m. as R7 ambulated down the hallway alone, she walked past both the dietary manager and licensed practical nurse (LPN)-C, who did not intervene or offer assistance. On 10/17/19, at 9:51 a.m. the health unit coordinator (HUC) was observed pushing a wheelchair behind R7 as she ambulated with a walker. The HUC acknowledged she was not a trained nursing assistant, or nurse. She also verified if R7's lost balance while she was walking behind her, she would not be able to support the resident to prevent a fall. A review of facility incident reports and Clinical Note Reports identified R7 had experienced numerous falls, with a variety of interventions attempted, but failed to conduct a root cause analysis to identify effective interventions to minimize or prevent falls. An incident report dated 5/4/19, at 7:40 p.m. included: Resident was found on the floor in her room laying on her right side. She was holding her cellphone which was not working. Walker was next to her and was tipped over. She was wearing gripper socks, call light was in place. The report indicated R7 had sustained a skin tear to right forearm 1.0 centimeter (cm) by 0.5 cm. The Intervention/action put in place was R7 was reminded to use the call light when in need. An incident report dated 5/6/19, at 5:15 p.m. indicated a NA had found resident on her knees, went to call the nurse and when the nurse arrived, R7 was observed laying on her right side and stated, I fell . The intervention/action: R7 was educated to use the call light and call for help during transfers or when needing help. An incident report dated 5/8/19, at 6:38 p.m. included: At 1830 (6:30 p.m.), staff went to answer resident call light and found resident lying on her back, close to bed, alongside to wheelchair (w/c), floor dry, no rugs noted on the floor, gripper socks on, call light within reach, lights were on. The intervention/action was R7 was educated on use of call light and safety checks every 15 to 30 minutes were initiated. An incident report dated 5/24/19, at 3:01 p.m. included: Resident was found sitting on the floor with legs flat on the floor hands stretched backwards. The chair and wheelchair were near. The intervention/action: R7 was reminded to use the call light whenever she needs help. R7 was reminded that she should feel the chair behind her knee before sitting. Staff members were also reminded to check on R7 regularly whenever she was in her room. An incident report from 6/1/19, at 3:30 p.m. included: Resident was observed sitting on the floor in the hallway by the nursing station with the legs straight out on the floor. The resident had her walker, was wearing her shoes and floor was dry. The intervention/action was identified as remindering R7 to call for help, and to teach her to always feel the chair behind her before sitting. An incident report dated 6/15/19, at 1:57 p.m. included: Resident was observed on the floor in her room. The intervention/action: Resident will be checked frequently to prevent from falling. An incident report dated 7/1/19, at 1:38 p.m. indicated R7 was found on the floor in her room lying on her back at 1:30 p.m., and the wheelchair was next to the bed. The intervention/action: (R7) Educated on importance of using call light and call for help during transfer, call light left within reach. An incident report dated 7/17/19, at 3:03 p.m. included: Resident was found sitting on the floor holding a pen and papers in her left hand. The walker was near her bed. The intervention/action: Resident was reminded to use her walker whenever moving in the room, use the call light if help is needed. An incident report dated 8/6/19, at 5:40 p.m. included: Resident was found sitting on the floor in her room. Resident was wearing shoes, walker was next to her, floor was dry and free of clutter. Intervention/action R7 was encouraged to call for help when in need. The staff was to monitor resident closely and assist her as needed. Also therapy was requested to evaluate R7. An incident report dated 8/12/19, at 2:09 p.m. indicated R7 was Found on the floor lying on her right side by staff member in the dining room. The walker was just beside her but far from dining table. The intervention/action indicated staff was educated to make frequent checks on the resident, and to keep reminding resident to use the walker and to call for help whenever needed. Also staff not to leave R7 alone in the dining room. An incident report dated 8/18/19, at 4:30 p.m. included: Resident had un-witnessed fall in the room. Writer was informed about the fall by family member of another resident, who saw resident on the floor while walking in the hallway. Resident found in a sitting position next to the bed, leg flat on the floor facing the door way, and walker to the left beside her. The intervention/action taken indicated staff was educated to encourage resident to be in the common areas when not in bed, for easy eye reach due to multiple falls in the room. An incident report dated 9/15/19, at 4:00 p.m. indicated the writer heard resident yelling she had fallen in her room. When writer went to room R7 was observed on her left side with head towards the door, walker was at the foot of her bed. No intervention/action was identified. An incident report dated 9/15/19, at 7:03 p.m. included: Around 6:25 p.m. resident (R7) was alert, sitting in the dining area eating and had requested the writer get her yogurt. As the writer went to get yogurt from the cart that was on the east hallway next to the north nursing station, the writer heard a loud bang and resident was observed on the floor on her left side with blood oozing out from her forehead. The report indicated R7 stated, I was trying to stand up, the chair slipped and I lost balance from my chair and fell . The intervention/action taken indicated the resident was sent to the hospital and discharged on [DATE], with a laceration on the right forehead measuring 3 centimeter (cm) which required sutures, and a large bruise on the right thigh measuring 10.5 cm by 7.5 cm. An incident report dated 9/21/19, at 7:20 a.m. included: Resident was found sitting on the floor near the bed with her legs flat while facing the bed. The intervention/action identified included: Resident reminded to use the call light. Resident was monitored frequently while in and outside her room. She was encouraged to spend most of her time in activities and near the nursing station. Nursing staff will continue to monitor. An incident report dated 9/23/19, at 6:47 a.m. included: Resident was found on the floor facing the door with her back resting on the bed and her legs stretched forward in her room. No injuries. The intervention/action identified included for the physical therapist to continue working with resident on her muscle strength, to see determine when/if R7 could use her walker. In addition the actions identified nursing assistants were educated to do more frequent checks on the resident to meet her needs An incident report dated 9/26/19, at 9:20 a.m. included: Resident was found sitting on the floor near the bed. The intervention/action identified included: Resident was taken to activities and the nursing aide will stay with her all the time. An incident report dated 9/27/19, at 12:20 p.m. indicated R7 was found sitting on the floor in her room with three bottles of drinks nearby. The report included: This happened a few minutes after (R7) had refused to go to the dining room for lunch. The interventions/action identified included: Resident did not follow instructions for safety. Nursing assistant stayed with her all the time to ensure her safety. An incident report dated 10/10/19, at 11:05 a.m. indicated R7 was found sitting on the floor in the bathroom, the water faucet was open and her walker was by the door. The intervention/action identified post fall included: Nursing staff will continue to monitor her closely while in and out of her room and also staff will continue to encourage her to engage in activities. An incident report dated 10/12/19, at 1:30 p.m. included: Writer was informed by nursing staff about resident on the floor in the dining room with head towards the door and legs inside. No new or revised interventions were identified. An incident report dated 10/13/19, at 3:48 p.m. included: Resident was found lying on the floor near the bed, head closer to the drawer. Writer noted a scratch and scanty blood behind her head. The post fall intervention/action included: Resident was reminded to use the call light, staff members will continue to monitor her closely. An incident report dated 10/15/19, at 6:16 a.m. included: Writer had just left the resident room and was standing at the medication cart when he heard a loud bang from the resident room. Writer rushed to the room to check on the resident and found her lying on her stomach bleeding from her forehead. Room was well lit, floor was dry with no rugs on it. Resident was lying beside a wheelchair and a table chair, her walker was next to her bed at the time. Her bed was low with brakes on and the call light within reach. Resident was dry. The intervention/action identified included: Resident forehead injury was assessed, cleaned and pressure was applied to the area awaiting ambulance. Resident was assisted to the wheelchair with two staff assist. Additional documentation indicated R7 had returned to the facility from the hospital with 15 stitches to a laceration on her forehead, a skin tear on the left hand measuring 2.0 cm by 2.0 cm, and bruises to the left eye. On 10/16/19, at 11:35 a.m. family member (FM)-A was interviewed and stated, They call about her falls very regularly as this has become an issue. She is stubborn about using the walker and it is a combination of the facility being short staffed at times. She has [MEDICAL CONDITION] and at times would ask for assistance but the staff don't come and at times she refuses the staff's help. She has had multiple medication changes in the past and has been followed by a neurologist and with the progression of [MEDICAL CONDITION] it's only going to get worse. They are trying to do the best but the disease is progressing. When she was at home she fell a lot and that was when we had to move her out. I don't want her medications to be messed around with and think it is a project. They don't seem to be attentive with her when I come there at times. On 10/16/19, at 12:08 p.m. when asked about R7's falls RN-A stated, Sometimes she is busy walking around and when she is agitated she wants to go home. It is not easy to re-direct her even if you bring her to activities as it will not work. She doesn't want to do activities and would only stay there for five minutes and leave, she wants to go to her room. She is able to ask to use the bathroom, and if she is in the room she will come to the door and ask for help. On 10/16/19, from 12:55 p.m. to 1:30 p.m. R7's 22 falls were reviewed with the director of nursing (DON) and RN-C. During the review the DON stated, We try to find what caused the fall and the aides would say they had just toileted her. We try to keep an eye on her to find why she is falling. She does refuse cares and we ask if the call light was in reach. We have asked staff at times if she was wet. We try to evaluate the circumstances and we educate her but she needs constant reminders because sometimes she doesn't remember and sometimes she does. Staff are to anticipate her needs and they are supposed to go into the room. Both the DON and RN-C acknowledged several of the interventions identified were the same and may not have been appropriate for R7. RN-C stated she thought the nurse practitioner (NP) had reviewed and adjusted R7's medications following the 9/15/19 fall. Both the DON and RN-C acknowledged a root cause analysis had not been completed for resident's falls in an effort to determine why R7 continued to fall. In addition, both acknowledged R7's toileting program had not been reviewed following the falls. When asked if R7's falls were being reviewed by the interdisciplinary team (IDT), RN-C stated R7's falls were discussed weekly in the meeting however, RN-C stated there was no documentation. The DON stated R7's care plan was supposed to be followed and staff were supposed to ambulate with her with assistance of supervision contact guard (SCG) as recommended by therapy on 6/27/19. During the interview, the surveyor requested documentation of the NP's medication reviews, and the documentation of the 15 to 30 minutes checks completed by RN-C. On 10/26/19, at 1:47 p.m. RN-C acknowledged she was supposed to ambulate with R7 on 10/14/19, this was a recommendation by therapy and I added it to the care plan. On 10/17/19, at 7:18 a.m. RN-C stated she had not found any documentation for the checks that had been initiated for the falls adding, I will take full responsibility. Again, the surveyor requested the NP's medication reviews. On 10/17/19, at 1:29 p.m. the nurse practitioner stated she had been working at the facility for a month and knew that R7's [MEDICAL CONDITION] medications had been adjusted. The NP also said she had decreased R7's [MEDICATION NAME] ([MEDICAL CONDITION] medication) from seven times daily to five times daily, but R7 continued to fall. The NP stated R7 had not seen the neurologist for a while so she had asked FM-A if she wanted R7 to be seen, and FM-A had stated nothing was going to get better. The NP also stated, I had the nurses check orthostatic blood pressures and those were normal, we trying, but nothing has really stood out for us as the cause of her falls. We think it's just the disease progression. We are taking one step at a time and I am going to change the [MEDICATION NAME] again and if it does not work will put it back. The NP also stated she had asked nursing to track the time of the falls however this had not been completed yet. The NP acknowledged the facility fall IDT committee needed to do a root cause analysis for falls and indicated there were not a lot of medication adjustments that needed to be done as FM-A was reluctant to make further adjustments. The facility's undated Accidents and Incidents- Investigating and Reporting policy, included: The staff will evaluate and document falls that occur while the individual is in the facility; for example when and where they happened, any observations of the events etc. For an individual who has fallen, the staff will attempt to define possible causes within 24 hours of the fall. Causes refer to factors that are associated with or that directly result in a fall. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or that finding a cause would not change the outcome or the management of falling and fall risk. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation . R13's quarterly MDS dated [DATE], indicated she was severely cognitively impaired and required extensive assistance for eating. R13's care plan dated 10/3/19, identified a self care deficit and indicated R13 liked to feed herself but required more time, cues and supervision to eat. The care plan further identified chewing and swallowing difficulty related to dysphagia and orders for a mechanical soft diet. The care plan, updated following surveyor inquiry directed staff to alternate small bites of food and sips of fluids and to eat only with supervision. A Progress Note dated 8/20/19, indicated R13 had a swallow study completed the previous day. Recommendations were to remain on puree diet with thin liquids. Precautions/feeding instructions as follows. - Seated fully upright for all intake. - No straws - Alternate solids/liquids. - Go slowly and make sure she has swallowed before taking another bite/sip. During observation in 10/14/19, at 6:10 p.m. staff sat next to R13 in the dining room. At 6:19 p.m. R13 was observed coughing. At 6:38 p.m. staff left R13 unattended at the dining table. R13 was observed putting food into her glass of cranberry juice and drinking from her water glass. On 10/15/19, at 8:34 a.m. staff brought R13 a glass of orange juice and a glass of milk and left her unattended at the table. At 9:06 a.m. R13 sat in the dining room unattended with a glass in front of her and was coughing. At 2:12 p.m. R13 sat in the activity room watching a movie. R13 was drinking from a water cup and was unsupervised in the room. On 10/16/19, at 8:52 a.m. R13 started to cough after taking a sip of her milk. RN-C was seated next to R13 and stood up and took the cup from her. RN-C stated R13 was supposed to drink with a spoon but refused. At 8:54 a.m. R13 was still coughing and had tears coming out of her eyes. During interview on 10/16/19, at 9:09 a.m. nursing assistant NA-H said staff sit with R13 to supervise and encourage her to eat and drink. NA-H was not aware of any restrictions to R13's diet. During interview on 10/16/19, at 11:59 the speech language pathologist (SLP) stated it had been noticed by several staff that R13 was coughing with meals. The SLP stated she did an evaluation and was hard to tell exactly what was going on so she put her on precautions and had a swallow study done. She said R13 returned with precautions but she didn't think they were practical so she removed the liquids by spoon only precaution but said R13 should have staff with her at all times when eating and drinking. At 12:54 p.m. R13 was again seated at the dining table unattended and was reaching for other residents liquids on the table. At 12:55 p.m. NA-I stated R13 was independent with eating and drinking. At 12:28 p.m. NA-J stated R13 was independent with meals. At 12:59 p.m. NA-G stated R13 was on a pureed diet and thin liquids. NA-G stated R13 was on swallow precautions and was supposed to have tiny swallows at a time. NA-G stated she usually gave R13 her drinks with a spoon and she would spoon the liquids herself. At 9:36 a.m. registered nurse (RN)-A stated R13 had a swallow test done and speech recommended with thin liquids she use spoons, no straws. RN-A said when R13 was not able, staff assist her to drink. RN-A stated staff should supervise R13 and said no one should give her a cup and walk away. On 10/18/19, at 10:47 a.m. the director of nursing stated staff should be sitting with R13 during the entire meal.

Based on interview and document review, the facility failed to implement procedures for supervision of cognitively impaired residents residing in the facility to ensure sexual abuse does not occur for 1 of 2 residents (R1) reviewed for sexual abuse. In addition the facility failed to complete a thorough investigation following an alleged incident of sexual relations between two residents residing in the facility. The facility failed to ensure the whereabouts of R1 who was cognitively impaired and had been observed outside the facility with R2 on at least two occasions resulting in the placement of a wander guard device. The immediate jeopardy began on 4/27/19, when R1 was hospitalized following an incident in which staff realized she was not in her room and she was found in a male resident's (R2) room. It was confirmed R1 had engaged in sexual intercourse with R2, but due to cognitive deficits is unable to give consent for sexual relations. The facility failed to thoroughly investigate the circumstances related to the incident. The adminstrator was informed of the immediate jeopardy on 5/2/19, at 5:00 p.m. While the immediate jeopardy was removed on 5/4/19, at 9:12 a.m., non-compliance remained at the lower scope and severity of a G. R1's admission Minimum Data Set ((MDS) dated [DATE], identified a cognitive assessment had not been completed due to R1 being rarely/never understood. The staff assessment for cognition indicated severe impairment. The MDS indicated R1 required assist of one staff for all activities of daily living (ADL)'s. R1's care plan dated 4/17/19, identified cognitive impairment, impaired safety awareness and amnesiac behaviors and identified a communication deficit related to receptive/[MEDICAL CONDITION] (loss of ability to understand or express speech) and weak or absent voice. The care plan directed staff to monitor R1's whereabouts every 30 minutes and document wandering behavior along with the placement of a wanderguard device. The care plan further identified R1 as a vulnerable adult and indicated a safety risk and potential for abuse related to her current medical condition. The care plan directed staff to ensure she was safe around others who may take advantage of her confusion. R2's quarterly MDS dated [DATE], indicated a cognitive assessment was not completed. The MDS further indicated R2 was independent with all ADL's. A facility assessment titled BIMS (brief interview for mental status) dated 3/7/19, identified a staff assessment that revealed no memory problem and indicated R2 was independent in making decision regarding tasks of daily life. R2's care plan dated 3/5/19, indicated he was independent with activities of daily living including dressing, transfers and ambulation. The care plan identified R2 as a vulnerable adult with [DIAGNOSES REDACTED]. A facility Progress Note dated 4/26/19, indicated, R2 was spoken to by writer about not taking other residents outside. R2 stated he would no longer do so. A facility Progress Note dated 4/27/19, indicated at 11:20 p.m. staff informed writer R1 was not in her room and was not in her bathroom. While doing a search of other rooms on the unit staff approached R2's room. R2 started yelling at staff and asked them to get out of his room. The nurse went to R2's room and knocked at which time R2 opened his door a little and stood behind it. Staff noted R2 was not wearing a shirt but did not pay attention to what he was wearing on his bottom. When asked if he had seen R1, R2 answered no. When staff told R2 they needed to check his room, he told them he was naked and staff could not go in. Staff told R2 to put some clothes on so staff could enter his room. R2 went into his room for awhile so staff again knocked on his door. R2 opened the door and was dressed, appeared he was going to leave the room and pointed to R1 who was now coming out of R2's side of the room without any shoes or socks. When R2 was asked why he denied knowing where R1 was, he replied, we were sleeping. R1 was sent to the hospital for evaluation. A Progress Note dated 4/29/19, indicated the health unit coordinator (HUC) stated she saw R2 outside the front door sitting with R1, after R2 stated on Friday (4/26/19), at 2:00 p.m. he would not do that anymore. HUC stated this was on 4/26/19, around 5:00 p.m. During interview on 5/2/19. at 1:11 p.m. social worker (SW)- A stated when R1 admitted to the facility a care conference was held with her daughter and stated R1's daughter was working on getting power of attorney. SW-A stated R1's daughter felt she was not able to make her own decisions, was cognitively at a teenage level and could not always be understood. SW-A stated when she spoke to R1 she would often just have a blank stare and did not have a good memory. Regarding the events that occurred on 4/27/19, SW-A stated her understanding of the events were as follows: R1 was out in a common area of the unit crying, another resident (R2) asked what was wrong and when he went to walk away, R1 asked where he was going. R2 invited R1 to watch television in his room. R2 stated he sat in the chair and R1 was on the bed. R1 fell asleep and R2 did not want to wake her. SW-A stated R1 was found in R2's bed with no incontinent brief on and R2 had no shirt on. In regard to R2, SW-A stated he was interviewable and appeared very helpful but stated he had made some comments to her that had caught her off guard. SW-A stated R2 had made comments to her such as telling her she had a nice figure and asked her if she stayed there all the time. SW-A further stated she knew R2 to be a heavy drinker and stated recently she was assisting him and he was not making sense, had slurred speech and was wobbling in his chair. -During interview at 1:22 p.m. registered nurse (RN)-A stated she had received a call in the middle of the night on 4/27/19, that R1 was not in her room. RN-A stated according to notes staff had checked on her at 11:30 p.m. and she was not in her room. RN-A stated staff did a room search to locate her and when they knocked on R2's room he would not let staff in. RN-A stated when staff told R2 they needed to do a room search R2 yelled that R1 was not in there so staff went to get the nurse who told R2 he had to let staff in his room. RN-A stated when staff entered the room, R1 was coming from R2's side of the room and when staff asked R2 why R1 was in his room, he stated they were just sleeping. RN-A stated she had spoken to R1's family member (FM)-A after the incident and FM-A told her there were positive signs R1 had had sexual intercourse. RN-A stated she had not questioned R2 at any time but stated she had done an investigation on her floor. RN-A stated she had asked everyone if between the hours of 10:00 p.m. and 12:00 a.m. if they had heard anyone yelling for help, distressful or yelling and screaming. RN-A stated no one in the rooms next to R2 heard anything. RN-A stated a meeting had taken place on the unit in which the administrator had explained to residents that it was okay to engage in a sexual relationship as long as both parties were consenting and able to make that decision. In regard to R1's ability to consent, RN-A stated, It's hard to know for sure. RN-A stated R2 was placed on 15 minute checks on 4/27/19, and stated it was to continue until the administrator told them it was no longer needed. Upon reviewing the documentation titled, Wandering Observation 15 Minute Checks, there were times when the sheet was not filled out and other times when the sheet indicated R2 was downstairs on the first floor. RN-A stated, I don't believe anyone was checking on him when he was off the unit. A review of facility documents titled, Wandering Observation 15 Minute Checks identified the following: 4/27/19, 1:30 a.m. to 8:00 a.m. R2's whereabouts were not accounted for. 4/27/19, 12:00 p.m. to 1:00 p.m. R2 was downstairs in the first floor dining room. R2 resided on the third floor of the facility. 4/27/19, 5:00 p.m. to 10:30 p.m. R2 was downstairs on first floor. 4/28/19, 11:00 a.m. to 1:15 p.m. R2 was downstairs on the first floor and again from 5:45 p.m. to 7:00 p.m. 4/28/19, 5:00 p.m. to 5:45 pm. R2 was out for a walk, then on the first floor until 6:30 p.m. During interview on 5/2/19, at 2:27 p.m. the administrator stated he had spoken to R2 following the incident. The administrator stated R2 said he did not have any sexual relationship with R2 and that R2 told him R1 was in his room watching television, fell asleep and the next thing he knew staff was knocking on the door. The administrator stated when he asked R2 about the semen that was found on R1, R2 stated it was not him. The administrator stated he told R2 it was okay to have a relationship with another resident but he was responsible for making sure the other resident was capable of making that decision. The administrator stated R2 was placed on 15 minute checks and stated he believed staff were following up on the checks. He further stated staff had gotten together with the most competent residents and went through the same thing he had with R2 about ensuring consent. When asked about documention of the 30 minute checks R1 was placed on, the administrator stated he would have to look into it. During interview on 5/2/19, at 3:19 p.m. HUC-A stated the other resident referred to in the progress notes in which R2 was outside the facility was R1. During interview on 5/2/19, at 4:19 p.m. the director of nursing (DON) stated the licensed nurses were responsible for completing the 15 minutes checks on R2 but stated the over all responsibility belonged to herself and the nurse manager. The DON further stated when R2 was not on the unit, whoever was responsible for that shift should have known where he was every 15 minutes. The DON stated prior to the incident that occurred with R1, she had never had a problem with R2. The DON stated she had interviewed R2 following the incident and R2 told her nothing had happened. When asked what time the last staff person had seen R1 prior to being found in R2's room, the DON stated she thought around 11:00 p.m. When asked if other residents were interviewed regarding unwanted attention or sexual advances by other residents, the DON stated, no, we did not ask. She stated they had in-services with staff related to reporting. At 4:33 p.m. the administrator stated he had spoke to the nurse manger on the unit about R1's 30 minute check. The administrator stated the 30 minute checks were never implemented. During interview on 5/2/19, at 4:36 p.m. FM-A stated the hospital had performed an assessment of R1 that was positive for seminal fluid. FM-A stated she had concerns about R1's stay at the facility including R1 being put on a wander list, stating she found out after the fact. FM-A stated at one point SW-A had eluded to a resident hanging out around R1's room or seeking her out and after the incident occurred, RN-A had left her a message stating R2 had been asked not to have contact with R1. FM-A stated there were a lot of gray areas and the facility is being very tight lipped. FM-A stated other than what the doctors at the hospital told her, she did not have a lot if information. In regard to R1, FM-A stated she would cry a lot since she admitted to the facility, especially when she and her sister would leave, but R1 could not articulate details of why she was sad. FM-A stated, I doubt (R1) would have been able to say no or have the capacity to understand and stated the only thing the doctors got out of her was she was scared and didn't know what to do. During interview on 5/3/19, at 9:21 a.m. the medical director stated she was aware of the incident involving R1 and R2. The medical director stated she knew R1 was sent to the hospital and the hospital found seminal fluid. The medical director stated, It's difficult, I don't think (R2) has much awareness, I don't know how much he is aware of the harm he has done. She further stated she knew R1 certainly is not able to give consent. A copy of the facility investigation was reviewed and contained the following: An incident report form dated 4/27/19, indicated at 11:20 p.m., following a search for R1 who was not in her room, she was located in a male resident's (R2) room. The report contained the above mentioned progress note dated 4/27/19. The report further indicated R2 was placed on 15 minute checks. The report contained no further details. An untitled piece of paper dated 4/29/19, at 10:20 (no indication of a.m. or p.m.) signed with initials: (Administrator and SW-A) interview with R2: R2 talking with resident in tears asking if she was okay (referring to R1). R1 asked R2 where he was going and he said to watch television. R1 asked to go in his room. R1 sat on bed, R2 on chair. R2 took medications and passed out. When R2 woke up and saw R1 sleeping he did not want to wake her. Then police were there and took the bed sheet and took R1 away. In regard to the semen found on R1, R2 stated if did not happen, could not have happened. In regard to R1's incontinent brief, R2 stated not knowing why it was on the floor. Administrator let R2 know if another resident was not capable of making decisions he could be charged with rape. R2 understood. R2 was told it was never a good idea to have a woman in his room at midnight, R2 understood. Untitled documents completed by staff with the following information: Regarding the alleged sexual incident reported by staff on 4/26/19, involving another resident (R1). - were you assigned to her? - When did you se her last? - Did she appear afraid? Guarded? - Was evening care rendered to her? What time? - staff signature. 4/26/19, Nursing assistant (NA-)-A wrote on a blank piece of paper: I left (R1) in her room on her bed, changed her and left after my shift 11 p.m. 4/27/19, RN-B indicated she was assigned to R1, last saw her at 11:30 p.m. and she appeared calm. RN-B did not indicate where R1 was when seen at 11:30 p.m. 4/27/19, licensed practical nurse (LPN)-A indicated he was not assigned to R1, had last seen her at 11:30 p.m. and R1 did not appear afraid. LPN-A did not indicate where R1 was when last seen. 4/27/19, unidentified staff member indicated being assigned to R1, last saw her at 11:45 p.m. and R1 did not appear afraid. The unknown staff member did not indicate where R1 was last seen. All of the staff interviewed indicated they last saw R1 between 11:00 p.m. and 11:45 p.m. even though Progress Notes indicated R1's whereabouts were unknown at 11:20 p.m. and a room search was conducted. The investigation file further contained multiple statements from residents asking if they had heard or were awakened by anyone yelling for help as if they were in any kind of distress between 10:00 p.m. and 12:00 a.m. on 4/26/19, even though R1's care plan indicated she was rarely or ever able to be understood and had a weak or absent voice. All residents asked indicated they had not heard anything. The immediate jeopardy was removed on 5/4/19, at 9:12 a.m. when the facility implemented and the following was verified: Assessment of vulnerable adults in the facility to determine their capacity to make decisions about relationships and monitoring of potential relationships, interviews with residents asking if anyone had approached them with sexual advances, development of a policy and procedure to identify residents who may begin a relationship in the facility, including; what to monitor and who to report to, staff education related to resident relationships and resident education related to potential relationships while residing in the facility. A facility policy titled Vulnerable Adult dated 5/10/18, indicated the primary goal of the faciltiy will be to ensure all residents are safe; all residents under the care of the facility are considered vulnerable. A vulnerable adult assessment and care plan will be completed upon admission and reviewed quarterly and annually. A facility policy titled Abuse Prevention Program undated, indicated our residents have the right to be free from abuse, neglect The policy defined sexual abuse as, but not limited to, sexual harassment, sexual coercion or sexual assault. Upon receiving reports of abuse an immediate investigation will be conducted.

Based on observation, interview, and document review, the facility failed to ensure 1 of 1 resident (R31) who used oxygen and smoked was assessed and provided appropriate supervision with smoking which resulted in an immediate jeopardy (IJ) with risk for serious injury when R31 was observed smoking while using oxygen. In addition, the facility failed to ensure mechanical lift transfers were conducted in a safe manner, resulting in an immediate jeopardy (IJ) with risk for serious injury to 1 of 1 resident (R42) when transferred with a lift and the straps were not connected appropriately to the lift and the sling was too large. The facility also failed to investigate falls for 1 of 3 residents (R17) reviewed. The IJ began on 12/27/18, when staff were aware R31 was smoking while using oxygen, and failed to conduct a smoking assessment and implement interventions to prevent risk for fire [MEDICAL CONDITION] R31. The administrator and director of nursing (DON) were informed of the IJ on 1/10/18, at 10:21 a.m The IJ was removed on 1/11/18, at 1:34 p.m. but non-compliance remained at the lower scope and severity of D -isolated scope and severity level, which indicated no actual harm with the potential for more than minimal harm that is not an immediate jeopardy. The IJ began on 1/11/19, at 10:45 a.m. when staff were observed to transfer R42 with a mechanical lift in a manner inconsistent with safe implementation. The administrator was informed of the IJ at 1:34 p.m. on 1/11/18. The immediate jeopardy was removed on 1/12/18, at 11:50 a.m. but non-compliance remained at the lower scope and severity of D -isolated scope and severity level, which indicated no actual harm with the potential for more than minimal harm that is not an immediate jeopardy. Findings include: R31 was observed on 1/9/19, at 12:27 p.m. in a motorized wheelchair outside in the smoking shed with a lit cigarette. R31 had a portable liquid oxygen tank on the back of the wheelchair and a nasal cannula in his nostrils. A licensed practical nurse (LPN)-D was notified of the issue, removed the oxygen tank from the wheelchair and brought it into the building. LPN-D verified the oxygen tank was on at the time R31 was smoking. At 1:43 p.m. R31 was observed again smoking a cigarette in the smoking shed with the oxygen off the wheelchair, but R31 still had the nasal cannula in his nostrils. R31's admission Minimum Data Set ((MDS) dated [DATE], indicated R31 had intact cognition with [DIAGNOSES REDACTED]. A review of R31's physician orders [REDACTED]. A review of the re-admission orders [REDACTED]. A review of R3's progress note dated 12/27/18, at 3:18 p.m. indicated, Occupational therapist (OT) caught patient in the smoking shed with his O2 (oxygen) on, OT yelled at him to back out of there immediately, he did and stated his 02 was empty. OT explained that any O2 tank is not allowed out by or in the smoking shed. On 1/9/19, at 1:04 p.m. and 2:30 p.m. R31 stated he smoked a cigarette with oxygen running and the staff had talked to him about removing the oxygen prior to smoking, but he did not do it. He also stated he had not had a cigarette since (MONTH) (YEAR), and the order for a nicotine patch had stopped, and he was craving nicotine. When asked how often he smoked daily, R31 stated that was the first time he had smoked since (MONTH) (YEAR). On 1/9/19, at 1:46 p.m. registered nurse (RN)-B stated R31 had told her that morning he was craving a cigarette and would not allow her to do the wound dressing. RN-B stated she had put a call out to the primary care provider for an order for [REDACTED]. A nurse progress note dated 1/9/19, at 11:30 a.m. indicated R31 refused to lay down for his dressing change because he was craving nicotine and wanted the nicotine patch back. On 1/9/19, at 1:50 p.m. the receptionist was interviewed and stated usually residents signed out when they left the property, but did not sign out if they are going to sit outside. The receptionist stated because other people coming in and residents going out to appointments, she did not always know who went out to smoke. The receptionist stated no one was allowed to smoke out front and she had not seen anyone smoking with oxygen. When asked if she knew all the residents who had been identified to smoke she stated she did not have list, but knew who went out to smoke. On 1/9/19, at 1:55 p.m. which was 1 hour 28 minutes since R31 had been observed smoking with oxygen, the director of nursing (DON) stated she was unaware of the situation and nothing had been reported to her. On 1/10/19, at 7:45 a.m. during an interview the director of therapy (DT) stated on 12/27/18, she saw R31 in the smoking shed when she was going to her car to get something. The DT noticed he had his oxygen tank on and remembered R31 had an electronic cigarette that he used in the past. The DT stated she ran up to R31 and told him to get out of the shed with his oxygen on. The DT stated R31 did not have anything in his hands at the time. R31 told DT the oxygen was off. The DT stated she asked R31 how did he know when he could not reach it. The DT stated she reported the incident, because everyone needed to know. The DT could not remember who was told about the incident. The DT did not know that R31 had been smoking with his oxygen on, on 1/9/19. Review of R31's medical record indicated R31 had been assessed for smoking when admitted , and it was determined R31 did not smoke. A new assessment was not found after the incident on 12/27/18. After concern was brought to the facility's attention a new smoking assessment was completed on 1/10/19, indicating R31 was safe to smoke cigarettes independently. R31's care plan was updated on 1/9/19, and indicated a problem and interventions related to R31 not following the facility's smoking policy. Review of the facility's Smoking Policy dated 9/18/18, and revised 1/10/19, indicated in item eleven the staff were supposed to review the status of a resident's smoking privileges upon admission/readmission, quarterly, significant change and annually. The immediate jeopardy that began on 1/10/19, was removed on 1/11/19, when R31 had been reassessed for his ability to safely smoke. All residents identified to smoke were educated on the risks of smoking near an oxygen tank and educated to report to a nurse if this was observed. R31's plan of care was updated; nursing staff education on how to respond if residents were observed smoking near oxygen and when to report to the nurse. Noncompliance remained at the lower scope and severity level of D due to ongoing educational needs of staff. R42 was observed on 1/11/19, at approximately 10:45 a.m. being assisted by nursing assistant (NA)-C and NA-D to transfer from her wheel chair to bed using a mechanical lift that NA-C had retrieved from another resident's room. RN-A was present during the transfer. As NA-C and NA-D began raising R42 up in the lift, surveyor had to intervene and instruct the NAs the sling was not correctly connected to the machine. The loop that secured the sling to the machine was not connected correctly into the hook. During the initial transfer from chair to bed, R42 was observed in a large sling with her bottom falling through the sling. Due to the small amount of space in the room NA-C and NA-D lifted R42 in the lift and while she was hanging, moved the lift to the back of her bed while they moved the chair out of the way then moved the machine back to the bed before lowering R43 onto the bed. When asked about the size of the sling, NA-C stated the sling came with the machine. RN-A stated R42 could use a smaller sling and stated, I think we talked about getting more. RN-A further stated the sling size should be based on the residents body weight. At 11:17 a.m. NA-C and NA-D prepared to transfer R42 back into her chair. At that time, surveyor identified a piece of tape adhered to the lift. The word broken was written in red marker on the tape. When asked what was broken, NA-D stated the leg of the lift was broken. The leg did not fully close and did not touch the floor. NA-C and NA-D proceeded to use the broken lift to transfer R42 from the bed to her chair. The sling used during the transfer was faded, burgundy in color and did not include a label that identified the size. At 11:48 a.m. the broken lift was observed in the hallway in the basement. The administrator confirmed it was the lift removed from the second floor. At 1:05 p.m. the administrator stated he had reviewed the maintenance requests and stated there was no record of the lift being broken. The administrator stated the lift should have been removed from the floor and a maintenance request completed. An undated document titled, EZ Way Sling Sizing Chart was provided by the administrator. The chart identified a color coding system for the mechanical lift slings and indicated burgundy was a large sling. The adminstrator indicated staff received training on the use of lifts during employee orientation. R42's quarterly MDS dated [DATE], indicated she had moderately impaired cognition and required extensive assist of two staff for transfers. R42's care plan dated 1/2/19, identified R42 had limited physical mobility and weakness and directed staff to assist with transfer using a mechanical lift. During interview on 1/11/19, at 3:03 p.m. NA-C stated she received training on the use of mechanical lifts when she was hired at the facility but stated she had not received any education or direction related to which size sling to use for each resident. During interview on 1/11/19, at 3:30 p.m. RN-A stated she did not observe the sling was too big until R42 was already in the air. RN-A was unable to explain why she did not intervene and get an appropriate sized sling before R42 was transferred back to her wheel chair. In regard to the broken lift, RN-A stated she was not sure why it was on the unit. On 1/12/18, an undated document titled, Sling Sizes 2nd Floor provided by the administrator indicated R42's appropriate sling size was petite/small. The immediate jeopardy that began on 1/11/19, was removed on 1/12/19 , when R42, and all other residents who required mechanical lift transfer assistance had been reassessed for their transfer ability, and use of appropriate transfer equipment by nursing and/or physical therapy; resident plans of care were updated; nursing staff education on how to appropriately use mechanical lifts along with appropriate sling size. These interventions were verified by interviews with staff, review of resident records, and review of training documentation. Noncompliance remained at the lower scope and severity level of D due to ongoing educational needs of staff. R17 had four falls in the last four months (10/21/18, 12/1/18, 12/11/18, and 1/8/19), and staff did not investigate the reason for the falls or attempt to revise interventions to meet R17's needs. R17 was admitted on [DATE], with [DIAGNOSES REDACTED]. R17's quarterly MDS dated [DATE], identified R17 had severe impaired cognition. Fall Risk Data Collection Tool dated 10/24/18, identified R17 had no current falls (R17 had a fall on 10/21/18). R17 was at risk for fall related to unstated gait, poor standing balance, history of fall, and dependence on staff for locomotion with wheelchair. Current fall interventions included: hip protectors, hi/low bed, floor mat and anti roll back device on wheelchair. R17's care plan with revision date of 1/2/19, identified high risk for falls related to confusion, gait/balance problems, incontinence, and poor communication/comprehension. Interventions included: anticipate and meet R17's needs, encourage R17/family/caregivers about safety reminders and what to do if a fall occurs. Encourage R17 to participate in activities that promote exercise, physical activity for strengthening and improved mobility such as exercising and singing sessions with therapeutic recreation services. Ensure R17 is in her own wheelchair at all times, R17 likes to switch wheelchairs with other residents. Ensure R17 is wearing appropriate footwear and non-skid slippers or socks when ambulating or mobilizing in wheelchair. Follow facility fall protocol. Observe and redirect R17 when she gets out of her wheelchair to self-ambulate on the nursing unit. Perform frequent checks on R17 to ensure safety. Group sheet for R17 identified R17 was fall risk and was in the habit of ambulating in the hallway without any devices. Staff were to encourage R17 to use her wheelchair all the time. Staff were to perform frequent checks and R17 should be within eye reach. Group sheet identified it was okay to lay R17 down after lunch if she would remain in bed. Untitled incident report and progress notes dated 10/21/18, at 5:40 p.m. indicated R17 was found on the floor in another resident's room. R17 sustained a laceration to the back of the head measuring 2.5 centimeters (cm). Nurse practitioner was notified and gave orders to send R17 to the hospital for stitches. Immediate action included staff requested a therapy evaluation and staff to kept R17 in high traffic areas when awake. Untitled incident report and progress notes dated 12/1/18, at 3:34 p.m. indicated R17 fell in the television lounge. R17 walked in the lounge and held on to the television stand and the stand moved and R17 fell . R17 was assessed and able to move extremities without complaints of pain had scrapes to left iliac crest (left hip bone). Immediate action included: moved television stand against the wall and reminded R17 to constantly use the wheelchair. Staff to supervise R17 when in the lounge. Untitled incident report and progress notes dated 12/11/18, at 12:30 p.m. indicated R17 was found sitting on the dining room floor. R17 denied pain and no skin tears or bruises were observed. Immediate action taken included: head to toe assessment completed. Staff educated to monitor/supervise R17 closely in the dining room and in common areas. Untitled incident report and progress notes dated 1/8/19, at 1:20 p.m. indicated R17 was found lying down on the dining room floor. R17 was found lying to the left of the table and the wheelchair to the right of the table. Staff noted some swelling to the back of the head which resolved after the cold pack was applied. Immediate action taken included: staff monitored R17 every 15 minutes, staff reminded the importance of one person to remain in the dining room while other staff move residents to their various places. R17 was observed on 1/7/19, at 6:51 p.m. to stand up from her wheelchair in the dining room. Staff intervened. R17 was observed on 1/9/19, at 9:48 a.m. in the dining room by herself and stood up from her wheelchair and used her shirt protector to clean the dining room table. Staff was notified by surveyor and staff intervened. R17 was observed on 1/10/19, at 7:26 a.m. in another resident's room with the door closed with no wheelchair or walker. R17 was bent over and picked a piece of paper off the floor. Registered nurse (RN)-E was notified and brought R17 back to her room and back to bed. RN-E said that R17 will at times get out of bed and wander around. When asked why RN-E put R17 back to bed when she was awake, RN-E said there were times that staff would keep R17 up but RN-E felt it was appropriate to put R17 back to bed. LPN-F and RN-E were interviewed on 1/11/19, at 8:53 a.m. and asked about fall interventions for R17. LPN-F and RN-E said staff try to keep R17 close to the desk because R17 will attempt to self transfer. LPN-F said all staff try to watch her and someone needs to be in the dining room during meals. R17 should be served first so she can eat. LPN-F also said fall interventions included staff to meet her needs and offer the bathroom. R17 was observed on 1/11/19, at 9:35 a.m. R17 walked out of her room and pushed a wheelchair down the hall. Activity aide saw R17 and came to her side and assisted her to sit down in the wheelchair and had R17 sit by the nursing station. Licensed practical nurse (LPN)-F said to staff at 9:37 a.m. to keep an eye out for R17 because LPN-F didn't want her to get up and fall. Nurse manager, RN-A was interviewed on 1/11/19, at 9:03 a.m. about fall interventions for R17. RN-A said fall interventions included staff to supervise R17 when she is in common areas including the lounge and dining room. RN-A said staff remind R17 to use her wheelchair and said R17 understands at times. In regards to falls that occurred in the dining room, RN-A said staff were educated to monitor residents in common areas including the dining room on all shifts. RN-A said staff need to watch all resident's carefully because they were on a memory unit. Falls and Fall Risk Managing Policy (undated) directed staff to monitor and document each resident's response to interventions intended to reducing falling or the risks of falling. If interventions have been successful in preventing falling, staff will continue the intervention or reconsider where these measure are still needed if a problem that required intervention has resolved. If a resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions.

Based on observation, interview and document review, the facility failed to ensure 3 of 5 residents (R34, R51, R42) identified at risk for pressure ulcers received timely repositioning and wounds were assessed accordingly. The failure of the facility to consistently implement a turning, positioning and assessment programs resulted in actual harm, when R34 acquired two (2) new stage II pressure ulcers (partial-thickness loss of skin with exposed dermis). Findings include: R34's [DIAGNOSES REDACTED]. In addition, the MDS identified R34 required extensive to total assistance of two staff with bed mobility, transfers and toileting; The MDS further indicated R34 did not have a pressure ulcer. R34's care plan dated 11/15/18, indicated R34 had two pressure injuries on right buttock related to immobility and incontinence. The care plan directed staff to assess/record/monitor wound healing weekly, to measure length, width and depth where possible, to assess and document status of wound perimeter, wound bed and healing progress. In addition, the care plan identified R34 had declined in continence and was now fully incontinent of bowel and bladder and staff was to check and change at least every two hours and as needed. R34's Weekly Wound Observation dated 9/27/18, identified a pressure injury to the left buttock first identified on 8/16/18. The observation identified two wounds, upper measuring .3 centimeters (cm) x .2 cm and lower measuring .3 cm x .3 cm, wound bed red and dry with intact edges. The observation did not include staging of the wounds but indicated the wound had improved. R34's physician order [REDACTED]. --Clean Coccyx area, apply house barrier cream with toileting three times a day --Reposition every two hours for Open area On 1/9/19, at 8:00 a.m. when asked where R34 was, night shift registered nurse (RN)-L stated R34 was at an appointment and had been picked up around 6:45 a.m. Upon return, at 8:27 a.m. nursing assistant (NA)-F was observed escorting R34 to the dining room. During a continuous observation from 8:29 a.m. to 9:12 a.m. R34 remained in the dining room and was assisted to eat the meal by NA-E. At 9:12 a.m. NA-E was observed escorting R34 out of the dining room and as she got to the hallway NA-E asked R34 Is it okay to take you to watch television (TV)? At 9:14 a.m. registered nurse (RN)-B approached R34 and asked him where he wanted to go but R34 did not respond. As NA-A wheeled R34 to the day room, R34 stated he wanted to go to his room. NA-E escorted R34 to his room. At 9:15 a.m. both NA-E and NA-F were observed in R34's room as NA-E parked R34 in front of the TV. Both NA's then left the room without offering to reposition or toilet R34. At 9:57 a.m. RN-B went into R34's room and administered medications. RN-B did not offer repositioning. At 10:24 a.m. when asked when R34 was last repositioned NA-E stated, when she had arrived for the morning shift R34 had already left for his appointment. NA-E stated when R34 returned to the unit at 8:20 a.m. she had not repositioned him as he had been brought into the dining. NA-E further stated after breakfast R34 wanted to watch television but now she was going to lay him down. At 10:31 a.m. NA-E and NA-F transferred R34 to bed using a full body mechanical lift. At 10:36 a.m. as NA's and RN-B turned R34 to the right side two small red open areas were observed on the left buttock and a scabbed area on the coccyx. At 10:41 a.m. RN-B measured the opens on the lower left buttock as 1.4 cm by 0.7 cm, upper left buttock as 1.0 cm by 0.7 cm. RN-B stated both areas were red in the center with a grayish border edge that was dry and not presenting any signs of bleeding or seeping. In addition, RN-B stated the coccyx scab which measured 0.6 cm by 0.6 cm was pre-existing and was healing. On 1/9/19, at 11:00 a.m. RN-B stated she had gone to get NA-E and NA-F to lay R34 down about the same time surveyor started to ask but they were both in a room where a resident required two staff assistance with cares. RN-B verified R34 had gone out of the facility at 6:45 a.m. for an appointment and had not been repositioned since. RN-B stated R34 had not been repositioned at the clinic and was unsure what time the night shift had gotten him up and indicated it had likely been at least 4 hours. -At 11:03 a.m. both NA's and RN-B stated they were aware R34 was supposed to be repositioned every two hours however, most residents in that half of the unit required two staff assist and the NA's had been caught up in another resident room. RN-B stated the unit in general was on the heavy side with cares. RN-B stated R34 had problems with the area on the coccyx re-occurring but the two areas on the left buttock were new. At 11:06 a.m. RN-B reviewed the progress notes from 1/9/19, through 12/13/18, and verified according the notes R34 did not have any open areas identified. In addition, RN-B reviewed the assessment and verified the weekly skin assessment completed on 1/8/19, had indicated R34 had intact skin. On 1/9/19, at 12:26 p.m. the director of nursing (DON) stated she expected the aides to report to the nurse when there was any change in residents skin so an assessment could be completed and proper interventions be put in place. The DON further stated residents were supposed to be repositioned timely every 2 hours as this is standard. When asked if the unit was heavy with resident cares, the DON stated the unit was all long term care and she would have to see all the care needs on the floor and acuity to respond to the question. On 1/10/19, at 9:05 a.m. the DON stated I know it is serious and looks like he had the open areas in the same area a while back. Left heel wound: . R51's [DIAGNOSES REDACTED]. In addition, the MDS indicated R51 had intact cognition, was at risk for pressure ulcers, had no pressure ulcers at the time of the assessment and required total staff dependence with bed mobility, toileting and transfers. R51 admitted from the hospital with a wound on left heel. Although the wound was addressed and being tended to, the area was never assessed or staged. R51's care plan dated 12/5/18, indicated R51 had the potential for pressure ulcer development related to immobility and indicated R51 was bed bound. The care plan identified R51 preferred to be re positioned with three staff people, was supposed to be turned and repositioned at least every 2 hours then more often as needed or requested. In addition, the care plan directed staff to complete weekly treatment documentation to include measurement of each area of skin breakdown's with width, length, depth, type of tissue and exudate. On 1/7/19, at 4:46 p.m. when asked if he had any open areas, R51 stated he had an open area in the left heel. During the observation R51 was observed lying in bed on a air mattress however was not able to see the heels as they were covered with blankets. During review of the Nurse Bath Skin Check assessment dated [DATE], it was revealed the nurse had documented the following Given bed bath. No new skin issues noted. Wound on left heel re-bandaged . The assessment lacked documentation on the wounds measurement to include the width, length, depth, type of tissue, exudate, staging and condition of skin around the wounds. On 1/9/19, at 12:17 p.m. when asked if R51 had any open areas licensed practical nurse (LPN)-D stated R51 had a pressure ulcer on the left heel which the staff were doing treatments, he thought. On 1/9/19, at 12:23 p.m. the DON and surveyor reviewed R51's entire medical record and verified there was no left heel wound documentation I don't see anything even from the last assessment we can get that done. The nurse on the floor is designated to do this and the assistant director of nursing (ADON) was doing it and the nurse managers were supposed to make sure it was being done. R42's quarterly Minimum Data Set ((MDS) dated [DATE], indicated she was moderately cognitively impaired, required extensive assistance for bed mobility, transfers and toileting and was always incontinent of bowel and bladder. The MDS further indicated R42 had a stage III pressure ulcer ([MEDICAL CONDITION] that involves the entire thickness of the skin and may affect the subcutaneous tissue layer) and a suspected deept issue injury (purple or maroon localized area of discolored intact skin due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler compared to adjacent tissue). R42's care plan dated 1/2/19, identified one stage III pressure area and a suspected deep tissue injury to her coccyx related to immobility, low body weight and decresed ability to change positions in bed and chair. The care plan directed staff to offload pressure upon rising, after meals, prior to naps and bedtime. A facility Progress Note dated 1/7/19, indicated R42 had a wound to her right foot and and open area to her coccyx. A weekly Wound Evaluation Flow Sheet dated 1/8/19, indicated R42 had a stage III pressure ulcer on her coccyx 2.3 centimeters (cm) x .8 cm. R42 was continuously observed on 1/11/19. At 1/11/19, at 8:08 a.m. R42 was in her wheel chair. At 8:30 a.m. staff escorted her to the dining room where she remained until 8:50 a.m. At 9:06 a.m. R42 was escorted to a common area of the unit. At 9:21 a.m. nursing assistant (NA)-C escorted R42 to her room, assisted her with facial grooming and returned her to the activity room at 9:50 a.m. without repositioning or off-loading. R42 remained on the activity room until 10:41 a.m. when registered nurse (RN)-A was notified of the last time R42 had been repositioned. At 10:45 a.m. staff assited R42 to lay down in bed. At 11:04 a.m. RN-A observed R42's bottom with surveyor. RN-A stated R42 had two areas on her bottom. RN-A described a stage III pressure ulcer on R42's coccyx as healing and pre-exisiting. A second area was identifed as a new open area near the coccyx approximately 2.0 cm x 1.5 cm. In regard to repositioning, RN-A stated in regard to R42's care plan, after meals depended on when the resident got out of bed and stated if the resident had a pressure ulcer they should be repositioned every two hours.

Based on interview and document review, the facility failed to ensure timely identification, evaluation, and treatment of [REDACTED]. This resulted in actual harm for R1, when a family member scheduled and arranged transportation for R1 to a clinic doctor's appointment, and the doctor determined R1 required immediate inpatient hospital treatment. In the emergency room , hospital staff treated R1, and then transferred her to another hospital that was better equipped to provide infectious disease treatment. Findings include: R1 transferred to the facility on (MONTH) 11, (YEAR), with [DIAGNOSES REDACTED]. R1's hospital discharge summary, dated (MONTH) 11, (YEAR) at 10:12 a.m., indicated her discharge [DIAGNOSES REDACTED]. The hospital physician's discharge instructions indicated for a provider at the facility to see R1 in three to four days. A nursing admission packet, dated (MONTH) 12, (YEAR) at 3:48 p.m., indicated R1 admitted to the facility for rehabilitation from a hospital and was cognitively intact. R1 had slight [MEDICAL CONDITION] to her left lower leg, a blister on the front of her left lower leg, and redness on her left ankle and heel. R1 had a superficial wound on her buttocks and redness to her groin. She used a wheelchair and could not walk. R1's pain assessment indicated that over the past five days her worst pain was ,[DATE] on a 10-point scale, with 10 being worst. A progress note on (MONTH) 12, (YEAR) at 4:21 p.m. indicated R1 required the assistance of two staff for transfers, toileting, bed mobility, and dressing. She was independent with eating, grooming, and wheeling herself in a wheelchair. A progress note on (MONTH) 13, (YEAR) at 4:39 p.m., indicated R1 complained of pain in her left leg rated ,[DATE] that was alleviated when resting. The nurse noted mild [MEDICAL CONDITION] in R1's left leg and right leg stump. A progress note on (MONTH) 14, (YEAR) at 12:01 p.m. indicated R1's family member left a voice mail for social services (SS) and then came to the facility to speak with a SS staff in person (this occurred on the evening of (MONTH) 13 per the family member). On (MONTH) 13, (YEAR), the family member said she noticed red marks on R1's left leg, and on the side of her leg new bumps that were red, white, and blue. The family member said the skin concerns were not present when R1 discharged from the hospital to the facility a couple days prior. A nurse said that a spot on the resident's leg was hot to the touch and might be infected. The family member said the doctor at the hospital wrote in the discharge orders sent with the resident that R1 should see a doctor within three days of admitting to the facility. The family member wondered if R1 had seen a doctor at the facility, and if not, said R1 could go outside the facility to see her primary care physician (PCP) for evaluation. At that point, the family member wanted R1 to see a doctor by the next day, Tuesday (MONTH) 14. The SS staff person spoke with a nurse manager about her conversation with the family member, and the nurse manager said she would call the daughter. R1's treatment administration record (TAR), indicated a once weekly head to toe skin and body assessment was entered into the TAR on (MONTH) 14, (YEAR), three days after R1 had admitted to the facility. A progress note on (MONTH) 15, (YEAR) at 10:05 a.m indicated R1 stated she needed help to get out of bed and to get ready for an appointment (family had scheduled an appointment for R1 to see a doctor outside of the facility on (MONTH) 15). A progress note on (MONTH) 15, (YEAR) at 12:13 p.m. indicated a nurse explained to the concerned family member that the facility doctor would be able to see R1 that week. The family member stated she would make her own appointment for R1. The nurse notified the on-call provider, and the provider gave an order that staff could send R1 to the hospital if needed. The note indicated staff did not send R1 to the hospital. (According to a family member, this note describes events that occurred on (MONTH) 14). A progress note on (MONTH) 15, (YEAR) at 12:43 p.m. indicated R1's left leg was swollen, slightly red to purple in color, with small weeping blisters on her outer thigh. R1 complained of pain rated ,[DATE]. A progress note on (MONTH) 15, (YEAR) at 13:31 p.m. indicated an in house provider saw R1 and explained to her that she did in fact have an infection and the provider would start antibiotics (this was approximately one hour before R1's PCP appointment, whom a family member initiated, scheduled, and arranged transportation). On (MONTH) 15, (YEAR) at 1:48 p.m., a Physician Assistant (PA) at the facility documented seeing R1. The PA's documentation indicated R1 had an infected rash on her entire leg, and reported rigors. The PA noted pustular areas on R1's upper lateral thigh, and weeping from her lower leg with [MEDICAL CONDITION]. The PA ordered an oral antibiotic and steroid cream, and she was going to check R1's labs the following day. A progress note on (MONTH) 15, (YEAR) at 4:03 p.m. indicated R1 complained of pain in her left leg rated ,[DATE] that was relieved when lying down. R1 continued to have mild [MEDICAL CONDITION] in her left leg and right leg stump (R1 was not in the facility at this time). An emergency room (ER) physician's note, dated (MONTH) 15, (YEAR) at 4:56 p.m., indicated R1 came to the ER after her PCP noted extensive redness with pustules along R1's left thigh and buttocks, and became concerned [MEDICAL CONDITION]. R1 had severe pain in her buttocks, and she complained of chills and tremors since transferring to the facility. R1 also had [MEDICAL CONDITION] on her inner and outer right thigh, without pustules. Physician hospital notes, dated (MONTH) 15, (YEAR), indicated R1 transferred to the hospital with a [DIAGNOSES REDACTED]. R1's family member noticed R1's legs had worsened with formation of new pustules and drainage. R1 was seen by her PCP and referred to the ER for evaluation, with complaint of chills. R1 had multiple pustules on her lower left leg, with pain and redness, and the pustules extended up to R1's groin area. The pustules were draining yellow pus fluids, and R1 had chills and night sweats. In the ER, the physician diagnosed R1 [MEDICAL CONDITION], likely due to lower left leg [MEDICAL CONDITION] with infected pustules. R1's lower left leg was tender and hot to the touch. A progress note on (MONTH) 15, (YEAR) at 10:48 p.m. indicated R1's family member called the facility and informed a nurse that R1 admitted to the hospital for increased drainage onto her legs, and R1 would not be returning to the facility. A progress note on (MONTH) 16, (YEAR) at 10:11 a.m. indicated R1 was gone from the facility for most of the day at an appointment (referring to events that occurred on (MONTH) 15), from which she did not return to the facility. R1 transferred to the hospital from the appointment and would not return to the facility. A physician's hospital note, dated (MONTH) 18, (YEAR) at 9:24 a.m., indicated that a wound culture confirmed R1 became septic due to [MEDICAL CONDITION] (infection) of her left lower leg with bacteria. When interviewed on (MONTH) 14, (YEAR) at 12:53 p.m., the Director of Nursing (DON) stated she was not aware of how soon the physician is to see a resident who newly admits to the facility, per the facility's policy. The DON was fairly new to the facility and unfamiliar with the situation involving R1. The DON noted a nurse did notice warmth of the area of concern on R1's left leg the day before a family member took R1 to the hospital. The DON stated if it was not an emergency, staff might not have sent R1 to the hospital for that reason, and that it depends on the resident. The DON stated there was a possibility staff inaccurately assessed the urgency of the situation. The DON stated she would have taken R1's vital signs, assessed her, and notified the physician, especially if the resident complained about her leg and it had increased warmth. The DON stated with a newly admitted resident, a physician has to see the resident before a nurse practitioner does. The DON stated she has seen where the physician does not always send a resident to the hospital for warmth of skin where there is the possibility of [MEDICAL CONDITION], and that it would depend on the appearance of the resident's leg. During an interview on (MONTH) 9, 2019 at 11:06 a.m., Registered Nurse (RN)-B stated she recalled R1 had an issue with her leg. A nursing assistant (NA) came and requested RN-B look at R1's leg, because the NA thought something was wrong. RN-B stated R1 complained of pain in her leg and staff could not get her out of bed, as they were supposed to weigh R1, but R1 refused due to the pain. RN-B stated she helped the NA get R1 ready for the morning, and then told the NP about the concern for R1's left leg, and the NP assessed R1. RN-B observed that R1 had little blisters all over her left lower leg and just above the knee, weeping clear fluid to the point that RN-B could see R1's bedding was wet. R1's skin was red to purplish in color and her left leg was swollen. RN-B stated when she saw R1's left leg, she thought it could be an infection such as [MEDICAL CONDITION] due to the leg being red, swollen, and tender to touch with weeping fluid. RN-B stated [MEDICAL CONDITION] is a tissue infection and a serious matter that requires action. RN-B was concerned that if staff did not take action R1 could lose her left leg, as R1 already had an amputation of part of her right leg. RN-B stated R1 was diabetic and thus at a higher risk than normal of infections. RN-B thought staff should have sent R1 to the hospital, but stated she had to accept what the NP decided. RN-B stated not long after the NP saw R1, her family came and took R1 somewhere outside of the facility. RN-B stated if she had been aware that family members came and were concerned, she would have sent R1 to the hospital for evaluation. RN-B stated she did not know the on call provider had previously given an order to send R1 to the hospital if needed. RN-B stated she would rather hospital staff evaluate R1 to know if something was wrong or not. RN-B stated knowing R1 already lost a leg, it should have been a red flag for staff to be concerned that R1 could lose her other leg. If RN-B knew R1's family requested that R1 see a doctor, RN-B stated she would have sent R1 to the hospital, per the family's request. RN-B stated lack of communication amongst staff was an issue because she did not receive report about a concern with R1's leg, and she was not aware an order existed to send R1 to the hospital if needed. RN-B reiterated that if she knew about the doctor's order, she would have sent R1 to the hospital without even consulting the NP, and then informed the NP about her concern for R1 having an infected leg. RN-B stated R1's family took her to an appointment after that. When interviewed on (MONTH) 9, 2019 at 12:03 p.m., family member (F)-C stated her sister visited R1 at the facility on a Monday, two days before they took R1 to the hospital, and her sister took photos of R1's leg. The family member also photographed R1's leg two days later on Wednesday, while R1 was still in the facility, and prior to family taking R1 to an appointment they scheduled with R1's PCP. F-C stated during her sister's visit to R1 on Monday, two days prior to hospitalization , her sister told staff that it looked like R1's leg had [MEDICAL CONDITION]. A staff person was applying salve to the lower part of R1's foot and leg and said they were treating R1 for [MEDICAL CONDITION]. F-C stated staff told her the doctor was only available on Monday and Wednesday, and a doctor had not seen R1 that Monday, so a doctor would not see R1 until the following week on Monday, as the provider's schedule was full on Wednesday. F-C stated she and her sister communicated to staff that R1 needed to see an actual physician. F-C stated since there was no staff in charge at the time, staff told them to call back the next day, Tuesday. F-C stated she and her sister called the facility many times on Tuesday, left messages, and F-C never received a call back. F-C stated she and her sister arranged to take R1 to see her PCP because the facility was not going to provide transportation to see the doctor within a set timeframe. F-C stated on Wednesday her sister went to the facility to visit R1 and get R1 transported to her PCP. F-C stated when her sister got to the facility, R1's leg sores were oozing fluid so much that her wheelchair pad was wet, as well as the floor under where R1 was sitting. F-C stated she and her sister took these actions for R1 to be evaluated by a doctor on their own, due to their concern for R1, and not once had staff contacted F-C. F-C stated when R1 saw her PCP, the doctor determined R1 needed to go to the hospital immediately, with concern [MEDICAL CONDITION]. F-C stated in the ER, R1 received intravenous (IV) fluids and antibiotics, and hospital staff said they did not have the means, with an infectious disease team, to treat R1. R1 then transported via ambulance to another hospital and admitted for treatment. F-C stated R1's leg infection never resolved. F-C stated when R1 first admitted to the facility, she did not have the bumps on her legs. When F-C saw the photos her sister took of R1's leg, she stated she was greatly surprised that staff was not taking the matter seriously, and R1 needed a physician to evaluate her. F-C stated a big cluster of bright red, white, and black bumps were near R1's upper thigh and extended down to below her knee. F-C stated after her sister told staff via phone on Wednesday she was upset that a doctor had not seen R1, and she was coming to the facility to arrange transport for R1 to her PCP, the NP saw R1 and ordered antibiotics, right before F-C's sister arrived. F-C stated at that point it was a little late, and antibiotics was not what R1 needed when at her PCP appointment the doctor said to get R1 to the hospital. During an interview on (MONTH) 9, 2019 at 1:19 p.m., RN-D stated the day R1's family member came to the facility to take R1 to an appointment, a PA saw R1 and was going to start treating her with antibiotics. RN-D stated the family member took R1 to the appointment, and R1 never returned to the facility. RN-D stated R1 and her family were upset that a facility doctor did not see R1 within 48 hours of admission, and RN-D stated that a doctor is supposed to see newly admitted residents within ,[DATE] hours, per her understanding. RN-D stated R1 arrived on a Saturday and a doctor could have seen her on Monday, but did not. RN-D stated at the time the doctor would sometimes come on a Monday or Wednesday, but there was not a set schedule of when the doctor would be there, so staff could not provide R1 or her family with a date and time the doctor would see R1. RN-D stated the day she looked at R1's left leg was the day her family took R1 to the hospital. RN-D stated R1's leg was red and looked possibly infected, like [MEDICAL CONDITION]. RN-D stated R1's leg looked pretty bad, and she thought staff should have addressed it earlier. RN-D thought on the day staff admitted R1 to the facility, they noted some sort of rash, and the rash became worse over the time that R1 was in the facility. RN-D stated the Wednesday R1 went to the hospital was the first time she saw R1's skin concerns. RN-D stated she had worked the two previous days, Monday and Tuesday, and staff had not said anything to her about it. RN-D stated if she was aware of R1's skin, she could have consulted with the wound team. RN-D stated [MEDICAL CONDITION] involves painful inflammation, can cause further infection, and if the person is immunocompromised or has other comorbidities, could affect those and lead [MEDICAL CONDITION] without treatment. RN-D stated prior to the PA seeing R1, on the day family took R1 to the hospital, a facility doctor had not seen her. RN-D stated communication from facility staff to the physicians group was not great when a resident admitted on the weekend. RN-D explained that staff is supposed to fax the new resident's referral and any other paperwork to the physician's office, so a physician can review the resident's orders, see why the resident came to the facility, and schedule to see the resident. RN-D stated if staff does not fax the paperwork on the weekend, it delays when the doctor will see the resident, as there was not a set schedule at the time. Overall, RN-D's opinion was R1 should have been evaluated sooner rather than later, and the nurses working at the time should have known when to press the issue to send R1 to the hospital, and what infection looks like. RN-D stated it is better to send the resident to the hospital for evaluation and have them come back with a clean bill of health than not send them and the resident becomes worse. RN-D stated with a new admission staff were supposed to check the resident's skin daily during the first five days that they were new to the facility. RN-D stated staff could have seen R1's skin was getting worse and addressed it earlier, but staff failed to do so. RN-D made the point that the physician is not going to know what is wrong unless staff inform them and fully explain it, giving the example that it would not be enough so say R1 had a red spot. RN-D stated the physicians have a lot of trust in the nursing staff, as the physicians cannot be at the facility all of the time, and they rely on nursing judgement. RN-D stated she did not think nursing judgement was appropriate for R1. If staff had an order to send R1 to the hospital, and family was pressing the issue, nursing staff should have sent R1 to the hospital for evaluation. RN-D also thought staff should have been more diligent about skin assessments, and stated 24 hours can make a significant difference if a resident has an infection. The resident can progress from being okay to near death, if it is severe enough, and depending on the resident and what comorbidities they have. On (MONTH) 10, 2019, photos of R1's left leg were examined from two days prior to her family taking her to the hospital, and photos on the day she went to the hospital. Two days prior to hospitalization , R1 had many small red, white, and black bumps on her upper left leg that extended to below her knee. R1's skin was red around and between the bumps. She also had extensive pink coloration of the skin on her left leg below the knee, with a wound on her lower left leg above the ankle. On the day of hospitalization , the skin on R1's upper left leg had blistered, with an area of the top layer of skin that was not intact and showing the tissue beneath. The blisters were predominately white in color, with white bumps/blisters progressing further down the left leg below the knee. Staff providing personal cares on either day would easily have seen the skin concerns. When interviewed on (MONTH) 11, 2019 at 11:19 a.m., F-E stated she visited R1 in the facility on the evening of (MONTH) 13, (YEAR). That evening F-E had a conversation with the doctor that discharged R1 from the hospital to the facility the past weekend. The hospital doctor had ordered wound care on both of R1's legs, including the left leg where most of the skin breakdown was occurring. F-E stated facility staff was to apply an antifungal cream, and then apply a barrier-type tape over the open skin to prevent exposure to germs in the environment. F-E stated initially the skin breakdown included a small area on R1's shin and left ankle, and F-E checked R1's legs when she visited on (MONTH) 13. F-E brought up her concerns with a SS staff person, including that in the hospital discharge orders a provider was to see R1 within 72 hours, stating the hospital doctor told her within three days maximum, to see how the medication was working. F-E stated R1 had similar skin breakdown when she had her right leg amputated below the knee, due to flesh-eating bacteria. F-E stated she told the SS person she wanted R1 to see the doctor with 72 hours. F-E stated the SS person said she would track down the charge nurse and relay the message about R1 seeing the doctor and being treated for [REDACTED]. F-E saw the barrier tape in one little area, but stated from R1's ankle up to her thigh had red pimple-like spots, and F-E wondered why staff was not treating all of the area, as the barrier tape was only on the front of R1's shin. F-E stated the red spots had also spread to R1's right stump, while previously there had been nothing on the right stump. F-E stated she pushed for a facility doctor to see R1 that day, (MONTH) 13, but it did not happen. F-E stated that on (MONTH) 14 she called the charge nurse approximately every hour, leaving messages each time, without return calls. Eventually F-E spoke with the charge nurse. F-E stated the nurse told her the doctors were only seeing residents on Monday and Wednesday, and the nurse did not know why a doctor had not seen R1 on Monday. F-E sought verification from the nurse that a doctor would evaluate R1 that day, (MONTH) 14, but the nurse told F-E she could not guarantee it. F-E asked the nurse to arrange transportation for R1 to a clinic appointment that F-E would schedule. F-E stated the nurse never called her back and confirmed the facility had arranged transportation. As a result, on (MONTH) 14 F-E called R1's primary care clinic and scheduled an appointment for (MONTH) 15. F-E stated on (MONTH) 15 she called the charge nurse and social worker multiple times, never reached them or received a return call from either, and arranged transportation for R1 to a primary care clinic appointment herself. F-E stated if necessary, she was going to push R1 in her wheelchair the three miles to the clinic, so that a doctor could evaluate R1 on (MONTH) 15. F-E stated by (MONTH) 15, R1's skin breakdown on her left leg had turned into blisters that popped and oozed onto R1's wheelchair, with liquid dripping down to the ground. F-E thought it odd that no staff had called for R1 to go to the hospital, and R1's skin was fragile due to being diabetic with liver [MEDICAL CONDITION]. R1 told F-E that staff had not said anything about her left leg. Since R1 had [MEDICAL CONDITION] and poor vision, F-E stated R1 was unaware of her leg's condition until F-E took a photo and showed R1. F-E stated at the clinic appointment, two doctors looked at R1's left leg and directed her to go to a hospital for immediate treatment, including intravenous (IV) antibiotics. At the first hospital, F-E stated they did not have the infectious disease team necessary to treat R1, so they transferred her to another hospital for inpatient admission and treatment. F-E stated at approximately 9:45 p.m. on (MONTH) 15, she received a call from the facility wondering where R1 was, and by that time, she had already come to the facility and removed R1's belongings from her room. Documentation received via email on (MONTH) 12, 2019, indicated the facility could not locate documentation that they had educated their nurses on physician notification and when to seek medical treatment. R1's death record indicated she died due to a blood clot in a deep vein (deep venous [MEDICAL CONDITION]) due to an infection in her blood (sepsis), resulting from a spreading bacterial infection of her skin ([MEDICAL CONDITION]), with liver [MEDICAL CONDITION]. An undated facility policy titled Admission Assessment and Follow Up: Role of the Nurse, indicated under Reporting to Notify the supervisor and the Attending Physician of immediate needs that the resident may have. The policy also indicated, Report other information in accordance with facility policy and professional standards of practice. An undated facility policy titled Change in a Resident's Condition or Status indicated, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, resident rights, etc.). The policy further indicated a nurse supervisor/charge nurse would notify the attending physician or on call physician when there has been a significant change in the resident's physical condition, a need to alter the resident's medical treatment significantly, or a need to transfer the resident to a hospital.

Based on observation, interview, and document review, the facility failed to provide an environment free from accidents/hazards for 1 of 4 residents (R4) reviewed when staff left a loose handrail on a bariatric scale unbolted. When R4 attempted to stand up from his wheelchair and get onto the scale, he grabbed the handrail and it lifted out of place. R4 experienced actual harm when he fell and injured his healing stump, which caused significant bleeding and pain, required six stitches, and delayed healing and fitting for a prosthesis. Findings include: R4's admission assessment, dated (MONTH) 4, (YEAR), indicated he was cognitively intact, with [DIAGNOSES REDACTED]. Staff assessed R4 to be unsteady, but able to stabilize without human assistance, when moving from seated to standing position. R4 was unsteady, and only able to stabilize with human assistance, when walking and turning around. R4 required supervision for transfers and one person to assist with walking. R4's care plan, dated (MONTH) 9, (YEAR), indicated he had stitches to his left [MEDICAL CONDITION]/stump, which required skin and wound treatments per doctor orders. The care plan indicated R4 had one fall while standing for staff to weigh him. A facility provider's assessment, dated (MONTH) 2, (YEAR) at 11:24 a.m., indicated R4 fell while getting on the scale with staff. The documentation indicates R4 fell on his left leg residual limb, splitting open his surgical incision and resulting in a laceration that drained a large amount of blood. The provider concluded R4 needed to go to the emergency room (ER) for suturing and had staff call emergency medical services (EMS). An ER provider noted, dated (MONTH) 2, (YEAR) at 1:17 p.m., indicated R4 presented to the ER with a laceration to his left leg stump. R4 stated he fell off a scale that broke when he tried to grab the handle. When he fell , R4 injured his left leg and hit his left elbow. The provider's note indicated the fall caused R4's surgical wound to dehisce approximately 5 x 1 centimeters (cm), requiring six sutures to repair. R4 also had an abrasion on his left elbow. A fall incident report, completed (MONTH) 2, (YEAR) at 2:21 p.m., indicated an aide assisted R4 to the tub room for a weight check. R4 locked his wheelchair and the aide applied a gait belt. R4 grabbed the handrail on the scale and stood up. When R4 hopped to stabilize his balance, the handrail came out of place, causing R4 to lose his balance and fall. R4 hit his left stump and elbow, and his stump was bleeding. R4 stated as he was getting on the scale, the handrail came off and he fell and hit his elbow and stump. The fall report indicated, Resident was asked if the blood was there prior he said no. It just started. This will be a set back. Due to blood, staff removed R4's left stump socks and blood started gushing so that staff had to apply pressure and call the provider. When a nurse applied a pressure dressing to R4's new open area, she noted a piece of skin was torn off, and bleeding became uncontrolled. An ambulance subsequently transported R4 to the ER. During an interview on (MONTH) 13, (YEAR) at 10:45 a.m., and on (MONTH) 14, (YEAR) at 9:24 a.m., R4 stated he had a fall on a scale in the tub room, that the rail pulled out and he hit and damaged his stump. R4 stated he had to get six stitches and now had a pocket of fluid at the bottom of his stump. R4 stated he was not wearing a gait belt, and staff called 911 after seeing the injury to his stump. R4 thought his fall involved faulty equipment. R4 stated his stump was almost healed before the fall. R4 stated he was not on the scale with his wheelchair when he grabbed the top of the handrail with his right hand and tried to stand, and the handrail came out and he fell on to his stump. R4 thought that an aide told him to stand. R4 stated at the time he was approximately two weeks away from getting a prosthesis. R4 stated when he fell , the bone on his stump punched out a piece of skin about the size of a quarter through his surgical incision. The wound gushed blood and staff wrapped it tightly with bandages and called 911. R4 stated consequently he has experienced pain, initially rated 10/10, but ongoing pain and a seroma. R4 rated his current pain at approximately 6/10, and stated he takes Tylenol for it. R4 stated the plan is to get his prosthesis as soon as the pocket of fluid goes away, that he will then start wearing a shrinker sock again. Observations on (MONTH) 13, (YEAR) before noon indicated the handrail had bolts in the bottom of it that were not attached to the base of the scale. The two bottom ends of the handrail were sitting on the heads of the bolts in their respective slots. When interviewed on (MONTH) 13, (YEAR) at 12:02 p.m., a maintenance employee (M)-B stated the Director of Nursing (DON) told him not to secure the handrail to the base of the scale. M-B was aware a resident had fallen on the scale. When shown bolts that were screwed only into the bottom of the handrail but not through to the bottom of the base of the scale, to attach the two parts, M-B concluded the bolts were designed to hold the handrail in place on the base. M-B concluded the scale came with the handrail attached to the base, and R4's fall was preventable. M-B then prepared to bolt the handrail to the base of the scale. During an interview on (MONTH) 13, (YEAR) at 12:40 p.m., the DON stated she was told the handrail naturally comes off and staff left it unbolted from the base for ease of transport. The DON stated the day R4 fell on the scale, a visiting regional nurse, a maintenance employee, and herself all looked at the scale, and it was a team decision to leave the handrail unbolted from the base so nursing staff could move the scale. The facility did not have the operation manual for the scale; however, when asked for it the Administrator printed the manual from online and provided it on (MONTH) 13, (YEAR) at 2:25 p.m. The operation manual did not contain relevant information about the scale's handrail. When interviewed on (MONTH) 13, (YEAR) at 3:37 p.m., and (MONTH) 14, (YEAR) at 8:22 a.m., the Administrator stated the handrail might not have been bolted down due to staff moving the scale out of the tub room to weigh residents. The Administrator stated there is a scale on every floor of the facility, and the scale is for those who are ambulatory or who are in a wheelchair, so there was no reason for staff to move the scale to other rooms. The Administrator confirmed the handrail was now secured to the base of the scale, and they no longer planned to move the scale from the tub room. The Administrator asked M-B if he had done any assessments on the scale's handrail, and M-B told the Administrator he did not have any record of doing so. When interviewed on (MONTH) 14, (YEAR) at 12:53 p.m., the DON stated R4 fell when staff was trying to obtain his weight. The DON stated staff was supposed to roll R4 onto the scale in his wheelchair, but R4 stood up when the wheelchair was not on the scale, and when he did the handrail came up out of place and R4 fell . The DON had not heard that an aide asked R4 to stand up, and she did not know why a staff person did not stop him from standing. The DON acknowledged the handrail on the scale was not bolted down, and if it was supposed to be, it was a concern because R4 used the handrail to pull himself up to a standing position. The DON stated R4 opened his stump in the fall and went to the ER to get stitches. The DON stated that due to the fall R4 experienced pain, a seroma (a collection of fluid that builds up under the surface of the skin), and the injury delayed his healing and readiness for a prosthesis. During a phone interview on (MONTH) 28, (YEAR) at 2:54 p.m., a sales employee for the manufacturer of the scale stated the scale has screws to hold the handrail to the base, and they screw into the handrail from the bottom of the base. The employee stated the handrail should be very snug in the base. Regarding use of the handrail, the sales employee stated some persons are able to walk, so they can walk onto the scale and then hang onto the handrail, to stabilize themselves while already in the standing position on the scale. The employee stated the handrail is not intended to bear a person's weight as they pull themselves up from a sitting to standing position, but to stabilize someone who is already standing on the scale. An undated facility policy titled Safety and Supervision of Residents indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The policy indicated, When accident hazards are identified, the QA&A/Safety Committee shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards to the extent possible.

Based on record review, observation and interview, the facility failed to provide an environment free from accidents/hazards for one of six residents (R1) reviewed when facility maintenance failed to repair a reported water leak from the ceiling in R1's bathroom. R1's safety was not maintained. R1 used the bathroom, water was on floor, R1 fell and was transferred to the hospital for back and neck pain, was admitted , and returned to the facility with activity limitations for four to six weeks. Findings include: R1's medical record was reviewed and indicated R1 had [DIAGNOSES REDACTED]. Current physician orders [REDACTED]. R1 had a Brief Interview for Mental Status (BIMS) assessment conducted 8/13/18, scoring 15/15 which indicated R1 was cognitively intact and could make his needs known. R1's care plan, dated 8/20/18 indicated R1 was able to perform activities of daily living (ADLs) with little or no help other than supervision in the shower room. In addition the care plan indicated R1 was on bleeding precautions related to use of an anticoagulant and interventions included: using care with sharp objects like scissors or knives, using an electric razor to shave, using soft bristle toothbrushes, avoiding toothpicks and dental floss. Further the care plan indicated R1 was a vulnerable adult due to living in a long term care facility and care plan interventions included providing a safe environment for all residents. A facility Maintenance Request form dated 7/25/18, indicated: room [ROOM NUMBER] bathroom ceiling leaking. Sections of the request form for maintenance including check, status and completed by/date were left blank. A facility Incident Audit Report documented 8/3/18, indicated licensed practical nurse (LPN)-A heard R1 calling for help from his room. LPN-A documented having found R1 lying on the bathroom floor. The note indicated R1 was in tears and had reported to LPN-A he'd slipped and fallen. The report also indicated staff had assessed R1's vital signs, and that R1 stated he had neck pain and had requested to go to the hospital via ambulance. The Incident Audit Report indicated the floor in R1's bathroom was wet at the time of the fall. An interdisciplinary team (IDT) note dated 8/5/18 at 18:27 (6:27 p.m.) indicated nursing staff had called the hospital to follow up on R1's condition. The note indicated R1 had been admitted , was stable and was expected to be discharged back to the facility in 1-2 days. A hospital discharge summary dated 8/6/18, indicated R1 had right side weakness with no acute findings and was discharged from the hospital with activity limitations for four to six weeks. The facility's post fall investigation report dated 8/9/18, indicated the resident's fall was due to water on the resident's bathroom floor. During a facility observation on 8/28/18 at 12:20 p.m. room [ROOM NUMBER] was empty. A lockout tag on the bathroom door in room [ROOM NUMBER] dated 7/17/18, listed leak in bathroom as a problem. One bathroom ceiling tile was observed to have been removed exposing a plumbing pipe. There were dark brown stains on the sheetrock adjacent to the pipe. During an interview on 8/29/18 at 12:45 p.m., R1 said his bathroom ceiling had leaked since May. R1 said he had told maintenance and nursing staff about the problem and stated on the night he'd fallen, he'd woken up at 8:30 p.m. to use the restroom, had walked into the bathroom and realized there was water on the floor. R1 stated he'd tried to step back from the water but slipped and fell . R1 said he had experienced pain and numbness along his back, neck and arms and had yelled out for help. During an interview on 8/28/18 at 3:08 p.m., LPN-A said there had been a rainstorm the day R1 had fallen, and the roof had leaked. LPN-A stated room [ROOM NUMBER] had water running down the wall by the bathroom sink and a puddle on the floor in his room when they came to assess him after the fall. During an interview on 8/28/18 at 9:30 am, maintenance director (Maint-B) said the facility roof drains were plugged with debris and contributed to the leaking roof. Maint-B said he is new to the job and fixing the leaking roof and clogged gutters was a priority. Maint-B said there were simple maintenance tasks that were not done by previous staff. During an interview on 8/29/18 at 10:30 a.m., the director of nursing (DON)-C said the age of the building and unaddressed maintenance issues were a twofold problem. DON-C said R1 and his roommate were moved to a new room after the fall. During an interview on 8/29/18 at 2:03 p.m., administrator (Admin)-F said he'd gone up onto the facility roof with the previous maintenance director and had observed areas where the rubber coating on the roof had separated. Admin-F said maintenance staff were supposed to to get sealant and fix the roof and clean the roof drains because they were full of cottonwood seeds and leaves. Admin-F said the previous maintenance director was terminated after the incident and associate maintenance staff did not return to work after the incident. The adminsitrator stated the new maintenance director had repaired the roof and cleaned the drains. The facility's undated policy Assessing Falls and Their Causes, included: relevant environmental issues should be addressed promptly; staff will evaluate chains of events or circumstances preceding a recent fall including whether the resident was trying to get to the toilet; or whether any environmental risk factors were involved (e.g. slippery floor, poor lighting, objects in the way).

Based on observation, interview, and document review, the facility failed to implement interventions to reduce the risk of falls for 1 of 3 residents (R78) reviewed for falls. This resulted in actual harm for R78 who sustained a fracture resulting from a fall. In addition, the facility failed to provide adequate supervision for 1 of 1 resident (R104) reviewed for elopements and the facility failed to supervise 1 of 1 resident (R66) for safety related to use of a disposable razor. Findings include: R78 was observed on 12/20/16, at 2:20 p.m. R78 was lying in bed while a holiday party was in progress on the unit. During an interview on 12/20/16, at 3:11 p.m., registered nurse (RN)-D stated R78 was on bed rest following a fracture of her right hip. R78's significant change Minimum Data Set ((MDS) dated [DATE], indicated she was severely cognitively impaired, required extensive assist of two staff for bed mobility, toileting, and personal hygiene and did not transfer or ambulate. A previous MDS dated [DATE], indicated R78 had been independent with ambulation and required only one staff assistance for all other activities of daily living. R78's care plan dated 12/7/16, indicated a potential for falls due to cognitive deficit and identified a right hip fracture had been sustained on 11/15/16, as a result of a fall. The care plan directed staff to anticipate her needs, offer diversion, reminders to slow down and ensure proper foot wear (currently on hold due to bed rest.) A Area Assessment (CAA) dated 11/28/16, identified a risk for falls based on an actual fall on 11/15/16, and indicated R78 was at moderate risk for falls. A review of R78's Progress Notes and corresponding Incident Post Fall Scene Investigation Tools were reviewed from 2/5/16 to 11/15/16, and identified the following falls: - On 2/15/16, Progress Note indicated R78 was observed on the east hallway floor lying flat on her stomach. The correlating incident report indicated R78 was helped to bed and monitored by night shift. The interdisciplinary team (IDT) review indicated a new intervention of offering R78 tasks such as folding washcloth or cleaning to re-direct had been implemented. - On 2/22/16, Progress Note indicated R78 was walking very fast in hallway, missed her step and fell on to left side. The corresponding incident report indicated R78 was redirected and put in close observation. The IDT review of the fall indicated staff were to remind R78 to slow down when walking too fast, and to redirect as able. - On 3/1/16, Progress Note indicated R78 slid to the floor and landed on her bottom. The corresponding incident report indicated R78 was helped to a chair and educated on proper sitting position. The IDT review intervention initiated as a result included to encourage her to sit back in the chair. - On 3/20/16, Progress Note indicated R78 was found sitting on the floor facing the elevator. The corresponding incident report indicated she was immediately put on a one to one and pain medication was administered. An IDT review of the fall was not completed. - On 4/8/16, progress note indicated R78 was found on the floor at 9:00 a.m. by the nurse's station lying on her left side and again an hour later was found sitting on the floor. The corresponding incident report indicated she was immediately brought closer to the nursing station. An IDT review of the incident was not completed. - On 4/22/16, a note labeled IDT Note indicated R78 had multiple falls related to pacing/fast walking. The recommended intervention included for staff to continue to re-direct prn (as needed). - On 5/13/16, Progress Note indicated R78 was found sitting on the floor in her room. The immediate intervention implemented was to advise R78 to use her call light. An IDT review of the fall was not completed. - On 7/8/16, a note labeled IDT note, indicated R78 had experienced two falls without injury related to rapid pace of wandering. There was no evidence the IDT had evaluated or assessed causative factors of the falls. - On 7/16/16, progress note indicated R78 was found on the floor in the dining room at 7:50 p.m. The corresponding incident report indicated an immediate intervention of offering her a snack. The IDT review portion of the incident form was not completed. - On 10/28/16, Progress Note indicated R78 fell following a loss of balance. No incident report was completed for the fall, nor was an IDT review documented. - On 11/15/16, Progress Note indicated R78 was found lying on floor near the elevator on her right side. She was complaining of hip pain and unable to bear weight. - On 11/16/16, Progress Note indicated x-ray results had been called in to the physician and orders received to keep R78 at the care center for non-operative fracture care. The corresponding Incident Report form indicated no IDT review was completed. During an interview on 12/21/16, at 2:05 p.m. nursing assistant (NA)-B stated R78 had a history of [REDACTED]. She stated R78 used to walk very fast on the unit. NA-B further stated she was not aware of any fall prevention interventions other than to watch R78. During an interview on 12/21/16, at 2:19 p.m. registered nurse (RN)-D stated when a resident has a fall, the nurse on duty fills out a risk management report. She stated the nurse will put an immediate intervention in place. RN-D stated the IDT reviews falls quarterly when completing an MDS but does not do a review following each fall. During an interview on 12/21/16, at 2:37 p.m., the director of nursing (DON) stated when R78 fell , It wasn't a surprise. The DON said R78 walks very fast and does not understand when staff tell her to slow down. The DON further stated falls were reviewed by a fall committee and stated the fall committee was trying to meet every two months. She stated the committee looks at the incident reports and tries to determine causative factors of the falls. The DON stated if she has concerns about a particular resident she will meet with the nurse manager after a fall, and stated prior to R78's fall with fracture, she (the DON) had no concerns about R78. The DON stated, since I have been here (she started in January of 2016) I don't think she's had any other falls. The DON did not express an awareness of R78's nine falls since February of 2016. During a subsequent interview at 3:12 p.m., the DON verified there was no review of R78's fall history in the falls meeting minutes and stated we were going to look at her this week. During an interview on 12/22/16, at 1:30 p.m., the medical director (MD) stated he was aware of R78's fall history. The MD stated, with all the changes in the facility, the falls program needs to be re-invigorated. He stated the person who used to review falls was no longer at the facility and the fall program went away when she left. An undated facility policy titled Assessing Falls and Their Causes was reviewed. The policy included: Falls are a leading cause of morbidity and mortality among the elderly in nursing homes. The policy directed staff to begin to try to identify possible or likely causes of the fall. The policy further indicated documentation should include appropriate interventions taken to prevent future falls. While R78 sustained multiple falls in the facility. There was no evidence the facility reviewed the falls since March of 2016. There was no evidence of interventions to prevent future falls or to reduce injury. Further, the facility initiated interventions in February and March that included reminders, however, R78 was severely cognitively impaired and the DON indicated she was unable to understand the directions. R104's care plan dated 7/31/16, indicated R104 had limited physical mobility, needed reminders to use his walker, and may need a wheelchair when going out of the building. R104's MDS dated [DATE], noted R104 had severe cognitive impairment and was admitted to the facility with a [DIAGNOSES REDACTED]. The care plan also included a date of 9/30/16, which indicated R104 was a smoker who required supervision with smoking in the outside designated area. R104's Physician order [REDACTED]. Review of R104's Progress Notes included the following entries: On 11/8/16, at 5:54 p.m. family member (F)-B had called 1st floor/Tcu mgr (transitional care unit/manager -RN-B) to report that R104 had gone shopping by cab yesterday and was staff aware. This writer asked R104 for the details and he stated the following 'Talked to 1st floor male honcho. Talked about rides available. Cab was ok. Went to Cub (grocery store) for some fruit and stuff. Why is she sticking her nose in? Why is she calling people.' Gave him names of men working on 1st floor and then he said 'The one who's (sic) name is on a plaque in the front.' On 11/19/16, at 6:13 p.m. Writer noticed at 1800 res (resident - R104) is not in his room. South nurse told writer that a family member came to visit and went with res (R104) on first floor. Writer checked on 1st floor, the smoking area and front of the building res (R104) was not there. On 12/16/16, at 2:04 p.m. Resident was reported to be walking on the road this morning by the staff along vera cruz ave n (sic) about 350 meters from the facility. Writer went to get him back to the facility but he refused and insisted that he was going to cub he was redirected several time back but still he refused and kept on walking with the walker towards 36th. Staff called the facility who in turn called 911. After about 10 minutes, the police arrived who then talked to him and he accepted to comeback. Vital signs were completed see vital section he denied having pain no SOB (shortness of breath) noted at the time morning medication administered and a 15 minutes check was initiated. All parties were notified hospice nurse gave new orders for see orders. He is currently out with (family). Staff will cont. (continue) to monitor the resident. A care conference note dated 11/17/16, indicated R104 and family received re-clarification R104 required supervision out of the building. R104's medical record and facility documentation lacked evidence of any accident/incident reports regarding R104 missing from the facility on 12/16/16, R104 missing on 11/19/16 or R104's leave on 11/7/16. The medical record also lacked evidence of a comprehensive assessment of R104's risk for potential elopements. RN-A was interviewed on 12/20/16, at 3:12 p.m. who confirmed she called police on 12/16/16, when R104 went outside of the facility. RN-A indicated R104 can be totally wonderful one moment and then confused, and he was confused on this morning, it took police another 10 minutes to talk him into coming back here. RN-A indicated R104 was discovered missing during morning rounds around 6:30 a.m. RN-A stated licesned practical nurse (LPN)-C was the nurse working and searched the building after R104 was not in his room. RN-A indicated someone outside the building alerted staff that R104 was walking down the road and LPN-C went outside to redirect R104 into the building. LPN-C could not redirect R104 and called RN-A from his cell phone. RN-A then called the police who were able to bring R104 back into the building. When R104 was back in the building, the facility began every 15 minute checks and updated family, hospice, the NP and the DON. RN-A indicated the DON did the reporting to the SA and believed the incident was reported. When asked about the 11/8/16, Progress Note which indicated R104 left the facility in a cab, RN-A stated the incident did not occur. RN-A stated staff knew he wanted to call a cab and intervened before anything occurred. RN-A was not familiar with R104 missing from the facility at any other time and not familiar with the 11/19/16, Progress Note entry. RN-A stated she did not complete a wandering assessment for R104. RN-A stated this one little trip outside the building was not an elopement; he had a destination and further indicated the incident really was not dangerous in any way. The DON was interviewed on 12/20/16, at 3:30 p.m. The DON stated R104 goes for walks and goes out every day and smokes. The DON did not know if R104 required supervision for smoking. The DON stated R104 was dressed appropriately for the weather on 12/16/16, and R104 was not confused. The DON confirmed R104 was not on facility grounds when he was found by staff on 12/16/16, and she did not consider the incident an elopement. The DON went on to say R104 has been trying to go out and smoke and she did not think R104 had a WanderGuard, but they had tried on in the past but staff keep a really close eye on him. The DON confirmed an elopement assessment or wandering assessment had not been completed for R104 and stated there was a difference between going out and going for a walk. The DON further confirmed R104 was not on the facility WanderGuard list and stated he shouldn't be, he goes out all the time. The DON further indicated R104 had the right to wander and confirmed again the incident was not reported because she did not view the incident as an elopement as he was found immediately by staff. The DON defined an elopement a someone who has a WanderGuard but is gone, and cannot be found. On 12/21/16, at 3:21 p.m. LPN-C was interviewed. LPN-C stated he was the nurse working on 12/16/16, and during morning report a night shift staff member who had left for the morning, returned to the facility and stated R104 was outside on the street. LPN-C confirmed no staff was aware R104 had left the building. LPN-C then went outside the facility to bring R104 back in. LPN-C stated it was freezing outside however R104 was dressed in a coat and had shoes on and was approximately 300 meters from the building. LPN-C stated he was unable to persuade R104 into the building and called RN-A to call police. LPN-C stated police arrived and persuaded R104 back into the building and police gave both R104 and LPN-C a ride back to the facility. LPN-C stated he assessed R104 when they returned to the facility and updated Hospice and F-B. LPN-C stated they then implemented every 15 minute checks. LPN-C was unaware of any other time R104 had left the building unsupervised. LPN-C stated he was unaware at how long R104 had been outside. The director of social services (DSS) was interviewed on 12/21/16, at 8:42 a.m. and on 12/22/16, at 2:23 p.m. regarding R104's 12/16/16, leave from the facility. DSS stated she was aware of the incident and stated there was discussion of reporting the incident later in the day however, it was not reported because there was no harm to the resident and he was returned to the facility safely and appropriately. DSS stated she was on vacation during the week of 11/8/16, and did not know if R104 actually left the facility. DSS was not familiar with any other time R104 had been missing or left the facility without supervision. R104's F-B was interviewed on 12/21/16, at 12:43 p.m. F-B stated she was informed of R104 being outside on 12/16/16, and stated she was told staff observed R104 was gone from the facility and was found walking up the path outside of the facility. F-B stated R104 had a Wanderguard but it does not alwasy work when he has a coat on and was not sure if the wandergaurd had sounded. F-B stated R104 had left the faciity on e other time unsupervised, probably in November, when he went to Cub Foods in a cab. F-B stated facility staff contacted her and had said R104 told them the administrator told R104 he could call a cab and leave. F-B did not believe that the administrator had given permission for R104 to leave in a cab. RN-B was interviewed on 12/21/16, at 12:06 p.m. who stated she never received a call from R104's F-B on 11/8/16. RN-B stated F-B stopped in her office and asked her if she had heard R104 left in a cab to Cub Foods yesterday. RN-B was unaware of that and contacted RN-A and the DON about what was told to her about R104 from F-B. RN-B stated she did not hear anything further regarding the situation from the DON or RN-A. RN-B was not aware of R104 ever leaving the facility unsupervised. RN-B stated she was aware of the 12/16/16, incident however, was not working at the time the incident occurred. The administrator was interviewed on 12/21/16, at 1:04 p.m. The administrator stated he was notified on 12/16/16, R104 was outside and to his understanding staff had let him out front and he was walking down the side walk and a nurse followed him outside. The administrator confirmed the incident was not reported and stated the DON was aware of the incident and she had told him she had taken care of the situation. The administrator confirmed he was aware of what an elopement was and if that was what had been told to him it would have been reported. The administrator was interviewed regarding the 11/8/16, Progress Note and stated he did not tell the R104 that he could call a cab to leave the facility. The administrator was unaware if R104 left the facility. The administrator was not familiar with the 11/18/16, Progress Note or incident. R66 was observed in hallway with an abrasion on the top of nose and one on the side of nose on 12/19/16, at 12:28 p.m. Traces of blood were noted on the face. R66 said, I am okay I just cut myself shaving. During observation on 12/21/16, at 7:27 a.m. R66 was observed coming out of his room. There was fresh blood on the right side of chin and jaw. R66 said, It is just from shaving and wiped at the blood. It will go away soon. I just cut myself shaving. Surveyor notified unknown nursing assistant of R66's bleeding. At 8:13 a.m. R66 observed in dining room, blood had been washed off R66's face. There was a 1 centimeter (cm) to 1.5 cm longitudinal cut on right side of the jaw. R66's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R66 had moderate cognitively impaired and required assistance with personal hygiene. R66's MDS indicated R66's had [DIAGNOSES REDACTED]. The ADLs Function/Rehabilitation Potential CAA dated 7/8/16, indicated R66 required, Assist with dressing grooming and personal hygiene with set up and supervision to ensure tasks have been completed. Staff were to continue with current care plan and monitor for decline in self-care. The ADL care plan revised 7/15/15, indicated R66 had altered status in ADLs related to alteration in decision making and thought process. The ADL care plan instructed staff, R66 was independent with shaving. The cardiac care plan revised 10/7/16, indicated R66 was on Coumadin and at risk for bruising and bleeding and instructed nursing assistants to observe and report blood in urine or pad tarry stools, bruises skin discolorations prolong bleeding from nose, gums or lab draw sites. The nurses were instructed to report to medical doctor or nurse practitioner and family bruises and symptoms of bleeding. The care plan did not address how to minimize bleeding risks while shaving, effect of [DIAGNOSES REDACTED] on R66's safety to shave self with a disposable razor, or other interventions for staff to take to prevent bleeding. Review of Progress Notes from 11/1/16, to 12/22/16, indicated - On 11/12/16, R66 was noted to be bleeding from right thumb. Staff cleaned area applied triple antibiotic cream and a Band-Aid. The note indicated R66 stated, to have injured self from trying to shave. Will continue to be monitored. - On 12/5/16, R66 was noted to have scratches on head with a small amount of bleeding. Note indicated staff cleaned up the area and warned R66 not to use razor on his own. Per progress note, (R66) stated it was a result of him shaving himself. Writer (sic) took all razors from his drawers as well. Will continue to be monitored. - On 12/19/16, progress note indicated, Resident noted to have blood to nose when walking to the dining room for lunch. Resident's nasal was cleaned and two spots noted like from a scratch. Resident stated did not know how it happened. Will continue to monitor. - On 12/21/16, progress note indicated, Resident noted to have blood to his cheek this morning. Scratches noted to the area. Resident stated no idea where it came from. Will continue to be monitored. The unlabeled Coumadin flow sheet indicated on 12/9/16, R66's INR was 1.9 and staff were to recheck INR on 12/23/16. The flow sheet also indicated R66 was on Coumadin 4 milligrams (mg) on Monday, Wednesday, Friday and Saturday. R66 was to receive Coumadin 3 mg. on Tuesday Thursday and Sunday. The 3rd Floor NA sheets dated 12/13/16, indicated R66 was independent with shaving. During interview on 12/21/16, at 2:19 p.m. registered nurse (RN)-A said, Monday I noticed blood on his nose. I took him back to his room and washed it off and it was two small scrapes. I asked him, where did it come from? He said he did not know. I don't know where it came from but he has a tendency to shave himself. I took all razors out that I found in his room. I have found razors in there in the past and that seems to be the cause. It would not surprise me to see that the nursing assistants are giving him more razors. I chart on the incident at the time but I do not do follow up on skin issues if they are small cuts from shaving. During interview on 12/21/16, at 2:34 p.m. nursing assistant (NA)-G said, I do not have any idea who shaves him. I have seen regular razors in his room. I give him razors as he requests, the plastic ones. During interview on 12/21/16, at 2:37 p.m. nurse manager (NM)-A said, He scratches himself sometimes. We have an electric razor if he wants it. He sometimes uses a regular razor. NM-A verified that care plan lacked specific interventions to prevent bleeding with ADLs. During interview on 12/22/16, at 11:16 a.m. R66 said, I ask the staff for a razor and they give it to me. Sometimes I cut myself but the bleeding will stop eventually. During interview on 12/22/16, at 10:37 a.m. RN-E Staff development nurse said, for residents who are on blood thinners the staff need to be aware of bleeding risk, use electric razors not the hand razors to shave a resident, and notify the nurse if there are any problems. During interview on 12/22/16, at 2:32 p.m. the director of nursing (DON) said lately the staff have been just using the disposable razors. We have not had any issues with residents bleeding. I know that we are trying to initiate electric razors for everyone but they disappear. When informed of the progress notes and observations of R66 the DON said, We will buy him his own electric razor. This is the first time I have heard about this. I expect the staff to chart at the time of the event. We should have done something the first time he cut himself. Undated Shaving the Resident policy page 78 provided by facility instructed staff The purpose of this procedure is to promote cleanliness and to provide skin care. 1. Review the resident's care plan to assess for any special needs of the resident. The policy did not indicate when to use an electric versus a safety razor. The complete policy requested but not received.

Based on record review and interviews the facility failed to provide adequate supervision to prevent a choking episode for one of one resident's (R1) reviewed. As a result R1 took food off another resident's plate and ingested it. R1 choked on the food requiring emergent surgery to remove. Findings include: Review of R1's medical record indicates R1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Progress note written August 2, 2013 at 8:29 p.m. states that R1 eats independently while using her hands during meals and that R1's husband indicated that finger foods might be the best fit. Progress note dated August 5, 2013 at 3:06 p.m. indicates R1's diet would be switched that same day to mechanical soft diet while R1 is waiting for new upper dentures to be made. R1's Individual Resident Care Plan dated August 5, 2013 indicates R1 is at risk for choking related to ingestion of medicine cups, gloves, and papers. Goal is to prevent choking episodes or injury relating to choking with specific interventions included for staff to remove or keep gloves, medicine cups, papers in safe place where R1 cannot reach. Staff are to monitor the resident and check anything in her mouth. R1's Individual Resident Care Plan dated August 14, 2013 indicates R1 needs assist with tray set-up and limited assistance with meals. Staff are to observe for changes in chewing, swallowing, and eating ability.Progress note dated September 7, 2013 at 1:06 p.m. written by Licensed Practical Nurse (LPN)-L indicated that a family member present in the dining room noticed R1 to be choking at 12:05 p.m. and alerted facility staff. Note indicates that R1 was yelling for help while holding her neck and left side. Resident appeared to be having a difficult time breathing. Heimlich maneuver was performed multiple times with only a small piece of chicken brought up. When checked, R1's oxygen saturations were 37%, oxygen was applied. R1 was transported to the hospital by emergency medical services.Hospital records dated September 7, 2013 indicate that R1 needed to have emergency surgery to remove a large (serving size) piece of chicken that had been placed in R1's mouth and swallowed. The piece of chicken was "too big to go down and got stuck." R1 was transported back to the facility on [DATE]. Facility schedule dated September 7, 2013 indicates that three nursing assistants were scheduled for the 7:00 a.m. - 3:30 p.m. shift along with one LPN for R1's unit. Interview with nursing assistant (NA)-C on September 24, 2013 at 2:10 p.m. revealed that she was working on September 7, 2013 during the day shift and did not witness R1 choking as NA-C was sitting in a different area of the dining room and was not facing R1. NA-C indicated that s/he observed that R1 did get a mechanical soft diet during lunch. NA-C stated that s/he was aware that R1 would pick food off of other residents' trays and eat it and would take R1 out of the dining room if s/he noticed this behavior. Interview with NA-B on September 24, 2013 at 3:00 p.m. indicated that s/he was working on September 7, 2013 during the day shift but was not sitting in the same section as R1 during lunch, and did not observe R1 eat another resident's piece of chicken. NA-B stated s/he was aware that R1 would attempt to eat other residents' food and if s/he noticed this behavior would attempt to remove R1 from the dining room. Interview with NA-M on October 9, 2013 at 1:57 p.m. revealed that s/he was working on September 7, 2013 during the day shift and was unable to see R1 during lunch as s/he was sitting on the other side of the dining room. NA-M indicated that s/he observed that R1's food was untouched and assumed she picked a piece of chicken off of her neighbor's plate. NA-M stated that s/he was aware from others that R1 would pick food off of other residents' trays but did not state any specific intervention that would be done when this behavior was observed. Interview with LPN-L on October 10, 2013 at 9:45 a.m. revealed that s/he was working on September 7, 2013 during the day shift and was not present in the dining room at the time R1 began choking. LPN-L was notified of R1 choking by another resident's family member who was coming down the hall to find him/her. LPN-L stated that s/he immediately had R1 sit down in the hall by the nurses station and attempted the Heimlich maneuver. LPN-L asked an aide to run and call registered nurse (RN)-D/Supervisor. LPN-L stated that LPN-A also attempted the Heimlich maneuver on R1 after s/he was unsuccessful. R1 was "gasping for air", oxygen was checked and was "very low, 30 something." 911 was called and oxygen was administered via nasal cannula (liter flow unknown). LPN-L stated that s/he was aware that R1 would pick food off of other resident's trays but did not state any interventions that were to be done if this behavior was observed. LPN-L stated that it is facility policy to have at least one staff, either a nurse or aid in the dining room area while the residents' are eating. LPN-L stated that because the three aids were in the dining room s/he went to another resident's room in an attempt to get them to join the other residents for lunch, thus why s/he was not present when the choking began. Interview with LPN-A on September 24, 2013 at 3:20 p.m. revealed that s/he was working on a different unit on the same floor as R1's unit. LPN-A stated that s/he was made aware of R1 choking when an aide from R1's unit came running to get him/her. LPN-A stated s/he ran down to the unit's nurses station where R1 was and observed LPN-L to be attempting the Heimlich maneuver on R1. LPN-A stated that R1 was "gurgling" and s/he attempted the Heimlich maneuver on R1 but was unable to get anything up. LPN-A stated that at that time RN-D came to the floor, 911 was called, and RN-D checked R1's oxygen level . Oxygen was applied at that time via nasal cannula (liter flow unknown), paramedics arrived right afterwards and R1 was taken to the emergency room . LPN-A stated that s/he was not familiar with R1 as s/he does not normally work on her unit. Interview with RN-D on September 24, 2013 at 2:00 p.m. revealed that s/he was aware of R1 choking when they received a phone call from a nursing assistant on the floor where R1 was. RN-D stated s/he went up to the unit and and observed the Heimlich maneuver being attempted on R1. RN-D stated that R1 did respond to her name and was gasping for air and 911 was called. R1's oxygen level was checked, it was noted to be 37%, oxygen via nasal cannula (liter flow unknown) was applied and R1's oxygen level came up to 100%. RN-D stated that after oxygen had been applied the paramedics arrived at the facility and transported R1 to the emergency room . RN-D stated that s/he was aware of R1 picking food off of other residents' trays previous to this incident and did notify staff on the unit of these behaviors. RN-D stated that if these behaviors were observed from R1 that s/he would attempt to remove R1 from the dining room. Interview with LPN-I/Nurse Manager on October 15, 2013 at 2:50 p.m. revealed that they, along with staff on the unit, were aware that R1 would pick food off of other resident's trays in the dining room and attempt to eat the food. LPN-I stated that staff needed to monitor R1 during meals along with being aware of what she was eating, watching what she was eating, and to make sure R1 did not "get into anyone's food." LPN-I stated s/he was unsure if anyone was watching R1 during the lunch meal. LPN-I confirmed that there was no care plan interventions in place prior to R1 choking for R1's behavior of picking food off other residents' trays and attempting to eat it. R1's Individual Care Plan did not indicate that R1 was at risk for choking due to the known behavior of picking food off of other resident's trays and attempting to eat the food. R1's Care Plan did not direct staff to be present and watching R1 during meals, which could have prevented the behaviors that led to R1's choking.